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IK6 - Exams > Core Content > Flashcards

Core Content Flashcards

1
Q

Acute DKA management

A

A-E, senior, admit

  1. Fluids resuscitation (0.9% saline)
  2. Insulin (0.1 unit/kg/hour)
  3. Potassium and glucose replacement

Monitor - VBG (pH and electrolytes), capillary glucose, capillary ketones

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2
Q

DKA diagnostic criteria

A

PH < 7.3
Glucose > 11
Ketones > 3 serum, ++ urine

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3
Q

Acute stroke (ischaemic)

A
  1. A-E, alert stroke team (stroke call)
  2. CT Head, BP, ECG, bloods (esp. clotting)
  3. Aspirin 300mg
  4. Thrombolysis if within 4.5 hours +/- thrombectomy

If > 4.5 hours supportive treatment on specialist stroke ward

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4
Q

Acute stroke (haemorrhagic)

A
  1. A-E, stroke call/senior
  2. CT head, ECG, BP, bloods (esp. clotting)
  3. BP control if HTN, aim 130-140
  4. Reverse coagulation if patient on
  5. Surgical decompression if severe, else supportive care
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5
Q

Acute ACS management - STEMI

A
  1. A-E, cardio bleep
  2. ECG, trop, BP, bloods incl. VBG, CXR
  3. MONA - morphine + anti-emeric , oxygen, nitrate, aspirin 300mg
  4. Ticareglol 180mg
  5. PCI or thrombolysis (alteplase, if no PCI)
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6
Q

Acute ACS management - NSTEMI

A
  1. A-E, cardio bleep
  2. ECG, trop, BP, bloods incl. VBG, CXR
  3. MONA - morphine + anti-emeric , oxygen, nitrate, aspirin 300mg
  4. Fondaparinux (LMWH)
  5. Calculate GRACE score (6 month mortality)
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7
Q

How does GRACE score change treatment of NSTEMI patients?

A

GRACE - 6 month mortality score, considered high if > 3%

HIGH - second anti-platelet (ticagrelol), PCI within 72 hours

LOW - can be d/c once stable, likely elective OP PCI

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8
Q

Long term post MI management

A

Conservative

  1. Lifestyle - smoking, diet, activity
  2. Cardiac rehabilitation programme

Medicine - BADS
Beta blocker
ACEi
Dual antiplatelet - aspirin 75mg (lifelong) + ticagrelol 90mg (1 year)
Statin - high dose

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9
Q

Complications of MI

A

DARTH VADAR

Death
Arrythmia
Rupture - V wall, papillary muscle (MR)
Tamponade
Heart failure

Valve disease
Aneurysm of ventricle
Dressler’s syndrome (pericarditis)
thromboEmbolism
Recurrence

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10
Q

Acute management of heart failure

A

POD MAN

Position - sit up
Oxygen
Diuretics - furosemide 50mg IV

Morphine
Anti-emetic
Nitrates

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11
Q

Long term management of heart failure

A

CONSERVATIVE

  1. Cardiology MDT
  2. Lifestyle - smoking, execise

MEDICAL
Treat the underlying cause if possible

  1. ACEi + beta blocker + loop diuretic if oedema
  2. Add spironolactone
  3. Specialist Tx such as ibravadine, sacubitral-valsartan

SURGICAL

  1. Cardiac resynchronisation
  2. ICD
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12
Q

Interpreting NT pro BNP

A

> 2000 ng/L - 2 week referral to cardio

400-2000 - 6 week referral to cardio

< 400 - unlikely heart failure

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13
Q

Acute management of PE

A

A-E assessment, breif history for RF, alert seniors

Calculate wells score

  • low - D.Dimer
  • high - CTPA

CXR, ECG, BP, bloods incl. clotting

Unstable - thrombolysis with alteplase
Stable - anti-coagulation with apixaban

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14
Q

Acute management of asthma

A

A-E

O SHIT ME

Oxygen

Salbutamol nebs
Hydrocortisone
Ipratropium nebs
Theophylline IV

Magnesium sulphate IV
Escalation - intubation and ventilation

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15
Q

Acute management of COPD

A

O SHIT

Oxygen - titrate with venturi

Salbutamol nebs
Hydrocortison
Ipratropium nebs
Theophylline

If infection + antibiotics e.g. doxy
If not responding - NIV (BiPaP)

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16
Q

When do you use BiPap vs CPAP?

A

Type 1 RF - 1 thing wrong (hypoxic) - CPAP

Type 2 RF - 2 things wrong (hypoxic, hypercapnic) - BiPaP

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17
Q

Acute management of pneumothorax

A

A-E assessment
CXR, sats, RR, tracheal deviation, BP
Stop NIV if running and high suspicion of pneumo

Tension - needle decompression 2nd ICS MCL then chest drain

Non tension - assess size of rim of air on CXR, if patient is symptomatic and if primary/secondary

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18
Q

Management of a non tension pneumothorax (after A-E)

A

Primary

  • < 2cm and no SOB - d/c, repeat CXR in 2-3 weeks
  • > 2cm or Sx - needle aspirate
  • failure of aspiration - chest drain

Secondary - always admit

  • <1cm + no SOB - 24 hours oxygeb
  • 1-2cm + no SOB - needle aspiration
  • > 2cm, SOB or failed aspiration - chest drain
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19
Q

Management of sepsis

A

A-E, senior input

Sepsis 6
Urine output, IV fluids
Blood cultures, IV antibiotics
Lactate (Blood gas), Oxygen

Assess for source - CXR, urine dip, cultures, assess neuro/CNS

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20
Q

Management of meningitis and/encephalitis

A
  1. A-E approach, senior input
  2. CT head, lumbar puncture
  3. IV antibiotics (ceftriaxone +/- amoxicillin)
  4. Anti-viral if ?encephalitis/viral → IV aciclovir
  5. Sepsis 6 if unstable/septic
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21
Q

Long term stroke management (ischaemic specific?

A

Reducing recurrence risk

  • CVD RF modification
  • look for emboli - ECG and ECHO
  • look for carotid stenosis (doppler)

Conservative

  • SALT, OT/PT
  • lifestyle - smoking, alcohol, etc

Medical

  • aspirin 300mg for 2 weeks then life long clopidogrel
  • BP control
  • high dose statin
  • glycaemic control if DM
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22
Q

Acute management of upper GI bleed

A
  1. A-E, if shocked major haemorrhage call
  2. Fluid resusciation +/- blood
  3. Fastbleep gastro for endoscopy consideration
  4. NBM
  5. IV Abx
  6. Analgesia + anti-emetic
  7. Terlipressin if likely/known varicela bleed
  8. Stengstaken-blakemore if life-threatening
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23
Q

Acute management of anaphylaxis

A
  1. A-E, if stridor - anaesthetics, stop ?offending drugs, IV access
  2. IM Adrenaline 0.5ml 1 in 1000 (500mcg)
  3. IV fluids - manage hypotension
  4. Repeat IM adrenaline if 5 minutes if no change

After 2 doses = refractory - set up IV infusion adrenaline via central line, goes to ITU

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24
Q

Acute management of status epilepticus

A
  1. A-E, start timing, follow status protocol, alert seniors
  2. Reversible causes - VBG, glucose, blood panel
  3. 5 minutes - IV lorazepam or buccal midazolam
  4. After 10 minutes - repeat benzo, ensure ITU/anaesthetics attending
  5. After another 10 minutes - IV phenytoin + cardiac monitoring
  6. After another 10 minutes - RSI with propofol, ITU + EEG
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25
Q

components of A in A-E

airway

A
  • assessment
    • talking = patent
    • stridor
    • sounds of upper airway obstruction
  • interventions
    • head tilt + chin lift
    • jaw thrust
    • oro/nasopharyngeal airway
    • LMA
    • ET/tracheostomy
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26
Q

components of B in A-E

breathing

A
  • assessment
    • RR + sats
    • Auscultate, percuss, expansion, trachea
    • CXR
    • ABG
  • interventions
    • 15L non-rebreathe mask
    • ventilation in severe
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27
Q

components of C in A-E

circulation

A
  • assessment
    • BP, HR
    • heart sounds
    • fluid status - JVP, mucus membranes, CRT, UO
    • ECG
    • bloods - VBG + specific for scenario
  • interventions
    • 2 x large bore IV cannula
    • fluid challenge if hypotensive
    • blood transfusion if major bleed
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28
Q

components of D in A-E

disability

A
  • assessment
    • capillary blood glucose
    • GCS calculation
    • Pupils - equal/reactive to light
    • CT head if reduced GCS
  • intervention
    • glucose replacement
    • head up, neuro + mannitol for raised ICP
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29
Q

components of E in A-E

exposure/everything else

A
  • assessment
    • limbs - neurovascular status
    • skin - rash
    • abdo - SNT?
    • orifices for other sites of bleeding
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30
Q

Acute management of hypoglycaemia

A
  • conscious + moderate - glucogel
  • unconscious/severe + IV access - 75ml 10% glucose
  • unconscious, no access - IM glucagon
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31
Q

acute management of bradycardia with life-threatening signs

A
  1. A-E with IV access, seniors
  2. monitor BP, sats + cardiac monitoring, ECG
  3. Atropine 500mcg IV - repeat up to 6 doses
  4. Transcutaneous pacing or IV adrenaline or IV isoprenaline
  5. Transvenous pacing
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32
Q

what are the life-threatening signs in arrhythmias?

A

HISS

  • heart failure
  • ischaemia (MI)
  • shock
  • syncope
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33
Q

acute management of bradycardia without life-threatening signs

A
  1. A-E approach
  2. monitor BP, ECG, sats, cardiac monitoring
  3. observe and urgent cardio review
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34
Q

what are the shockable rhythms of arrest?

A

ventricular fibrillation

pulseless ventricular tachycardia

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35
Q

what are the non-shockable rhythms of arrest?

A

PEA

asystole

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36
Q

management of regular narrow complex tachycardia

no life-threatening features

A
  1. A-E, cardiac monitoring, sats, BP
  2. Vagal manoeuvres
  3. IV adenosine - up to 3 doses
    1. verapamil if asthmatic
  4. beta-blocker or verapamil
  5. synchronised DC cardioversion
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37
Q

management of regular narrow complex tachycardia

with life-threatening features

A
  1. A-E, senior support
  2. synchronised DC cardioversion
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38
Q

management of narrow complex, irregular tachycardia

no life-threatening features

A
  1. A-E, senior input, likely AF
  2. beta-blocker
    1. if evidence of HF - digoxin or amiodarone
  3. anticoagulation if > 48 hours, consider DC if < 48 for rhythm control
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39
Q

management of polymorphic broad complex tachycardia

no life-threatening features

A
  1. A-E, senior
  2. IV magnesium sulphate
  3. assess for reversible causes - drug review, electrolytes
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40
Q

management of broad complex tachycardia

with life threatening features

A
  • synchronised DC cardioversion
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41
Q

management of regular broad complex tachycardia

no life-threatening signs

A
  1. A-E, senior input, monitoring
  2. 300mg IV amiodarone over 10-20 minutes, then 900mg over 24 hours
  3. consider DC cardioversion if no response

via central line

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42
Q

ALS algorithm for shockable rhythms

A
  1. Defibrillation shock
  2. CPR - 30:2
  3. Reassess rhythm
  4. Repeat steps 1-3 provided rhythm remains shockable

Drugs

  • after 3rd shock
    • 1mg adrenaline IV/IM
    • 300mg IV amiodarone bolus
  • after
    • continue adrenaline every 3-5 mins
    • another 150mg amiodarone after 5th shock
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43
Q

ALS algorithm for non-shockable rhythms

A
  1. Start CPR - 30:2
  2. Adrenaline 1mg IM - give every other cycle of CPR
  3. Atropine 3mg IV if rate < 60bpm
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44
Q

what type of hypersensitivity reaction is asthma?

A

type 1

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45
Q

Ix for diagnosing asthma

A
  • bedside
    • Peak flow diary
    • sats + RR + resp examination
  • bloods - FBC, IgE
  • imaging - CXR
  • special
    • spirometry + bronchodilator - improvement of FEV1 > 12% or volume > 200
    • FeNO > 40 parts per billion
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46
Q

aims of asthma treatment?

A
  • no daytime symptoms
  • no night time waking due to symptoms
  • no need for rescue medications
  • no attacks
  • no limitations on daily activities
  • normal lung function
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47
Q

CXR features of bronchiectasis

A
  • tram lines
  • ring shadows
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48
Q

describe the CURB-65 score

A
  • confusion (AMTS < 8)
  • urea ( > 7)
  • respiratory rate (>30)
  • blood pressure (low, SBP < 90 or DBP < 60)
  • age ( >65)
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49
Q

what are the drugs used to treat TB?

A

RIPE

rifampicin, isoniazid, pyrazinamide, ethambutol

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50
Q

SE of rifampicin

A

orange secretions e.g. urine
hepatitis
induces liver enzymes

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51
Q

SE of isoniazid?

A

hepatitis
peripheral neuropathy

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52
Q

SE of pyrazinamide

A

hepatitis
photo sensitivity
gout

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53
Q

SE of ethambutol

A

optic neuritis

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54
Q

causes of upper lobe fibrosis?

A

A TEA SHOP

  • A - allergic bronchopulmonary aspergillosis
  • T - TB
  • E - extrinsic allergic alveolitis
  • A - ankylosing spondylitis
  • S - sarcoidosis
  • H - histiocytes
  • O - occupation (silicosis, berylliosis)
  • P - pneumoconiosis (coal worker’s)
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55
Q

causes of lower lobe fibrosis

A

IPAS - BM

  • IP - infection, interstitial pneumonia
  • A - alpha-1 anti-trypsin deficiency, asbestosis
  • S - systemic sclerosis, CTD e.g. RA
  • B - bronchiectasis
  • M - medications
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56
Q

causes of exudative pleural effusion

A
  • Infection
  • Malignancy
  • Inflammation e.g. RA, SLE, acute pancreatitis
  • Pulmonary infarct e.g. secondary to PE
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57
Q

causes of transudative pleural effusion

A
  • ↑ capillary hydrostatic pressure
    • Heart failure
  • ↓ capillary oncotic pressure
    • Cirrhosis
    • Nephrotic syndrome
    • CKD
    • GI malabsorption or malnutrition e.g. Crohn’s
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58
Q

medications that cause fibrosis

A

BANS ME

  • Bleomycin
  • Amiodarone
  • Nitrofurantoin
  • Sulfasalazine
  • MEthotrexate
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59
Q

PEF criteria for grading asthma attack

A
  • 50-70 = moderate
  • 33-49 - severe
  • < 33 - life-threatening
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60
Q

who does ABPA tend to effect? what does it lead to?

A

asthmatics

poor control

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61
Q

Allergic bronchopulmonary aspergillosis management

A
  1. oral glucocorticoids
  2. itraconazole
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62
Q

NICE treatment ladder for asthma (long-term)

A
  1. SABA, salbutamol
  2. SABA + ICS e.g. budesonide
  3. SABA + ICS + LTRA e.g. Montelukast, PO
  4. SABA + ICS + LABA (salmeterol) + LTRA
    • Continue LTRA if responsive
  5. Switch LABA/ICS → maintenance and reliever herapy with low-dose ICS
    • SABA + MART + LRTA
  6. Increase ICS to medium dose - SABA + MART with medium dose ICS + LRTA
  7. Referral to specialist - biologic, high dose ICS
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63
Q

drugs contraindicated in asthma

A

beta-blockers

NSAIDs

ACEi

adenosine

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64
Q

conservative management of COPD

A
  • smoking cessation
  • flu + pneumococcal vaccines
  • pulmonary rehabilitation/chest physio
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65
Q

long term medical management of COPD

A
  • 1st - SABA or SAMA
  • 2nd - Asthmatic features → add LABA + ICS
  • 2nd - No asthmatic features → add LABA and LAMA
    • if on SAMA → SABA
  • 3rd line - LAMA + LABA + ICS
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66
Q

what are the asthmatic features of COPD?

A

PEDS

  • PMHx atopy/asthma
  • Eosinophils high
  • Diurnal variation PEFR
  • Steroid responsive before
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67
Q

what are the specialist medical interventions for COPD?

A
  • prophylactic antibiotics (azithromycin) - multiple exacerbations/year
  • LTOT
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68
Q

what is the criteria for LTOT in all resp conditions (COPD, fibrosis)

A
  • non smoker
  • PaO2 < 7.3 kPa on 2 ABG 3 weeks apart
  • PaO2 7.3 - 8 kPa with 1 of:
    • polycythaemia
    • peripheral oedema
    • pulmonary HTN
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69
Q

what are the surgical options for COPD?

A

bullectomy

lung volume reduction surgery

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70
Q

diagnostic test for pulmonary fibrosis?

A

high resolution CT

honeycombing

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71
Q

management of idiopathic pulmonary fibrosis

A

best supportive care pathway, respiratory MDT.

  • Conservative
    • Chest physiotherapy
    • Pulmonary rehabilitation
    • Smoking cessation
  • Medical
    • Anti-fibrotic - Pirfenidone,
    • LTOT
  • Surgical
    • Transplant
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72
Q

features of small cell lung cancer

A
  • central
  • associated with smoking
  • paraneoplastic syndromes - ACTH, lambert-eaton
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73
Q

features of squamous cell lung cancer

A
  • associated with smoking
  • central tumours
  • cavitating lesions
  • paraneoplastic - high calcium, PTHrP secreting
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74
Q

features of adenocarcinoma of the lung

A
  • non-smokers
  • peripherally located
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75
Q

investigations for suspected lung cancer

A

CXR

CT chest

then if confirmed- imaging to stage

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76
Q

common pneumonia CAP organisms

A
  • Streptococcus pneumoniae (70% of CAP)
  • Haemophilus influenzae (2nd most common)
  • Morexalla catarrhalis
  • Group A streptococci
  • Klebsiella pneumoniae
  • Staphylococcus Aureus
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77
Q

what are the common atypical pathogens of CAP?

A
  • Chlamydia pneumonia
  • Mycoplasma pneumoniae
  • Legionella
  • Chlamydia psittaci
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78
Q

what pathogen of pneumonia:

  • rusty coloured sputum
  • lobar on CXR
  • +ve diplococci
A

s. pneumoniae

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79
Q

what pathogen of pneumonia:

  • smoking + COPD
  • gram -ve cocco-baccili
A

haemophilus influenzae

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80
Q

what pathogen of pneumonia

  • following recent viral infection/flu
  • cavitation on CXR
  • +ve cocci
A

s. aureus

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81
Q

who gets klebsiella pneumonia?

A

alcoholics and elderly

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82
Q

treatment of pneumonia

A

admit if high CURB

  • medical treatment
    • Typical CAP
      • Mild → (amoxicillin)
      • Moderate-severe → penicillin + macrolide
    • Atypical CAPs
      • generally = clarithromycin or doxycycline
  • supportive treatment
    • Oxygen, IV fluids, Analgesics
    • NIV/ventilation
    • Drainage of abscess or empyema
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83
Q

acute abdomen core principles

A

NBM

IV fluids

analgesia

antiemetic

Abx (cef + met)

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84
Q

investigations for the surgeon

A
  • CT abdo
  • FBC + CRP
  • U&E, LFTs
  • clotting + G&S
  • amylase
  • calcium
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85
Q

definition of AAA?

A

Abdominal aorta develops a permanent localised dilation of > 50% of expected artery diameter (>3cm)

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86
Q

cardiovascular RF

A
  • HTN
  • Hyperlipidaemia
  • Smoking
  • Previous CVD disease
  • DM
  • Male
  • Older
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87
Q

what conditions in which to screen/consider for CVD RF?

A
  • stroke
  • ACS
  • AAA/aneurysms
  • peripheral vascular disease
  • CKD
  • DM
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88
Q

describe screening for AAA

A
  • men one off USS at 65
  • women at high risk USS at 70
    • (RF - vascular disease, FHx AAA, high risk of CVD)
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89
Q

describe the monitoring of AAA

A
  • 3-4.4cm - yearly USS
  • 4.4 - 5.4cm - USS every 3 months
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90
Q

indications for elective repair of AAA

A
  • symptomatic
  • asymptomatic + > 5.5 cm
  • asymptomatic + growing > 1cm/year
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91
Q

acute management of ruptured AAA

A
  1. A-E assessment, major haemorrhage call, vascular
  2. CT with contrast, G&S + X-match, IV access + resuscitate
  3. permissive hypotension (< 100mmHg)
  4. surgery - open repair usually
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92
Q

management of unruptured AAA

A
  • active monitoring
  • conservative - stop smoking
  • medical - HTN Tx, statin, aspirin
  • surgery - EVAR or open procedure
    • EVAR for older/frail
    • open for younger
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93
Q

6 P’s of acute limb ischaemia

A
  • Pain - constant, persistent
  • Pulseless - ankle pulses absent
  • Pallor (or cyanosis or mottling)
  • Perishingly cold
  • Paraesthesia or ↓ sensation or numbness
  • Paralysis or power loss
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94
Q

key vascular investigations

A
  • bedside
    • vascular examination
    • BP, HR
    • ECG
    • ABPI
    • handheld doppler USS
  • bloods
    • FBC, lipids, HbA1c
    • clotting
  • imaging
    • doppler USS
    • CT angiogram
    • digital subtraction angiography
  • special
    • carotid dopplers
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95
Q

acute management of acute limb ischaemia

A
  1. A-E, vascular review urgent
  2. Limb down (promote blood flow)
  3. Heparin IV
  4. Assess if salvageable → if yes revascularisation (embolectomy, thrombolysis or bypass)
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96
Q

what are the revascularisation options for acute limb ischaemia?

A
  • emboli
    • embolectomy (balloon, Fogarty catheter)
  • thrombus
    • bypass grafting (usually if incomplete occlusion)
    • thrombolysis + stent
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97
Q

how to assess limb viability in acute ischaemia?

A
  • neurosensory deficit → time critical, late stage ischamia
    • paraesthesia + paralysis
  • skin appearance
    • mottling → suggests non-salvageable
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98
Q

options for non-salvageable limbs

A
  • amputation
  • palliation - supportive measures until auto-amputation
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99
Q

what are the risks of revascularisation?

A
  • reperfusion injury → hyperkalaemia, acidosis, rhabdomyolysis, acute renal failure, sepsis
  • compartment syndrome
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100
Q

describe IV maintenance fluid guidance

A
  • daily requirements
    • water - 30ml/kg/day if fit; 25ml/kg/day if old, kidney or heart failure
    • 1 mmol/kg per day of K+, Na+, Cl-
    • 50g-100g of glucose each day
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101
Q

how you could estimate surface area of burns?

A

rule of 9s

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102
Q

acute management of burns (A-E)

A
  • severe → Burns centre
  • A - assess for inhalation injury, consider pre-emptive intubation if high risk
  • B - 100% O2, ABG, check carboxyhaemoglobin levels
  • C - 2 large bore IV
    • routine bloods, G&S, clotting, CK
    • aggressive fluid therapy - Parkland’s formula, 0.9% NaCl warmed
    • IV analgesia (morphine)
  • D - GCS, temperature (risk of hypothermia), PEARL
  • E - estimate % burns + wound care
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103
Q

describe Parkland’s formula for burns fluid resuscitation in adults

A
  • Parklands = fluid volume for 1st 24 hrs after major burns
  • Adults - 4mL (Hartmann’s) x weight (kg) x % TBSA burned
  • Give 50% calculated in 8 hours post burn and 50% in remaining 16 hours
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104
Q

differentials for life-threatening chest injuries

A

ATOMIC

  • airway obstruction
  • tension pneumothorax
  • open pneumothorax (sucking)
  • massive haemothorax
  • intercostal disruption + pulmonary contusion
  • cardiac tamponade
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105
Q

what is the management of variceal bleeding?

A
  • acute upper GI management
  • acute specific
    • Terlipressin + IV Abx pre-op
    • endoscopy - variceal banding, endoscopy ligation, endoscopic injection
  • long term
    • beta-blocker (propanolol)
    • TIPSS procedure
    • address chronic liver disease
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106
Q

causes of cauda equina syndrome

A
  • disc prolapse (most common, L4/5, L5/S1)
  • trauma - #
  • malignancy
  • infection - discitis, Pott’s
  • iatrogenic - haematoma after spinal anaesthetic
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107
Q

red flags for cauda equina syndrome?

A
  • Bilateral sciatica
  • Progressive evolving neurology, rapid
  • Saddle anaesthesia
  • Urinary symptoms - incontinence, loss of urge or retention
  • Bowel symptoms - unable to open bowels, incontinence
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108
Q

acute management of spinal compression/CES

A
  1. Urgent MRI and urgent referral to neurosurgery
  2. Pre-op measures → Analgesia + NBM + G&S
  3. Catheterisation - prevent post-renal AKI
  4. Metastatic spinal cord compression
    • Dexamethasone 16mg in divided doses PO (high dose corticosteroids) + PPI
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109
Q

definitive management of spinal compression/cauda equina syndrome

A
  • surgical
    • Surgical decompression - within 48 hours, laminectomy, posterior decompression
    • Radiotherapy + chemotherapy if cancer
    • Steroids - if cancer, some inflammation e.g. AS
  • post-operative
    • PT/OT
    • treat any underlying/contributive cause
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110
Q

causes of encephalitis?

A
  • infection
    • viruses → herpes simplex virus 1 (most common)
    • bacteria - N. meningitides
    • fungal
  • autoimmune encephalitis
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111
Q

cord compression vs cauda equina

differentiating by: tone, power, reflex, clonus, plantars, bowel, bladder and sensation

A
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112
Q

what are the CSF findings in bacterial infection?

variables: appearance; WCC, protein, glucose

A
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113
Q

what are the CSF findings in virus infection?

variables: appearance; WCC, protein, glucose

A
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114
Q

what are the CSF findings in GBS infection?

variables: appearance; WCC, protein, glucose

A
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115
Q

what are the CSF findings in SAH infection?

variables: appearance; WCC, protein, glucose

A
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116
Q

what are the CSF findings in TB infection?

variables: appearance; WCC, protein, glucose

A
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117
Q

describe the components of GCS (broad categories + total score) ?

A

eye - 4

verbal - 5

motor - 6

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118
Q

detailed GCS score

A
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119
Q

what are the signs of basal skull #?

A
  • haemotympanum
  • “panda” eyes
  • CSF leak from ear or nose
  • Battle’s sign
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120
Q

what are the indications for CT head within 1 hour ADULT?

A
  • consciousness related
    • Initial A&E GCS < 13
    • GCS < 15 at 2 hours after the injury
  • injury related
    • Suspected open or depressed skull fracture
    • Any sign of basal skull #
  • concerning neurology
    • Focal neurological deficit
    • Post-traumatic seizure
    • > 1 episode of vomiting
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121
Q

what are the indications for CT head within 8 hours in ADULTS?

A
  • over 65 years
  • Hx of bleeding or clotting disorder
  • On anti-coagulants
  • Dangerous mechanism of injury
  • > 30 minutes retrograde amnesia of events immediately prior to head injury
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122
Q

acute management of raised ICP

A
  1. A-E
  2. Urgent neurosurgical referral
  3. Head up 40 degrees
  4. If intubated → hyperventilate (↓ PaCO2 → cerebral vasoconstriction → ↓ ICP)
  5. Osmotic agents e.g. mannitol
  6. Steroids - if ↑ ICP due to malignancy
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123
Q

what are the common organisms of meningitis in neonates?

A
  • group B streptococci
  • listeria monocytogenes
  • Escherichia coli
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124
Q

what are the common organisms of meningitis overall?

A

NHS

  • N. meningitides
  • H. influenza B
  • S. pneumoniae,
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125
Q

what are encapsulated bacteria that are clinically important after splenectomy?

A

NHS

  • N. meningitides
  • H. influenza B
  • S. pneumoniae
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126
Q

what are the common organisms of meningitis older and immunocompromised?

A
  • s. pneumoniae
  • L. monocytogenes
  • TB
  • gram negative organisms
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127
Q

what is the prophylaxis for meningococcal meningitis?

A

ciprofloxacin to close household contacts

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128
Q

what are the causes of spinal cord compression?

A
  • metastatic cord compression (most common)
    • lung, breast, prostate
  • traumatic
  • infective - abscess, TB, discitis
  • disc prolapse (rare in upper spine)
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129
Q

what # are most commonly associated with compartment syndrome?

A

supracondylar

tibial

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130
Q

key features of compartment syndrome

A
  • pain out of proportion to injury
  • sensation of pressure
  • paraesthesia
  • paralysis of muscle group
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131
Q

management of compartment syndrome

A
  1. Dressing release
  2. Analgesia + urgent T&O/surgery review
  3. Fasciotomy
  4. Monitor for rhabdomyolysis and renal impairment
  5. Surgical intervention - if frankly necrotic muscle is seen on fasciotomy → debridement + amputation
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132
Q

what is the diagnostic criteria of creatine kinase?

A

5 x the upper limit of normal

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133
Q

what are some causes of rhabdomyolysis?

A
  • Trauma
  • long lie - elderly after falls
  • Ischaemia - compartment syndrome, reperfusion
  • Medical causes - seizure, infections, metabolic abnormalities
  • Drug induced - cocaine, diuretics (severe K+ depletion), statin, anti-psychotics, DDP-4 inhibitors (e.g. sitagliptin)
  • Toxins - cyanide, copper, CO
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134
Q

management of rhabdomyolysis

A
  1. IV fluids + correct electrolyte abnormalities
  2. Urine alkalinisation - IV sodium bicarbonate
  3. Haemodialysis - refractory raised K+ or acidosis
    • Helps with ↑ K+ and acidosis
    • Indicated if anuric with severe acidosis and hyperkalaemia
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135
Q

management of acute alcohol withdrawal?

A
  1. seizure prevention - reducing dose of chlordiazepoxide
  2. Wernicke-Korsakoff prevention - IV thiamine
  3. screen for liver disease
  4. involve alcohol services
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136
Q

features of salicyclate/aspirin OD?

A
  • flushed
  • fever
  • hyperventilation
  • tinnitus, dizziness
  • Respiratory alkalosis → lactic acidosis (mixed pH disturbance)
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137
Q

management of salicyclate OD?

A
  • IV sodium bicarbonate
  • emergency haemodialysis if life-threatening OD or coma due to OD
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138
Q

treatment of opiate OD?

A

naloxone 400mcg IM/IV

can repeat if unresponsive

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139
Q

risks of hepatotoxicity after paracetamol OD?

A
  • enzyme inducing medication (PC BRASS)
  • malnourish - anorexia, chronic ETOH
  • staggered OD
  • delayed presentation
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140
Q

what is the management of paracetamol OD?

A
  • N-acetylcysteine
  • anti-emetic + fluids, monitor electrolytes + LFTS
  • liver transplant - acute liver failure
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141
Q

who should get an immediate NAC infusion? what is usually done?

A
  • single OD → bloods at 4 hours, nomogram to see if needs NAC
  • immediate NAC at presentation if:
    • staggered, unsure of time of ingestion
    • high risk of toxicity e.g. alcoholic
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142
Q

benzodiazepine antidote

A

flumazenil

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143
Q

management of beta blocker OD

A
  • atropine for bradycardia
  • anti-dote = glucagon
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144
Q

antidote to digoxin

A

digifab

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145
Q

antidote for ethylene glycol poisoning

A

fomepizole

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146
Q

antidote for local anaesthetic overdose

A

intralipid

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147
Q

management of TCA overdose

A
  • cardiac monitoring - risk of QTc prolongation and ventricular arrhythmias
  • sodium bicarbonate
    *
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148
Q

features + treatment of duct ectasia

A
  • older woman
  • characterised by dilation of ducts
  • nipple discharge - green/brown
  • management
    • conservative - reassurance
    • surgical - if persistent Sx - duct excision
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149
Q

most common type of breast cancer

A

ductal carcinoma (either in situ or invasive)

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150
Q

RF for breast cancer

A
  • genetic - BRCA 1 or 2
  • high oestrogen exposure
    • nulliparity
    • early menarche, late menopause
    • COCP/HRT
  • PMHx breast, ovarian, endometrial, colorectal cancer
  • obesity
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151
Q

what is the triple assessment for breast cancer?

A
  1. clinical examination
  2. imaging - USS < 35; mammogram if > 35
  3. histology - FNA or core biopsy
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152
Q

what is the screening program for breast cancer?

A

mammogram every 3 years (2 views) from 50-70

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153
Q

general description of cancer treatment

A
  • MDT
  • treatment combination based on patient factors, tumour staging and patient wishes
  • curative or palliative intent
  • conservative - psychological support
  • medical - chemotherapy, radiotherapy, immunotherapy
  • surgical - resection
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154
Q

management of breast cancer

A
  • general
    • MDT
  • surgical resection
    • wide local excision - if small, localised
    • mastectomy
    • + axillary LN clearance
  • adjunct treatment
    • radiotherapy
    • chemotherapy
    • hormonal treatment
      • tamoxifen (SERM) if pre-menopausal
      • anastrozole (aromatase inhibitor) if post-menopausal
  • reconstruction - prosthetic or flap
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155
Q

complications of mastectomy

A
  • Pain
  • Infection
  • Bleeding
  • Lymphoedema of the arm if axillary clearance conducted
  • Phantom breast pain
  • Seroma
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156
Q

common cause of mastitis/breast abscess?

A

flucloxacillin

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157
Q

management of mastitis

A
  1. anti-pyretic
  2. antibiotics - flucloxacillin PO, if severe IV Abx
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158
Q

management of breast abscess

A
  1. anti-pyretic
  2. antibiotics - flucloxacillin PO, if severe IV Abx
  3. needle aspiration - LA, USS, send for MC&S
  4. Incision and drainage - if failed multiple aspiration, very large or multi-loculated
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159
Q

classification of aortic dissection (stanford)

A
  • Type A - dissection of the ascending aorta or arch of the aorta
    • Most common
  • Type B - dissection of aorta distal to the left subclavian aorta (descending)
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160
Q

diagnostic test for aortic dissection

A

CT angiogram

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161
Q

acute management of aortic dissection

A
  • A-E assessment, major haemorrhage protocol, vascular referral
  • haemodynamically unstable
    • theatre - graft or repair
  • haemodynamically stable
    • type A - surgery, graft repair
    • type B - strict BP control (IV labetalol), bed rest, EVAR/open if develop end organ damage
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162
Q

RF for aortic dissection

A
  • HTN
  • CTD (EDS, SLE, Marfan’s)
  • aortitis
  • trauma/iatrogenic
  • cocaine/amphetamines
  • valvular heart disease
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163
Q

common secondary causes of AF

A
  • ischaemic heart disease
  • rheumatic heart disease
  • thyrotoxicosis
  • pneumonia
  • PE
  • sepsis
  • alcohol
  • mitral valve disease
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164
Q

investigations for AF

A
  • Bedside
    • ECG - diagnostic. Irregularly irregular rhythm, No P waves
  • Bloods
    • Exclude contributing cause - FBC + CRP, TFTs, U&Es
  • Imaging
    • Echocardiogram - structure heart disease
  • Specialist or scoring
    • CHA2DS2-VASc stroke risk score
    • ORBIT bleeding risk score
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165
Q

what is the CHADsVASc and how to interpret?

A
  • > 2 F - should be anticoagulated
  • > 1 M - should be
  • C - congestive cardiac failure (1)
  • H - HTN (1)
  • A2 - > 75 (2)
  • D - DM (1)
  • S2 - Stroke/TIA (2)
  • V- Vascular disease (1)
  • A - 65-74 (1)
  • Sc - female (1)
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166
Q

new-onset AF - guidance for DC cardioversion?

A

< 48 hours - can cardiovert

48+ hours - TOE to exclude thrombus + DC or anti-coagulate for 3/52 then elective cardiovert

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167
Q

management of AF

A
  • conservative
    • cardiovascular RF modification
    • education about AF + stroke signs
  • medical
    • rate control
    • rhythm control
    • stroke prevention
  • surgical
    • atrial ablation - refractory, identifiable originating loci
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168
Q

detailed medical management of AF?

A
  • rate control
    • beta-blocker (bisoprolol)
    • rate-limiting CCB (verapamil)
    • digoxin - if hypotension, heart failure
  • rhythm control
    • elective electrical cardioversion
    • pharmacological - flecainide (pill in pocket), amiodarone
  • stroke prevention - DOAC (apixiban), warfarin + LMWH bridging (always if valvular AF)
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169
Q

what is atrial flutter?

A
  • re-entrant atrial tachycardia
  • atrial rate 250-320 bpm
  • fixed or variable AV condition, narrow QRS
  • saw-tooth pattern on ECG
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170
Q

management of atrial flutter

A
  • haemodynamically unstable → DC cardioversion
  • stable
    • rate control - beta-blocker, CCB
    • rhythm control - elective cardioversion
    • VTE prophylaxis e.g. apixiban
    • catheter radiofrequency ablation - 1st line if normal/mild enlarged LA
    • pacemaker (atrial if refractory to Tx)
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171
Q

causes of high output failure?

A

anaemia

sepsis

pregnancy

Paget’s

hyperthyroidism

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172
Q

what is a reduced EF?

A

< 45%

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173
Q

features of LV heart failure

A
  • pulmonary congestion - SOB, PND, orthopnoea
  • hypotension/syncope - low CO
  • S3 gallop
  • functional MR
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174
Q

CXR features of heart failure

A
  • A - alveolar oedema (“batwing” perihilar shadowing)
  • B - Kerley B lines, interstitial oedema
  • C - Cardiomegaly (> 0.5)
  • D - upper lobe blood diversion
  • E - pleural effusions (usually bilateral, transudates)
  • F - fluid in the horizontal fissure
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175
Q

types of cardiomyopathy

A
  • dilated
  • hypertrophic
  • restrictive
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176
Q

Dilated cardiomyopathy summary

  • description
  • causes
  • management
A

Dilated cardiomyopathy summary

  • description- systolic dysfunction, dilation of heart
  • causes - idiopathy (majority), post-viral, alcoholism, post-partum
  • management
    • symptomatic support + HF management
    • ICD if arrhythmias
    • heart transplant
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177
Q

Ix for cardiomyopathy

A
  • bedside - ECG
  • bloods - NT pro-BNP, lipids, HBA1c, U&Es, FBC
  • imaging - CXR, echo
  • specialist
    • endomyocardial biopsy
    • genetic analysis
    • cardiac catheterisation
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178
Q

Hypertrophic cardiomyopathy summary

  • description
  • causes
  • management
A

Hypertrophic cardiomyopathy summary

  • description - thickened heart tissue, diastolic dysfunction, preserved EF till end
  • causes - genetic, AD
  • management
    • ICD - high risk of sudden cardiac death
    • exercise restriction
    • reducing outflow obstruction
      • beta-blocker, verapamil
      • surgical myomectomy
      • alcohol septal ablation
    • screening of relatives
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179
Q

Restrictive cardiomyopathy summary

  • description
  • causes
  • management
A

Restrictive cardiomyopathy summary

  • description - diastolic dysfunction, reduced compliance of heart tissue, RARE
  • causes - familial, infiltrative (sarcoid, amyloid), storage (haemochromatosis), radiation induced fibrosis
  • management
    • symptomatic + HF
    • ICD if arrhythmia
    • heart transplant
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180
Q

DVT well’s score

A
  • 2+ - likely, 1 or less - unlikely.
  • Criteria are:
    • Active cancer 1
    • Paralysis, paresis or recent plaster immobilisation of lower extremities 1
    • Recently bedridden for > 3 days, or major surgery within 3/12 = 1
    • Tenderness along deep vein system = 1
    • Entire leg swollen = 1
    • Calf swelling at least 3 cm = 1
    • Pitting oedema = 1
    • Collateral superficial veins (non-varicose) = 1
    • Previously documented DVT = 1
    • An alternative diagnosis is at least as likely as DVT = -2
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181
Q

management if high DVT Well’s score (> 2)

A
  • USS to confirm diagnosis within 4 hours
  • anticoagulation if +ve USS → DOAC (apixiban), LMWH
  • mechanical intervention - thrombectomy + IVC filter only if can’t anticoagulate
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182
Q

how long to anti-coagulate for in VTE?

A

3 months if provoked

6 months if unprovoked

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183
Q

management if low DVT Well’s score

A

D-dimer test within 4 hours

  • If cannot get result within 4 hr → offer interim anticoagulation
  • If negative - consider alternative diagnosis
  • If positive - offer USS (if within 4 hours) + interim anticoagulation
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184
Q

what to do if D-dimer +ve and USS negative in DVT?

A

stop anti-coagulation

repeat USS in 1 week

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185
Q

what is the primary prevention statin choice?

A

20mg atorvastatin

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186
Q

what is the secondary prevention statin of choice?

A

80mg of atorvastatin

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187
Q

indications for amputation

A
  • Death → tissue death most commonly due PAD
  • Dangerous → infected or malignancy in limb
  • Damage → trauma, burns, frostbite
  • Damn annoying → pain, etc, refractory to other treatment
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188
Q

what are the types of heart block?

A
  • first degree - consistent PR prolongation, no loss of QRS
  • Second degree - prolonged PR with loss of QRS complexes in a predictable manner
    • Mobitz type 1 - progressive lengthening of the PR interval until P wave with failed conduction of QRS
    • Mobitz type 2 - intermittent non-conduction of P to QRS with a fixed constant PR interval
  • Third degree - complete heart block, atrial impulses fail to be conducted to ventricles
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189
Q

causes of 1st degree heart block?

A
  • athletes - high vagal tone (not pathological)
  • acute inferior MI
  • electrolyte abnormalities
  • meds
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190
Q

what medications can cause heart block?

A
  • beta-blockers
  • CCB
  • digoxin
  • amiodarone
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191
Q

what is a major cause of second and third degree heart block?

A

myocardial infarction

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192
Q

management of 1st degree heart block?

A

benign, doesn’t require treatment

screen for any underlying cause, if found treat

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193
Q

management of second degree heart block

A
  • Mobitz type 1
    • asymptomatic - no Tx
    • symptomatic - most no Tx, ECG monitoring, review medication, consider pacemaker
  • Mobitz type 2
    • pace maker as high risk of complete high block
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194
Q

management of third degree heart block

A

permanent pacemaker

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195
Q

what is malignant HTN

A

> over 180/120

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196
Q

secondary causes of HTN

A
  • Renal: renal artery stenosis, PCKD, CKD
  • Endocrine: hyperthyroidism, Cushing’s, Conn’s syndrome, pheochromocytoma, acromegaly
  • Cardiovascular: coarctation of aorta
  • Drugs: sympathomimetics, corticosteroids, COCP
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197
Q

investigations of HTN

A
  • diagnosis
    • clinic + confirmed with ambulatory (1st line) or home BP readings
  • assess for complications
    • urine dipstick - protein
    • ECG
    • bloods - U&E (renal function), HbA1c (CVD risk), lipids (CVD risk)
    • fundoscopy
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198
Q

medical management of HTN

A
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199
Q

management of severe HTN (> 180/120)

A
  • asymptomatic
    • urgent assessment for end organ damage - headache, eyes, renal, heart
    • initiate oral HTN treatment
  • symptomatic
    • hospital assessment + admission
    • IV labetalol
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200
Q

what are the HTN retinopathy stages

A
  1. Silver wiring
  2. Silver wiring + arteriovenous nipping
  3. Silver wiring, arteriovenous nipping, flame haemorrhages and cotton wool exudates
  4. Silver wiring, arteriovenous nipping, flame haemorrhages, cotton wool exudates + papilloedema
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201
Q

complications of HTN

A
  • cardiac - HF, coronary artery disease, PVD
  • neuro - CVA, HTN encephalopathy
  • renal - HTN nephropathy, CKD
  • eyes - hypertensive retinopathy
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202
Q

Duke’s criteria for infective endocarditis

A
  • major
    • +ve blood cultures (2 +ve, 12 hours apart, different site)
    • echocardiogram findings - vegetations
  • minor
    • RF e.g. IVDU
    • fever > 38
    • immune complex - haematuria/glomerulonephritis, osler’s, roth spots
    • embolic phenomena - stroke/PE, splinter, janeway
    • +ve echo not meeting criteria
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203
Q

pathogens seen in IE

A
  • subacute - Strep. viridans
  • acute - S. Aureus, S. epidermis
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204
Q

what valves are most common affected in IE?

A

mitral and aortic, unless IVDU then RH valves

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205
Q

management of infective endocarditis

A
  1. Admit
  2. A-E
  3. IV antibiotics - 4-6 week course, should respond within 48 hours of initiation treatment
  4. Surgical intervention - severe cases, uncontrolled infection
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206
Q

management of stable angina

A
  • conservative
    • education
    • lifestyle and RF modification
  • medical
    • short term nitrate PRN
    • anti-anginal medication
      • 1st - beta blocker or CCB
      • 2nd - ivabradine
    • secondary prevention - 75mg aspirin, 80mg statin, HTN management
  • surgical
    • CT angiography 1st line to assess suitability for surgery
    • PCI + stenting
    • CABG
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207
Q

management of intermittent claudication

A
  • conservative
    • RF - smoking, lifestyle
    • supervised exercise program
  • medical
    • secondary prevention - 75mg clopidogrel
    • vasodilator
  • surgical
    • revascularisation - angioplasty + stenting; bypass
208
Q

what does ABPI tell you?

A
  • high - calcification, seen in DM
  • < 0.9 = PAD
  • 0.9-0.8 - mild; 0.8-0.5 - moderate; < 0.5 - severe/critical
209
Q

what is the management of critical limb ischaemia?

A
  • urgent referral vascular
  • medical
    • analgesia
    • secondary prevention - clopidogrel
  • surgical
    • revascularisation - bypass
    • amputation if gangrene
210
Q

what is rheumatic fever?

A

Rheumatic fever is a systemic inflammatory condition following group A beta-haemolytic streptococcal infection

211
Q

what is the Jones criteria

A

Infection + 2 major or 1 major + 2 minor

  • Evidence of recent streptococcal infection
  • Major criteria
    • Arthritis
    • Pancarditis
    • Sydenham’s chorea
    • Erythema marginatum
    • Subcutaneous nodules
  • Minor criteria
    • Fever
    • Arthralgia - unless arthritis met as major
    • ↑ acute phase proteins (ESR, CRP)
    • Prolonged PR interval on ECG
212
Q

which valves are most commonly affected in rheumatic fever?

A

most common = mitral

2nd most common = aortic

213
Q

treatment of rheumatic fever

A
  • eradicate group A beta-haemolytic strep - IV benzypenicillin
  • bed rest
  • analgesia
  • cardiac assessment - may require valve replacement
214
Q

general ulcer management

A
  • treat any underlying contributing cause
  • wound care
  • treat any complicating infection
  • severe wounds - assessment by plastics for ?debridement + grafting
215
Q

features of arterial ulcers

A
  • lower legs, areas of trauma or pressure
  • small, deep lesions
  • painful
  • clear edges
  • features of peripheral arterial disease - cold peripheries, thick nails, hair loss, long CRT
216
Q

features of venous ulcers

A
  • gaiter region
  • large and shallow
  • sloped edges
  • sloughing ulcer
  • painful
  • features of venous insufficiency e.g. varicose veins
217
Q

4 main types of ulcers

A
  • arterial
  • venous
  • neuropathic
  • pressure
218
Q

features of neuropathic ulcers

A
  • bony areas e.g. heel, plantar aspect
  • deep, clear edges
  • painless
  • surrounding features - dry, cracked, insensate, calluses, charcot joint
  • associated with peripheral neuropathies (DM, B12)
219
Q

treatment of arterial ulcers

A
  • general ulcer principles
  • refer to vascular as sign of critical limb ischaemia
  • CVD risk factor modification
  • surgery - revascularisation (stenting or bypass)
220
Q

treatment of venous ulcers

A
  • conservative
    • leg elevation, increased exercise, weight reduction
  • medical
    • general ulcer principles
    • compression bandaging - check ABPI first
  • surgical
    • treat concurrent venous insufficiency
221
Q

management of neuropathic ulcers

A
  • wound care
  • optimise factors affecting peripheral neuropathy - e.g. glycaemic control in DM
222
Q

causes of aortic regurgitation

A
  • acute
    • IE
    • aortic dissection
    • trauma
  • chronic
    • rheumatic heart disease
    • bicuspid valve
    • IE
    • CTD
223
Q

key clinical features of AR

A
  • early diastolic murmur, LLSE, expiration
  • wide pulse pressure
  • collapsing pulse
  • LH failure - SOB
224
Q

eponymous signs of aortic regurgitation

A
  • Corrigans - exaggerated carotid
  • Quinke’s - nailbed pulsation
  • De Musset’s - head nodding
  • Traube’s sign - “pistol shot” at femoral
225
Q

investigating valve disease

A
  • bedside
    • cardio examination, ECG
  • bloods - FBC, U&E, lipids, glucose
  • imaging - echo, CXR
  • special - angiogram if for open repair
226
Q

management of aortic regurgitation

A
  • conservative
    • RF modification
    • regular review by cardio
  • medical
    • reducing afterload → beta-blocker, ACEi, diuretics
    • treat underlying cause
  • surgical
    • open aortic valve replacement + aortic root graft
227
Q

general indications for valve replacement (R heart)

A
  • symptomatic
  • features of heart failure
  • severe valve disease on echo
228
Q

causes of aortic stenosis

A
  • bicuspid valve
  • senile calcification
  • rheumatic heart disease
229
Q

clinical features of aortic stenosis

A
  • ejection systolic murmur, aortic region, 2nd ICS
  • S4
  • heaving, non-displaced apex beat
  • slow rising pulse, narrow pulse pressure
  • quiet S2 (severe)
230
Q

what are the key symptoms of aortic stenosis?

A

syncope

angina

dyspnoea

231
Q

management of aortic stenosis

A
  • conservative
    • monitoring, severe 6-12 monthly
    • RF modification
  • medical
    • symptomatic treatment if features of HF
  • surgical
    • open aortic valve repair
    • TAVI (preferred in older/frail)
232
Q

causes of mitral regurgitation

A
  • acute
    • ischaemic - papillary muscle rupture
    • IE
    • rheumatic heart disease
  • chronic
    • degeneration of valve (age)
    • CTD
    • dilated cardiomyopathy
233
Q

clinical features of mitral regurgitation

A
  • pansystolic murmur at the apex, radiate to axilla, expiration
  • quiet/soft S1
  • parasternal heave
  • irregularly irregular pulse
  • prolapse - mid-systolic click
234
Q

management of mitral regurgitation

A
  • conservative- monitoring and RF
  • medical
    • AF management
    • HF management if present
  • surgery
    • valve repair (1st)
    • valve repalcement (2nd)
235
Q

causes of mitral stenosis

A
  • rheumatic heart disease (most common)
  • mitral calcification
  • carcinoid syndrome
236
Q

clinical features of mitral stenosis

A
  • rumbling mid-diastolic murmur over apex, bell, expiration, left lateral
  • tapping + non-displaced apex
  • parasternal heave
  • loud S1
  • malar flush
  • AF
237
Q

management of mitral stenosis

A
  • conservative - monitoring and RF
  • medical
    • manage AF
    • consider diuretics (reduce pre-load)
  • surgical
    • transcatheter valvotomy (rheumatic MS)
    • mitral valve replacement
238
Q

complications of varicose veins

A
  • bleeding
  • superficial vein thrombosis
  • skin ulceration
  • depression
  • reduced QOL
239
Q

RF for varicose veins

A
  • older age
  • FHx
  • female
  • pregnancy
  • obesity
  • prolonged sitting/standing
  • Hx of DVT
240
Q

management of varicose veins

A
  • conservative
    • reduce standing, elevate stocking, weight loss
  • medical
    • compression stocking
  • interventional
    • radiofrequency ablation
    • injection sclerotherapy
  • surgery
    • ligation
    • stripping
241
Q

what are the indications for interventional or surgical treatment of varicose veins?

A

bleeding, symptomatic, venous insufficiency chronic changes, venous ulcers

242
Q

pathology of vasovagal syncope

A
  • neural mediated reflex syncope
  • excessive vagal discharge causing reflex bradycardia + peripheral vasodilation.
243
Q

management of vagal attack

A
  • education about triggers
  • if impending syncope → lie down, legs up, volume expansion (more fluids, salt)
  • severe/unpredictable → tilt training, isometric counterpressure manoeuvres
244
Q

what is wolff-Parkinson white?

A

WPW is a syndrome characterised by a congenital abnormality which predisposes to supraventricular tachycardia secondary to an accessory pathway

245
Q

clinical features of WPW

A
  • bundle of kent (congenital)
  • syncope, palpitation, dizzy
  • short PR
  • delta wave on ECG
246
Q

management of WPW

A
  • acute
    • unstable - cardiovert
    • stable - IV adenosine, if feature of flutter amiodarone
  • chronic
    • medication review
    • ablation of accessory pathway - radiofrequency or surgical
247
Q

indications for carotid endarterectomy

A
  • Carotid artery disease - in prevention of ischaemia stroke
    • Symptomatic carotid stenosis of 50-99%
    • > 50% stenosis and > 1 TIA in last six months provided stenosis on side accounting for TIA
248
Q

clinical features of cluster headache

A
  • trigger - ETOH, smoking, exercise
  • severe, unilateral headache, rapid, clustered, night
  • associated - red, teary eye, rhinorrhoea, lacrimation, facial vasodilation
249
Q

management of cluster headache

A
  • conservative
    • avoid trigger, good sleep hygiene
  • acute
    • high flow O2
    • sumatriptan SC
  • long term
    • verapamil
250
Q

what are the types of seizure?

A
  • focal
    • simple
    • complex - impaired consciousness
  • generalised
    • absence
    • tonic
    • myoclonic
    • tonic-clonic
    • atonic
251
Q

features of temporal lobe seizure

A
  • automatism e.g. lip smacking
  • deja vu
  • emotional disturbance
  • hallucination (sensory e.g. olfactory)
252
Q

features of frontal lobe seizure

A

motor

jacksonian march, Todd’s paresis

253
Q

features of parietal lobe seizures

A

sensory - tingling, numbness

can develop into motor as electrical activity spreads into frontal lobe

254
Q

management of alzheimer’s dementia

A
  • bio
    • acetylcholinesterase inhibitor (donepezil)
    • NMDA antagonist (memantine)
  • psycho
    • managing psychological symptoms e.g. mood disturbance
  • social
    • support at home + carers
    • home safety
255
Q

features of Miller Fisher syndrome

A

ataxia + opthalmoplegia + areflexia

subtype of GBS

256
Q

key features of Guillain-Barre syndrome

A
  • ascending symmetrical paralysis (LMN)
  • risk of T2RF
  • anti-ganglioside antibodies
  • LP - raised protein, normal cell count + glucose
  • reduced nerve conduction studies
257
Q

what are the main triggers for GBS?

A

respiratory or GI infection (Campylobacter, mycoplasma, EBV)

258
Q

management of GBS?

A
  • serial ABG + spirometry for resp. function
  • IVIG + plasmapheresis
  • ventilation of required
259
Q

causes of horner’s syndrome

A
  • central
    • stroke, MS, tumour
  • pre-ganglionic
    • Pancoast, trauma, cervical rib
  • post-ganglionic
    • carotid dissection, endartectomy, cavernous sinus thrombosis
260
Q

triad of Horner’s

A
  • ptosis
  • miosis
  • anhidrosis
261
Q

what is the genetics of Huntingtons?

A

trinucleotid repeat (CAG, Chr 4, huntingtin protein)

AD condition

262
Q

what are the clinical features of Huntington?

A
  • choreoathetosis (chorea)
  • dementia
  • familial condition
263
Q

what are the types of hydrocephalus?

A
  1. Non-communicating/obstructive where the flow of CSF is blocked
  2. Communicating - is an issue with reduced absorption or blockage of the venous drainage system
264
Q

causes of obstructive hydrocephalus

A
  • obstructing tumour or cyst
  • congenital
265
Q

causes of communicating hydrocephalus

A
  • infective meningitis
  • SAH
  • normal pressure hydrocephalus
266
Q

management of hydrocephalus

A
  • medical - acetazolamide (limited use)
  • surgical - ventriculo-peritoneal shunt
267
Q

What bleeds in an extradural?

A

Middle meningeal artery (most common)

268
Q

Key features of extradural

A
  • blood collects between bone and dura - lucid period then reduced GCS - features of raised ICP
269
Q

What is the appearance of an extradural on CT?

A

Hyperdense biconvex/lentiform haematoma

270
Q

Management of extradural

A

General principles - A-E - neurosurgery - raised ICP management Definitive - surgery (burr holes, craniotomy) if GCS < 8, large, midline shift, focal neuro deficits - conservative - everyone else - neurorehab

271
Q

What bleeds in a subarachnoid haemorrhage?

A

Aneurysm - e.g Berry AV malformations

272
Q

Key features of SAH

A
  • blood accumulating in subarachnoid space - sudden onset thunderclap headache - associated with PCKD
273
Q

Diagnosing SAH

A
  • CT head - blood in SA space often around circle Willis - CT angiogram/DSA - LP 12 hours after Sx onset - xanthochromia
274
Q

Management of SAH

A
  1. A-E, neurosurgical review 2. Nimodipine 4hrl to prevent vasospasm 3. BP control < 180 systolic 4. Surgical - coiling or clipping of aneurysm 5. Neuro-obs + rehab
275
Q

What is bleeding in a subdural?

A

Briding veins between cortex and venous sinuses

276
Q

Types of subdural haemorrhage

A

Acute - <72hrs, associated with trauma Subacute - 3-20 days Chronic - > 3 weeks

277
Q

Key features of subdural

A
  • bleeding between dura mater and brain surface
  • fluctuating consciousness
  • may have long hx
  • gait deterioration
  • psych symptoms / CI
278
Q

appearance of a subdural haemorrhage on CT?

A
  • crescent shaped
  • acute - homogenous hyperdensity
  • subacute/chronic - varying density
279
Q

management of subdural haemorrhage

A
  • A-E, neurosurgical review
  • anti-convulsant for 1 week (seizure prophylaxis)
  • surgical intervention - large, midline shift, neurological deficit
    • trauma craniotomy
    • burr hole + drain
  • conservative otherwise
280
Q

classical migraine features

A
  • unilateral throbbing headache, hours
  • aura
  • N&V
  • photophobia
  • phonophobia
  • still/reduction in function
281
Q

acute management of migraine

A
  • oral triptan e.g. sumitriptan
  • analgesia - OTC
  • anti-emetic e.g. metoclopramide
282
Q

long term management of migraine

A
  • conservative
    • trigger avoidance
    • OCP CI (meds r/v)
  • medical
    • indicated - multiple episodes in month
    • 1st line - propranolol (F), topiramate
    • 2nd - amitriptyline
283
Q

what is motor neurone disease

A

Motor neurone disease refers to a spectrum of heredodegenerative disease of the peripheral and central motor neurones

has UMN and LMN features

284
Q

what are the 4 types of MND?

A
  • amyotrophic lateral sclerosis
  • bulbar amyotrophic lateral sclerosis
  • progressive muscular atrophy
  • progressive lateral sclerosis
285
Q

what is the most common form of MND?

A

amyotrophic lateral sclerosis

286
Q

key features of bulbar amyotrophic lateral sclerosis

A
  • early bulbar involvement
  • dysarthria, dysphagia, wasted fasciculation tongue
  • poor prognosis
287
Q

investigations for MND

A
  • bedside - neuro examination
  • bloods - CK, ESR, anti-ganglioside AB (Exclude GBS)
  • imaging - MRI head and spine
  • special
    • nerve conduction studies
    • spirometry
288
Q

management of MND

A
  • neurology MDT
  • conservative
    • PT/OT
    • education
    • psych
  • medical
    • riluzole
    • respiratory support e.g. NIV
    • symptom management
      • cramps → quinine
      • spasticity → baclofen
      • pain Tx
289
Q

what is the medication used to treat/prolong life in MND?

A

riluzole

290
Q

what is MS?

A

MS is an autoimmune condition whereby T cell mediated immune response leads to discrete areas of demyelination within the CNS.

291
Q

what are the types of MS?

A
  • Relapsing-remitting - 80% at PC
  • Primary progressive
  • Progressive-relapsing disease
  • Secondary progressive
292
Q

what criteria is used to diagnose MS?

A

McDonald

293
Q

what investigations for MS?

A
  • bedside - neuro + eye exam
  • blood - exclude other causes
  • imaging
    • MRI brain + spine with contrast (plaques of demyelination)
  • special
    • LP - IgG oligoclonal bands, electrophoresis
294
Q

management of acute MS relapse?

A
  1. high dose glucocorticoids
  2. plasma exchange if no response to steroids
295
Q

long term management of MS

A
  • MDT neuro
  • conservative
    • PT/OT, psych, education
  • medical - disease modifying
    • beta-interferon (glatiramir) - 1st line
    • biologic - natalizumab
  • medical - symptoms
    • spasticity - baclofen
    • clonazepam - tremor
    • anti-cholinergic/catheter = bladder dysfunction
296
Q

what is the 1st line disease modifying drug for MS?

A

beta-interferon (glatiramir)

297
Q

what is a biologic used in MS?

A

natalizumab

prevents migration of leucocytes over BBB by blocking receptor

298
Q

what are the key Ab in myasthenia gravis?

A

anti-acetylcholine receptor Ab

299
Q

what is myasthenia gravis associated with? how to assess?

A

thymoma

CT chest

300
Q

what are complications of myasthenia gravis?

A
  • myasthenic crisis (respiratory failure)
  • reduced QOL
301
Q

how to differentiate myasthenia gravis from lambert eaton?

A

MG - worse with repetition

LE - better with repetition

302
Q

management of acute myasthenia gravis crisis

A
  1. A-E
  2. serial FVC monitoring + ventilatory support
  3. steroids
  4. IVIG or plasmapheresis if severe/steroid unresponsive
303
Q

long term management of myasthenia gravis

A
  • thymectomy if thymoma +
  • anti-cholinesterase inhibitor - pyridostigmine
304
Q

core features of parkinson’s

A

rest tremor

rigidity

bradykinesia

postural instability

305
Q

what are the parkinson plus syndromes?

A
  • progressive supranuclear palsy - impaired downgaze
  • multiple system atrophy - autonomic + cerebellar signs
  • corticobasal degeneratoin
  • lewy-body - fluctuating consciousness, hallucination
306
Q

what is the underlying issue in parkinsons (pathology)

A

loss of DA neurons in substantia nigra

307
Q

medical management of parkinson’s disease

A
  • Levodopa + COMT inhibitor
    • inhibitor - prevent peripheral metabolism
    • Levodopa - boost DA levels
308
Q

key features of tension headache

A
  • mild
  • bilateral, non pulsatile headache
  • tight band
  • often end of day/associated with stress
309
Q

management of tension headache

A
  • OTC pain relief - advice r.e. overuse
  • stress management
  • reassure benign condition
310
Q

TIA vs stroke?

A

TIA refers to focal neurology which resolves with no evidence of infarct on scans (MRI)

311
Q

what are the Ix for TIA

A
  • bedside
    • neuro exam + cardio
    • BP
    • ECG
  • bloods
    • FBC, U&E, LFTs, lipids, glucose
  • imaging
    • CT head (acute, current neurology)
    • diffusion weight MRI - assess for ischemia
    • carotid USS
312
Q

what is the initial management of TIA?

A
  • 300mg aspirin
  • referral
    • ongoing neuro Sx → A&E
    • TIA in last 7 days → TIA clinic within 24 hours
    • TIA > 7 days → TIA clinic within a week
313
Q

long term management of TIA

A
  • CVD risk reduction
  • anti-platelet - clopidogrel
  • treat AF if present
  • consider carotid endarterectomy
314
Q

key features of trigeminal neuralgia

A
  • severe sharp pain in trigeminal distribution
  • unilateral
  • triggers - light touch, wind, shaving
315
Q

what is the treatment for trigeminal neuralgia?

A
  • medical
    • 1st line - carbamazepine
  • surgical
    • microvascular decompression
316
Q

what is Wernicke’s encephalopathy?

A

triad of: mental status change + ophthalmoplegia + gait dysfunction

317
Q

what causes Wernicke’s encephalopathy?

A

B12 deficiency

318
Q

what is the management of Wernicke’s encephalopathy

A
  • acute
    • IV pabrinex (thiamine)
  • long term
    • reduce drinking if alcoholic
    • manage liver disease if present
319
Q

definition of achalasia

A

oesophageal motility disorder of impaired muscle activity leading to failure/incomplete relaxation of the lower oesophageal sphincter

320
Q

gold standard test for achalasia

A

oesophageal manometry

  • shows:
    • Absence of oesophageal peristalsis
    • Failure of relaxation of lower oesophageal sphincter
    • High resting lower oesophageal sphincter tone
321
Q

management of achalasia

A
  • conservative
    • reflux management strategies
    • nutritional support if required
  • medical
    • botulinum toxin injection
    • CCB/nitrates - short lasting effect
  • surgical
    • oesophageal endoscopic balloon dilatation
    • Heller’s myotomy - division of lower oesophageal sphincter
322
Q

stages of alcoholic liver disease

A

fatty liver → alcoholic hepatitis → alcoholic cirrhosis

323
Q

what LFT would suggest alcoholic liver disease?

A
  • LFTs - ↑ AST + ALT, AST:ALT > 2 → indicative of alcoholic liver disease; ↓ albumin
  • GGT - ↑↑
324
Q

what is seen on biopsy of alcoholic liver disease?

A
  • centrilobar hepatocyte balooning
  • Mallory-Denk bodies (mallory-hyaline inclusion)
  • evidence of inflammation and fibrosis
325
Q

management of alcoholic liver disease

A
  • acute
    • acute withdrawal - chlordiazepoxide + pabrinex
    • manage liver decompensation as appropriate
  • conservative
    • reduce ETOH
  • medical
    • prednisolone
  • surgical
    • liver transplant - abstinent for 3/12
326
Q

causes of anal fissure

A
  • primary
  • secondary
    • constipation
    • IBD
    • STI
    • rectal malignancy
    • birth
327
Q

management of anal fissure

A
  • conservative
    • high fibre diet + good hydration
  • medical
    • laxatives - bulk forming (ispaghula husk)
    • local anaesthetic ointment
    • GTN ointment if > 1 week + no improvement
    • Topical 2% diltiazem, specialist guidance
  • surgical
    • lateral sphincterotomy - unresponsive to medical Tx
328
Q

management of anal fissure

A
  • conservative
    • high fibre diet + good hydration
  • medical
    • laxatives - bulk forming (ispaghula husk)
    • local anaesthetic ointment
    • GTN ointment if > 1 week + no improvement
    • Topical 2% diltiazem, specialist guidance
  • surgical
    • lateral sphincterotomy - unresponsive to medical Tx
329
Q

what are the signs associated with appendicitis?

A
  • periumbilical pain → RIF
  • Rovsing’s sign - palpation of LIF produces pain in RIF
  • Psoas sign - RIF pain with extension of right hip
  • Cope sign - pain on flexion + internal rotation of hip (occurs if appendix near obturator internus)
330
Q

differentials for appendicitis?

A
  • Gynae - ovarian cyst accident, ectopic, PID
  • Renal - ureteric stone, UTI
  • GI - obstruction, strangulated hernia, IBD
  • Urological - testicular torsion, epididymo-orchitis
  • Other - DKA, pneumonia, porphyria
331
Q

what score is used for appedicitis?

A

Alvarado

332
Q

what is the management of appendicitis?

A
  • Medical
    • Septic 6 - if required
    • IV antibiotics - cefuroxime, metronidazole
    • NBM + IVF + analgesia + anti-emetic
  • Surgery
    • Laparoscopic appendicectomy (1st line)
333
Q

antibodies associated with autoimmune hepatitis

A
  • type 1 - anti-smooth muscle Ab, ANA
  • type 2 - anti liver/kidney microsomal Ab type 1
334
Q

what are the nerves for the ankle reflex?

A

S1/S2

335
Q

nerves for patella reflex?

A

L3/L4

336
Q

nerve for triceps reflex?

A

C7-C8

337
Q

nerve for biceps reflex?

A

C5/C6

338
Q

supinator reflex (brachioradialis) nerve root

A

C5/C6

339
Q

management of autoimmune hepatitis

A
  • Medical
    • Induction → steroids
    • Maintenance therapy → azathioprine
    • Vaccinate against hepatitis A and B, test prior to vaccination
    • surveillance for HCC → USS + serum AFP
  • Surgical
    • Liver transplant - terminal stages, recurrence after transplant occurs in some
340
Q

what is Barret’s oesophagus?

A

Barrett’s oesophagus refers metaplasia of squamous epithelium to columnar epithelium following chronic acid exposure

341
Q

Ix for Barret’s

A
  • Gi examination
  • H. pylori testing
  • endoscopy + biopsy - histological diagnosis
342
Q

complications of Barret’s oesophagus

A

Oesophageal adenocarcinoma, oesophageal stricture

343
Q

management of Barret’s oesophagus

A
  • Conservative - all
    • ↓ ETOH intake, normal weight
    • meds r/v - ↓ gastric protection or affecting oesophageal motility
    • Reflux prevention
  • No dysplasia
    • Endoscopy every 2-5 years
  • Low grade dysplasia
    • High dose PPI (BD)
    • Endoscopic surveillance every 6/12, quandrantic biopsies every 1cm
  • High grade dysplasia
    • Endoscopy every 3/12
    • Treat any visible lesions → resection (photodynamic, radiofrequency or laser)
344
Q

what is cholangiocarcinoma?

A
  • cancer of biliary tree - usually extrahepatic
  • most common at bifurcation of hepatic duct
  • 95% adenocarcinoma
345
Q

what is the tumour marker for cholangiocarinoma?

A

CA19-9

346
Q

management of cholangiocarcinoma

A
  • Management under MDT
  • Curative treatment
    • Surgical
      • Complete surgical resection - gives definitive treatment
      • Intrahepatic and tumours at hepatic bifurcation → partial hepatectomy and reconstruction of biliary tree
      • Distal common duct tumours - pancreaticoduodenectomy (Whipple’s procedure)
    • Radiotherapy
  • Palliative treatment
    • ERCP stenting - dilate bile duct to relieve obstruction
    • Surgical bypass procedures
    • Chemotherapy
347
Q

what is cirrhosis?

A

Cirrhosis refers to the diffuse fibrosis and structural abnormality of liver characteristic of chronic liver disease

  • impairment of Liver function
348
Q

major causes of cirrhosis

A

Alcoholic liver disease

  • Non-alcoholic fatty liver disease
  • Chronic viral hepatitis
  • Autoimmune hepatitis
  • Biliary causes - PBC, PSC
  • Genetic causes - haemochromatosis, Wilson’s disease, alpha-1 antitrypsin deficiency,
  • Medications
  • Budd-Chiari syndrome
349
Q

liver panel bloods

A
  • LFTs
  • bone profile + albumin
  • FBC + clotting
  • U&E - hepatorenal
  • cause:
    • viral hepatitis serology
    • iron studies
    • auto-antibodies - smooth muscle, anti-mitochondrial, etc
    • aceruloplasmin
    • alpha-1 anti-trypsin
350
Q

what are the components of the Child Pugh score?

A
  • Albumin
  • Bilirubin
  • Clotting - PT/INR
  • Distended abdomen - Ascites
  • Encephalopathy

graded A-C with C most severe, high risk for variceal bleed if B/C

351
Q

what is coeliac disease?

A

T cell mediated inflammation AI disease due to sensitivity to gluten components (prolamin) resulting in villous atrophy + malabsorption

352
Q

investigations for coeliac disease

A
  • bedside
    • stool MC&S - exclude infection
  • bloods
    • total IgA
    • IgA anti-TTG, and IgA anti-endomysial
    • FBC, U&E/bone profile, LFT, iron, B12, folate
  • imaging
  • specialist
    • jejunal/duodenal biopsy - villous atrophy, crypt:villous ratio < 2:1
353
Q

what are the biopsy features of coeliac?

A
  • villous atrophy, ↑ intraepithelial lymphocytes, crypt hyperplasia
    • ↓ crypt: villous ratio ( < 2:1)
354
Q

what do patients going for endoscopy for coeliacs need to do?

A

eat gluten for 6 weeks

355
Q

management of coeliac

A
  • conservative
    • gluten exclusion
  • medical
    • screening for other AI disease
    • management malnutrition complications e.g. Fe2+ supplements
356
Q

what cancer is coeliac a RF for?

A

T cell lymphoma (enteropathy associated T cell lymphoma)

357
Q

what are the familial syndrome associated with colorectal cancer?

A
  • familial adenomatosis polyposis - APC gene
  • Gardner’s
  • Peutz-Jegher’s
  • hereditary non-polyposis colorectal cancer (NPCC/Lynch syndrome)
358
Q

what runs through the cavernous sinus?

A
  • Abducens nerve (CN VI)
  • Carotid plexus (post-ganglionic sympathetic nerve fibres)
  • Internal carotid artery (cavernous portion)
359
Q

what runs lateral to the cavernous sinus?

A
  • Oculomotor nerve (CN III)
  • Trochlear nerve (CN IV)
  • Ophthalmic (V1) and maxillary (V2) branches of the trigeminal nerve
360
Q

investigations for colon cancer?

A
  • bedside
    • GI examination + DRE
    • faecal immunohistochemistry test
  • bloods
    • CEA - tumour marker
    • routine
  • imaging
    • barium enema - apple core stricture
    • CT colonoscopy - if unable to do actual
    • Staging CT (CAP)
  • specialist
    • colonoscopy + biopsy = gold standard for diagnosis
361
Q

what is the tumour marker for colon cancer?

A

carcinoembryonic antigen (CEA)

362
Q

describe the 2WW for colorectal cancer

A
  • > 40 + unexplained weight loss + abdominal pain
  • > 50 + unexplained PR bleeding
  • > 60 with IDA or changes in bowel habit
  • +ve occult blood in faeces
363
Q

describe the screening for colorectal cancer

A
  • Kit sent at: 56 years, then every 2 years from 60-74
  • Colonoscopy if +ve
  • ↓ risk of dying from bowel cancer by 16%
  • Offer another FIT to those with PR bleeding, IDA, CIBH who don’t meet 2WW
364
Q

describe the Duke’s criteria for colorectal cancer

A
365
Q

what is the management of colorectal cancer?

A
  • Management under MDT
  • curative
    • surgery → Resection
      • Type of surgery is depending on region affected by malignancy
    • + chemotherapy (before or after depends on staging)
    • + neoadjuvant radiotherapy - rectal cancers
  • Non-surgical treatments
    • FOLFOX or FOLRIR chemotherapy regime - unsuitable for surgery
  • Stenting - palliative procedure for symptomatic relief
366
Q

what are the surgeries for colorectal cancer?

A
  • No rectal-disease
    • Right hemicolectomy - caecum + ascending colon
    • Left hemicolectomy - distal transverse colon descending colon
    • Sigmoid colectomy - sigmoid colon
  • Rectal disease
    • Anterior resection - tumour > 8cm from anal canal or involving proximal 2/3 of rectum
    • Abdomino-perineal resection - tumour < 8cm from anal canal or involves distal 1/3 of rectum
367
Q

key histological features of Crohn’s

A
  • transmural inflammation
  • goblet cells
  • non-caseating granulomas
368
Q

features of crohn’s

A
  • mouth → anus
  • skip lesions
  • bowel obstruction
  • fistula
  • usually non bloody diarrhoea
  • arthritis
  • erythema nodosum
  • pyoderma gangrenosum
369
Q

features of UC

A
  • continuous disease
  • no inflammation beyond submucosa
  • crypt abscess
  • bloody diarrhoea
  • PSC
  • uveitis
  • colorectal cancer
  • erythema nodosum
  • pyoderma gangrenosum
370
Q

what is the genetic link with crohn’?

A

CARD15

371
Q

Ix for Crohn’s

A
  • bedside
    • GI examination + PR
    • faecal calprotectin
  • bloods
    • FBC, CRP, ER, LFT, bone, TPMT
  • imaging
    • CT abdomen
  • specialist
    • ileocolonoscopy + biopsy - gold standard Dx
372
Q

management of Crohn’s

A
  • conservative
    • smoking cessation
    • education + IBD nurse, nutrition
  • medical
    • remission - corticosteroids
    • maintenance (>2/yr) - azathioprine, methotrexate
    • biologic - TNF-alpa (infliximab)
    • symptomatic Mx
  • surgical
    • resection + stoma as required
373
Q

treatment of pyoderma gangrenosum?

A

topical or systemic steroids

ciclosporin if resistant

374
Q

types of diverticular disease

A
  • diverticula - outpouching of gut wall
  • diverticulosis - asymptomatic
  • diverticular disease - symptomatic
  • diverticulitis - inflammation + bleeding
375
Q

RF for diverticulitis

A

older age, low dietary fibre, obesity

376
Q

complications of diverticulitis

A
  • recurrence
  • perforation
  • haemorrhage
  • abscess
  • stricture/obstruction
  • fistula
377
Q

management of diverticulosis?

A

high fibre diet + fluid intake

laxatives if ongoing constipation

378
Q

management of diverticular disease

A
  • high fibre diet
  • bulk forming laxatives
  • analgesia
  • anti-spasmodic - relief cramping if required
379
Q

management of diverticulitis

A
  • admission if severe
  • antibiotics
    • co-amoxiclav (IV or PO)
    • cef + met IV (2nd)
  • transfusion if required
  • angiography + embolectomy for haemorrhage if distal branch
  • surgical
    • Hartmann’s - emergency
    • resection + stoma elective
380
Q

what are the types of gallstone?

A
  • cholesterol (90%)
  • pigment - associated with haemolysis
  • mixed stones
381
Q

RF for gallstone disease

A

fat, fair (Caucasian), fertile, forties, female, FHx

382
Q

management of biliary colic

A
  1. Analgesia
  2. Lifestyle advice - Low fat diet, maintain normal weight, ↑ exercise
  3. Elective laparoscopic cholecystectomy - within 6 weeks of 1st PC
383
Q

acute cholecystitis vs ascending cholangitis

A
  • acute cholecystitis - no jaundice
  • ascending cholangitis - jaundice, transaminases deranged, CBD obstruction
384
Q

what is mirizzi syndrome?

A

stone in Hartmann’s pouch of gallbladder or in cystic duct → can compressed adjacent common hepatic duct causing an obstructive jaundice despite no stone in the CBD

385
Q

what is gallstone ileus?

A

after formation of a cholecystoduodenal fistula → gallstone passes into bowel and impacts terminal ileum → small bowel obstruciton

386
Q

what are features of mild vs moderate vs severe cholecystitis

A
  • mild - stable, short Hx
  • moderate - majority, raised WCC, palpable mass in RUQ, > 72hrs, localised inflammation
  • severe - resistant hypotension, lowered GCS, oliguria, hepatic dysfunction, hypoxia
387
Q

management of mild cholecystitis

A
  • oral antibiotics
  • analgesia (OTC)
  • early laparoscopic cholecystectomy - 1 week within 1st PC
388
Q

management of moderate cholecystitis

A
  • A-E + admit + general surg. pt Tx
  • IV antibiotics
  • laparoscopic cholecystectomy - within 1 week (NICE)
  • percutaneous cholecystostomy - IR, unfit for surgery + not responding to Abx, drain insertion + delayed cholecystectomy (6 weeks)
389
Q

management of severe cholecystitis

A
  • as moderate + ICU
  • more likely for drain + delayed cholecystectomy
  • open cholecystectomy if: mass, sig. inflammation or bleeding, pregnant
390
Q

major organisms of ascending cholangitis?

A

E. coli, klebsiella, enterococcus

391
Q

what is Charcot’s triad? what for?

A

RUQ pain + fever + jaundice

ascending cholangitis

392
Q

management of ascending cholangitis

A
  • A-E, resuscitation
  • IV antibiotics
  • ERCP (1st line)
  • percutaneous transhepatic cholangiography - T-tube for drainage (2nd)
  • cholecystectomy - definitive
393
Q

indications for ERCP

A
  • Choledocholithiasis
  • Acute pancreatitis
  • Chronic pancreatitis (dilatation or stent placement)
  • Lesion within biliary system that requires biopsy
  • Dilatation of benign stricture
  • Manometry reading for sphincter of Oddi dysfunction
394
Q

types of gastric cancer

A
  • adenocarcinoma (95%)
    • intestinal type - smoking, chronic gastritis, lesser curve
    • diffuse type - signet cell CA, leather bottle stomach
  • SCC
  • lymphoma/MALT - H.pylori
395
Q

what are some associated conditions with gastric cancer

A
  • GI - pernicious anaemia, H. pylori, atrophic gastritis, adenomatous polyps
  • blood group A
  • smoking
  • diet - high nitrates, high salt, low Vit C
  • nitrosamine exposure
396
Q

where does gastric cancer usually affect?

A

antrum

397
Q

investigations for gastric cancer

A
  • bedside
    • GI examination
  • bloods
    • FBC, LFTs
  • imaging
    • endoscopic USS - assess depth
    • CT CAP
  • specialist
    • gastroscopy + biopsy
398
Q

2WW for gastric cancer

A

2WW appointment:

  • Upper abdominal mass

Urgent upper GI endoscopy with 2/52 if:

  • Dysphagia
  • > 55 + weight loss + one of: upper abdominal pain, reflux, dyspepsia
399
Q

management of gastric cancer

A
  • MDT
  • surgical
    • early T1a - endoscopic mucosal resection
    • locally invasive - partial/total gastrectomy + reconstruction + neoadjuvant chemo
  • medical - nutritional
  • palliative - majority by time diagnosed
400
Q

causes of GORD

A
  • Lower oesophageal sphincter incompetence
  • Hiatus hernia
  • Loss of oesophageal peristaltic function
  • obesity
  • Gastric factors - gastric acid hypersecretion, slow gastric emptying
  • Patient factors - smoking, alcohol, pregnancy
  • medications (TCA, anti-cholinergic, nitrates)
  • Associated conditions - systemic sclerosis, H. pylori infection
401
Q

Ix for GORD

A
  • bedside- GI exam
  • bloods - FBC
  • imaging
  • specialist
    • endoscopy (OGD) + biopsy
    • H. pylori (urea breath, stool antigen)
    • barium swallow - if ? hernia
    • 24 hour pH monitoring - gold standard, uncommon
402
Q

management of GORD

A
  • conservative
    • medication r/v
    • raise bed
    • smoking cessation, low fat, smaller meals
    • avoid triggers
  • medical
    • acute - anti-acid, alginate
    • PPI
403
Q

management of dyspepsi

A
  • dyspepsia = reflux, no OGD, clinically diagnosed
  • review meds
  • trial full dose PPI 4 weeks or “test and treat” H. pylori
  • treatment resistant → non urgent OGD
404
Q

what should be done after H. pylori eradication treatment in ulcer patients?

A

test of cure 6-8 weeks after treatment

405
Q

what is the treatment of H. pylori

A
  • PPI + amoxicillin + clarithromycin/metronidazole BD 7 days
  • pen allergic = PPI + clarithromycin + metronidazole BD 7 days
406
Q

management of GORD

A
  • reflux + histological Dx after OGD
  • full dose PPI 4-8 weeks
  • recurrent → high dose PPI
  • refractory + sever → Nissen fundoplication
407
Q

treatment of C. Diff

A
  • 1st line - oral vancomycin 10/7 or oral fidaxomicin
  • 2nd line - oral vancomycin + IV metronidazole (1st if severe, life-threatening)
408
Q

key facts of haemochromatosis including issue

A
  • hereditary, AR
  • increased intestinal iron absorption → iron overload
  • HFE C282Y Chr 6
409
Q

key Ix for haemochromatosis

A
  • FBC
  • iron studies - raised ferritin, transferrin saturation, low transferrin, low TIBC
  • LFTs - deranged
  • CRP - exclude acute ferritin
  • HbA1c, hormone levels
410
Q

complications of haemachromatosis

A
  • Liver fibrosis, cirrhosis, hepatocellular carcinoma
  • Severe myocardial siderosis, cardiac dysfunction
  • DM
  • Skin hyperpigmentation
  • Arthropathy
411
Q

management of haemochromatosis

A
  • venesection - 500mg (450mg iron) 1-2 x week; aim ferritin < 50 ug/L
  • desferrioxamine
  • liver transplant
  • screening for HCC, monitor ferritin levels
412
Q

what are the types of haemorrhoid?

A

internal - above dentate

external - below dentate line

413
Q

what are the grades of haemorrhoids?

A
  1. Project into lumen of canal but don’t prolapse
  2. Prolapse on straining but spontaneously reduce
  3. Prolapse on straining, require manual reduction
  4. Prolapsed and incarcerated, cannot be reduced
414
Q

what is the management of haemorrhoids?

A
  • conservative - minimise straining, fibre + fluid
  • medical
    • laxative
    • analgesia - LA + steroid
  • minor procedure
    • rubber band ligation
    • injection sclerotherapy
    • photocoagulation
  • surgical
    • haemorrhoidectomy
415
Q

RF for hepatocellular carcinoma

A
  • hep B and hep C - chronic
  • alcoholism
  • haemochromatosis
  • PBC
  • aflatoxins
  • cirrhosis
416
Q

Ix for hepatocellular carcinoma

A
  • LFT
  • clotting
  • liver screen
  • AFP
  • abdominal USS + biopsy
417
Q

tumour marker for hepatocellular carcinoma

A

alfa-fetoprotein

418
Q

how to differentiate groin hernia using pubic tubercle?

A

superior + medial → inguinal

inferior and lateral → femoral

419
Q

hernia superior + medial to pubic tubercle

A

inguinal

420
Q

hernia inferior and lateral to pubic tubercle

A

femoral hernia

421
Q

differentiating inguinal hernias related to inferior epigastric vessels

A

direct = medial

indirect = lateral

422
Q

differentiating indirect vs direct clinically

A

pressure on deep inguinal ring and assess cough impulse

  • direct = protrudes
  • indirect - no protrusion
423
Q

descriptions of hernia

A
  • Reducible hernia - uncomplicated
  • Irreducible or incarcerated - contents of hernia cannot be returned to their original cavity
  • Obstruction - bowel lumen becomes obstructed
  • Strangulated - compression of hernia which cannot be reduced leads to blood supply compromise, leading to the bowel becoming ischaemia
424
Q

RF for femoral hernia

A

female, pregnancy, raised intra-abdominal pressure, older age

425
Q

RF for inguinal hernia

A

male, increasing age, raised intra-abdominal pressure, obesity

426
Q

management of inguinal hernia

A
  • non-surgical/conservative
    • small + no sx → watchful wait
    • RF modification
  • surgical
    • open mesh repair - primary unilateral
    • laparoscopic repair - bilateral, recurrent, primary unilateral, female
427
Q

management of femoral hernia

A
  • surgical - urgent, within 2 weeks
    • low or high approach repair relative to inguinal ligament
    • repair defect with suture or mesh
    • high approach preferred for emergencies
428
Q

types of hiatus hernia

A
  • sliding
    • 80%, gastro-oesophageal junction moves up into chest
  • rolling
    • 20%, stomach herniates into chest (upward movement of fundus)
429
Q

management of hiatus hernia

A
  • conservative
    • elevate head at night, small meals, avoid alcohol, smoking cessation
  • medical
    • PPI
  • surgical
    • Nissen fundoplication
430
Q

what is acute mesenteric ischaemia?

A
  • acute compromise to blood flow, usually emboli in arteries, usually small bowel
    • Life-threatening, surgical emergency
    • Sudden onset intestinal hypoperfusion
    • Most common site → superior mesenteric artery
431
Q

what is chronic mesenteric ischaemia

A
  • “intestinal angina”, ↓ blood supply which gradually deteriorates over time, usually due to atherosclerosis
    • Common sites - coeliac trunk, SMA, IMA
432
Q

what is ischaemic colitis?

A

acute but transient compromise in blood flow to large bowel. Can result in inflammation, ulceration and haemorrhage

433
Q

causes of acute mesenteric ischaemia

A
  • thrombus due to atherosclerotic plaque
  • emboli - AF, aneurysm
  • non-occlusive e.g. cardiogenic shock
  • venous occlusion + congestion
434
Q

definitive diagnostic test for acute mesenteric ischaemia>

A

CT abdomen with IV contrast (CT angiogram) - triple phase scan with thin slices in arterial phase → definitive diagnosis of acute mesenteric

435
Q

management of acute mesenteric ischaemia

A
  • A-E, admit, surgical Tx + referral
  • surgical
    • necrotic bowel resection
    • re-vascularisation - IR + angioplasty 1st line
436
Q

management of chronic mesenteric ischaemia

A
  • conservative - cardio RF modification
  • medical
    • anti-platelet + statin
    • nutritional optimisation
  • surgical
    • EVAR - angioplasty and stenting of mesenteric vessels
    • open re-vascularisation (endartectomy or bypass)
437
Q

management of ischaemic colitis

A
  • supportive care incl. transfusion
  • broad spec IV Abx
  • surgery - if generalised peritonitis, perforation, ongoing bleeding, failed conservative Tx
438
Q

causes of small bowel obstruction?

A

HAT

Hernia

Adhesions

Tumour

439
Q

causes of large bowel obstruction?

A

CVS

cancer

volvulus

strictures (diverticular > IBD)

440
Q

pathophysiology in SBO

A

The blockage → proximal dilation → perforation. In acute cases hyperperistalsis distal to obstruction occurs leading to diarrhoea.

441
Q

pathophysiology of LBO

A

Colon proximal to obstruction dilates → increased colonic pressure → mesenteric blood flow reduced → mucosal oedema. If arterial supply is compromised → ulceration and necrosis. Perforation eventually occurs

442
Q

management of sigmoid volvulus

A
  • decompression with flexible sigmoidoscope
  • open/laparoscopic repair if fails
443
Q

management of SBO

A
  • conservative
    • dip + suck
    • water soluble contrast study - if no contrast in colon after 6 hrs → surgery
  • surgery
    • adhesionlysis, resection, hernia repair
444
Q

what are the functional bowel obstructions?

A

paralytic ileus

pseudo-obstruction (large bowel)

445
Q

what is the criteria for IBS?

A

Manning criteria for IBS - NICE recommended

  • At least 6/12
  • Abdominal discomfort of pain relieved by defecation or associated with altered bowel habit or stool form
  • At least 2 of:
    • Altered stool passage e.g. straining or urgency
    • Abdominal bloating
    • Symptoms made worse by eating
    • Passage of mucus
446
Q

how to diagnose IBS?

A
  • diagnosis of exclusion
  • conservative
    • diet, review fibre, low FODMAP
  • medical - symptomatic
    • anti-spasmodic - buscopan
    • prokinetic (metoclopramide)
    • anti-diarrhoea - loperamide
    • laxative
  • psych - CBT, relaxation
447
Q

what is the most common cause of amoebic liver abscess? + treatment

A

Entamoeba histolytica

metronidazole + drainage/resection

448
Q

what scores are used to assess for liver transplant?

A

MELD score - chronic liver disease

King’s college hospital criteria - acute liver failure

449
Q

factors in Child Pugh score

A

Albumin

Bilirubin

Clotting (INR)

Distended abdomen (ascites)

Encephalopathy (present, grade)

A-C, associated with life expectancy

450
Q

complications of liver failure

A
  • infection - usually bacterial
  • cerebral oedema + high ICP
  • bleeding
  • hypoglycaemia
  • SBP
  • portal HTN
  • variceal bleeding
  • hepatorenal syndrome
451
Q

management of ascites?

A
  • dietary salt + fluid restrict
  • spironolactone + furosemide
  • therapeutic paracentesis
  • IV albumin
  • < 15 g/L prophylactic Abx (ciprofloxacin)
  • TIPSS procedure
452
Q

when to give ABx in ascites? and which?

A

< 15 g/L protein in ascitic fluid or previous SBP

ciprofloxacin

453
Q

management of SBP

A

broad spectrum IV Abx

454
Q

describe serum-ascites albumin gradient

A

> over 11g/L = transudate

< 11 g/L = exudate

455
Q

causes of ascitic transudate

A
  • > 11g/L SAAG
  • portal HTN
    • cirrhosis, acute liver failure, liver met/cancer
  • RH failure
  • constrictive pericarditis
  • budd-chiari
  • portal vein thrombosis
456
Q

causes of ascitic exudate

A
  • SAAG < 11g/L
  • low albumin - nephrotic, malnutrition
  • peritoneal cancers
  • TB peritonitis
  • pancreatitis
  • biliary ascites
  • post-op lymphatic leak
457
Q

management of hepatic encephalopathy

A
  • conservative
    • avoid sedatives
    • 30 degree head tilt
  • medical
    • lactulose
    • rifaximin (secondary prophylaxis)
    • IV mannitol
458
Q

management of variceal bleeding

A
  • A-E resuscitation
  • Blood transfusion
  • Vitamin K, FFP and platelet transfusions as required
  • Terlipressin - splanchnic vasoconstriction, ↓ portal pressure and bleeding
  • Broad spectrum Abx
  • Sengstaken-Blakemore tube -
  • Urgent OGD ideally within 24 hrs (band, sclerotheraoy)
459
Q

long term prophylaxis of variceal bleeding

A

propranolol (beta blocker)

460
Q

stages of non-alcoholic liver disease

A

steatosis → steatohepatitis (NASH) → liver fibrosis → cirrhosis

461
Q

what test is used to assess for liver fibrosis?

A

enhanced liver fibrosis blood test

hyaluronic acid + procollagen III + tissue inhibitor of metalloproteinase 1

462
Q

gold standard for diagnosis of NASH

A

USS guided liver biopsy (histological diagnosis)

463
Q

management of NASH

A
  • refer to HBP team if fibrosis/end stage liver disease
  • healthy weight (weight loss)
  • healthy diet
  • avoid ETOH and hepatotoxic drugs
  • CVD risk factor modification
464
Q

types of oesophageal cancer?

A
  • squamous cell - upper oesophagus, aggressive
  • adenocarcinoma - most common UK, lower ⅓, reflux
465
Q

1st line for focal seizures

A

carbamazepine or lamotrigine

466
Q

1st line for absence seizure

A

sodium valproate or ethiosuximide

467
Q

1st line for tonic clonic seizures

A

sodium valproate or lamotrigine

468
Q

1st line for myoclonic seizures

A

sodium valproate

469
Q

1st line for atonic seizures

A

sodium valproate or lamotrigine

470
Q

what is oesophageal adenocarcinoma associated with?

A

barrett’s oesophagus, GORD, smoking, high fat intake

471
Q

Ix for oesphageal cancer

A
  • bedside
  • blood - baseline bloods
  • imaging
    • endoscopic USS - assess depth of invasion
    • staging CT CAP + neck
  • specialist
    • OGD + biopsy - gold standard, diagnostic
    • staging laparoscopy - junctional tumor for intra-peritoneal metastases
472
Q

2WW rules for urgent OGD for oesophageal cancer

A
  • Dysphagia
  • > 55 years + weight loss + 1 of: abdominal pain, reflux, dyspepsia
473
Q

management of oesophageal cancer

A
  • MDT
  • curative
    • adenocarcinoma - surgery + chemo/radiotherapy
      • oesophagectomy with reconstruction
    • SCC - chemoradiotherapy
    • intense nutritional support - jejunostomy
  • palliative - majority
    • stent
    • chemo/radiotherapy
    • nutritional support including RIG
474
Q

types of pancreatic cancer

A
  • ductal adenocarcinoma = 90%, from exocrine region
  • exocrine tumours
  • endocrine tumours - derived from islet cell, better prognosis
475
Q

where is the most common site for pancreatic cancer?

A

head

476
Q

Rf for pancreatic cancer

A
  • smoking
  • chronic pancreatitis
  • diet - high red meat
  • FHx - MEN, HNPCC, FAP, VHL
  • late onset DM
477
Q

Ix for pancreatic cancer

A
  • bedside
  • bloods - baseline
    • CA19-9 (tumour marker), clotting
  • imaging
    • abdominal USS
    • CT imaging with panreatic protocol (HR) - gold standard for prelim diagnosis
    • endoscopic USS + biopsy
478
Q

2WW for pancreatic cancer

A

> 40 + jaundice

479
Q

management of pancreatic cancer

A
  • MDT
  • curative
    • radial resection
    • adjuvant chemotherapy
  • palliative - majority
    • chemotherapy
    • symptom control - biliary stenting, Creon, pain management (coeliac plexus block)
480
Q

what are the radical resections for pancreatic cancer?

A
  • Pancreaticoduodenectomy (Whipple’s) + regional lymphadenectomy → if head of pancreas cancer
    • Remove head of pancreas, antrum of stomach, 1st + 2nd part of duodenum, CBD, gallbladder
  • Distal pancreatectomy + splenectomy + regional lymphadenectomy → if body/tail of pancreas cancer
    • High morbidity associated
481
Q

causes of acute pancreatitis

A

GET SMASHED (mnemonic)

  • Gallstones
  • Ethanol
  • Trauma
  • Steroids
  • Mumps
  • Autoimmune (PAN, SLE)
  • Scorpion bite
  • Hyperlipidaemia, hypothermia, hypercalcaemia
  • ERCP and emboli
  • Drugs - azathioprine, NSAIDs, diuretics
482
Q

ix for pancreatitis (acute)

A
  • bedside - exam
  • blood
    • VBG
    • bone profile - Calcium
    • LFT + albumin
    • clotting
    • serum amylase/lipase
      • lipase - more sensitive
  • imaging
    • abdominal USS - ?gallstones
  • specialist
    • calculate glasgow score
483
Q

when should a contrast enhanced CT be done in pancreatitis and why?

A

6-10 days after PC

assess for severity - indicated if persistent inflammatory response or organ failure

e.g. detect pseudocyst

484
Q

describe the glasgow criteria for pancreatitis

A
  • PaO2 < 8kPa on ABG
  • Age > 55 years
  • Neutrophilia – WBC > 15x 109/L
  • Calcium <2mmol/L
  • Renal function – urea >16mmol/L
  • Enzymes – LDH >600iu/L or AST > 200 iu/L
  • Albumin < 32 g/L (serum)
  • Sugar – blood glucose > 10mmol/L
485
Q

complications of acute pancreatitis

A
  • Chronic pancreatitis
  • DIC, ARDs, hypocalcaemia, hyperglycaemia
  • Pancreatic necrosis, pancreatic pseudocyst, pancreatic abscess, haemorrhage
486
Q

management of acute pancreatitis

A
  • A-E, admit, glasgow > 3 ITU
  • conservative
    • UO
  • medical
    • treat underlying e.g. ERCP
    • aggressive IV fluid resuscitation
    • NG if sig. vomit else oral intake as tolerated
    • opioid analgesia
    • broad spec Abx if confirmed necrosis
  • surgical
    • pancreatic debridement
487
Q

management of pancreatic pseudocyst

A
  • 50% spontaneously resolve, give up to 12 weeks to resolve
  • If there after 6/52 unlikely to resolve → surgical debridement or endoscopic drainage often into stomach
488
Q

causes of chronic pancreatitis

A
  • Chronic alcohol excess (80%)
  • Idiopathic (15-20%)
  • Cystic fibrosis
  • Obstruction - pancreatic cancer
  • Recurrent acute pancreatitis
  • Metabolic - ↑ triglycerides, hypercalcaemia
  • Autoimmune - autoimmune pancreatitis, SLE
489
Q

what is chronic pancreatitis?

A

caused by chronic inflammation and fibrosis of both the exocrine and endocrine components of the pancreas

490
Q

Ix for chronic pancreatitis

A
  • baseline bloods
  • glucose/HbA1c
  • faecal elastase
  • AXR/CT - pancreatic calcification
  • secretin stimulation test - only if dx uncertain
491
Q

management of chronic pancreatitis

A
  • conservative
    • reduce alcohol
  • medical
    • analgesia + coeliac plexus block
    • insulin
    • Creon - exocrine enzyme replacement
    • A, D, E, K vitamin supplement
  • surgical
    • pancreatectomy
492
Q

duodenal vs gastric ulcer

A
  • duodenal more common 4:1
  • worse after eating - gastric
  • better with food, worse with fast/night → duodenal
493
Q

tests for peptic ulcer disease

A
  • bedside
    • H. pylori carbon 13 urea breath test
    • H. pylori stool antigen
  • blood - FBC, CRP
  • imaging
    • erect CXR in acute
  • specialist
    • upper GI endoscopy
494
Q

prep urea breath test for h. pylori what can’t patients do?

A

No Abx or bismuth products for 4 weeks and no PPI for 2 weeks before H. Pylori diagnosis

495
Q

complications of peptic ulcer disease

A

gastric outlet obstruction, upper GI bleed, perforation

496
Q

acute management of peptic ulcer disease

A
  • A-E approach
  • Urgent endoscopy
    • PPI after endoscopy
  • Urgent intervention angiography with trans-arterial embolization or surgery
    • If endoscopic procedures fail or too unstable for endoscopy
497
Q

management of peptic ulcer disease

A
  • conservative
    • stop smoking, less ETOH
    • diet - avoid trigger, healthy, weight loss
    • medication r/v
    • stress management
  • medical
    • 4-8 weeks full dose PPI
    • H. pylori eradication if +ve
  • surgical
    • partial gastrectomy in severe/emergencies
498
Q

what drugs are associated with peptic ulcer disease

A

NSAIDS, steroids, bisphosphonates, potassium supplements, SSRIs, cocaine

499
Q

management of peri-anal fistula

A
  • asymptomatic - watch and wait
  • surgical
    • drainage seton (1st line if trans-sphinteric)
    • fistulotomy (1st line if low, submucosal fistula)
500
Q

definition of portal hypertension

A

portal HTN is abnormally high pressure in hepatic portal vein > 10 mmHg

501
Q

causes of portal HTN

A
  • pre-hepatic
    • thrombosis (splenic vein)
    • extrinsic compression
  • intra-hepatic
    • cirrhosis
    • idiopathic portal HTN
  • post-hepatic
    • Budd-chiari
    • right heart failure
    • constrictive pericarditis
502
Q

management of portal HTN

A
  • conservative
    • salt restriction _ fluid
  • medical
    • spiro + furo
    • non-selective beta blocker - propranolol
    • terlipressin - acute
  • surgical
    • transjugular intrahepatic portosystemic shunt (TIPSS)
    • liver transplant
503
Q

definition of primary biliary cirrhosis

A

Autoimmune inflammatory destruction of the intrahepatic bile ducts which results in cholestasis and progressive development of cirrhosis over many years.

504
Q

antibody for primary biliary cirrhosis

A

anti-mitochondrial

505
Q

treatment of PBC

A
  • conservative
    • avoid systemic oestrogen
  • medical
    • ursodeoxycholic acid - can induce remission
    • cholestyramine - itch tx
  • surgical - transplant (liver)
506
Q

what is primary sclerosing cholangitis?

A

chronic cholestatic disorder characterised by inflammation and fibrosis of intrahepatic and extrahepatic bile ducts, resulting in multifocal biliary strictures

507
Q

what is PSC associated with?

A

IBD esp. UC

508
Q

antibodies associated with PSC

A

pANCA

anti-smooth muscle

509
Q

Ix for PSC

A
  • LFT
  • anti-smooth muscle, pANCA
  • biliary tree USS - duct dilation
  • ERCP/MRCP - beading of bile ducts
  • biopsy - onion skinning fibrosis
510
Q

management of PSC

A
  • yearly screening for malignancy
  • cholestyramine - manage pruritus
  • stricture dilation via ERCP
  • liver transplant
511
Q

what is ulcerative colitis?

A

Ulcerative colitis is the most common form of inflammatory granulomatous bowel disease

  • Characterised by diffuse continual mucosal inflammation of the large bowel, beginning in rectum and spreading proximally
512
Q

investigations of UC

A
  • bedside - faecal calprotectin
  • bloods - FBC, CRP, U&Es, LFTs, clotting
  • imaging
    • AXR - lead pipe colon, thumbprinting, toxic megacolon
    • barium - lead-pipe
  • specialist
    • colonoscopy + biopsy = diagnostic
513
Q

how is UC severity graded in acute?

A

truelove and witt score

514
Q

management of UC

A
  • Medical
    • Inducing remission - severe disease
      • IV fluid resuscitation
      • Nutritional support
      • Prophylactic heparin - VTE prevention
      • IV corticosteroids + immunosuppression (ciclosporin or 5-ASA suppositories)
    • Inducing remission - mild-moderate
      • topical/oral 5-ASA (aminosalicylates)
      • + oral prednisolone
      • Oral tacrolimus
    • Maintaining remission
      • 1st line - 5-ASA’s e.g. mesalazine or sulfasalazine
      • 2nd line - azathioprine
  • Colonoscopic surveillance - if > 10 yrs with > 1 segment of bowel affected
  • Surgical
    • Segmental bowel resection + stome
    • Total proctocolectomy - curative, forms end-ileostomy
515
Q

what is the most common renal stone?

A

calcium oxalate

516
Q

what stone is associated with haemolysis?

A

uric acid

renal stone

517
Q

what bacteria is associated with staghorn calculus

A

proteus

made of struvite

IK6 - Exams (24 decks)

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