Corrections 1 Flashcards by Esme Cosham

Why is a rhythm control approach ofter preferred for AF in younger patients?

This eliminates the need to take medications long term.

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Interaction between macrolides & statins?

Particularly with simvastatin.

Clarithromycin inhibits the P450 system, which results in increased levels of simvastatin in the body.

This increases the risk of statin related side effects such as myalgia, myopathy and rhabdomyolysis (elevated CK levels).

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When is new onset considered for electrical cardioversion?

If presents <48 hours

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What valvular defect does a mid-diastolic murmur heard best in expiration indicate?

Mitral stenosis

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How are mitral stenosis patients who are asymptomatic generally monitored?

Monitor with regular echos

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Next step for woman <30 presenting with an unexplained breast lump?

Non-urgent referral

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For patients with breast cancer presenting with clinically palpable lymphadenopathy, how can this be confirmed?

With US guided biopsy

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For patients with breast cancer presenting with clinically palpable lymphadenopathy (which is confirmed with an US guided biopsy), what indicated?

Axillary node clearance is indicated at primary surgery

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When is surgical excision for a breast fibroadenoma indicated?

If >3cm

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What is tamoxifen?

A SERM (selective oestrogen receptor modulator).

It acts as an oestrogen receptor antagonist and partial agonist.

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Indication for tamoxifen?

Management of oestrogen receptor-positive breast cancer.

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Adverse effects of tamoxifen?

menstrual disturbance e.g. abnormal bleeding, amenorrhoea
hot flushes
VTE
endometrial cancer

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What are aromatase inhibitors?

Anastrozole & letrozole - these reduce peripherla oestrogen synthesis.

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Indication for aromatase inhibitors e.g. anastrozole?

ER+ve breast cancer in post-menopausal women

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What drug is indicated for neuropathic pain (both peripheral and central)?

Pregabalin, amitriptyline & gabapentin.

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What are 2 good choices of antiemetics in Parkinsons?

Cyclizine & domperidone

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1st line for spasmodic pain in palliative care?

Diazepam

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What type of respiratory failure can MND cause?

Type 2 (due to muscle weaknes, leading to a buildup of CO2)

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An air embolus is a rare but severe complication of central line insertion (where a large air embolus enters the venous circulation).

How may patients present?

Sudden circulatory collapse immediately after insertion.

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What are 2 methods of reducing the risk of an air embolus during central line insertion?

1) Trendelenburg position: patient lies with their head tilted down 15 degrees and feet elevated in air

2) Flush line whilst advancing it to aid distension

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how does the Trendelenburg position reduce risk of air embolus in central line insertion?

This allows gravity to assist the filling and distension of the upper central veins to reduce the risk of air entering the system.

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Which bacteria is the most common cause of endocarditis in patients following prosthetic valve surgery (i.e. <2 months)?

Coagulase-negative Staphylococci e.g. Staph. epidermis

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Which bacteria is the most common cause of endocarditis in patients >2 months following prosthetic valve surgery?

Staph aureus (i.e. same as normal population)

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What should be considered in HF if the patient has sinus rhythm >75 bpm and an LVEF <35% and have not responded to ACEi, beta blockers and aldosterone antagonist therapy (e.g. spironolactone)?

Ivabradine

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When is digoxin preferred in HF?

if patients have co-existing AF

What murmur can HOCM present with?

Ejection systolic murmur louder on performing a Valsalva and quieter on squatting.

What will an ECG typically show evidence of in HOCM?

LV hypertrophy

What causes an ejection systolic murmur in HOCM?

Subaortic hypertrophy of the ventricular septum, resulting in LV outflow tract obstruction and functional aortic stenosis.

What is management of aortic stenosis based on?

1) If the patient is symptomatic 2) LV systolic function

In asymptomatic patients with aortic stenosis, what is the LVEF cut off for aortic valve replacement?

LVEF <50%

In asymptomatic patients with aortic stenosis, what is the mean aortic valve gradient cut off for aortic valve replacement?

>40 mmHg

What is the mean aortic valve gradient?

This measures the average pressure difference across the aortic valve during the cardiac cycle. A gradient of <40 mmHg indicates that the degree of aortic stenosis may be mild or moderate rather than severe.

Which bronchus are inhaled foreign objects most likely found in?

Right main bronchus

Which antiparkinson drug is associated with the greatest improvements in symptoms and ADLs?

Co-careldopa (levodopa + carbidopa)

What is carbidopa?

A decarboxylase inhibitor that prevents the peripheral metabolism of levodopa to dopamine.

1st line for focal seizures?

Lamotrigine or levetiracetam

Which migraine feature is more common in children?

GI disturbance e.g. N&V, diarrhoea

What is gold standard investigation for demyelinating lesions?

MRI with contrast

What is the most common neurological manifestation of sarcoidosis?

Facial nerve palsy

Which antieplieptic drug is most associated with weight gain?

Sodium valproate

1st line for post-herpetic neuralgia?

Amitriptyline, duloxetine, gabapentin or pregabalin

What is the preferred imaging modality in patients with suspected TIA who require brain imaging?

MRI of brain with diffusion-weighted imaging

What artery is affected in amaurosis fugax?

Retinal/ophthalmic artery

What condition does over-replacement of thyroxine increase the risk of?

Osteoporosis. This is because thyroid hormones lead to increased activity of osteoclasts and bone resorption.

What is immune/idiopathic thrombocytopenia (ITP)?

An immune mediated reduction in the platelet count. Antibodies are directed against the glycoprotein IIb/IIIa or Ib-V-IX complex.

What are Abs directed against in ITP?

The glycoprotein IIb/IIIa or Ib-V-IX complex.

ITP in adults vs children?

Children with ITP usually have an acute thrombocytopenia that may follow infection or vaccination. In contrast, adults tend to have a more chronic condition.

How may ITP present in symptomatic adults?

- petechiae, purpura - bleeding (e.g. epistaxis) Note - catastrophic bleeding (e.g. intracranial) is not a common presentation

What does a FBC show in ITP?

Isolated thrombocytopenia

1st line treatment of ITP?

Oral prednisolone

What does ITP typically follow?

Infection or vaccination.

Who should be offered a platelet transfusion?

Platelet count <30 x 10^9 AND clinically significant bleeding (e.g. haematemesis, melaena, prolonged epistaxis).

What is Cushing's triad?

1) widening pulse pressure 2) bradycardia 3) irregular breathing

What can be given to patients with raised ICP 2ary to traumatic brain injury?

IV mannitol

Role of IV mannitol in raised ICP 2ary to traumatic brain injury?

IV mannitol is a HYPERTONIC agent which increases systemic osmolality, causing an osmotic shift of water out of the brain parenchyma.

Is IV mannitol hypo/iso/hypertonic?

Hypertonic

Which type of dementia is motor neurone disease (MND) most typically associated with?

Frontotemporal dementia

Which type of dementia is Parkinson's disease most typically associated with?

Lewy Body dementia

What is disproportionate microcytic anaemia indicative of (i.e. severe microcytosis that is disproportionately lower than the Hb level)?

Beta-thalassaemia trait

Which type of pneumonia can cause erythema nodosum or erythema multiforme?

Mycoplasma pneumoniae

Features of pneumonia caused by Mycoplasma pneumoniae?

- prolonged and gradual onset - flu-like symptoms classically precede a DRY COUGH - bilateral consolidation on x-ray complications: - cold agglutins (IgM): may cause an haemolytic anaemia, thrombocytopenia - erythema multiforme, erythema nodosum

What may a peripheral blood smear show in mycoplasma pneumoniae?

RBC agglutination

What is the most common cause of peritonitis secondary to peritoneal dialysis?

Coagulase-negative Staphylococcus e.g. Staphylococcus epidermis These organisms are part of the normal skin flora and can be introduced into the peritoneal cavity during the process of connecting or disconnecting dialysis bags.

What is the investigation of choice for suspected aortic dissection (depending on stability of patient)?

CT aortic angiogram

Why can ST elevation be seen in the inferior leads (II, III & aVF) in an aortic dissection?

2ary to dissection of the RCA.

Are crypt abscesses seen in Crohn's disease or UC?

What are the warfarin targets in the following MECHANICAL valves: a) aortic b) mitral

a) 3.0 b) 3.5

Define stage 1 HTn

Clinic BP >= 140/90 mmHg and subsequent ABPM daytime average or HBPM average BP >= 135/85 mmHg

In T2DM, if a triple combination of drugs has failed to reduce HbA1c, what is recommended if the BMI is >35?

Switch one of the drugs for a GLP-1 mimetic (e.g. liraglutide), particularly if the BMI > 35.

What is sick euthyroid syndrome?

A condition in which serum levels of thyroid hormones are low in patients who have nonthyroidal systemic illness but who are actually euthyroid. Changes are reversible upon recovery from the systemic illness and hence no treatment is usually needed.

What is a pharyngeal pouch?

A small bulge, like a hernia, that occurs in the pharynx. This is most commonly in elderly patients (over 70 years). It occurs through a weakness in the muscle layer called the Killian dehiscence.

Symptoms of a pharyngeal pouch?

- dysphagia - regurgitation - chronic cough - aspiration - weight loss

Diagnostic investigation of a pharyngeal pouch?

Barium swallow

What is achalasia?

Primarily a neurogenic oesophageal motility disorder with IMPAIRED OESOPHAGEAL PERISTALSIS and a LACK OF LOWER OESOPHAGEAL SPHINCTER RELAXATION.

Symptoms of achalasia?

- dysphagia - regurgitation of undigested food

What does a barium swallow investigation typically show in a pharyngeal pouch?

'Bird beak appearance'

BP in Cushing's reflex?

HTN

What disease does a combination of liver and neurological disease points towards?

Wilson's disease

Which artery is affected in an ischaemic stroke: Contralateral hemiparesis and sensory loss with the lower extremity being more affected than the upper?

Anterior cerebral artery

What is the 1st line test for acromegaly?

Serum IGF-1

What are the vast majority of cases of acromegaly caused by?

Excess GH secretion from pituitary adenoma

What features are seen in pneumonia caused by Legionella?

- dry cough - hyponatraemia (& possible confusion) - flu-like symptoms - deranged LFTs - relative bradycardia - lymphopaenia

How does lithium cause polyuria?

As lithium causes nephrogenic diabetes insipidus.

Does lithium cause cranial or nephrogenic DI?

Nephrogenic Lithium decreases insertion of aquaporin 2 channels into the distal nephron, leading to NDI.