Corrections 4 Flashcards
What is the most appropriate investigation to visualise fibroids?
Transvaginal US
Is salbutamol safe in breastfeeding?
Yes
When should women with dichorionic twins be offered an elective c section?
37 weeks
FSH and LH levels in premature ovarian insuffiency?
High FSH and LH in response to lack of oestrogen release from ovaries.
Symptoms of a cystocele?
- symptoms of stress incontinence
- sensations of heaviness or dragging in vagina
Is anti-D required after light spotting <12 weeks gestation?
no
Is anti-D require before amniocentesis?
Yes
Is HRT or COCP preferred for management of premature ovarian insufficiency?
HRT
What does WHO performace status 3 mean?
An individual is confined to a bed or chair for more than 50% of their waking hours and that they are capable of only limited self-care.
Is post-term gestation a risk factor for poly or oligohydramnios?
Oligohydramnios
Is oesophageal atresia a risk factor for poly or oligohydramnios?
Polyhydramnios
Prevents the foetus from swallowing
What is the best treatment for PID?
Ceftriaxone + doxycyline + metronidazole
What is given 1st line in active management of 3rd stage of labour?
IM oxytocin
How soon after mifepristone should misoprostol be given in a TOP?
24-48 hours later
Dose of folic acid in pregnant women with coeliac disease?
5mg (considered higher risk)
When is ECV offered?
37 weeks
What is the danger of correcting a low serum sodium level too quickly?
Can lead to central pontine myelinosis (where the osmotic pressure of the influx of Na+ molecules strips water from the brain).
This causes destruction of the pontine myelin.
This leads to osmotic demyelination syndrome –> dysarthria, quadriparesis, seizures, coma, locked-in syndrome.
What are some complications of a SAH?
1) Hyponatraemia
2) Seizures
3) Vasospasm
4) Chronic hydrocephalus (due to effects of haemorrhage on resorption of CSF)
5) Cognitive impairment
6) Re-bleeding
What can be given to reduce risk of vasospasm in SAH?
Nifedipine
What are the vitamin K dependent clotting factors?
II, VII, IX and X.
Mneumonic 2 + 7 = 9, not 10
What are the management options for a subdural haematoma?
1) Conservative
2) Medical:
- prophylactic antiepileptics
- coagulopathy reversal
3) Surgical:
- decompressive craniotomy
- Burr hole decompression
- craniectomy
What are the features suggestive of hypernatraemic dehydration?
1) jittery movements
2) increased muscle tone
3) hyperreflexia
4) convulsions
5) drowsiness or coma
How soon should any person on anticoagulants with a head injury receive a CT head?
Within 8 hours
1st line investigation in suspected prostate cancer?
Multiparametric MRI
1st line management of a strangulated inguinal hernia?
Immediate open surgical repair
What are 2 treatment options for achalasia?
1) Endoscopic injection with botulinum toxin (but not long lasting)
2) Cardiomyotomy (more durable alternative)
What are 4 recognised complications of enteral feeding?
1) Diarrhoea
2) Aspiration
3) Hyperglycaemia
4) Refeeding syndrome
What is the 1st line investigation of choice in SAH?
Non-contrast CT head
CT head rules for SAH?
If CT head is done within 6 hours of symptom onset and is normal –> do NOT do LP, consider alterantive
If CT head is done >6 hours of symptom onset and is normal –> perform LP
When should an LP be done in suspected SAH?
If CT head is done >6 hours after symptom onset and is normal.
LP should be performed at least 12 hours following onset of symptoms.
How long after onset of symptoms in SAH should be LP be performed?
Why?
At least 12 hours after
To allow the development of xanthochromia (the result of RBC breakdown).
What 2 CSF findings on an LP indicate SAH?
1) Xanthochromia
2) Normal or raised opening pressure
1st & 2nd line management of diverticulitis flare?
1st –> oral Abx at home
2nd –> if they do not improve within 72 hours, admission to hospital for IV ceftriaxone + metronidazole is indicated
What are 4 absolute contraindications to laparoscopic surgery?
1) haemodynamic instability/shock
2) raised ICP
3) acute intestinal obstruction with dilated bowel loops (e.g. > 4 cm)
4) uncorrected coagulopathy
What medications are indicated in PAD? (2)
1) Atorvastatin 80mg
2) Clopidogrel
What type of renal stone does not show up on XR?
Uric acid stones
What time limit for retrograde amnesia following a head injury is an indicaction for a CT head?
Over 30 mins of retrograde amnesia
Is anterograde amnesia an indication for a CT head following head injury?
No
What is beck’s triad?
Indicates the presence of cardiac tamponade.
1) Hypotension
2) Muffled heart sounds
3) Raised JVP
1st line in BPH if the patient has troublesome symptoms?
Alpha-1 antagonists e.g. tamsulosin, alfuzosin
What does neurogenic shock most commonly occur following?
Spinal cord transection (usually at a high level).
There is an interruption of the autonomic nervous system.
The result is either decreased sympathetic tone or increased parasympathetic tone, the effect of which is a decrease in peripheral vascular resistance mediated by marked vasodilation.
What is indicated in recurrent balanitis?
Circumcision
What is the most effective management option in renal cell carcinoma?
Radical nephrectomy (RCC is usually resistant to radiotherapy or chemotherapy)
What condition is associated with pigmented gallstones?
Pigmented gallstones are primarily made of bilirubin and are associated with haemolytic anemia (e.g. sickle cell) and liver cirrhosis.
What early imaging is indicated in acute pancreatitis?
US abdomen –> to determine the aetiology as this may affect management (e.g. patients with gallstones/biliary obstruction)
How can pelvic fractures cause urinary retenion?
Pelvic fractures may cause laceration of the urethra.
What is the appropriate surgical management for caecal, ascending or proximal transverse colon cancer?
Right hemicolectomy
In haemorrhagic shock, at what blood loss does BP start to fall?
Doesn’t start to fall until around 30% of blood volume is lost (class III).
What class of haemorrhagic shock is BP reduced in?
III and IV
Symptoms of haemorrhagic shock in class I to IV?
I - normal
II - anxious
III - confused
IV - lethargic
Blood loss in haemorrhagic shock in class I to IV?
I: <750ml
II: 750-1500ml
III: 1500-2000ml
IV: >2000ml
What cancer marker may be raised in cholangiocarcinoma?
Ca 19-9
What is a useful test for determining whether the cause of the isolated hyperbilirubinaemia is due to haemolysis or Gilbert’s syndrome?
FBC
Mx of Bell’s palsy with eye involvement (i.e. patient unable to fully close eye)?
Prednisolone + eye care advice e.g. drops, lubricants and night time taping
Mx of extensive otitis externa?
Flucloxacillin
How can steroids affect neutrophils?
Can cause neutrophilia
Which diabetic drug is contraindicated in HF?
Pioglitazone –> has been found to cause fluid retention and exacerbate heart failure
Presentation of a pontine haemorrhage?
1) Reduced GCS
2) Paralysis
3) Bilateral pin point pupils
What is diptheria?
A bacteria that commonly affects the throat, causing a sore throat with a ‘diphtheric membrane’ - grey, pseudomembrane on the posterior pharyngeal wall.
What is Beck’s triad of cardiac tamponade?
1) Falling BP
2) Rising JVP
3) Muffled heart sounds
In patients with an adenoma causing 1ary hyperparathyroidism who are not suitable for surgery, what is the management?
Cinacalcet –> a calcimimetic
This ‘mimics’ the action of calcium on tissues by allosteric activation of the calcium-sensing receptor.
How is uptake of radioactive iodine-131 affected in De Quervain’s thyroiditis?
Reduced
How is uptake of radioactive iodine-131 affected in Grave’s disease?
Globally increased uptake
How is uptake of radioactive iodine-131 affected in a thyroid nodule?
Locally increased uptake
Mx of a DVT with a Wells score of ≤1?
1) Arrange a D-dimer with result within 4 hours
if this is not possible (i.e. results are delayed)
2) Arrange a D-dimer + prescribe interim anticoagulation
How soon after possible exposure should you test for HIV in asymptomatic patients?
4 weeks
What type of diuretic can worsen glucose tolerance?
Thiazides
What paraneoplastic syndrome is most commonly associated with squamous cell lung cancer?
PTHrP
Mx of an acute ischaemic stroke in patients who present within 4.5 hours?
Alteplase + thrombectomy
What is the goal of phases 0 to IV of a clinical trial?
0 –> Exploratory studies (involves a very small number of participants and aim to assess how a drug behaves in the human body i.e. pharmacokinetics and pharmacodynamics)
1 –> Safety assessment
2 –> Assess efficacy
3 –> Assess effectiveness
4 –> Postmarketing surveillance
What type of organism is Trichomonas vaginalis?
Protozoa
What is the typical presenting feature of a ductal papilloma?
Discharge from nipple (can be blood stained)
What is pyoderma gangrenosum?
A rare, non-infectious, inflammatory disorder.
It is an uncommon cause of very painful skin ulceration.
Lower legs are most common site.
Causes of pyoderma gangrenosum?
1) Idiopathic (50%)
2) IBD (10-15%): Crohn’s & UC
3) Rheum: RA & SLE
4) Haem: lymphoma, myeloid leukaemias, myeloproliferative disorders
5) Granulomatosis with polyangiitis
6) Primary biliary cirrhosis
What implies a poor prognosis in HL?
1) Presence of B symptoms
2) Age >45
3) Stage IV disease
4) Hb <105
5) Male
6) WBC >15,000
What cancer is Hashimoto’s thyroiditis associated with the development of?
MALT lymphoma
Which type of medication are known to induce neutrophilia?
Corticosteroids
What is the most common malignancy in renal transplant patients?
Skin cancer (particularly squamous cell) –> 2ary to immunosuppression.
Pepperpot skull is a characteristic XR finding of what?
Hyperparathyroidisim
High circulating levels of PTH stimulate increased osteoclast activity. Increased uptake of trabecular bone leads to the formation of multiple small radiolucent lesions of the skull which gives the appearance of a pepperpot.
What is a key contraindication of metformin?
CKD
- Review if eGFR <45 or creatinine >130
- STOP if eGFR is <30 or creatinine is >150
When is SGLT-2 monotherapy indicated in diabetes?
If meformin is contraindicated AND has a risk of CVD, established CVD or chronic heart failure.
What should be used for diabetes if metformin is contraindicated but the patient doesn’t have a risk of CVD, established CVD or chronic heart failure?
DPP-4 inhibitor or pioglitazone or a sulfonylurea
Which diabetes drug can cause fluid retention?
Pioglitazone
Which diabetes drug can cause SIADH?
Sulfonylureas e.g. gliclazide, glimepiride
What class of drug is glimepiride?
Sulfonylurea
What is key blood test to get in suspected pancreatitis?
1) Amylase/lipase
2) +/- G&S
3) Lactate
Mx of patients treated with insulin who have good glycaemic control and are undergoing minor procedures?
Can be managed during the operative period by adjustment of their usual insuline regimen
Mx of patients having surgery requiring a long fasting period of more than one missed meal, OR whose diabetes is poorly controlled?
Will usually require a variable rate IV insulin infusion (VRIII)
Most patients taking only oral antidiabetic drugs may be managed by manipulating medication on the day of surgery, depending on the particular drug.
What are 3 exceptions to this?
1) if more than one meal is to be missed
2) patients with poor glycaemic control
3) risk of renal injury (e.g. low eGFR, contrast being used)
In such cases –> a VRIII should be used.
Mx of patients on metformin prior to surgery:
1) day prior to admission
2) day of surgery (morning op)
3) day of surgery (afternoon op)
1) take as normal
2a) If taken OD or BD a day - take as normal
b) If taken TDS - omit lunchtime dose
3a) If taken OD or BD - take as normal
3b) If taken TDS - omit lunchtime dose
Mx of patients on sulfonylureas prior to surgery:
1) day prior to admission
2) day of surgery (morning op)
3) day of surgery (afternoon op)
1) take as normal
2a) If taken OD in the morning - omit the dose that
day
b) If taken BD - omit the MORNING dose that day
Mx of patients on SGLT-2 inhibitors prior to surgery:
1) day prior to admission
2) day of surgery (morning op)
3) day of surgery (afternoon op)
1) take as normal
2) omit on day of surgery
3) omit on day of surgery
Mx of patients on once daily insulins prior to surgery:
1) day prior to admission
2) day of surgery (morning op)
3) day of surgery (afternoon op)
1) reduce dose by 20%
2) reduce dose by 20%
3) reduce dose by 20%
Mx of patients on twice daily biphasic or ultra long acting insulins prior to surgery:
1) day prior to admission
2) day of surgery (morning op)
3) day of surgery (afternoon op)
1) no dose change
2) Halve the usual morning dose. Leave evening dose unchanged.
3) Halve the usual morning dose. Leave evening dose unchanged.
What is the diagnostic threshold for gestational diabetes?
fasting glucose is >= 5.6 mmol/L
2-hour glucose is >= 7.8 mmol/L
Features of subacute degeneration of the spinal cord
1) dorsal column involvement:
- distal tingling/burning/sensory loss is symmetrical and tends to affect the legs more than the arms
- impaired proprioception and vibration sense
2) lateral corticospinal tract involvement:
- muscle weakness, hyperreflexia, and spasticity
- UMN signs typically develop in the legs first
- brisk knee reflexes
- absent ankle jerks
- extensor plantars
3) spinocerebellar tract involvement:
- sensory ataxia → gait abnormalities
- positive Romberg’s sign
What condition does hypokalaemia associated with HTN point towards?
Primary hyperaldosteronism
What condition should you suspect in patients with T2DM and/or obesity + abnormal LFTs?
NAFLD
Acute vs chronic mesenteric ischaemia?
Acute –> typically caused by an embolism resulting in occlusion of an artery which supplies the small bowel e.g. the SMA.
Chronic –> ‘intestinal angina’, colickly, intermittent abdominal pain
What do patients classically have a history of in acute mesenteric ischaemia?
AF
Ischaemia to the lower GI tract can be separated into what 3 categories?
1) acute mesenteric ischaemia
2) chronic mesenteric ischaemia
3) ischaemic colitis
What is the investigation of choice in bowel ischaemia?
CT
What is ischaemic colitis?
An acute but transient compromise in the blood flow to the large bowel.
This may lead to inflammation, ulceration and haemorrhage.
Where is ischaemic colitis most likely to occur?
‘watershed’ areas such as the splenic flexure that are located at the borders of the territory supplied by the superior and inferior mesenteric arteries
What is seen on AXR in ischaemic colitis?
‘thumbprinting’ may be seen on AXR due to mucosal oedema/haemorrhage
Mx of alcoholic ketoacidosis?
IV saline 0.9% + thiamine
What are 4 drugs that can cause SIADH
1) Carbamazepine
2) Sulfonylureas e.g. gliclazide
3) SSRIs
4) TCAs
1st line investigation is TCA OD?
ECG –> if changes such as QRS widening are seen then IV bicarbonate should be given
Why should flumenazil not be given in a mixed benzo + TCA OD?
The potential risk of doing this would be inducing a seizure given the coexistent TCA OD
How to calculate alcohol units?
Per day;
alcohol units = volume (ml) x % /1000
What are the 5 features that make up the ORBIT score?
1) Hb <130 g/L for males and < 120 g/L for females, or haemtocrit < 40% for males and < 36% for females (2)
2) Age >74 (1)
3) Bleeding history (GI bleeding, intracranial bleeding or haemorrhagic stroke) (2)
4) Renal impairment (GFR < 60 mL/min/1.73m2) (1)
5) Treatment with antiplatelet agents (1)
What ORBIT score is ‘high risk’ for bleeding?
4-7
What ORBIT score is ‘low risk’ for bleeding?
0-2
What is the definitive diagnostic investigation for SBO?
Abdo CT
What is the key risk factor for transient tachypnoea of the newborn (TTN)?
C-section
Features of TTN?
Slightly raised RR and increased work of breathing.
All other obs normal.
When does TTN present?
Within first few hours of birth
In what 4 situations would you see hyaline casts in urine?
1) normal urine
2) after exercise
3) during fever
4) loop diuretics e.g. furosemide
In what situation would you seen brown granular casts in the urine?
Acute tubular necrosis
In what situation would you seen red cell casts in the urine?
Nephritic syndrome
What should you check before starting azathioprine therapy?
Check thiopurine methyltransferase deficiency (TPMT).
TPMT deficiency is present in about 1 in 200 people and predisposes to azathioprine related pancytopaenia
What does TPMT deficiency predispose to in azathioprine therapy?
azathioprine related pancytopaenia
What is Asherman’s syndrome?
Intrauterine adhesions that may occur following dilation and curettage.
This may prevent the endometrium responding to oestrogen as it normally would –> 2ary amenorrhoea.
