CPS Flashcards
Which one of the following is most characteristically caused by hyperosmolar non-ketotic diabetic coma?
Hypernatraemia
For a women who is breastfeeding, lithium:
Must be avoided
Breast feeding: drugs Must be avoided
lithium
aspirin
benzodiazepines
amiodarone
carbimazole
ciprofloxacin
sulphonamides
sulphonylureas
methotrexate
tetracyclines
Breast feeding: drugs considered safe to use
trimethoprim
digoxin
beta-blockers
heparin
warfarin
levothyroxine
glucocorticoids
theophyllines
antipsychotics
penicillins
tricyclic antidepressants
cephalosporins
carbamazepine
hydralazine
What is the most appropriate next step in the following scenario: COPD not controlled with SABA/SAMA + LABA + ICS, asthmatic/steroid responsive features present?
Add a LAMA
Which one of the following conditions is most likely to cause hyperkalaemia?
metabolic acidosis
Hyperkalaemia
*Metabolic acidosis
ACEIs/ARBs
Acute renal failure
Addison’s disease
Aldactone (spironolactone)
Ciclosporin
Rhabdomyolysis
Massive blood transfusion
Hypokalaemia
Cushing’s syndrome
magnesium deficiency
primary hyperaldosteronism
thiazides
vomiting
diarrhoea
acetazolamide
Ovarian cancer Tumour marker
CA 125
Pancreatic cancer Tumour marker
CA 19-9
Breast cancer Tumour marker
CA 15-3
Prostatic carcinoma
Prostate specific antigen (PSA)
Alpha-feto protein (AFP)
Hepatocellular carcinoma, teratoma
Carcinoembryonic antigen (CEA)
Colorectal cancer
S-100
Melanoma, schwannomas
Bombesin
Small cell lung carcinoma, gastric cancer, neuroblastoma
What is the treatment of choice for migraine prophylaxis (woman of childbearing age)?
Propranolol
migraine prophylaxis (not a woman of childbearing age)
Topiramate or propranolol
An elderly man with a long history of diabetes presents with sudden visual loss in one eye. For the past few days he had been experiencing floaters and ‘cobwebs’. Visual acuity is reduced to sensing light is a stereotypical history of:
Vitreous haemorrhage
an elderly patient with a history of chronic glaucoma and hypertension presents with a sudden painless loss of vision in one eye. Fundoscopy reveals multiple flame-shaped haemorrhages and optic disc oedema
Central retinal vein occlusion
Flashes of light (photopsia) - in the peripheral field of vision
Floaters, often on the temporal side of the central vision
Posterior vitreous detachment
Dense shadow that starts peripherally progresses towards the central vision
A veil or curtain over the field of vision
Straight lines appear curved
Central visual loss
Retinal detachment
Large bleeds cause sudden visual loss
Moderate bleeds may be described as numerous dark spots
Small bleeds may cause floaters
Vitreous haemorrhage
Crypt abscesses
ulcerative colitis
Kantor’s string sign
Crohn’s disease
Ciclosporin AEs (immunosuppressent),
(note how everything is increased - fluid, BP, K+, hair, gums, glucose)
nephrotoxicity
hepatotoxicity
fluid retention
hypertension
hyperkalaemia
hypertrichosis
gingival hyperplasia
tremor
impaired glucose tolerance
hyperlipidaemia
increased susceptibility to severe infection
Interestingly for an immunosuppressant, ciclosporin is noted by the BNF to be ‘virtually non-myelotoxic’.
NSTEMI identified - what is the best next step in the management of this patient with an ACS? (assume normal bleeding risk and not on anticoagulants)
Give aspirin 300mg + fondaparinux
Medication causing Increased susceptibility to severe infection
corticosteroids
Cobble-stone appearance on endoscopy
Crohn’s disease
Continuous disease
ulcerative colitis
Development:
A normal 3 year old child cannot
The correct answer is A. Copy a cross
A child learns to copy a
-circle by 3 years of age,
-cross at 4,
-square at 4 ½ and
-triangle by 5 years.
Transferring around 6 months
Tell age at 3 years.
At 2 year old uses 2 or more words to make simple phrases.
At 18-24 months children enjoy symbolic play when playing with dolls, brush, spoon. By 3 years they enjoy interactive play.
Febrile convulsions
Febrile convulsions are common,
-Occur in around 3% of children aged 6 months to 3 years.
-Peak incidence is at around 18 months
-Episodes are commonly associated with
–viral infections,
–tonsillitis and
–otitis media.
Convulsions are described as complex if..
-they last more than 15 minutes,
-are repeated within 24 hours or
-if they are focal at the onset or during the convulsion.
The risk of subsequent epilepsy is about 2%.
Convulsions associated with low fever are associated with a higher risk of recurrence.
Limping in children
- Age of patient:
0-5 year DDH
5-10 years Perthes’ disease
10-15 years SUFE - Pain:
Painless (DDH),
Slow developing chronic pain (Perthes’ disease),
Acutely painful (septic arthritis, transient synovitis). - Body habitus:
SCFE: obese pubertal children,
Osgood-Schlatter disease (knee pain due to repeated traction at the tibial tubercle): active, sporty early teenagers.
- Systemic features: f
Fevers (septic arthritis, JIA),
Blanching rash (JIA),
Malaise and tiredness (JIA, ALL),
Bruising (ALL). - Sex: more common in boys: Perthes’ disease, SCFE, Osgood-Schlatter; more common in girls: DDH.
a 60-year-old man has recurrent episodes of atrial fibrillation which don’t self terminate. He uses flecanide to cardiovert himself into sinus rhythm
Persistent atrial fibrillation
a 70-year-old man is treated with a beta-blocker to control his atrial fibrillation. A previous attempt to cardiovert him failed
Permanent atrial fibrillation
X-ray findings include subluxation
rheumatoid arthritis
Commonly affects the CMC carpometacarpal joint
osteoarthritis
X-ray findings
Loss of joint space
Juxta-articular osteoporosis
Periarticular erosions
Subluxation
Rheumatoid arthritis
X-ray findings
Loss of joint space
Subchondral sclerosis
Subchondral cysts
Osteophytes forming at joint margins
Osteoarthritis
Typical affected joints
MCP, PIP joints
Rheumatoid arthritis
Typical affected joints
Large weight-bearing joints (hip, knee)
Carpometacarpal joint
DIP, PIP joints
Osteoarthritis
Hypokalaemia causing drugs
thiazides
loop diuretics
Electrolyte imbalance caused by Metabolic acidosis
hyperkalaemia
Antiplatelets
Acute coronary syndrome (medically treated)
1st line
Aspirin (lifelong) & ticagrelor (12 months)
2nd line
If aspirin contraindicated, clopidogrel (lifelong)
Antiplatelets
Percutaneous coronary intervention
1st line
Aspirin (lifelong) & prasurgrel or ticagrelor (12 months)
2nd line
If aspirin contraindicated, clopidogrel (lifelong)
Antiplatelets
TIA
1st line
Clopidogrel (lifelong)
2nd line
If aspirin contraindicated, clopidogrel (lifelong)
Antiplatelets
Ischaemic stroke
1st line
Clopidogrel (lifelong)
2nd line
If aspirin contraindicated, clopidogrel (lifelong)
Antiplatelets
Peripheral arterial disease
1st line
Clopidogrel (lifelong)
2nd line
Asprin (lifelong)
a man who has a history of syphilis presents with bilateral small, irregular pupils which respond to accomodation but not to light
Argyll-Robertson pupil
a patient presents with a ‘droopy eyelid’. On examination they have unilateral miosis, ptosis and narrow palpebral aperture giving the appearance of enophthalmos
Horner’s syndrome
Pulses
greater than the normal (10 mmHg) fall in systolic blood pressure during inspiration → faint or absent pulse in inspiration
severe asthma, cardiac tamponade
Pulsus paradoxus
Pulses
aortic stenosis
Slow-rising/plateau
Pulses
aortic regurgitation
patent ductus arteriosus
hyperkinetic states (anaemia, thyrotoxic, fever, exercise/pregnancy)
Collapsing
Pulses
regular alternation of the force of the arterial pulse
severe LVF
Pulsus alternans
Pulses
‘double pulse’ - two systolic peaks
mixed aortic valve disease
Bisferiens pulse
Pulses
hypertrophic obstructive cardiomyopathy*
‘Jerky’ pulse
Precipitation of digoxin toxicity (medicine)
thiazides
loop diuretics
verapamil
diltiazem
amiodarone
ciclosporin
quinidine
Ototoxicity causing medicine
loop diuretics
aminoglycosides
Breastfeeding safe drugs
antibiotics: penicillins, cephalosporins, trimethoprim
endocrine: glucocorticoids (avoid high doses), levothyroxine*
epilepsy: sodium valproate, carbamazepine
asthma: salbutamol, theophyllines
psychiatric drugs: tricyclic antidepressants, antipsychotics**
hypertension: beta-blockers, hydralazine
anticoagulants: warfarin, heparin
digoxin
Breastfeeding Unsafe drugs
antibiotics: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides
psychiatric drugs: lithium, benzodiazepines
aspirin
carbimazole
methotrexate
sulfonylureas
cytotoxic drugs
amiodarone
Causes of hypernatraemia
HONK
Dehydration
Diabetes insipidus
Excess IV saline
Drug monitoring Statins
LFT
Drug monitoring ACE inhibitors
U&E
Drug monitoring Amiodarone
TFT, LFT
Drug monitoring Methotrexate
FBC, LFT, U&E
Drug monitoring Azathioprine
FBC, LFT
Drug monitoring Lithium
Lithium level, TFT, U&E
Drug monitoring Sodium valproate
LFT
Drug monitoring Glitazones
LFT
Late menopause: female cancers
breast cancer
endometrial cancer
ovarian cancer
Tamoxifen: female cancers
endometrial cancer
Breast cancer: risk factors
BRCA1, BRCA2 genes
1st degree premenopausal relative with breast cancer (e.g. mother)
Past breast cancer
Nulliparity, 1st pregnancy > 30 yrs (twice risk of women having 1st child < 25 yrs)
Not breastfeeding
Early menarche, Late menopause
CHR/COCP - Combined hormone replacement therapy, combined oral contraceptive use
ionising radiation
p53 gene mutations
obesity
previous surgery for benign disease (?more follow-up, scar hides lump)
Breast cancer drug associated with an increased risk of venous thromboembolism
tamoxifen
Breast cancer drugs oestrogen receptor-positive breast cancer.
Tamoxifen (SERM)
-menstrual disturbance: vaginal bleeding, amenorrhoea
-hot flushes - 3% of patients stop taking tamoxifen due to climacteric side-effects
-venous thromboembolism
-endometrial cancer
Anastrozole (Aromatase inhibitors)
-osteoporosis
-hot flushes
-arthralgia, myalgia
-insomnia
Breast cancer drug used if women are HER2 positive
trastuzumab
Contraceptives: time until effective
progestogen only pill
After 2 days
Contraceptives: time until effective
Depo Provera (injectable contraceptive)
Nexplanon (implantable contraceptive)
combined oral contraceptive pill
intrauterine system (e.g. Mirena)
After 7 days
Contraceptives: time until effective
IUD
Immediately
Loop diuretics AEs
Adverse effects
hypotension
hyponatraemia
hypokalaemia, hypomagnesaemia
hypochloraemic alkalosis
ototoxicity
hypocalcaemia
renal impairment (from dehydration + direct toxic effect)
hyperglycaemia (less common than with thiazides)
gout
A 5-year-old child develops fever, cough and conjunctivtis. On examination the child is irritable and has a blanching erythematous rash on the face and upper chest. Small white spots can also be seen on the inside of the cheeks
measles virus
A 20-year-old woman with a history of emotional lability and depression presents with an asymmetrical tremor. On examination she has early stigmata of chronic liver disease
Wilson’s disease
NSTEMI identified, aspirin given, 6-month mortality low (<3%)
conservative management - give ticagrelor
Adult with newly diagnosed asthma - Next?
low-dose ICS/formoterol combination inhaler as required
ECG: coronary territories
Anteroseptal V1-V4
Left anterior descending
ECG: coronary territories
Inferior II, III, aVF
Right coronary
ECG: coronary territories
Anterolateral V1-6, I, aVL
Proximal left anterior descending
ECG: coronary territories
Lateral I, aVL +/- V5-6
Left circumflex
ECG: coronary territories
Posterior Changes in V1-3
Reciprocal changes of STEMI are typically seen:
horizontal ST depression
tall, broad R waves
upright T waves
dominant R wave in V2
Usually left circumflex, also right coronary
Generalised tonic-clonic seizures
males: sodium valproate
females: lamotrigine or levetiracetam
Focal seizures
first line: lamotrigine or levetiracetam
second line: carbamazepine, oxcarbazepine or zonisamide
Absence seizures (Petit mal)
first line: ethosuximide
second line:
male: sodium valproate
female: lamotrigine or levetiracetam
carbamazepine may exacerbate absence seizures
Myoclonic seizures
males: sodium valproate
females: levetiracetam
Tonic or atonic seizures
males: sodium valproate
females: lamotrigine
Verapamil AEs
Heart failure,
constipation,
hypotension,
bradycardia,
flushing
Diltiazem AEs
Heart failure,
constipation,
hypotension,
ankle swelling
Nifedipine, amlodipine, felodipine
(dihydropyridines) AEs
Flushing,
headache,
ankle swelling
a patient develops acute heart failure 10 days following a myocardial infarction. On examination he has a raised JVP, pulsus paradoxus and diminished heart sounds
Left ventricular free wall rupture
Maculopapular rash appears 48 hours after high fever
roseola infantum
Next step—Adult with asthma, not controlled with low-dose ICS/formoterol combination inhaler as required
regular low-dose ICS/formoterol combination inhaler and as required (MART)
Hypokalaemia is most associated with which one of the following ECG changes?
J waves
PR depression
A short PR interval
Increased P wave amplitude
A long QT interval
Epsilon waves
A long QT interval
Hypokalaemia ECG
U waves
long QT interval
prolonged PR interval
ST depression
A middle aged woman presents with a tender goitre and symptoms of hyperthyroidism. Bloods show a suppressed TSH and raised T4. There is a globally reduced uptake on iodine-131 scan -
subacute thyroiditis
high LH and low testosterone
Klinefelter’s syndrome
high LH and normal/high testosterone
Androgen insensitivity syndrome
TIA 1 day before
A. Aspirin 300mg and urgent assessment (within 24 hours)
NICE Guidelines state that where someone has had a suspected TIA you should give aspirin 300 mg immediately (unless contraindicated) and arrange urgent assessment (within 24 hours) by a specialist stroke physician.
If the patient has a bleeding disorder then immediate admission is necessary. Immediate admission may also be necessary if the patient has had more than one TIA or lacks a reliable observer at home.
Conductive hearing loss: Rinne’s and Weber’s
In conductive hearing loss BC > AC and Weber’s lateralises to the affected ear.
sensorineural hearing loss: Rinne’s and Weber’s
In sensorineural hearing loss AC>BC in both ears and with Weber’s test lateralisation occurs to the unaffected ear (right) i.e. away from the affected ear (left)
If a child with a limp/hip pain has a fever they should be referred for same-day assessment, even if a diagnosis of transient synovitis is suspected
Transient synovitis
Organisms which may colonise CF patients
Staphylococcus aureus
Pseudomonas aeruginosa
Burkholderia cepacia*
Aspergillus
-Crescendo-decrescendo murmur (ejection systolic murmur) due to bicuspid aortic valve
-daughter 15 yrs old hasn’t started her periods yet
On general examination, she is in the 9th percentile of height for her age, has short ring fingers, poor breast development, and a high arched palate.
Turner’s syndrome
Contraceptives - time until effective (if not first day period):
instant: IUD
2 days: POP
7 days: COC, injection, implant, IUS
COCPs absulute contraindications
Absolute CIs
-more than 35 years more than 15 ciggs/day
-migraine with aura
-H/O thromboembolic disease or thrombogenic mutation
-H/O stroke or ischaemic heart disease
-breast feeding < 6 weeks post-partum
-uncontrolled hypertension
-current breast cancer
-major surgery with prolonged immobilisation
-positive antiphospholipid antibodies (e.g. in SLE)
Relative CIs
-more than 35 years old and smoking less than 15 cigarettes/day
-BMI > 35 kg/m^2*
-family history of thromboembolic disease in first degree relatives < 45 years
-controlled hypertension
-immobility e.g. wheel chair use
-carrier of known gene mutations associated with breast cancer (e.g. BRCA1/BRCA2)
-current gallbladder disease
The major risk factors for SIDS are:
prone sleeping
parental smoking
bed sharing
hyperthermia and head covering
prematurity
Risk factors for gestational diabetes
BMI of > 30 kg/m²
previous macrosomic baby weighing 4.5 kg or above
previous gestational diabetes
first-degree relative with diabetes
family origin with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern)
Diagnostic thresholds for gestational diabetes
fasting glucose is >= 5.6 mmol/L
2-hour glucose is >= 7.8 mmol/L
Targets for self monitoring of pregnant women (pre-existing and gestational diabetes)
Fasting 5.3 mmol/l
1 hour after meals 7.8 mmol/l, or:
2 hour after meals 6.4 mmol/l
Ovarian cancer Screening
At the moment, there is no screening test that reliably detects ovarian cancer at an early stage.
Ovarian cancer should be suspected and further tests should be carried out in any woman (particularly those over 50 years of age), who persistently have any of the following symptoms:
Abdominal distension/bloating
Feeling full (early satiety) or loss of appetite
Pelvic or abdominal pain.
Increased urinary urgency or frequency
Ottowa ankle rules:
Bony tenderness over the malleoli zones OR an
Inability to walk four weight-bearing step
Ankle injury: Ottawa rules
Pain, Tenderness, Walk
The Ottawa Rules for ankle x-rays have a sensitivity approaching 100%
An ankle x-ray is required only if there is any pain in the malleolar zone and any one of the following findings:
-Bony tenderness at the lateral malleolar zone
-Bony tenderness at the medial malleolar zone
-Inability to walk four weight-bearing steps immediately after the injury and in the emergency department
nocturnal enuresis
majority of children achieve day and night time urinary continence? 3-4 years old
Children under the age of 5 years who have nocturnal enuresis can be managed with reassurance and advice
Whooping cough
Whooping cough - azithromycin or clarithromycin if the onset of cough is within the previous 21 days
Women who are between 16-32 weeks pregnant will be offered the vaccine.
Patients who refuse treatment
The Mental Health Act overrides the Mental Capacity Act and enables people with capacity to be given treatment against their will
Premature menopause
Premature menopause is associated with increased all cause mortality including increased risk of osteoporosis and cardiovascular disease
Meconium aspiration syndrome
Meconium aspiration syndrome
-Respiratory distress in the newborn as a result of meconium in the trachea.
-In immediate neonatal period.
-More common in post-term deliveries, with rates of up to 44% reported in babies born after 42 weeks.
-It causes respiratory distress, which can be severe.
-Higher rates occur where there is a history of maternal hypertension, pre-eclampsia, chorioamnionitis, smoking or substance abuse.
Cushing reflex in Cerebral perfusion pressure
Cushing reflex is a physiological nervous system response to increased intracranial pressure (ICP) that results in
-Hypertension
-Bradycardia
-Wide pulse pressure
Deprivation of Liberty Safeguards DOLS
A patient must be placed on a DOLS if they are to be treated in hospital and they do not have capacity to consent for this
He must be placed on a deprivation of liberty safeguard (DOLS) regardless of his compliance with treatment as he lacks capacity to consent for treatment
PDA with Duct dependent cardiac lesions
A patent ductus arteriosis can be kept open with prostaglandins. This may be useful in duct dependent cardiac lesions
Primary amenorrhoea, little or no axillary and pubic hair, elevated testosterone →
androgen insensitivity syndrome
Aortic stenosis in children
Aortic stenosis accounts for 5% of congenital heart disease
Associations include:
William’s syndrome (causes supravalvular aortic stenosis)
coarctation of the aorta
Turner’s syndrome
Management
aim is to avoid or delay valve replacement if possible
if gradient across valve is > 60 mmHg then balloon valvotomy may be indicated
Maternal mortality includes any death in
any death in pregnancy and labour as well as up to six weeks post partum
Asbestos and the law
*If a person with an asbestos related condition dies, regardless of the cause of their death, the coroner should be notified
Patients who have developed certain complications following exposure to asbestos are entitled to compensation.
Patients can claim if they develop the following conditions:
mesothelioma
asbestosis
pleural thickening causing disability
lung cancer caused by asbestos
Under current law patients who have developed pleural plaques are not entitled to compensation.
The coroner should be notified when a patient who had an asbestos-related condition dies.
Gestational diabetes
Gestational diabetes
Gestational diabetes is the second most common medical disorder complicating pregnancy (after hypertension), affecting around 4% of pregnancies.
Risk factors for gestational diabetes
BMI of > 30 kg/m²
previous macrosomic baby weighing 4.5 kg or above
previous gestational diabetes
first-degree relative with diabetes
family origin with a high prevalence of diabetes (South Asian, black Caribbean and Middle Eastern)
Screening for gestational diabetes
the oral glucose tolerance test (OGTT) is the test of choice
women who’ve previously had gestational diabetes: OGTT should be performed as soon as possible after booking and at 24-28 weeks if the first test is normal. NICE also recommend that early self-monitoring of blood glucose is an alternative to the OGTTs
women with any of the other risk factors should be offered an OGTT at 24-28 weeks
Diagnostic thresholds for gestational diabetes
these have recently been updated by NICE, gestational diabetes is diagnosed if either:
fasting glucose is >= 5.6 mmol/L
2-hour glucose is >= 7.8 mmol/L
Management of gestational diabetes
newly diagnosed women should be seen in a joint diabetes and antenatal clinic within a week
women should be taught about self-monitoring of blood glucose
advice about diet (including eating foods with a low glycaemic index) and exercise should be given
if the fasting plasma glucose level is < 7 mmol/l a trial of diet and exercise should be offered
if glucose targets are not met within 1-2 weeks of altering diet/exercise metformin should be started
if glucose targets are still not met insulin should be added to diet/exercise/metformin
gestational diabetes is treated with short-acting, not long-acting, insulin
if at the time of diagnosis the fasting glucose level is >= 7 mmol/l insulin should be started
if the plasma glucose level is between 6-6.9 mmol/l, and there is evidence of complications such as macrosomia or hydramnios, insulin should be offered
glibenclamide should only be offered for women who cannot tolerate metformin or those who fail to meet the glucose targets with metformin but decline insulin treatment
Management of pre-existing diabetes
weight loss for women with BMI of > 27 kg/m^2
stop oral hypoglycaemic agents, apart from metformin, and commence insulin
folic acid 5 mg/day from pre-conception to 12 weeks gestation
detailed anomaly scan at 20 weeks including four-chamber view of the heart and outflow tracts
tight glycaemic control reduces complication rates
treat retinopathy as can worsen during pregnancy
Targets for self monitoring of pregnant women (pre-existing and gestational diabetes)
Time Target
Fasting 5.3 mmol/l
1 hour after meals 7.8 mmol/l, or:
2 hour after meals 6.4 mmol/l
Causdative organisms
Acute epiglottitis is caused by Haemophilus influenzae type B (Hib). Since 1992 Hib has been included in the childhood vaccination programme and is now thankfully rare. It can also cause other serious infections including meningitis and septicaemia etc.
Haemophilus influenzae type A is a rare disease.
Staphylococcus aureuscommonly causes skin infections including abscesses, respiratory infections such as sinusitis, and food poisoning.
Streptococcus pneumoniae commonly causes bronchitis, otitis media ans sinusitis.
Meningococcal type B is the most common cause meningococcal disease in the UK and is routinely vaccinated against in the national childhood vaccination programme.
SDLS-Surfactant deficient lung disease
caused by
-insufficient surfactant production and
-structural immaturity of the lungs
*Other risk factors for SDLD include
male sex
diabetic mothers
Caesarean section
second born of premature twins
Clinical features are those common to respiratory distress in the newborn, i.e.
-tachypnoea,
-intercostal recession,
-expiratory grunting and cyanosis
Chest x-ray characteristically shows ‘ground-glass’ appearance with an indistinct heart border
Hypertension in children
In younger children secondary hypertension is the most common cause, with renal parenchymal disease accounting for up to 80%
Causes of hypertension in children
renal parenchymal disease
renal vascular disease
coarctation of the aorta
phaeochromocytoma
congenital adrenal hyperplasia
essential or primary hypertension (becomes more common as children become older)
asthma attack in children
Steroid therapy should be given to all children who have an asthma attack
IUD
The answer here is the copper intrauterine device. According to the Faculty of Reproductive and Sexual health guidelines, breast cancer is a contraindication to all hormonal forms of contraception, rated as a Category 4- an unacceptable health risk to the patient.
Hernia: High risk of strangulation
High risk of strangulation: femoral hernia
Passes lateral to the inferior epigastric artery: indirect inguinal hernia
Causes of persistent non-visible haematuria
Cancers of the bladder, kidney and prostate
Stones
Benign prostatic hyperplasia
Renal causes: such as IgA nephropathy, thin basement membrane disease
Infections: such as Prostatitis and Urethritis e.g. Chlamydia
Undescended testicles are associated with an increased risk of
infertility,
torsion and
testicular cancer
Medical treatments for postpartum haemorrhage secondary to uterine atony include oxytocin, ergometrine, carboprost and misoprostol
oxytocin,
ergometrine,
carboprost and
misoprostol
In addition to the usual steps taken in an episode of PPH (including an ABC approach if the patient is unstable), the following management should be initiated in sequence:
bimanual uterine compression to manually stimulate contraction
intravenous oxytocin and/or ergometrine
intramuscular carboprost
intramyometrial carboprost
rectal misoprostol
surgical intervention such as balloon tamponade
If fetal movements have not yet been felt by ? weeks, referral should be made to a maternal fetal medicine unit
24 weeks
Haemochromatosis: features
Reversible complications
Cardiomyopathy
Skin pigmentation
Irreversible complications
Liver cirrhosis**
Diabetes mellitus
Hypogonadotrophic hypogonadism
Arthropathy
Quick comparison: Acute coronary syndrome: NICE guidance management
Radial access, give unfractionated heparin, use drug-eluting stent
STEMI identified, aspirin given, having PCI, prasugrel given
NSTEMI identified, aspirin given, intermediate/high risk, ticagrelor given, having PCI
Give ticagrelor
STEMI identified, aspirin given, has had fibrinolysis + antithrombin given
Quick comparison: Aggravating factors
Beta-blockers
psoriasis
glycaemic control in diabetes
Tricyclic antidepressants
urinary retention
Quick comparison: Antibodies
P-ANCA
primary sclerosing cholangitis
ulcerative colitis
Churg-Strauss syndrome
Rheumatoid factor
Sjogren’s syndrome
Quick comparison: Stomas
Any location, flush to skin
loop colostomy
Right iliac fossa, spouted
end ileostomy
loop ileostomy
Intravenous cefotaxime + amoxicillin
initial empirical therapy of meningitis (aged > 50 years)
initial empirical therapy of meningitis (aged < 3 months)
Hypocalcaemia: causes and management
Causes
vitamin D deficiency (osteomalacia)
chronic kidney disease
hypoparathyroidism (e.g. post thyroid/parathyroid surgery)
pseudohypoparathyroidism (target cells insensitive to PTH)
rhabdomyolysis (initial stages)
magnesium deficiency (due to end organ PTH resistance)
massive blood transfusion
acute pancreatitis
Contamination of blood samples with EDTA may also give falsely low calcium levels.
Management
severe hypocalcaemia (e.g. carpopedal spasm, tetany, seizures or prolonged QT interval) requires IV calcium replacement
the preferred method is with intravenous calcium gluconate, 10ml of 10% solution over 10 minutes
intravenous calcium chloride is more likely to cause local irritation
ECG monitoring is recommended
further management depends on the underlying cause
Anaphylaxis & Adrenaline dose
< 6 months
100 - 150 micrograms (0.1 - 0.15 ml 1 in 1,000)
6 months - 6 years
150 micrograms (0.15 ml 1 in 1,000)
6-12 years
300 micrograms (0.3ml 1 in 1,000)
Adult and child > 12 years
500 micrograms (0.5ml 1 in 1,000)
Chicken pox & pregnancy
Pregnant with rash:
Pregnant women ≥ 20 weeks who develop chickenpox are generally treated with oral aciclovir if they present within 24 hours of the rash
screening tool for postnatal depression
Edinburgh Scale
Umbilical cord prolapse
Risk factors for cord prolapse include:
-*Artificial amniotomy: Around 50% of cord prolapse occurs after artificial rupture of membranes
-prematurity
-multiparity
-polyhydramnios
-twin pregnancy
-cephalopelvic disproportion
-abnormal presentations e.g. Breech, transverse lie
Cephalic presentation, nulliparity and prolonged pregnancy all reduce the likelihood of umbilical cord prolapse
Umbilical cord prolapse involves the umbilical cord descending ahead of the presenting part of the fetus.
Suspected PE in pregnant women with a confirmed DVT
-Treat with LMWH first then investigate to rule in/out
-Thrombolysis is contraindicated in pregnancy as it can cause catastrophic haemorrhage of the placenta and the foetus.
For patients with a suspected deep vein thrombosis (DVT):
Compression duplex ultrasound should be undertaken where there is clinical suspicion of DVT
For patients with a suspected pulmonary embolism (PE):
ECG and chest x-ray should be performed in all patients
In women who also have symptoms and signs of DVT, compression duplex ultrasound should be performed. If compression ultrasonography confirms the presence of DVT, no further investigation is necessary and treatment for VTE should continue
the decision to perform a V/Q or CTPA should be taken at a local level after discussion with the patient and radiologist
CTPA
CTPA slightly increases the lifetime risk of maternal breast cancer
V/Q scanning
V/Q scanning carries a slightly increased risk of childhood cancer compared with CTPA
D-dimer is of limited use in the investigation of thromboembolism as it often raised in pregnancy.
A calcified Ghon complex may be seen on the CXR of a patient with
latent TB
purely motor, a purely sensory or a mixed motor and sensory deficit in
A patient having a lacunar stroke would present with either a purely motor, a purely sensory or a mixed motor and sensory deficit
ACS & Anemia
The transfusion threshold for patients with ACS is 80 g/L
without ACS with ACS Transfusion threshold 70 g/L 80 g/L Target after transfusion 70-90 g/L 80-100 g/L
Rheumatoid arthritis: ocular manifestations
keratoconjunctivitis sicca (most common)
episcleritis (erythema)
scleritis (erythema and pain)
corneal ulceration
keratitis
Rheumatoid arthritis most common ocular manifestations
keratoconjunctivitis sicca (most common)
A 56-year-old woman who is known to have gallstones presents with severe epigastric pain and vomiting. On examination she is apyrexial and tender in the epigastrium.
Acute pancreatitis
Gallstones and alcohol are the two most common causes of acute pancreatitis. The site of pain and absence of fever point away from a diagnosis of acute cholecystitis.
PAOG Drugs AEs
Prostaglandin analogues (e.g. latanoprost)
-Increases uveoscleral outflow
-Brown pigmentation of the iris, increased eyelash length
Beta-blockers (e.g. timolol, betaxolol)
-Reduces aqueous production
-Should be avoided in asthmatics and patients with heart block
Sympathomimetics (e.g. brimonidine, an alpha2-adrenoceptor agonist)
-Reduces aqueous production and increases outflow
-Avoid if taking MAOI or tricyclic antidepressants
–Adverse effects include hyperaemia
Carbonic anhydrase inhibitors (e.g. Dorzolamide)
-Reduces aqueous production
-Systemic absorption may cause sulphonamide-like reactions
Miotics (e.g. pilocarpine, a muscarinic receptor agonist)
-Increases uveoscleral outflow
-Adverse effects included a constricted pupil, headache and blurred vision
BPH/Prostatitis:
Tamsulosin: Alpha blockers can cause first dose hypotension
Finasteride: Oligospermia
Tamsulosin: Alpha blockers can cause first dose hypotension
Finasteride: Oligospermia
Tamsulosin is an alpha adrenergic blocker which preferentially acts on receptors in the prostate. This causes improved urine flow in benign prostatic hypertrophy. Alpha blockers can cause first dose hypotension - a reduction in blood pressure following the first dose, causing a vasovagal faint.
Finasteride: Oligospermia
Finasteride inhibits the enzyme 5 ɑ-redutase, reducing conversion of testosterone to dihydrotesterone. Dihydrotestosterone promotes prostate growth. Finasteride is licensed for benign prostatic hypertrophy, and can be used off-license in chronic prostatitis. It can cause infertility, sexual dysfunction, and abnormal breast growth
Quick comparison: Hepatitis viruses
Quick comparison: Hepatitis viruses
Hepatitis E:
is spread by the faecal-oral route
has a particularly high mortality rate in pregnant women
Hepatitis C:
may cause chronic hepatitis
cannot be vaccinated against
causes the most morbidity in IVDUs
is spread by the parenteral, sexual and vertical transmission route
may cause cryoglobulinaemia
increases the risk of hepatocellular cancer
Quick comparison: Risk factors: female cancers
HNPCC: endometrial cancer
Smoking: cervical cancer
Endometrial cancer
-Risk factors
-Protective factors
Risk factors
excess oestrogen
-nulliparity
-early menarche
-late menopause
-unopposed oestrogen. The addition of a progestogen to oestrogen reduces this risk (e.g. In HRT)
metabolic syndrome
-obesity
-diabetes mellitus
-polycystic ovarian syndrome
–tamoxifen
–hereditary non-polyposis colorectal carcinoma
Protective factors
-multiparity
-combined oral contraceptive pill
-smoking (the reasons for this are unclear)
Lung cancer: paraneoplastic features
Small cell
-ADH
-ACTH - not typical, hypertension, hyperglycaemia, hypokalaemia, alkalosis and muscle weakness are more common than buffalo hump etc
-Lambert-Eaton syndrome
Squamous cell
-parathyroid hormone-related protein (PTH-rp) secretion causing hypercalcaemia
-clubbing
-hypertrophic pulmonary osteoarthropathy (HPOA)
-hyperthyroidism due to ectopic TSH
a non-pulsatile raised JVP
SVC obstruction
Jugular venous pulse
‘a’ wave = atrial contraction
large if atrial pressure e.g. tricuspid stenosis, pulmonary stenosis, pulmonary hypertension
absent if in atrial fibrillation
Cannon ‘a’ waves
caused by atrial contractions against a closed tricuspid valve
are seen in complete heart block, ventricular tachycardia/ectopics, nodal rhythm, single chamber ventricular pacing
‘c’ wave
closure of tricuspid valve
not normally visible
‘v’ wave
due to passive filling of blood into the atrium against a closed tricuspid valve
giant v waves in tricuspid regurgitation
‘x’ descent = fall in atrial pressure during ventricular systole
‘y’ descent = opening of tricuspid valve
Blood product transfusion complications
Non-haemolytic febrile reaction
Fever, chills
Minor allergic reaction
Pruritus, urticaria
Anaphylaxis
Hypotension, dyspnoea, wheezing, angioedema.
Acute haemolytic reaction
Fever, abdominal pain, hypotension
Transfusion-associated circulatory overload (TACO)
Pulmonary oedema, hypertension
Transfusion-related acute lung injury (TRALI)
Hypoxia, pulmonary infiltrates on chest x-ray, fever, hypotension
HLA associations
HLA antigens are encoded for by genes on chromosome 6. HLA A, B and C are class I antigens whilst DP, DQ, DR are class II antigens. Questions are often based around which diseases have strong HLA associations. The most important associations are listed below:
HLA-A3
haemochromatosis
HLA-B51
Behcet’s disease
HLA-B27
ankylosing spondylitis
reactive arthritis
acute anterior uveitis
psoriatic arthritis
HLA-DQ2/DQ8
coeliac disease
HLA-DR2
narcolepsy
Goodpasture’s
HLA-DR3
dermatitis herpetiformis
Sjogren’s syndrome
primary biliary cirrhosis
HLA-DR4
type 1 diabetes mellitus*
rheumatoid arthritis - in particular the DRB1 gene (DRB104:01 and DRB104:04 hence the association with DR4)
Blood films: pathological cell forms
Target cells:
-Sickle-cell/thalassaemia
-Iron-deficiency anaemia
-Hyposplenism
-Liver disease
‘Tear-drop’ poikilocytes:
Myelofibrosis
Spherocytes:
Hereditary spherocytosis
Autoimmune hemolytic anaemia
Basophilic stippling:
Lead poisoning
Thalassaemia
Sideroblastic anaemia
Myelodysplasia
Howell-Jolly bodies:
Hyposplenism
Heinz bodies:
G6PD deficiency
Alpha-thalassaemia
Schistocytes (‘helmet cells’):
Intravascular haemolysis
Mechanical heart valve
Disseminated intravascular coagulation
‘Pencil’ poikilocytes:
Iron deficency anaemia
Burr cells (echinocytes):
Uraemia
Pyruvate kinase deficiency
Acanthocytes:
Abetalipoproteinemia
Other blood film abnormalities:
hypersegmented neutrophils: megaloblastic anaemia
Disorders of sex hormones
Androgen insensitivity syndrome:
High LH Normal/high Testosterone
Testosterone-secreting tumour:
Low LH High Testosterone
Primary hypogonadism (Klinefelter’s syndrome) High LH Low Testosterone
Hypogonadotrophic hypogonadism (Kallman’s syndrome)
Low LH Low Testosterone
Unfractionated heparin & low molecular weight heparin: MOA
Unfractionated heparin
activates antithrombin III. Forms a complex that inhibits thrombin, factors Xa, IXa, Xia and XIIa
low molecular weight heparin
Activates antithrombin III. Forms a complex that inhibits factor ONLY Xa
Hypersensitivity
Type I - Anaphylactic
Antigen reacts with IgE bound to mast cells
* Anaphylaxis
* Atopy (e.g. asthma, eczema and hayfever)
Type II - Cell bound
IgG or IgM binds to antigen on cell surface
* Autoimmune haemolytic anaemia
* ITP
* Goodpasture’s syndrome
* Pernicious anaemia
* Acute haemolytic transfusion reactions
* Rheumatic fever
* Pemphigus vulgaris / bullous pemphigoid
Type III - Immune complex
Free antigen and antibody (IgG, IgA) combine
* Serum sickness
* Systemic lupus erythematosus
* Post-streptococcal glomerulonephritis
* Extrinsic allergic alveolitis (especially acute phase)
Type IV - Delayed hypersensitivity
T-cell mediated
* Tuberculosis / tuberculin skin reaction
* Graft versus host disease
* Allergic contact dermatitis
* Scabies
* Extrinsic allergic alveolitis (especially chronic phase)
* Multiple sclerosis
* Guillain-Barre syndrome
Type V
Antibodies that recognise and bind to the cell surface receptors.
This either stimulating them or blocking ligand binding * Graves’ disease
* Myasthenia gravis
COPD standby medication
short course of oral corticosteroids and oral antibiotics to keep at home
Palliative care prescribing: pain
Opioid side-effects:
Usually transient
Nausea
Drowsiness
Usually persistent:
Constipation
Conversion between opioids:
Oral codeine - Oral morphine Divide by 10
Oral tramadol - Oral morphine Divide by 10**
Oral morphine - Oral oxycodone Divide by 1.5-2
Oral morphine - S/C morphine Divide by 2
Oral morphine - S/C diamorphine Divide by 3
Oral oxycodone - S/C diamorphine Divide by 1.5
A single dose of oral dexamethasone (0.15 mg/kg) is to be taken immediately regardless of severity
Croup
guttate psoriasis mgt
Reassurance + topical treatment if lesions are symptomatic
-‘evidence does not support a therapeutic benefit from antibiotic therapy’.
Management
most cases resolve spontaneously within 2-3 months
there is no firm evidence to support the use of antibiotics to eradicate streptococcal infection
topical agents as per psoriasis
UVB phototherapy
tonsillectomy may be necessary with recurrent episodes
Differentiating guttate psoriasis and pityriasis rosea
Guttate psoriasis:
Classically preceded by a streptococcal sore throat 2-4 weeks
Tear drop’, scaly papules on the trunk and limbs
Most cases resolve spontaneously within 2-3 months
Topical agents as per psoriasis
UVB phototherapy
Pityriasis rosea:
Many patients report recent respiratory tract infections but this is not common in questions
Herald patch followed 1-2 weeks later by multiple erythematous, slightly raised oval lesions with a fine scale confined to the outer aspects of the lesions.
May follow a characteristic distribution with the longitudinal diameters of the oval lesions running parallel to the line of Langer. This may produce a ‘fir-tree’ appearance
Self-limiting, resolves after around 6 weeks
Hepatitis B serology
HBsAg negative, anti-HBs positive, IgG anti-HBc positive - previous infection, not a carrier
HBsAg = ongoing infection, either acute or chronic if present > 6 months
anti-HBc = caught, i.e. negative if immunized
It is important to remember a few key facts:
-HBsAg-surface antigen implies DISEASE
*first marker to appear
*causes the production of anti-HBs
*HBsAg normally implies acute disease (present for 1-6 months)
*if HBsAg is present for > 6 months then this implies chronic disease (i.e. Infective)
-Anti-HBs implies IMMUNITY (either exposure or immunisation).
*negative in chronic disease
-Anti-HBc implies previous (or current) infection.
*IgM anti-HBc appears during acute or recent hepatitis B infection and is present for about 6 months.
*IgG anti-HBc persists
-HbeAg results from
*breakdown of core antigen from infected liver cells as is, therefore,
*a marker of infectivity.
*Marker of HBV replication and infectivity
Example results
previous immunisation: anti-HBs positive, all others negative
previous hepatitis B (> 6 months ago), not a carrier: anti-HBc positive, HBsAg negative
previous hepatitis B, now a carrier: anti-HBc positive, HBsAg positive
All patients with peripheral arterial disease should take
clopidogrel and atorvastatin
CKD: only diagnose stages 1 & 2 if
-supporting evidence to accompany eGFR
-such as urinalysis or renal ultrasound are abnormal
-*i.e. normal U&Es and no proteinuria
Clindamycin treatment is associated with a high risk of
C. difficile
Clostridioides difficile Management
First episode of C. difficile infection:
first-line therapy is oral vancomycin for 10 days
second-line therapy: oral fidaxomicin
third-line therapy: oral vancomycin +/- IV metronidazole
Recurrent episode:
within 12 weeks of symptom resolution: oral fidaxomicin
after 12 weeks of symptom resolution: oral vancomycin OR fidaxomicin
Life-threatening C. difficile infection:
oral vancomycin AND IV metronidazole
specialist advice - surgery may be considered
Other therapies:
bezlotoxumab is a monoclonal antibody which targets C. difficile toxin B
NICE do not currently support its use to prevent recurrences as it is not cost-effective
faecal microbiota transplant
may be considered for patients who’ve had 2 or more previous episodes
A beta-blocker or a calcium channel blocker is used first-line to prevent
angina attacks
Start alendronate in patients without waiting for a DEXA scan
> = 75 years following a fragility fracture, without waiting for a DEXA scan
Causes of raised prolactin - the p’s
pregnancy
prolactinoma
physiological
polycystic ovarian syndrome
primary hypothyroidism
phenothiazines, metoclopramide, domperidone
Klebsiella most commonly causes a
-cavitating pneumonia in the upper lobes, mainly in
-diabetics and
-alcoholics
Obese, young female with headaches / blurred vision think
idiopathic intracranial hypertension
Unexplained symptoms
Somatisation = Symptoms
hypoChondria = Cancer
Migraine
acute: triptan + NSAID or triptan + paracetamol
prophylaxis: topiramate or propranolol
Shingles Mgt:
Oral aciclovir
-Steroids not recommended
Glasgow Coma Scale: adults
Eye opening
4. Spontaneous
3. To speech
2. To pain
1. None
Verbal response
5. Orientated
4. Confused
3. Words
2. Sounds
1. None
Motor response
6. Obeys commands
5. Localises to pain
4. Withdraws from pain
3. Abnormal flexion to pain (decorticate posture)
2. Extending to pain
1. None
Red Flags for back pain include
Thoracic pain
Age <20 or >55 years
Non-mechanical pain
Pain worse when supine
Night pain
Weight loss
Pain associated with systemic illness
Presence of neurological signs
Past medical history of cancer or HIV
Immunosuppression or steroid use
IV drug use
Structural deformity
generalised anxiety disorder mgt
SSRIs are the first-line pharmacological therapy for generalised anxiety disorder
Rotator cuff injury
Rotator cuff injuries are the most common cause of shoulder problems. A spectrum of disease is recognised:
1. Subacromial impingement (also known as impingement syndrome, painful arc syndrome)
2. Calcific tendonitis
3. Rotator cuff tears
4. Rotator cuff arthropathy
Symptoms
shoulder pain worse on abduction
Subacromial impingement
-painful arc of abduction.
-typically between 60 and 120 degrees (rotator cuff tears in the first 60 degrees)
Eyelid problems
Eyelid problems commonly encountered include:
blepharitis: inflammation of the eyelid margins typically leading to a red eye
stye: infection of the glands of the eyelids
chalazion (Meibomian cyst)
entropion: in-turning of the eyelids
ectropion: out-turning of the eyelids
Stye
Different types of stye are recognised:
external (hordeolum externum): infection (usually staphylococcal) of the glands of Zeis (sebum producing) or glands of Moll (sweat glands).
internal (hordeolum internum): infection of the Meibomian glands. May leave a residual chalazion (Meibomian cyst)
management includes hot compresses and analgesia. CKS only recommend topical antibiotics if there is an associated conjunctivitis
A chalazion (Meibomian cyst) is a retention cyst of the Meibomian gland. It presents as a firm painless lump in the eyelid. The majority of cases resolve spontaneously but some require surgical drainage
Trimethoprim and co-trimoxazole should be avoided in patients on
methotrexate
ankylosing spondylitis mgt
Exercise regimes and NSAIDs are the 1st line management for ankylosing spondylitis
Campylobacter jejuni infection
Campylobacter jejuni infection may cause marked right iliac fossa pain mimicking appendicitis
Gastroenteritis: causes
Incubation period
1-6 hrs: Staphylococcus aureus, Bacillus cereus*
12-48 hrs: Salmonella, Escherichia coli
48-72 hrs: Shigella, Campylobacter
> 7 days: Giardiasis, Amoebiasis
Escherichia coli
Common amongst travellers
Watery stools
Abdominal cramps and nausea
Giardiasis
Prolonged, non-bloody diarrhea
Cholera
Profuse, watery diarrhoea
Severe dehydration resulting in weight loss
Not common amongst travelers
Shigella
Bloody diarrhoea
Vomiting and abdominal pain
Staphylococcus aureus
Severe vomiting
Short incubation period
Campylobacter
A flu-like prodrome is usually followed by crampy abdominal pains, fever and diarrhoea which may be bloody
May mimic appendicitis
Complications include Guillain-Barre syndrome
Bacillus cereus
Two types of illness are seen
vomiting within 6 hours, stereotypically due to rice
diarrhoeal illness occurring after 6 hours
Amoebiasis
Gradual onset bloody diarrhoea, abdominal pain and tenderness which may last for several weeks
TIA in pts with warfarin/a DOAC/ or has a bleeding disorder
If a patient is on warfarin/a DOAC/ or has a bleeding disorder and they are suspected of having a TIA, they should be admitted immediately for imaging to exclude a haemorrhage
Uncomplicated tympanic membrane perforation can be managed with
watchful waiting for a month
Post term 42 weeks presents in the first 24-48 hours of life with abdominal distension and bilious vomiting, more common in cystic fibrosis
Meconium ileus
Necrotising enterocolitis usually presents after the second week of life & preterm usually
Subacute vs Hashimoto’s thyroiditis
Subacute thyroiditis can be distinguished from Hashimoto’s as a cause of hypothyroid by tenderness of the thyroid gland
Breast fibroadenoma
less than 3cm on imaging:
watchful waiting without biopsy
If >3cm:
surgical excision is usual
Hypoxia kills
Any critically ill patient (including CO2 retainers) should initially be treated with high flow oxygen which is then titrated to achieve target sats. Hypoxia kills
Patient >= 60 years old with new iron-deficiency anaemia → urgent colorectal cancer pathway referral
NICE now recommend doing Faecal Immunochemical Test (FIT) testing before deciding whether to refer people of the urgent suspected colorectal cancer pathway for a colonoscopy.
A patient with AF + an acute stroke (not haemorrhagic) should have anticoagulation therapy started
two weeks after the event
Atrial fibrillation: post-stroke
Atrial fibrillation is one of the key risk factors for ischaemic stroke. It is therefore very important to recognise and treat atrial fibrillation if it’s identified in a patient following a stroke or transient ischaemic attack (TIA).
Management
following a stroke or TIA it is obviously important to exclude a haemorrhage before starting any anticoagulation or antiplatelet therapy
for longer-term stroke prevention, NICE recommend warfarin or a direct thrombin or factor Xa inhibitor
the timing of when to start depends on whether it is a TIA or stroke
following a TIA, anticoagulation for AF should start immediately once imaging has excluded haemorrhage
in acute stroke patients, in the absence of haemorrhage, anticoagulation therapy should be commenced after 2 weeks. Antiplatelet therapy should be given in the intervening period. If imaging shows a very large cerebral infarction then the initiation of anticoagulation should be delayed
If a mild-moderate flare of ulcerative colitis does not respond to topical or oral aminosalicylates then
oral corticosteroids are added
Ulcerative colitis: management
Treatment can be divided into inducing and maintaining remission. NICE updated their guidelines on the management of ulcerative colitis in 2019.
The severity of UC is usually classified as being mild, moderate or severe:
mild: < 4 stools/day, only a small amount of blood
moderate: 4-6 stools/day, varying amounts of blood, no systemic upset
severe: >6 bloody stools per day + features of systemic upset (pyrexia, tachycardia, anaemia, raised inflammatory markers)
Inducing remission
Treating mild-to-moderate ulcerative colitis
proctitis
topical (rectal) aminosalicylate: for distal colitis rectal mesalazine has been shown to be superior to rectal steroids and oral aminosalicylates
if remission is not achieved within 4 weeks, add an oral aminosalicylate
if remission still not achieved add topical or oral corticosteroid
proctosigmoiditis and left-sided ulcerative colitis
topical (rectal) aminosalicylate
if remission is not achieved within 4 weeks, add a high-dose oral aminosalicylate OR switch to a high-dose oral aminosalicylate and a topical corticosteroid
if remission still not achieved stop topical treatments and offer an oral aminosalicylate and an oral corticosteroid
extensive disease
topical (rectal) aminosalicylate and a high-dose oral aminosalicylate:
if remission is not achieved within 4 weeks, stop topical treatments and offer a high-dose oral aminosalicylate and an oral corticosteroid
Severe colitis
should be treated in hospital
IV steroids are usually given first-line
IV ciclosporin may be used if steroids are contraindicated
if after 72 hours there has been no improvement, consider adding IV ciclosporin to IV corticosteroids or consider surgery
Maintaining remission
Following a mild-to-moderate ulcerative colitis flare
proctitis and proctosigmoiditis
topical (rectal) aminosalicylate alone (daily or intermittent) or
an oral aminosalicylate plus a topical (rectal) aminosalicylate (daily or intermittent) or
an oral aminosalicylate by itself: this may not be effective as the other two options
left-sided and extensive ulcerative colitis
low maintenance dose of an oral aminosalicylate
Following a severe relapse or >=2 exacerbations in the past year
oral azathioprine or oral mercaptopurine
Other points
methotrexate is not recommended for the management of UC (in contrast to Crohn’s disease)
there is some evidence that probiotics may prevent relapse in patients with mild to moderate disease
TIA according to new guidance.
The definition of a TIA is now tissue-based, not time-based: a transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischaemia, without acute infarction
The fact that Mary’s symptoms lasted 22 hours would fit with the old definition of a TIA- a sudden onset of a focal neurologic symptom and/or sign lasting less than 24 hours, however this is not mentioned in the new guidance.
The presence of a new infarct on MRI attributable to this episode means that this cannot be defined as a TIA according to new guidance.
A transient ischaemic attack (TIA), as the name suggests, is a brief period of neurological deficit due to a vascular cause, typically lasting less than an hour. The National Clinical Guideline for Stroke was published in 2023 and made a number of updated recommendations, including the use of dual antiplatelet therapy (DAPT). It should be noted that DAPT is not currently recommended for ‘major’ ischaemic stroke as the risk of haemorrhagic transformation is too high.
The original definition of a TIA was time-based: a sudden onset of a focal neurologic symptom and/or sign lasting less than 24 hours, brought on by a transient decrease in blood flow. However, this has now changed as it is recognised that even short periods of ischaemia can result in pathological changes to the brain. Therefore, a new ‘tissue-based’ definition is now used: a transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischaemia, without acute infarction. REF
Patients often use the term ‘mini-stroke’ for TIAs.
manage the acute flares of rheumatoid arthritis with
Intramuscular steroids such as methylprednisolone
prophylaxis for contacts of patients with meningococcal meningitis
Oral ciprofloxacin or rifampicin
Lithium toxicity may be precipitated by: DRD damn
DRD:
-dehydration
-renal failure
-drugs: damn
–diuretics (especially thiazides),
–ACEIs/ARBs
–NSAIDs and
–metronidazole.
Pneumothorax: management
The British Thoracic Society (BTS) published updated guidelines for the management of spontaneous pneumothorax in 2023.
The updated guidelines put less emphasis on the size of the pneumothorax and more emphasis on whether the patient is symptomatic and the presence of high-risk characteristics.
Decision algorithm
The first step is assessing whether the patient is symptomatic
-minimal symptoms defined as ‘no significant pain or breathlessness and no physiological compromise’
-(Negative) or minimal symptoms → conservative care, regardless of pneumothorax size
-(Positive) symptomatic → assess for high-risk characteristics
If a pneumothorax is symptomatic, the next step is assessment for high-risk characteristics
-high-risk characteristics are as follows:
–haemodynamic compromise (suggesting a tension pneumothorax)
–significant hypoxia
–bilateral pneumothorax
–underlying lung disease
–≥ 50 years of age with significant smoking history
–haemothorax
(Negative) no high-risk characteristics are present, and it is safe to intervene, then there is a choice of intervention:
–conservative care
–ambulatory device
–needle aspiration
(Positive) high-risk characteristics are present, and it is safe to intervene → chest drain
How is safety or intervention determined?
-before a needle aspiration/chest drain insertion, the safety of intervention should be assessed
-this depends on the clinical context, but is usually:
–2cm laterally or apically on chest x-ray, or
–any size on CT scan which can be safely accessed with radiological support
Management options
Conservative care
-patients with a primary spontaneous pneumothorax that is managed conservatively should be reviewed every 2-4 days as an outpatient
-patients with a secondary spontaneous pneumothorax that is managed conservatively should be monitored as an inpatient
-if stable, follow-up in the outpatients department in 2-4 weeks
Ambulatory care
-an example of an ambulatory device is the Rocketµ Pleural Vent„
-it includes an 8FG catheter mounted on an 18G needle and a pigtail catheter to minimize the risk of occlusion
-ambulatory devices typically have a one-way valve and vent to prevent air and fluid return to the pleural space while allowing for controlled escape of air and drainage of fluid
-many devices also have an indication diaphragm that signals when the catheter tip enters the pleural space and continues to fluctuate with respiration, aiding in the assessment of pneumothorax resolution
Needle aspiration
-a chest drain should be inserted if needle aspiration of a pneumothorax is unsuccessful
-if resolved, discharge and follow-up in the outpatients department in 2-4 weeks
Chest drain insertion
-daily review as an inpatient
-remove drain when resolved
-discharge and follow-up in the outpatients department in 2-4 weeks
Persistentent / recurrent pneumothorax
If a patient has a persistent air leak or insufficient lung reexpansion despite chest drain insertion, or the patient has recurrent pneumothoraces, then video-assisted thoracoscopic surgery (VATS) should be considered to allow for mechanical/chemical pleurodesis +/- bullectomy.
Discharge advice
Smoking
patients should be advised to avoid smoking to reduce the risk of further episodes - the lifetime risk of developing a pneumothorax in healthy smoking men is around 10% compared with around 0.1% in non-smoking men
Fitness to fly
absolute contraindication, the CAA suggest patients may travel 2 weeks after successful drainage if there is no residual air. The British Thoracic Society used to recommend not travelling by air for a period of 6 weeks but this has now been changed to 1 week post check x-ray
Scuba diving
the BTS guidelines state: ‘Diving should be permanently avoided unless the patient has undergone bilateral surgical pleurectomy and has normal lung function and chest CT scan postoperatively.’
Primary biliary cholangitis - the M rule
IgM
anti-Mitochondrial antibodies, M2 subtype
Middle aged females
flu-like symptoms, RUQ pain, tender hepatomegaly and deranged LFTs
Hepatitis A
Miscarriage management
Expectant management is not suitable if evidence of infection or increased risk of haemorrhage
Acute pancreatitis mgt
Fluids and analgesia
Antibiotics should not be offered routinely to patients with acute pancreatitis
Anaphylaxis & Adrenaline
<6m: 100 - 150 micrograms (0.1 - 0.15 ml 1 in 1,000)
6 m - 6 y: 150 micrograms (0.15 ml 1 in 1,000)
6-12 y: 300 micrograms (0.3ml 1 in 1,000)
Adult and child > 12 y: 500 micrograms (0.5ml 1 in 1,000)
In the treatment of anaphylaxis, you can repeat adrenaline every 5 minutes
COPD standby medication:
NICE recommend offering a short course of oral Corticosteroids and Oral antibiotics (Azithromycin prophylaxis) to keep at home
Azithromycin prophylaxis is recommended in COPD patients who meet certain criteria and who continue to have exacerbations
In the 2010 NICE guidelines, there is a recommendation that patients who have frequent exacerbations of COPD should be given a home supply of corticosteroids and antibiotics
->3 exacerbations requiring steroid therapy and
-at least one exacerbation requiring hospital admission in the previous year
MHA Sections
Section 2
admission for assessment for up to 28 days, not renewable
treatment can be given against a patient’s wishes
Section 3
admission for treatment for up to 6 months, can be renewed
treatment can be given against a patient’s wishes
Section 4
72 hour assessment order
used as an emergency, when a section 2 would involve an unacceptable delay
often changed to a section 2 upon arrival at hospital
Section 5(2)
voluntary in-patient in hospital can be legally detained by a doctor for 72 hours
Section 5(4)
voluntary in-patient in hospital, allows a nurse to detain a patient for 6 hours
Section 17a
Supervised Community Treatment (Community Treatment Order)
can be used to recall a patient to hospital for treatment if they do not comply with conditions of the order in the community, such as complying with medication
Section 135
court order can be obtained to allow the police to break into a property to remove a person to a Place of Safety
Section 136
someone found in a public place who appears to have a mental disorder can be taken by the police to a Place of Safety
can only be used for up to 24 hours, whilst a Mental Health Act assessment is arranged
Asthma: new management in adults
In 2024 NICE, the British Thoracic Society and SIGN produced joint guidelines on the management of asthma following many years of conflicting guidelines. The new guidelines represent a major step change in the management of asthma is both diagnosed and treated.
For many years patients with asthma were started on a short-acting beta-2 agonist (SABA) inhaler before ‘stepping up’ to a regular inhaled corticosteroid with a SABA as required. The new guidelines now advocate the use of combined inhalers (ICS + long-acting beta-2 agonist) as reliever therapy or regularly, depending on the severity of asthma. Given the prevalence of asthma, it is likely that doctors will have to deal with patients on ‘conventional’ asthma treatments for many years to come. The joint guidelines therefore include guidance on how to manage these patients if their current treatment is controlling their symptoms sufficiently.
Management of adult patients aged children aged ≥ 12 years with newly diagnosed asthma
Step 1 NICE
a low-dose inhaled corticosteroid (ICS)/formoterol combination inhaler to be taken as needed for symptom relief
this is termed anti-inflammatory reliever (AIR) therapy
if the patient presents highly symptomatic (for example, regular nocturnal waking) or with a severe exacerbation:
start treatment with low-dose MART (maintenance and reliever therapy, see below)
treat the acute symptoms as appropriate (e.g. a course of oral corticosteroids may be indicated)
Step 2 NICE
a low-dose MART
MART describes using an inhaled corticosteroid (ICS)/formoterol combination inhaler for daily maintenance therapy and the relief of symptoms as needed, i.e. regularly and as required
Step 3
a moderate-dose MART
Step 4
check the fractional exhaled nitric oxide (FeNO) level if available, and the blood eosinophil count NICE
if either of these is raised, refer to a specialist in asthma care
if neither FeNO nor eosinophil count is raised, consider a trial of either a leukotriene receptor antagonist (LTRA) or a long-acting muscarinic receptor antagonist (LAMA) used in addition to moderate-dose MART
if control has not improved, stop the LTRA or LAMA and start a trial of the alternative medicine (LTRA or LAMA)
Step 5
refer people to a specialist in asthma care when asthma is not controlled despite treatment with moderate-dose MART, and trials of an LTRA and a LAMA
Transferring people aged 12 and over from other treatment pathways
There will be many people whose asthma was managed according to the previous guidelines that present with uncontrolled asthmatic symptoms. The guidelines give advice on how these people should be switched: NICE
Existing asthma treatment New asthma treatment
SABA as required only Low-dose ICS/formoterol combination inhaler used as needed (as-needed AIR therapy)
SABA as required + regular low-dose ICS
SABA as required + regular low-dose ICS/LABA
SABA as required + regular low-dose ICS + LTRA
SABA as required + regular low-dose ICS/LABA + LTRA Regular low-dose regular ICS/formoterol combination inhaler (MART therapy)
SABA as required + regular moderate-dose ICS
SABA as required + regular moderate-dose ICS/LABA
SABA as required + regular moderate-dose ICS + LTRA or LAMA
SABA as required + regular moderate-dose ICS/LABA + LTRA or LAMA Regular moderate-dose MART therapy
Treatment regime containing a high-dose ICS Refer to a respiratory specialist
Thought disorders
Circumstantiality is the inability to answer a question without giving excessive, unnecessary detail. However, this differs from tangentiality in that the person does eventually return to the original point.
Tangentiality refers to wandering from a topic without returning to it.
Neologisms are new word formations, which might include the combining of two words.
Clang associations are when ideas are related to each other only by the fact they sound similar or rhyme.
Word salad describes completely incoherent speech where real words are strung together into nonsense sentences.
Knight’s move thinking is a severe type of loosening of associations, where there are unexpected and illogical leaps from one idea to another. It is a feature of schizophrenia.
Flight of ideas, a feature of mania, is a thought disorder where there are leaps from one topic to another but with discernible links between them.
Perseveration is the repetition of ideas or words despite an attempt to change the topic.
Echolalia is the repetition of someone else’s speech, including the question that was asked.
Fluoxetine & tamoxifen
Fluoxetine is predicted to decrease the effectiveness of tamoxifen, and the manufacturer advises avoidance.
A 65 year old man suffers an ischaemic stroke after starting a medication for gout.
Which medication is most likely to cause this effect?
C. Colchicine
A 40 year old man forgot to pack his gout medication when traveling abroad for several months. On his return home he restarts his medication, and within days suffers a severe attack of gout.
Which medication is most likely to cause this effect?
A. Allopurinol
It’s typically recommended that allopurinol be restarted gradually, and that medications like colchicine or NSAIDs (e.g., ibuprofen) be used simultaneously for the first few months to prevent flare-ups when starting urate-lowering therapy.
A woman with rheumatoid arthritis is required to have urinalysis every three months.
Which medication is she most likely to be taking?
Penicillamine (causing nephrotic syndrome)
A woman with rheumatoid arthritis is assessed for signs of chicken pox at her weekly appointments.
Which medication is she most likely to be taking?
A. Adalimumab
A 60-year-old man with hypertension and type 2 diabetes starts a fourth antihypertensive medication. Paramedics are called after he suddenly collapses at home, and he is found to be hypoglycemic.
Which medication is most likely to cause this effect?
F. Propranolol
A 30 year old man takes medication on an aeroplane flight due to fear of flying. He becomes uncharacteristically hostile and aggressive, and the flight makes an emergency landing to remove him.
Which medication is most likely to cause this effect?
A. Diazepam
BZDs cause paradoxical & hostility as side effect
Drug induced Psoriasis
Beta-blockers are well known to cause drug-induced psoriasis
A 9 month old baby with non-IgE mediated cow’s milk protein allergy drinks milk from another infant’s bottle. She develops itching, abdominal pain and diarrhoea.
Which milk is most likely to produce this effect?
A. Amino acid formula
B. Extensively hydrolysed formula
C. Extensively hydrolysed follow-on formula
D. Human breast milk
E. Lactose-free formula
E. Lactose-free formula
? also calld glandular fever is caused by the
Epstein-Barr virus (EBV, also known as
human herpesvirus 4, HHV-4
Deranged liver function tests
Infectious mononucleosis
Chronic lymphocytic leukaemia: complications: WHAT
Complications WHAT
anaemia
hypogammaglobulinaemia leading to recurrent infections
warm autoimmune haemolytic anaemia in 10-15% of patients
transformation to high-grade lymphoma (Richter’s transformation)
Richter’s transformation
Ritcher’s transformation occurs when leukaemia cells enter the lymph node and change into a high-grade, fast-growing non-Hodgkin’s lymphoma. Patients often become unwell very suddenly.
Ritcher’s transformation is indicated by one of the following symptoms:
lymph node swelling
fever without infection
weight loss
night sweats
nausea
abdominal pain
Quick comparison: Arterial blood gas interpretation
↓ pH - ↓ CO2 - ↓ HCO3-
metabolic acidosis with respiratory compensation
↓ pH - Normal CO2 - ↓ HCO3-
metabolic acidosis
ABG
ROME
Respiratory = Opposite
low pH + high PaCO2 i.e. acidosis, or
high pH + low PaCO2 i.e. alkalosis
Metabolic = Equal
low pH + low bicarbonate i.e. acidosis, or
high pH + high bicarbonate i.e. akalosis
Quick comparison: Stereotypical histories (bone disorders)
Quick comparison: Stereotypical histories (bone disorders)
Pott’s disease (TB)
a 35-year-old man who has recently emigrated to the country presents with back pain associated with night sweats. He has also lost 5kg in weight over the past month
Osteomalacia
a female immigrant from the Indian subcontinent presents with ‘bone pain’, muscle weakness and anorexia. Bloods show a decreased calcium and phosphate level
Murmurs
Ejection systolic
-louder on expiration
–aortic stenosis
–hypertrophic obstructive cardiomyopathy
-louder on inspiration
–pulmonary stenosis
–atrial septal defect
also: tetralogy of Fallot
Holosystolic (pansystolic)
-mitral/tricuspid regurgitation (high-pitched and ‘blowing’ in character)
-tricuspid regurgitation becomes louder during inspiration, unlike mitral reguritation
during inspiration, the venous blood flow into the right atrium and ventricle are increased → increases the stroke volume of the right ventricle during systole
-ventricular septal defect (‘harsh’ in character)
Late systolic
-mitral valve prolapse
-coarctation of aorta
Early diastolic
-aortic regurgitation (high-pitched and ‘blowing’ in character)
-Graham-Steel murmur (pulmonary regurgitation, again high-pitched and ‘blowing’ in character)
Mid-late diastolic
-mitral stenosis (‘rumbling’ in character)
-Austin-Flint murmur (severe aortic regurgitation, again is ‘rumbling’ in character)
Continuous machine-like murmur
-patent ductus arteriosus
RILE
Right-sided murmur → heard best on Inspiration
Left-sided murmur → heard best on Expiration
Quick comparison: Stereotypical histories (respiratory infections)
Quick comparison: Stereotypical histories (respiratory infections)
Mycoplasma pneumonia
a 20-year-old man presents in summer with gradually worsening flu-like symptoms and a dry cough. On examination he is noted to have erythema multiforme
Legionnaires’ disease
a 60-year-old man presents with flu-like symptoms and a dry cough. On examination he has a relative bradycardia and appears slightly confused. His blood tests show a low sodium
UK perinatal mortality rate definition
The number of stillbirths and early neonatal deaths (less than 7 days) per 1000 live births and stillbirths
The UK perinatal mortality rate includes all deaths that occur after 24 weeks gestation and 7 days of life. This differs from the World Health Organisation (WHO) definition, which also includes late miscarriages between 22 and 23+6 weeks gestation. The total number of neonatal deaths per 100 live births’ as described in option C is the Neonatal Mortality Rate.
indication for tonsillectomy
Enlargement of tonsils is not in itself an indication for tonsillectomy. The indications are:
- Airway obstruction with persistent noisy breathing and suspected or proven sleep apnea
- Suspicion of lymphoma
- Recurrent attacks of tonsillitis (7 in a year / 5 per year for 2 years/ 3 per year for 3 years)
- 2 or more attacks of peritonsillar abscess.
Quick comparison: Drug adverse effects
Flushing
sildenafil
adenosine
amlodipine
verapamil
nicorandil
isosorbide mononitrate
tamoxifen
nicotinic acid
Hypotension
diltiazem
verapamil
levodopa
isosorbide mononitrate
bromocriptine
Quick comparison: Blood film abnormalities
Thalassaemia
target cells
Heinz bodies
basophilic stippling
Sickle-cell anaemia
target cells
Quick comparison: Features (vasculitides)
Thrombophlebitis and deep vein thrombosis
Behcet’s syndrome
An association with heavy smoking
Buerger’s disease
Syphilis: Treponema pallidum
Primary features
chancre - painless ulcer at the site of sexual contact
local non-tender lymphadenopathy
often not seen in women (the lesion may be on the cervix)
Secondary features - occurs 6-10 weeks after primary infection
systemic symptoms: fevers, lymphadenopathy
rash on trunk, palms and soles
buccal ‘snail track’ ulcers (30%)
condylomata lata (painless, warty lesions on the genitalia )
Tertiary features
gummas (granulomatous lesions of the skin and bones)
ascending aortic aneurysms
general paralysis of the insane
tabes dorsalis
Argyll-Robertson pupil
Features of congenital syphilis
blunted upper incisor teeth (Hutchinson’s teeth), ‘mulberry’ molars
rhagades (linear scars at the angle of the mouth)
keratitis
saber shins
saddle nose
deafness
Heparin AEs
Adverse effects of heparins include:
bleeding
thrombocytopenia - see below
osteoporosis and an increased risk of fractures
hyperkalaemia - this is thought to be caused by inhibition of aldosterone secretion
Graves’ disease: features
Graves’ disease: features
Graves’ disease is an autoimmune thyroid disease in which the body produces IgG antibodies to the thyroid-stimulating hormone (TSH) receptor. It is the most common cause of thyrotoxicosis and is typically seen in women aged 30-50 years.
Features
typical features of thyrotoxicosis
specific signs limited to Grave’s (see below)
Features seen in Graves’ but not in other causes of thyrotoxicosis
eye signs (30% of patients)
exophthalmos
ophthalmoplegia
pretibial myxoedema
thyroid acropachy, a triad of:
digital clubbing
soft tissue swelling of the hands and feet
periosteal new bone formation
Autoantibodies
TSH receptor stimulating antibodies (90%)
anti-thyroid peroxidase antibodies (75%)
Thyroid scintigraphy
diffuse, homogenous, increased uptake of radioactive iodine
Table Respiratory pathogens
The table below lists the more common respiratory pathogens:
-Bronchiolitis: Respiratory syncytial virus
-Croup: Parainfluenza virus
-Common cold: Rhinovirus
-Flu: Influenza virus
Pneumonias:
Streptococcus pneumoniae: most common cause of community-acquired pneumonia
Haemophilus influenzae:
-Community-acquired pneumonia
-Most common cause of bronchiectasis exacerbations
-Acute epiglottitis
Staphylococcus aureus Pneumonia, particularly following influenza
Atypical pneumonias: Legionella & Mycoplasma
Mycoplasma pneumoniae: Atypical pneumonia
-Flu-like symptoms classically precede a dry cough.
-Complications include haemolytic anaemia and erythema multiforme
Legionella pneumophilia: Atypical pneumonia
-spread by air-conditioning systems, causes dry cough.
-Lymphopenia, deranged liver function tests and hyponatraemia may be seen
Pneumocystis jiroveci:
-Common cause of pneumonia in HIV patients.
-Typically patients have few chest signs and develop exertional dyspnea
Mycobacterium tuberculosis: Causes tuberculosis.
-Cough, night sweats and weight loss may be seen
Smoking Protective in:
UC & Ca endometrium
Lung Ca not associated with smoking:
non-small cell lung cancer (NSCLC), particularly adenocarcinoma, which is the most common type of lung cancer in non-smokers.
SJT MCCD (medical certificate of cause of death) RULES
When a patient dies it is the statutory duty of the doctor who has attended in the last illness to issue the MCCD (medical certificate of cause of death). There is no clear legal definition of “attended”, but it is generally accepted to mean a doctor who has cared for the patient during the illness that led to death and so is familiar with the patient’s medical history, investigations and treatment. The certifying doctor should also have access to relevant medical records and the results of investigations. There is no provision under current legislation to delegate this statutory duty to any non-medical staff.
If the attending doctor has not seen the patient within the 14 days preceding death, and has not seen the body after death either, the registrar is obliged to refer the death to the coroner before it can be registered. In these circumstances, the coroner may instruct the registrar to accept the attending doctor’s MCCD for registration, despite the prolonged interval.
In contrast, a doctor who has not been directly involved in the patient’s care at any time during the illness from which they died cannot certify under current legislation, but he should provide the coroner with any information that may help to determine the cause of death. The coroner may then provide this information to the registrar of deaths. It will be used for mortality statistics, but the death will be legally “uncertified” if the coroner does not investigate through an autopsy, an inquest, or both.
Antenatal screening
Screening tests are offered, with various combinations of tests and scans, eg
-Combined test with blood tests and nucal scan, or
-Quadruple test if booking later.
These give more specific screening results to identify those at higher risk, and if a risk then diagnostic test is offered.
The two diagnostic tests are
-Chorionic villus sampling (CVS) (performed before 13 weeks)
-Amniocentesis (performed after 15 weeks)
Childhood infections
Chickenpox:
Initially Fever
Itchy, rash starting on head/trunk before spreading.
Initially macular then papular then vesicular
Systemic upset is usually mild
Measles
Prodrome: irritable, conjunctivitis, fever
Koplik spots: white spots (‘grain of salt’) on buccal mucosa
Rash: starts behind ears then to whole body, discrete maculopapular rash becoming blotchy & confluent
Mumps
Fever, malaise, muscular pain
Parotitis (‘earache’, ‘pain on eating’): unilateral initially then becomes bilateral in 70%
Rubella Rash:
pink maculopapular, initially on face before spreading to whole body, usually fades by the 3-5 day
Lymphadenopathy: suboccipital and postauricular
Erythema infectiosum: parvovirus B19-5th or slapped cheek
Also known as fifth disease or ‘slapped-cheek syndrome’
Caused by parvovirus B19
Lethargy, fever, headache
‘Slapped-cheek’ rash spreading to proximal arms and extensor surfaces
Scarlet fever: Group A hemolytic streptococci
Reaction to erythrogenic toxins produced by Group A hemolytic streptococci
Fever, malaise, tonsillitis
Strawberry’ tongue
Rash - fine punctate erythema sparing the area around the mouth (circumoral pallor)
Hand, foot and mouth disease: coxsackie A16 virus
Caused by the coxsackie A16 virus
Mild systemic upset: sore throat, fever
Vesicles in the mouth and on the palms and soles of the feet
> Autosomal recessive
> For autosomal recessive conditions, if both parents are carriers (heterozygote) there is a 25% chance of having an affected (homozygote) child
In autosomal recessive inheritance
only homozygotes are affected
males and females are equally likely to be affected
not manifest in every generation - may ‘skip a generation’
If two heterozygote parents
25% chance of having an affected (homozygote) child
25% chance of having an unaffected (i.e. genotypical) child
50% chance of having a carrier (heterozygote) child
If one affected parent (i.e. homozygote for gene) and one unaffected (i.e. not a carrier or affected)
all the children will be carriers
Autosomal recessive disorders are often metabolic in nature and are generally more life-threatening compared to autosomal dominant conditions
> Autosomal dominant
In autosomal dominant diseases: no carrier state, only disease state
both homozygotes and heterozygotes manifest disease (there is no carrier state)
both males and females affected
only affected individuals can pass on disease
disease is passed on to 50% of children
normally appears in every generation (although see below)
risk remains same for each successive pregnancy
Complicating factors:
non-penetrance: lack of clinical signs and symptoms (normal phenotype) despite abnormal gene. E.g. 40% otosclerosis
spontaneous mutation: new mutation in one of gametes e.g. 80% of individuals with achondroplasia have unaffected parents
> X-linked recessive
In X-linked recessive inheritance only males are affected. An exception to this seen in examinations are patients with Turner’s syndrome, who are affected due to only having one X chromosome. X-linked recessive disorders are transmitted by heterozygote females (carriers) and male-to-male transmission is not seen. Affected males can only have unaffected sons and carrier daughters.
Each male child of a heterozygous female carrier has a 50% chance of being affected whilst each female child of a heterozygous female carrier has a 50% chance of being a carrier.
The following conditions are autosomal dominant:
Achondroplasia
Acute intermittent porphyria
Adult polycystic disease
Antithrombin III deficiency
Ehlers-Danlos syndrome
Familial adenomatous polyposis
Hereditary haemorrhagic telangiectasia
Hereditary spherocytosis
Hereditary non-polyposis colorectal carcinoma
Huntington’s disease
Hyperlipidaemia type II
Hypokalaemic periodic paralysis
Malignant hyperthermia
Marfan’s syndromes
Myotonic dystrophy
Neurofibromatosis
Noonan syndrome
Osteogenesis imperfecta
Peutz-Jeghers syndrome
Retinoblastoma
Romano-Ward syndrome
tuberous sclerosis
Von Hippel-Lindau syndrome
Von Willebrand’s disease*
CHA₂DS₂-VASc score
The CHA₂DS₂-VASc score
C - Congestive heart failure 1 point
H - Hypertension 1 point
A - Age 75 years or older 2 points
D - Diabetes mellitus 1 point
S - Stroke 2 points
V - Vascular disease 1 point
A - Age 65-74 years 1 point
Sc - Sex category (female) 1 point
The maximum score is 9
infective endocarditis (IE)
The modified Duke criteria are used for diagnostic classification of infective endocarditis (IE).
Major criteria:
Positive blood culture
Endocardium involved
Minor Criteria:
Predisposition (cardiac lesion, IVDU)
Fever >38°C
Vascular phenomena (emboli, Janeway’s lesions etc)
Immunological phenomena (glomerulonephritis, Osler’s nodes etc.)
Positive blood culture that does not meet major criteria
Diagnosis of definite IE: 2 major or 1 major and 3 minor or all 5 minor criteria.
IE of the tricuspid valve (more frequent in IVDU) can lead to regurgitation and the presence of a pansystolic murmur.
Rheumatic fever
Rheumatic fever can develop following an immunological reaction secondary to a Streptococcus pyogenes infection. Diagnosis is made on evidence of recent streptococcal infection with either 2 major criteria or 1 major with 2 minor criteria (Revised Jones criteria).
Major criteria include: CASES
Carditis (clinical and/or subclinical)
Arthritis (polyarthritis)
Sydenham’s chorea
Erythema marginatum
Subcutaneous nodules
Minor criteria include:
Raised ESR/CRP
Fever
Olyarthralgia
Prolonged PR interval (unless carditis is a major criterion)
Oesophageal disorders
Plummer-Vinson syndrome:
Triad of: DIG
-dysphagia (secondary to oesophageal webs)
-iron-deficiency anaemia
-glossitis
Treatment includes iron supplementation and dilation of the webs
Mallory-Weiss syndrome:
Severe vomiting → painful mucosal lacerations at the gastroesophageal junction resulting in haematemesis. Common in alcoholics
Boerhaave syndrome Severe vomiting → oesophageal rupture
Visual field defects
The main points for the exam are:
-left homonymous hemianopia means visual field defect to the left, i.e. Lesion of right optic tract
-homonymous quadrantanopias: PITS (Parietal-Inferior, Temporal-Superior)
-incongruous defects = optic tract lesion; congruous defects = optic radiation lesion or occipital cortex
A congruous defect simply means complete or symmetrical visual field loss and conversely an incongruous defect is incomplete or asymmetric. Please see the link for an excellent diagram.
Homonymous hemianopia:
incongruous defects: lesion of optic tract
congruous defects: lesion of optic radiation or occipital cortex
macula sparing: lesion of occipital cortex
Homonymous quadrantanopias*
superior: lesion of the inferior optic radiations in the temporal lobe (Meyer’s loop)
inferior: lesion of the superior optic radiations in the parietal lobe
mnemonic = PITS (Parietal-Inferior, Temporal-Superior)
Bitemporal hemianopia
lesion of optic chiasm
upper quadrant defect > lower quadrant defect = inferior chiasmal compression, commonly a pituitary tumour
lower quadrant defect > upper quadrant defect = superior chiasmal compression, commonly a craniopharyngioma
*this is very much the ‘exam answer’. Actual studies suggest that the majority of quadrantanopias are caused by occipital lobe lesions. Please see the link for more details.
Retinoids Most common AE
dry skin, eyes and lips/mouth
-the most common side-effect of isotretinoin
Quick comparison: Risk factors: female cancers
Quick comparison: Risk factors: female cancers
Combined oral contraceptive pill use
-cervical cancer
-breast cancer
Mutations of the BRCA2 gene
-ovarian cancer
-breast cancer
Pleural effusion: exudative vs transudative
Exudative: protein level greater than 35g/L is an exudate
-MIS-malignancy, inflammation & sepsis tend to be exudative
-produced as a result of fluid leakage through abnormally permeable pleural capillaries.
Transudative: protein level of less than 25g/L is a transudate
-heart failure, liver cirrhosis and renal failure
-disruption of hydrostatic and oncotic pressures across pleural membranes
LTOT
Whilst LTOT is indicated in chronic hypoxaemia, the British Thoracic Society (BTS) guidelines advise that that patient should have a PaO2 that is
-consistently below 7.3kPa OR
-stable between 7.3 and 8.0kPa in addition to
–secondary polycythaemia or
–clinical/echocardiographic signs of pulmonary hypertension.
All of the other conditions are indications for LTOT as needed along with conditions such as
severe chronic asthma,
cystic fibrosis,
bronchiectasis,
pulmonary vascular disease and
pulmonary malignancy.
32 years old female with breast lump
The correct answer is A. Ultrasound scan of the breast
Breast lumps should be investigated using the triple assessment approach which comprises
-History,
-Examination and
-Radiological assessment.
Young (less than 30):
-Ultrasound
-Mammogram would not be helpful as the patient is young and therefore it would be difficult to interpret.
-A fine needle aspiration or core biopsy would be the next step if a suspicious lump was seen on ultrasound/mammogram
-A CT scan would expose the patient to radiation unnecessarily and would not provide as useful results as an ultrasound scan.
Choriocarcinoma mgt
Choriocarcinoma is a rare malignant germ cell tumour. It secretes HCG and is extremely responsive to methotrexate-based combination chemotherapy.
Keratomalaci & Kwashiorko
Keratomalacia is an eye condition which occurs as a results of Vitamin A deficiency.
Symptoms include nightblindness, tunnel vision, dry conjunctiva and decreased visual acuity.
Kwashiorkor is a form of severe protein and energy malnutrition. Symptoms include oedema, irritability and anorexia. It occurs when there is sufficient calorie intake but insufficient protein. It is rare in the developed world.
Pleomorphic adenoma & other salivery glands problems
Pleomorphic adenoma
-Approximately 80% of all salivary gland tumours occur in the parotid gland
-Of these approximately 80% are benign tumours.
-Benign parotid tumours have a higher incidence in females. Involvement of the facial nerve can occur with pleomorphic adenomas but generally cranial nerve signs raise the suspicion of a malignant tumour.
Parotidectomy can be performed.
This operation requires careful dissection around the facial nerve to avoid damage.
Salivary duct stones are more common in the submandibular salivary glands.
The blockage causes painful swelling of the gland which, crucially, is exacerbated on eating.
Sialadenitis can cause swelling of a salivary gland but it is usually painful with associated swelling.
Thyroid cancers
Anaplastic Carcinoma is a rare but deadly form of thyroid cancer. Typically the disease is aggressive with early spread to lymph nodes and infiltration of local structures leading to symptoms of stridor and hoarseness.
Papillary Adenocarcinoma tends to affect younger patients and generally has a good prognosis.
Medullary Carcinoma may produce calcitonin which can lead to symptoms of hypocalcaemia.
