Easy Qs Flashcards
Which antibodies useful for pernicious anaemia?
Intrinsic factor - High specificity but only 50% sensitive
Anti-gastric parietal cell - High sensitivity but low specificity
Which antibodies are associated with primary biliary cholangitis and autoimmune hepatitis?
Anti mitochondrial
Typical symptoms are malaise, anorexia and weight loss. The associated RUQ pain tends to be mild and jaundice is uncommon
Diagnosis?
Amoebic Liver Abscess
What is Murphy’s sign and what condition is it found in?
Murphy’s sign = arrest of inspiration on palpation of the RUQ
It is found in acute cholecystitis
Advice on alcohol consumption per week?
If you do drink as much as 14 units per week, it is best to spread this evenly over 3 days or more
Advice on alcohol consumption per week?
If you do drink as much as 14 units per week, it is best to spread this evenly over 3 days or more
Most common cause of dysphagia for both SOLIDS and LIQUIDS?
Achalasia
displaying elements of both liver disease (jaundice, hepatocellular LFTs) and neuropsychiatric disease (depression, dementia, behavioural change, tremor)
What should be considered as Dx?
Wilsons disease - needs copper studies
Ix for Wilson’s disease
- slit lamp examination for Kayser-Fleischer rings
- reduced serum caeruloplasmin
- reduced total serum copper (counter-intuitive, but 95% of plasma copper is carried by ceruloplasmin)
free (non-ceruloplasmin-bound) serum copper is increased - increased 24hr urinary copper excretion
- the diagnosis is confirmed by genetic analysis of the ATP7B gene
Signs of Vit C Deficiency?
Easy bruising, prolonged gum bleeding, lethargy, tiredness, and joint pain on a background of poor diet
What marker in blood can give insight into an upper GI bleed?
Upper GI bleed -> can act as a ‘protein meal’ -> Raised urea
What criteria are used to assess risk in upper GI bleeds?
- Glasgow-Blatchford score at first assessment (helps clinicians decide whether patient patients can be managed as outpatients or not)
- Rockall score is used after endoscopy (provides a percentage risk of rebleeding and mortality - includes age, features of shock, co-morbidities, aetiology of bleeding and endoscopic stigmata of recent haemorrhage)
What is the only test recommended for H. pylori post-eradication therapy?
Urea breath test
Need to wait 2 weeks post anti secretory (PPI) use and 4 weeks post anti-bacterial use (abx)
What is the only test recommended for H. pylori post-eradication therapy?
Urea breath test
Need to wait 2 weeks post anti secretory (PPI)W use and 4 weeks post anti-bacterial use (abx)
What are the following scoring systems used for?
APACHE
Gleason
Glasgow
Dukes
TNM
APACHE - ICU mortality score
Gleason Score - Prostate Ca
Glasgow Score - Acute pancreatitis
Duke’s Criteria - Endocarditis
TNM - tumor nodes mets
What is used prohylactically to prevent variceal bleeds?
Non-cardioselective BB eg Propanolol
Signs and symptoms of pharyngeal pouch?
New onset dysphagia
w/out unexplained weight loss and abdominal masses
+ normal endoscopy, in an older male and neck swelling
Ix of choice for pharyngeal pouch?
Barium swallow with fluoroscopy which shows protrusion of the pharynx posteriorly
An upper GI endoscopy may sometimes detect a pharyngeal pouch, but not always.
Red flag symptoms for gastric cancer include:
new-onset dyspepsia in a patient aged >55 years
unexplained persistent vomiting
unexplained weight-loss
progressively worsening dysphagia/
odynophagia
epigastric pain
Classically causes left lower quadrant pain, diarrhoea (acute <14d) and fever
Dx?
Diverticulitis
Bloody diarrhea - UC or Crohns?
UC
Mx of the following billiary conditions?
Gallstones (asymptomatic)
Biliary Colic
Acute cholecystitis
Ascending cholangitis
Gallstones but asymptomatic = Observe
Biliary colic (stones + crampy pain) = Outpatient laparoscopic cholecystectomy
Acute cholecystitis (stones + crampy pain + fever/inflammatory markers) = Emergency laparoscopic cholecystectomy (w/in 48hrs)
Ascending cholangitis (stones + crampy pain + fever/inflammatory markers + jaundice) = MRCP=>ERCP
When should you consider mx for asymptomatic gallstones + why?
If stones are present in the common bile duct there is an increased risk of complications such as cholangitis or pancreatitis and surgical management should be considered
1st line mx of IBS?
First-line pharmacological treatment - according to predominant symptom
- Pain: antispasmodic agents
- Constipation: laxatives but avoid lactulose
- Diarrhoea: loperamide is first-line
New onset diabetes + raised serum lipase + painless jaundice = dx?
What imaging sign?
Pancreatic Cancer
Double duct sign - not seen in all cases of pancreatic cancer but if it is present is either pancreatic or ampulla vater cancer. It is a dilated common bile duct and dilated pancreatic duct.
Pharyngeal pouch - what happens if you try OGD?
Upper GI endoscopy is potentially hazardous and may result in iatrogenic perforation
What score is used to estimate the risk of a patient developing a pressure sore?
Waterlow score
What is ischaemic hepatitis?
Diffuse hepatic injury resulting from acute hypoperfusion (sometimes known as ‘shock liver’)
Often has a percipitating event eg MI
Often, it will occur in conjunction with acute kidney injury (tubular necrosis) or other end-organ dysfunction
What is ischaemic hepatitis?
Diffuse hepatic injury resulting from acute hypoperfusion (sometimes known as ‘shock liver’)
Often has a percipitating event eg MI
Often, it will occur in conjunction with acute kidney injury (tubular necrosis) or other end-organ dysfunction
What do the following signify:
HBsAg
anti-HBc
HBsAg = ongoing infection, either acute or chronic if present > 6 months
anti-HBc = caught, i.e. negative if immunized
NICE recommends: Offer urgent direct access upper gastrointestinal endoscopy (to be performed within 2 weeks) to assess for oesophageal cancer in which people?
In people with dysphagia, or aged 55 and over with weight loss and any of the following:
- Upper abdominal pain
- Reflux
- Dyspepsia
Vasculopath (hypertension, diabetes, smoker) + AF + Diffuse severe abdo pain = dx?
Acute mesenteric ischaemia
Triad of mesenteric ischaemia?
Mesenteric ischaemia: triad of CVD, high lactate and soft but tender abdomen
What is specific to Graves disease and not other forms of hyperthyroidism?
Exophthalmos, diplopia and eye pain in the context of hyperthyroidism are suggestive of thyroid eye disease which is specific to Graves and not any cause of hyperthyroidism
Pretibial myxoedema
Thyroid acropachy, a triad of: (digital clubbing, soft tissue swelling of the hands and feet and periosteal new bone formation)
What should patients on insulin do when they are unwell?
Diabetes sick day rules: when unwell, If a patient is on insulin, they must not stop it due to the risk of diabetic ketoacidosis. They should continue their normal insulin regime but ensure that they are checking their blood sugars frequently
What should patients on insulin do when they are unwell?
Diabetes sick day rules: when unwell, If a patient is on insulin, they must not stop it due to the risk of diabetic ketoacidosis. They should continue their normal insulin regime but ensure that they are checking their blood sugars frequently
What should diabetic pts on oral hypoglycaemics do if they become unwell?
If a patient is taking oral hypoglycaemic medication, they should be advised to continue taking their medication even if they are not eating much. Remember that the stress response to illness increases cortisol levels pushing blood sugars high even without much oral intake. The possible exception is with metformin, which should be stopped if a patient is becoming dehydrated because of the potential impact upon renal function
What should be offered to pts newly diagnosed w/ Graves and awaiting treatment?
Propranolol is a beta-blocker used to provide symptomatic relief
NB - Carmbimazole = main treatment for Graves however this takes a while to act hence pts will require symptomatic control before then (generally secondary care however can be initiated in primary care if propanolol doesnt successfully control sx)
hypothyroidism + goitre + anti-TPO = dx?
Hashimotos thyroiditis
hypothyroidism + goitre + anti-TPO = dx?
Hashimotos thyroiditis
also anti-thyroglobulin (Tg) antibodies
What type of cancer is Hashimotos thyroiditis associated w/?
development MALTomas (likely related to increased risk of other AI conditions such as Coeliac)
Which antibodies are found in 90% of patients with Graves’ disease and can help distinguish from other forms of hyperthyroidism
TSH receptor stimulating antibodies
What are anti-centromere antibodies implicated in?
Cutaneous systemic sclerosis
What are anti-centromere antibodies implicated in?
Cutaneous systemic sclerosis
Hospital mx of hypoglycaemia?
Alert and concious? - Quick acting carb eg glucogel
Unconcious / unable to swallow? - SC / IM glucagon OR IV 20% glucose solution via large vein
Hospital mx of hypoglycaemia?
Alert and concious? - Quick acting carb eg glucogel
Unconcious / unable to swallow? - SC / IM glucagon OR IV 20% glucose solution via large vein
Pt w/ thyroid eye disease has changes in vision what should be done?
Urgent review by eye casualty
Commonly loss of colour vision in Graves has been associated w/ upcoming sudden vision loss
Pt w/ thyroid eye disease has changes in vision what should be done?
Urgent review by eye casualty
Commonly loss of colour vision in Graves has been associated w/ upcoming sudden vision loss
Most common cause of hypothyroidism?
AI thyroiditis (Hashimotos)
What drugs can cause hypercalcaemia mainly?
Thiazides
Ca-containing antacids
What drugs can cause hypercalcaemia mainly?
Thiazides
Ca-containing antacids
What should be done if a pt w/ T2DM develops CVD, are at high risk of CVD or chronic heart failure?
Add a SGLT-2 inhibitor eg empagliflozin
High dose dexamethasone suppression test:
- Cortisol (not suppressed), ACTH (suppressed)
- Cortisol (suppressed), ACTH (suppressed)
- Cortisol (not suppressed), ACTH (not suppressed)
What creps are found in idiopathic pulmonary fibrosis?
Fine end-inspiratory creps
UMN v LMN signs?
UMN:
- No wasting / fasiculations
- Raised tone, reflexes (brisk), upgoing plantars
- Clonus
- Absent abdominal reflex
LMN:
- Wasting / fasiculations
- Reduced tone, reflexes (hypo), downgoing plantars
Spinothalamic v dorsal column pathways?
Spinothalamic = pain + temp - cross at the level
Dorsal = vibrational sense, proprioception and touch - cross in medulla
What level does spinal cord end?
L2
Stroke definition?
TIA?
Rapid onset focal neurological deficit lasting more than 24 hrs v less than 24 hrs
Vaguely describe anterior and posterior cerberal circulation:
Anterior consists of ACA and MCA arising from Internal carotid
Posterior consists of basilar and PCA arising from vertebral arteries
Signs of anterior circulation v posterior circulation?
Anterior:
- Hemiparesis (face, arm, leg)
- Aphasia
- Apraxia
- Neglect
Posterior:
- Diplopia
- Dysarthria
- Dizziness
- Dysphagia
- Crossed findings
Bells palsy v stroke?
LMN weakness hence forehead is not spared!!
Optic pathway and problems caused during it
- Singular eye blindness / englarged blindspot
- Homonymous Hemianopia
- Bitemporal Hemianopia
Where is the leison
- Singular eye blindness / englarged blindspot = Optic nerve
- Homonymous Hemianopia = Occipital lobe (before the optic chiasm)
- Bitemporal Hemianopia = Optic Chiasm
(focus on 1st a,c,f for finals)
Quadrantopias are switched - superior optic radiation gives you bottom corner, inferior optic radiation gives you top corner
Best antithrombotic for atherosclerotic strokes?
Clopidogrel
Best mx for cardioembolic stroke?
Apixaban
Unless metallic heart valve –> Warfarin
When there is cerebellar signs is the leison on the contralateral or ipsilateral side?
Ipsilateral
Cerebellar leison signs?
DANISH
Dysdiadokinesia
Ataxia (unsteadiness)
Nystagmus
Intention tremor (dysmetria)
Slurred / scanning speech
Hypotonia
contralateral hemiplegia + ipsilateral facial weakness - where is the leison?
Brainstem - whichever side has the facial weakness
contralateral hemiplegia + ipsilateral facial weakness - where is the leison?
Brainstem - whichever side has the facial weakness
What is Lateral medullary syndrome caused by?
Infarction of lateral medulla and inferior olivary nucleus - due to damage to vertebral artery or posterior inferior cerebellar artery
What is Horners syndrome?
Ptosis, Miosis and Anhydrosis (+ enopthalmos)
can be caused by brainstem strokes or dissection of carotids - presence of ataxia can help distinguish
GCS Scoring:
What do the following CSF results mean
What type of epilepsy is it?
What type of epilepsy is it?
What is the criteria for a total anterior circulation infarct?
Total anterior circulation infarcts - all 3 of the following:
- unilateral hemiparesis and/or hemisensory loss of the face, arm & leg
- homonymous hemianopia
- higher cognitive dysfunction e.g. dysphasia
NB partial = 2 of the criteria
What do lacunar infarcts present with? + what do they involve?
involves perforating arteries around the internal capsule, thalamus and basal ganglia
presents with 1 of the following:
1. unilateral weakness (and/or sensory deficit) of face and arm, arm and leg or all three.
2. pure sensory stroke.
3. ataxic hemiparesis
What Rankin and NIHSS scores do patients need to qualify for mechanical thrombectomy?
Rankin score of less than 3 and a National Institutes of Health Stroke Scale (NIHSS) score of more than 5
What Rankin and NIHSS scores do patients need to qualify for mechanical thrombectomy?
Rankin score of less than 3 and a National Institutes of Health Stroke Scale (NIHSS) score of more than 5
Haemorrhagic transformation of ischaemic stroke treated w Aspirin - wyd?
Stop any anti-coagulants + maintain BP (target 140)
Haemorrhagic transformation of ischaemic stroke treated w Aspirin - wyd?
Stop any anti-coagulants + maintain BP (target 140)
Which primary tumours are the most common cause of brain metastases?
Lung
Which primary tumours are the most common cause of brain metastases?
Lung
Localising features of seizures:
Floaters / flashes
What area of the brain is affected?
Occipital (visual)
Localising features of seizures:
May occur with or without impairment of consciousness or awareness
An aura occurs in most patients
- typically a rising epigastric sensation
- also psychic or experiential phenomena, such as déjà vu, jamais vu
- less commonly hallucinations (auditory/gustatory/olfactory)
Seizures typically last around one minute
- automatisms (e.g. lip smacking/grabbing/plucking) are common
Post ictal dysphagia
What area of the brain is affected?
Temporal
Localising features of seizures:
Head/leg movements, posturing, post-ictal weakness, Jacksonian march
What area of the brain is affected?
Frontal (motor)
Localising features of seizures:
Paraesthesia
What area of the brain is affected?
Parietal (sensory)
DDx? Papilloedema + 6th nerve palsy (headache + features of raised ICP)
Idiopathic intercranial HTN
Headaches w blurred vision in an obese young female - likely dx? mx?
Idiopathic intercranial HTN
Prescribe acetazolamide (diuretic) and advise weight loss - can also offer topiramate
Headaches w blurred vision in an obese young female - likely dx? mx?
Idiopathic intercranial HTN
Prescribe acetazolamide (diuretic) and advise weight loss - can also offer topiramate
Mx of acute MS relapse?
High dose steroids
Mx of acute MS relapse?
High dose steroids
How does acoustic neuroma / vestibular schwannoma present?
Vertigo, tinnitus and unilateral sensorineural hearing loss -> invasion of the trigeminal nerve can cause absent corneal reflex
How does acoustic neuroma / vestibular schwannoma present?
Vertigo, tinnitus and unilateral sensorineural hearing loss -> invasion of the trigeminal nerve can cause absent corneal reflex
Ix - MRI of cerebellopontine angle
Triad of Menieres disease?
tinnitus, vertigo and sensorineural hearing loss
Vertigo lasts hours at a time, disease has relapsing remitting patterns and fullness of ear present
Which nerve lesion can cause weakness of foot dorsiflexion and foot eversion? where does injury tend to occur?
Common peroneal nerve - injury often occurs at neck of fibula
Which nerve lesion can cause weakness of foot dorsiflexion and foot eversion? where does injury tend to occur?
Common peroneal nerve - injury often occurs at neck of fibula
Mid-humeral shaft fracture - what nerve is likely to be damaged and what sign can be seen?
Radial nerve - wrist drop
Management of myasthenic crisis? - intravenous immunoglobulin, plasma electrophoresis
- intravenous immunoglobulin, plasma electrophoresis
Visual field defects, what commonly causes these:
- 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
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
What is neuropathic pain + examples?
Neuropathic pain may be defined as pain which arises following damage or disruption of the nervous system.
Examples include:
- diabetic neuropathy
- post-herpetic neuralgia
- trigeminal neuralgia
- prolapsed intervertebral disc
What is neuropathic pain + examples?
Neuropathic pain may be defined as pain which arises following damage or disruption of the nervous system.
Examples include:
- diabetic neuropathy
- post-herpetic neuralgia
- trigeminal neuralgia
- prolapsed intervertebral disc
Mx of neuropathic pain?
first-line treatment: amitriptyline, duloxetine, gabapentin or pregabalin
if the first-line drug treatment does not work try one of the other 3 drugs
Tramadol - immediate rescue therapy
Topical capsaicin - localised pain
What is a high-stepping gait? when is it found?
A high-stepping gait develops to compensate for foot drop.
- If found unilaterally then a common peroneal nerve lesion should be suspected.
- Bilateral foot drop is more likely to be due to peripheral neuropathy.
What is a high-stepping gait? when is it found?
A high-stepping gait develops to compensate for foot drop.
- If found unilaterally then a common peroneal nerve lesion should be suspected.
- Bilateral foot drop is more likely to be due to peripheral neuropathy.
Is Bells palsy UMN or LMN?
LMN - forehead isnt spared
Gold standard imaging for degenerative cervical myelopathy?
MRI C-Spine
How to distinguish between degenerative cervical myelopathy and carpal tunnel?
+Hoffmans sign - flicking middle finger gets the thumb and index finger to go closer
Homonymous quadrantanopias - which lobe is the leison in?
PITS (Parietal-Inferior, Temporal-Superior)
What is autonomic dysreflexia and who is at risk?
This clinical syndrome occurs in patients who have had a spinal cord injury at, or above T6 spinal level.
Briefly, afferent signals, most commonly triggered by faecal impaction or urinary retention (but many other triggers have been reported) cause a sympathetic spinal reflex via thoracolumbar outflow.
The usual, centrally mediated, parasympathetic response however is prevented by the cord lesion.
The result is an unbalanced physiological response, characterised by extreme hypertension, flushing and sweating above the level of the cord lesion, agitation, and in untreated cases severe consequences of extreme hypertension have been reported, e.g. haemorrhagic stroke.
What is autonomic dysreflexia and who is at risk?
This clinical syndrome occurs in patients who have had a spinal cord injury at, or above T6 spinal level.
Briefly, afferent signals, most commonly triggered by faecal impaction or urinary retention (but many other triggers have been reported) cause a sympathetic spinal reflex via thoracolumbar outflow.
The usual, centrally mediated, parasympathetic response however is prevented by the cord lesion.
The result is an unbalanced physiological response, characterised by extreme hypertension, flushing and sweating above the level of the cord lesion, agitation, and in untreated cases severe consequences of extreme hypertension have been reported, e.g. haemorrhagic stroke.
What is found in CSF of MS patients?
Oligoclonal bands
How can aphasia be categorised?
When should trigeminal neuralgia be referred to secondary care?
Sensory changes
Deafness or other ear problems
History of skin or oral lesions that could spread perineurally
Pain only in the ophthalmic division of the trigeminal nerve (eye socket, forehead, and nose), or bilaterally
Optic neuritis
A family history of multiple sclerosis
Age of onset before 40 years
Mx of trigeminal neuralgia?
Carbamazepine - 1st line
Epilepsy mx - why do you need to be careful of combining Lamotrigine and Sodium Valproate?
Risk of skin reaction - SJS
Nerve root for ankle reflex?
S1-S2
Nerve root for knee reflex?
L3-L4
Nerve root for bicep reflex?
C5-C6
Nerve root for tricep reflex?
C7-C8
Nerve root for brachioradialis reflex?
C5-C6
Neuroleptic malignant syndrome tetrad?
Hyperthermia, muscle rigidity, autonomic instability, altered mental status
Most common manifestation of neurological sarcoidosis?
Facial nerve palsy
Absence of ear discharge + discrete lesion on palpation excludes other causes of facial nerve palsy
Unilateral facial nerve palsy + clear nasal discharge + recent head injury = ddx?
Basal skull fracture eg Petrous temporal fracture
Histological differences between Crohns and UC?
UC:
- Inflammation stops at submucosa
- Crypt abscesses
Crohns:
- Skip leisons
- Inflammation across all layers
- Goblet cells + granulomas
Mx of hemochromatosis?
1st line = Venesection - make sure transferrin saturation is below 50% and serum ferritin below 50ug/l
2nd line = Iron chelation therapies eg. desferrioxamine or deferasirox
Mx of hemochromatosis?
1st line = Venesection - make sure transferrin saturation is below 50% and serum ferritin below 50ug/l
2nd line = Iron chelation therapies eg. desferrioxamine or deferasirox
Prevention of variceal bleeds mx?
Propanolol
Endoscopic band ligation > Endoscopic sclerotherapy - offered in medium to large varicies (2wly until all are eradicated)
TIPSS (transjugular intrahepatic portosystemoc shunt) useful if other mx doesnt work
What vaccine should be offered to people with coeliac disease and why?
Pneumococcal every 5 years due to functional hyposplenism
What vaccine should be offered to people with coeliac disease and why?
Pneumococcal every 5 years due to functional hyposplenism
Which antibodies are most commonly associated w PBC?
Primary biliary cholangitis - the M rule
- IgM
- anti-Mitochondrial antibodies, M2 subtype
- Middle aged females
Ascites what is the likely causes based on SAAG >11g/l
SAAG >11g/L
Lynch syndrome (HNPCC) - what cancers is it most associated with?
Proximal colorectal cancer - main
Endometrial - 2nd most
Mx of liver abscesses?
Management:
- Drainage (typically percutaneous) and antibiotics
- Amoxicillin + ciprofloxacin + metronidazole
- If penicillin allergic: ciprofloxacin + clindamycin
In pts where there is suspicion of Upper GI bleed what is required to be done in 1st 24hrs?
Any patient with a suspected upper GI bleed requires endoscopy within 24 hours of admission unless they score less than 1 on the Glasgow-Blatchford score
What are the early signs of Haemochromatosis?
fatigue, erectile dysfunction and arthralgia
Which medications used to treat UC could cause pancreatitis?
Aminosalicyates - Mesalazine > sulfasalazine in terms of acute pancreatitits risk
Metoclopramide MoA?
D2 Receptor Agonist
When should abx be used in mx of pressure ulcers?
- clinical evidence of systemic sepsis
- spreading cellulitis
- underlying osteomyelitis.
Which tool identifies medications where the risk outweighs the therapeutic benefits in certain conditions?
The STOPP tool identifies medications where the risk outweighs the therapeutic benefits in certain conditions
What is hypoactive delirium?
Hypoactive delirium is a subtype of delirium characterised by withdrawal and sleepiness
When should men with UTIs be referred to urology?
NICE advises us that men with UTIs should not routinely be referred to urology unless the infection is recurrent. The two-week rule pathway should be used if the man is;
- Aged 45 years and over with unexplained visible haematuria without urinary tract infection, or visible haematuria that persists or recurs after successful treatment of urinary tract infection.
- Aged 60 years and over who have unexplained non-visible haematuria and either dysuria or a raised white cell count on a blood test.
Which organism causing pneumonia can cause a dry cough and erythema multiforme?
Mycoplasma pneumoniae
What CXR finding may be seen in a pt w latent TB?
The nodule described is a calcified Ghon focus.
This indicates that he has had a primary TB infection in the past, which became contained in a granuloma (the Ghon focus) and over time has calcified.
TB bacteria may still be present in the lesion and he could develop active disease, particularly if he becomes immunocompromised
What CD4 count does Pneumocystis jirovecii pneumonia usually occurs at?
<200 cells/mm³
What adverse reactions should you be worried about with Metronidazole?
disulfiram-like reaction with alcohol
increases the anticoagulant effect of warfarin
Ongoing diarrhoea, lethargy, bloating, flatulence, steatorrhoea, weight loss +/- recent travel → what potential dx?
Giardiasis
How can you distinguish between BV and TV?
Mx of pneumocystis jiroveci ?
Co-trimoxazole
IV pentamidine in severe cases
Mx of Lyme disease?
14-21 days of oral doxycycline uncomplicated disease - can use amoxicillin if CI eg in pregnancy
IV ceftriaxone / cefotaxime - if cardiac (heart block/ pericarditis) or neuro (facial nerve palsy, meningitis) complications
What is a Jarisch-Herxheimer reaction? When is it seen?
is sometimes seen after initiating therapy: fever, rash, tachycardia after first dose of antibiotic (more commonly seen in syphilis, another spirochaetal disease or lyme disease)
What bacteria is most commonly associated with gangrene?
Clostridium perfringens
Which bacteria are gram+ve and gram-ve cocci?
Gram-positive cocci = staphylococci + streptococci (including enterococci)
Gram-negative cocci = Neisseria meningitidis + Neisseria gonorrhoeae, also Moraxella catarrhalis
Which bacteria are gram +ve rods (bacilli)?
Therefore, only a small list of Gram-positive rods (bacilli) need to be memorised to categorise all bacteria - mnemonic = ABCD L
Actinomyces
Bacillus anthracis (anthrax)
Clostridium
Diphtheria: Corynebacterium diphtheriae
Listeria monocytogenes
Which organisms are gram -ve rods (bacilli)?
Escherichia coli
Haemophilus influenzae
Pseudomonas aeruginosa
Salmonella sp.
Shigella sp.
Campylobacter jejuni
If atypical lymphocytes are seen on blood film, what infection is likely?
Infectious mononucleosis
Which vaccines pose a risk to immunocompressed people?
Live attenuated
- BCG
- measles, mumps, rubella (MMR)
- influenza (intranasal)
- oral rotavirus
- oral polio
- yellow fever
- oral typhoid
What is the triad of disseminated gonococcal infection?
tenosynovitis, migratory polyarthritis, dermatitis
Which TB drug causes orange secretions
Rifampicin
What are the indications for performing a microbiological stool investigations
1) You suspect septicaemia
2) there is blood and/or mucus in the stool or
3) the pt is immunocompromised
What is a possible complication due to repeated gonorrhoea infection in women?
Infertility secondary to PID
Which penile spots are benign and dont need investigation?
Pearly penile papules
What is the investigation for genital herpes?
NAAT
What is the investigation for genital herpes?
NAAT
Investigation of choice for chlamydia?
NAAT
How might Kaposi Sarcoma present in children?
Kaposi’s sarcoma may present in children with only generalised lymphadenopathy suggestive of lymphoma
What are the following classifications used for:
Garden
Salter-Harris
Gartland
Ottawa Rules
Weber
Garden - NOF
Gartland - Supracondylar in children
Salter-Harris - Growth plate fractures in children
Ottawa Rules - Ankle fractures
Weber - Ankle fractures around syndesmosis
What should you consider if there is sudden deterioration in a pt with ventilation?
Tension pneumothorax
What is the pattern of FVC, FEV1 and FEV1/FVC ratio in restrictive and obstructive ventilatory patterns?
What are some examples of each type?
Abnormal spirometry is divided into restrictive and obstructive ventilatory patterns:
A restrictive ventilatory pattern is seen in conditions where lung volume is reduced - eg, pulmonary fibrosis, scoliosis. The spirometry results will show the following:
- FVC and FEV1 are reduced proportionately so the FEV1/FVC is normal
- FVC reduced <70%
- FEV1 reduced
An obstructive ventilatory pattern is seen in conditions in which airways are obstructed due to diffuse airways narrowing of any cause - eg, COPD, cystic fibrosis, asthma, bronchiectasis and airway obstruction due to lung tumours. Spirometry results will show the following:
- The FVC and FEV1 are reduced disproportionately so the FEV1/FVC reduced (<70%)
- FVC normal or reduced
- FEV1 reduced <80%
Which organisms are responsible for acute COPD exacerbations?
Bacteria
- Haemophilus influenzae (most common cause)
- Streptococcus pneumoniae
- Moraxella catarrhalis
Respiratory viruses
- account for around 30% of exacerbations
- human rhinovirus is the most important pathogen
CRP v WBC in response to bacterial infections?
CRP will lag behind WBC
This means at the start of infections it can be slow to rise and once the infection is starting to be cleared it can be slow to fall
Gold standard diagnosis for mesotheliomas?
Mesothelioma = cancer in asbestos exposure (eg ship building)
Gold standard ix is thoracoscopic biopsy
What abx prophylaxis can be offered to COPD patients who have frequent exacerbations? What criteria need to be fulfilled first?
NICE guidelines suggest a prescription of 250mg azithromycin three times per week if:
- The patient no longer smokes.
- Has optimised non-pharmacological management & inhaled therapies.
- Referred to pulmonary rehab (if appropriate).
- 4 acute exacerbations in the last year (producing sputum), requiring hospital admission at least once.
Discharge advice for pts who have a pneumothorax which has been treated?
Stop smoking
No flying - until 2 weeks after treatment / 1 week post check x ray
Scuba diving - never unless they’ve had bilateral surgical pleurectomy, normal lung function + clear chest CT post surgery
What finding on high res CT is in keeping with a diagnosis of bronchiectasis?
Tram track opacities - occur secondary to bronchial airway dilation
Pts will have coarse crackles
What finding on high res CT is in keeping with a diagnosis of bronchiectasis?
Tram track opacities - occur secondary to bronchial airway dilation
Pts will have coarse crackles
What type of cancer can cause Lambert Eaton syndrome? Which parts of the body are mainly affected?
Small cell lung cancer
Legs > Arms - better w movement
What type of cancer can cause Lambert Eaton syndrome? Which parts of the body are mainly affected?
Small cell lung cancer
Legs > Arms - better w movement
Sarcoidosis - what electrolyte abnormality may be found?
Hypercalcaemia
Sarcoidosis - what electrolyte abnormality may be found?
Hypercalcaemia
What criteria do COPD patients have to fulfill to get long term O2 therapy?
Assess ABG 2 occasions at least 3 weeks apart in a pt w stable COPD on optimal mx
Offer LTOT to patients with a pO2 of < 7.3 kPa or to those with a pO2 of 7.3 - 8 kPa and one of the following:
- secondary polycythaemia
- peripheral oedema
- pulmonary hypertension
What are the features of Granulomatosis w/ polyangiitis (wegners) and Churg-Strauss syndrome?
What are the three main systems involved in granulomatosis w/ polyangiitis?
ENT, resp and kidney involvement
What ECG changes are found in Brugada syndrome? Mx?
convex ST segment elevation > 2mm in > 1 of V1-V3 followed by a negative T wave
partial right bundle branch block
the ECG changes may be more apparent following the administration of flecainide or ajmaline - this is the investigation of choice in suspected cases of Brugada syndrome
Implantable cardioverter-defibrillator
Wells score - what are the different things
Wells score - what are the different things
What are the features of acute limb ischaemia?
Features - 1 or more of the 6 P’s
pale
pulseless
painful
paralysed
paraesthetic
‘perishing with cold’
What does the initial mx of acute limb ischaemia involve? Wb definitive mx?
Initial:
Analgesia (usually IV opioids), IV heparin and vascular review
Definitive:
- intra-arterial thrombolysis
- surgical embolectomy
- angioplasty
- bypass surgery
- amputation: for patients with irreversible ischaemia
What should all patients with peripheral arterial disease take? what is the 1st line imaging?
They should all take clopidogrel and atorvastatin
Imaging - Duplex USS
Mx of superficial thrombophlebitis?
Patients with clinical signs of superficial thrombophlebitis affecting the proximal long saphenous vein should have an ultrasound scan to exclude concurrent DVT.
- Patients with superficial thrombophlebitis should have anti-embolism stockings and can be considered for treatment with prophylactic doses of LMWH for up to 30 days or fondaparinux for 45 days.
- If LMWH is contraindicated, 8-12 days of oral NSAIDS should be offered.
Patients with superficial thrombophlebitis at, or extending towards, the sapheno-femoral junction can be considered for therapeutic anticoagulation for 6-12 weeks.
What does the presence of a high / low anion gap tell you in the context of ABGs?
increased acid production/ingestion - high anion = acidic
or reduced acid secretion/loss of HCO3 - low anion = alkaline
What does the presence of a high / low anion gap tell you in the context of ABGs?
increased acid production/ingestion - high anion = acidic
or reduced acid secretion/loss of HCO3 - low anion = alkaline
The anion gap is used to classify metabolic acidosis into either:
- Raised anion gap seen in e.g. diabetic ketoacidosis
- Normal anion gap seen in patients with diarrhoea due to gastrointestinal bicarbonate loss.
What causes asceites in patients with hepatic cirrhosis? How can this be treated?
Secondary hyperaldosteronism which causes ascietes
Treated w spironolactone (aldosterone antagonist in CCD)
What are pts w nephrotic syndrome at increased risk of?
VTE - they need prophylactic LMWH
What are pts w nephrotic syndrome at increased risk of?
VTE - they need prophylactic LMWH
Which drugs can cause acute interstitial nephritis?
penicillin
rifampicin
NSAIDs
allopurinol
furosemide
What are some causes of Gout?
D- iuretics
A- lcohol
R- enal disease
T- rauma
What crystals are found in the following conditions:
Gout
Pseudogout
Osteoarthritis
Rheumatoid arthritis
Gout- monosodium urate crystals that are needle-shaped that are negatively birefringent under polarised light
Pseudogout- calcium pyrophosphate crystals are rhombic/brick shaped that are positively birefringent under polarised light
Osteoarthritis- calcium phosphate crystals associated with degeneration of cartilage, coffin-lid shaped with no birefringence
Rheumatoid arthritis- cholesterol crystals, these are rhombic/brick-shaped with a negative birefringence
What are some poor prognostic features of rheumatoid arthritis?
- rheumatoid factor positive
- anti-CCP antibodies
- poor functional status at presentation
- X-ray: early erosions (e.g. after < 2 years)
- extra articular features e.g. nodules
- HLA DR4
- insidious onset
Abx for septic arthritis? What if allergic?
Flucloxacillin
Clindamycin
For 4-6 weeks (IV 2 weeks then oral)
Oral steroid use in polymyalgia rheumatica and bone protection plan?
If patient not on steroid :
Aged > 75 yo, a DEXA scan may not be required
If <75 yo than do DEXA first
If patient on steroid :
aged > 65 no need DEXA
aged <65 do DEXA first
Bone protection = bisphosphonate and ensuring calcium and vit d repletion
Treatment of choice for SLE?
Hydroxychloroquine
Treatment of choice for polymyalgia rheumatica?
Steroids - should respond dramatically, failure to do so = consider alternative diagnosis
Most useful ix in diagnosing ankylosing spondylitis?
Sacroilliac xray which can show the following:
- sacroiliitis: subchondral erosions, sclerosis
- squaring of lumbar vertebrae
- ‘bamboo spine’ (late & uncommon)
- syndesmophytes: due to ossification of outer - fibers of annulus fibrosus
- chest x-ray: apical fibrosis
The duration of bisphosphonate treatment varies according to the level of risk. Some authorities recommend stopping bisphosphonates at 5 years if the following apply:
patient is < 75-years-old
femoral neck T-score of > -2.5
low risk according to FRAX/NOGG
Which antibiotic is not appropriate to prescribe alongside methotrexate due to the risk of severe bone marrow suppression?
Trimethoprim (and co-trimoxazole)
What are some early x ray findings in rheumatoid arthritis?
loss of joint space
juxta-articular osteoporosis
soft-tissue swelling
What are some late x ray findings in rheumatoid arthritis?
periarticular erosions
subluxation
What are some late x ray findings in rheumatoid arthritis?
periarticular erosions
subluxation
What is the underlying pathology in temporal arteritis?
Anterior ischaemic optic neuropathy (occlusion of posterior ciliary artery -> ischaemia of optic nerve head)
What is the suffix for SGLT-2 inhibitors?
-flozin
What effect do corticosteroids have on glucose control?
Impaired control due to anti-insulin effects –> can cause hyperglycaemia
Hypokalaemia + HTN –> ???
Primary hyperaldosteronism - Conns (adrenal adenoma) or bilateral adrenal hyperplasia
What is HHS characterised by?
1.) Severe hyperglycaemia
2.) Dehydration and renal failure
3.) Mild/absent ketonuria
What is HHS characterised by?
1.) Severe hyperglycaemia
2.) Dehydration and renal failure
3.) Mild/absent ketonuria
Which antibodies present in Graves? Which is more commonly found?
Anti-TPO
Anti-TSH (more common) 90% v 75%
What drugs can cause gynaecomastia? which is the most common cause?
spironolactone (most common drug cause)
cimetidine
digoxin
cannabis
finasteride
GnRH agonists e.g. goserelin, buserelin
oestrogens, anabolic steroids
Best way to reduce the risk of thyroid eye disease? what might make it worse?
Stop smoking
Radioiodine tx may increase inflammatory sx seen - prednisolone may help reduce this risk
What class of drugs increase the risk of osteonecrosis?
Steroids - eg prednisolone
Which pts w diabetes need to talk to the DVLA?
Patient with diabetes who have had two hypoglycaemic episodes requiring help needs to surrender their driving licence
How can the following high-dose dex supression tests be interpreted?
CRH stimulation test in Cushings - what would you see in pituitary source and what would you see in ectopic / adrenal cause?
if pituitary source then cortisol rises
if ectopic/adrenal then no change in cortisol
What do the following water deprevation test results mean?
Which HTN pts should be screened for primary hyperaldosteronism?
hypertension with hypokalemia
treatment-resistant hypertension
What does patchy uptake on nuclear thyroid scintigraphy mean?
Toxic multinodular goitre -> hyperthyroidism
What should be used to assess for diabetic neuropathy in the feet?
A 10 g monofilament
What electrolyte abnormality suggest chronic kidney disease v acute?
Hypocalcaemia - this would be secondary to vit D deficiency due to reduced activation by kidneys
In acute testicular pain, a unilateral swollen and retracted testicle, with loss of the cremasteric reflex, is characteristic of what condition?
testicular torsion
Patients with suspected neoplastic spinal cord compression should have what investigation?
Urgent MRI of the whole spine (<24hrs) - bony mets rarely only one site
Use CT if MRI is CI
In which pts may MRI be CI?
permanent pacemaker or certain metal implants in-situ
1st line ix of testicular mass?
USS
Top dx for frank haematuria?
Cancer
Stones
Infection
Which pts >=60y should be referred for 2w wait to exclude bladder cancer?
Unexplained non-visible haematuria and either dysuria
A raised white cell count on a blood test
What are the signs of SVC obstruction? what is the initial mx?
Dyspnoea is the most common symptom
swelling of the face, neck and arms - conjunctival and periorbital oedema may be seen
headache: often worse in the mornings
visual disturbance
pulseless jugular venous distension
Administer dex
What are some common causes of SVC obstruction?
common malignancies: small cell lung cancer, lymphoma
other malignancies: metastatic seminoma, Kaposi’s sarcoma, breast cancer
aortic aneurysm
mediastinal fibrosis
goitre
SVC thrombosis
How does rhabdomyolysis cause AKI? What are some other examples of things that cause AKI in the same way?
Via ATN
ischaemia
- shock
- sepsis
nephrotoxins
- aminoglycosides
- myoglobin secondary to rhabdomyolysis
- radiocontrast agents
- lead
Most common type of Prostate ca?
Adenocarcinoma - 95%
How can CKD lead to increased fractures?
CKD -> reduced vit D activation -> reduced Ca (+ high PO4-) -> High PTH (Secondary hyperparathyroidism)
When suspecting neoplastic spinal cord compression - what should be given to pts whilst awaiting ix?
High dose oral dex
What is the most common cause of scrotal swelling seen in primary care?
Epididymal cysts
What is a cause of scrotal swelling which can be palpated as separate from the body of the testicle? where is it found relative to testicle?
Epididymal cyst - found posterior to testicle
Mx of BPH?
Watchful waiting if not problematic
If moderate-to-severe ex (IPSS >=8):
- a-1 antagonists (eg tamsulosin, alfuzosin)
If significantly enlarged / high risk of progression:
- 5 a-reductase inhibitors eg finasteride
Surgery:
- TURP
Acute mx of renal colic - which analgesic to give?
IM diclofenac
Mx of OAB?
antimuscarinic drugs should be offered if symptoms persist. NICE recommend oxybutynin (immediate release), tolterodine (immediate release), or darifenacin (once daily preparation)
mirabegron may be considered if first-line drugs fail
Triad of nephrotic syndrome? most common cause in children?
–oedema, substantial proteinuria (> 3.5 g/24 hours) and hypoalbuminaemia (< 30 g/L)
Children = Minimal change
What is the investigation of choice in diagnosing bladder cancer
Cystoscopy
Mx of renal stones based on size?
What is the most common extra renal manifestation of ADPKD?
Liver cysts - 70% of pts (can cause hepatomegaly)
When investigating mets disease of unknown primary what should be checked in every pt?
Which specific tests are required for which sx?
NICE recommends the following investigations for all patients:
- FBC, U&E, LFT, calcium, urinalysis, LDH
- Chest X-ray
- CT of chest, abdomen and pelvis
- AFP and hCG
NICE recommends the following investigations for specific patients:
- Myeloma screen (if lytic bone lesions)
- Endoscopy (directed towards symptoms)
- PSA (men)
- CA 125 (women with peritoneal malignancy or ascites)
- Testicular US (in men with germ cell tumours)
- Mammography (in women with clinical or pathological features compatible with breast cancer)
What ix is needed in pts w/ AKI of unknown cause?
USS
Which lung cancer is most associated with smoking?
Squamous cell lung cancer has the strongest association with smoking
Mx of bladder ca?
Superficial lesions - Trans-urethral removal of bladder tumour (TURBT)
Recurrence / high grade / risk on histology - May be offered intravesical chemotherapy
T2 disease - Either surgery (radical cystectomy and ileal conduit) or radical radiotherapy
Urinalysis and microscopy reveals muddy brown granular casts - what does this mean?
This means there has been acute tubular necrosis - ranular renal cell casts, which are collections of dead renal tubular cells sloughing in the tubular lumen
What is decompression haematuria
Decompression haematuria occurs commonly after catheterisation for chronic retention due to the rapid decrease in the pressure in the bladder. It usually does not require further treatment.
What drugs should be stopped in AKI due to risk of toxicity?
- Metformin
- Lithium
- Digoxin
Which drugs should be stopped in AKI as they can worsen renal function?
- NSAIDs (except if aspirin at cardiac dose e.g. 75mg od)
- Aminoglycosides
- ACE inhibitors
- Angiotensin II receptor antagonists
- Diuretics
Which malignancy can varicoceles be a sign of and why?
Varicocele can be a sign of malignancy due to compression of the renal vein between the abdominal aorta and the superior mesenteric artery - known as the nutcracker angle
Triad of renal cell carcinoma? How is this mx?
haematuria, abdominal mass and loin pain
Mx:
- for confined disease a partial or total nephrectomy depending on the tumour size
patients with a T1 tumour (i.e. < 7cm in size) are typically offered a partial nephrectomy
- alpha-interferon and interleukin-2 have been used to reduce tumour size and also treat patients with metatases
- receptor tyrosine kinase inhibitors (e.g. sorafenib, sunitinib) have been shown to have superior efficacy compared to interferon-alpha
Ankylosing spondylitis - x-ray findings:
subchondral erosions, sclerosis
and squaring of lumbar vertebrae
What is schobers test? what is abnormal?
Schober’s test is performed by identifying L5, and then marking 10cm above and 5cm below this point whilst the patient is stood upright. The patient is then asked to bend forwards to touch their toes whilst keeping their knees straight.
Used to test for loss of lumbar flexion - seen in ank spond (less than 5cm is abnormal)
Renal impairment, respiratory symptoms, joint pain, systemic features → consider ????
ANCA associated vasculitis
When should PSA testing not be done?
NICE advise that, as PSA levels may be increased, testing should not be done within at least:
- 6 weeks of a prostate biopsy
- 4 weeks following a proven urinary infection
- 1 week of digital rectal examination
- 48 hours of vigorous exercise
- 48 hours of ejaculation
elbow pain is worse on wrist extension against resistance, when the elbow is straightened- dx?
Lateral epicondylitis
Elbow pain is worse on flexion and pronation of the wrist - dx?
Medial epicondylitis
What are the causes of drug induced lupus?
Most common causes
- procainamide
- hydralazine
Less common causes
- isoniazid
- minocycline
- phenytoin
Two main components of Goodpastures / Anti-GBM disease? How can this present?
Pulmonary haemorrhage + rapidly progressive glomerulonephritis –> haemoptysis + AKI/proteinuria/haematuria
What are Gottrons papules? What condition are they seen in?
Gottron’s papules = roughened red papules over the knuckles mainly
Seen in dermatomyositis
What hand lump does this describe:
Swelling in association with a tendon sheath commonly near a joint. They are common lesions in the wrist and hand. Usually they are asymptomatic and cause little in the way of functional compromise. They are fluid filled although the fluid is similar to synovial fluid it is slightly more viscous. When the cysts are troublesome they may be excised.
Ganglion
What hand lump does this describe:
Typically develop in middle age, beginning either with a chronic swelling of the affected joints or the sudden painful onset of redness, numbness, and loss of manual dexterity. This initial inflammation and pain eventually subsides, and the patient is left with a permanent bony outgrowth that often skews the fingertip sideways
Herberdens nodes
What hand lump does this describe:
Hard, bony outgrowths or gelatinous cysts on the proximal interphalangeal joints (the middle joints of fingers or toes.) They are a sign of osteoarthritis, and are caused by formation of calcific spurs of the articular cartilage.
Bouchards nodes
What hand lump does this describe:
Painful, red, raised lesions found on the hands and feet. They are the result of the deposition of immune complexes.
Oslers nodes
What is the most common cause of peritonitis secondary to peritoneal dialysis?
coagulase-negative staphylococci such as Staphylococcus epidermidis is the most common cause. Staphylococcus aureus is another common cause
How can you prevent contrast-induced nephropathy?
volume expansion with 0.9% saline
How long to wait after methotrexate before conceiving males and females?
6m
Which pts could be allergic to sulfasalazine as well?
allergy to aspirin or sulphonamides (cross-sensitivity)
Cubital tunnel syndrome
Occurs at elbow
Causes parasthesia in ulnar distribution
How to differentiate between statin-induced myopathy and polymyalgia rheumatica?
Raised ESR in polymyalgia
Describe a hydrocele:
This man has a swelling confined to the scrotal sac. It is non-tender and fully transluminates
How to avoid contrast nephrotoxicity in pts?
Offer 1ml/kg/hr of IV NaCl 12 hrs pre and post procedure
What drug needs to be used with caution alongside Azathioprine due to risk of bone marrow suppression?
Allopurinol
What is the treatment of choice for methotrexate toxicity?
Folinic acid
What is TURP syndrome?
Rare + life threatening complication following TURP due to irrigation w glycine hypo-osmolar and is systemically absorbed when prostatic venous sinuses are opened up during prostate resection. This results in hyponatremia, and when glycine is broken down by the liver into ammonia, hyper-ammonia and visual disturbances.
Causes CNS resp and systemic sx
RFs for TURP syndrome?
surgical time > 1 hr
height of bag > 70cm
resected > 60g
large blood loss
perforation
large amount of fluid used
poorly controlled CHF
Metformin - when should it be used with caution / stopped in CKD?
Stop when eGFR <30mmol/mol
Caution when eGFR <45mmol/mol
Fracture of distal humerus - what anatomical structure are you worried about?
Brachial artery - important to check for distal neurovascular loss
X ray changes in Osteoarthritis?
X-ray changes of osteoarthritis (LOSS)
- Loss of joint space
- Osteophytes forming at joint margins
- Subchondral sclerosis
- Subchondral cysts
Why are pts w nephrotic syndrome at increased risk of VTE?
Loss of antithrombin-III, proteins C and S and an associated rise in fibrinogen levels predispose to thrombosis
What does this show? How is it managed?
Acromioclavicular joint injury
AC joint injuries are graded I to VI depending on the degree of separation.
- Grade I and II injuries are very common and are typically managed conservatively including resting the joint using a sling.
- Grade IV, V and VI are rare and require surgical intervention.
- The management of grade III injuries is a matter of debate and often depends on individual circumstances.
Triad of Behcets?
classically: 1) oral ulcers 2) genital ulcers 3) anterior uveitis
What is important to check in males w osteoporosis?
Testosterone levels
Which diabetes is acanthosis nigricans present in and why?
Type 2 - it is a sign of insulin resistance
Which auto-antibody is indicated in reactive arthritis?
HLA-B27
HLA-B51 - what disease is implicated?
Behcets
HLA-DQ2 - what disease is implicated?
Coeliac
HLA-DR3 - what disease is implicated?
Addisons, SLE, T1DM, Graves and Myastenia gravis
HLA-DR4 - what disease is implicated?
T1DM (stronger here than DR3) and RA
What questionnaire is a marker of disease activity in RA?
DAS28 - assesses 28 joints
Which drug used in T2DM can cause weight gain? Example?
Sulfonylureas eg Gliclazide
What is a myxoedema crisis and how does it generally present?
Hypothyroid crisis - typically presenting with confusion and hypothermia
How is a myxoedema crisis mx?
IV thyroid replacement
IV fluid
IV corticosteroids (until the possibility of coexisting adrenal insufficiency has been excluded)
electrolyte imbalance correction
sometimes rewarming
How is acromegaly tested for?
Serum IGF-1
How are scaphoid fractures mx?
Undisplaced waist fractures:
- Cast 6-8w - can consider early surgery if in certain people eg sports
Displaced scaphoid waist fractures:
- Surgical fixation
Proximal scaphoid pole fractures:
- Surgical fixation
When unsure if T1DM or T2DM what test can be used to distinguish between the two?
C- peptide - its a breakdown product of insulin precursor hence would be low in T1DM and normal / high in T2DM
Describe different BMI ranges:
Underweight <18.5
normal 18.5 - 25
overweight - 25-30
Obese class 1 - 30-35
Obese class 2 - 35-40
Obese class 3 - 40<
What bloods can be found in addisonian crisis?
High K
Low Na
Low glucose
Can be percipitated by steroid withdrawal eg during surgery
1st line Mx of RA?
DMARD monotherapy +- short course of bridging prednisolone
Mx of toxic multinodular goitre?
Radioiodine
What is Meralgia paraesthetica and where does it cause pain and why?
A syndrome of paraesthesia or anaesthesia in the distribution of the lateral femoral cutaneous nerve (LFCN) - seen in upper lateral aspect of thigh
Main features of Alports syndrome?
Recurrent painless haematuria, poor renal function and a sensorineural deafness
Which psych drug may cause polyuria?
Lithium
Testicular torsion - where is normally affected, where is affected if cremastermic reflex is preserved?
Normally - spermatic cord
Cremasteric preserved - testicular appendage
Features seen in MEN1, 2a, 2b?
MEN1 = 3Ps - Parathyroid (hyperplasia), Pituitary and Pancreas
MEN2a = Medullary thyroid cancer + 2Ps - Parathyroid and Phaeochromocytomas
MEN2b = Medullary thyroid cancer + 1P - Phaeochromocytoma + Marfanoid body + Neuromas
What can predispose to development of charcot joint?
Most common cause is diabetic neuropathy but there are several other conditions which may lead to it including alcoholic neuropathy, syphilis and cerebral palsy
Which T2DM pts have a target of 53mmol/mol HbA1c?
Those taking more than one medication / having a medication associated w hypoglycaemia
1st line mx of reactive arthritis?
NSAIDs
What does fused podocytes on electron microscopy suggest?
non-proliferative glomerulonephritis eg minimal change disease in children
Blood test for HF?
NT-proBNP (N-terminal pro-B-type natriuretic peptide)
Describe the different ECG changes seen in the following coronary territory MIs:
Anteroseptal
Inferior
Anterolateral
Lateral
Posterior
What blood vessel supplies the following coronary territories?
Anteroseptal
Inferior
Anterolateral
Lateral
Posterior
What type of murmur is found in VSD?
Pansystolic murmur - larger the defect the smaller the murmur
What is this? How is mx?
Torsades de pointes (‘twisting of the points’) is a form of polymorphic ventricular tachycardia associated with a long QT interval -> can become VF -> sudden death
Treat w IV Magnesium sulfate
What vaccinations do people with HF require? How often?
offer annual influenza vaccine
offer one-off pneumococcal vaccine - adults usually require just one dose but those with asplenia, splenic dysfunction or chronic kidney disease need a booster every 5 years
What does this X-Ray show? What features can you see?
A is for alveolar oedema, which is widespread on this x-ray. B is for Kerley B lines, which can be seen on the lateral edges of both lungs. C is for cardiomegaly, which unfortunately cannot be assessed as there is no indication this is an anteroom-posterior (AP) x-ray. D is for dilated upper lobe vessels, which are not visible in this chest x-ray. E is for pleural effusion, here there is notching of the costophrenic angles, indicative of fluid pooling there.
What is becks triad of cardiac tamponade?
Classical features - Beck’s triad:
* hypotension
* raised JVP
* muffled heart sounds
What are J-waves (Small hump at the end of QRS complex) on ECG associated w?
Hypothermia
Hypothermia, hyporeflexia, bradycardia and seizures, think x??
myxoedemic coma
Another name for trochanteric bursitis?
Greater trochanteric pain syndrome - can cause nighttime pain
Another name for trochanteric bursitis?
Greater trochanteric pain syndrome - can cause nighttime pain
Most common cause of Addisonns in the UK? In the world?
UK = AI
World = TB
If a pt has their steroids stopped and present hypotensive and with reduced Na and raised K - what needs to be done?
Prescribe their steroids to prevent adrenal failure
What can cause azathioprine toxicity?
TMPT deficiency (Thiopurine methyltransferase)
What class of drugs is Etanercept? What is a possible adverse effect?
TNF-a inhibitors and they can re-activate TB
What are the different types of Salter-Harrise fractures?
There are classically 5 types that can be remembered with the mnemonic SALTER with each letter corresponding to a type:
S: straight across the epiphyseal plate (type I).
A: above the plate (type II).
L: lower than the plate (type III).
T: transversing the plate (type IV).
ER: erasing the plate (type V).
III, IV and V need surgery - V can cause disruption to growth
What ECG changes are an indication for thrombolysis or PCI?
ST elevation of > 2mm (2 small squares) in 2 or more consecutive anterior leads (V1-V6) OR
ST elevation of greater than 1mm (1 small square) in greater than 2 consecutive inferior leads (II, III, avF, avL) OR
New Left bundle branch block
mx of peri-arrest bradycardia?
indapamide - what type of drug?
Thiazide-like diuretic
Which HTN requires same-day specialist assessment?
If new BP >= 180/120 mmHg + new-onset confusion, chest pain, signs of heart failure, or acute kidney injury then admit for specialist assessment
What is S1 HTN, S2 HTN and Severe HTN??
Describe the following eponymous signs of aortic regurgitation:
Corrigan’s
Quinke’s
De Musset’s
Duroziez’s
Traube’s
Corrigan’s - exaggerated carotid pulse
Quinke’s - nailbed pulsation
De Musset’s - head nodding
Duroziez’s - diastolic femoral murmur
Traube’s - ‘pistol shot’ femorals
