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EXAM 1 Flashcards

1
Q

Top 3 causes of CLD

A
  1. Alcoholic fatty liver
  2. NAFLD
  3. Chronic HBV/HCV
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2
Q

Wilson’s disease

  1. Symptoms
  2. Diagnosis
  3. Treatment
A
  1. Young dementia, movement disorder (Parkinsonism, Chorea, depression, phobias, compulsive behaviours), Kaiser Fleischer rings, blue lunula, haemolytic anaemia.
  2. Decreased ceruloplasmin, increased urinary and serum copper
  3. Avoid copper containing foods –> Chelation (penicillamine + zinc + Trientine + tetrathiomolybdate) –> liver transplant
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3
Q
  1. Causes of hemochromatosis
  2. Symptoms
  3. Diagnosis
  4. Pathology
  5. Management
A
  1. Autosomal recessive (hepcidin deficiency) OR iron excess (thalassemia - iron not utilised in Hb and myelodysplasia - ring sideroblasts)
  2. Bronzed diabetes (70-80%), CLD (100%), HCC, restrictive cardiomyopathy (HFpEF), arthritis. Pretty much anything it can deposit in and cause dysfunction.
  3. High ferratin and high transferrin saturation (carrying iron)
  4. Iron stain blue with Perls stain and brown with H&E. Liver is large (iron accumulation), brown (pigmentation), and dense (iron)
  5. Avoid vitamin C and iron, Phlebotomy, deferoxamine (iron binder & urinary secretion).
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4
Q

Alpha-1 antitrypsin deficiency pathology and management

A
  1. Dark pink cytoplasmic inclusion of alpha-1 antitrypsin on PASD satin.
  2. Liver transplant
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5
Q

Primary sclerosing cholangitis

  1. Epidemiology
  2. Pathophysiology
  3. Diagnosis
  4. Pathology
A
  1. Men, U/C (70%), 30-50yrs
  2. T-cell mediated autoimmunity, damage of the medium and large bile ducts (common bile duct), 10% develop cholangiocarcinoma,
  3. p-ANCA, beads on string (strictures on ERCP/MRCP)
  4. Onion skin fibrosis, neutrophil infiltrate with associated oedema.
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6
Q

3 causes of ascites in CLD

A
  1. Portal HTN - increased hydrostatic pressure forces fluid into the space of disse overwhelming the lymphatics leading to fluid leaking into the peritoneum
  2. Hypoalbuminaemia - decreased albumin production, decreased oncotic pressure cause peritoneal extravasation
  3. Splanchnic vasodilation and hepatorenal syndrome - increased permeability and hydrostatic forces
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7
Q

Primary biliary cholangitis

  1. Epidemiology
  2. Pathophysiology
  3. Symptoms
  4. Diagnosis
  5. Pathology
  6. Management
A
  1. Women, 30-50yrs, Sjogren’s (65-80%, RA, thyroid, CREST), Northern Europe/US
  2. Antibody and T-cell mediated autoimmunity of the small intrahepatic ducts
  3. Pruritus, Skin hyperpigmentation, xanthomas, fatigue, low risk of cholangiocarcinoma
  4. Isolated ALP rise and anti-mitochondrial antibodies
  5. Destruction of interlobular bile ducts by lymphoplasmacytic inflammation and granulomas
  6. Ursodeoxycholic acid (alters bile composition) –> liver transplant
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8
Q

Autoimmune hepatitis

  1. Epidemiology
  2. Pathophysiology
  3. Diagnosis
  4. Pathology
A
  1. Young women
  2. T-cell mediated autoimmunity
  3. Anti-smooth muscle antibodies & ANA
  4. Interface hepatitis - T-cell and plasma cells spill out of the portal tracts into adjacent hepatocytes
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9
Q

Hepatic encephalopathy

  1. Cause
  2. Exacerbates
  3. Symptoms
  4. Management
A
  1. Failure of the liver to convert TOXIC ammonia to urea –> increased ammonium
  2. Dietary protein, constipation, fluid and electrolyte disturbances (haemorrhage), anaemia, hypoxia, hypotension, TIPS
  3. AMS/coma, asterixis, hypertonia, hyperreflexia, slurred speech
  4. Stop known cause, lactulose, Rifaximin (rifamycin - if refractive to treatment)
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10
Q

Signs and symptoms of compensation liver failure

A
  • Anorexia
  • Fatigue
  • Weight loss/cachexia
  • Clubbing
  • Pruritus
  • Fetor hepaticus
  • Increased estrogen (gynecomastia, spider naevi, testicular atrophy, palmar erythema, loss of chest hair)
  • Impaired biosynthesis (easy bruising and petechiae, leukonychia, muscle wasting, bilateral pitting oedema, hypotension)
  • Portal HTN (splenomegaly/thrombocytopenia, caput medusae, haemorrhoids)
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11
Q

Signs of decompensated liver failure

A
  1. Jaundice
  2. Hepatic encephalopathy (AMS/coma, slurred speech, asterixis, hypertonia ad hyperreflexia)
  3. Ascites
  4. Varices
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12
Q

Biochemistry & investigation findings in CLD

A
  • Thrombocytopenia (hypersplenism and decreased thrombopoietin) - most sensitive and specific for cirrhosis
  • Anaemia of chronic disease (increased inflammatory state)
  • Normal or slightly elevated liver enzymes (X5)
  • High mixed bilirubin (inability to conjugate and poor excretion of conjugated)
  • Elevated INR and aPTT (lack of all clotting factors and fat soluble vit K)
  • High Ammonia and low urea (hepatic encephalopathy)
  • Hyponatraemia and hypokalaemia (perceived hypovolaemia caused ADH)
  • Osteoporotic DEXA (lack of vit D fat soluble vitamin thus calcium)
  • High hepatic venous pressure gradient (portal HTN)
  • Hypoalbuminaemia acidic tap (transudative process)
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13
Q

HAP antibiotics

A
  1. PO Augmentin
  2. IV ceftriaxone
  3. IV Pip-tazo (tazocin) +/- vancomycin
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14
Q

CAP antibiotics

A
  1. PO amoxicillin +/- Doxycycline
  2. IV benzylpenicillin +/- Doxycycline
  3. IV ceftriaxone + azithromycin
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15
Q

Child-Pugh elements and interpretation

A
  1. Bilirubin
  2. Albumin
  3. INR/PT
  4. Ascites (mild, mod, severe)
  5. Hepatic encephalopathy

Score 5-15
Class ABC
Indicates 1 and 2 year survival

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16
Q

Ascites management

A
  1. ABC
  2. Diagnostic paracentesis
  3. Nutritionist review –> salt restriction and nutrients
  4. Spironolactone +/- frusemide
  5. Paracentesis + IV 20% albumin
  6. TIPS - transjugular intrahepatic portosystemic shunt
  7. Liver transplant
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17
Q

Varices management

A
  1. ABC
  2. 2X large bore cannula
  3. Aggressive fluid resus w/ IV albumin (or dextrose) +/- blood transfusion (aim for 70-80, to high increases portal pressure)
  4. EMERGENCY endoscopic band ligation
  5. Terlipressin (ADH analogue vasoconstrictor)
  6. IV ceftriaxone
  7. TIPS
  8. Preventative propranolol - promotes splanchnic vasoconstriction
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18
Q

What is considered excessive alcohol consumption?

A

Men >21 standard per week

Women >14 standards per week

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19
Q

Stages of Alcoholic liver disease (pathophysiology)

A
  1. Acute fatty liver - completely reversible, excessive NADH –> increased acetyl-CoA –> increased lipids AND lipid synthesis required NADH which is in excess!!
  2. Alcoholic steatohepatitis - ethanol metabolism requires CYP enzymes which release ROS –> bacterial endotoxins –> Kupffer cell cytokines –> hepatocellular death
  3. Fibrosis - Kupffer cell cytokines –> stellate cells become myofibroblasts –> fibrosis
  4. Alcoholic cirrhosis –> interrupted bile and blood flow –> portal HTN
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20
Q

Fatty liver disease (alcholic and NAFLD) pathology

A
  • Hyper-echogenicity on U/S
    Steatosis
  • enlarged, pale, yellow, and soft liver
  • Intrahepatocyte fat filled vacuoles
    Steatohepatitis
  • Neutrophilic infiltrate, hepatocyte ballooning and necrosis, Mallory hyaline denk bodies (cytoskeleton collapse)
    Steatofibrosis
  • Chicken-wire fence fibrosis (fibrosis radiating from the central vein and eventually linking portal tracts forming central-portal septa
    Cirrhosis
  • Non-function green nodules
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21
Q

Symptoms of chronic alcoholism and management

A
  • Palmar erythema
  • Parotid enlargement
  • Fine resting tremor
  • Dupuytren’s contracture
  • Wernicke’s encephalopathy (alcohol withdrawal) - ataxia, confusion, nystagmus
    1. Psychological therapy
    2. Naltrexone (opioid antagonist) - stops euphoria
    3. Acamprosate (GABA enhancer)
    4. Disulfiram - induce unpleasant symptoms w/ alcohol use
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22
Q

Cellulitis antibiotics + penicillin rash and anaphylaxis

A

Outpatient - not-systemic

  • Strep –> PO phenoxymethylpenicillin OR benzylpenicillin
  • Staph –> PO flucloxacillin
  • Rash –> PO cefalexin
  • Anaphylaxis –> PO Clindamycin

Inpatient - systemic

  • Strep –> IV benzylpenicillin
  • Staph –> IV flucloxacillin
  • Rash –> IV cefazolin
  • Anaphylaxis –> IV vancomycin

MRSA –> Vancomycin

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23
Q

Diverticulosis

A
  • Sigmoid and descending colon
  • True/congenital = all 3 layers
  • False/acquired = mucosa and submucosa
  • Constipation & low fibre diet & alcohol
  • Old age
  • CTD - Marfan’s and Ehlers Danlos
  • Obesity
  • > 50yrs
  • Yong males, old females
  • Asians = right sides
  • Post prandial pain - better with defecation and worse with straining
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24
Q

Diverticular bleed

A
  • Painless haematochezia
  • Ascending colon - diverticular are larger
  • 75% spontaneously resolve
  • Blood transfusion
  • Endoscopic or angiographic embolisation
  • Surgery (continuous bleeding)
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25
Diverticulitis 1. Where and who? 2. Complications 3. Symptoms 4. Gold standard & follow-up imaging 5. Management
- Left colon - 63yrs - Abscess - Perforation - Ileus - Aseptic cystitis - Fistula - Pyogenic liver abscess - Bowel obstruction - LLQ pain - Alternating bowel habits (diarrhoea --> constipation) - Dysuria, frequency and urgency - Pneumaturia - Anorexia - Low grade fever - Bloating - Contrast CT abdomen pelvis - Colonoscopy 1. ABC 2. Call gen surgery 3. NPO 4. IV Augmentin (Amoxicillin + clavulanate) 5. +/- IV gentamicin + amoxicillin + metronidazole 6. +/- Abscess drain 7. +/- Hartmann's
26
Crohn's Vs U/C pathology
Crohn's - Transmural inflammation - Fissures, strictures, fistulae - Skip lesion (cobble stone) - Non-caseating granulomas - Thickened bowel wall - Migrating fat - Branching and shortening of bowel crypts U/C - Mucosal inflammation - Haemorrhagic - Continuous lesion (linear ulceration) - Pseudo-polyps - Broad based ulcer
27
Crohn's Vs U/C complication
Crohn's - Iron deficiency anaemia --> duodenum - B12 deficiency anaemia --> Ileum - Osteoporosis, easy bleeding, steatorrhea --> bile salt malabsorption --> ileum - Small bowel obstruction --> strictures - Oral ulcers (gum) - Peri-anal disease (bum) - Erythema nodosum - subcutis inflammation with neutrophils, giant cells and haemorrhage U/C - Iron deficiency anaemia --> Bloody diarrhoea - Toxic megacolon (severe disease) - Colorectal cancer - Primary sclerosing cholangitis --> pANCA & cholangiocarcinoma - Pyoderma gangrenosum --> Neutrophilic dermatosis with pain out of proportion
28
Crohn's Vs U/C presentation
Crohn's - Water diarrhoea --> malabsorption - Weight loss - RIF pain --> terminal ileitis - Clubbing U/C - Bloody diarrhoea - Months of active colitis - Better with smoking
29
Crohn's Vs U/C management
Crohn's Mild/Mod --> PO steroids Severe 1. PO azathioprine/mercaptopurine (antimetabolites) 2. Methotrexate (DMARDS) 3. bDMARDS - infliximab/adalimumab/vedolizumab U/C 1. 5-aminosalicylates --> PO/rectal Mesalazine 2. Corticosteroids 3. Immunosuppressants --> azathioprine/mercaptopurine 4. Biologics --> vedolizumab/infliximab Acute --> IV pred + 5-aminosalicylates --> ciclosporin/infliximab --> colectomy
30
IBD gold standard investigation and AXR findings
Scope w/ biopsy | Thumbprinting and lead-pipe
31
Acute cholecystitis pathology
- Enlarged, tense, erythematous, with fibropurulent exudate and a thick wall - Neutrophilic infiltrate
32
Chronic cholecystitis pathology
- Smooth, subserosal fibrosis, grey/white and a thickened wall - Mixed inflammatory infiltrate - Mucosal and muscle proliferation - Rokitansky Ascoff sinuses - herniation of mucosa through the muscularis
33
Gold standard investigation and findings for cholecystitis
U/S gallbladder - Thickened wall - Probe tender - Pericholecystic oedema - Stones
34
Gall stone management
Cholelithiasis 1. Simple analgesia & antiemetic 2. PO fluids 3. Elective cholecystectomy 4. Ursodeoxycholic acid - reduced the cholesterol saturation of bile Acute Cholecystitis 1. ABC 2. IV fluids 3. NPO 4. Simple analgesia & antiemetics 5. IV gentamicin and amoxicillin 6. Urgent Lap cholecystectomy 7. Percutaneous cholecystostomy Choledocholithiasis 1. ABC 2. IV fluids 3. NPO 4. Simple analgesia & antiemetics 5. IV gentamicin and amoxicillin 6. Urgent ERCP 7. Elective Lap cholecystectomy Cholangitis 1. ABC 2. IV fluids 3. NPO 4. simple analgesia & antiemetics 5. IV gentamicin + amoxicillin + metronidazole 6. Urgent ERCP w/ stenting 7. Elective Lap cholecystectomy
35
Acute interstitial pancreatitis
- 85% - Swollen oedematous inflamed pancreas - Focal fat necrosis --> fat stranding & chalky white foci --> increased CT enhancement - Peripancreatic pseudocysts - Saponification --> calcium + fat --> soap which stain blue - Neutrophilic infiltrate
36
Acute necrotising pancreatitis
- 15% - Thrombosis of the microcirculation - Acinar (enzymes), ductal (bicarb), islets of Langerhans (endocrine) necrosis - ICU admission - Gram negative bacillus infection - Haemorrhagic pancreatitis - Decreased enhancement on CT
37
Acute pancreatitis complications
<4 weeks - Peripancreatic fluid collection - Necrotic collections >4 weeks - Peripancreatic pseudocyst - enclosed by fibrous granulation tissue, self-limiting - Walled off necrosis - necrotic collection which become loculated
38
Hereditary non-polyposis colon cancer (HNPCC) (lynch syndrome)
- Autosomal dominant - DNA mismatch repair gene - Microsatellite instability --> hypermutability - 45yrs - Right sided - Mucinous adenocarcinoma - Associated malignancies (endometrial --> small intestine, urinary, gastric, biliary, pancreatic, cerebral, ovarian) - Turcot's --> + primary brain tumour
39
Familial adenomatous polyposis (FAP)
- Autosomal dominant - Adenomatous polyposis coli (APC) mutation - 1000+ polyps by 20 - 100% risk --> sub-total colectomy - Gardener's syndrome --> + mandibular/skull tumours, epidermal cysts, fibromatosis - Turcot's --> + primary brain tumour
40
Peutz-Jeghers Syndrome
- Autosomal dominant - Loss of tumour suppressor gene - Hamartomatous polys --> arborizing and non-cystic - Intussusception + PR bleeding - 11yrs - Mucocutaneous melanocytic lesions - Associated tumours: pancreas --> small bowel --> stomach --> breast, ovarian, uterine, lung, testicular
41
Juvenile polyposis
- Autosomal dominant Hamartomatous polyps --> cystic, rectum (PR bleed + anaemia) - <5yrs symptoms - 60yrs CRC - Associated gastric, duodenal, pancreatic cancer
42
Thyroid papillary carcinoma
- Most common - Palpable LNs - 25-50yrs - Radioactive iodine ablation --> good prognosis - Branching papillae - fibrovascular core with tumour cells - Psammoma bodies - Orphan Annie nuclei - Nuclear grooves - Nuclear pseudo-inclusions
43
Non-neoplastic polyps
Inflammatory - Inflamed regenerating mucosa (e.g., U/C) - Ulcerative --> PR bleeding - Mucus Hyperplastic - 60-70s --> delayed shedding of surface cells - No malignant potential - Left colon Hamartomatous - 90% sporadic - 10% juvenile polyposis or peutz-Jeghers - Normal mature tissue growth
44
Dysplastic colonic polyps 1. sessile 2. pedunculated 3. tubular 4. villous
Sessile - Broad attachment - Flat - High malignancy risk Pedunculated - Attached by a stalk - Ulcerate Tubular - Elongated branched crypts Villous - High malignancy risk
45
Colorectal adenocarcinoma
- 80% undergo the adenoma to carcinoma pathway: APC/p53 --> dysplasia --> K-ras/BRAF --> adenoma --> APC/p53 --> carcinoma --> metastatic disease - Rectum > sigmoid > caecum > ascending > transverse > descending - graded based on gland formation and resemblance to original epithelium - Mucinous: extracellular mucin pool, HNPCC - Signet ring: intracellular mucin
46
Dukes criteria
A - Into bowel wall B - Through bowel wall C - Through bowel wall and LNs D - distant metastasis
47
CRC staging
I - Submucosa/muscularis propria II - T3/T4 - sub-serosa and/or neighbouring tissues III - LN IV - M1
48
CRC screening
FOBT - 50-74yrs - Every 2yrs - Asymptomatic - No family history - Relies on cancer being ulcerative Colonoscopy - Family history (every 5 yrs) - IBD - Familial syndrome - Personal history (every 3-5 yrs)
49
Management of CRC
Stage I - muscularis propria & submucosa - Resection - 90-95% prognosis (5yr survival) Stage II - Serosa & neighbouring tissues - Resection - 80-85% prognosis Stage III - LNs - Resection - Adjuvant chemotherapy - 60-70% Stage IV - isolate metastasis - Primary resection - Secondary resection - Adjuvant resection - 30-40% Rectal - Neoadjuvant chemotherapy - Radiotherapy Metastatic - Palliative care - Chemotherapy - prolong survival for 24 months - Local radiotherapy and stenting - relieve symptoms - incurable Follow up - Surgical history and exam every 3-6 months - CEA every 3 months for the first 2yrs - Colonoscopy 3-5yrs
50
Appendicitis examination signs
McBurney's --> appendix base Rovsing's --> right sided local peritoneal irritation Psoas --> pain on hip extension --> retrocaecal appendix Obturator --> pain in hip internal rotation and knee flexion --> pelvic appendix
51
Alvarado score
>6-7 = appendicitis --> operate without CT ``` Migratory pain Anorexia Nausea Tenderness in the RIF (2) Rebound tenderness Elevated temperature Leucocytosis (2) Shift on blood film ```
52
Reflux oesophagitis pathology
- Mild GORD - Acute inflammation with eosinophils - Elongation of the lamina propria - Linear ulcers
53
GORD diagnosis
- Clinical - >2 episodes of heart burn per week - Resolution with PPI and lifestyle modifications within 6 weeks - Still symptomatic --> endoscopy
54
Oesophagitis pathology
Chemical - Odynophagia - Haemorrhage - Structure - Perforation - Alcohol, acids/alkalis, hot fluids, smoking, pills, drugs Herpes - Multinucleated epithelial cells - Ground glass nuclei due to viral inclusions CMV - Endothelial and stromal cell viral inclusions Candida - HIV/AIDS Eosinophilic - Allergic reaction to food OR corticosteroid induced - Children and young adults - Men > women - Associated with autoimmune disease - Intraepithelial eosinophils and micro abscess - Furrows and rings macroscopically
55
Stress stomach ulcers
Cushing's - Increased ICP --> increased PSNS tone --> increased acid production Ventilators & bariatric surgery Curling's Severe burn --> hypovolaemia --> decreased gastric blood flow --> epithelial sloughing
56
Duodenal Vs gastric ulcer
Duodenal - H. pylori > NSAIDS - Post-prandial and nocturnal pain - Weight gain - Gastroduodenal rupture - Superior duodenum Gastric - NSAIDS > H. pylori - Prandial pain - Weight loss - Splenic artery rupture - Pylorus and lesser curvature
57
PUD Vs cancer pathology
PUD - 'Punched out' lesion - Clear base +/- granulation tissue and fibrotic scaring - Inflammatory infiltrate covered over granulation tissue over fibrous scar tissue Gastric adenocarcinoma - Heaped up edges - Necrotic base
58
Gold standard tests for PUD
Urea breath tests --> H. pylori | Endoscopy
59
Acute gastritis
- Erosion (mucosa) - Neutrophils - Fibropurulent luminal exudate
60
Chronic gastritis
- More common than acute H. pylori - Most common - Antral - Bacteria concentrate on the luminal surface - Mixed inflammatory cell infiltrate - Intraepithelial neutrophils - Sub-epithelial plasma cells - Lymphoid follicles --> MALToma - Atrophy and intestinal metaplasia --> adenocarcinoma Autoimmune/pernicious anaemia - Body and fundus - Compensatory parietal pseudohypertrophy - Endocrine cell hyperplasia --> carcinoid tumour - Intestinal metaplasia --> gastric adenocarcinoma
61
H. pylori management
1. Esomeprazole + Amoxicillin (metronidazole) + clarithromycin 2. Esomeprazole + Amoxicillin + Levofloxacin 3. Esomeprazole + metronidazole + tetracycline + bismuth chelate
62
Primary ventral hernia's
Umbilical - Women > men - Increased intrabdominal pressure - Omentum or extraperitoneal fat Epigastric - Men > women - True --> peritoneal sac of omentum +/- small bowel - False --> extraperitoneal fat - Weak linea alba - Forceful diaphragmatic contractions Spigelian - >40yrs and obese - Weak linear semilunaris - Below the arcuate line
63
Groin hernia's
Indirect inguinal - Most common - Patent processus vaginalis - Younger boys and men - Lateral to the epigastric artery - Above the inguinal ligament - Through the superficial and deep inguinal ring (midpoint of the inguinal point) - Scrotal swelling Direct inguinal - Weak abdominal wall - Medial to the epigastric artery - Above the inguinal ligament - Trough Hesselbach's triangle - Superolateral to the pubic tubercle - Impulse medial to the superficial inguinal ring Femoral hernia - Women - Through the femoral canal - Strangulation due to sharp medial border of the lacunar ligament - Below the inguinal canal - Mid-inguinal point - Referred lumbar pain
64
Saphena varix
- Benign dilation of the great saphenous vein - Reduced when lying down - Women > men
65
What is the difference between a reducible, incarcerated, and strangulated hernia?
Reducible - moves in and out of the opening with changes in position Incarcerated - non-reducible hernia with compromised blood supply and drainage Strangulated - ischaemia incarcerated hernia
66
Hernia diagnosis
Clinical | - If unable to visualise can CT
67
Hernia management
Hernioplasty (most common) --> mesh repair Herniorrhaphy --> tissue stitched together Elective - Reducible + pain - Incarcerated + minimal pain Urgent - Incarcerated + pain Emergent - Strangulated hernia open approach
68
Functional bowel obstruction
Temporary impairment of peristalsis - Ileus - Drugs (Anticholinergics, opioids, TCA, frusemide, CCB) - Spinal cord injury - Electrolyte disturbances
69
Acute bowel obstruction signs
- Increased intestinal mobility - Borborygmi - 'tinkling bowel sounds' - Colicky abdominal pain - Diarrhoea
70
Late bowel obstruction
- Abdominal distention - Bowel collapse --> obstipation - Lymphatic and venous compression --> oedema --> dehydration and hypovolaemia - Arterial compression --> ischaemia --> perforation --> sepsis - Diaphragm splinting --> hypoventilation
71
Small Vs large bowel obstruction
Small - Periumbilical pain - N+V --> obstipation - 1min duration every 5 minutes Large - Lower abdominal pain - Obstipation --> N+V - Continuous every 10-15 minutes
72
Bowel obstruction imaging and findings
AXR (gold standard) - Dilated bowel loops - Air fluid levels - String of pears/step ladder sign --> mechanical obstruction - Pneumoperitoneum Gastrograffin enema - draws fluid out of the bowel wall - Birds beak --> volvulus - Apple core --> CRC
73
Acute ischaemic bowel 1. Cause 2. Thickness 3. Symptoms
- Hypotension --> HF, sepsis, anaphylaxis, cocaine, DKA, burns, arrhythmias - Embolism - Thrombosis - Aneurysm/dissection - VTE - Transmural infraction --> not time for collaterals - Sudden, severe, diffuse abdominal pain out of proportion to physical exam worse post-prandially - Anorexia - N+V - Bloody mucous diarrhoea
74
Chronic ischaemic bowel 1. Cause 2. Thickness 3. Symptoms
- Atherosclerosis - Median arcuate ligament syndrome - coeliac artery compressed by median arcuate ligament - Fibromuscular dysplasia - Aortic or mesenteric dissection - Vasculitis - Mucosal infarct - time for collaterals - Post prandial abdominal pain, better after 2 hours - Anorexia - Weight loss
75
Ischaemic bowel imaging
CTA - no oral contrast - Bowel wall thickening - Absent wall enhancement - Fat stranding AXR (if CTA not available) - Distended bowel loops - Bowel wall thickening - Pneumatosis intestinalis
76
Signs of compromised bowel in CTA & management
- Gas in the intestinal wall - Portal venous gas - Mesenteric stranding EMERGENCY THEATRE 1. ABC 2. IV fluids 3. NBM & NGT 4. Analgesia & antiemetics 5. IV ceftriaxone and metronidazole 6. Correct acidosis and electrolyte abnormalities 7. IV heparin 8. Surgery within 30 minutes! --> Resect non-viable bowel and revascularise
77
Acute mesenteric ischaemic management
1. ABC 2. IV fluids 3. NBM + NGT 4. Analgesia + antiemetics 5. IV ceftriaxone + metronidazole 6. Correct electrolyte disturbance + acidosis 7. IV heparin 9. Clot --> tPA HF --> dobutamine 10. Surgery - stable and no bowel compromise - Balloon angioplasty +/- stent - Clot aspiration - Catheter directed thrombolysis
78
Chronic mesenteric ischaemia management
1. Lifestyle 2. Revascularisation - Angioplasty +/- stenting - Bypass - Endarterectomy
79
Viral gastroenteritis
- Most common - Self-limiting - Watery diarrhoea Norovirus - Adult - RNA - Most common - Outbreaks - restaurants, cruise ships, healthcare, military - 24-48hrs - Shellfish, prepared food, fruit/vegetables Rotavirus - Children - day-care centres - dsRNA - Vaccine - Cause outbreaks - 10-72hrs - Faecal oral route
80
Bacterial gastroenteritis - campylobacter
- Most common bacterial - Gran negative bacillus - 1-3 day incubation (2-5 days) - Poultry (raw chicken), meat, unpasteurised milk - Animal contact (young puppies and kittens) - Dysentery
81
Bacterial gastroenteritis - Salmonella
- Most common bacterial - Gram negative bacillus - Uncooked chicken and eggs - Petting zoo's, live poultry, pets - 1-3 days incubation (8-72 hours) - Cause an acute abdomen - Dysentery
82
Bacterial gastroenteritis - Shigella
- Gram negative bacillus - Dysentery - 1-7 days incubation - MSM, crowded living - HUS - AKI, haemolytic anaemia, thrombocytopenia (MAHA)
83
Bacterial gastroenteritis - EHEC
- Gram negative bacillus - HUS & TTP - Undercooked ground beef - 3-4 days incubation period - Dysentery
84
Bacterial gastroenteritis - Yersinia
- Undercooked pork and unpasteurised milk - 1-14 days incubation - Dysentery - Pharyngitis - Gram negative
85
Bacterial gastroenteritis - ETEC
- Gram negative bacillus - Travellers diarrhoea - 1-3 day incubation - Faecal-oral route - Watery diarrhoea
86
Bacterial gastroenteritis - Vibrio cholerae
- Gram negative bacillus - Rice water diarrhoea - Contaminated water in developing countries
87
Bacterial gastroenteritis - Staph. Aureus
- Gram positive cocci - Proteinaceous unrefrigerated food - 4-6 hours incubation
88
Bacterial gastroenteritis - Bacillus cereus
- Gram positive bacillus - Fried rice - 1-6 hours incubation - Vomiting
89
Bacterial gastroenteritis - Clostridium Perfringens
- Gram positive bacillus - Poor reheating meat, poultry, gravy - Water diarrhoea - 6-24 hour incubation period - Ileus
90
Bacterial gastroenteritis - Giardia
- Most common parasitic - Flagellated parasite - Waterborne - Incubation 7-14 days - Bloating and foul smelling steatorrhea - Trophozoites - Sulphur breath - Cysts in stool sample
91
Bacterial gastroenteritis - cryptosporidium
- Waterborne (drinking and swimming) | - Severe dehydrating diarrhoea
92
Bacterial gastroenteritis - Entamoeba histolytica
- Parasite - Migrants & MSM - Dysentery - Liver cysts - Toxic megacolon
93
Hypertension management
Uncomplicated - isolated HTN 1. ACEi 2. ACEi + thiazide 3. ACEi + thiazide + dihydropyridine CCB (amlodipine, nifedipine) Complicated - Stable angina, AMI 1. BB (metoprolol/atenolol) 1. Dihydropyridine (verapamil/diltiazem) Add on therapy 1. Spironolactone BPH 1. Prazosin (alpha-1 blocker) Pregnant 1. Methyldopa (centrally acting antiadrenergic) 1. Monoxidine (centrally acting antiadrenergic) Uncontrollable 1. Minoxidil (vasodilator) + BB + frusemide 2. Hydralazine (vasodilator)
94
HFrEF management
1. Bisoprolol/carvedilol/metoprolol/nebivolol (BB) - Must be euvolemic and stable - May cause hypotension & bradyarrhythmia's acutely - DO NOT commence during decompensation - Start LOW and up-titrate over weeks 1. ACEi 2. Spironolactone Still symptomatic 1. ADD sacubitril + valsartan to BB Not tolerating ACEi or ARB 1. ADD hydralazine (vasodilator) + isosorbide dinitrate (nitrate) to BB Final straw 1. ADD digoxin to ACEi + BB + spironolactone + frusemide
95
Anal abscess signs & symptoms and management
- Constant throbbing anal pain - Tender erythematous fluctuant mass w/ indurated skin - Purulent discharge - +/- fever and malaise - Pain on sitting - PO Augmentin - pre-surgical - Surgical drainage
96
Anal fistula
- 30-70% of perianal abscesses progress to fistula if left untreated - Intermittent anal pain - Purulent, watery, bloody discharge 1. Drain causative abscess if present 2. Seton - band that removes pus prior to surgery 3. Surgical repair - lay-open, fibrin glue, fistulotomy
97
Internal haemorrhoid
Above the pectinate line --> endoderm --> painless - Blood upon wiping - Pruritus - Tenesmus I - in the anal canal --> bleed with defecation II - prolapse during defecation --> bleed with defecation III - manual reduction IV - irreducible - bleeds, painful, mucus discharge, faecal incontinence
98
External haemorrhoids
- Below the pectinate line --> ectoderm --> painful - Pruritus - Blood on toilet paper - Tenesmus Thrombosed/perianal haematoma - Prolapsed external haemorrhoid due to clot - Blue/black & very painful - Thrombosed vein can rupture and haemorrhage - Self-limiting leaving a sentinel skin tag - If present within 72 hours can remove thrombus or haemorrhoid
99
Internal haemorrhoid diagnosis and management
Anoscope (gold standard) 1. Laxative, avoid straining, fluids and fibre 2. Sitz baths, haemorrhoid pillows, emollients, astringents (shrinks haemorrhoid) Internal grade I - topical corticosteroid --> reduce itch Internal grade II/III 1. Band ligation 2. Sclerotherapy OR photocoagulation 3. Artery ligation Internal grade IV 1. Haemorrhoidectomy
100
Hepatitis A
1. RNA 2. Acute ONLY does not persist once cleared 3. Faecal-oral, fomites, saliva 4. Travel, shellfish, childcare 5. 2-6 week incubation 6. RUQ pain, jaundice & dark urine, hepatomegaly, anorexia, fever, fatigue, arthralgia, myalgia 7. HAV antigen, IgM (prior to symptoms onset), IgG (exposed immunity) 8. Self-limiting within 3-6 months 9. Vaccination (e.g., prior to travel & at risk pops for hepatitis) 10. Supportive care
101
Hepatitis B
1. DNA 2. acute and CHRONIC 3. Vertical and blood, semen, saliva 4. Pregnancy, unprotected sex, blood exposure 5. 1-4 months 6. 25% icteric HAV + serum sickness/type III hypersensitivity (Polyarteritis nodosa, membranous GN, arthralgia) 7. Surface antigen --> acute OR chronic infection Surface IgG --> vaccination OR natural immunity Surface IgM --> acute infection Core IgM --> acute infection Core IgG --> chronic infection OR natural immunity HBe antigen --> acute infection and transmissible 8. 65% asymptomatic and clear 25% icteric --> 99% clear & <1% liver transplant 10% chronic carriers --> 1-2% recover, 20-30% cirrhosis, 2-3% HCC, rest 'healthy carrier' HDV super infection --> chronic liver disease and HCC 9. Vaccination scheme 10. peg-IFN, Tenofovir, entecavir - slows disease process NOT curative
102
Hepatitis C
1. RNA 2. CHRONIC and acute 3. Blood 4. IVDU, tats, piercings, needle stick, transfusion 5. 1-5 months 6. Acute (15%) --> jaundiced, membranoproliferative GN 35% of chronic's --> cryoglobulinemia --> mononeuropathy, arthritis, membranoproliferative GN, linchen planus, white sloughing of mucosa 7. HCV antigen --> acute or chronic HCV antibody --> Acute or chronic HIV --> commonly co-infected 8. Acute --> 85% asymptomatic, 15% symptomatic, 1/4 clear Chronic (80-90%) --> 20% cirrhosis, HCC (esp, with HBV), 9. No vaccine 10. CURABLE - ribavirin, peg-IFN
103
Hepatitis D
- RNA - Protected with HBV vaccine - Superinfection on HBV only --> cirrhosis and HCC - Cannot infect alone or without carrier HBV
104
Hepatitis E
- RNA - ACUTE only - 6-8 days incubation - Faecal oral and vertical - IgG and IgM - Liver necrosis in pregnant women - Not vaccine - Self-limiting
105
Chronic hepatitis pathology
Interface hepatitis HBV - Lymphocytic infiltrate - Ground-glass hepatocytes (viral inclusions) - Loss of architecture HCV - Lymphocyte follicles - Steatosis - Bile duct injury
106
BRACA gene
- 5-10% of breast cancers - Increased risk of recurrence Suspect in - <40yr old - Ashkenazi Jewish ethnicity - Triple negative breast cancer - Bilateral breast cancer - Two primary tumours --> breast & ovarian OR prostate
107
Lobular carcinoma in situ (LCIS)
- Multifocal AND bilateral - LOW RISK of invasive malignancy --> NOT resected - Highly invasive --> high risk of developing lesion at another site in the breast - E-cadherin mutation --> non-mass forming - No-calcification --> not screened for on mammography - Discohesive monomorphic malignant cells
108
Ductal carcinoma in situ
- 30% of all breast cancers - Single lesion - Desmoplastic stroma --> palpable mass - Calcifications --> screening mammography - Nipple discharge - 1% increase PER YEAR --> resected - Heterogenous lesion with a mix of high grade (necrosis and calcification) and low grade (papillae)
109
Paget's disease of the breast
- Manifestation of DCIS - 'eczema of the nipple' - Erythematous, ulcerated and scaly nipple - Paget cells --> clear halos
110
Invasive lobular carcinoma
- 10% of invasive carcinoma - Multifocal and bilateral - Single lines of malignant cells invading the stroma - No desmoplastic stroma - No calcifications
111
Invasive ductal carcinoma of the breast
- 75% of all invasive carcinomas - 50% in upper outer quadrant - Desmoplastic stroma - Calcifications - Hard, gritty, poorly circumscribed, haemorrhagic, necrotic, and cystic, stellate mass - Skin dimpling and nipple retraction - Irregular, firm, fixed mass
112
Invasive ductal carcinoma of the breast grades
I - duct forming with few mitosis II - ducts, cords of cells, pleomorphism, mitosis III - cords of cells, pleomorphic, very mitotic
113
Lumina A invasive ductal carcinoma
- 50% of invasive ductal carcinoma - Low grade (grade I-II) - HER 2 negative - Hormone positive (tamoxifen & Aromatase inhibitors) - Low replicative capacity (Ki67)
114
Luminal B invasive ductal carcinoma
- 15% of invasive ductal carcinoma - High grade (grade III) - Triple positive - High replicative capacity (Ki67)
115
Basal type invasive ductal carcinoma
- 15% of invasive ductal carcinoma - Triple negative - Poor prognosis (less medical therapy) - High grade (grade III)
116
Isolated HER2+ invasive ductal carcinoma
- 15% of invasive ductal carcinoma - High grade (grade III) - LN positive --> poor prognosis
117
Phyllodes stromal tumour of the breast
- Mesenchymal AND epithelial proliferation - Aggressive - Estrogen independent - Post-menopausal women - Benign OR malignant - Hypercellular stroma +/- atypia - 'Clover leaf pattern' --> dilated, ectatic and clefted ducts - Rapidly growing large firm well demarcated mobile mass - Shiny stretched skin
118
Metaplastic stromal breast carcinoma
- Metaplasia of glandular epithelium into squamous epithelium OR spindle, chondroid, osseous, or Rhabdomyoid - Distance metastasis without LNs
119
Angiosarcoma of the breast
- Associated with breast radiation and/or lymphedema from mastectomy - Distant metastasis with no LNs - Ill-defined haemorrhagic lesion
120
Inflammatory carcinoma of the breast
- Aggressive - Malignant cell occlude lymphatics - Firm, enlarged, warm, painful, pruritic breast - Peau d'orange - Thickened skin - LN metastasis
121
Ductal carcinoma TNM staging
T1 - 2cm T2 - 2-5cm T3 ->5cm
122
DCIS management
- Change contraception - non-estrogen and/or progesterone containing - Discuss pregnancy - chemo (premature ovarian insufficiency) GnRH agonist during chemotherapy can protect against this 1. Wide local local excision 2. Radiotherapy - clear any residual tissue
123
Invasive ductal carcinoma management
- Discuss contraception - Discuss pregnancy Option 1 1. Neoadjuvant chemotherapy - shrinks the tumour and decreases need for mastectomy and LN removal 2. Radiotherapy - shrinks the tumour and LNs 3. Lumpectomy +/- LN dissection 3. Targeted therapy - depending on receptor status (core biopsy) Option 2 1. Mastectomy - LARGE (>2 quadrants) and/or MULTIPLE +/- LN resection 2. Adjuvant chemotherapy 3. Targeted therapy - depending on receptor status (core biopsy) 3. Targeted therapy
124
Targeted therapy for invasive ductal carcinoma
Trastuzumab (Herceptin) - HER+ (HER+ positive and luminal B) - CCF - get serial TTE Tamoxifen (SERM) - Pre-menopausal women (& post-menopausal) - ER+ (luminal A and luminal B) - Agonist on vessels --> DVT - Agonist on bone --> osteoporosis protective! - Agonist on the endometrium --> Endometrial cancer >55yrs Aromatase inhibitor - Post-menopausal women - Relied on non-functional ovaries - Decrease only estrogen left - -> osteoporosis (monitor BMD) - -> CVD - Arthralgia and myalgia
125
Mammography
- Women >30/40yrs - Women invited 50-75yrs - Personal history every 5yrs - BRCA + 30-75yrs annual
126
Breast cancer prognostic factors
Major - TNM stage Minor - Grade & subtype - Receptor status - Proliferative rate - Age - Comorbidities
127
Plasmodium falciparum
- Most common cause of malaria - Most pathogenic (along with knowlesi) - Symptom onset within 1 months of infection - Generative a surface protein on RBCs which prevents splenic clearance! - Can be fatal within 24-48 hours of presentation - Ring-form trophozoites (thin film)
128
Plasmodium vivax
- Second most common cause of malaria - Present month to year post infection - Duffy antigen bind RBCs to enable infection - Hypnozoites --> sporozoites that lay dormant in the liver for months to years (also occurs in ovale) - Merozoites only infect reticulocytes
129
Malaria signs and symptoms
- Rigors - Paroxysmal fever - Haemolytic anaemia --> jaundice, splenomegaly, anaemia (headache, fatigue, SOB) - Hepatomegaly
130
Malaria diagnosis
Immunochromatographic test - detects malarial antigen Thick and thin films (GOLD STANDARD) - Repeat every 6-12 hours for 36-48 hours - Thick film --> merozoites - Thin film --> secicies
131
Uncomplicated malaria management
- Not complicated :) PO artemether + lumefantrine - Take with fatty foot or full cream milk - Thick and thin 7-28 days P. vivax or ovale (hypnozoites) PO artemether + lumefantrine + primaquine -Test for G6PD
132
Severe malaria diagnostic criteria
``` >1 of the following Parasitaemia >100,000 ARDS - cytokine storm AMS - 'cerebral malaria' Jaundice - haemolytic anaemia Vomiting - metabolic acidosis Oliguria - AKI Hypotension - vomiting, poor oral intake, cytokine storm Abnormal coagulation - cytokine storm Hypoglycaemia - liver failure and plasmodium consumption ```
133
Complicated/severe malaria management
IV Artesunate + ceftriaxone (spesis) + paracetamol (AKI)
134
Malaria prophylaxis
- Light coloured long sleeved clothes - Insecticides - Avoid perfume and aftershave - Bed nets - Removal of stagnant water PO doxycycline - Continue 4 weeks after leaving area - Not suitable for children <8yrs PO Atovaquone + proguanil - Commence 1-2 days prior to entering area - Continue 1 week post leaving - Suitable for children >8yrs
135
EBV signs and symptoms
2-6 week incubation Tonsillopharyngitis - Enlarged tonsils with purulent exudate (lasting 3-5 days) - Sore throat and odynophagia - Dyspnoea - Ear pain (referred by glossopharyngeal) - Mild fever - Malaise & fatigue - Cervical lymphadenopathy - Hepatosplenomegaly - Leucoplakia - Fine maculopapular rash
136
EBV diagnosis
Capsid IgM - acute infection Capsid IgG- chronic infection OR natural immunity Nuclear IgG - natural immunity --> indicative of resolution Mono-spot - heterophile IgM --> acute symptomatic infection Thrombocytopenia --> hypersplenism Atypical mononuclear cell on PBS
137
EBV management
Self-limiting within 2-3 weeks - Simple analgesia - Fluids and rest - No contract sports Recurrent - Tonsillectomy
138
Influenza A
- Antigenic shift --> Pandemic | - Infects humans, mammals and birds
139
Influenza B
- Antigenic drift --> seasonal flu vaccine --> epidemics | - Only infects humans
140
Influenza 1. Transmission 2. Incubation 3. Signs and symptoms
1. Faecal-oral, respiratory droplets, fomites 2. 1-14 days, infective 1 day prior to symptom onset and 7 days post resolution 3. 2-7days of URTI symptoms - Cough - Rhinorrhoea - Sore throat - Sinusitis - Malaise and myalgias
141
Influenza diagnosis & management
Clinical - Can do swab + PCR and/or acute and convalescent serology (haemagglutinin) Conservative (majority) - Hygiene - Rest - Hydrate - Simple analgesia - Isolate At risk patients (minority) - treatment and prophylaxis - PO oseltamivir/Zanamivir (neuraminidase inhibitors) - Commence within 48hrs
142
HIV seroconversion
- High viral load - CD4 count drops but recovers to near baseline - CD8>CD4 Seroconversion illness - 2-4 weeks post infection - 10% develop meningitis - Maculopapular rash - Non-tender lymphadenopathy - Splenomegaly - Aphthous mucocutaneous ulcers - mouth, genitals, anus - Sore throat - Fever - Fatigue & malaise
143
HIV latency (chronic phase)
- 2-10 years - Slow decline in CD4+ cells - Progressive increase in viral load CD4 count 200-500 - EBV - Strep. pneumoniae - Oral candidiasis - TB reactivation - Herpes zoster reactivation
144
AIDS defining illnesses & management
- Progressive multifocal leukoencephalopathy (PML) - reactivation of JC polyomavirus causing demyelination - HIV encephalopathy - dementia + sensory loss + paralysis - HIV wasting syndrome - unintentional weight loss >10% of body weight 50-200 cells - Pneumocystis Jirovecii pneumonia (PJP) --> prophylactic Bactrim - Toxoplasmosis cerebral abscess grey/white junction --> prophylactic Bactrim - Cryptococcal meningitis --> Fluconazole prophylaxis - Oesophageal candida - Kaposi's sarcoma - Non-Hodgkin's lymphoma - CNS DLBCL <50 cells - Disseminated Mycobacterium Avium Complex (MAC) --> azithromycin prophylaxis - CMV retinitis - attack photoreceptors causing loos of vision --> Valganciclovir prophylaxis - Cryptosporidiosis
145
HIV diagnosis
Home finger prick - HIV antigen - When viral load is high --> within 3 weeks of exposure - Required lab confirmation 4th generation ELISA (gold standard) - HIV p24 antigen - IgG and IgM --> take 3 months to form! - 14-28 days for results Western blot (confirmatory test) - HIV protein - 28-42 days for results
146
HIV infection non-pharmacological
- Reassure individual - Safe sex practices - Safe needle practices - Put in touch with peer support groups - Optimise CV health, bone health, DM (drugs worsen these) - Regular cervical cancer screen
147
HIV infection pre-treatment testing
- CD4 count --> track progression - HIV genotype --> identify resistant strain --> modify therapy - HLA-B5710 --> Abacavir contraindication - HBV/HCV serology --> co-infected AND drug hepatotoxicity - FBE & LFTs --> drugs mess with these - U/E/C, glucose, urine protein --> hyperglycaemia - Serum lipids --> increased - Test for opportunistic infections --> prevent immune reconstitution inflammatory syndrome
148
HIV infection medical management
2 NRTI + integrase inhibitor Abacavir + Lamivudine + Dolutegravir 2 NRTI + NNRTI Abacavir + Lamivudine + Etravirine 2 NRTI + protease inhibitor + protease booster Abacavir + lamivudine + Darunavir + Cobicistat - Follow-up 2-4 weeks --> 3-4 months
149
HIV PrEP 1. Indication 2. Pre-treatment testing
- MSM - IVDU - Women with HIV + partner trying to fall pregnant - Unprotected sex - sex worker - HIV/HBV/HCV/STI - b-HCG - U/E/C PO Tenofovir (NtRTI) + Emtricitabine (NRTI)
150
HIV PEP
- Within 72 hours of exposure - Continue for 28 days - Obtain HIV load & CD4 count from infector PO Tenofovir (NtRTI) + Emtricitabine (NRTI)
151
TIA & Amaurosis fugax
- FND lasting <1 hour - No infarction - Complete recovery - No MRI changes - Transient loss of monocular vision - Ischaemia of the central retinal artery (ICA --> ophthalmic) - Resolves in minutes to hours - Cherry red spot on fundoscopy - Give aspirin or Clopidogrel
152
Stroke pathology
12-24 hours - micro only - Red neurons (acute neuronal injury) - Cerebral oedema - Demyelination 48 hours - Soft, pale, swollen brain with indistinct grey/white junction - Neutrophilia 2-10days - Gelatinous, friable, well-defined lesion 2 weeks - Liquefactive necrosis - Macrophages - Vascular proliferation >2 weeks - Loss of brain tissue - Reactive gliosis (hyperplasia and hypertrophy of astrocytes)
153
Ischaemic stroke management
1. ABC 2. Assess swallowing 3. Manage glucose - stroke mimic AND contraindication to tPA 4. Bloods - coagulopathy and renal function 5. Call stroke team and interventional radiologist Within 9 hours - IV alteplase (tPA) - Negative imaging + persistent FND + within 9 hours >70% occlusion + >9 hours OR tPA contraindicated - Endovascular clot removal All patients - 24 hours --> aspirin - 48 hours --> enoxaparin - Chronic --> Stain and anti-HTN (<140/90) - Stroke rehab - Physio - OT - Nutritionist Thrombosis/TIA/lacunar - Aspirin or Clopidogrel AF - NOAC or Warfarin
154
Haemorrhagic stroke management
1. ABC 2. Swallowing assessment 3. Glucose 4. Bloods --> coagulation and U/E/C 5. Call stroke team 6. Metoprolol - reduce bleed <140mmHg 7. Reverse coagulopathy - Warfarin --> vitamin K, FFP, prothrombin complex concentrate - Heparin --> protamine sulphate - tpA --> tranexamic acid + cryoprecipitate +/- platelets 8. Surgery - stop the bleed
155
Tension headache 1. Epidemiology 2. Symptoms
- Most common primary headache - Caused by stress, poor sleep, and dehydration --> right neck muscles - Bilateral, band-like head pain +/- neck tightness - Constant moderate intensity - Variable 30min - 7 days in duration - Exercise and removal of cause makes it better - Aggravated by loud noise and stress
156
Migraine 1. Epidemiology 2. Symptoms
- Women, family history - Unilateral throbbing headache, moderate-severe - Lasting 4-72 hours - Alleviated with rest, dark room, analgesia - Noise, lights, and trigger makes it worse - Aura, N+V, photophobia, and phonophobia smell intolerance - Prodrome 1-2 days prior to headache - Postdrome feeling tired and drained
157
Cluster headache 1. Epidemiology 2. Symptoms
- Men, family history - Unilateral, periorbital/temporal - Severe stabbing pain - Acute onset lasting 30min-3hours 8-10/day - Better by covering the eye - Bright lights, alcohol, and late night make it worse - Chemosis, lacrimation, rhinorrhoea, ptosis, miosis
158
Diagnosis of migraine without aura
1. 5 episodes 2. Each episode lasting 4-72 hours 3. >2 - Unilateral - Pulsating - Moderate-severe intensity - Aggravated by PA 3. >1 - Nausea - Vomiting - Photophobia - Phonophobia
159
Diagnosis of migraine with aura
1. 2 episodes 2. >3 - Aura spread gradually over 5 minutes - 2 auras occurring in succession - Aura lasting 5-60 minutes - Unilateral aura - Aura occurs with or followed by headache within 60 minutes
160
Cluster headache diagnosis
1. >5 attacks 2. >1 ANS symptom 3. Restless
161
Tension headache diagnosis
1. >2 - Non-pulsatile - No N+V - No phonophobia or photophobia 2. Not worse with exercise 3. Increased sensitivity to light and sound
162
Status migrainosis diagnosis and management
Migraine lasting >72 hours 1. Rehydrate 2. SC sumatriptan - rescue therapy 3. IV chlorpromazine (anti-psychotic) - unresponsive to triptan
163
Chronic headache definition
1. >15 days per month 2. Lasting >4 hours 3. Ongoing for >6 months
164
Medication overuse headache
- Caused by frequent use of triptans and/or opioids (and coffee) - Morning headache once medication had worn off - Associated with memory impairment, poor sleep, fatigue, nausea, irritability 1. >15 days/month 2. Pre-existing headache (for which they are medicated for) 3. Using drugs for >3 months
165
Life-style management for primary headaches
- Regular sleep schedules (7-9 hours) - Regular exercise - Diet & hydration - minimise glucose and electrolyte imbalances - Workplace ergonomic, breaks, & physiotherapist - Limit caffeine - Mindfulness & CBT - Trigger avoidance
166
Migraine medical management
OVOID OPIOIDS - Make N+V worse - Risk of dependence and medication overuse headache - Minimal efficacy in migraine headache Preventative - Propranolol/Timolol (BB) - Topiramate/Valproate (antiepileptics) - Amitriptyline (TCA) - Oestradiol gel - menstrual headache - Botox injections Rescue therapy 1. Ibuprofen/naproxen (NSAIDs) - <15 days per month 2. NSAID + metoclopramide (antiemetic) - increases NSAID absorption and aids N+V 3. Eletriptan (serotonin agonist) - <10 days per month
167
Cluster headache management
Preventative 1. Verapamil (non-dihydro CCB) 2. Prednisolone - if verapamil unsuccessful 2. Lithium - if verapamil unsuccessful Rescue therapy 1. Non-rebreather high flow oxygen 2. Triptans
168
Tension headache management
1. Ibuprofen/naproxen (NSAIDs) 2. NSAID + amitriptyline (TCA) 3. Mirtazapine (tetracyclic antidepressant)
169
Axonal peripheral polyneuropathy
- Distal > proximal - Length dependent - Glover + stocking = length dependent + symmetrical - Small fibres --> spinothalamic tract --> pain and temperature - Hypo-reflexive/a-reflexive - Decreased amplitude (NCS) Metabolic - Diabetes - Alcohol - B12 deficiency - Hypothyroidism Infective - HIV Inherited - Fredricks ataxia - <25yrs - HOCM - DM - Scoliosis
170
Demyelinating peripheral polyneuropathy
- Symmetrical - Large myelinated fibres - -> dorsal column --> vibration and proprioception - -> motor neurons --> weakness - Decreased velocity (NCS)
171
Charcot Marie Tooth
- Most common inherited peripheral polyneuropathy - Demyelinating - Autosomal dominant (hence most common) - Present 10-20yrs - Falls --> loss of proprioception - Foot drop --> common peroneal nerve palsy - Champaign bottle leg --> distal muscle atrophy w/ proximal sparing - Pes Cavus (high arched foot)
172
Gillian Barre + diagnosis & management
- Following Campylobacter gastroenteritis or viral URTI - Molecular mimicry targeting Schwann cells - Demyelinating - Acute LMN distal > proximal palsy - Progresses to --> bulbar palsy (speech and swallowing), diaphragm palsy, ophthalmoplegia, ANS - LP --> Albuminocytologic dissociation - elevated protein but normal cell count - 14% persistent motor weakness - 3-7% die 1. IVIG 2. plasma exchange 3. Analgesia for neuropathic pain
173
Bell's palsy
- Axonal peripheral mononeuropathy - CN VII (facial nerve) palsy - Idiopathic (majority), Lyme's, EBV, AIDS, tumour, Ramsay-hunt (Herpes Zoster) - Self-limiting --> resolves in 4 months
174
L3/L4 palsy
- Femoral nerve (L2,L3,L4) - Week knee extension - Anterior and lateral thigh analgesia - Knee jerk areflexia
175
L5
- Foot drop --> weak dorsiflexion - Analgesia to the dorsum of the foot - Ankle jerk areflexia - Weak eversion and inversion
176
S1
- Weak plantar flexion - Lateral and sole of the foot analgesia - Ankle jerk hyporeflexia
177
Carpal tunnel syndrome management
1. Treat cause - hypothyroidism, acromegaly, obesity 2. Wrist support for typing 3. Ibuprofen/naproxen (NSAID) 4. Steroid injection 5. Flexor retinaculum release surgery
178
Neisseria Meningitidis meningitis
- Notifiable disease & contact tracing - <5yrs most common due to be unvaccinated - only against 2 serotypes so can occur >5yrs - Transmitted via airborne droplets and mucus - 2-10 day incubation - Gram negative diplococcus - Can cause sepsis without meningitis - Acute --> leg pain + cold peripheries - Late --> non-blanching purpuric rash, purpura gangrenous, sepsis, Waterhouse-Friedrichsen syndrome
179
Chronic meningitis pathology
- Basal brain involvement --> cranial nerve palsies - Arachnoid granulation fibrosis --> hydrocephalus - Cortical adhesions - Endarteritis obliterans --> multiple infarcts - Chronic --> mixed inflammatory cell infiltrate - Neurosyphillis --> cerebral gumma's --> plasma cell lesion
180
Live vaccinations
- BCG --> TB - Japanese encephalitis --> dengue - MMR - Rotavirus --> gastroenteritis - Typhoid - Varicella --> chickenpox - Yellow fever - Zoster --> shingles
181
Inactivated vaccines for immunocompromised
1. Pneumococcal 2. Influenza 3. Meningococcal - HPV - HBV
182
Basilar skull fracture
- Require high impact - Periorbital haematoma --> 'black eye' 'raccoon eye' - Posterior auricular haematoma --> 'battle sign' - Stylomastoid foramen --> facial nerve palsy - Ethmoid --> CSF rhinorrhoea + anosmia - Petrous temporal bone --> bloody otorrhea - Meningitis - Internal acoustic meatus --> sensorineural hearing loss, vertigo + disequilibrium --> CNVIII - CT brain --> fluid level in sphenoid sinus
183
Diffuse axonal injury
- Angular trauma --> brain shaken --> shear axons - 50% die within 2 weeks - LOC --> coma --> death - Leading cause of traumatic brain injury - Retraction balls at the grey/white junction --> balls of contracted axons - Non-con CT --> grey/white blurring
184
Concussion
- LOC --> massive depolarisation - Retrograde amnesia - Ischaemia
185
Glasgow coma scale
``` Eyes 1 - do not open 2 - open to pain 3 - open to voice 4 - open spontaneously ``` ``` Speech 1 - mute 2 - sounds 3 - inappropriate words 4 - slightly confused words 5 - normal speech ``` ``` Motor 1 - no movement 2 - extension response 3 - flexion response 4 - pain withdrawal 5 - localised pain withdrawal 6 - spontaneous movement ```
186
Head injury management
Simple fracture or concussion --> monitor Depressed fracture --> valproate + cranioplasty Contusion - bleeding ceases without intervention 1. Lay patient flat with neck brace 2. Minimise exertion for 2-3 days 3. Cognitive rest 4. Ask patient to return if - headache, N+V, visual changes, ataxia
187
BCC microscopic appearance
- Atypical basal keratinocytes - Uniform atypia - Palisading nuclei - Minimal cytoplasm - Arranged in nests - Mucinous stroma
188
BCC biopsy + management
- Shave OR excisional Low risk on head/neck 1. Excision 2. Topical chemotherapy - alternative Low risk trunk/limbs 1. Curettage and electrodesiccation 2. Topical chemotherapy - alternative Low risk trunk/limbs nodular 1. Excision High risk 1. Mohs micrographic surgery OR excision 2. Radiation - alternative
189
SCC microscopic pathology
Actinic/solar keratosis - Partial involvement of the epidermis by atypical squamous cells - Parakeratosis --> nucleated thick stratum corneum Bowens disease (SCC in situ) - Severe dysplasia --> pleomorphic, hyperchromatic, mitotic - Full thickness of the epidermis - Slow growing Invasive - Full thickness of the epidermis invading the dermis - Atypical squamous cells - Lots of cytoplasm - Arranged in nests - Keratin pearls
190
Keratoacanthoma
- Benign self-limiting proliferation of squamous cells - Rapidly growing - UV exposure - Dome shaped cup-like nodules with central keratin plug - Mobile over subcutis
191
SCC management
Actinic solar keratosis 1. Cryotherapy 2. Topical chemotherapy - alternative or multiple SCC in situ (Bowens disease) 1. Excision 2. Topical chemotherapy - alternative Low risk invasive SCC 1. Excision High risk invasive SCC 1. Mohs micro surgery OR excision 2. Adjuvant radiotherapy
192
Venous leg ulcer 1. Cause 2. Appearance 3. Management
- Most common ulcer - Venous insufficiency most common cause --> varicose veins, pregnancy, obesity, injury/surgery - Oedema --> nephrotic syndrome, CCF, cirrhosis, CKD, lymphedema - Minimal pain - Medical malleolus (great saphenous veins) > ankle and calf - Large, shallow ulcer with a sloughed base, irregular margins and excaudate - Stasis dermatitis --> dry, thick/woody, erythematous, brown pigmented, indurated skin on a Champaign bottle leg (Lipodermatosclerosis) - Leg elevation - promote venous return - Compression stocking - promote venous return - Moist wound dressing - dry skin - Venous insufficiency --> laser, stripping, sclerotherapy, ablation
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Arterial ulcer 1. Cause 2. Appearance 3. Management
- Second most common (with pressure ulcers) - PVD + smoking - Painful - worse with elevation and exercise - Toe and foot bony prominences - Small deep 'punched out' with pale white surrounds and minimal exudate with a necrotic base - Cold, pulseless, shiny, hairless, thick skin - Moist dressing --> dry skin - Leg rest & analgesia --> minimise pain
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Pressure ulcer 1. Cause 2. Appearance 3. Stages 4. Management
PREVENT!!! - Second most common ulcer (w/ arterial) - Compression of the microvascular - Painful becoming painless (neuropathy) + itch - Occiput, sacrum, heel - Small becoming large, pink becoming blistered, shallow becoming deep, erythematous and irregular I - superficial epidermis II - Epidermis full thickness III - Dermis IV - bone and soft tissue 1. Most or vacuum assisted closure (VAC) dressing
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Neuropathic diabetic ulcer
- Least common - Peripheral neuropathy + PVD + pressure - Painless - Ball of the foot - Small, deep, bell defined (PVD), calloused (pressure), most base with minimal exudate (PVD)
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Cellulitis vs erysipelas
Cellulitis - Epidermis + dermis + subcutis - Subacute - Gradual spread Erysipelas - Epidermis + dermis - Acute onset - Rapid spread - Well demarcated - Raised rash - Facial rash (butterfly rash) - Strep. Pyogenes
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Strep Vs Staph cellulitis
Strep - Non-purulent - Rapid spread - Recurrent - Well demarcated - Raised Staph - Purulent - Not-well demarcated - Blisters, abscess, penetrating trauma - Lymphatic spread
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Peri-orbital vs orbital cellulitis
- Children > adults - Local spread or trauma/bite - Unilateral, erythematous, oedematous eye - Tender to touch Peri-orbital - Pre-septal subcutaneous tissue and orbit - No pain on eye movement - Not systemic - Cold compress, anti-histamine (bite), PO flucloxacillin Orbital - MEDICAL EMERGENCY - Pre-septal and deep orbital subcutaneous tissue and extraocular muscles - Pain on eye movement - Diplopia - Fever & malaise - systemic - IV flucloxacillin + ceftriaxone
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Eczema pathology
- Spongiosis - intercellular oedema with intercellular bridges - Acanthosis - thickening on the squamous cell layer - Parakeratosis - nucleated thick corneal layer - Excoriation - chronic itch --> skin sloughing - Lichenification --> thick leathery skin - Eosinophils --> allergic - Lymphocytes --> non-allergic - Poorly demarcated dry, erythematous and intensely itchy vesicles and papules on the flexor surfaces
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Eczema 1. What 2. Treatment
- Chronic T-cell mediated type IV hypersensitivity dermatosis - Infective flares --> Staph aureus, strep pyogenes, HSV (eczema herpeticum) - Aggravators --> soap, dust, sweat - Children > adults - often out-grow - Clinical diagnosis --> can measure IgE in blood Non-pharmacological 1. Cut child's nails - prevent itching 2. Non-scented emollients - dry skin 3. Avoid known irritants and triggers Pharmacological 1. Topical corticosteroids 2. Topical immunosuppressants 3. Topical therapy + Tars Severe - referral --> derm and imm - Wet wraps in hospital - Phototherapy - Systemic immunosuppression - Sedating antihistamines - prevent nocturnal scratch
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Pre-diabetes
- Can cause microvascular complication --> monitor & lifestyle modifications Fasting - 5.5-6.7mmol/L Random - 5.5-11.0mmol/L OGTT - 7.8-11.0mmol/L
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Type A insulin resistance
- Insulin receptor mutations - Peripheral insulin resistance - Lipoatrophic diabetes --> hyperglycaemia with loss of subcutaneous adiposity - Acanthosis nigricans (neck and axillae) - NAFLD - Hypertriglyceridemia
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T2DM diagnosis
Symptomatic 1 diabetic range HbA1c, fasting or random blood glucose Asymptomatic 1 diabetic range HbA1c confirmed with repeat 1 diabetic range random or fasting confirmed with repeat random 1 diabetic range OGTT HbA1c >6.5% Fasting >7.0mmol/L Random >11.1mmol/L OGTT >11.1mmol/L
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Hyperosmolar hyperglycaemia (HHS)
- Insulin resistance cause glucagon release and gluconeogenesis leading to profound hyperglycaemia - Water drawn out off cells + osmotic diuresis cause dehydration - Polyuria + polydipsia --> peeing and hyperglycaemia - Drowsy --> coma - dehydration - Hypovolaemic shock - Weakness --> cells lacking glucose 1. ABC 2. IV fluid resus 3. Call endo 4. IV insulin + dextrose + potassium
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Diabetes blood glucose aims
- HbA1c <7% - Fasting + pre-meal 4-7mmol/L - 2 hours post-meal <10mmol/L - Random 5-10mmol/L
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Gliptins
DPP-4 inhibitors - Euglycemic - Promote weight loss - delay gastric emptying MOA: inhibit incretin (GLP-1 analogue) ! - reduce dose in renal disease Contraindications: CCF ADRs - GI upset, MSK pain, pancreatitis
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Diabetes complications screening & management
Podiatry 1. Neurological exam 2. Peripheral vascular exam Retinopathy 1. Dilated fundoscopy (gold standard) Optical coherence tomography - macular oedema Fluorescein angiography - proliferative retinopathy 2. Low risk --> optometrist High risk --> ophthalmologist 3. Non-proliferative --> review and monitor Proliferative --> Laser, anti-VEGF injections, vitrectomy Macular oedema --> anti-VEGF, laser, steroid injections CVD 1. Dietitian - low GI, Mediterranean 2. Exercise - anything they can manage 3. Smoking cessation & alcohol limitation 4. LDL<1.8 TC <4.0 5. BP control - <140mmHg w/o renal disease Neuropathy 1. Annual peripheral neurological exam + microfilament 2. PO metoclopramide OR IV erythromycin --> gastroporesis Nephropathy 1. Annual ACR & eGFR (24hr urine gold standard) 2. BP >130/80 mmHg if albuminuria 3. ACEi/ARB - prevent microalbuminuria
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Diabetes complications
Retinopathy - Glaucoma - Cataracts 1. Background - Microaneurysms and dot haemorrhages 2. Non-proliferation - Hard exudates - Cotton wool spots - Dot and blot haemorrhages - Venous bleeding 3. Proliferative - Disc neovascularisation - Vitreous haemorrhage - Iris neovascularisation --> glaucoma - Retinal detachment --> painless monocular vision loss 4. Macular oedema Autonomic neuropathy - Postural hypotension - Impotence & erectile dysfunction - Silent AMI - Occurs with peripheral neuropathy - Resting tachycardia - Hypoglycaemia unawareness - Incontinence and urinary retention - Gastroparesis
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T1DM serology
Anti-insulin Anti-islet Anti-GAD Anti-IA2
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Insulin regimes
Basal bolus - Opti-slim (insulin glargine) - long acting, prior to bed or early morning - Novorapid/Humalog (aspart/lispro) - ultra short acting prior to meals Continuous SC insulin infusion - Carb count and entry - Rapid acting according to glucose levels Split dosing - Novomix-30/Humalog-25 - ultra-short mixed with intermediate Protaphane twice daily
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Peri-operative diabetes management
NEVER WITHOLD GLUCOSE - AM session - Frequent BSL monitoring - 5-10mmol/L General principles - Reduce long acting by 1/2 - Stop rapid acting - Top up insulin as required based on BSL
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DEXA
- Less sensitive than MTF - Osteoarthritis can cause a low score due to subchondral sclerosis - Scan every 2yrs Z-score - age matched --> young women T-score - general population --> post menopausal women > -1 = normal bone density -1 - -2.5 = osteopenia < -2.5 = osteoporosis
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FRAX calculation
- Age - Gender - BMI - Secondary causes - Femoral neck BMD - Past history of fractures Estimates 10yr probability of his fracture and MTF >3% probability of a hip fracture >20% probability of MTF
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Weight measurements
``` BMI - disease risk <18.5 - underweight 18.5-25 - normal weight >25 - overweight 30-35 - class III 35-40 - class II >40 - class III ``` Waist circumference - informs metabolic risk esp. >65yrs Caucasian male - >94cm (102) Caucasian female - >80cm (88) Asian male - >90cm
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Hashimoto's thyroiditis | - Everything
- Most common cause of primary hypothyroidism - Anti-thyroglobulin + thyroid peroxidase autoantibodies - May initially present hyperthyroid - Associated with MALToma (marginal cell non-Hodgkin's indolent lymphoma) & thyroid papillary carcinoma - Associated with T1DM, pernicious anaemia, coeliac disease, and Addison's disease - Thyroid is rubbery and hard to palpation - Diffusely enlarged tan/brown thyroid - Destroyed follicular cells replaced with non-function Hurthle cells - Lymphoid follicles --> MALToma - Parenchyma replaced with fibrosis - MUST measure cortisol prior to management to prevent Addisonian crisis - Vitiligo --> T-cells attack melanocytes
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Myxoedema coma
- Depressed - Hypothermic - SIADH - TSH affect the release of ADH - Bradycardia - Hypotension - Oedema - Hypoglycaemia 1. ABC 2. IV fluids 3. IV Liothyronine (T3)
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Thyroid storm - thyrotoxicosis
- Hypotensive - Tachycardic - Tremor - Thyroid thrill - N + V - Diarrhoea and abdominal pain - Jaundice - Agitation --> delirium --> coma - CCF + AF 1. ABC 2. IV fluids 3. Propranolol - slow HR prevent arrhythmia 4. Propylthiouracil - Prevent thyroid hormone production 5. Potassium - blocks thyroid hormone release 6. Dexamethasone - Prevent conversion of T4-T3 7. Cholestyramine - prevent resorption and recycling 8. Plasmapheresis - refractive
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Follicular thyroid carcinoma
- Haematogenous metastasis - Women > men - 40-60yrs - Radioactive iodine ablation --> good prognosis - Small follicles surrounded by penetrated capsule - Minimally invasive --> microscopic penetrance - Maximally invasive --> macroscopic penetrance
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Medullary thyroid carcinoma
- Neuroendocrine parafollicular cell carcinoma producing calcitonin - Hypoglycaemia and water diarrhoea - Bimodal - MEN IIA - pheochromocytoma and hyperparathyroidism - RET proto-oncogene - Distant metastasis - Spindle cells forming nests, cords, and follicles - Amyloid stroma --> Congo red stain
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Anaplastic thyroid carcinoma
- Completely de-differentiated cells - Progression of follicular or papillary - Highly metastatic - 65yrs - Multinucleate giant cells - Spindle cells - Highly pleomorphic - Frequent mitosis
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Follicular thyroid adenoma
- Most common benign thyroid tumour - Follicular epithelium forming hyperplastic follicles in a fibrous capsule - Follow-up --> if volume >50% then repeat FNA (process for all benign nodules
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De Quevain's thyroiditis
Granulomatous thyroiditis - Women > men - Viral illness - Painful diffuse goitre - Hyperthyroid --> hypothyroid --> euthyroid - Non-necrotising
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Riedel's fibrosing thyroiditis
- IgG4 sclerosing disease --> autoimmune pancreatitis, retroperitoneal fibrosis, orbital pseudotumours - Fibrous tissue replaces thyroid tissue - Stony hard thyroid to palpation - Euthyroid
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Thyroid cancer management
1. Surgery >4cm - total 1-4cm - lobectomy or total <1cm papillary - watch and weight OR lobectomy 2. High dose radioactive iodine ablation - Removes missed tissue - Follicular and papillary ONLY 3. Chemotherapy - Lymphoma 4. Thyroxine - Supressed TSH driving tumour growth - Follicular and papillary ONLY Follow-up - CEA + calcitonin --> medullary - Thyroglobulin antibodies --> poor prognosis - Thyroglobulin levels - Low dose radioactive iodine --> ensure all tissue removed
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Psoriasis Pathology
- Hypogranulosis: thinning of the granulosum layer - Acanthosis: thickening of the squamous layers - Elongation of the epidermal rete - Dilated capillaries in the dermal papillae - Hyperkeratosis: thickening of the corneum - Parakeratosis: thick corneum with nuclear retention and associated neutrophilic infiltrate - Monro microabscesses in the epidermis - Perivascular lymphohistiocytic infiltrate
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Psoriasis appearance
- Well defined, salmon pink plaques with silver scales on the extensor surfaces, scalp, gluteal cleft, and periumbilical - Mildly pruritic causing bleeding - Better with sunlight - Arthritis involving the DIPs and axial skeleton - Pitting, ridging, hyperkeratosis, onychosis, and oil spots - Dactylitis
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Psoriasis hand x-ray
- DIP involvement - Soft tissue swelling - Periarticular erosions - Pencil in a cup - Periostitis
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What score is used for psoriasis severity?
PASI - psoriasis area and severity index - Considers erythema, scale/desquamation, and thickness/induration and surface area - Directs indication for biologic therapy
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Psoriasis management
Non-pharmacological - Emollient - dry skin --> prevent cracks and infection - SNAP-W --> CV risk factor Pharmacological 1. Topical corticosteroids 1. Topical corticosteroid + topical tar 1. Topical corticosteroid + topical vitamin D 2. Phototherapy 3. Systemic therapy - Methotrexate/acitretin/cyclosporine - Biologics Arthritis 1. NSAIDs 2. DMARDS 3. Biologics
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Seborrheic dermatitis
- Inflammation of the sebaceous glands causing oily and pruritic skin - Cause of dandruff - Involves the flexor surfaces - Ketoconazole, topical corticosteroids, and selenium shampoo
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Contact dermatitis
Allergic - Type IV hypersensitivity - Like eczema BUT only occurs at point of contact with the allergen - Pruritic --> pain - Pustular erythematous bullous rash - Skin patch testing - Topical steroids Non-allergic - Irritation e.g., chemicals, soap, water, temperature - Persistent LOW GRADE exposure - Pain --> itch - Purely clinical diagnosis - Non-pustular erythematous bullous rash - PPE + topical steroids
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Urticaria
- Migrating pruritic erythematous weals - Children > adults - Idiopathic > drug reaction, allergy, virus - Antihistamine and corticosteroids - Internal = angioedema
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Asymptomatic hyperuricaemia
- Most common - Elevated serum urate (uric acid) - ~10yrs prior to gout = SYNDROME of hyperuricaemia - NOT medically treated
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Podagra
- Acute flare of gout - Uric acid exceeds the solubility capacity --> precipitates in joints --> macrophages engulf releasing cytokines - Solubility decreases with cold temperatures - Articular AND periarticular disease e.g., bursae - May be self-limiting due to immune system retraction - Often superimposed on OA
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Intercritical gout
NOT asymptomatic hyperuricaemia, rather, the periods between podagra.
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Tophaceous gout
- 'chronic gout' - Develops 5-10yrs following onset of flares - EROSIVE disease - Subcutaneous tophi at sites of friction and trauma - erythematous, yellow, pearly nodules (can burst and express white uric acid) - Renal stones + nephropathy - Reactive fibrous tissue around tophus with giant cells
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Tophaceous gout hand x-ray
- Hooked/'punched out' erosions - Subcortical cysts - Tophi
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Gold standard investigation for gout & interpretation
Arthrocentesis - MCS, cell count, crystal analysis - Yellow opaque non-viscous - Negatively birefringent needle shaped crystals - Elevated but not septic range WCC <50,000 - High cell count
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Pseudogout
- Commonly superimposed on OA - Positively birefringent rhomboid shaped calcium pyrophosphate crystals - Elderly women - Early morning & inactivity stiffness - Limited ROM and pain - Secondary causes --> haemochromatosis, hypophosphatasemia, hypomagnesia, acromegaly, hypothyroidism, hyperparathyroidism - Chondrocalcinosis on x-ray - Self-limiting
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Podagra management
1. Rest and ice 2. High dose Indomethacin (NSAID) 5-10 days 2. 1mg colchicine --> 0.5mg 1 hour later --> 0.5-1mg daily until resolution 2. PO/IM/IA corticosteroids 7-10 days - in combo if polyarticular, isolation if CKD.
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Long term gout management
Non-pharmacological - Avoid shellfish, offal, beer, wine, spirits and soft drink - Increase coffee, low-fat diary, cherries and vitamin C - Medication review - thiazides, diuretics, calcineurin inhibitors - DASH diet - lowers urate and cardioprotective Pharmacological - tighter control for chronic gout 1. Allopurinol/Febuxostat (xanthine oxidase inhibitors) - DO NOT STOP during a flare --> worsen flare - START LOW and up-titrate --> prevent ADRs - Commence WITH 6 months of NSAID/Colchicine/Pred - Keep increasing until 900mg max dose - ADRs --> DRESS, liver damage, hypersensitivity 2. Probenecid (uricosuric) - first line not tolerated
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Causative organisms of septic arthritis
1. Staph Aureus 2. Streptococcus 3. Gran negative bacillus - E. coli, pseudomonas 4. Gonococcal - dermatitis, migratory, tenosynovitis 5. Potts disease - spine
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Septic arthritis management
1. ABC 2. IV fluids resuscitation 3. Call orthopaedic surgeons & ID 4. NPO 5. IV ABX - 3 weeks --> switch to oral when better 6. URGENT arthroscopic washout OR daily needle aspiration Flucloxacillin --> Staph Aureus Vancomycin --> MRSA Ceftriaxone --> Gonorrhoea or strep Doxycycline --> Chlamydia (often co-infected with gonorrhoea) Theatre aspiration for prosthetic joint
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Seropositive rheumatoid arthritis
- Strong link with smoking - Majority - Anti-CCP & RF (IgM) positive Extra-articular disease - Serositis --> pleurisy & pericarditis - Pulmonary fibrosis (LL) --> NSIP pattern (ground glass), LL - Sjogren's - Ischaemic heart disease - Vasculitis - Subcutaneous non-tender mobile rheumatoid nodules - Mitral regurgitation - Thrombocytosis - Osteoporosis - Depression - T2DM
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Rheumatoid arthritis hand x-ray
L - loss of joint space concentrically O - osteopenia (subchondral & systemic) S - soft tissue swelling E - erosions (periarticular)
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Atlantoaxial subluxation
- Tenosynovitis of the transverse ligament causing it to rupture - Long standing RA - Shooting paraesthesia's down the arms - Occipital headache - X-ray --> MRI
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Fetty's syndrome
RA + neutropenia + splenomegaly | - Recurrent infections
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Caplan's syndrome
- Granuloma formation when exposed to dusts - Cough - SOB - Haemoptysis
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Rheumatoid arthritis management
Non-pharmacological - SNAP-W - Sun protection and regular skin checks - Vaccination --> pneumococcal, meningococcal, influenza, COVID-19 Symptomatic control 1. Ibuprofen/meloxicam (NSAIDs) - never monotherapy 2. PO/IA prednisolone - flares Pharmacological 1. Methotrexate (DMARD) + folic acid - LFTs, teratogenic 2. Leflunomide (DMARD) - LFTs, teratogenic 3. Hydroxychloroquine (DMARD) - eye toxicity, Sjogren's 3. Sulfasalazine (DMARD) - cytopenia, agranulocytosis Biologics - Failing combination DMARDs - Ensure TB negative and fully vaccinated
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Massive/hemodynamically unstable PE management
1. ABC 2. Oxygen - V/Q mismatch 3. Analgesia - chest pain 4. IV Alteplase (tPA) + SC enoxaparin (LMWH) OR IV heparin infusion if ESRF
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Sub-massive/hemodynamically stable PE
1. ABC 2. Oxygen - V/Q mismatch 3. Analgesia - Chest pain Uncomplicated --> Apixaban/rivaroxaban (DOACs) Pregnant OR cancer --> Enoxaparin (LMWH) CKD/ESRF --> Warfarin + bridging enoxaparin/clexane
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Duration of anticoagulation following DVT/PE
Distal provoked DVT --> 6 weeks (1.5 months) Proximal DVT --> 3 months Provoked PE --> 3 months Unprovoked DVT or PE --> > 3 months + haematology referral Recurrent DVT or PE --> life long anticoagulation
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Primary osteoarthritis
- Idiopathic - Affects >3 joints - Spares the MCPs, wrist, elbow and shoulder - >40yrs - Women > men - Genetic link - Obesity, overuse, abnormal joint structure
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Secondary osteoarthritis
- Underlying pathology - Suspect if OA in a atypical joints (MCPs, wrist, shoulder, elbow) and/or younger patient (<40yrs) - Inflammatory arthritis - Trauma - Haemophilia - Haemochromatosis - 1st and 2nd MCPs with hook osteophytes - Acromegaly - Pseudogout
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Knee OA
- Varus deformity --> medial degeneration - Quadricep wasting - Patellofemoral disease --> anterior knee pain, pain with stairs
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Hip OA
- Groin and buttock pain radiating to the knee - Antalgic gain - Trendelenburg sign --> week adductors - Pain with hip flexion and internal rotation
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OA weight baring x-ray findings
L - loss of joint space (eccentric) O - osteophytes S - subchondral sclerosis S - subchondral cysts
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OA management
Non-pharmacological - Muscle strengthening --> decrease joint pressure - Weight loss - Curcumin --> decrease low grade inflammation Pharmacological 1. PO paracetamol osteo 2. IA steroid injections - prior to arthroplasty 3. Topical capsaicin Surgery 1. Total joint arthroplasty - nocturnal & rest joint pain
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Seminoma
- Germ cell testicular tumour - Most common testicular tumour - 14-40yrs - Slow growing - Dense lymphocytic infiltrate - Atypical sperm breach BM
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Non-seminoma germ cell tumour
- Second most common testicular tumours - Teratoma - Yolk-sac tumour --> alpha-fetoprotein, replicate extra-embryonic membranes (yolk-sac, allantoid) - Choriocarcinoma --> beta-HCG, mononucleated cytotrophoblasts and multinucleated syncytiotrophoblasts
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Leydig cell testicular tumour
- Sertoli-Leydig cell tumour - Testosterone secreting - Premature puberty - Gynecomastia --> foci of b-HCG producing cells - Impotence - Loss of libido
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Testicular cancer risk factors
- Cryptorchid tests --> testicular atrophy: absent germ cells, thick BM, Leydig cell hyperplasia - Personal or family history - Infertility - HIV (seminoma) - Androgen insensitivity - Gonadal dysgenesis - Hypospadias
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Germ cell neoplasm in situ
- Non-functional atypical germ cells - Abundant clear cytoplasm - Large central nuclei - Confined to the seminiferous tubule lumen - Precursor lesion to all germ cell tumours
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Testicular cancer symptoms
- Painless irregular scrotal mass - Dull scrotal ache - Heavy scrotal sensation - Absent cremaster reflex
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Testicular cancer investigation
DO NOT BIOPSY Scrotum U/S - Well defined hypoechoic mass (dark) --> seminoma - Ill-defined, calcification, cystic --> non-seminoma germ cell Staging CT Diagnostic and therapeutic orchiectomy + retroperitoneal LN dissection
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Testicular cancer management
95% cure with early detection Stage I - Orchiectomy - Testosterone Stage II - Orchiectomy - Testosterone - Radiation --> seminoma - Cisplatin --> LNs - Retroperitoneal LN dissection --> non-seminoma
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Renal stone aetiology
Calcium (majority) - radiopaque - Hyperparathyroidism - Multiple myeloma - High salt diet Urate stones - radiolucent (not on AXR but CT) - Tumour lysis - CKD - Gout Struvite - radiopaque - Proteus or Klebsiella UTI
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Renal stone imaging
Non-contrast CT KUB (gold standard) - Detect 99% stones - Hydroureter - Hydronephrosis U/S - Pregnancy - Much less sensitive - Doppler can help
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Renal stone management
1. ABC 2. IV fluids - vomiting, anorexia 3. NBM 4. Analgesic - severe pain 5. Antiemetics - vomiting <5 mm --> width of ureter --> wait to pass 5-10 mm --> Tamsulosin (alpha-1 antagonist) --> peristalsis and dilation >10 mm - Lithotripsy (U/S mediated shattering) - Urethroscopy (distal stone or JJ stent) - Percutaneous nephrolithotomy (laparoscopic removal) Long-term - Diet and fluid - Frequent urination - Calcium stone --> thiazide + increase fruit and veg (citrus and magnesium) + limit red meat (oxalate)
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Cystitis pathology
Acute inflammatory infiltrate in the LP and uroepithelium
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Pyelonephritis pathology
- Renal inflammation sparing the glomeruli - Diffuse pinpoint yellow abscess - Tubular dilation - Neutrophils in tubular lumen
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Uncomplication symptomatic cystitis
PO trimethoprim (folate metabolism) for 3 days
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Pregnancy symptomatic and asymptomatic cystitis
PO nitrofurantoin for 5 days with follow-up MSU
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Non-severe pyelonephritis
Fever <38 and/or no sepsis PO Augmentin
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Severe or pregnancy pyelonephritis
Fever >38 and/or urosepsis IV gentamicin and amoxicillin
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Recurrent cystitis
- KUB U/S - Low dose antibiotics at night for 6 weeks - Estrogen pessary for post-menopausal women
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Chlamydia STI
- Gram negative diplococci - Most common STI - 75% asymptomatic - Mucopurulent discharge - Dysuria - Post coital bleeding - Coital pain - PO Doxycycline - Urethral swab or first void urine
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Gonorrhoea STI
- Gram negative diplococci - Urethral swab or first void urine PCR - Discoloured discharge - Dysuria - Coital pain - PR bleeding - Ceftriaxone + Amoxicillin
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HSV - 2
- Painful genital ulcers - Dysuria - Urethral discharge - Lymphadenopathy - Urinary retention
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Prostate cancer pathology
Dysplasia of the glandular columnar epithelium in the peripheral zone of the prostate
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Prostate cancer staging
1. TNM 2. ISUP - grade based of Gleason 3. PSA
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Prostate cancer grading
Gleason score Grade I - <6 --> benign glandular proliferation Grade II - 3 + 4 --> moderate differentiation Grade III - 4 + 3 --> poor differentiation Grade IV - 8 --> poor differentiation grade V - 9-10 --> anaplastic
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Prostate cancer work-up
1. Repeat PSA and/or DRE 2. MRI - see lesion and directs biopsy and provides PSA density --> >20% = cancer 2. Trans-perineal biopsy (new gold standard)
284
Prostate cancer screening
PSA - prostate specific antigen - 50-70yrs - If positive AND no symptoms --> repeat in 1-3 months - Low free: total (<15%) --> cancer i.e. high total = cance
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Prostate cancer management
Gleason 6/benign proliferation/ grade I Gleason 3 + 4/Grade II - Active surveillance - PSA every 6 months --> MRI is up-trend >grade III - Prostatectomy --> incontinence & erectile dysfunction - Metastatic --> androgen deprivation therapy
286
BPH management
Prazosin/Tamsulosin (Alpha-1 antagonist) - Prevent prostate contraction and relax internal sphincter - Orthostatic hypotension - Retrograde ejaculation Finasteride/Dutasteride (5-alpha reductase inhibitor) - Prevents conversion of testosterone to DHEA - Gynecomastia - Erectile dysfunction - Decreased libido Transurethral prostatectomy - Urinary incontinence - Erectile dysfunction
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Acute tubular necrosis (ATN)
- Most common renal cause of AKI - Ischaemic --> embolic, HTN, Pre-renal - Contrast nephropathy - Rhabdomyolysis - Gentamicin & PPI > vancomycin, chemo, NSAID - Heme pigments - Uric acid - Light chains - Muddy brown casts & epithelial cell casts - Necrotic sloughed epithelium clogging tubular lumen causing dilation
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Acute interstitial nephritis (AIN)
1. Drugs --> penicillin & cephalosporins > PPI, NSAID 2. Systemic disease --> SLE, Sjogren's, sarcoid 3. Infection Allergic --> eosinophils Drug induced --> granulomas - Inflammation migrates into the tubules --> white cell casts & pyuria 1. AKI 2. Rash 3. Fever
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Pre-renal AKI 1. urine concentration 2. Sodium avidity 3. Casts 4. Urea: creatine
- Urine concentration NOT impaired - Sodium avidity --> fractional excretion of sodium <20/<1% - Bland cast - Increased urea : creatinine
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Renal AKI
- Tubular --> oliguria - Impaired concentration of urine --> decreased urine specific gravity - Not sodium avidity --> fractional urinary sodium >20/>1% - Hyponatraemia --> inability to reabsorb - Decreased urea : creatinine
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AKI complications
Metabolic acidosis - Impaired hydrogen excretion - Impaired bicarb re-absorption - Hyperchloremic - Increased anion gap Hyperkalaemia - Impaired excretion - Acute --> tall tented T-waves - Chronic --> wide QRS, PR prolongation, absent P-waves - Pre-death --> sine waves
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AKI management
1. ABC 2. Hypovolaemia --> IV fluid Euvolemic --> vasopressors Hypervolemic --> frusemide 3. Stop nephrotoxins 4. Fluid balance chart +/- IDC Hyperkalaemia 1. Stop spiro, ACEi/ARB 2. calcium gluconate - stabalise cardiac membrane 3. Insulin + dextrose - shunt into cells 4. Resonium 5. Salbutamol 6. IV saline and frusemide 7. Dialysis Metabolic acidosis - should correct with fluids 1. Bicarbonate 2. Dialysis
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CKD definition
1. GFR <60ml/min 2. 24hr protein >30mg/day (microalbuminuria) 3. Intrarenal diagnosis
294
Top 4 causes of CKD in order
1. Diabetic 2. GN 3. HTN 4. PKD
295
ESRF pathology
- Small kidneys with irregular scared surface - Global glomerulosclerosis - Thyroidisation - Interstitial and cortical fibrosis - Chronic inflammatory cell infiltrate - Thickened arteries
296
Benign nephrosclerosis
- Hypertensive nephrosclerosis --> HTN CKD (3) - Hyaline arteriolosclerosis of the AA - Fine pitting of the kidney surface
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Aqcuired cystic renal disease
- Multiple renal cysts due to ESRF on LT dialysis - Increased risk of RCC - Atrophic small kidneys
298
CKD proteinuria
<30mg/mmol (microalbuminuria) = normal/mild >300mg/mmol (macroalbuminuria) = severe - Hyperfiltration/GBM damage/tubular damage - Indicator of rapidly progressing disease - Poor prognostic factor - BP <135/75 mmHg - Independent CV risk factors - ACEi/ARB
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4 essential tests for CKD
1. U/S KUB --> find the cause 2. Creatinine : urea --> assess kidney functionality 3. Urine MCS --> find the cause 4. Albumin : creatine ratio --> assess the severity
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CKD U/S
- <9cm - >13cm = infiltrative disease - Thin cortex - Hypo-echogenicity
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Mineral bone disorder
Renal osteodystrophy Early --> secondary hyperparathyroidism - High phosphate --> drives pathology - Hypocalcaemia --> drives PTH - High PTH --> outcome Late --> tertiary hyperparathyroidism - High phosphate --> drives pathology - Hypercalcaemia --> autonomous PTH - High PTH --> outcome 1. Avoid phosphate containing food 2. Calcium carbonate/sevelamer (phosphate binders) 3. Calcium: usually corrected by normalising phosphate 1. Cholecalciferol --> kidneys still functioning 1. Calcitriol --> ESRF Dialysis 1. Cinacalcet - increase PTH receptor sensitivity Tertiary 1. Parathyroidectomy
302
Dialysis indications
Absolute - Uraemic pericarditis - Uraemic encephalopathy - eGFR <5ml Elective - Anorexia - N+V - Cognitive impairment - Chronic fatigue and malaise - Refractive - hyperkalaemia, metabolic acidosis, fluid overload, hyperphosphatasemia
303
Viral conjunctivitis
- Most common cause - Bilateral becoming unilateral - Chemosis - Bumps on the conjunctiva (lymphoid follicles) - Water discharge - Self-limiting --> cold compress, lubricant drops - Isolate and hygiene --> HIGHLY contagious - Adenovirus > HSV > HZ - Adults > children - Recent URTI - Tender lymphadenopathy
304
Bacterial conjunctivitis
- Unilateral red eye - Purulent yellow, sticky discharge - Children > adults - Strep. pneumoniae, Staph. Aureus, H. influenzae - Gonorrhoea and chlamydia - Conjunctival swab for MCS & PCR +/- first void - Self limiting --> cold compress, lubricant eye drops - Chloramphenicol drops - Chlamydia PO azithromycin (trachoma - blindness) - Gonorrhoea PO ceftriaxone (corneal ulceration + perforation)
305
Allergic conjunctivitis
- Bilateral red itchy eyes - Water or purulent discharge - Chemosis - Papillae - Anti-histamine drops
306
Cataract risk factors
- Age (most common) - Diabetes - LT steroid use - Severe myopia (near sighted) - LT UV exposure - Congenital - Trauma
307
Cataract symptoms
- Gradual decline in vision - Glare with lights esp. at night - Coloured halos - Brunescent or yellow hue to lens - Diminished red reflex
308
Cataract management
1. Sunglasses and corrective lenses | 2. Lens transplant
309
Common causes of osteomyelitis
1. Staph aureus 2. Staph epidermidis 3. Gram negative bacillus 4. Beta haemolytic strep - TB --> Pott's - Salmonella --> sickle cell anaemia
310
Osteomyelitis investigations
Back pain + fever = osteomyelitis until proven otherwise --> urgent MRI - Probe to bone --> treat - Blood cultures - MRI --> X-ray inconclusive in first 2-weeks - Bone scan --> MRI not available - Bone biopsy --> if blood cultures are negative
311
Osteomyelitis management
1. ABC 2. Call orthopaedic surgeons Long bone --> IV flucloxacillin (empirical) Vertebral + normal neuro exam --> wait for cultures --> directed Vertebral + abnormal neuro exam --> IV flucloxacillin + Vancomycin + ceftriaxone 3. Surgery --> abscess, SA, antibiotics refractive 4. Zinc, calcium, vitamin C, protein
312
Colles fracture
'Dinner fork' fracture - FOOSH & osteoporosis MTF - Distal 2cm of radius dorsally angulated - Radial shortening - 50% associated avulsion of the radial styloid process - Median, radial and ulna nerve palsies
313
Smith fracture
- FOOSH & osteoporosis MTF - Distal 2cm of radial in volar angulation - Shortening of the radius
314
NOF
- Most common femoral fracture - Leg shortened and in external rotation - Distortion of Shenton's line - Sever retinacula arteries (ascending lateral circumflex femoral artery) --> avascular necrosis of the femoral head - Non-displaced --> open reduction and internal fixation - Displaced --> arthroplasty
315
Spinal stenosis 1. Pseudoclaudication 2. Radiculitis 3. Radiculopathy
1. Claudication in buttock an thigh when leaning forward 2. Inflammation of the dural sleeve causing local back pain 3. Dermatomal and myotomal paraesthesia, weakness and hyporeflexia corresponding to the compressed nerve root - Sharp, shooting, burning pain - Worse with straining
316
Pulmonary infarct pathology
- Peripheral --> blood supply originates from the centre - Haemorrhagic --> dual blood supply Acute - Haemorrhagic --> raised blue/red lesion - Fibropurulent pleura --> pleuritis --> friction rub, chest pain, effusion >48 hours - RBC lysis --> red/brown lesion - Scaring Lines of Zahn: RBCs + fibrin lines indicated clot formed during life not post mortem
317
Wells criteria
Pre-test probability - DVT - PE likely - HR >100 - Immobilisation OR surgery - Past history - Haemoptysis - Malignancy >6 --> PE certain --> treat 2-6 --> PE likely --> CTPA or V/Q scan <2 --> PE unlikely --> D-dimer to safely rule out
318
Massive, sub-massive and low risk PE
Massive --> haemodynamic instability Sub-massive --> RVH strain and/or elevated troponin Low risk --> None of the above
319
PE ECG findings
1. Sinus tachycardia 2. RV strain pattern --> TWI V1-V4 3. SI, QIII, TIII --> deep, waves, inversion 4. RBBB 5. RAD 6. P-pulmonale
320
PE imaging
CTPA (gold standard) V/Q scan - Renal disease - Contrast allergy - Pregnancy - Obese - Young TTE - Hemodynamically instable
321
DVT/PE prevention
1. Early mobilisation 2. Pre-op --> LMWH - enoxaparin/clexane 3. Compression stockings, intermittent pneumatic compression, foot impulse device 4. Post-op --> LMWH or DOAC
322
Gliflozins
SGLT-2 inhibitor - Osmotic diuresis --> polyuria and polydipsia - UTI/Thrush - Cause release of EPO --> raised HCT - Euglycemic - Must cease 48hrs pre-op to avoid euglycemic DKA - Slow progression of renal disease - Cardioprotective due to diuretic affect acting as anti-HTN - Promote weight loss
323
Glutides
GLP-1 analogues - incretin mimetic - Decrease glucose absorption --> GI upset - Stimulate insulin release - Decrease glucagon release - Euglycemic - Promote weight loss - Weekly SC injection at the GP - Cardioprotective - Pancreatitis - Family or personal history of medullar thyroid or MEN2 (pheochromocytoma and hyperparathyroidism)
324
Hypercholesterolaemia management
1. Statin - HMG-CoA reductase inhibitor within the liver - Rhabdomyolysis - Insomnia - Deranged LFTs ! Pregnancy 2. Statin + ezetimibe - Decreased cholesterol absorption in the GIT - Headache - Diarrhoea 2. Stain + PCSK9 inhibitor - Increased LDL receptor expression - Rash - Hypersensitivity - Infection 3. Statin + PCSK9i/ezetimibe + fenofibrate - PPAR-alpha agonist promote beta oxidation - Rhabdomyolysis with stain - Liver derangements - Stones
325
Hyperlipidaemia & Hypercholesterolaemia non-pharmacological management
- Reduce saturated fats --> animal fat, dairy + processed food - Increase mono + polyunsaturated fat --> nuts, seeds, avo, olive oil, sou products - Plant sterol-enriched diary - Weight loss + PA --> best at increasing HDL
326
Hyperlipidaemia & Hypercholesterolaemia target levels
Total cholesterol <4.0mmol/L LDL <2.0mmol/L or <1.8mmol/L (high risk e.g., DM) TAGs <2.0mml/L HDL >1.0mmol/L Cholesterol --> LDL TAGs --> TAGs and HDL
327
Intermittent claudication management
- Walking program & Foot care - Statin --> increases walking distance & primary prevention - Aspirin --> primary prevention - ACEi --> increase walking distance
328
Critical limb ischaemia management
``` Revascularisation - Angioplasty +/- stent - Bypass - Embolectomy Analgesia --> burning pain Limb protection --> cage, heel pad Maintain high BP --> promote perfusion Amputation --> gangrene Alprostadil --> Prostanoids if revascularisation is contraindicated ```
329
Familial combined hyperlipidaemia
- Polygenetic --> heterozygote most common - Premature corneal arcus - High TC, LDL, and TAGs - Tendon xanthomas & xanthelasma - Premature atherosclerosis and CVD - Diagnosed with aid of the Dutch lipid network
330
Acquired hyperlipidaemia
- Obesity --> poor diet + ROS - Hypothyroidism --> slowed metabolism - Corticosteroids/Cushing's --> altered metabolism - PCOS, pregnancy, OCP --> estrogen - DM, alcohol, smoking --> ROS - Nephrotic syndrome --> Liver compensation
331
Familial hyperapobetalipoproteinemia
- Corneal arcus - High LDL (apo-b) - Premature CAD - Xanthomas
332
Familial dysbetalipoproteinemia
- Tubero-eruptive xanthomas - High cholesterol + TAGs - Impaired clearance of chylomicrons and VLDL - Autosomal recessive + acquired factor - Palmer crease xanthomas - Premature CAD
333
Chylomicronaemia
- Eruptive xanthomas - Pancreatitis, memory loss, flushing with alcohol, lipemia retinalis, SOB - thick blood clogs arteries - Increased chylomicrons and VLDL - Elevated TAGs - Creamy plasma supernatant - Hepatosplenomegaly
334
Thromboangiitis obliterans
Buerger's disease - Very strong link with smoking - Acute onset <2 weeks - Medium muscular vessel vasculitis - Men > 20yrs - Stopping smoking can slow disease progression - Ischaemia of the fingers and toes --> amputation
335
PVD investigations
ABI 0.9-1.1 = normal <0.9 = intermittent claudication <0.5 = critical limb ischaemia Buerger's test - Raise leg --> pale and pain - Dangle leg --> reactive hyperaemia Doppler U/S - Visualise stenosis Angiography - Critical limb ischaemia - Prior to revascularisation to visualise stenosis of occlusion
336
Localising stenosis in PVD
Thigh buttock pain --> external iliac Calf pain --> femoral or popliteal Foot pain --> posterior tibial (medial malleolus) or anterior tibial (dorsalis pedis)
337
Valve replacement - prosthetic vs mechanical
Prosthetic - Porcine - Shorter life-span - Older patients - Anticoagulate for 3 months with DOACs Mechanical - Synthetic - Longer life-span - Younger patients - Anti-coagulate for life with warfarin
338
Aortic stenosis investigations
ECG --> LVH, infarct, baseline Lipids, BSLs, U/E/Cs --> treat metabolic syndrome BNP --> heart failure TTE --> extend of valvular disease + heart failure + increased ejection time
339
Aortic stenosis aetiology
1. Age --> wear and tear 2. Congenital bicuspid --> hemodynamic stress 3. RHD --> scaring - HTN --> increased after load damages the valve - Hypercholesterolaemia --> deposition - Hypercalcaemia/ESRF --> calcification
340
Hypertriglyceridemia management
>2mmol/L 1. Statin 2. Statin + fenofibrate >4mmol/L 1. Statin + fenofibrate >10mmol/L 1. Fish oil + fenofibrate Resistant 1. Nicotinic acid/niacin/B3 - Decreases VLDL, LDL, Lip(a) - Increased HDL - Flushing, itch, ab pain, PUD, nausea
341
LVH ECG & causes
- Aortic stenosis - HOCM - HTN - Deep S-waves in III & V2-V3 - Tall R-waves lateral leads (I, aVL, V5-V6) LV strain pattern in lateral leads (I, aVL, V5-V6) - ST-depression - TWI
342
Superficial spreading melanoma
- Most common - Trunk and limbs - Slow growth - Radial growth - Pagetoid spread - buckshot scatter - Late metastasis - 40yrs
343
Nodular melanoma
- Aggressive --> poor prognosis & rapid growth - Vertical growth - Thin atrophic epidermis - Dermal proliferation - Head and neck - Large epithelioid or spindle atypical melanocytes - 50% amelanotic
344
Lentigo maligna melanoma
- Arise from a lentigo maligna (Hutchinson Freckle) - in situ - Accumulative sun exposure --> elderly - Head and neck - Radial growth - Changing lesion present for 20+ years - Proliferation at the dermal/epidermal (basal) junction
345
Acral lentiginous melanoma
- Dark skinned individuals - Palms, soles and nails - >50% amelanotic - Less associated with sun exposure - Radial growth
346
Nodular BCC
- Most common - Pearly papule - Raised edges - Telangiectasia - Ulcerative centre --> rodent ulcer --> local destruction - Face
347
Superficial spreading BCC
- Limbs and trunk - Erythematous, scaly patch - Surface erosions and crusting
348
Morphoeic BCC
Scar-like plaque
349
Heart block aetiology
- BB/CCB/Digoxin - Increased vagral tone --> young athletes - Age related scaring - IHD related scaring - Hyperkalaemia (prolongation the PR interval)
350
First degree heart block management
TRICK! | Benign rhythm --> reassure patient
351
Second & third degree heart block management
1. Atropine | 2. Isoprenaline (beta agonist) + PPM
352
Psychogenic seizure
- Eyes closed - Pelvic thrusting - Immediate recovery or prolonged recovery - Investigated with video EMG - Wax and waning consciousness - Last 10-20 minutes
353
Generalised seizures
- L.O.C --> reticular formation and thalamus - Post-ictal state - No aura
354
Generalised motor seizures
- Ictal cry --> diaphragm contraction - Foaming --> oropharyngeal muscles - Eye rolling --> extraocular muscles - Tongue biting --> mastication muscles - Incontinence --> ANS - Increased HR and BP --> SNS Tonic clonic --> stiff becoming convulsive, post ictal confusion and agitation, gradual regain of consciousness Clonic --> convulsions Atonic --> flaccid Tonic --> stiff Myoclonic --> Single muscles jerks, tired/fatigue, alcohol, may develop into tonic clonic later in life Absent --> >200/day, automatisms (typical), 5-10 seconds, no post ictal
355
Focal complex seizure
- Impaired awareness or total LOC - Aura Temporal - Most common - ANS symptoms - incontinence, BP, HR, sweat, salivation - Mouth automatisms - Sensory auras - gustatory, noises, smells - Deja vu & Jamais vu Occipital - Visual auras - Post ictal blindness - Blinking automatism Parietal - Somatosensory - Vertigo Motor - Jacksonian march - Todd's paralysis - Atonic, clonic or myoclonic Frontal - Common during sleep - Aphasia - Motor automatism
356
Simple partial seizure
- No LOC or impaired awareness - No post ictal - No aura
357
Pancreatitis severity score
Glasgow-Imrie ``` P - pCOs <59.3 A - >55yrs N - Neutrophilia C - Hypocalcaemia R - AKI (urea) E - LDH (enzymes) A - hypoalbuminaemia S - hyperglycaemia (sugar) ```
358
Pancreatitis diagnosis
>2 of the following --> may not have to image - Lipase >2X ULN - Abdominal pain - Radiological evidence
359
Epilepsy diagnosis
1. >2 unprovoked seizures >24 hours apart 2. 1 unprovoked seizure with a high probability of recurrence 3. Epilepsy syndrome
360
Epilepsy management
Non-Pharmacological - Educate --> DO NOT stop medication - DO NOT swim or climb unsupervised - DO NOT operate heavy machinery - Diver --> 5-10yrs seizure free - 1st presentation seizure --> 6 months seizure free - 12 months seizure free - Discuss pregnancy --> some drugs teratogenic - Seizure diary - Trigger avoidance Focal 1. Carbamazepine 2. Lamotrigine 3. Levetiracetam Tonic clonic 1. Sodium valproate 2. Phenytoin 3. Carbamazepine Myoclonic --> sodium valproate Absent --> ethosuximide
361
Lateral medullary syndrome
PICA stroke Contralateral pain and temperature loss --> spinothalamic Ipsilateral facial sensory loss --> CN V sensory nucleus Ipsilateral Horner's syndrome --> SNS Ipsilateral ataxia --> Spinocerebellar ``` Nucleus ambiguus Dysphagia Dysphonia Hoarse throat Uvular deviation ``` ``` Vestibular nucleus Hiccups Vertigo Nystagmus N + V ```
362
Medial medullary syndrome
Anterior spinal artery Ipsilateral CN 12 - Tongue deviation - Dysarthria Contralateral hemiparalysis --> corticospinal Contralateral vibration and proprioception --> dorsal column
363
Lacunar stroke syndrome
1. Contralateral motor --> internal capsule - Limbs +/- dysphagia and dysarthria 2. Somatosensory --> internal capsule + thalamus 3. Sensory --> thalamus 4. Ipsilateral ataxia + weakness --> corona radiata, pons, and internal capsule 5. Dysarthria and clumsy hand --> pons and internal capsule
364
PCA stroke syndrome
Contralateral homonymous hemianopia with macular sparing Quadrantic homonymous hemianopia Alexia without agraphia Colour anomia --> cannot recognise colours Visual agnosia --> Cannot recognise objects Contralateral hemi-sensory loss
365
Dominant hemisphere MCA stroke
- Contralateral homonymous hemianopia without macular sparing - Ipsilateral gaze --> gaze towards the lesion - Broca's/expressive aphasia - Wernicke's/receptive aphasia - Dyscalculia - Dysgraphia - Left right dissociation - Contralateral somatosensory loss arm/face > leg
366
Non-dominant MCA stroke
- Contralateral homonymous hemianopia without macular sparing - Contralateral hemi-somatosensory loss face/arm > leg - Apraxia's --> know what something is and how to use it BUT cannot perform the task - Contralateral hemineglect - Emotional speech
367
ACA stroke
Contralateral hemi-somatosensory loss leg > arm > face Transient urinary and faecal incontinence Inability to repeat back Agnosia --> lack of motivation Contralateral primitive reflexes --> grasp, palmar-facial and suckling
368
STEMI
New sudden central crushing chest pain lasting >20 minutes Occurring at rest Increasing in severity Diaphoresis & N+V Elevated serial troponins ST-elevation >2mm in two contiguous chest leads OR >1mm in the limb leads OR new LBBB Not relieved with normal GTN
369
NSTEMI
``` New sudden central crushing chest pain occurring at rest Lasting >20 minutes Increasing in severity Serial elevated troponin rise +/- ST-depression and/or TWI Not relieved with normal GTN ```
370
Stable angina
Predictable onset chest sensation with exertion Relieved by rest and GTN Occurs <10-20 minutes No troponins or ECG
371
Unstable angina
``` Unpredictable chest pain occurring at rest New feeling chest pain No troponin rise +/- ST-depression or TWI >20 minutes Increasing pain Relieved with GTN ```
372
Pyrexia of unknown origin
Fever >38 for >3 weeks despite >1 week of investigations | Idiopathic prolonged fever
373
Pain management
Non-pharmacological - Distraction & CBT --> music, visitors, games, books - Early mobilisation - Reassurance - Physiotherapy - RICE - Calm private room (if possible ) - Rest and relaxation - Support person ``` Pharmacological 1. Paracetamol 2. Paracetamol + NSAID 3. Paracetamol + NSAID + low dose opioid +/- gabapentin/pregabalin/amitriptyline (neuropathic pain) ```
374
Portal HTN aetiology
Pre-hepatic - Splenic, mesenteric and portal VTE - Splanchnic AV fistula Intrahepatic - Cirrhosis (western) - Schistosomiasis (developing) - PSC Post-hepatic - Budd-Chiari --> compression of the hepatic vein, myeloproliferative neoplasm (PRV), OCP/pregnancy, malignancy - RHF
375
Portal HTN signs and symptoms
- Ascites & spontaneous bacterial peritonitis - Haemorrhoids - Varices - Caput medusae - Hepato-renal syndrome - Hepato-pulmonary syndrome - Gastropathy
376
Peritonitis management
Primary - IV ceftriaxone - IV albumin Secondary - IV gentamicin + amoxicillin + metronidazole - Perforated viscus --> laparoscopy Abscess - Surgical drain
377
Primary v secondary peritonitis
Primary - Spontaneous bacterial infection of the peritoneum - Monomicrobial - Enter via haem, lymph or transcoelomic - CLD --> ascites --> 70% recurrence --> Bactrim Secondary - a result of an acute abdomen, perforation, abscess, peritoneal dialysis, anastomotic leak - Polymicrobial
378
AKI diagnostic criteria
Creatinine rise >26.5mmol/L within 48 hours Creatinine rise >1.5X baseline within 7 days Oliguria <0.5ml/kg/hr or <500ml/day for 6 hours Anuria <50ml/day = severe SKI
379
Mechanical small bowel obstruction aetiology
1. Adhesions 2. Hernia 3. Malignancy - Crohn's strictures - Volvulus - Intussusception - Gallstones
380
Mechanical large bowel obstruction aetiology
1. Malignancy (CRC) 2. Volvulus (sigmoid and caecum) 3. Stricture (U/C, Crohn's, diverticulitis) 4. Adhesions (iatrogenic) 5. Hernia (inguinal or femoral)
381
OSA diagnosis
1. STOP BANG >4 OR Epworth sleepiness scale >8 2. Polysomnography (gold standard) Apnoea-hypopnea index >5/hr = OSA >30/hr = severe OSA Hypoxia burden 1-5% = moderate >5% = severe
382
Hypopnea
Decreased airflow >30% from baseline for >10 seconds | A reduction in oxygen saturation by >3% OR EEG arousal
383
Apnoea
Respiratory arrest for >10 seconds
384
OSA management
Non-pharmacological - Don't drink alcohol prior to bed - Avoid sleeping flat - Weight loss - Smoking cessation - Avoid driving and operating heaving machinery Pharmacological 1. CPAP 2. Intranasal corticosteroids 3. Mandibular advancement splint Surgical 1. Oropharyngeal debulking
385
Pleural effusion management
1. ABC 2. Treat the cause (e.g., heart/liver failure, pneumonia) 3. Thoracentesis (chest tube) 9th ICS mid-axillary line Recurrent 4. Pleurodesis - obliteration of the pleural space chemically (talc) or mechanically (abrasion or pleurectomy)
386
Empyema management
1. ABC 2. Treat the cause 3. Thoracentesis - chest tube 9th ICS mid axillary line 4. DNase and Alteplase - decrease pleural viscosity Mild --> IV Benzylpenicillin + metronidazole Severe --> Ceftriaxone + metronidazole 6. Video assisted thoracoscopic surgery (VATS)
387
Lights criteria
Diagnosing transudative or exudative pleural effusion Transudative - pleural: serum protein <0.5 - pleural: serum LDH <0.6 - pleural LDH <2/3X ULN Exudative - pleural: serum protein >0.5 - Pleural: serum LDH >0.6 - Pleural LDH >2/3X ULN
388
Transudative pleural effusion aetiology
Increased hydrostatic pressure and/or decreased oncotic pressure - CCF - Liver failure - CKD/ESRF - Nephrotic syndrome - Hypothyroidism - Pulmonary embolus
389
Exudative pleural effusion aetiology
Increase vascular permeability and increased cells, protein, tissue - Pneumonia - cells and Ig - Malignancy - neoplastic cells - Empyema - dead neutrophils - Trauma - tissue - SLE/RA - immune complexes - Acute pancreatitis - cells and Ig - TB - cells - Sarcoidosis - cells
390
Torsade De Pointes aetiology
Electrolyte disturbances - hypokalaemia, hypomagnesia, & hypocalcaemia Congenital prolonged QT QT prolonging drugs - erythromycin, sotalol, amiodarone, TCA, SSRIs
391
Torsade De Pointes management
Unstable --> DC cardioversion 1. ABC 2. Stop known cause 3. IV magnesium 4. Isoprenaline (beta agonist) Long-term - cardiologist referral 1. Metoprolol 2. PPM
392
Ventricular tachycardia aetiology
``` AMI Dilated cardiomyopathy Myocarditis Digoxin Increased sympathetic tone ```
393
Ventricular tachycardia management
Hemodynamically unstable OR unconscious --> DC cardioversion Hemodynamically stable --> IV amiodarone (chemical cardioversion) or IV Lidocaine
394
Aortic aneurysm aetiology
1. Uncontrolled HTN --> internal and external 2. Atherosclerosis - Syphilis --> vaso-vasorum - Marfan's --> fibrillin synthesis defect - Ehlers Danlos --> type III collagen defect - Turners --> 45X0 - Coarction of the aorta --> increased upstream pressure - Bicuspid aortic valve --> increased outflow pressure - Scurvy --> lack of vitamin C affects collagen - Vasculitis - Iatrogenic - Mycotic --> IE septic emboli - PKD - Age --> >65yrs
395
Aortic regurgitation aetiology
Primary - tissue with the leaflets - RHD - valvular destruction - Bicuspid - altered hemodynamics - Age - wear and tear - IE - Idiopathic autoimmune - Ankylosing spondylitis Secondary - issue with the root - Dilated cardiomyopathy - Aortic dissection - HTN - Infarction - Marfan's - Ehlers Danlos
396
Infective endocarditis risk factors
3/4 have structural heart disease 1. Prosthetic heart valve 2. RHD 3. Mitral valve prolapse 4. Aortic stenosis 5. congenital heart disease IVDU Dental & genitourinary procedures Indwelling catheter and cannula Immunosuppression Past history of IE Recent illness Dialysis PPM
397
Aneurysm management
<5.5cm - 6 monthly abdominal U/S >5.5cm or >10mm increase/year 1. Metoprolol 2. Endovascular or open repair 3. +/- statin
398
Dissection management
1. ABC 2. Aggressive fluid resuscitation +/- blood transfusion 3. NBM 4. Call vascular surgeons 5. IV morphine - pain and anxiety Stanford A - ascending aorta 6. IV prophylactic antibiotics 7. Graft +/- AVR Stanford B - descending aorta 6. Metoprolol OR endovascular stenting
399
Dukes criteria
Diagnostic criteria for infective endocarditis - 2 major - 1 major and 3 minor - All minor Major criteria - 2+ positive blood cultures - Echocardiogram showing vegetations or NEW murmur Minor criteria - Immunologic --> GN, osler nodes, roth spots. rheumatoid factor - Vascular --> Janeway lesions, splinter haemorrhages, emboli, PE, aneurysm, conjunctival haemorrhage - Fever >38 - Risk factors
400
NSTEMI & UA management
Acute 1. ABC 2. Nitrates High risk 3. Dual antiplatelet - aspirin & Clopidogrel 4. Metoprolol/Atenolol 5. IV heparin infusion while awaiting angiogram to asses PCI + angiogram --> PCI Ongoing chest pain --> Glycoprotein IIa inhibitor Low risk 2. Aspirin On going chest pain and/or ECG changes --> upgrade to high risk
401
Long term ACS management
1. Nitrate PRN 2. Statin 3. ACEi 4. Aspirin 5. Clopidogrel or Ticagrelor 6. Metoprolol/Atenolol +/- spironolactone LVHF
402
STEMI management
1. ABC 2. Oxygen 3. Nitrate 4. Morphine 5. Dual antiplatelet 6. PCI within 30 minutes OR transfer to centre who can within 90 minutes OR tPA + LMWH heparin
403
Infective endocarditis antibiotics
Native valve IV Benzylpenicillin + flucloxacillin + gentamicin Prosthetic valve or MRSA IV vancomycin + flucloxacillin + gentamicin ``` Genitourinary & dental prophylaxis - Past history - Prosthetic valve - RHD - Transplant PO amoxicillin or cefalexin ```
404
Stable angina managment
1. Nitrate PRN - hypotension, headache, flushing, tachycardia 2. Statin - rhabdomyolysis, LFTs, insomnia 3. Aspirin - PUD, bleeding, SJS, TEN 4. Metoprolol/atenolol - bradyarrhythmia, cardiogenic shock, bronchospasm
405
Malignant HTN symptoms
Hypertensive encephalopathy - Headache - Papilledema & blurred vision - N + V - Delirium - Seizures Hypertensive retinopathy - Hard exudates - Cotton wool spots --> nerve sheath infarct - Conjunctival haemorrhage - Copper & sliver wire --> atherosclerosis causing wall thickening - AV nipping --> artery crosses and occludes vein - Retinal haemorrhages Cardiac - Bruits - Angina - Aneurysm/dissection - Heart failure
406
HTN management
Uncomplicated 1. ACEi 2. ACEi + thiazide or dihydropyridine CCB (amlodipine/nifedipine) 3. ACEi + thiazide + CCB Complicated 1. Atenolol/metoprolol or non-dihydropyridine CBB (verapamil/Diltiazem) Add on therapy 1. Spironolactone Pregnant - alpha-2 agonist/centrally acting 1. Methyldopa 2. Monoxidine BPH 1. Prazosin (alpha-1 antagonist) Refractive 1. Minoxidil + frusemide + BB 2. Hydralazine
407
Anti-hypertensive indications & aims
>220/140 = medical emergency - Central line - IV hydralazine/BB while awaiting infusion prep - IV sodium nitroprusside infusion >160/100mmHg = absolute indication <140 SBP w/ diabetes OR uncomplicated CKD <135/75 w/ CKD proteinuria <130/80 w/ diabetic proteinuria <120 SBP w/ CKD and multiple CV risk factors
408
Acute atrial fibrillation management
Hemodynamically unstable - DC cardioversion into sinus rhythm Hemodynamically stable <48 hours 1. Rate control --> BB > CCB > amiodarone 2. Anticoagulate + DC cardioversion into sinus rhythm OR IV amiodarone/flecainide Hemodynamically stable >48 hours 1. Rate control --> BB > CCB > amiodarone 2. TOE or 3 week anticoagulate 3. DC cardioversion + 4 weeks anticoagulation
409
Chronic atrial fibrillation management
Asymptomatic 1. Rate control --> BB > CCB > Amiodarone (LVHF) > digoxin Symptomatic 1. Rate control --> BB > CCB > Amiodarone > digoxin 2. Rhythm control --> flecainide (Na) > sotalol (K + BB) > amiodarone (K, Na, BB) All patients --> anticoagulate CKD4/5, ESRF, mechanical valve, mitral stenosis --> warfarin + bridging LMWH Native valve --> Apixaban/rivaroxaban
410
Paroxysmal supraventricular tachycardia (SVT) management
1. Carotid massage and/or valsalva - ! elderly & valve disease 2. Adenosine --> t1/2 10s (acute) 3. BB or CCB 4. Ablate accessory pathway and pace OR amiodarone if contraindicated
411
SVT symptoms & ECG
``` Sudden onset palpitations --> rapid atrial rate On and off --> paroxysmal Pre-syncope/syncope --> decreased CO Dyspnoea --> decreased CO Angina --> decreased CO Fatigue --> decreased CO Polyuria --> ANP release Neck sensation --> AV dissociation ``` - Narrow complex tachycardia - Very high rate AVNRT --> absent P-wave (buried in QRS) + ST-depression AVRT/WPW --> delta wave + short PR interval
412
AMI pathology
4-12 hours - No macroscopic change - Coagulative necrosis + wavy elongated fibres 12-24hours - Dark mottling due to secondary haemorrhage - Myocytolysis 1-3days - Mottling with yellow/tan infarct centre - Neutrophilic infiltrate 3-7 days - Hyperaemic border with yellow/tan infarct centre - Macrophage infiltrate 1-2 weeks - No change - Granulation tissue >2 weeks - Grey/white firm scar tissue - Collagenous scar + hypertrophied myocytes
413
Anti-centromere antibody
CREST/ limited scleroderma
414
Anti Scl-70 & anti-topoisomerase
Diffuse cutaneous scleroderma (systemic sclerosis)
415
Infective endocarditis pathology
- Septic vegetations containing inflammatory infiltrate and fibrin - Fibrotic changes - Friable vegetations - Ring abscess --> erosion through myocardium
416
RHD pathology
Mitral valvulitis - Verrucae resolve leaving dense fibrosis and neovascularisation causing thick valves - Chordae tendineae thickening and shortening - Fish mouth/buttonhole stenosis --> due to commissure fusion - Aschoff bodies --> T, plasma, Anitschkow (macrophages) + fibrinoid necrosis in all three layers of the heart - Fibrinoid necrosis on the free edge of the valve - Verrucae (vegetation) covering the fibrinoid necrosis - MacCallum plaques --> thick subendocardium due to regurgitant jets
417
Libman-Sacks endocarditis pathology
- SLE - Sterile thrombi of fibrin + eosinophils + complement --> fibrinoid necrosis + vasculitis - Mitral (commissure fusion) and tricuspid - Chordae tendineae involvement and shortening
418
Thrombotic endocarditis pathology
- Small aseptic non-inflammatory thrombi on the orifice - Top of the valve - No local affects - Indwelling catheters, hypercoagulability, malignancy
419
TB management
Non-pharmacological - Notifiable disease - Negative pressure room - Isolation - N95 mask - Air-drop precautions Pre-treatment testing - LFTs - Eye assessment - Medication review - U/E/C - dose adjustment - Weight - dosing - FBE - neutropenia and thrombocytopenia - HIV/HBV/HCV Pharmacological - RIPE for 2 months - RI 4 months (longer is extrapulmonary) Rifampicin - red/orange secretions + LFTs + OCP/warfarin interaction Isoniazid - peripheral neuropathy (B6) + LFTs Pyrazinamide - hyperuricaemia + LFTs Ethambutol - red/green colour blindness + optic neuritis +/- prednisone if extra-pulmonary manifestations for 6-8 weeks Latent --> isoniazid + B6 for 6-9 months
420
COPD management
Non-pharmacological - Weight loss + PA - GORD, depression, CVD - Smoking cessation - Respiratory rehabilitation - Vaccinations --> pneumococcal, meningococcal, influenza, COVID-19 Pharmacological 1. SABA (salbutamol) or SAMA (ipratropium) 2. LABA (salmeterol) or LAMA (tiotropium) 3. LABA and LAMA 3. LABA + LABA + ICS (Fluticasone) Other - Home oxygen - Mucolytics - Macrolides - frequent exacerbations
421
GOLD stages
Severity of COPD based on FEV1 Mild --> >80% +/- chronic cough Moderate --> 50-80% + exertional dyspnoea Severe --> 30-50% + SOB + exercise intolerance + repeated exacerbations Very severe --> <30% OR <50% + respiratory failure or RHF
422
Small cell lung cancer
- Very aggressive - Macro or micro metastases at time of diagnosis --> not for surgery - Neuroendocrine tumour - Small round cells with salt and pepper chromatin - Central peri-hilar lesion --> bronchoscopy + biopsy - Palliative care + local radiotherapy + chemotherapy + O2 - 99% associated with smoking - Ionising radiation RF - 1yr survival from diagnosis Paraneoplastic syndrome - SIADH --> hyponatraemia - Eaton Lambert --> MG --> frequently used muscle fatigue - ACTH --> Cushing's syndrome
423
Lung adenocarcinoma
- Most common lung cancer - Peripheral mass --> CT guided biopsy - Young Asian women - Least associated with smoking - Pancoast tumour - HPOA --> wrist tenderness and finger clubbing - K-RAS oncogene + EGFR - Intracytoplasmic mucin OR glands in fibroblast/lymphocyte dense reactive tissue - Creamy dense mass with yellow granular tissue - Lepidic growth --> growth along septa
424
Lung SCC
- Smoking - Metaplasia from pseudostratified columnar to squamous epithelium - PTH-rp paraneoplastic syndrome --> hypercalcaemia - Central infiltrative mass --> bronchoscopy and biopsy - Slow growing - Necrotic cavities - Mediastinal and hilar LN involvement - Keratin pear formation - Intercellular bridges
425
Non-Small cell lung carcinoma management
Central LN metastasis = not for surgery Pleural effusion = stage IV = not for surgery 1. Lobectomy (gold standard) - III-A almost 100% cure in Australia 2. Targeted - If harbour mutations (K-RAS & EGFR)
426
Pneumothorax management
1. ABC 2. Analgesia Simple primary 3. 4 hour monitor 4. Follow up CXR 2 weeks Unstable primary or secondary 3. thoracentesis 5th ICS mid axillary line 4. Follow up CXR 2 weeks Tension 3. URGENT needle decompression 2nd ICS mid clavicular line 4. thoracentesis 5th ICD mis axillary line 5. Valve dressing
427
Inhaled asthma medication
Salbutamol & terbutaline (SABA) - 5-15 minutes, 3-6hr duration - Tremor, tachycardia, headache, anxiety, hypokalaemia, hyperglycaemia ICS (Budesonide/Fluticasone) - Oral thrush, itchy face (nebs), dysphonia, bruising Salmeterol/Formoterol (LABA) - 12hrs Ipratropium (SAMA) Tiotropium (LAMA)
428
Asthma exacerbation severity score
Mild/moderate - Full sentences - Walking - Saturation >94% Severe - any of the following - Phrases/words - Respiratory distress --> accessory muscles, tracheal tug - Saturation 90-94% Life threatening - Mute - Silent or decreased breath sounds - Cyanotic - Drowsy/decreased consciousness --> collapse - Saturation <90%
429
Community acquired pneumonia organisms
Strep pneumonia (most common) - Gram positive cocci in chains/diplococci - IgA protease - Urinary antigen - Rust coloured sputum H. influenzae - Gram negative cocci - Unvaccinated children - COPD exacerbation - Serology Staph Aureus - Gram positive cocci - Past URTI - Empyema + abscess complication Klebsiella pneumonia - Gran negative bacillus - Alcoholics - Red current jelly sputum Moraxella catarrhalis - Gram negative diplococcus - COPD exacerbation Mycoplasma pneumonia (most common atypical) - Rod shaped - Serology - Cold autoimmune haemolytic anaemia Legionella penumophilia - Gram negative bacillus - Air conditioning - Water contamination - Urinary antigen - SIADH - Notifiable disease Chlamydia psittaci &pneumoniae - Gram negative diplococci - Serology
430
Hospital acquired pneumonia organisms
>48 hours post admission Within 10 days of discharge Strep pneumonia (most common) - Staph Aureus --> MRSA + MSSA - Gram negatives --> E. coli, pseudomonas, Klebsiella - H. influenzae
431
Acarbose
- Alpha glucoside inhibitor - Slows glucose absorption and digestion - Flatulence, diarrhoea + abdominal pain
432
Gliclazide
``` Sulfonylurea's - Depolarise beta cells causing insulin release - Hypoglycaemic - Weight gain - Cease when fasting peri-op - Can OD --> measure blood levels ! renal + liver impairment ! warfarin + aspirin ```
433
Metformin
Biguanide - 1st line - Euglycemic - do not need to cease peri-op - Increases insulin sensitivity & decreases gluconeogenesis - Lactic acidosis esp. in the elderly - B12 deficiency - LFT derangements - Renal dose adjustment - Contrast nephropathy - Weight loss - Diarrhoea and vomiting - Hepatitis
434
Dominant parietal lobe signs
MCA stroke Serial 7s --> acalculia Write --> agraphia Left and rights --> left/right disorientation Name fingers --> finger agnosia
435
Non-dominant parietal lobe signs
Draw on palm --> Agraphesthesia Tap sides of the body --> Sensory inattention Place object in hand --> tactile agnosia Put on shirt --> Dressing apraxia Draw clock face --> spatial neglect - draw only on the Copy a drawn object --> constructional apraxia
436
Temporal lobe signs
Short term memory loss Long term memory loss Confabulation --> make up stories to fill in lost memories
437
Frontal lobe signs
Primitive reflex - Grasp - Palmomental - Pout and snout Proverb Anosmia gat apraxia --> shuffling gait
438
Anti ro and la
Sjogren's
439
Adrenal glands in Cushing's
Disease --> ACTH causing continuous stimulation of BOTH adrenal glands --> bilateral hyperplasia enabling the autonomous over-production of adrenal hormones Adrenal adenoma --> contralateral adrenal atrophy as it lacks ACTH stimulation. Adenoma is a bright yellow mass due to lipid inclusions. Exogenous steroids --> literal adrenal atrophy as the adrenals are rendered redundant and lack ACTH stimulation.
440
Benign adrenal cortical adenoma
- Most are cold - Some produce cortisol or aldosterone - Microscopically bland - Small, well circumscribed solitary yellow mass due to lipid inclusions
441
Adrenal cortical carcinoma
- Primary = unilateral - Metastasis = bilateral - Functional --> androgens --> virilisation - >10cm or 100g - Large, haemorrhagic, necrotic and often infiltrating surrounding structures
442
Pheochromocytoma
10% - Benign medullary adenoma's 10% - Malignant 10% - Paraganglioma's --> carotid body 10% - Bilateral 10% - MEN IIA (hyperparathyroidism & medullary thyroid carcinoma) - Dark haemorrhagic mass (not yellow like cortical lesions)
443
Mallory Weiss tear
- Longitudinal mucosal tear - Gastro-oesophageal junction --> due to vomiting - Severe vomiting OR retching --> alcoholism and bulimia - 10% of all upper GI bleeds - Usually self limiting
444
Boerhaave syndrome
- Transmural tear --> haemorrhage --> cardiogenic shock - Mediastinitis --> chest pain & tachypnoea - Severe vomiting, iatrogenic, caustic, drugs - EMERGENCY surgery or 100% death
445
Acute liver failure pathology
- Paracetamol - HEP A and E - Autoimmune hepatitis - Toxins - Hepatomegaly from oedema and inflammatory infiltrate - Massive hepatic necrosis --> parenchymal loss with islands of regenerating hepatocytes - Pregnancy/valproate/tetracyclines --> diffuse microvesicular steatosis --> hepatocyte poisoning, no cell death they just lose functionality
446
Benign adenomyoma
Hyperplasia of Rokitansky Ascoff sinuses and smooth muscle
447
Gallbladder adenoma
Mucosal polyps | Usually incidental finding on U/S
448
Gallbladder adenocarcinoma
- Women > men - Most common extrahepatic biliary cancer - 5yr survival <10% - 95% associated with gallstones - 70yrs - Thickened wall --> epithelial hyperplasia - Haemorrhagic mucosa - Chronic inflammation - Asia --> bacterial and parasitic infections Papillary/exophytic --> well-differentiated --> better prognosis - Irregular cauliflower mas growing into the lumen and invading the gallbladder wall Infiltrative --> poor differentiation - Diffuse mural thickening and fibrosis - Deep ulceration --> penetrate the liver and adjacent viscera
449
Acute lung injury (ALI)
Non-cardiac pulmonary oedema - Sudden hypoxia due to V/Q mismatch - Bilateral pulmonary infiltrate - No CCF - Natural progression to acute respiratory distress syndrome (ARDS) - Most common causes --> sepsis, lung infection, aspiration, trauma - Inflammation --> vascular permeability --> fluid - Inflammation --> epithelial and pneumocyte injury and apoptosis Acute interstitial pneumonia - Idiopathic rapidly progressing widespread ALI - Follows in URTI - High mortality rate - Persistent interstitial lung disease may persist in survivors
450
Pulmonary abscess | 1. Cause
Cause - Aspiration pneumonia --> superior segment of the right LL --> right lung due to vertical dilated right main bronchus - Staph Aureus and Klebsiella pneumonia infection --> multiple and basal - Septic emboli - Lung cancer CXR - Air fluid level --> abscess communicating with a bronchus
451
Flattening of the inspiratory curve
Extra-thoracic obstruction --> decreased inspiratory flow due to inlet obstruction - Glottic stricture - Tumour - Vocal cord paralysis
452
Flattening of the expiratory curve
Intra-thoracic obstruction --> lung compressing on lesion - Lung tumour - Tracheomalacia
453
Flattening of the inspiratory and expiratory curves
Fixed obstruction --> no affected by changes in lung volumes - Post intubation stricture - Tracheal tumour - Thyroid goitre
454
Aortic stenosis pathology
- Calcification occurs on the outflow surface of the leaflets preventing it from opening - Commissural fusion occurs in bicuspid and RHD induced AS - Calcification in RHD often spreads to the mitral valve causing BOTH mitral and aortic stenosis
455
False aneurysm
Pseudoaneurysm - Tear through all three layers of the vessel - Formation of an extravascular haematoma which communicated with the lumen
456
True aneurysm
- Dilation in all three layers of the vessel wall - Saccular --> single sided - Fusiform --> both sides
457
Dissection definition
- Intimal tear only | - Blood accumulated in the tunica media layers
458
Intramural haematoma
- Rupture of the vasa vasorum - Blood accumulates in the vessel wall - Communicating if it ruptures into the thoracic cavity OR vessel lumen
459
Chronic dissection
- Blood enters back into the vessel due to a second intimal tear OR intramural haematoma - No extra-mural haemorrhage --> hence chronic
460
Mitral valve prolapse
- Enlarged leaflets with myxomatous (mucus and gelatinous) CT deposition - Thing and elongated chordae tendinea - Young women - PKD - Mid systolic clicks --> snapping of the chordae tendinea as it prolapses - Louder on valsalva and inspiration - Managed with BB and exercise avoidance to promote diastolic filling which fixes the prolapse
461
Aetiology of mitral regurgitation
Primary - leaflet - Myxomatous degeneration --> leaflets and chordae tendinea degenerate - Infective endocarditis - RHD - Marfan's - Ehlers Danlos - Mitral annular calcification --> prevents valve closing - Aging Secondary - Dilated cardiomyopathy - Papillary muscle rupture from AMI (most common in Aus)
462
Mitral regurgitation murmur signs
- Pansystolic murmur increased with expiration, squatting, hand-grip - Radiates to the axilla - Loudest at the apex - Diminished S1 - Splitting of S2 - S3 - Low/narrow pulse pressure --> decreased CO - Brisk upstroke pulse - Volume loaded/dyskinetic/displaced apex beat - Apex thrill
463
Mitral valve murmur signs
- Mid diastolic with an opening snap - Louder on inspiration and squatting - S1 snap - Tapping apex beat - Malar facies - Low/narrow pulse pressure --> decreased CO -
464
HOCM pathology
- Banana-shaped left ventricle - Wall thickening - Anterior mitral leaflet plaque from contact with septum - Myocyte hypertrophy with hyperchromatic nuclei - Haphazard disarray of myocytes with branching - Interstitial fibrosis in response to insufficient blood supply
465
Carcinoid syndrome
- Tumour products (e.g., serotonin) cause the syndrome - Diarrhoea - Flushing - Bronchospasm - Skin lesions - Tricuspid/pulmonary insufficiency --> RHF
466
Centriacinar/centrilobular emphysema
- Most common pattern - Smoking - Respiratory bronchioles - DCLO normal - Apical lobes
467
Panacinar emphysema
- Least common pattern - Alpha-1 antitrypsin - Lower lobes - Respiratory bronchioles AND alveoli - DCLO reduced
468
Chronic bronchitis pathology
Mucus hypersecretion - Goblet cell metaplasia & hyperplasia - Seromucous gland hyperplasia BM fibrotic thickening Mononuclear cell infiltrate Epithelial squamous metaplasia --> SCC Bronchiolitis obliterans --> obliteration of the bronchiole lumen due to fibrosis
469
Asthma pathology
Curschmann's spirals - mucus plug with sloughed epithelium Charcot Leyden crystal - eosinophil protein Airway remodelling - Goblet cell metaplasia - Submucosal gland hyperplasia - Increased vascularity - DM fibrosis - Smooth muscle hypertrophy and hyperplasia
470
Lobar pneumonia pathology
- >90% strep. pneumoniae - Unilateral, entire lobe 1. 24hrs - Congestion, vessel engorgement & dilated, intra-alveolar oedema & bacterial exudate - Heavy, boggy, red lung 2. Day 2-4 --> red hepatisation - RBCs, fibrin and neutrophils - Lung dry, firm and airless 3. Day 5-9 --> grey hepatisation - Grey/brown firm liver - Lysed RBCs and fibropurulent exudate 4. Resolution day 8-9 - Enzymatic digestion, phagocytosis, resorption - Coughing up exudate
471
Bronchopneumonia
- Patchy opacities - Bilateral - Basal - Immunocompromised and post URTI
472
Silicosis lung path
Wide spread fibrosis nodules | Egg shell calcifications
473
Asbestosis pathology
- Pleural plaques - Bronchial fibrosis --> where the highest concentration of dust is - Ferruginous bodies --> golden brown beads of protein and iron which a central colourless core --> macrophages and hemosiderin
474
Sarcoidosis pathology
Schumann bodies - giant cell calcium and protein inclusions Asteroid bodies - giant cell stellate inclusion
475
Bronchiectasis
- LL bilaterally - Airway dilation - Fibrosis - Acute and chronic inflammatory infiltrate - Ulceration - Squamous metaplasia --> cancer - Abscesses HRCT (gold standard) - Signet sign --> dilated bronchi with thick walls - Tram tracking --> bronchial wall thickening
476
True v false diverticular
``` True = congenital dilation of all layers False = acquired involving mucosa and submucosa ```
477
HCC pathology
- Disorganised arrangement of atypical hepatocytes - Hepatocytes >3 cells thick - Pseudo-glandular structures - Distended canaliculi - Beta-catenin & p53 mutations Pre-malignant dysplasia - Small cell --> common lesion in cirrhosis - Large cell -->multinucleated hepatocytes
478
Hepatocellular adenoma
- Benign - Women > men - OCP - Resected if large and causing abdominal pain due to pressure on liver capsule
479
Cavernous haemangioma
- Common benign liver neoplasm - Blood vessel forming tumour in a fibrous bed - Subcapsular - Intra-abdominal bleeding
480
Chronic pancreatitis
- Dilated ducts - Hard due to calcification and fibrosis - Patchy mononuclear infiltrate - Epithelial atrophy + hyperplasia + squamous cell metaplasia --> carcinoma
481
Intestinal type gastric adenocarcinoma
- Most common - Men > women - H. pylori & autoimmune gastritis - 55yrs - Adenoma precursor in the antrum --> intestinal metaplasia and dysplasia - Desmoplastic stroma - Heaped up edges and central ulceration
482
Diffuse type gastric adenocarcinoma
Signet ring carcinoma - No precursor lesion - Linitis plastica --> rigid, leather bottle like stomach - Shrunken stomach - Loss of rugae - Diffuse ulceration and haemorrhage - Malignant ascites - Discohesive sheets of cells - Intracytoplasmic mucus vacuoles
483
Cholangiocarcinoma pathology
- Adenocarcinoma most common - Desmoplastic stroma - Perilymphatic and neural growth --> metastasis - Intrahepatic (10%) --> no obstructive jaundice Extrahepatic (90%) - 15% 2yr survival - Firm grey nodule within the bile duct - Klatskin (60%) - perihilar - CBD (30%) - posterior duodenum
484
Benign pancreatic masses
Cystadenoma - Serous cyst - Tail - Old women Mucinous cyst - Women - Precancerous - Tail
485
Exocrine pancreatic tumour
- Most common - Head - Cystic or solid - Highly invasive w/ desmoplastic stroma - Cuboidal/columnar cells - Ductal adenocarcinoma --> most common, 85% liver/LN mets, 1% 5yr survival - Acinar cell carcinoma --> increased zymogens causes fat necrosis
486
Endocrine pancreatic tumour
- Very uncommon - Low grade --> slow growing - Insulinoma most common - VIPoma --> hypokalaemia and water diarrhoea - Somatostatinoma --> hypochloridria, steatorrhea and diabetes
487
Gastrointestinal stromal tumour (GIST)
- Large, well circumscribed fleshy nodules with haemorrhage, necrosis and cysts - Elongated spindle or epithelioid like cells - Most common mesenchymal abdominal tumour - Stomach most common - Interstitial cells of Cajal - KIT mutations --> hyperplasia of Cajal cells - Gleevec
488
Stroke pathology
12-24 hours - Red neurons (acute neuronal injury) - Cerebral oedema - Demyelination 24-48 hours - Soft, pale, swollen brain with an indistinct grey/white junction - Neutrophilia 2-10days - Well-defined gelatinous, friable tissue 2 weeks - Liquefactive necrosis, macrophages, vascular proliferation >2 weeks - Loss of brain tissue - Reactive gliosis
489
Cells most affected by watershed infarcts
Purkinje cells in the cerebellum | Pyramidal cells in the hippocampus
490
Cingulate herniation
Subfalcine - Frontal lobe beneath the cingulate gyrus - ACA compression --> ACA stroke syndrome - Foramen of Monroe compression --> Hydrocephalus
491
Uncal herniation
Transtentorial - Uncus through tentorium cerebelli - Altered consciousness --> reticular formation - Duret haemorrhaged (secondary haemorrhage) - Ipsilateral CN III palsy - Ipsilateral CN VI palsy - Contralateral cerebral peduncle --> ipsilateral hemiparesis - PCA occlusion --> PCA syndrome
492
Tonsillar herniation
- Cerebellar tonsils through foramen magnum | - Medulla compression --> respiratory and cardiac arrest
493
Pilocytic astrocytoma
- Considered 'benign' because it is slow growing and cured with excision - Most common childhood brain malignancy - Most common in the cerebellum - Associated with neurofibromatosis type I - Ill-defined mass that blends with the normal brain tissue
494
Diffuse astrocytoma
- 20-40yrs - Slow growth - Usually progresses to higher histological grade - Firm OR gelatinous mass +/- cystic degeneration - Normal astrocytes arranged atypically
495
Anaplastic astrocytoma
- Rapidly growing --> poor prognosis - Highly cellular and pleomorphic - Poorly demarcated expansive mass - 40yrs
496
Glioblastoma multiforme
- Most common adult brain malignancy - Rapid growth - Necrotic (pseudo-palisading) and haemorrhagic - 60yrs - Poor prognosis - Crosses the midline --> butterfly lesion - Highly cellular and pleomorphic - GFAP immunoreactivity - Ring enhancement --> well-circumscribed
497
Ependymoma
- 4th ventricle --> children - Central canal --> adults - Obstructive hydrocephalus - Poor prognosis - Peri-vascular pseudo-rosettes
498
Meningioma
- Most common benign brain tumour - Women > men (?estrogen) - Adults - Arachnoid mater cells (mesenchyme) mimic arachnoid granulations arranged in a whirlpool pattern - Brain compression OR the brain simply grows around the mass - Well-demarcated round mass - Reactive bone changes
499
Medulloblastoma
- Second most common childhood malignancy - Grade IV - ONLY in the cerebellum - Invades the 4th ventricle --> hydrocephalus - Seeds the CSF --> spinal lesions - Well circumscribed grey mass - Highly cellular, mitotic, chromatic - Anaplastic round/oval cells - Homer-Wright rosettes of neuroblasts
500
Oligodendroglioma
- Seizures - Well circumscribed, gelatinous, haemorrhagic, calcified, grey mass - Low mitosis --> better prognosis - Monomorphic cells - Cerebral hemisphere white matter - Anaplastic transformation --> high cellularity and mitosis & necrosis
501
Neurofibromatosis
- Autosomal dominant - Formation of benign tumours Type I - Most common - Coffee macules - Optic glioma - Lisch nodules on the iris Type II - Bilateral schwannoma (acoustic neuroma) --> sensorineural hearing loss and disequilibrium - Meningiomas - Ependymomas
502
Encephalitis pathology 1. Acute 2. HSV 3. CMV 4. HZ 5. Rabies
Acute - Perivascular cuffing - Petechial haemorrhages HSV - Most common - Bitemporal - Cowdry body inclusions CMV - Periventricular --> hydrocephalus - Owl eye neuronal and glial cell inclusions HZ - Granulomatous arteritis --> infarcts Rabies - Negri bodies
503
Multiple sclerosis (MS) pathology
- Peri-ventricular glassy well-circumscribed plaques - Demyelination - Lymphocytic infiltrate - Oligodendrocytes replaced with reactive gliosis
504
Motor neurone disease pathology
Misfolded TDP-43 proteins - Anterior horn --> UMN and LMN palsy - Motor nuclei of the medulla --> bulbar palsy - Cerebral cortex --> frontotemporal dementia Amyotrophic lateral sclerosis - Most common - Loss of anterior horn neurons --> reactive gliosis - Atrophic precentral motor gyrus
505
Hashimoto's Thyroiditis pathology
Follicular cell destruction replaced with non-function Hurthle cells with abundant cytoplasm and chronically fibrosis Lymphocytic infiltrate forms lymphoid follicles --> MALToma
506
Graves disease pathology
- Diffusely enlarged 'beefy' thyroid - Hyperplastic follicular epithelium causing papillary growth - Scalloped margins --> colloid taken up by hyperplastic epithelium - Lymphocytic infiltrate
507
Toxic multinodular goitre
- Asymmetrically enlarged gland - Most common cause of hyperthyroidism in the older population - Most common cause of a goitre - Common cause subclinical hyperthyroidism - Hyperplasia, colloid involution, focal calcification +/- cysts and haemorrhage
508
Benign vs malignant thyroid nodule FNA
Benign - Lots of colloid - Few follicular cells Malignant - Hypercellular - Follicles cells in aggregates - Minimal colloid
509
Wilms tumour
Nephroblastoma - 4th most common paediatric tumour - Aggressive often diagnosed with lung metastasis - Good prognosis with chemo and radio - Large --> abdominal mass - Cystic, haemorrhagic, necrotic - Embryonic tissue --> triphasic --> immature glom, spindle cell, blastemal tissue
510
RCC pathology
- Yellow cut surface, well circumscribed, necrotic, haemorrhagic and cystic - Clear cell > chromophobe > papillary - Sarcomatous & rhabdoid differentiation = poor prognosis - Proximal convoluted tubule most common - Males > females - Grow into the renal vein Clear cell (most common) - Von Hippel Lindau - Lipid laden cells Chromophobe carcinoma - Birt-Hogg Dube - Peri-nuclear halo Papillary carcinoma - MET oncogene - Fibrovascular core with foamy macrophages surrounded by tumour cells
511
Oncocytoma
- Most common benign renal tumour - Birt-Hogg Dube - Incidental finding - Mahogany tan lesion with central stellate scare - Oncocytes (lots of cytoplasm) arranged in nests
512
Angiomyolipoma
- Mesenchymal benign neoplasm - Comprised of vessels, muscle and fat - Tubular sclerosis - Yellow mass with haemorrhage
513
Pre-cursor urothelial neoplasms
Papillary - Low grade --> papillae lined with atypical urothelium - High grade --> irregular papillae with atypia, can progress to invasive carcinoma Flat (in situ) - High grade - Cellular atypia - Frequent mitosis - Loss of adhesions
514
Invasive urothelial carcinoma
- High grade - 10% 5yr survival - Squamous or glandular metaplasia - CK7 and p63 positive - Men > women - Often multiple and recurrent
515
Testicular torsion symptoms and pathology
- Acellular testicular ischaemia - Acute severe testicular and abdominal pain out of proportion to exam - Absent cremaster reflex - Scrotal swelling - N + V
516
Bladder cancer staging
``` Non-invasive Ta - urothelium T1 - lamina propria - TURBT - Local adjuvant cisplatin & BCG washouts ``` ``` Invasive T2 - muscle T3 - fat T4 - surrounding organs - Cystectomy - Radiotherapy - Systemic chemotherapy ```
517
Autosomal dominant PKD
- Adult - PKD1 mutation encoding polycystin-1/2 - Formation of cysts in utero and overtime --> ESRF - Hepatic and pancreatic cysts - Bilateral large kidneys - Clear and haemorrhagic cysts - Mitral valve prolapse - SAH
518
Autosomal recessive PKD
- Children - PKHD1 encoding fibrocystin - Hepatic cysts - Kidney malformation in utero --> not compatible with life - Slit-like cysts radiating from the hilum - Smooth exterior - Bilateral flank masses
519
Simple renal cyst
- Single or multiple - >50yrs - Cortex - Asymptomatic - One chamber - Small - Lined with simple cuboid or squamous cells
520
HSV keratitis
- Corneal and bulbar conjunctival infection forming a dendritic ulcer - Fluorescein dye - Ulcer --> surgical debridement - Acyclovir eye drops - Grey branching opacities with a penlight - Water discharge - Vesicle on eyelid and nose - Photophobia - Sensation of foreign body in the eye - Red painful eye
521
Bacterial keratitis
- White corneal infiltrate --> corneal ulcer - Purulent discharge - Hypopyon --> pus in the anterior chamber - Red painful eye - Photophobia - Sensation of foreign body in the eye - Poor use of contact lenses - MEDICAL EMERGENCY --> ophthalmologist referral and ciprofloxacin drops
522
Uveitis
- Red eye ache - Worse with accommodation - Floating opacities - Burred vision - Ciliary flush - Synechiae - iris stick to the lens - Spondyloarthropathy
523
Blepharitis
- Burning, irritable gritty eye - Feeling of foreign body in the eye - Crusty eyelid Hordeolum - External --> Stye --> Staph - Internal --> Chalazoin --> seborrheic dermatitis
524
Episcleritis
- RA - Painless red eye - Itchy - Lacrimation - No visual changes
525
Retinal detachment
- Acute painless monocular blindness - Flashes - Floaters - Curtain - Folded retina - Loss of red reflex - Blood in vitreous humour

Y3B (4 decks)

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