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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
Q

Diverticulitis

  1. Where and who?
  2. Complications
  3. Symptoms
  4. Gold standard & follow-up imaging
  5. Management
A
  • 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
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26
Q

Crohn’s Vs U/C pathology

A

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
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27
Q

Crohn’s Vs U/C complication

A

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
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28
Q

Crohn’s Vs U/C presentation

A

Crohn’s

  • Water diarrhoea –> malabsorption
  • Weight loss
  • RIF pain –> terminal ileitis
  • Clubbing

U/C

  • Bloody diarrhoea
  • Months of active colitis
  • Better with smoking
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29
Q

Crohn’s Vs U/C management

A

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

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30
Q

IBD gold standard investigation and AXR findings

A

Scope w/ biopsy

Thumbprinting and lead-pipe

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31
Q

Acute cholecystitis pathology

A
  • Enlarged, tense, erythematous, with fibropurulent exudate and a thick wall
  • Neutrophilic infiltrate
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32
Q

Chronic cholecystitis pathology

A
  • 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
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33
Q

Gold standard investigation and findings for cholecystitis

A

U/S gallbladder

  • Thickened wall
  • Probe tender
  • Pericholecystic oedema
  • Stones
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34
Q

Gall stone management

A

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
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35
Q

Acute interstitial pancreatitis

A
  • 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
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36
Q

Acute necrotising pancreatitis

A
  • 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
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37
Q

Acute pancreatitis complications

A

<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
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38
Q

Hereditary non-polyposis colon cancer (HNPCC) (lynch syndrome)

A
  • 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
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39
Q

Familial adenomatous polyposis (FAP)

A
  • 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
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40
Q

Peutz-Jeghers Syndrome

A
  • 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
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41
Q

Juvenile polyposis

A
  • Autosomal dominant
    Hamartomatous polyps –> cystic, rectum (PR bleed + anaemia)
  • <5yrs symptoms
  • 60yrs CRC
  • Associated gastric, duodenal, pancreatic cancer
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42
Q

Thyroid papillary carcinoma

A
  • 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
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43
Q

Non-neoplastic polyps

A

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
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44
Q

Dysplastic colonic polyps

  1. sessile
  2. pedunculated
  3. tubular
  4. villous
A

Sessile

  • Broad attachment
  • Flat
  • High malignancy risk

Pedunculated

  • Attached by a stalk
  • Ulcerate

Tubular
- Elongated branched crypts

Villous
- High malignancy risk

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45
Q

Colorectal adenocarcinoma

A
  • 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
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46
Q

Dukes criteria

A

A - Into bowel wall
B - Through bowel wall
C - Through bowel wall and LNs
D - distant metastasis

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47
Q

CRC staging

A

I - Submucosa/muscularis propria
II - T3/T4 - sub-serosa and/or neighbouring tissues
III - LN
IV - M1

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48
Q

CRC screening

A

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)
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49
Q

Management of CRC

A

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
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50
Q

Appendicitis examination signs

A

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

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51
Q

Alvarado score

A

> 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
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52
Q

Reflux oesophagitis pathology

A
  • Mild GORD
  • Acute inflammation with eosinophils
  • Elongation of the lamina propria
  • Linear ulcers
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53
Q

GORD diagnosis

A
  • Clinical
  • > 2 episodes of heart burn per week
  • Resolution with PPI and lifestyle modifications within 6 weeks
  • Still symptomatic –> endoscopy
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54
Q

Oesophagitis pathology

A

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
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55
Q

Stress stomach ulcers

A

Cushing’s
- Increased ICP –> increased PSNS tone –> increased acid production

Ventilators & bariatric surgery

Curling’s
Severe burn –> hypovolaemia –> decreased gastric blood flow –> epithelial sloughing

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56
Q

Duodenal Vs gastric ulcer

A

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
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57
Q

PUD Vs cancer pathology

A

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
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58
Q

Gold standard tests for PUD

A

Urea breath tests –> H. pylori

Endoscopy

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59
Q

Acute gastritis

A
  • Erosion (mucosa)
  • Neutrophils
  • Fibropurulent luminal exudate
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60
Q

Chronic gastritis

A
  • 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
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61
Q

H. pylori management

A
  1. Esomeprazole + Amoxicillin (metronidazole) + clarithromycin
  2. Esomeprazole + Amoxicillin + Levofloxacin
  3. Esomeprazole + metronidazole + tetracycline + bismuth chelate
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62
Q

Primary ventral hernia’s

A

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
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63
Q

Groin hernia’s

A

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
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64
Q

Saphena varix

A
  • Benign dilation of the great saphenous vein
  • Reduced when lying down
  • Women > men
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65
Q

What is the difference between a reducible, incarcerated, and strangulated hernia?

A

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

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66
Q

Hernia diagnosis

A

Clinical

- If unable to visualise can CT

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67
Q

Hernia management

A

Hernioplasty (most common) –> mesh repair
Herniorrhaphy –> tissue stitched together

Elective

  • Reducible + pain
  • Incarcerated + minimal pain

Urgent
- Incarcerated + pain

Emergent
- Strangulated hernia open approach

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68
Q

Functional bowel obstruction

A

Temporary impairment of peristalsis

  • Ileus
  • Drugs (Anticholinergics, opioids, TCA, frusemide, CCB)
  • Spinal cord injury
  • Electrolyte disturbances
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69
Q

Acute bowel obstruction signs

A
  • Increased intestinal mobility
  • Borborygmi - ‘tinkling bowel sounds’
  • Colicky abdominal pain
  • Diarrhoea
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70
Q

Late bowel obstruction

A
  • Abdominal distention
  • Bowel collapse –> obstipation
  • Lymphatic and venous compression –> oedema –> dehydration and hypovolaemia
  • Arterial compression –> ischaemia –> perforation –> sepsis
  • Diaphragm splinting –> hypoventilation
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71
Q

Small Vs large bowel obstruction

A

Small

  • Periumbilical pain
  • N+V –> obstipation
  • 1min duration every 5 minutes

Large

  • Lower abdominal pain
  • Obstipation –> N+V
  • Continuous every 10-15 minutes
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72
Q

Bowel obstruction imaging and findings

A

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
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73
Q

Acute ischaemic bowel

  1. Cause
  2. Thickness
  3. Symptoms
A
  • 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
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74
Q

Chronic ischaemic bowel

  1. Cause
  2. Thickness
  3. Symptoms
A
  • 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
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75
Q

Ischaemic bowel imaging

A

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
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76
Q

Signs of compromised bowel in CTA & management

A
  • 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
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77
Q

Acute mesenteric ischaemic management

A
  1. ABC
  2. IV fluids
  3. NBM + NGT
  4. Analgesia + antiemetics
  5. IV ceftriaxone + metronidazole
  6. Correct electrolyte disturbance + acidosis
  7. IV heparin
  8. Clot –> tPA
    HF –> dobutamine
  9. Surgery - stable and no bowel compromise
    - Balloon angioplasty +/- stent
    - Clot aspiration
    - Catheter directed thrombolysis
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78
Q

Chronic mesenteric ischaemia management

A
  1. Lifestyle
  2. Revascularisation
    - Angioplasty +/- stenting
    - Bypass
    - Endarterectomy
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79
Q

Viral gastroenteritis

A
  • 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
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80
Q

Bacterial gastroenteritis - campylobacter

A
  • 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
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81
Q

Bacterial gastroenteritis - Salmonella

A
  • 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
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82
Q

Bacterial gastroenteritis - Shigella

A
  • Gram negative bacillus
  • Dysentery
  • 1-7 days incubation
  • MSM, crowded living
  • HUS - AKI, haemolytic anaemia, thrombocytopenia (MAHA)
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83
Q

Bacterial gastroenteritis - EHEC

A
  • Gram negative bacillus
  • HUS & TTP
  • Undercooked ground beef
  • 3-4 days incubation period
  • Dysentery
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84
Q

Bacterial gastroenteritis - Yersinia

A
  • Undercooked pork and unpasteurised milk
  • 1-14 days incubation
  • Dysentery
  • Pharyngitis
  • Gram negative
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85
Q

Bacterial gastroenteritis - ETEC

A
  • Gram negative bacillus
  • Travellers diarrhoea
  • 1-3 day incubation
  • Faecal-oral route
  • Watery diarrhoea
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86
Q

Bacterial gastroenteritis - Vibrio cholerae

A
  • Gram negative bacillus
  • Rice water diarrhoea
  • Contaminated water in developing countries
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87
Q

Bacterial gastroenteritis - Staph. Aureus

A
  • Gram positive cocci
  • Proteinaceous unrefrigerated food
  • 4-6 hours incubation
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88
Q

Bacterial gastroenteritis - Bacillus cereus

A
  • Gram positive bacillus
  • Fried rice
  • 1-6 hours incubation
  • Vomiting
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89
Q

Bacterial gastroenteritis - Clostridium Perfringens

A
  • Gram positive bacillus
  • Poor reheating meat, poultry, gravy
  • Water diarrhoea
  • 6-24 hour incubation period
  • Ileus
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90
Q

Bacterial gastroenteritis - Giardia

A
  • Most common parasitic
  • Flagellated parasite
  • Waterborne
  • Incubation 7-14 days
  • Bloating and foul smelling steatorrhea
  • Trophozoites
  • Sulphur breath
  • Cysts in stool sample
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91
Q

Bacterial gastroenteritis - cryptosporidium

A
  • Waterborne (drinking and swimming)

- Severe dehydrating diarrhoea

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92
Q

Bacterial gastroenteritis - Entamoeba histolytica

A
  • Parasite
  • Migrants & MSM
  • Dysentery
  • Liver cysts
  • Toxic megacolon
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93
Q

Hypertension management

A

Uncomplicated - isolated HTN

  1. ACEi
  2. ACEi + thiazide
  3. ACEi + thiazide + dihydropyridine CCB (amlodipine, nifedipine)

Complicated - Stable angina, AMI

  1. BB (metoprolol/atenolol)
  2. Dihydropyridine (verapamil/diltiazem)

Add on therapy
1. Spironolactone

BPH
1. Prazosin (alpha-1 blocker)

Pregnant

  1. Methyldopa (centrally acting antiadrenergic)
  2. Monoxidine (centrally acting antiadrenergic)

Uncontrollable

  1. Minoxidil (vasodilator) + BB + frusemide
  2. Hydralazine (vasodilator)
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94
Q

HFrEF management

A
  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
  2. ACEi
  3. 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

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95
Q

Anal abscess signs & symptoms and management

A
  • 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
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96
Q

Anal fistula

A
  • 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
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97
Q

Internal haemorrhoid

A

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

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98
Q

External haemorrhoids

A
  • 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
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99
Q

Internal haemorrhoid diagnosis and management

A

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

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100
Q

Hepatitis A

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
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101
Q

Hepatitis B

A
  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
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102
Q

Hepatitis C

A
  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
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103
Q

Hepatitis D

A
  • RNA
  • Protected with HBV vaccine
  • Superinfection on HBV only –> cirrhosis and HCC
  • Cannot infect alone or without carrier HBV
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104
Q

Hepatitis E

A
  • RNA
  • ACUTE only
  • 6-8 days incubation
  • Faecal oral and vertical
  • IgG and IgM
  • Liver necrosis in pregnant women
  • Not vaccine
  • Self-limiting
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105
Q

Chronic hepatitis pathology

A

Interface hepatitis

HBV

  • Lymphocytic infiltrate
  • Ground-glass hepatocytes (viral inclusions)
  • Loss of architecture

HCV

  • Lymphocyte follicles
  • Steatosis
  • Bile duct injury
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106
Q

BRACA gene

A
  • 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
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107
Q

Lobular carcinoma in situ (LCIS)

A
  • 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
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108
Q

Ductal carcinoma in situ

A
  • 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)
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109
Q

Paget’s disease of the breast

A
  • Manifestation of DCIS
  • ‘eczema of the nipple’
  • Erythematous, ulcerated and scaly nipple
  • Paget cells –> clear halos
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110
Q

Invasive lobular carcinoma

A
  • 10% of invasive carcinoma
  • Multifocal and bilateral
  • Single lines of malignant cells invading the stroma
  • No desmoplastic stroma
  • No calcifications
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111
Q

Invasive ductal carcinoma of the breast

A
  • 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
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112
Q

Invasive ductal carcinoma of the breast grades

A

I - duct forming with few mitosis
II - ducts, cords of cells, pleomorphism, mitosis
III - cords of cells, pleomorphic, very mitotic

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113
Q

Lumina A invasive ductal carcinoma

A
  • 50% of invasive ductal carcinoma
  • Low grade (grade I-II)
  • HER 2 negative
  • Hormone positive (tamoxifen & Aromatase inhibitors)
  • Low replicative capacity (Ki67)
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114
Q

Luminal B invasive ductal carcinoma

A
  • 15% of invasive ductal carcinoma
  • High grade (grade III)
  • Triple positive
  • High replicative capacity (Ki67)
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115
Q

Basal type invasive ductal carcinoma

A
  • 15% of invasive ductal carcinoma
  • Triple negative
  • Poor prognosis (less medical therapy)
  • High grade (grade III)
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116
Q

Isolated HER2+ invasive ductal carcinoma

A
  • 15% of invasive ductal carcinoma
  • High grade (grade III)
  • LN positive –> poor prognosis
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117
Q

Phyllodes stromal tumour of the breast

A
  • 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
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118
Q

Metaplastic stromal breast carcinoma

A
  • Metaplasia of glandular epithelium into squamous epithelium OR spindle, chondroid, osseous, or Rhabdomyoid
  • Distance metastasis without LNs
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119
Q

Angiosarcoma of the breast

A
  • Associated with breast radiation and/or lymphedema from mastectomy
  • Distant metastasis with no LNs
  • Ill-defined haemorrhagic lesion
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120
Q

Inflammatory carcinoma of the breast

A
  • Aggressive
  • Malignant cell occlude lymphatics
  • Firm, enlarged, warm, painful, pruritic breast
  • Peau d’orange
  • Thickened skin
  • LN metastasis
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121
Q

Ductal carcinoma TNM staging

A

T1 - 2cm
T2 - 2-5cm
T3 ->5cm

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122
Q

DCIS management

A
  • 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
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123
Q

Invasive ductal carcinoma management

A
  • 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
  4. 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)
  4. Targeted therapy
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124
Q

Targeted therapy for invasive ductal carcinoma

A

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
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125
Q

Mammography

A
  • Women >30/40yrs
  • Women invited 50-75yrs
  • Personal history every 5yrs
  • BRCA + 30-75yrs annual
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126
Q

Breast cancer prognostic factors

A

Major
- TNM stage

Minor

  • Grade & subtype
  • Receptor status
  • Proliferative rate
  • Age
  • Comorbidities
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127
Q

Plasmodium falciparum

A
  • 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)
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128
Q

Plasmodium vivax

A
  • 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
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129
Q

Malaria signs and symptoms

A
  • Rigors
  • Paroxysmal fever
  • Haemolytic anaemia –> jaundice, splenomegaly, anaemia (headache, fatigue, SOB)
  • Hepatomegaly
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130
Q

Malaria diagnosis

A

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
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131
Q

Uncomplicated malaria management

A
  • 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

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132
Q

Severe malaria diagnostic criteria

A 
>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
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133
Q

Complicated/severe malaria management

A

IV Artesunate + ceftriaxone (spesis) + paracetamol (AKI)

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134
Q

Malaria prophylaxis

A
  • 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
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135
Q

EBV signs and symptoms

A

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
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136
Q

EBV diagnosis

A

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

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137
Q

EBV management

A

Self-limiting within 2-3 weeks

  • Simple analgesia
  • Fluids and rest
  • No contract sports

Recurrent
- Tonsillectomy

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138
Q

Influenza A

A
  • Antigenic shift –> Pandemic

- Infects humans, mammals and birds

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139
Q

Influenza B

A
  • Antigenic drift –> seasonal flu vaccine –> epidemics

- Only infects humans

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140
Q

Influenza

  1. Transmission
  2. Incubation
  3. Signs and symptoms
A
  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
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141
Q

Influenza diagnosis & management

A

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
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142
Q

HIV seroconversion

A
  • 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
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143
Q

HIV latency (chronic phase)

A
  • 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
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144
Q

AIDS defining illnesses & management

A
  • 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
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145
Q

HIV diagnosis

A

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
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146
Q

HIV infection non-pharmacological

A
  • 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
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147
Q

HIV infection pre-treatment testing

A
  • 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
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148
Q

HIV infection medical management

A

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
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149
Q

HIV PrEP

  1. Indication
  2. Pre-treatment testing
A
  • 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)

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150
Q

HIV PEP

A
  • Within 72 hours of exposure
  • Continue for 28 days
  • Obtain HIV load & CD4 count from infector

PO Tenofovir (NtRTI) + Emtricitabine (NRTI)

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151
Q

TIA & Amaurosis fugax

A
  • 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
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152
Q

Stroke pathology

A

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)
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153
Q

Ischaemic stroke management

A
  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

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154
Q

Haemorrhagic stroke management

A
  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
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155
Q

Tension headache

  1. Epidemiology
  2. Symptoms
A
  • 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
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156
Q

Migraine

  1. Epidemiology
  2. Symptoms
A
  • 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
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157
Q

Cluster headache

  1. Epidemiology
  2. Symptoms
A
  • 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
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158
Q

Diagnosis of migraine without aura

A
  1. 5 episodes
  2. Each episode lasting 4-72 hours
  3. > 2
    - Unilateral
    - Pulsating
    - Moderate-severe intensity
    - Aggravated by PA
  4. > 1
    - Nausea
    - Vomiting
    - Photophobia
    - Phonophobia
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159
Q

Diagnosis of migraine with aura

A
  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
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160
Q

Cluster headache diagnosis

A
  1. > 5 attacks
  2. > 1 ANS symptom
  3. Restless
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161
Q

Tension headache diagnosis

A
  1. > 2
    - Non-pulsatile
    - No N+V
    - No phonophobia or photophobia
  2. Not worse with exercise
  3. Increased sensitivity to light and sound
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162
Q

Status migrainosis diagnosis and management

A

Migraine lasting >72 hours

  1. Rehydrate
  2. SC sumatriptan - rescue therapy
  3. IV chlorpromazine (anti-psychotic) - unresponsive to triptan
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163
Q

Chronic headache definition

A
  1. > 15 days per month
  2. Lasting >4 hours
  3. Ongoing for >6 months
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164
Q

Medication overuse headache

A
  • 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
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165
Q

Life-style management for primary headaches

A
  • 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
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166
Q

Migraine medical management

A

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
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167
Q

Cluster headache management

A

Preventative

  1. Verapamil (non-dihydro CCB)
  2. Prednisolone - if verapamil unsuccessful
  3. Lithium - if verapamil unsuccessful

Rescue therapy

  1. Non-rebreather high flow oxygen
  2. Triptans
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168
Q

Tension headache management

A
  1. Ibuprofen/naproxen (NSAIDs)
  2. NSAID + amitriptyline (TCA)
  3. Mirtazapine (tetracyclic antidepressant)
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169
Q

Axonal peripheral polyneuropathy

A
  • 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
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170
Q

Demyelinating peripheral polyneuropathy

A
  • Symmetrical
  • Large myelinated fibres
  • -> dorsal column –> vibration and proprioception
  • -> motor neurons –> weakness
  • Decreased velocity (NCS)
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171
Q

Charcot Marie Tooth

A
  • 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)
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172
Q

Gillian Barre + diagnosis & management

A
  • 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
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173
Q

Bell’s palsy

A
  • 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
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174
Q

L3/L4 palsy

A
  • Femoral nerve (L2,L3,L4)
  • Week knee extension
  • Anterior and lateral thigh analgesia
  • Knee jerk areflexia
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175
Q

L5

A
  • Foot drop –> weak dorsiflexion
  • Analgesia to the dorsum of the foot
  • Ankle jerk areflexia
  • Weak eversion and inversion
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176
Q

S1

A
  • Weak plantar flexion
  • Lateral and sole of the foot analgesia
  • Ankle jerk hyporeflexia
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177
Q

Carpal tunnel syndrome management

A
  1. Treat cause - hypothyroidism, acromegaly, obesity
  2. Wrist support for typing
  3. Ibuprofen/naproxen (NSAID)
  4. Steroid injection
  5. Flexor retinaculum release surgery
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178
Q

Neisseria Meningitidis meningitis

A
  • 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
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179
Q

Chronic meningitis pathology

A
  • 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
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180
Q

Live vaccinations

A
  • BCG –> TB
  • Japanese encephalitis –> dengue
  • MMR
  • Rotavirus –> gastroenteritis
  • Typhoid
  • Varicella –> chickenpox
  • Yellow fever
  • Zoster –> shingles
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181
Q

Inactivated vaccines for immunocompromised

A
  1. Pneumococcal
  2. Influenza
  3. Meningococcal
    - HPV
    - HBV
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182
Q

Basilar skull fracture

A
  • 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
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183
Q

Diffuse axonal injury

A
  • 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
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184
Q

Concussion

A
  • LOC –> massive depolarisation
  • Retrograde amnesia
  • Ischaemia
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185
Q

Glasgow coma scale

A 
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
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186
Q

Head injury management

A

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
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187
Q

BCC microscopic appearance

A
  • Atypical basal keratinocytes
  • Uniform atypia
  • Palisading nuclei
  • Minimal cytoplasm
  • Arranged in nests
  • Mucinous stroma
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188
Q

BCC biopsy + management

A
  • 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
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189
Q

SCC microscopic pathology

A

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
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190
Q

Keratoacanthoma

A
  • Benign self-limiting proliferation of squamous cells
  • Rapidly growing
  • UV exposure
  • Dome shaped cup-like nodules with central keratin plug
  • Mobile over subcutis
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191
Q

SCC management

A

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
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192
Q

Venous leg ulcer

  1. Cause
  2. Appearance
  3. Management
A
  • 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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193
Q

Arterial ulcer

  1. Cause
  2. Appearance
  3. Management
A
  • 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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194
Q

Pressure ulcer

  1. Cause
  2. Appearance
  3. Stages
  4. Management
A

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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195
Q

Neuropathic diabetic ulcer

A
  • 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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196
Q

Cellulitis vs erysipelas

A

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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197
Q

Strep Vs Staph cellulitis

A

Strep

  • Non-purulent
  • Rapid spread
  • Recurrent
  • Well demarcated
  • Raised

Staph

  • Purulent
  • Not-well demarcated
  • Blisters, abscess, penetrating trauma
  • Lymphatic spread
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198
Q

Peri-orbital vs orbital cellulitis

A
  • 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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199
Q

Eczema pathology

A
  • 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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200
Q

Eczema

  1. What
  2. Treatment
A
  • 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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201
Q

Pre-diabetes

A
  • 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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202
Q

Type A insulin resistance

A
  • 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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203
Q

T2DM diagnosis

A

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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204
Q

Hyperosmolar hyperglycaemia (HHS)

A
  • 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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205
Q

Diabetes blood glucose aims

A
  • HbA1c <7%
  • Fasting + pre-meal 4-7mmol/L
  • 2 hours post-meal <10mmol/L
  • Random 5-10mmol/L
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206
Q

Gliptins

A

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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207
Q

Diabetes complications screening & management

A

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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208
Q

Diabetes complications

A

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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209
Q

T1DM serology

A

Anti-insulin
Anti-islet
Anti-GAD
Anti-IA2

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210
Q

Insulin regimes

A

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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211
Q

Peri-operative diabetes management

A

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
212
Q

DEXA

A
  • 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
213
Q

FRAX calculation

A
  • 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

214
Q

Weight measurements

A 
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

215
Q

Hashimoto’s thyroiditis

- Everything

A
  • 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
216
Q

Myxoedema coma

A
  • Depressed
  • Hypothermic
  • SIADH - TSH affect the release of ADH
  • Bradycardia
  • Hypotension
  • Oedema
  • Hypoglycaemia
  1. ABC
  2. IV fluids
  3. IV Liothyronine (T3)
217
Q

Thyroid storm - thyrotoxicosis

A
  • 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
218
Q

Follicular thyroid carcinoma

A
  • 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
219
Q

Medullary thyroid carcinoma

A
  • 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
220
Q

Anaplastic thyroid carcinoma

A
  • Completely de-differentiated cells
  • Progression of follicular or papillary
  • Highly metastatic
  • 65yrs
  • Multinucleate giant cells
  • Spindle cells
  • Highly pleomorphic
  • Frequent mitosis
221
Q

Follicular thyroid adenoma

A
  • 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
222
Q

De Quevain’s thyroiditis

A

Granulomatous thyroiditis

  • Women > men
  • Viral illness
  • Painful diffuse goitre
  • Hyperthyroid –> hypothyroid –> euthyroid
  • Non-necrotising
223
Q

Riedel’s fibrosing thyroiditis

A
  • IgG4 sclerosing disease –> autoimmune pancreatitis, retroperitoneal fibrosis, orbital pseudotumours
  • Fibrous tissue replaces thyroid tissue
  • Stony hard thyroid to palpation
  • Euthyroid
224
Q

Thyroid cancer management

A
  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
225
Q

Psoriasis Pathology

A
  • 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
226
Q

Psoriasis appearance

A
  • 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
227
Q

Psoriasis hand x-ray

A
  • DIP involvement
  • Soft tissue swelling
  • Periarticular erosions
  • Pencil in a cup
  • Periostitis
228
Q

What score is used for psoriasis severity?

A

PASI - psoriasis area and severity index

  • Considers erythema, scale/desquamation, and thickness/induration and surface area
  • Directs indication for biologic therapy
229
Q

Psoriasis management

A

Non-pharmacological

  • Emollient - dry skin –> prevent cracks and infection
  • SNAP-W –> CV risk factor

Pharmacological

  1. Topical corticosteroids
  2. Topical corticosteroid + topical tar
  3. Topical corticosteroid + topical vitamin D
  4. Phototherapy
  5. Systemic therapy
    - Methotrexate/acitretin/cyclosporine
    - Biologics

Arthritis

  1. NSAIDs
  2. DMARDS
  3. Biologics
230
Q

Seborrheic dermatitis

A
  • Inflammation of the sebaceous glands causing oily and pruritic skin
  • Cause of dandruff
  • Involves the flexor surfaces
  • Ketoconazole, topical corticosteroids, and selenium shampoo
231
Q

Contact dermatitis

A

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
232
Q

Urticaria

A
  • Migrating pruritic erythematous weals
  • Children > adults
  • Idiopathic > drug reaction, allergy, virus
  • Antihistamine and corticosteroids
  • Internal = angioedema
233
Q

Asymptomatic hyperuricaemia

A
  • Most common
  • Elevated serum urate (uric acid)
  • ~10yrs prior to gout = SYNDROME of hyperuricaemia
  • NOT medically treated
234
Q

Podagra

A
  • 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
235
Q

Intercritical gout

A

NOT asymptomatic hyperuricaemia, rather, the periods between podagra.

236
Q

Tophaceous gout

A
  • ‘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
237
Q

Tophaceous gout hand x-ray

A
  • Hooked/’punched out’ erosions
  • Subcortical cysts
  • Tophi
238
Q

Gold standard investigation for gout & interpretation

A

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
239
Q

Pseudogout

A
  • 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
240
Q

Podagra management

A
  1. Rest and ice
  2. High dose Indomethacin (NSAID) 5-10 days
  3. 1mg colchicine –> 0.5mg 1 hour later –> 0.5-1mg daily until resolution
  4. PO/IM/IA corticosteroids 7-10 days - in combo if polyarticular, isolation if CKD.
241
Q

Long term gout management

A

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
242
Q

Causative organisms of septic arthritis

A
  1. Staph Aureus
  2. Streptococcus
  3. Gran negative bacillus - E. coli, pseudomonas
  4. Gonococcal - dermatitis, migratory, tenosynovitis
  5. Potts disease - spine
243
Q

Septic arthritis management

A
  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

244
Q

Seropositive rheumatoid arthritis

A
  • 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
245
Q

Rheumatoid arthritis hand x-ray

A

L - loss of joint space concentrically
O - osteopenia (subchondral & systemic)
S - soft tissue swelling
E - erosions (periarticular)

246
Q

Atlantoaxial subluxation

A
  • Tenosynovitis of the transverse ligament causing it to rupture
  • Long standing RA
  • Shooting paraesthesia’s down the arms
  • Occipital headache
  • X-ray –> MRI
247
Q

Fetty’s syndrome

A

RA + neutropenia + splenomegaly

- Recurrent infections

248
Q

Caplan’s syndrome

A
  • Granuloma formation when exposed to dusts
  • Cough
  • SOB
  • Haemoptysis
249
Q

Rheumatoid arthritis management

A

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
  4. Sulfasalazine (DMARD) - cytopenia, agranulocytosis

Biologics

  • Failing combination DMARDs
  • Ensure TB negative and fully vaccinated
250
Q

Massive/hemodynamically unstable PE management

A
  1. ABC
  2. Oxygen - V/Q mismatch
  3. Analgesia - chest pain
  4. IV Alteplase (tPA) + SC enoxaparin (LMWH) OR IV heparin infusion if ESRF
251
Q

Sub-massive/hemodynamically stable PE

A
  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

252
Q

Duration of anticoagulation following DVT/PE

A

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

253
Q

Primary osteoarthritis

A
  • Idiopathic
  • Affects >3 joints
  • Spares the MCPs, wrist, elbow and shoulder
  • > 40yrs
  • Women > men
  • Genetic link
  • Obesity, overuse, abnormal joint structure
254
Q

Secondary osteoarthritis

A
  • 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
255
Q

Knee OA

A
  • Varus deformity –> medial degeneration
  • Quadricep wasting
  • Patellofemoral disease –> anterior knee pain, pain with stairs
256
Q

Hip OA

A
  • Groin and buttock pain radiating to the knee
  • Antalgic gain
  • Trendelenburg sign –> week adductors
  • Pain with hip flexion and internal rotation
257
Q

OA weight baring x-ray findings

A

L - loss of joint space (eccentric)
O - osteophytes
S - subchondral sclerosis
S - subchondral cysts

258
Q

OA management

A

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

259
Q

Seminoma

A
  • Germ cell testicular tumour
  • Most common testicular tumour
  • 14-40yrs
  • Slow growing
  • Dense lymphocytic infiltrate
  • Atypical sperm breach BM
260
Q

Non-seminoma germ cell tumour

A
  • 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
261
Q

Leydig cell testicular tumour

A
  • Sertoli-Leydig cell tumour
  • Testosterone secreting
  • Premature puberty
  • Gynecomastia –> foci of b-HCG producing cells
  • Impotence
  • Loss of libido
262
Q

Testicular cancer risk factors

A
  • Cryptorchid tests –> testicular atrophy: absent germ cells, thick BM, Leydig cell hyperplasia
  • Personal or family history
  • Infertility
  • HIV (seminoma)
  • Androgen insensitivity
  • Gonadal dysgenesis
  • Hypospadias
263
Q

Germ cell neoplasm in situ

A
  • Non-functional atypical germ cells
  • Abundant clear cytoplasm
  • Large central nuclei
  • Confined to the seminiferous tubule lumen
  • Precursor lesion to all germ cell tumours
264
Q

Testicular cancer symptoms

A
  • Painless irregular scrotal mass
  • Dull scrotal ache
  • Heavy scrotal sensation
  • Absent cremaster reflex
265
Q

Testicular cancer investigation

A

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

266
Q

Testicular cancer management

A

95% cure with early detection

Stage I

  • Orchiectomy
  • Testosterone

Stage II

  • Orchiectomy
  • Testosterone
  • Radiation –> seminoma
  • Cisplatin –> LNs
  • Retroperitoneal LN dissection –> non-seminoma
267
Q

Renal stone aetiology

A

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

268
Q

Renal stone imaging

A

Non-contrast CT KUB (gold standard)

  • Detect 99% stones
  • Hydroureter
  • Hydronephrosis

U/S

  • Pregnancy
  • Much less sensitive
  • Doppler can help
269
Q

Renal stone management

A
  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)
270
Q

Cystitis pathology

A

Acute inflammatory infiltrate in the LP and uroepithelium

271
Q

Pyelonephritis pathology

A
  • Renal inflammation sparing the glomeruli
  • Diffuse pinpoint yellow abscess
  • Tubular dilation
  • Neutrophils in tubular lumen
272
Q

Uncomplication symptomatic cystitis

A

PO trimethoprim (folate metabolism) for 3 days

273
Q

Pregnancy symptomatic and asymptomatic cystitis

A

PO nitrofurantoin for 5 days with follow-up MSU

274
Q

Non-severe pyelonephritis

A

Fever <38 and/or no sepsis

PO Augmentin

275
Q

Severe or pregnancy pyelonephritis

A

Fever >38 and/or urosepsis

IV gentamicin and amoxicillin

276
Q

Recurrent cystitis

A
  • KUB U/S
  • Low dose antibiotics at night for 6 weeks
  • Estrogen pessary for post-menopausal women
277
Q

Chlamydia STI

A
  • Gram negative diplococci
  • Most common STI
  • 75% asymptomatic
  • Mucopurulent discharge
  • Dysuria
  • Post coital bleeding
  • Coital pain
  • PO Doxycycline
  • Urethral swab or first void urine
278
Q

Gonorrhoea STI

A
  • Gram negative diplococci
  • Urethral swab or first void urine PCR
  • Discoloured discharge
  • Dysuria
  • Coital pain
  • PR bleeding
  • Ceftriaxone + Amoxicillin
279
Q

HSV - 2

A
  • Painful genital ulcers
  • Dysuria
  • Urethral discharge
  • Lymphadenopathy
  • Urinary retention
280
Q

Prostate cancer pathology

A

Dysplasia of the glandular columnar epithelium in the peripheral zone of the prostate

281
Q

Prostate cancer staging

A
  1. TNM
  2. ISUP - grade based of Gleason
  3. PSA
282
Q

Prostate cancer grading

A

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

283
Q

Prostate cancer work-up

A
  1. Repeat PSA and/or DRE
  2. MRI - see lesion and directs biopsy and provides PSA density –> >20% = cancer
  3. Trans-perineal biopsy (new gold standard)
284
Q

Prostate cancer screening

A

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
285
Q

Prostate cancer management

A

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
Q

BPH management

A

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
287
Q

Acute tubular necrosis (ATN)

A
  • 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
288
Q

Acute interstitial nephritis (AIN)

A
  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
  4. AKI
  5. Rash
  6. Fever
289
Q

Pre-renal AKI

  1. urine concentration
  2. Sodium avidity
  3. Casts
  4. Urea: creatine
A
  • Urine concentration NOT impaired
  • Sodium avidity –> fractional excretion of sodium <20/<1%
  • Bland cast
  • Increased urea : creatinine
290
Q

Renal AKI

A
  • 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
291
Q

AKI complications

A

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
292
Q

AKI management

A
  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
293
Q

CKD definition

A
  1. GFR <60ml/min
  2. 24hr protein >30mg/day (microalbuminuria)
  3. Intrarenal diagnosis
294
Q

Top 4 causes of CKD in order

A
  1. Diabetic
  2. GN
  3. HTN
  4. PKD
295
Q

ESRF pathology

A
  • Small kidneys with irregular scared surface
  • Global glomerulosclerosis
  • Thyroidisation
  • Interstitial and cortical fibrosis
  • Chronic inflammatory cell infiltrate
  • Thickened arteries
296
Q

Benign nephrosclerosis

A
  • Hypertensive nephrosclerosis –> HTN CKD (3)
  • Hyaline arteriolosclerosis of the AA
  • Fine pitting of the kidney surface
297
Q

Aqcuired cystic renal disease

A
  • Multiple renal cysts due to ESRF on LT dialysis
  • Increased risk of RCC
  • Atrophic small kidneys
298
Q

CKD proteinuria

A

<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
299
Q

4 essential tests for CKD

A
  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
300
Q

CKD U/S

A
  • <9cm
  • > 13cm = infiltrative disease
  • Thin cortex
  • Hypo-echogenicity
301
Q

Mineral bone disorder

A

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
  4. Cholecalciferol –> kidneys still functioning
  5. Calcitriol –> ESRF

Dialysis
1. Cinacalcet - increase PTH receptor sensitivity

Tertiary
1. Parathyroidectomy

302
Q

Dialysis indications

A

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
Q

Viral conjunctivitis

A
  • 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
Q

Bacterial conjunctivitis

A
  • 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
Q

Allergic conjunctivitis

A
  • Bilateral red itchy eyes
  • Water or purulent discharge
  • Chemosis
  • Papillae
  • Anti-histamine drops
306
Q

Cataract risk factors

A
  • Age (most common)
  • Diabetes
  • LT steroid use
  • Severe myopia (near sighted)
  • LT UV exposure
  • Congenital
  • Trauma
307
Q

Cataract symptoms

A
  • Gradual decline in vision
  • Glare with lights esp. at night
  • Coloured halos
  • Brunescent or yellow hue to lens
  • Diminished red reflex
308
Q

Cataract management

A
  1. Sunglasses and corrective lenses

2. Lens transplant

309
Q

Common causes of osteomyelitis

A
  1. Staph aureus
  2. Staph epidermidis
  3. Gram negative bacillus
  4. Beta haemolytic strep
    - TB –> Pott’s
    - Salmonella –> sickle cell anaemia
310
Q

Osteomyelitis investigations

A

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
Q

Osteomyelitis management

A
  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

  1. Surgery –> abscess, SA, antibiotics refractive
  2. Zinc, calcium, vitamin C, protein
312
Q

Colles fracture

A

‘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
Q

Smith fracture

A
  • FOOSH & osteoporosis MTF
  • Distal 2cm of radial in volar angulation
  • Shortening of the radius
314
Q

NOF

A
  • 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
Q

Spinal stenosis

  1. Pseudoclaudication
  2. Radiculitis
  3. Radiculopathy
A
  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
Q

Pulmonary infarct pathology

A
  • 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
Q

Wells criteria

A

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
Q

Massive, sub-massive and low risk PE

A

Massive –> haemodynamic instability
Sub-massive –> RVH strain and/or elevated troponin
Low risk –> None of the above

319
Q

PE ECG findings

A
  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
Q

PE imaging

A

CTPA (gold standard)

V/Q scan

  • Renal disease
  • Contrast allergy
  • Pregnancy
  • Obese
  • Young

TTE
- Hemodynamically instable

321
Q

DVT/PE prevention

A
  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
Q

Gliflozins

A

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
Q

Glutides

A

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
Q

Hypercholesterolaemia management

A
  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
  3. Stain + PCSK9 inhibitor
    - Increased LDL receptor expression
    - Rash
    - Hypersensitivity
    - Infection
  4. Statin + PCSK9i/ezetimibe + fenofibrate
    - PPAR-alpha agonist promote beta oxidation
    - Rhabdomyolysis with stain
    - Liver derangements
    - Stones
325
Q

Hyperlipidaemia & Hypercholesterolaemia non-pharmacological management

A
  • 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
Q

Hyperlipidaemia & Hypercholesterolaemia target levels

A

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
Q

Intermittent claudication management

A
  • Walking program & Foot care
  • Statin –> increases walking distance & primary prevention
  • Aspirin –> primary prevention
  • ACEi –> increase walking distance
328
Q

Critical limb ischaemia management

A 
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
Q

Familial combined hyperlipidaemia

A
  • 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
Q

Acquired hyperlipidaemia

A
  • 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
Q

Familial hyperapobetalipoproteinemia

A
  • Corneal arcus
  • High LDL (apo-b)
  • Premature CAD
  • Xanthomas
332
Q

Familial dysbetalipoproteinemia

A
  • Tubero-eruptive xanthomas
  • High cholesterol + TAGs
  • Impaired clearance of chylomicrons and VLDL
  • Autosomal recessive + acquired factor
  • Palmer crease xanthomas
  • Premature CAD
333
Q

Chylomicronaemia

A
  • 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
Q

Thromboangiitis obliterans

A

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
Q

PVD investigations

A

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
Q

Localising stenosis in PVD

A

Thigh buttock pain –> external iliac
Calf pain –> femoral or popliteal
Foot pain –> posterior tibial (medial malleolus) or anterior tibial (dorsalis pedis)

337
Q

Valve replacement - prosthetic vs mechanical

A

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
Q

Aortic stenosis investigations

A

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
Q

Aortic stenosis aetiology

A
  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
Q

Hypertriglyceridemia management

A

> 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
Q

LVH ECG & causes

A
  • 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
Q

Superficial spreading melanoma

A
  • Most common
  • Trunk and limbs
  • Slow growth
  • Radial growth
  • Pagetoid spread - buckshot scatter
  • Late metastasis
  • 40yrs
343
Q

Nodular melanoma

A
  • Aggressive –> poor prognosis & rapid growth
  • Vertical growth
  • Thin atrophic epidermis
  • Dermal proliferation
  • Head and neck
  • Large epithelioid or spindle atypical melanocytes
  • 50% amelanotic
344
Q

Lentigo maligna melanoma

A
  • 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
Q

Acral lentiginous melanoma

A
  • Dark skinned individuals
  • Palms, soles and nails
  • > 50% amelanotic
  • Less associated with sun exposure
  • Radial growth
346
Q

Nodular BCC

A
  • Most common
  • Pearly papule
  • Raised edges
  • Telangiectasia
  • Ulcerative centre –> rodent ulcer –> local destruction
  • Face
347
Q

Superficial spreading BCC

A
  • Limbs and trunk
  • Erythematous, scaly patch
  • Surface erosions and crusting
348
Q

Morphoeic BCC

A

Scar-like plaque

349
Q

Heart block aetiology

A
  • BB/CCB/Digoxin
  • Increased vagral tone –> young athletes
  • Age related scaring
  • IHD related scaring
  • Hyperkalaemia (prolongation the PR interval)
350
Q

First degree heart block management

A

TRICK!

Benign rhythm –> reassure patient

351
Q

Second & third degree heart block management

A
  1. Atropine

2. Isoprenaline (beta agonist) + PPM

352
Q

Psychogenic seizure

A
  • Eyes closed
  • Pelvic thrusting
  • Immediate recovery or prolonged recovery
  • Investigated with video EMG
  • Wax and waning consciousness
  • Last 10-20 minutes
353
Q

Generalised seizures

A
  • L.O.C –> reticular formation and thalamus
  • Post-ictal state
  • No aura
354
Q

Generalised motor seizures

A
  • 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
Q

Focal complex seizure

A
  • 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
Q

Simple partial seizure

A
  • No LOC or impaired awareness
  • No post ictal
  • No aura
357
Q

Pancreatitis severity score

A

Glasgow-Imrie

P - pCOs <59.3
A - >55yrs
N - Neutrophilia 
C - Hypocalcaemia 
R - AKI (urea)
E - LDH (enzymes)
A - hypoalbuminaemia 
S - hyperglycaemia (sugar)
358
Q

Pancreatitis diagnosis

A

> 2 of the following –> may not have to image

  • Lipase >2X ULN
  • Abdominal pain
  • Radiological evidence
359
Q

Epilepsy diagnosis

A
  1. > 2 unprovoked seizures >24 hours apart
  2. 1 unprovoked seizure with a high probability of recurrence
  3. Epilepsy syndrome
360
Q

Epilepsy management

A

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
Q

Lateral medullary syndrome

A

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
Q

Medial medullary syndrome

A

Anterior spinal artery

Ipsilateral CN 12

  • Tongue deviation
  • Dysarthria

Contralateral hemiparalysis –> corticospinal
Contralateral vibration and proprioception –> dorsal column

363
Q

Lacunar stroke syndrome

A
  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
Q

PCA stroke syndrome

A

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
Q

Dominant hemisphere MCA stroke

A
  • 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
Q

Non-dominant MCA stroke

A
  • 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
Q

ACA stroke

A

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
Q

STEMI

A

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
Q

NSTEMI

A 
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
Q

Stable angina

A

Predictable onset chest sensation with exertion
Relieved by rest and GTN
Occurs <10-20 minutes
No troponins or ECG

371
Q

Unstable angina

A 
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
Q

Pyrexia of unknown origin

A

Fever >38 for >3 weeks despite >1 week of investigations

Idiopathic prolonged fever

373
Q

Pain management

A

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
Q

Portal HTN aetiology

A

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
Q

Portal HTN signs and symptoms

A
  • Ascites & spontaneous bacterial peritonitis
  • Haemorrhoids
  • Varices
  • Caput medusae
  • Hepato-renal syndrome
  • Hepato-pulmonary syndrome
  • Gastropathy
376
Q

Peritonitis management

A

Primary

  • IV ceftriaxone
  • IV albumin

Secondary

  • IV gentamicin + amoxicillin + metronidazole
  • Perforated viscus –> laparoscopy

Abscess
- Surgical drain

377
Q

Primary v secondary peritonitis

A

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
Q

AKI diagnostic criteria

A

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
Q

Mechanical small bowel obstruction aetiology

A
  1. Adhesions
  2. Hernia
  3. Malignancy
    - Crohn’s strictures
    - Volvulus
    - Intussusception
    - Gallstones
380
Q

Mechanical large bowel obstruction aetiology

A
  1. Malignancy (CRC)
  2. Volvulus (sigmoid and caecum)
  3. Stricture (U/C, Crohn’s, diverticulitis)
  4. Adhesions (iatrogenic)
  5. Hernia (inguinal or femoral)
381
Q

OSA diagnosis

A
  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
Q

Hypopnea

A

Decreased airflow >30% from baseline for >10 seconds

A reduction in oxygen saturation by >3% OR EEG arousal

383
Q

Apnoea

A

Respiratory arrest for >10 seconds

384
Q

OSA management

A

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
Q

Pleural effusion management

A
  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
Q

Empyema management

A
  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
  5. Video assisted thoracoscopic surgery (VATS)
387
Q

Lights criteria

A

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
Q

Transudative pleural effusion aetiology

A

Increased hydrostatic pressure and/or decreased oncotic pressure

  • CCF
  • Liver failure
  • CKD/ESRF
  • Nephrotic syndrome
  • Hypothyroidism
  • Pulmonary embolus
389
Q

Exudative pleural effusion aetiology

A

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
Q

Torsade De Pointes aetiology

A

Electrolyte disturbances - hypokalaemia, hypomagnesia, & hypocalcaemia
Congenital prolonged QT
QT prolonging drugs - erythromycin, sotalol, amiodarone, TCA, SSRIs

391
Q

Torsade De Pointes management

A

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
Q

Ventricular tachycardia aetiology

A 
AMI
Dilated cardiomyopathy 
Myocarditis 
Digoxin
Increased sympathetic tone
393
Q

Ventricular tachycardia management

A

Hemodynamically unstable OR unconscious –> DC cardioversion

Hemodynamically stable –> IV amiodarone (chemical cardioversion) or IV Lidocaine

394
Q

Aortic aneurysm aetiology

A
  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
Q

Aortic regurgitation aetiology

A

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
Q

Infective endocarditis risk factors

A

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
Q

Aneurysm management

A

<5.5cm
- 6 monthly abdominal U/S

> 5.5cm or >10mm increase/year

  1. Metoprolol
  2. Endovascular or open repair
  3. +/- statin
398
Q

Dissection management

A
  1. ABC
  2. Aggressive fluid resuscitation +/- blood transfusion
  3. NBM
  4. Call vascular surgeons
  5. IV morphine - pain and anxiety

Stanford A - ascending aorta

  1. IV prophylactic antibiotics
  2. Graft +/- AVR

Stanford B - descending aorta
6. Metoprolol OR endovascular stenting

399
Q

Dukes criteria

A

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
Q

NSTEMI & UA management

A

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
Q

Long term ACS management

A
  1. Nitrate PRN
  2. Statin
  3. ACEi
  4. Aspirin
  5. Clopidogrel or Ticagrelor
  6. Metoprolol/Atenolol
    +/- spironolactone LVHF
402
Q

STEMI management

A
  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
Q

Infective endocarditis antibiotics

A

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
Q

Stable angina managment

A
  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
Q

Malignant HTN symptoms

A

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
Q

HTN management

A

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
Q

Anti-hypertensive indications & aims

A

> 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
Q

Acute atrial fibrillation management

A

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
Q

Chronic atrial fibrillation management

A

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
Q

Paroxysmal supraventricular tachycardia (SVT) management

A
  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
Q

SVT symptoms & ECG

A 
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
Q

AMI pathology

A

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
Q

Anti-centromere antibody

A

CREST/ limited scleroderma

414
Q

Anti Scl-70 & anti-topoisomerase

A

Diffuse cutaneous scleroderma (systemic sclerosis)

415
Q

Infective endocarditis pathology

A
  • Septic vegetations containing inflammatory infiltrate and fibrin
  • Fibrotic changes
  • Friable vegetations
  • Ring abscess –> erosion through myocardium
416
Q

RHD pathology

A

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
Q

Libman-Sacks endocarditis pathology

A
  • SLE
  • Sterile thrombi of fibrin + eosinophils + complement –> fibrinoid necrosis + vasculitis
  • Mitral (commissure fusion) and tricuspid
  • Chordae tendineae involvement and shortening
418
Q

Thrombotic endocarditis pathology

A
  • Small aseptic non-inflammatory thrombi on the orifice
  • Top of the valve
  • No local affects
  • Indwelling catheters, hypercoagulability, malignancy
419
Q

TB management

A

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
Q

COPD management

A

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
  4. LABA + LABA + ICS (Fluticasone)

Other

  • Home oxygen
  • Mucolytics
  • Macrolides - frequent exacerbations
421
Q

GOLD stages

A

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
Q

Small cell lung cancer

A
  • 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
Q

Lung adenocarcinoma

A
  • 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
Q

Lung SCC

A
  • 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
Q

Non-Small cell lung carcinoma management

A

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
Q

Pneumothorax management

A
  1. ABC
  2. Analgesia

Simple primary

  1. 4 hour monitor
  2. Follow up CXR 2 weeks

Unstable primary or secondary

  1. thoracentesis 5th ICS mid axillary line
  2. Follow up CXR 2 weeks

Tension

  1. URGENT needle decompression 2nd ICS mid clavicular line
  2. thoracentesis 5th ICD mis axillary line
  3. Valve dressing
427
Q

Inhaled asthma medication

A

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
Q

Asthma exacerbation severity score

A

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
Q

Community acquired pneumonia organisms

A

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
Q

Hospital acquired pneumonia organisms

A

> 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
Q

Acarbose

A
  • Alpha glucoside inhibitor
  • Slows glucose absorption and digestion
  • Flatulence, diarrhoea + abdominal pain
432
Q

Gliclazide

A 
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
Q

Metformin

A

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
Q

Dominant parietal lobe signs

A

MCA stroke

Serial 7s –> acalculia
Write –> agraphia
Left and rights –> left/right disorientation
Name fingers –> finger agnosia

435
Q

Non-dominant parietal lobe signs

A

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
Q

Temporal lobe signs

A

Short term memory loss
Long term memory loss
Confabulation –> make up stories to fill in lost memories

437
Q

Frontal lobe signs

A

Primitive reflex

  • Grasp
  • Palmomental
  • Pout and snout

Proverb
Anosmia
gat apraxia –> shuffling gait

438
Q

Anti ro and la

A

Sjogren’s

439
Q

Adrenal glands in Cushing’s

A

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
Q

Benign adrenal cortical adenoma

A
  • Most are cold
  • Some produce cortisol or aldosterone
  • Microscopically bland
  • Small, well circumscribed solitary yellow mass due to lipid inclusions
441
Q

Adrenal cortical carcinoma

A
  • Primary = unilateral
  • Metastasis = bilateral
  • Functional –> androgens –> virilisation
  • > 10cm or 100g
  • Large, haemorrhagic, necrotic and often infiltrating surrounding structures
442
Q

Pheochromocytoma

A

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
Q

Mallory Weiss tear

A
  • 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
Q

Boerhaave syndrome

A
  • Transmural tear –> haemorrhage –> cardiogenic shock
  • Mediastinitis –> chest pain & tachypnoea
  • Severe vomiting, iatrogenic, caustic, drugs
  • EMERGENCY surgery or 100% death
445
Q

Acute liver failure pathology

A
  • 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
Q

Benign adenomyoma

A

Hyperplasia of Rokitansky Ascoff sinuses and smooth muscle

447
Q

Gallbladder adenoma

A

Mucosal polyps

Usually incidental finding on U/S

448
Q

Gallbladder adenocarcinoma

A
  • 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
Q

Acute lung injury (ALI)

A

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
Q

Pulmonary abscess

1. Cause

A

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
Q

Flattening of the inspiratory curve

A

Extra-thoracic obstruction –> decreased inspiratory flow due to inlet obstruction

  • Glottic stricture
  • Tumour
  • Vocal cord paralysis
452
Q

Flattening of the expiratory curve

A

Intra-thoracic obstruction –> lung compressing on lesion

  • Lung tumour
  • Tracheomalacia
453
Q

Flattening of the inspiratory and expiratory curves

A

Fixed obstruction –> no affected by changes in lung volumes

  • Post intubation stricture
  • Tracheal tumour
  • Thyroid goitre
454
Q

Aortic stenosis pathology

A
  • 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
Q

False aneurysm

A

Pseudoaneurysm

  • Tear through all three layers of the vessel
  • Formation of an extravascular haematoma which communicated with the lumen
456
Q

True aneurysm

A
  • Dilation in all three layers of the vessel wall
  • Saccular –> single sided
  • Fusiform –> both sides
457
Q

Dissection definition

A
  • Intimal tear only

- Blood accumulated in the tunica media layers

458
Q

Intramural haematoma

A
  • Rupture of the vasa vasorum
  • Blood accumulates in the vessel wall
  • Communicating if it ruptures into the thoracic cavity OR vessel lumen
459
Q

Chronic dissection

A
  • Blood enters back into the vessel due to a second intimal tear OR intramural haematoma
  • No extra-mural haemorrhage –> hence chronic
460
Q

Mitral valve prolapse

A
  • 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
Q

Aetiology of mitral regurgitation

A

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
Q

Mitral regurgitation murmur signs

A
  • 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
Q

Mitral valve murmur signs

A
  • 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
Q

HOCM pathology

A
  • 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
Q

Carcinoid syndrome

A
  • Tumour products (e.g., serotonin) cause the syndrome
  • Diarrhoea
  • Flushing
  • Bronchospasm
  • Skin lesions
  • Tricuspid/pulmonary insufficiency –> RHF
466
Q

Centriacinar/centrilobular emphysema

A
  • Most common pattern
  • Smoking
  • Respiratory bronchioles
  • DCLO normal
  • Apical lobes
467
Q

Panacinar emphysema

A
  • Least common pattern
  • Alpha-1 antitrypsin
  • Lower lobes
  • Respiratory bronchioles AND alveoli
  • DCLO reduced
468
Q

Chronic bronchitis pathology

A

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
Q

Asthma pathology

A

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
Q

Lobar pneumonia pathology

A
  • > 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
Q

Bronchopneumonia

A
  • Patchy opacities
  • Bilateral
  • Basal
  • Immunocompromised and post URTI
472
Q

Silicosis lung path

A

Wide spread fibrosis nodules

Egg shell calcifications

473
Q

Asbestosis pathology

A
  • 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
Q

Sarcoidosis pathology

A

Schumann bodies - giant cell calcium and protein inclusions

Asteroid bodies - giant cell stellate inclusion

475
Q

Bronchiectasis

A
  • 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
Q

True v false diverticular

A 
True = congenital dilation of all layers
False = acquired involving mucosa and submucosa
477
Q

HCC pathology

A
  • 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
Q

Hepatocellular adenoma

A
  • Benign
  • Women > men
  • OCP
  • Resected if large and causing abdominal pain due to pressure on liver capsule
479
Q

Cavernous haemangioma

A
  • Common benign liver neoplasm
  • Blood vessel forming tumour in a fibrous bed
  • Subcapsular
  • Intra-abdominal bleeding
480
Q

Chronic pancreatitis

A
  • Dilated ducts
  • Hard due to calcification and fibrosis
  • Patchy mononuclear infiltrate
  • Epithelial atrophy + hyperplasia + squamous cell metaplasia –> carcinoma
481
Q

Intestinal type gastric adenocarcinoma

A
  • 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
Q

Diffuse type gastric adenocarcinoma

A

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
Q

Cholangiocarcinoma pathology

A
  • 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
Q

Benign pancreatic masses

A

Cystadenoma

  • Serous cyst
  • Tail
  • Old women

Mucinous cyst

  • Women
  • Precancerous
  • Tail
485
Q

Exocrine pancreatic tumour

A
  • 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
Q

Endocrine pancreatic tumour

A
  • Very uncommon
  • Low grade –> slow growing
  • Insulinoma most common
  • VIPoma –> hypokalaemia and water diarrhoea
  • Somatostatinoma –> hypochloridria, steatorrhea and diabetes
487
Q

Gastrointestinal stromal tumour (GIST)

A
  • 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
Q

Stroke pathology

A

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
Q

Cells most affected by watershed infarcts

A

Purkinje cells in the cerebellum

Pyramidal cells in the hippocampus

490
Q

Cingulate herniation

A

Subfalcine

  • Frontal lobe beneath the cingulate gyrus
  • ACA compression –> ACA stroke syndrome
  • Foramen of Monroe compression –> Hydrocephalus
491
Q

Uncal herniation

A

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
Q

Tonsillar herniation

A
  • Cerebellar tonsils through foramen magnum

- Medulla compression –> respiratory and cardiac arrest

493
Q

Pilocytic astrocytoma

A
  • 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
Q

Diffuse astrocytoma

A
  • 20-40yrs
  • Slow growth
  • Usually progresses to higher histological grade
  • Firm OR gelatinous mass +/- cystic degeneration
  • Normal astrocytes arranged atypically
495
Q

Anaplastic astrocytoma

A
  • Rapidly growing –> poor prognosis
  • Highly cellular and pleomorphic
  • Poorly demarcated expansive mass
  • 40yrs
496
Q

Glioblastoma multiforme

A
  • 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
Q

Ependymoma

A
  • 4th ventricle –> children
  • Central canal –> adults
  • Obstructive hydrocephalus
  • Poor prognosis
  • Peri-vascular pseudo-rosettes
498
Q

Meningioma

A
  • 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
Q

Medulloblastoma

A
  • 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
Q

Oligodendroglioma

A
  • 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
Q

Neurofibromatosis

A
  • 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
Q

Encephalitis pathology

  1. Acute
  2. HSV
  3. CMV
  4. HZ
  5. Rabies
A

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
Q

Multiple sclerosis (MS) pathology

A
  • Peri-ventricular glassy well-circumscribed plaques
  • Demyelination
  • Lymphocytic infiltrate
  • Oligodendrocytes replaced with reactive gliosis
504
Q

Motor neurone disease pathology

A

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
Q

Hashimoto’s Thyroiditis pathology

A

Follicular cell destruction replaced with non-function Hurthle cells with abundant cytoplasm and chronically fibrosis
Lymphocytic infiltrate forms lymphoid follicles –> MALToma

506
Q

Graves disease pathology

A
  • Diffusely enlarged ‘beefy’ thyroid
  • Hyperplastic follicular epithelium causing papillary growth
  • Scalloped margins –> colloid taken up by hyperplastic epithelium
  • Lymphocytic infiltrate
507
Q

Toxic multinodular goitre

A
  • 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
Q

Benign vs malignant thyroid nodule FNA

A

Benign

  • Lots of colloid
  • Few follicular cells

Malignant

  • Hypercellular
  • Follicles cells in aggregates
  • Minimal colloid
509
Q

Wilms tumour

A

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
Q

RCC pathology

A
  • 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
Q

Oncocytoma

A
  • 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
Q

Angiomyolipoma

A
  • Mesenchymal benign neoplasm
  • Comprised of vessels, muscle and fat
  • Tubular sclerosis
  • Yellow mass with haemorrhage
513
Q

Pre-cursor urothelial neoplasms

A

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
Q

Invasive urothelial carcinoma

A
  • High grade
  • 10% 5yr survival
  • Squamous or glandular metaplasia
  • CK7 and p63 positive
  • Men > women
  • Often multiple and recurrent
515
Q

Testicular torsion symptoms and pathology

A
  • Acellular testicular ischaemia
  • Acute severe testicular and abdominal pain out of proportion to exam
  • Absent cremaster reflex
  • Scrotal swelling
  • N + V
516
Q

Bladder cancer staging

A 
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
Q

Autosomal dominant PKD

A
  • 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
Q

Autosomal recessive PKD

A
  • 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
Q

Simple renal cyst

A
  • Single or multiple
  • > 50yrs
  • Cortex
  • Asymptomatic
  • One chamber
  • Small
  • Lined with simple cuboid or squamous cells
520
Q

HSV keratitis

A
  • 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
Q

Bacterial keratitis

A
  • 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
Q

Uveitis

A
  • Red eye ache
  • Worse with accommodation
  • Floating opacities
  • Burred vision
  • Ciliary flush
  • Synechiae - iris stick to the lens
  • Spondyloarthropathy
523
Q

Blepharitis

A
  • Burning, irritable gritty eye
  • Feeling of foreign body in the eye
  • Crusty eyelid

Hordeolum

  • External –> Stye –> Staph
  • Internal –> Chalazoin –> seborrheic dermatitis
524
Q

Episcleritis

A
  • RA
  • Painless red eye
  • Itchy
  • Lacrimation
  • No visual changes
525
Q

Retinal detachment

A
  • Acute painless monocular blindness
  • Flashes
  • Floaters
  • Curtain
  • Folded retina
  • Loss of red reflex
  • Blood in vitreous humour

Y3B (4 decks)

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