EXAM QS I GET WRONG Flashcards
What do you do if a patient is on 500mg metformin 3x a day and complaining of diarrhoea?
GI side effects are common with metformin and can occur in up to 20% patients.
This patient is on immediate release as he takes it 3x a day
We can switch it to the modified release variant which is usually given once daily instead
How to differentiate the causes of primary hyperaldosteronism?
Primary hyperaldosteronism =Conns syndrome
caused by adrenal adenoma secreting aldosterone, this is the most common cause
Other causes are bilateral adrenal hyperplasia
To differentiate these two causes, imaging (CT) is used- if this doesn’t produce adequate results-perform adrenal venous sampling
If the cause is bilateral hyperplasia: you’d have bilaterally increased aldosterone in adrenal veins
If it’s an adrenal adenoma- unilateral increased aldosterone in adrenal vein
Endocrine parameters reduced in stress response- which hormones are reduced during major surgery?
Insulin
Testosterone
Oestrogen
In suspected cases of Graves disease what medication can be used to manage symptoms whilst patient is waiting to see endocrinologist?
Propanalol- non-selective BB, prevents the adrenergic effects of hyperthyroid
Works quickly to help control the symptoms
What drugs do you prescribe for controlling htn in pheochromocytoma?
Alpha and beta blockers
Remember labetalol blocks both alpha and beta
Female pt with hypothyroidism, treatment during pregnancy?
Women with hypothyroidism may need to increase their thyroid hormone replacement dose by up to 50% as early as 4-6 weeks of pregnancy
Is breast-feeding safe whilst on thyroxine?
Yes
Treatment of thyroid storm
Symptomatic- paracetamol
Treat cause
Beta blockers- IV propanolol
Anti-thyroid drugs- (thionamides)-methimazole or PTU
Lugol’s iodine
Dexamethasone- blocks conversion of T4 to T3
Role of steroids in thyrotoxic crisis
Blocks conversion T4 to T3
What is thyroid acropachy
Triad of digital clubbing, soft tissue swelling hands & feet, periosteal new bone formation
Specific to Graves’
Side effects of metaclopramide
Very common- diarrhoea, drowsy, hypotension, menstrual cycle irregularities, parkinsonism
Uncommon- arrhythmias
Rare- galactorrhoea, confusion, seizure
T1DM blood glucose targets
5-7 mmol/l on waking and
4-7 mmol/l before meals at other times of the day
under 4 you hit the floor, over 7 you may go to heaven
Addison’s patient unwell- what to do about their medications?
Double the glucocorticoids (hydrocortisone)
Child with palpable abdominal mass or unexplained enlarged abdominal organ- what to do
Refer very urgently <48 hrs for specialist assessment for neuroblastoma and Wilms’ tumour
Malignancy until proven otherwise
What is primigravid
Pregnant for first time
Most common cause of primary hypothyroidism
In UK- Hashimoto’s thyroiditis
In the developing world- iodine deficiency
Hashimoto’s thyroiditis = ?
hypothyroidism + goitre + anti-TPO
What is sick euthyroid syndrome
Where TSH, thyroxine and T3 are all low
But most of the time TSH is normal
No treatment usually necessary-repeat TFTs in 6wks
What drug causes hyperCa
Thiazides- increase calcium reabsorption in DCT because they block NaCl on apical side, which reduces Na conc in DCT cells, which upregulates Na/Ca antiporter on basolat side, meaning more Na influx into the cells and calcium efflux into systemic circulation –> hyperCa and hypoNa
How to monitor recurrence in medullary thyroid cancers?
Medullary thyroid cancers often secrete calcitonin and monitoring the serum levels of this hormone is useful in detecting sub clinical recurrence.
They are a part of MEN-2
How to differentiate causes of diabetes insipidus
Water deprivation test: cranial DI
urine osmolality after fluid deprivation: low
urine osmolality after desmopressin: high
Nephrogenic DI;
Osmolality remains low
2 main causes of high calcium
malignancy and primary hyperPTH account for 90% cases
Treating thyrotoxic storm (3)
1- BB
2- PTU
3- hydrocortisone
Graves’ disease antibodies
TSH receptor stimulating antibodies
Most common cause of primary hyperaldosteronism
Bilateral idiopathic adrenal hyperplasia 70% cases
Anti coagulant of choice in AKI
Warfarin- generally safe to continue
Renal transplant complications
Early e.g. infection, urinary leak, haemorrhage, impaired graft function.
Late e.g. lymphocele, ureteric stenosis, renal artery thrombosis.
Key blood test for rhabdomyolysis
creatine kinase - elevates in first 12 hrs and remains high for 1-3 days
Complications AKI
Metabolic acidosis, hyperkalaemia, uraemia, pulmonary oedema
What is the cause of renal artery stenosis in young pts
Fibromuscular dysplasia
Causes to remember of sterile pyuria
renal TB, partially treated UTI, drug causes (antibiotics, NSAIDs, PPI, cyclophosphamide), urinary tract stones, and papillary necrosis.
Assessment of sleepiness (OSA)
Epworth sleepiness scale- done by patient +/- partner
Pigmented gallstones are associated with…
Sickle cell anaemia
Drugs causing pancreatitis
azathioprine, mesalazine, didanosine, bendroflumethiazide, furosemide, pentamidine, steroids, sodium valproate
Where does breast cancer metastasise…
Lungs, Liver, Bones, Brain
Gastric MALT lymphoma…
H Pylori eradication
Sudden onset abdominal pain, very intense and severe- out of proportion with clinical findings… has AF and htn
Mesenteric ischaemia
Who gets urgent colorectal 2WW referral
patients >= 40 years with unexplained weight loss AND abdominal pain
patients >= 50 years with unexplained rectal bleeding
patients >= 60 years with iron deficiency anaemia OR change in bowel habit
tests show occult blood in their faeces (see below)
Caecal volvulus associations
all ages
adhesions
pregnancy
Duke staging
A- mucosa
B- bowel wall
C- lymph node mets
D- distant mets
Acute limb ischaemia in age <50 what ix to do
Thrombophilia screen
Gynaecomastia- which lung cancer
Adenocarcinoma
Features of Addisonian crisis
Hyponatraemia
Hyperkalaemia
Hypoglycaemia
Galactorrhoea drugs
Metaclopramide, domperidone
Haloperidol
Painful shin rash + cough → ?
sarcoidosis
NIV for COPD pts when?
NIV should be considered in all patients with an acute exacerbation of COPD in whom a respiratory acidosis (PaCO2>6kPa, pH <7.35 ≥7.26) persists despite immediate maximum standard medical treatment
Facial rash plus lymphadenopathy think?
Sarcoidosis
Can alpha1 anti trypsin deficiency be diagnosed prenatally?
Yes
via Amniocentesis
bronchiectasis and eosinophilia…?
Allergic bronchopulmonary asperigillosis
Vaccinations for COPD pt?
Annual influenza + one-off pneumococcal
Where is the triangle of safety?
The triangle of safety for chest drain insertion involves the base of the axilla, lateral edge pectoralis major, 5th intercostal space and the anterior border of latissimus dorsi
Causes of ILD
Drugs- methotrexate, amiodarone, nitrofurantoin, cyclophosphamide
Other causes- idiopathic pulmonary fibrosis, extrinsic allergic alveolitis, sarcoidosis, systemic sclerosis, asbestosis
Gold standard ix for ILD
High resolution CT scan- ground glass appearance
Kartagener’s syndrome
triad of bronchiectasis, sinusitis (Primary ciliary dyskinesia), and situs
inversus (all organs are on opposite side- heart on R, stomach bubble seen on R)
+ subfertility
Young’s syndrome
triad of bronchiectasis, sinusitis, and reduced
fertility
Bronchiectasis- who gets pulm rehab
MRC >3 (breathless walking flat, has to walk slower than everyone else)
Causes of upper zone lung fibrosis
CHARTS
Coal workers’ pneumoconiosis
Histiocytosis
Ankylosing spondylitis/Allergic bronchopulmonary aspergillosis
Radiation
Tuberculosis
Silicosis (progressive massive fibrosis), sarcoidosis
Treatment of allergic bronchopulmonary aspergillosis
First line is prednisolone
Second line is itraconazole
How is asthma diagnosed?
An exhaled FeNO of 40 parts per billion or greater
A post-bronchodilator improvement in lung volume of 200 ml
A post-bronchodilator improvement in FEV1 of 12% or more
A peak expiratory flow rate variability of 20% or more
An FEV1/FVC ratio <70% (it is an obstructive lung disease)
Contraindications to lung cancer surgery
SVC obstruction, FEV < 1.5, MALIGNANT pleural effusion, and vocal cord paralysis
Acute respiratory distress syndrome is a complication of what?
Acute pancreatitis
Does biliary colic radiate?
Yes interscapular region
Fluctuating cognition- which dementia?
Lewy Bodies
Differentiating LB dementia from Parkinson dementia?
Lewy body dementia can be differentiated from idiopathic Parkinson’s disease dementia by the time of onset of the dementia compared to the motor symptoms- LB 1year before parkinsonian symptoms
How is orthostatic hypotension diagnosed
a. A drop in systolic BP of 20mmHg or more (with or without symptoms)
b. A drop to below 90mmHg on standing even if the drop is less than 20mmHg (with or without symptoms)
c. A drop in diastolic BP of 10mmHg with symptoms (although clinically much less significant than a drop in systolic BP).
Causes of delirium
PINCH ME Pain Infection Nutrition Constipation Hydration
Medications
Environment/ Electrolytes
When is S3 normal
<30years
Causes of S3
Diastolic filling of ventricle
Normal < 30 (can persist up to age 50 in female)
heard in LV failure (eg dilated cardiomyopathy), constrictive pericarditis (pericardial knock) and MR
Causes of S4
Aortic stenosis, HOCM, htn
Caused by atrial contraction against a stiff ventricle therefore coincides with P wave on ECG
What valvular pathology is associated with PCKD
Mitral valve prolapse
Most common ECG sign for PE
Sinus tachycardia
Less common ECG signs for PE
RBBB
T wave inversion and ST depression in V1 and V2
S1Q3T3- indicating right heart strain- it is the ECG pattern that most likely suggests PE but it is not the most common its quite rare
Causes of VT
HypoK is the most important clinical cause
hypoMg next
DVLA advice post MI
cannot drive for 4 weeks
First line gout
NAPROXEN- NSAIDs
Second line gout
COLCHICINE
Prophylaxis gout
ALLOPURINOL- URATE LOWERING THERAPY
Name some vaccines you shouldn’t give to immunocompromised
LIVE VACCINES AKA MI BOOTY
MMR
Intranasal Influenza
BCG Oral Rotavirus Oral polio (double check this one) Typhoid Yellow Fever
Maintaining remission for Crohns
Azathioprine or mercaptopurine first line
Mx of C diff
Oral metronidazole 10-14 days
stop opioids
Severe flare UC
IV corticosteroids - hydrocortisone or methylprednisolone
Diagnosis of SBP
Paracentesis
Confirmed by neutrophil count >250 cells /ul
side effects PPI
Hyponatraemia
hypoMg
osteoporosis
C diff infections
Gold standard diagnosis of Coeliac disease
Endoscopic intestinal biopsy
Perform in all pts if suspecting following pathology
Ankylosing spondylitis X-ray
Sacroiliitis-Subchondral erosions, sclerosis
Squaring lumbar vertebrae
Bamboo sign- late, uncommon
syndesmophytes
CXR- apical fibrosis
Which antibodies to test to rule out SLE
ANA
which RA drug can cause reactivation of TB
Etanercept
Features of PM
Age 60+
rapid onset <1mnth
Aching, morning stiffness proximal limb muscles
Raised inflamamtory markers
Normal CK
Tennis elbow
Lateral epicondylitis
Worse on resisted wrist extension/suppination when elbow extended
Which immunoglobulin is passed to baby in breast milk
IgA
Septic arthritis abx
IV flucloxacillin
Pt about to be put on long term steroid, what is your approach to bone protection
Oral alendronate
ensure calcium and vit D supplements
immediately
Imaging for alkylosing spondylitis
Sacro-ilitis on pelvix X ray
Which TB drug causes drug-induced lupus
isoniazid
