Final Push! Flashcards
Define Antepartum Haemorrhage?
Bleeding from the genital tract after 24 weeks gestation before delivery of the foetus
Why should you never do a vaginal examination in large APH?
There is a risk you can cause a massive bleed
Where is the pain in placental abruption?
Lower abdominal pain
What is the most common presentation in placental abruption?
Longitudinal lie cephalic presentation (this is the most common presentation in anyone)
Mx of placental abruption with foetal or maternal distress?
Cat 1 C-section
What is vasa praevia?
The foetal blood vessels run in front of the presenting part, this causes bleeding and foetal bradycardia following rupture of membranes
What is the earliest a pregnant uterus can be palpated if there is a single foetus?
12 weeks
What screening should you offer to all mothers at the booking visit
FBC, Blood group + rhesus status, Hep B and syphilis screen, haemoglobinopathies for sickle cell/thalassaemia and alloantibodies. Also offer HIV screen
Apart from Down’s syndrome what can cause thickened nuchal translucency?
Congenital heart defects and abdominal wall defects
What does the quadruple test show in Down’s Syndrome?
Low alpha fetoprotein and unconjugated oestradiol
High beta hCG and inhibin A
Name 5 risk factors for developing gestational diabetes?
Previous baby >4.5kg, BMI >30, previous gestational diabetes, first degree relative with diabetes and South Asian/Middle-Eastern origin
How does gestational diabetes cause macrosomia in the foetus?
Increased glucose is delivered to the foetus via the umbilical vein leading to hyperinsulinemia in the foetus which causes increased fat deposition
How does gestational diabetes affect future diabetic risk?
Increased risk of Gestational DM in future pregnancies and increased risk of developing DM in the future
When does post-partum psychosis typically develop? What is the risk of reoccurance?
Within the first 2-3 weeks following birth, usually around day 3-5
25-50% risk of reoccurrence. It also increases the risk of other mental illnesses
RFs for post-partum depression (starts within 1 month and peaks at 3 months)
Previous depression/bi-polar, previous episode of post-partum depression, lack of social support, recent stressful life event
What medical condition should you rule out in someone presenting with post-partum depression? Mx?
Post-partum thyroiditis.
Mx = propranolol in the thyrotoxic phase and thyroxine in the hypothyroid phase
RFs for ectopic pregnancy?
IUD/IUS in situ, previous PID, previous ectopic, endometriosis, IVF, previous fallopian tube surgery
Where is the most common site of ectopic pregnancy? Where is the most dangerous?
Most common = ampulla
Most dangerous = isthmus
How should you deliver methotrexate and anti-D immunoglobulin in the medical management of a Rhesus negative woman?
Both by IM injection
Name some important blood tests to perform in hyperemesis gravidarum?
U&Es, FBC, TFTs, LFTs and ABG
Mx of severe hyperemesis gravidarum?
IV fluids, Vitamin B1 to prevent Wernicke’s and LMWH
Antiemetics include prochlorperazine, cyclizine, ondansetron and metoclopramide
Define missed miscarriage?
There is a uterus containing a dead foetus, cervix is closed and there may have been light bleeding but no pain
Name some causes of recurrent spontaneous miscarriage?
Anti-phospholipid syndrome, uterine abnormality e,g, uterine septum, parental chromosomal abnormality, smoking and cervical incompetence
What investigations should you do in menorrhagia?
FBC, TFTs and clotting studies
Also TVUS and endometrial sampling/hyteroscopy
Name some contraindications (UKMEC 4) to the COCP?
> 35 years old smoking >15/day, migraine with aura, Hx DVT/PE, Hx stroke/IHD, uncontrolled HTN, current breast cancer, breast feeding <6 weeks post partum and positive antiphospholipid antibodies
Mx Menorrhagia which can be used in a patient who has completed their family?
IUS, Endometrial artery ablation and hysterectomy
What does the BRCA gene increase the risk of?
Breast, ovarian and prostate cancer
What is CIN (seen on cytology of cervical smear)? Mx?
Cervical intraepithelial neoplasia, it is pre-malignant
Mx = large loop excision of the transformation zone (LLETZ), test for cure 6 months after treatment
What are the two histological types of cervical cancer?
Squamous cell and adenocarcinoma
What should you always give pre-operatively to patients who take regular prednisolone and are awaiting moderate/major surgery?
Hydrocortisone IV
Dactylitis can be seen in psoriatic arthritis and what?
Reactive arthritis
What is the initial imaging for ?achilles tendon rupture?
USS
Name a cause of nephrogenic and craniogenic DI?
Cranuogenic = pituitary surgery
Nephrogenic = Lithium
What should you suspect if there is proximal muscle weakness with no rash but a riased CK? Ix and Mx?
Polymyositis
Ix = anti-Jo-1 (also seen in dermatomyositis)
Mx = steroids and methotrexate
Sx of Progressive Supranuclear Palsy?
Postural instability, impaired vertical gaze, parkinsonism and frontal lobe dysfunction
What is the most common presentation of Peutz-Jegher’s syndrome? Name another Sx?
SBO is the most common presentation
There will be dark blue/brown macules on the skin and mouth
What are the parameters of a severe asthma attack?
PEFR 33-50% predicted, RR >25, HR >110, can’t complete full sentences
What can cause gingival hyperplasia?
Phenytoin, ciclosporin, CCBs and AML
How long should you wait before re-starting hormonal contraception when taking ulipristal acetate?
5 days
Mx Non-Hodgkin’s lymphoma?
R-CHOP chemotherapy.
Unless it is gastric malt then just eradicate H.Pylori
What is seen in heparin induced thrombocytopenia?
> 50% reduction in platelets, thrombosis and skin allergy
Where should the contraceptive implant go?
Subdermally in the non-dominant arm
If you have AKI and proteinuria where is the problem?
Intrinsic (in the kidneys themselves)
Mx of patients with GI bleeds who have had multiple endoscopic therapies already?
Laparotomy and surgical exploration
What should you do if a salpingotomy fails to manage an ectopic pregnancy?
Give methotrexate or do a salpingectomy
Define Pre-eclampsia? Mx? Prevention?
New onset BP >=140/90 after 20 weeks of pregnancy with one or more of proteinuria and organ dysfunction
Mx = Labetalol and delivery
Prevent with 75-150mg aspirin daily from 12 weeks until birth
What is Wallen’s Syndrome?
Critical LAD stenosis characterised by self-resolving cardiac chest pain with a Hx of IHD and deeply inverted T waves in V2-V3.
Give PCI!
What must be true for a patient to have a bundle branch block?
They must have a widened QRS!
Mx of diverticulitis which has not responded to oral Abx?
IV ceftriaxone and metronidazole
Why should you never prescribe azathioprine and allopurinol together?
It can cause bone marrow suppresion
What is intestinal angina?
AKA chronic mesenteric ischaemia
Presents with severe colicky post-prandial abdo pain, weight loss and an abdominal bruit
Describe familial hypercholesterolaemia?
AD
Causes a mutation in LDL receptors leading to high cholesterol at a young age
How can you differentiate between haemophilia and von Wilebrand’s disease?
Haemophilia = Prolonged APTT, normal bleeding time
vWD = Prolonged APTT and prolonged bleeding time
What increases the risk of hepatotoxicity in paracetamol excess?
Enzyme inducing drugs (e.g. Rifampicin, Phenytoin, Carbamazepine, Chronic alcohol XS and St John’s wart) or if they are malnourished
What should you offer to patients presenting within 4.5 hours vs 6 hours of ischaemic stroke?
Thrombolysis and thrombectomy
If between 4.5-6 hours offer thrombectomy only
What should you do if a patient on the COCP experiences migraine with aura?
STOP COCP
What is the most common cause of amaurosis fugax? Will it be ipsilateral or contralateral
Atherosclerosis of the internal carotid artery is most common
It will be ipsilateral
Sx anterior inferior cerebellar stroke?
Sudden onset vertigo, vomiting, ipsilateral facial paralysis and deafness
What is Dermatitis Herpetiformis?
Itchy vesicular rash on the extensor surfaces, it is associated with Coeliac’s disease due to IgA skin depositis
What should you do if a patient has had an inadequate respond to the Hep B vaccine?
If anti-HBs levels are 10-100 give one further dose
If anti-HBs levels are <10 give a full course extra (3 further doses)
What is the most common type of renal cell carcinoma?
Clear cell carcinoma
Describe Chronic Pancreatitis?
Abdo pain after eating, steatorrhoea and DM
Most commonly caused by alcohol XS
Ix = CT abdo, if inconclusive do a faecal elastase
Mx = analgesia and pancreatic enzyme supplements
Where is the lymphadenopathy in rubella?
Suboccipital and post auricular
Describe subclinical hyperthyroidism?
Normal T3 and T4 but low TSH.
There is an increased risk of AF, osteoporosis and dementia
Describe the abortion laws?
Abortions can be done up to 24 weeks unless it is necessary to save the woman’s life, there is evidence of extreme foetal abnormality or there is risk of serious mental/physical harm to the woman
How can we perform abortions?
<9 weeks medically with mifepristone followed 48 hours later by misoprostol
After this surgically with dilation and suction
Describe mesenteric adenitis?
Appendicitis symptoms (RLQ pain, fever, nausea and vomiting) but with a recent sore throat
How can neuroleptic malignant syndrome affect creatinine kinase?
It causes it to rise as there is rhabdomyolysis
How can we differentiate between Neuroleptic Malignant Syndrome and Serotonin Syndrome?
NMS = Reduced reflexes, led pipe rigidity and normal pupils
SS = increased reflexes, clonus and dilated pupils
Both will have tachycardia, hypertension, pyrexia, rigidity and sweating
Define spondylosis and spondylolisthesis?
Spondylosis = vertebral stress fracture of the pars interarticularis
Spondylolisthesis = displacement of the vertebrae which may be secondary to spondylosis
Should we offer surgery to women with breast cancer?
In most cases yes
Unless they are frail/elderly with metastatic breast cancer
When is the latest you would expect a child to sit unsupported by?
12 months
What are some general symptoms of SLE?
Fatigue, fever, mouth ulcers, lymphadenopathy, arthritis, pleurisy, protein/hematuria, pericarditis and butterfly rash
How can we calculate number needed to treat?
1/(control event rate - experiment event rate)
How should we induce labour?
Bishops score =<6 = vaginal prostaglandin E2 (Dinoprostone) or oral misoprostol
Bishops score >6 = amniotomy or IV oxytocin
Membrane sweep is an adjunct to IOL NOT IOL itsself
Describe delusion disorder?
A patient has >= 1 non-bizzare delusional though for >= 1 month which are not explained by any other condition
What is the most common cause of ABO incompatibility on blood transfusion?
Patient being identified incorrectly
What is the most common primary malignant bone tumour? Who is it seen in?
Osteosarcoma
Seen in children and adolesents
Describe transposition of the great arteries?
Cyanosis, tachypnoea and a single loud S2 heart sound seen in new borns
Mx = give prostaglandin E1 e.g. Alprostadil to maintain the PDA until surgery
What should you do with a child presenting with an unexplained petechial rash and hepatosplenomegaly?
Urgently refer to paeds assessment unit ?ALL
Mx of PPH?
Manual decompression of the uterus
IV oxytocin ,2nd line drugs include Ergometrine (not if HTN), Carboprost (not if asthma) or misoprostol
Finally balloon tamponade
What is the cause of a painful arc between 60-120 degrees?
Supraspinatus tendonitis (aka subacromial impingement)
What type of data is BMI an example of?
Continuous data
What virus is associated with tonsil cancer?
HPV
Mx of breathlessness in palliative care?
IV Morphine
What hormone spikes to cause ovulation?
LH
True or false, GCA can cause fever, weight loss and night sweats?
TRUE
When can we use the unpaired T-Test?
To analyse a sample and determine if there is any difference between 2 unrelated groups
When do we use procyclidine?
In the Mx of EPSEs and drug induced Parkinsonism
Mx of finger trauma?
Finger splint
When do diabetics require a variable rate insulin infusion?
In a major surgery
1st line Mx for lower back pain?
NSAIDs
How can we reverse neuromuscular blocks?
Neostigmine (this can also be used in MG)
Which analysis of data provides the highest quality evidence?
Meta analysis of trials
How are the electrolytes deranged in tumour lysis syndrome?
Increased potassium, increased phosphate, increased uric acid and low calcium
How long does passive immunity last in babies?
Around 6 months
Describe a fibroadenoma?
A mobile, firm, smooth breast lump (breast mouse)
Mx of thrombotic (painful) crises in sickle cell?
Supportive and analgesia
Name some causes of postural hypotension?
Antihypertensive drugs, diuretics, sedatives, antidepressants, hypovolaemia, DM, Parkinson’s
Name some management options for postural hypotension?
Education (advise to stand up slowly and teach to recognise symptoms), high salt diet, compression stockings, fludrocortisone and midodrine
Define Delirium?
An acute transient and reversible state of confusion, disturbed cognition and impaired consciousness
How can we differentiate delirium from dementia?
Confusion Assessment Method
How do penicillin antibiotics work? How have bacteria developed resistance to them?
They inhibit the production of the bacterial cell wall
Bacteria now produce beta-lactamase this stops penicillin’s from working - to combat this you should prescribe drugs such as co-amoxiclav or tazocin which are beta-lactamase inhibitors
How can dementia present?
Memory loss, personality/behavioural changes, mood changes, inattention and disorientation
Name 8 reversible causes of dementia?
Hypoglycaemia, hypothyroidism, normal pressure hydrocephalus, B12/thiamine deficiency, SDH, brain tumour and depression
What is seen on MRI in alzheimer’s disease?
Cerebral atrophy of the cortex and hippocampus
What are the first and second line treatments for Alzheimer’s dementia?
1st line = acetylcholinesterase inhibitors (e.g. Donepezil, Galantamine or Rivastigmine)
2nd line = NMDA receptor antagonists e.g. memantine
Name 2 drugs which may precipitate urinary incontinence?
Diuretics and sedatives e.g. opioids
Name 4 causes of pelvic floor muscle weakness?
Pregnancy, child birth, chronic constipation, chronic cough
Mx of stress incontinence?
Pelvic floor exercises, avoid caffeine and smoking, weight loss
Duloxetine (An SNRI, increases the noradrenaline and serotonin concentration in the pudendal neve causing increased urethral sphincter tone)
How can ACEis worsen stress incontinence?
They can cause a dry cough which may worsen symptoms
How does warfarin work?
Inhibits active vitamin K regeneration and so inhibits the production of clotting factors 2,7,9 and 10
Name some drugs which can cause mania?
Amphetamines, cocaine, steroids and levodopa
Which tests should you do before starting lithium therapy?
U&Es to check renal function (it is renally excreted), TFTs (it can affect thyroid function) and ECG (it can cause long QT syndrome)
Name 6 symptoms of lithium toxicity?
Coarse tremor, hyperreflexia, acute confusion, polyuria, seizures and coma
How are scores such as PHQ-9 and HADS useful? What are their drawbacks?
They can be diagnostic and allow symptom monitoring and assessment severity.
However they can be very subjective and are only validated for use within hospitals
Name 4 conditions which can be associated with depression?
Addison’s, hypothyroidism, bipolar, psychotic depression
What are some features of atypical depression?
Increased appetite, increased weight, catatonia and mood improves with positiv events
Name 5 ways you can differentiate delirium from dementia?
Features that point to delirium = acute onset, impaired consciousness, fluctuation of symptoms (often worse at night), abnormal perceptions (hallucinations and delusions), agitation/fear
List 6 causes of dementia?
Alzheimer’s, Vascular Dementia, Lewy Body Dementia, Frontal-Temporal dementia Parkinson’s dementia, Huntington’s disease
What are some risks associated with giving sedation to elderly patients?
Increased risk of falls, increased risk of confusion, can cause respiratory depression and hypotension
Define alcohol abuse?
Excessive alcohol consumption which is continued despite causing physical, mental, social or financial harm to the patient
Sx of Delirium Tremens?
Coarse tremor, confusion, delusions, visual/auditory hallucinations, fever and tachycardia
Why must we give B/C vitamins (Pabrinex) to patients withdrawing from alcohol?
To prevent progression to Wernicke’s encephalopathy and Korsakoff syndrome
Briefly describe how we can identify different types of cysts easily?
Epidermoid cysts = black heads
Sebaceous cysts = white heads
Dermoid cysts = contain hair
Desmoid cysts = benign tumours of connective tissue
Describe Ramsay Hunt Syndrome?
Caused by reactivation of VZV
Post-auricular pain, facial nerve palsy, vesicular rash, vertigo and tinnitus
Mx = acyclovir and prednisolone
What should you consider as the cause of dropping saturations post-intubation? How do we check for this
intubation of the oesophagus
Monitor with capnography
What is the most common cause of OE?
Pseudomonas aerginosa
Describe gall stone ileus?
SBO secondary to gall stone impaction, leading to abdo pain, distension and vomiting
Describe small bowel overgrowth syndrome?
Chronic diarrhoea, flatulence and abdominal pain associated with DM and scleroderma
Ix = hydrogen breath test
Mx = rifampicin
Describe a anal fissure?
Very painful rectal bleeding on defecation. Fissures are often seen at 6 o’clock position, DRE may be impossible due to pain
True or false, DRE can be normal in haemarrhoids?
TRUE
Mx of organophosphate poisoning?
Atropine
Which beta blockers can reduce mortality in heart failure?
Carvedilol and bisoprolol
Which diabetes drug can cause fournier’s gangrene (necrotising fasciitis of the genitalia/perineum)?
SGLT 2 inhibitors
Which position is best to place a patient with ARDS in?
Prone position
What do PHQ-9 and HAD assess?
PHQ-9 = depression
HAD = anxiety
What is seen in posterior STEMI?
ST depression, tall broad R waves in V1-V3 and upright T waves
Sx of hereditary spherocytosis?
Jaundice within the first 24 hours of life, gall stones, splenomegaly, haemolytic crises and if acutely unwell consider splenic rupture
What should you suspect in a patient with HIV, neuro symptoms and a brain lesion with homogenous enhancement?
CNS lymphoma
What are ‘orange-peel skin lesions’?
Pre-tibial myxoedema, associated with Grave’s
How long must you avoid driving for after a seizure? Should you inform the DVLA?
First seizure = 6 months
Epileptic seizure = 12 months
MUST inform DVLA
Mx of (occular) myasthenia gravis?
Pyridostigmine
True or false, high birth weight is a RF for neonatal sepsis?
FALSE! Low birth weight is a RF
What are the oxygen targets in acute asthma?
94-98%
Where is an inferior STEMI? Which vessel is affected?
Inferior = II, III and aVF = Right coronary artery
Can also cause AV node block
Where is an anterior STEMI? Which vessel is affected?
V1-V4
LAD artery
Where is a lateral STEMI? Which vessel is affected?
I, aVL, V5 and V6
Left circumflex
Which drug can worsen plaque psoriasis?
Beta blockers
How long should you receive aspirin for after a stroke? What should you give after that?
14 days of 300mg aspirin
After this give clopidogrel or anticoagulant if AF
Describe placenta accreta, placenta increta and placenta percreta?
Accreta = chorionic villi attach to the myometrium
Increta = chorionic villi invade the myometrium
Percreta = chorionic villi invade through the perimetrium
What is seen in wet ARMD?
Neovascularisation (new vessel formation)
What is the most common cause of hypopituitarism?
Non-secreting pituitary macroadenomas
What should you consider the cause of loss of fine motor function in both upper limbs? Ix? Mx?
Degenerative cervical myopathy
Ix = MRI
Mx = decompressive surgery
Which movement is affected first in adhesive capsulitis?
External rotation
What should you suspect if Schober’s test is <5cm in a young person?
Ankylosing spondylitis
Mx intermittent testicular torsion?
Prophylactic fixing
What is erysipelas? Mx?
Superficial cellulitis
Mx = flucloxacillin
How can we differentiate between bullous pemphigoid and pemphigus vulgaris?
Bulla/blisters with no mucosal involvement = bullous pemphigoid
Mucosal involvement = pemphigus vulgaris
True or false, finasteride can cause gynaecomastia?
True
Mx absence seizures?
Ethosuxamide
Mx focal seizures?
Lamotrigine or Levitiracetam
What is takotsubo cardiomyopathy/
ST elevation but no obstructive coronary artery disease
Where do inhaled foreign bodies most frequently become lodged?
R main bronchus
Describe a posterior cerebral artery stroke?
Contralateral homonymous hemianopia with macular sparring and visual agnosia
Describe Anti-HBs and Anti-HBc?
Anti-HBs = safe, have immunity
Anti-HBc = caught, have previously acquired the infection
Describe transfusion related lung injury?
Hypoxia, pulmonary infiltrates, fever and low blood pressure after blood transfusion
How can reticulocytes help us differentiate between haemolytic and aplastic crises?
Haemolytic = high
Aplastic = low
Is warfarin safe in AKI and breast feeding?
YES
What type of contraceptive pill is desogrestrel? How late can it be?
POP
But it can be up to 12 hours late without issue
Secondary prevention of MI?
ACEi, Beta blocker, Statin, Dual anti-platelet therapy (aspirin + ticagrelor/prasugrel)
Ix of chlamydia/gonorrhoea?
NAAT
In women = vulvovaginal swab
In men = 1st catch urine sample
How long before surgery can you drink fruit juice without pulp?
2 hours, it counts as a clear liquid
Where is the pulmonary fibrosis in TB?
Upper zone
What is pabrinex made of?
B and C vitamins
Mx of ?Neutropenic sepsis?
IV tazocin, give before blood test results are back
How are urea, creatinine and urinary protein affected in pregnancy?
Urea and creatinine go down, urinary protein increases
What does having a normal libido suggest about the cause of erectile dysfunction?
Suggests it is an organic cause
SE of doxycycline?
It can cause photosensitivity
Describe Adie’s tonic pupil?
Uneven sized pupils which are worse in bright light
Sx of an anterior cerebral artery stroke?
Leg weakness but no facial weakness or speech issues
How long can a pregnancy test remain positive after a TOP?
up to 4 weeks
What should you consider as the cause of a pansystolic murmur with a low grade fever?
Infective endocarditis
Sx of myxoedemic coma?
Hypothermia, hyporeflexia, bradycardia and seizures
What is seen on X-ray in ankylosing spondylitis??
Syndesmophytes
Subchondral erosions, sclerosis and squaring of the lumbar vertebrae
What is seen on BM aspirate in myeloma?
Plasma cells
Name 2 side effects of triptans?
Tightness of the throat and chest
When is a fluid exudate?
Pleural fluid protein:serum protein >0.5
Pleural fluid LDH:serum LDH >0.6
Pleural fluid LDH >2/3rds upper limit of normal
Define Acute dystonia, Akathisia and Tardive Dyskinesia?
Acute Dystonia = Sustained muscle contraction - manage with procyclidine
Akathisia = severe restlessness
Tardive Dyskinesia = late onset abnormal and involuntary movements e.g. chewing
What is the most common cause of bronchiolitis and how do you detect it?
Respiratory Syncytial Virus
Detect with immunofluorescence of nasopharyngeal secretions
When should you immediately refer a child to hospital with bronchiolitis?
Apnoea, child looks very unwell to a healthcare professional, severe respiratory distress (grunting, marked chest recessions or RR > 70), central cyanosis or oxygen sats <92% on air
Mx of bronchiolitis in hospital?
Humidified oxygen via a head box, NG feeding, suction of airway secretions
What is the most common cause of croup?
Parainfluenza virus
May also be caused by adenovirus
Mx of croup which does not respond to oral dexamethasone?
High flow oxygen and nebulised adrenaline
Sx of severe croup?
Marked sternal wall retractions, significant distress/agitation or lethargy/restlessness, tachycardia, cyanosis
When does pyloric stenosis normally present?
1st 2-4 weeks of life
Name the 4 areas of the stomach?
Fundus, body, cardia and the pylorus
What age does SUFE typically occur?
10-15
Name some risk factors for SUFE?
Male, obesity and local trauma
What cartilage is seen in the epiphyseal plate?
Hyaline cartilage
Causes of jaundice in the first 24 hours of life?
Rhesus haemolytic disease, ABO haemolytic disease, Hereditary spherocytosis, G6PD deficiency
What does the direct antiglobulin (Coomb’s test) screen for?
Autoimmune haemolytic anaemia
What is an important complication of neonatal jaundice? How do we prevent it?
Kernicterus
Prevent with UV therapy or exchange transfusion
How do we classify heart failure severity?
New York Hear Association Classification
Sx of Left ventricular failure?
SOB, reduced exercise tolerance, paroxysmal nocturnal dyspnoea, orthopnoea, pink frothy sputum and cough
How does furosemide work?
It inhibits the Na-K-2Cl co-transporter so reduces uptake of these salts in the ascending limb so reduces water uptake in the descending limb
Name some SEs of ACEi?
Dry cough, first dose hypotension, hyperkalaemia, renal impairment and angiooedema
How do statins work?
They inhibits HMG-CoA reductase which is the rate limiting step in cholesterol synthesis
Sx of hypercholesterolaemia?
Xanthalesmata, corneal arcus and tendon xanthoma
Name some common causes of AF?
Pneumonia, MI, PE, hyperthyroidism, alcohol XS, HF and endocarditis
Complications of AF?
Ischaemic stroke, TIA, HF, systemic emobli and falls
Describe Roth Spots?
Boat-shaped retinal haemorrhages with a pale centre seen in IE
What criteria is used in IE?
Modified Duke Criteria
Name some symptoms of aortic regurg?
Early diastolic murmur, wide pulse pressure, collapsing (waterhammer) pulse, nailbed pulsation and head bobbing
How do you take blood cultures in ?IE
Take 3 blood cultures from 3 separate sites at 3 separate times
RFs for IE? How do we prevent it in these patients?
IVDU, mechanical heart valves, bicuspid aortic valves, PDA, VSD
Offer prophylactic antibiotics before surgery (often amoxicillin)
What is the incidence of CF in the UK?
1 in 2500 live births, 1 in 25 are carriers
Define bronchiectasis and name 5 causes?
Chronic lung infection/inflammation leading to chronic and permanent dilation of the airways
Causes = CF, infection (TB/pneumonia), bronchial obstruction (lung CA or foreign body), Allergic Bronchopulmonary Aspergillosis and Immune deficiency
Which 2 organisms commonly colonise the lungs in CF?
Staph aureus and pseudomonas aerginosa
Name 2 tests which can confirm PE?
CTPA or V/Q scan (done in renal impairment when contrast can not be given)
Where does lung cancer commonly metastasise to? How can we assess the cancer and its spread?
Brain, liver, bones and adrenal gland
CT thorax and a PET scan
What is Pemberton’s sign?
Plethora/cyanosis when raising the arms as high as possible
Associated with thoracic inlet obstruction e.g. SVCO, retrosternal goitre e.t.c
What is seen on CXR in idiopathic pulmonary fibrosis?
Ground glass appearance, later there may be honeycombing
Name 3 respiratory and 3 non-respiratory causes of idiopathic pulmonary fibrosis?
Resp = extrinsic allergic alveolitis (pigeon fanciers lung, farmers lung, bakers lung)
Non-resp = RA, SLE, UC, Systemic sclerosis
Name 8 causes of clubbing?
Cyanotic heart disease, Cystic Fibrosis, Lung cancer, Lung abscess, Ulcerative Colitis, Bronchiectasis, Idiopathic Pulmonary Fibrosis and Infective Endocarditis
How can we assess OSA? Name some risk factors?
Epworth sleepiness score
RFs = obesity, large tonsils/adenoids, acromegaly and nasal polyps
What can be seen on CXR and ECG in Cor Pulmonale?
CXR = enlarged right ventricle/atrium
ECG = right axis deviation and increased P wave amplitude
What do you see on biopsy in sarcoidosis?
Non-caseating granulomas
Give 5 extra-pulmonary manifestations of sarcoidosis?
Erythema nodosum, lupus pernio, facial nerve palsy, anterior uveitis/conjunctivitis and cirrhosis
Name 10 side effects of steroids?
Impaired glucose regulation, weight gain, abdominal striae, thin skin, osteoporosis, proximal myopathy, avascular necrosis of the femoral head, immunosuppression, psychosis, peptic ulceration, acute pancreatitis and glaucoma
When performing a pleural tap should you put the needle above or below the ribs?
Above as the neurovascular bundle is below
What can you do to treat recurrent pleural effusions?
Pleurodesis with bleomycin
What should you do if a pleural effusion has a pH <7.2?
Insert a chest drain
How can we differentiate between gastric and duodenal ulcers?
Gastric = pain soon after eating
Duodenal = pain when hungry, relieved by eating
Mx of trace glycosuria in pregnancy?
Non needed - it is common so no need to do OGTT
Ix of AKI with unknown cause?
Renal USS
What is a good option for post operative pain relief?
PCA
What may you see on ECG in severe mitral stenosis?
A bifid P wave (P mitrale) due to left atrial hypertension and strain
What should you consider the cause of a ?seizure in a child where recovery is rapid?
Reflex anoxic seizure
Describe the paraneoplastic symptoms of lung cancers?
Small cell = ADH secretion, ACTH secretion and lambert-eaton syndrome
Squamous cell = PTHrP secretion, TSH secretion, clubbing and HPOA
Adenocarcinoma = HPOA and gynaecomastia
What is meralgia parasthetica?
Pain and numbness over the lateral thigh skin
What is it called if you have Perthe’s disease in adults?
Avascular necrosis of the femoral head
Describe Budd-Chiari syndrome?
Sudden onset abdo pain, ascites and tender hepatomegaly often seen secondary to a tumour or hypercoagulable state causing a clot in the hepatic vein
How does loperamide work?
Stimulates opioid receptors to reduce bowel motlitity
How likely are you to pass on the BRCA 1 gene
50%
What causes anaphylaxis?
IgE mediated mast cell release
What investigation should you always do in new dermatomyositis?
CT TAP ?Malignancy
Which antibiotic is known to cause IIH? Name 4 symptoms?
Tetracyclines
Sx = Raised ICP, enlarged blind spot, papilloedema, 6th nerve palsy
Sx of viral labyrinthitis?
Sudden onset horizontal nystagmus, sensorineural hearing loss, nausea and vomiting and vertigo
How is Marfan’s an Ehler-Danlos inherited?
AD
When can you stop anti-epileptics? How should you stop them?
When you have been seizure free for at least 2 years
Stop over 2-3 months
Antibodies in diffuse and central systemic sclerosis?
Diffuse = anti-scl-70
Central = anti-centromere
Define felt need?
Individual perceptions of deviation from normal health
Define expressed need?
Individual seeks help to overcome variation in normal health
Define normative need?
Professional defines intervention appropriate for the expressed need
Define comparative need?
Comparison between severity, range of interventions and cost
Define primary, secondary and tertiary prevention?
Primary = preventing a disease before it has occured
Secondary = catching a disease in a pre-clinical or early phase to prevent it progressing
Tertiary = Preventing complications of a disease
Define sensitivity?
The proportion of people with a disease who are correctly identified by the screening test
Define specificity?
The proportion of people without a disease who are correctly excluded by the screening test
Positive predictive value?
The proportion of people with a positive test who actually have the disease, this increases with prevalence
Negative predictive value?
The proportion of people with a negative test who do not have the disease, this decreases with prevalence
What is a cross section study?
Divides those with a disease and those without a disease and collects data at that specific point in time about associations
Case-control study?
Compares someone with a disease with someone without and looks back retrospectively to look at risk factor exposure
Cohort study?
Takes a population without a disease and watches them over time to see what risk factors they come across and if they develop the disease - prospective
Randomised control trial?
Split patients into groups, one is given an intervention where as the other is given a control. The results are then compared
Ecological study?
Uses routinely collected data to show trends and allow a hypothesis to be formed
Define relative risk and relative risk reduction?
Relative risk = how many times more likely it is that an event will occur in the intervention group as compared to the control
Relative risk reduction = reduction in the rate of outcome in the prevention group as compared to the control
Define number needed to treat?
The number of people needed to treat for a condition in order to prevent one bad outcome
What are the 5 stages of change?
PC PAM
Precontemplation, Contemplation, Preparation, Action and Maintenance
Name 8 causes of acute pericarditis?
Viral infections (e.g. coxsackie virus), TB, uraemia, post-MI, SLE, RA, trauma and malignancy
Mx of tension pneumothorax?
Needle decompression with a large bore cannula in the mid clavicular line 2nd intercostal space
How long does pneumothorax typically take to resolve? When can you fly?
1.25% of the lung volume can correct each day
Do not fly until full resolution is confirmed on x-ray
Which gene causes ADPKD?
PKD 1 gene
Why is ADPKD associated with bleeds on the brain?
Berry Aneurysms lead to SAH, there is also hypertension which increases this risk further
Name 4 examination findings and 6 complications of ADPKD?
Examination findings = enlarged irregular kidneys, hepatomegaly, HTN and mitral valve prolapse
Complications = CKD, haematuria, renal stones, livery cysts (most common), berry aneurysms and chronic pain
Who should you screen for ADPKD and how?
First degree relatives of someone with a confirmed diagnosis, screen with abdo USS
What are the main 2 investigations to perform in a cushingoid patient?
Overnight dexamethasone suppression test first line
Also 24 hour urinary free cortisol
Why can cushing’s syndrome lead to tanned skin?
ACTH stimulates melanocytes as there is an affinity for the MSH receptor, this causes darkening of the skin
Name 6 causes of acute pancreatitis?
Alcohol excess, gall stones, trauma, ERCP, hyperlipidaemia and scorpion venom
Name the 3 scoring systems to identify pancreatitis severity? Name some common factors in them?
Ranson score, Glasgow score and APACHE II
Age >55 years, hypocalcaemia, hyperglycaemia and hypoxia
Mx acute pancreatitis?
Aggressive fluid resuscitation, IV opioids, do not make NBM but consider enteral nutrition
What causes Grey-Turner’s and Cullen’s sign?
Retroperitoneal and intra abdominal bleeding secondary to acute pancreatitis
Name 5 complications of acute pancreatitis?
ARDS, pancreatic pseudocysts, pancreatic necrosis, pancreatic abscess and multi-organ failure
Name 5 autoimmune conditions associated with MG?
SLE, RA, Grave’s disease, Hashimoto’s thyroiditis and pernicious anaemia
What is the defining feature of muscle weakness in MG?
Fatiguability, gets worse with use and better with rest
Compare the symptoms to CA in the right colon vs left colon?
Left = bleeding/mucus per rectum, tenesmus and altered bowel habit
Right = weight loss, anaemia and abdo pain
What causes a thyroglossal cyst? Name some differentials?
Thyroglossal duct carries the thyroid gland from the foramen caecum to the tongue base. If it does not atrophy a cyst can form
Differentials = dermoid cyst, thymus mass and malignancy
Ix of thyroglossal cyst?
USS mass, TFTs, radioactive iodine scan
Name RFs for PPH?
Previous PPH, prolonged labour, pre-eclampsia, placenta praevia/accreta, polyhydramnios and increasing maternal age
How is female continence maintained?
The external urethral sphincter and the pelvic floor pressures exceed detrusor pressure
Name 2 medical problems which can worsen urinary incontience?
DM and UTI
Ix of incontinence and non-medical management?
Ix = urodynamics
Mx = reduce caffeine intake, pelvic floor exercises if stress incontinence and bladder retraining if urge incontinence
Mx of acute asthma?
Nebulised salbutamol, oral prednisolone
Nebulised ipratropium bromide and IV magnesium sulphate if severe/life-threatening
Consider IV aminophylline
Name 5 resp and 5 non-resp complications of cystic fibrosis?
Bronchiectasis, recurrent pneumonia, pneumothorax, pulmonary HTN and nasal polyps
Cirrhosis, meconium ileus, malabsorption, constipation/intussusception and infertility
Name the fat soluble vitamins
A, D, E, K
What is the best way to estimate the body surface area affected by burns?
Lund and Browder chart
Describe the Parkland formula?
( Weight (kg) x Burn surface area (%) ) x4
This is the total volume of Hartmann’s over 24 hours, give half in the first 8 hours!
What are the 2 most common causes of death in burns patients?
Infection and dehydration
Mx of severe urticaria?
Short course of oral steroids alongside non-sedating anti-histamines
Addison’s vs Conn’s?
Addison’s = primary adrenal insufficiency
Conn’s = primary hyperaldosteroneism
What is the diagnosis if there is a normal/raised total gas transfer with raised transfer coefficient?
Asthma or pulmonary haemorrhage
Mx acute limb ischaemia?
Analgesia, IV heparin and vascular review
When is DKA classed as resolves?
pH >7.3, ketones <0.6 and bicarbonate >15
Mx nasal polyps?
TOP internasal steroids and routine ENT referal
What can cause ischaemic hepatitis?
Acute hypoperfusion
What is sodium like in DI and SIADH?
DI = hypernatraemia
SIADH = hyponatraemia
What is the most common cause of septic arthritis?
Staph aureus. Except in young sexually active people when it is N. gonnorhoea
Mx of a new diagnosis of RA?
Methotrexate and consider a short course of oral steroids
Describe Still’s disease?
A maculopapular salmon pink rash with pyrexia which is worse in the evenings
What is acanthosis nigricans?
Black velvety skin lesions associated with GI cancer, DM and anything which increases insulin resistance (e.g. PCOS, cushings and acromegaly)
What is the cause of a pneumonia with low sodium, low lymphocytes and a raised ALT?
Legionella
Describe rheumatic fever?
A recent sore throat with erythema marginitum, arthritis and a heart murmur
Most commonly caused by strep pyogenes
Mx = Penicillin V
Describe retinopathy of prematurity?
Neovascularisation and loss of the red reflex in a premature baby
What is impaired fasting glucose?
FPG >= 6.1 but <7.0
What is impaired glucose tolerace?
FPG <7.0 but OGTT >= 7.8 but <11.1
When should you definitely offer a liver transplant in paracetamol OD?
If the blood pH is <7.3 after 24 hours
What should you consider as the cause of infection in someone who has received a renal transplant?
CMV
Name 3 drugs which should be avoided in PD?
Metoclopramide, Haloperidol (most anti-psychotics should be avoided) and anti-histamines
When should a child have developed a pincer grip by?
12 months
What are the kidneys like in CKD?
Small unless secondary to DM then they are normal sized to large
When are hyaline casts in the urine considered normal?
If the patient is on loop diuretics
What are bloods like in refeeding syndrome?
Low phosphate, low potassium and low magnesium
What are the most common cause of small and large bowel obstruction?
Adhesions = SBO
Malignancy = LBO
What is ludwig’s angina?
Neck swelling, dysphagia and a fever with recent dental surgery
This requires urgent hospital admission
1st line medical Mx of anal fissures?
Bulk forming laxatives
What is Weber’s syndrome?
A midbrain stroke causing ipsilateral CN III palsy and a contralateral hemiparesis
Ix ?gall stone pathology?
Abdo USS
What most commonly causes impetigo?
Staph Aureus
What is seen in severe congenital adrenal hyperplasia?
Shortly after birth there is hyponatraemia, hyperkalaemia and hypoglycaemia (due to low aldosterone and cortisol)
Also ambiguous genitalia if female (due to increased androgens)
Which type of testicular cancer is associated with raised alpha fetoprotien and beta hCG?
Non-seminoma
Which non-testicular cancer is alpha fetoprotein raised in?
Hepatocellular cancer
Acne Mx?
TOP retinoids/benzoyl peroxide
TOP retinoid/benzoyl peroxide + TOP antibiotic (e.g. clindamycin)
PO tetracycline or COCP
Refer to derm ?isotretinon
Ix ?ADPKD?
Abdo USS to visualise renal tract
Can gall stone pain be epigastric?
YES
When should you never give duloxetine?
If eGFR is <30
Sx scleritits?
Red painful eye, watering/photophobia and gradually reducing visual acuity
Sx episcleritis?
Red eye which is not painful (although there may be some discomfort, watering or photophobia), vessels are mobile when gentle pressure is applied
Above what albumin:creatinine ratios should you give ACEi?
ACR >3 if diabetic
ACR >30 if HTN
ACR >70 regardless of other medical conditions
What should you always rule out in painless jaundice and a palpable epigastric/RUQ mass?
Pancreatic cancer until proven otherwise!!
Serum osmolality calculation?
2xsodium + glucose + urea
Mx of pitting oedema?
PO Furosemide
Sx optic neuritis?
Reduced visual acuity, red desaturation, pain worse on eye movements, RAPD and central scotoma
Which side is the deviation if there is a defect in the following cranial nerves?
Trigeminal, Vagus, Accessory and Hypoglossal?
Trigeminal = deviation of the jaw towards the weaker side
Vagus = deviation of the uvula away from the weaker side
Hypoglossal = tongue deviation towards the weaker side
Accessory = weakness in turning the head away from the weaker side
DKA Mx?
First = IV isotonic saline (NaCl 0.9%)
IV insulin (0.1 units/kg/hr)
10% dextrose once BMs <14
K+ as required (<20mmol/hr)
Continue long acting insulin but stop short acting insulin
Sx IPF?
Progressive exertional dyspnoea, bibasal fine end-inspiratory crepitations, dry cough and clubbing
What should you consider the diagnosis if there is erratic blood glucose levels, bloating and vomiting?
Gastroparesis
Mx of temp >38 degrees whilst in labour?
IV benzylpenicillin as GBS prophylaxis
How can sarcoidosis cause bilateral facial nerve palsy? How can we manage?
It causes parotid swelling
Steroids will resolve it
Name some symptoms of mumps other than parotid gland swelling?
Pancreatitis, orchitis, reduced hearing and meningoencephalitis
Describe rickets in adults?
Osteomalacia
There will be bone pain, tenderness and proximal myopathy
SEs of suxamethonium?
Fasciculations before complete muscle paralysis, malignant hyperthermia and suxamethonium apnoea
Ix of PSC?
pANCA positive and beaded appearance of ERCP
How can you differentiate clinically between Horner’s syndrome and a CN III palsy?
Horner’s syndrome = ptosis and pupil constriction
CN III = ptosis and pupil dilation
How much should you increase levothyroxine by in pregnancy?
Up to 50%
How long should you continue HRT till in premature menopause?
50
How do you interpret the Well’s score for DVT?
> = 2 DVT likely, do proximal leg vein USS
<2 DVT unlikely, do D-dimer
When should you assess APGAR score?
At 1 min and 5 mins after birth
Mx of breast cancer when there are positive axillary lymph nodes or tumour noted at the resection margins post mastectomy?
Offer ipsilateral chest wall and lymph node radiotherpay
Where can you palpate epididymal cysts? Can they be painful?
Posterior to the testicle and palpated separately from the testicle
Yes they can be painful
What urine output is considered AKI?
<0.5ml/kg/hr for at least 6 hours
1st line Mx for hyperhidrosis (sweaty hands)?
Aluminium chloride
SEs of oestrogen receptor positive breast cancer treatments?
Tamoxifen can cause VTE and endometrial cancer
Anastrozole can cause osteoporosis
Most likely cause of a central line infection?
Staph Epidermidis
Ix of Premature Prelabour Rupture of Membranes?
Do a speculum examination looking for pooling of amniotic fluid in the posterior vaginal vault. If non is seen do an amnisure sample
Sx of central vs diffuse systemic sclerosis?
Central = CREST syndrome (Calcinosis, Raynaud’s, oEsophageal dysmotility, Sclerodactyly and Telangiectasia)
Diffuse = Scleroderma of the trunk and proximal limbs
SE of the 1st line Mx for SLE?
Hydroxychloroquine can cause retinopathy
Mx and prevention of venous ulcers?
Mx = compression bandaging
Prevention = compression stockings
Mx tonic or atonic seziures?
F = lamotrigine
M = sodium valporate
Mx myoclonic seizures?
F = levetiracetam
Mx = sodium valproate
Mx focal seizures?
Levetiracetam or lamotrigine
Mx tonic clonic seizures?
M = Sodium Valproate
F = Levetiracetam or lamotrigine
What should you consider if an ECG shows inferior MI but there is also aortic regurg?
Proximal aortic dissection
Sx of subacute combined degeneration of the spinal cord (B12 deficiency)?
Loss of proprioception and vibration, hyperreflexia but loss of the ankle jerk reflex, gait abnormalities and Rhomberg’s positive
Describe factor V leidin?
The most common inherited cause of thrombophilia, it increases the risk of clots as there is activated protein C resistance leading to slower inactivation of of factor V
Describe ITP?
Isolated thrombocytopenia with epistaxis and petechiae
In children management is generally not required but in adults give PO prednisolone
How can HF affect Na+?
It can cause hyponatraemia
When should you monitor digoxin levels?
At least 6 hours after the last dose
Mx of women >20 weeks pregnant with VZV exposure but no previous VZV antibodies?
If they present within 24 hours of rash onset give PO acyclovir immediately
If they present after this give PO acyclovir or VZIG after 7-14 days
Describe a dermatofibroma?
A solitary nodule which dimples on pinching
How can amiodarone affect the lungs?
It can lead to lower zone fibrosis
Whooping cough Mx?
Azithromycin or Clarithromycin
