finals 1 cardio/gynae/surigcal/gastro Flashcards

Question

what is the CHA2DS2-VASc score and opposite scoring systems?

Answer 1

CHA2DS2-VASc is a mnemonic for the factors that score a point: C – Congestive heart failure H – Hypertension A2 – Age above 75 (scores 2) D – Diabetes S2 – Stroke or TIA previously (scores 2) V – Vascular disease A – Age 65 – 74 S – Sex (female) NICE (2021) recommends, based on the CHA2DS2-VASc score: 0 – no anticoagulation 1 – consider anticoagulation in men (women automatically score 1) 2 or more – offer anticoagulation bleeding risk score - ORBIT (also HAS BLED) which is less accurate.

Answer 2

A QRS complex duration of less than 0.12 seconds or 3 small squares. -Sinus tachycardia -Supraventricular tachycardia -Atrial fibrillation -Atrial flutter

Answer 3

synchronised DC cardioversion under sedation or general anaesthesia. Intravenous amiodarone is added if initial DC shocks are unsuccessful.

Answer 4

C- ELECTIVE D- EMERGENCY C- Synchronised D- Unsyncronised C- lower energy D-high energy Unlike defibrillation, which is used in cardiac arrest patients, synchronized cardioversion is performed on patients that still have a pulse but are hemodynamically unstable.

Answer 5

Ventricular tachycardia or unclear cause (treated with IV amiodarone) Polymorphic ventricular tachycardia, such as torsades de pointes (treated with IV magnesium) Atrial fibrillation with bundle branch block (treated as AF) Supraventricular tachycardia with bundle branch block (treated as SVT)

Answer 6

Atrial flutter is caused by a re-entrant rhythm in either atrium. The electrical signal re-circulates in a self-perpetuating loop due to an extra electrical pathway in the atria.

Answer 7

Paroxysmal atrial fibrillation refers to episodes of atrial fibrillation that reoccur and spontaneously resolve back to sinus rhythm. These episodes can last between 30 seconds and 48 hours. Patients with a normal ECG and suspected paroxysmal atrial fibrillation can have further investigations with: - 24-hour ambulatory ECG (Holter monitor) - Cardiac event recorder lasting 1-2 weeks

Answer 8

gallstones alcohol post-ERCP

Answer 9

Idiopathic Gallstones Ethanol Trauma Steroids Mumps Autoimmune Scorpion bite Hyperlipidemia ERCP D (furosemide, thiazide diuretics and azathioprine)

Answer 10

The criteria for the Glasgow score can be remembered using the PANCREAS mnemonic (1 point for each answer): P – Pa02 < 8 KPa A – Age > 55 N – Neutrophils (WBC > 15) C – Calcium < 2 R – uRea >16 E – Enzymes (LDH > 600 or AST/ALT >200) A – Albumin < 32 S – Sugar (Glucose >10)

Answer 11

alcohol and same as acute but longer lasting and less intense Key complications are: -Chronic epigastric pain -Loss of exocrine function, resulting in a lack of pancreatic enzymes (particularly lipase) secreted into the GI tract -Loss of endocrine function, resulting in a lack of insulin, leading to diabetes -Damage and strictures to the duct system, resulting in obstruction in the -excretion of pancreatic juice and bile Formation of pseudocysts or abscesses

Answer 12

-Stop alcohol and smoking -Replacement pancreatic enzymes (Creon) may be required if there is a loss of pancreatic enzymes (i.e. lipase). Otherwise, a lack of enzymes leads to malabsorption of fat, greasy stools (steatorrhoea), and deficiency in fat-soluble vitamins. (A,D,E,K) Subcutaneous insulin regimes may be required to treat diabetes. ERCP with stenting can be used to treat strictures and obstruction to the biliary system and pancreatic duct. Surgery may be required by specialist centres to treat: Severe chronic pain (draining the ducts and removing inflamed pancreatic tissue) Obstruction of the biliary system and pancreatic duct Pseudocysts Abscesses

Answer 13

adenocarinomas head of pancreas TOM TIP: It is worth noting that a new onset of diabetes, or a rapid worsening of glycaemic control type 2 diabetes, can be a sign of pancreatic cancer. Keep pancreatic cancer in mind if a patient in your exams or practice has worsening glycaemic control despite good lifestyle measures and medication. only cancer where u can refer directly for ct - not everyone though

Answer 14

Courvoisier’s law states that a palpable gallbladder along with jaundice is unlikely to be gallstones. The cause is usually cholangiocarcinoma or pancreatic cancer.

Answer 15

CA 125 - Ovarian cancer CA 19-9 - Pancreatic cancer CA 15-3 - Breast cancer Alpha-feto protein (AFP) Hepatocellular carcinoma, teratoma Carcinoembryonic antigen (CEA) Colorectal cancer

Answer 16

Cyclical pain can be treated with hormonal medications that stop ovulation and reduce endometrial thickening. This can be achieved using the combined oral contraceptive pill, oral progesterone-only pill, the progestin depot injection, the progestin implant (Nexplanon) and the Mirena coil. GnRH agonists- to induce menopause but you also get menopause sympotoms e.g. hot flushes and risk of osteoperosis

Answer 17

Transvaginal ultrasound of the pelvis is the first-line investigation for suspected adenomyosis. MRI and transabdominal ultrasound are alternative investigations where transvaginal ultrasound is not suitable. The gold standard is to perform a histological examination of the uterus after a hysterectomy. However, this is not usually a suitable way of establishing the diagnosis for obvious reasons.

Answer 18

Adenomyosis is associated with: Infertility Miscarriage Preterm birth Small for gestational age Preterm premature rupture of membranes Malpresentation Need for caesarean section Postpartum haemorrhage

Answer 19

NICE recommend the same treatment for adenomyosis as for heavy menstrual bleeding. When the woman does not want contraception; treatment can be used during menstruation for symptomatic relief, with: - Tranexamic acid when there is no associated pain (antifibrinolytic – reduces bleeding) - Mefenamic acid when there is associated pain (NSAID – reduces bleeding and pain) Management when contraception is wanted or acceptable: Mirena coil (first line) COCP Cyclical oral progestogens Progesterone only medications such as the pill, implant or depot injection may also be helpful. Other options are that may be considered by a specialist include: GnRH analogues to induce a menopause-like state Endometrial ablation Uterine artery embolisation Hysterectomy

Answer 20

menorrhagia

Answer 21

Dysfunctional uterine bleeding (no identifiable cause) Extremes of reproductive age Fibroids Endometriosis and adenomyosis Pelvic inflammatory disease (infection) Contraceptives, particularly the copper coil Anticoagulant medications Bleeding disorders (e.g. Von Willebrand disease) Endocrine disorders (diabetes and hypothyroidism) Connective tissue disorders Endometrial hyperplasia or cancer Polycystic ovarian syndrome

Answer 22

When the woman does not want contraception; treatment can be used during menstruation for symptomatic relief, with: - Tranexamic acid when there is no associated pain (antifibrinolytic – reduces bleeding) - Mefenamic acid when there is associated pain (NSAID – reduces bleeding and pain) Management when contraception is wanted or acceptable: Mirena coil (first line) COCP Cyclical oral progestogens Progesterone only medications such as the pill, implant or depot injection may also be helpful. Other options are that may be considered by a specialist include: GnRH analogues to induce a menopause-like state Endometrial ablation Uterine artery embolisation Hysterectomy

Answer 23

Intermenstrual bleeding and post coital bleeding pain during sex

Answer 24

Suspected submucosal fibroids Suspected endometrial pathology, such as endometrial hyperplasia or cancer Persistent intermenstrual bleeding

Answer 25

investigation- Prolactin (hyperprolactinaemia is a cause of anovulation) when symptoms of galactorrhea or amenorrhoea

Answer 26

High FSH suggests poor ovarian reserve (the number of follicles that the woman has left in her ovaries). The pituitary gland is producing extra FSH in an attempt to stimulate follicular development.

Answer 27

High LH may suggest polycystic ovarian syndrome (PCOS).

Answer 28

Anti-Mullerian hormone can be measured at any time during the cycle and is the most accurate marker of ovarian reserve. It is released by the granulosa cells in the follicles and falls as the eggs are depleted. A high level indicates a good ovarian reserve.

Answer 29

The options for women with alterations to the fallopian tubes that prevent the ovum from reaching the sperm and uterus include: Tubal cannulation during a hysterosalpingogram Laparoscopy to remove adhesions or endometriosis In vitro fertilisation (IVF)

Answer 30

Pathology of the pituitary gland or hypothalamus Suppression due to stress, chronic conditions or hyperprolactinaemia Kallman syndrome which is a condition characterized by delayed or absent puberty and an impaired sense of smell. (genetic condition)

Answer 31

Hypogonadotrophic hypogonadism: a deficiency of LH and FSH (Leading to a deficiency of the sex hormones testosterone and oestrogen) Hypergonadotrophic hypogonadism: a lack of response to LH and FSH by the gonads (the testes and ovaries) - so the gonatrophins are being produced (LH and FSH) but the gonads (ovaries and testes) are not responding to it.

Answer 32

testes and ovaries

Answer 33

Hypergonadotrophic hypogonadism is the result of abnormal functioning of the gonads. This could be due to: - Previous damage to the gonads (e.g. testicular torsion, cancer or infections, such as mumps) - Congenital absence of the testes or ovaries -Kleinfelter’s Syndrome (XXY) -Turner’s Syndrome (XO)

Answer 34

when a cervical smear test is taken the sample is initially tested for the HPV virus. If the HPV is negative then the cells are not examined and the sample is considered negative. if HPV is positive then the cells are examined for precancerous/cancerous changes. HPV is a virus that is the most common cause of cervical cancer. precancerous changes =(dyskaryosis). Cytology results: Inadequate Normal Borderline changes Low-grade dyskaryosis High-grade dyskaryosis (moderate) High-grade dyskaryosis (severe) Possible invasive squamous cell carcinoma Possible glandular neoplasia

Answer 35

HPV is primarily a sexually transmitted infection. Increased risk of catching HPV occurs with: Early sexual activity Increased number of sexual partners Sexual partners who have had more partners Not using condoms

Answer 36

You can think of the risk factors for cervical cancer in terms of: Increased risk of catching HPV Later detection of precancerous and cancerous changes (non-engagement with screening) Other risk factors: -Smoking -HIV (patients with HIV are offered yearly smear tests) -Combined contraceptive pill use for more than five years -Increased number of full-term pregnancies -Family history Exposure to diethylstilbestrol during fetal development (this was previously used to prevent miscarriages before 1971)

Answer 37

Every three years aged 25 – 49 Every five years aged 50 – 64 There are some notable exceptions to the program: -Women with HIV are screened annually -Women over 65 may request a smear if they have not had one since aged 50 -Women with previous CIN may require additional tests (e.g. test of cure after treatment) -Certain groups of immunocompromised women may have additional screening (e.g. women on dialysis, cytotoxic drugs or undergoing an organ transplant) -Pregnant women due a routine smear should wait until 12 weeks post-partum

Answer 38

Inadequate sample – repeat the smear after at least three months HPV negative – continue routine screening HPV positive with normal cytology – repeat the HPV test after 12 months HPV positive with abnormal cytology – refer for colposcopy

Answer 39

It involves inserting a speculum and using equipment (a colposcope) to magnify the cervix. This allows the epithelial lining of the cervix to be examined in detail. During colposcopy, stains such as acetic acid and iodine solution can be used to differentiate abnormal areas. Acetic acid causes abnormal cells to appear white. iodine solution to stain the cells of the cervix. Iodine will stain healthy cells a brown colour. Abnormal areas will not stain. A punch biopsy or large loop excision of the transformational zone can be performed during the colposcopy procedure to get a tissue sample.

Answer 40

The HPV vaccine is ideally given to girls and boys before they become sexually active. The intention is to prevent them contracting and spreading HPV once they become sexually active. The current NHS vaccine protects against strains 6, 11, 16 and 18: Strains 6 and 11 cause genital warts Strains 16 and 18 cause cervical cancer TOM TIP: A common exam task is to counsel parents about their child receiving the HPV vaccine. They are upset because they believe this implies their daughter or son is sexually promiscuous. Focus on the fact it needs to be given before they become sexually active and that it protects them from cervical cancer and genital warts. HPV is very common and infection is the number one risk factor for cervical cancer.

Answer 41

it is an oestrogen-dependent cancer, meaning that oestrogen stimulates the growth of endometrial cancer cells. You can think of the risk factors for endometrial cancer in relation to the patient’s exposure to unopposed oestrogen. Unopposed oestrogen refers to oestrogen without progesterone (progesterone provides endometrial protection). Unopposed oestrogen stimulates the endometrial cells and increases the risk of endometrial hyperplasia and cancer. Situations where there is increased exposure of unopposed oestrogen are: - Increased age -Earlier onset of menstruation -Late menopause -Oestrogen only hormone replacement therapy -No or fewer pregnancies -Obesity (adipose tissue is a source of oestrogen) -Polycystic ovarian syndrome (due to a lack of ovulation and it is the corpus luteum that produces progesterone. For endo protection pcos women should be on cocp, ius or cyclical progesterones). -Tamoxifen (has an anti-oestrogenic effect on breast tissue, but an oestrogenic effect on the endometrium). - t2dm intrestingly smoking is protective

Answer 42

Risk factor for breast and cervical protective for ovarian and endometrial.

Answer 43

Having a higher number of lifetime ovulations increases the risk of ovarian cancer. Factors that stop ovulation or reduce the number of lifetime ovulations, reduce the risk: Combined contraceptive pill Breastfeeding Pregnancy

Answer 44

BRACA 1 AND 2

Answer 45

Lichen sclerosus is a chronic inflammatory skin condition that presents with patches of shiny, “porcelain-white” skin. It commonly affects the labia, perineum and perianal skin in women. It can affect other areas, such as the axilla and thighs. It can also affect men, typically on the foreskin and glans of the penis. Lichen sclerosis may be confused with other conditions that include “lichen” in the name. Lichen refers to a flat eruption that spreads. It is important not to get lichen sclerosus confused with lichen simplex or lichen planus. Lichen simplex is chronic inflammation and irritation caused by repeated scratching and rubbing of an area of skin. This presents with excoriations, plaques, scaling and thickened skin. Lichen planus is an autoimmune condition that causes localised chronic inflammation with shiny, purplish, flat-topped raised areas with white lines across the surface called Wickham’s striae.

Answer 46

Pelvic inflammatory disease (PID) is inflammation and infection of the organs of the pelvis, caused by infection spreading up through the cervix. It is a significant cause of tubular infertility and chronic pelvic pain. pyenlo is going up your wee hole, this is going up your vag hole

Answer 47

Most cases of pelvic inflammatory disease are caused by one of the sexually transmitted pelvic infections. There risk factors for pelvic inflammatory disease are the same as any other sexually transmitted infection: Not using barrier contraception Multiple sexual partners Younger age Existing sexually transmitted infections Previous pelvic inflammatory disease Intrauterine device (e.g. copper coil)

Answer 48

Examination findings may reveal: Pelvic tenderness Cervical motion tenderness (cervical excitation) Inflamed cervix (cervicitis) Purulent discharge Patients may have a fever and other signs of sepsis.

Answer 49

inflammation of the peritoneal lining

Answer 50

rebound and percussion tenderness, guarding and rigidity

Answer 51

palpation of the left iliac fossa causes pain in the RIF

Answer 52

pain on extending hip if retrocaecal appendix Psoas sign is elicited by having the patient lie on his or her left side while the right thigh is flexed backward. Pain may indicate an inflamed appendix overlying the psoas muscle.

Answer 53

The cystic duct (connected to gallbladder) and the common hepatic duct.

Answer 54

The ampulla of Vater is located where the bile duct and pancreatic duct join and empty into the small intestine. The sphincter of Oddi is a ring of muscle surrounding the ampulla of Vater that controls the flow of bile and pancreatic secretions into thde duodenum.

Answer 55

Cholecystitis: inflammation of the gallbladder Cholangitis: inflammation of the bile ducts

Answer 56

Fat entering the digestive system causes cholecystokinin (CCK) secretion from the duodenum. CCK triggers contraction of the gallbladder, which leads to biliary colic. Patients with gallstones and biliary colic are advised to avoid fatty foods to prevent CCK release and gallbladder contraction.

Answer 57

Biliary colic is caused by stones temporarily obstructing drainage of the gallbladder. when it falls back into the gallbladder the symptoms resolve. Lasting between 30 minutes and 8 hours cholecystitis is inflammation of the gallbladder , which is caused by a blockage of the cystic duct preventing the gallbladder from draining. usually caused by stones cholangitis- surgical emergency - blockage/inflammation in the common bile duct

Answer 58

Obstruction in the bile ducts stopping bile flow (i.e. gallstones in the common bile duct) Infection introduced during an ERCP procedure

Answer 59

Acute cholangitis presents with Charcot’s triad: Right upper quadrant pain Fever Jaundice (raised bilirubin)

Answer 60

Through the skin

Answer 61

Murphy's sign is elicited in patients with acute cholecystitis by asking the patient to take in and hold a deep breath while palpating the right subcostal area. If pain occurs when the inflamed gallbladder comes into contact with the examiner's hand, Murphy's sign is positive

Answer 62

it is conjugated in the liver. as unconjugated bilirubin is not water soulable it cannot be excretted in the urine (hence you DONT get that dark urine)

Answer 63

Dark urine: Urine becomes dark because of the excessive bilirubin is excreted through the kidneys. Pale stool: The presence of pale stools suggests an obstructive or post-hepatic/liver cause as normal feces get their color from bile pigments.

Answer 64

increases pH Above 4.5

Answer 65

Gardnerella vaginalis

Answer 66

Multiple sexual partners (although it is not sexually transmitted) Excessive vaginal cleaning (douching, use of cleaning products and vaginal washes) Recent antibiotics Smoking Copper coil

Answer 67

over 45 and FSH

Answer 68

Two years after the last menstrual period in women under 50 One year after the last menstrual period in women over 50

Answer 69

weight gain and reduced bone mineral density (osteoporosis).- only in depot Reduced bone mineral density makes the depot unsuitable for women over 45 years.

Answer 70

50 Consider combined oral contraceptive pills containing norethisterone or levonorgestrel in women over 40, due to the relatively lower risk of venous thromboembolism compared with other options.