FINALS Flashcards
AF and CCB or flecainide
Contraindicated if structural heart disease
Metallic click on auscultation
Metallic valve replacement, should be on warfarin with INR 3-4
Bleeding on dabigatran
Only DOAC with reversal agent, idarucizumab
1st line investigation for AF
ECG- irregularly irregular, absent P waves
Unstable patient with AF
Urgent DC cardioversion
First line for AF presenting within 48 hours without a precipitating cause
Rate control with beta blocker
All patients with AF should be assessed with
CHADsVASc and HASBLED
What is first line treatment for heart failure which improves mortality
Bisoprolol and Ramipril
Symptomatic relief in heart failure and given even when ejection fraction is preserved
Furosemide
Why bumetanide over furosemide
Better oral bioavailability
Why cant you give ACEi and Valsartan (entresto)
Risk of angioedema
1st line investigation in heart failure
BNP
How do you make a heart failure diagnosis
Specialist does based on echo
First line treatment for all heart failure with reduced ejection fraction
Bisoprolol and Ramipril (even if has COPD)
Monitoring for ACE-i and Spironolactone
Renal function checked 2 weeks after starting or changing dose
ACS, cold peripheries and poor urine output
cardiogenic shock
PCI with stents ongoing treatment
DAPT for atleast 12 months
ACS, bradycardia and AV node block
Inferior MI
First line investigation for ACS
ECG and troponin
Initial treatment of ACS
Morphine, Metaclopromide, Oxygen (if sats <94), Nitrates (GTN infusion), Aspirin (300mg)
Risk score for NSTEMI/ Unstable Angina
GRACE
Headache, sweating and palpitations with severe hypertension
Phaeochromocytoma
Pedal oedema resistant to diuretics
CCB side effect
AV nipping on fundoscopy
Hypertensive retinopathy
1st line investigation for hypertension
Ambulatory blood pressure monitoring or Home blood pressure monitoring
Threshold for HTN in normal people in clinic and home
140/90 in clinic, 135/85 at home
Target BP in diabetics
130/80
Target BP in over 80s
150/90
Which HTN patients need same day assessment
Severe (>180/120) or symptomatic
What does increased compliance of lung indicate
Emphysema
FEV1/FVC >0.7
Obstructive lung pathology
T2 respiratory failure with raised bicarbonate
Chronic T2RF, aim for sats 88-92
First line investigation for pneumothorax
Chest XR
What to do if Pneumothorax and underlying lung condition so is secondary pneumothorax
Always admit
How do you treat tension pneumothorax
Wide bore cannula into 2nd intercostal space mid clavicular line
FEV1/FVC more than 0.8 with reduced FVC
Restrictive lung disease
COPD exacerbation, pH <7.3 despite nebulisers
BiPAP
Nausea, refractory hypokalaemia and patient on theophylline
Theophylline toxicity
Cor Pulmonale first line investigation
Clinical diagnosis, echo to confirm
Symptoms of cor pulmonale
Peripheral oedema, raised JVP, loud P2
Big requirement for LTOT
Stop smoking
Pulmonary hypertension criteria
pulmonary artery pressure over 20
Recurrent miscarriages, prolonged APTT and thrombocytopenia
Antiphospholipid syndrome
ECG- ST depression, T wave inversion V1-4, 1,2 and aVF
Right ventricular strain
skin necrosis after warfarin
Protein C deficiency
1st line investigation in PE
CXR
Unprovoked PE and symptoms of possible malignancy
CT TAP
Most common ECG finding in PE
Sinus tachycardia
How long should a cancer patient be on a DOAC after PE
6 months
SCLC, Muscle strength improving on repetitive movement
Lambert eaton
Breast cancer or SCLC with progressive muscle stiffness
Stiff man syndrome, antiamphiphysin
SCLC, cerebellar symptoms and sensory neuropathy
Anti hu
1st line investigation for lung cancer
Chest XR
Consequences of SCLC
SIADH, Cushings, Lambert Eaton Syndrome
Why do Squamous cell cancers get hypercalcaemia
Parathyroid hormone related protein release
Chronic diarrhoea, bloating and scleroderma
Small bowel bacterial overgrowth
Bile acid malabsoprtion
SeHCAT test
Middle aged female, bloating, CA125
Ovarian Cancer
Barley Wheat and Rye
Coeliacs should avoid
1st line investigation for Coeliac
Serum IgA antiTTG and IgA levels
Definitive diagnosis of coeliac
Endoscopy and duodenal biopsy
Which HLA is coeliac
DQ2/8
Ulcerating legion on lower limb and PMH IBD
Pyoderma gangrenosum
Acute red eye, hypopyon, intense photophobia
Acute uveititis
IBD history, assymetrical joint swelling and HLA B27
Enteropathic arthritis
1st line investigation for IBD
Faecal calprotectin
First line investigation for bloody diarrhoea
Colonoscopy
How do you manage acute severe UC flares
In hospital with IV hydrocortisone
How do you treat mild-moderate UC
Topical mesalazine then oral if no response in 4 weeks
What do you have to do before you prescribe infliximab
Interferon gamma test and CXR (exclude TB)
middle aged female with very serious itching and anti mitochondrial antibody positive
Primary biliary cholangitis
pan acinar emphysema, early onset liver disease, PiZZ phenotype
Alpha 1 antitrypsin deficiency
Raised transferrin saturations, tanned, diabetes
Hereditary haemochromatosis
First lines investigation for decompensated liver disease
LFTs, U and Es, albumin, INR
Features of decompensated liver disease
Ascites, encephalopathy and coagulopathy
How to improve mortality in severe ALD
IV steroids
Most common causes of cirrhosis
Alcohol, NAFLD, Hep B and Hep C
AST/ ALT raised on LFT
Hepatitis picture
Bilirubin/ ALP raised on LFT
Cholestatic picture
AST more than double ALT
Alcohol related (shots, shots, shots)
Hep C, purpuric rash, deteriorating renal function
Type 2 cryoglobulinaemia
Needle stick injury from hep B patient and no previous vaccination
Accelerated Hep B vaccination
Raised BMI, raised ALT and AST
Non alcoholic fatty liver disease
1st line investigation for hepatitis
Liver screen including hepatitis A B and C serology
What must be present in the serology for it to be an active hepatitis B (both acute and chronic)
HBsAg
Which hepatitis is most likely to progress to chronic liver disease
Hepatitis C
First line treatment for Hep B
Interferon alpha
First line treatment for Hep C
Direct acting anti virals
Painless palpable gallbladder and jaundice
Pancreatic cancer
Small bowel obstruction after cholecystitis
Gallstone ileus
Beads on a string on ERCP
Primary sclerosing cholangitis
1st line investigation for gallstones
Ultrasound abdomen
What requires an urgent laparoscopic cholecystectomy
Pancreatitis, Cholecystitis, choledocholithiasis
What is the definitive treatment for any gallstone related disease
Laparoscopic Cholecystectomy
No CBD stone but deranged LFTs or bile duct dilatation on ultrasound
MRCP needed to clarify pathology and anatomy
Which operation leads to an ileostomy
Right hemicolectomy
What staging for colon cancer
TNM
Thousands of colonic polyps and autosomal dominant APC gene mutation
FAP
Mutation in the mismatch repair gene (MMR)
HNPCC (lynch syndrome)
Small bowel polyps, melanotic macules in lipds or genitals and STK11 gene mutation
Peutz Jueger Syndrome
1st line investigation for colorectal cancer
Coloscopy
Who gets FIT or FOB testing
Everyone 60-74
How is colorectal cancer diagnosis made
Colonoscopy
Closed loop obstruction
High risk of bowel ischaemia
Right iliac fossa pain after appendectomy
Meckels diverticulum
Unexplained acute LBO
Ogilvies syndrome
1st line investigation for acute abdomen (no indications for CAT 1 lap i.e. unstable patient)
CT abdomen and pelvis
How will SBO present
Colicky abdominal pain, vomiting and absolute constipation
What to do with patients in refractory shock i.e. shock even after fluids w/ acute abdomen
category 1 emergency laparotomy
What is the most common cause of SBO and how do you treat if no ischaemia or necrosis
Adhesions and conservative, IVI and NG tube
Screening for AAA
Every man over 65 gets a one off ultrasound
IVC collapse or halo sign on CT
Hypovolaemic shock
Anurysmal sac enlarging after AAA repair
Endoleak
Chest pain and connective tissue disorder like marfans
Aortic dissection
1st line investigation for stable AAA patient with suspicion of rupture
CT angiography
AAA screening
One off ultrasound to every male at 65
Which AAA require intervention
> 5.5cm or symptomatic
Microcytic anaemia and disproportionately low MCV
Thalassaemia
Normocytic anaemia and reduced renal function
CKD related anaemia
Macrocytic anaemia and mixed upper/lower neuro signs
B12 deficiency causing subactue degeneration of the cord
First line investigation if IDA and over 60
2WW colonoscopy
Dyspepsia and IDA investigation
2WW UGI-endoscopy
Asthma, eosinophila and pANCA
Churgg Strauss Syndrome
Obesity, Type 2 respiratory failure and obstructive sleep apnoea
Obesity hypoventilation syndrome
Asthmatic and pCO2 of 6.5
Near fatal asthma attack
Asthma diagnostic investigation
Clinical diagnosis, can use spirometry to confirm
Initial management of asthma
SABA (and ICS if symptoms)
How long before you know if LTRA isnt helping
8 weeks
Define life threatening asthma
PaCO2 above 6
Ankle swelling, erythema, loss of foot sensation and T2DM
Charcot arthopathy
Metformin and CKD
Stop metformin in eGFR under 30
Insulin and driving
DVLA must be informed and patient must record blood sugar every 2 hours
1st line investigation for diabetes
HbA1c or fasting blood sugar
When to intensify diabetes medication regime
HbA1c remains over 58
When to consider insulin in T2DM
When 3 oral medications are still not helping
How to treat hyperosmolar hyperglycaemic state
IV fluids and sometimes FRII
thunderclap occipital headache and reduced GCS
Subarachnoid haemorrhage
Temporal headache, jaw claudication, raised ESR
Giant cell arteritis
LP in last 24 hours, headache worst when upright
Low pressure headache
1st line investigation for migraine
Clinical diagnosis. Neuroimaging if red flags
1st line treatment for migraine
Sumatriptan and Ibuprofen
First line prophylaxis for migraine
Propanolol
Topiramate CI
Pregnancy. Make sure on reliable contraception
Multiple flat light brown plaques, waxy surface along the scalp or back
Sebhorreic keratosis
Multiple scaly thick plaques on sun exposed areas
Acitinic/ solar keratosis
A hard raised grown with an ulcerated centre that began as a boil
Keratoacanthoma
1st line investigation for skin cancer
Excision biopsy and breslow thickness
What to do with melanoma lesions
Excise and send for histology to guide staging
What stage is a melanoma with nodal involvement
3
What stage is a melanoma with metastases
4
How to treat basal or squamous cell carcinomas
Excision or topical chemotherapy
Visual hallucinations and macular degeneration
Charles Bonnet Syndrome
Parkinsonism, visual hallucinations and memory impairment
Lewy body dementia
Deranged LFTs, asterixis and confusion
Hepatic encephalopathy
Delirium first investigation
Clinical diagnosis but look for cuases
What to do if patient lacks capacity
Treat them in their best interests under the mental capacity act
Bisphosphonate use, jaw pain and swelling
Osteonecrosis of jaw
Fall onto outstretched hand and dinner fork deformity
Colles Fracture
Normal serum calcium and phosphate with elevated alk phos
Pagets disease of the bone
1st line investigation for osteoporosis
DEXA scan
Who gets osteoporosis commonly
Long term steroids and post menopausal
How do you calculate risk of osteoporosis
FRAX
What supplements might you need if have osteoporosis
Calcium and vitamin D
Involuntary upward eye movements
Oculogyric crisis
Alternating deep then shallow breathing with recurrent apnoea
Cheyne Stokes breathing
Prolonged QT interval and twisting of QRS complexes
Torsades de Pointes
First line investigation for end of life
Clinical assessment but need to rule out reversible causes
What needs to be considered in palliative care
Psychological, social and spiritual factors
What to do if frequently using as needed medications
Replace with syringe driver
Dendritic pattern on fluorescin stained cornea
Herpes simplex virus
Young female, very high BMI, on the pill with headaches
Check for papilloedema, idiopathic intracranial HTN (therapeutic LP)
White fluid level visible in the anterior chamber of the eye
Hypopyon
First line investigation for diabetic retinopathy
Fundoscopy
When does diabetic retinopathy become symptomatic
When it becomes proliferative
What is treatment of diabetic retinopathy
Radical control of Diabetes, Blood Pressure and Lipids
Is diabetic retinopathy reversible
No
Pigment in the anterior vitreous on fundoscopy
Schaffer sign of retinal detachment
Pale retina without cherry red spot on fundoscopy
Ophthalmic artery occlusion
Pale retina with cherry red spot on fundoscopy
Central retinal artery occlusion
Visual blurring made worse with heat
Optic neuritis (Uhthoffs Phenomenon)
Acute, painless loss of vision unilaterally
Vascular in origin
Bilateral acute visual field loss
TIA/Stroke/Optic chiasm i.e. not optic
Amaurosis Fugax
Associated with carotid artery stenosis and predicts future stroke
Chinese, facial pain, double vision and lymphadenopathy
Nasopharyngeal carcinoma
Young child with recurrent epistaxis and purpuric lesions on fingertips and tongue
Hereditary haemorrhagic telangiectasia
Evolving sunburn like erythema and confusion 48 hours after nasal packing
Toxic shock syndrome
Nose bleed first line investigation
Nasal speculum examination
Where do most nosebleeds come from
Anterior= first aid, then silver nitrate cautery then rapid rhino unilateral anterior packing
What to do if posterior bleed (profuse, bilateral, cant see bleeding point)
Posterior packing and antibiotics
Diabetic with persistent otalgia despite antibiotics
Malignant otitis externa
Progressive hearing loss and aural fullness with a persistent foul smell
Cholesteatoma
Vertigo, tinnitus, aural fullness, facial weakness +- neurofibromatomosis type 2
acoustic neuroma
First line investigation for vertigo
Thorough history and examination
First line investigation for menieres disease
Audiometry
Which direction is the dizziness in tru vertigo
Rotational
What is peripheral vertigo (ears)
Reproducible, fatiguable, horizontal nystagmus and no neuro signs
What is central vertigo (brain)
Doesn’t fatigue and cant be reproduced, multidirectional nystagmus, other neuro signs
Drooling, stridor and tripod sitting in a toxic looking child
Epiglottitis
Bilateral cervical lymphadenopathy, fever, myalgia and testicular swelling
Mumps
Acrid/bitter teast in mouth while eating, pain in parotid/ submandibular region
Salivary duct stones
First line investigation in tonsilitis
Oropharyngeal examination
FeverPAIN
Fever Pus on tonsils Attended in 3 days severely Inflamed tonsils No cough or coryza
FeverPAIN 2-3=
back up prescription(Phenoxymethylpenicillin) , self care advice
FeverPAIN 4+=
Phenoxymethylpenicillin
FeverPAIN 0-1=
Self care advice
Acute retention, acute glaucoma and tachycardia
Anticholinergic effects
LUTS with nocturnal enuresis
high pressure chronic urinary retention
Prolonged large urine production after catheter
Post obstructive diuresis
Acute retention first line investigation
Bladder scan if in doubt
Chronic retention first line investigation
Ultrasound KUB
Urgent first line treatment in acute retention
Catheterise first ask questions later !
What does failed TWOC suggest in acute retention
Chronic urinary retention
How to diagnose most causes of acute retention
Drug chart review, urine dip and bloods
Post URTI with flank pain
IgA nephropathy
Dry cough, dry/red eyes, sinusitis, joint pain and nephritis syndrome
Granulomatosis with polyangitis
Pulmonary haemorrhage, rapidly progressive GN and anti GBM antibodies
Goodpastures syndrome
1st line investigation in glomerulonephritis
Urine dip for protein and blood
3 signs of nephritis syndrome
Oedema, hypertension and haematuria
3 signs of nephrotic syndrome
Oedema, hypoalbuminaemia and proteinuria
Whats the main treatments for GN
Steroids and immunosuppressants
Painless testicular lump in male over 60
Benign seminoma
Painless testicular lump in a young male with positive bHCG
Non seminoma
Prolonged (longer than 1 day) pain and swollen testicle
Epididymoorchitis
What two things cause epididymoorchitis
STI and E Coli
1st line investigation for severe testicular pain
Surgery if torsion suspected !
What surgery is done for torsion
Bilateral orchidopexy
What is the ischaemic time for a testicle
4-8hours
Young patient treated for DKA with reduced GCS, severe acidosis and relative bradycardia
Cerebral oedema
Metformin use, impaired kidney and acidosis
Metformin induced lactic acidosis
Elderly patient, T2DM, hyperglycaemia and hypernatraemia
Hyperosmolar hyperglycaemic state
First line investigation for DKA
Venous blood gas and serum ketones
First line treatment in DKA
0.9% sodium chloride fluid bolus
How to avoid complications in DKA
Monitor glucose and potassium
When does a DKA require critical care input
If not resolved in 24hours
Sudden decline in GCS after correcting hyponatraemia
Osmotic demyelination syndrome
Polydipsia, normal glucose and high end of normal sodium
Diabetes insipidus
Large hands and jaw and bilateral hemianopia
Pituitary tumour with acromegaly
First line investigation for hyponatraemia
Paired osmolalities (serum and urinary)
First line treatment if hyponatraemic with symptoms
3% hypertonic saline in higher level care
If hyponatraemic but no symptoms or chronic then
Assess fluid status and do urinary sodium
How do you treat SIADH
Fluid restrict and look for cause
Whats diagnostic for SIADH
High urinary sodium in euvolaemic patient
Young female with resistant hypertension and hypokalaemia
Conns syndrome
Headache, sweating, tachycardia and hypertension
Phaeochromocytoma
Unduppressed cortisol levels following high dose dexamethasone suppression test
Cushings disease (pituitary adenoma). High dose= high up cause i.e. in brain i.e. pituitary adenoma
First line investigation for cushings syndrome
Urinary cortisol collection, low dose dexamethasone suppression test or salivary cortisol collection
What can happen if you suddenly stop long term steroids
Addisonian crisis
Hoarse voice post thyroidectomy
Recurrent laryngeal nerve injury
Low calcium, high phosphate, high PTH, short fingers
Pseudohypoparathyroidism
Facial twitching after tapping anterior to tragus
Chvosteks sign, hypocalcaemia
First line investigation in hypercalcaemia
Bone profile and parathyroid hormone
Normal treatment for primary hyperparathyroidism
Parathyroidectomy
Normal treatment for secondary hyperparathyroidism
Treat CKD and give phosphate binders for high phosphate
Normal treatment for tertiary hyperparathyroidism
Self limiting. Normally post kidney transplant when body readjusting.
primary parathyroid adenomas are associated with which gene
MEN
Philadelphia chromosome
Chronic Myeloid Leukaemia
Auer Rods
Acute Myeloid Leukaemia
DIC and t(15;17)
Acute promyelocytic leukaemia
1st line investigation in leukaemia
Peripheral Blood film
2nd line investigation in leukaemia
Bone marrow biopsy
First line treatment for CML
Imantinib
Treatment of CML when imantinib fails
stem cell transplant
Menorrhagia and prolonged bleeding time
Von Willebrands disease
Low platelets and low fibrinogen
DIC
Raised INR, low platelets and deranged LFTs
Liver cirrhosis
1st line investigation for haemophillia
Factor 8 and 9 assay levels
How do you treat life threatening bleeding in haemophilia A
Factor 8 concentrate
What is the most common presentation of haemophillia A
Bleeding into joints
Whats the difference between haemophillia and von willebrands
Von Willebrands has a prolonged bleeding time
Red scaly lesions on finger joints
Gottrons papules (dermatomyositis)
Episodes of white cold digits
Raynauds phenomenon
Telescopic digits
Arthitis mutilans
1st line investigation for polyarthritis
Bloods: RF, AntiCCP, ESR/CRP and XR affected joints
How do you treat acute flares of inflammatory arthritis
Bridging steroids and DMARDs
Urethritis, conjuncitivitis, arthritis
Reactive arthritis
Assymetric polyarthralgia, tenosynovitis and skin lesions
Gonococcal arthritis
HLA B27 POSITIVE
Seronegative spondyloarthropatheis
First line investigation of a hot swollen joint
Needle aspiration
First line investigation of a hot swollen joint
Needle aspiration
Hot swollen joint
Assume septic until proven otherwise
Should you give antibiotics straight away in septic arthritis
Aspirate first !!
Lateral tibial plateaux fracture
ACL rupture
Strong lateral blow to the knee
ACL, MCL and medial meniscus tears
Anterior drawer test for the ankle
Tests talofibular ligament
Light bulb sign on shoulder XRay
Posterior dislocation of the shoulder
Pain on palpation of the anatomical snuff box
Scaphoid fracture (AVN risk)
Paradoxical breathing after trauma to the chest
Flail segment
First line investigation for ankle fracture
AP, lateral and oblique XR of the ankle
What is the ottawa rule
A number of rules where you cant rule out ankle fracture if its yes to any
Ottawa rules
- Inability to weight bear immediately after injury and in A and E
- Pain on palpation of lateral malleolus
- Pain on palpation of medial malleolus
What happens if its yes to an ottawa rule
Lateral and AP XRs
What happens if a fracture is unstable
More likely to need surgery
If it is a closed fracture dislocation what should be done
Closed reduction in A and E
Heavy smoker and recurrent digit ischaemia
Thromboangitis obliterans
Haemoptysis, haematuria and antiGMI
Goodpastures syndrome
New agitation and hallucinations on prednisolone
Steroid induced psychosis
Fever >5 days, conjunctivitis and strawberry tongue
Kawasakis disease
Transmural inflammation and beads on a string angiography
Polyarteritis nodosa
Recurrent mouth and genital ulcers not due to infection
Behcet syndrome
First line investigation for vasculitis
Rheumatological antibody screen
Vasculitis plus renal, lung or skin involvement then what is needed for diagnosis
Biopsy
First line treatment for all small vessel vasculitis
Cyclophosphamide and corticosteroids
Ongoing treatment for small vessel vasculitis
Low dose steroid and Methotrexate or mycophenolate or azathioprine
LP= oligoclonal bands and high protein
Multiple sclerosis
Campylobacter, ascending polyneuropathy and antiGM1
Guillain Barre syndrome
Spinal cord lesion, normal MRI and anti-aquaporin4 positive
Nueromyelitis optica
First line investigation for MS
MRI head and spine
What is required for MS diagnosis
MRI/ clinical findings disseminated in both time and space
First line treatment for spasticity in MS
Baclofen or gapapentin
MS acute exacerbation medication
methylprednisolone
DMARD for MS
Interferon beta
Coarse tremor, confusion, hallucinations with history of alcohol excess
Delerium tremens = chlordiazepoxide
Alcoholic excess, metabolic acidosis and ketosis
Alcoholic ketoacidosis
Disulfiram
Promotes alcohol abstinence, inhibits acetaldehyde dehydrogenase
1st line investigation for wernickes encephalopathy
clinical diagnosis
What is wernickes encephalopathy
thiamine deficiency causes acute neurological symptoms: nystagmus, ataxia, confusion
What is korsakoffs
Chronic memory problem (retrograde and antegrade amnesia with confabulation) caused by thiamine defiency
What should you be aware of in wernickes encephalopathy
Hypoglycaemia
Cape like distribution of pain/ temperature loss
Syringomelia
Sensory level L1-2, up going plantars, absent knee reflexes
Conus medullaris lesion
VDLR positive, loss of vibration/proprioception
Tabes dorsalis (tertiary syphilis)
First line investigation for traumatic spine injury
CT spine
First line investigation for non traumatic spine injury
MRI spine
If spinal cord injury is secondary to trauma what should you do first
spinal immobilisation
RF for anterior spinal artery syndrome
Atherosclerosis, aortic aneurysm and dissection
Where should spinal cord injuries be managed
Tertiary neurosurgical centres
Hypertension, bradycardia and kussmaul breathing
Cushings triad of raised ICP
Fall in elderly patient on warfarin
Possible subdural, consider prothrombin complex if INR raised
High suspicion of SAH but normal CT
Lumbar puncture at 12 hours for Xanthochromia
First line investigation for intra cranial haemorrhage
CT Head
3 categories of traumatic subdural haematoma
Acute (1-2days, hyperdense)
Subacute (3-14 days, isodense)
Chronic (15 days, hypodense)
What to do if signs of raised ICP
Urgent referral to specialist neurosurgical centre
What to do in stroke prior to treatment
CT Head because might be secondary to haemorrhage
Type 1 hypersensitivity reaction
IgE mediated mast cell degranulation and histamine release (anaphylaxis)
Anaphylaxis to penicillin
3rd gen cephalosporins in 3%
Fever, rash, lymphadenopathy, deranged LFTs and eosinophilia
Drug reaction with eosinophilia and systemic symptoms
1st line investigation to confirm anaphylaxis
Mast cell tryptase
Initial treatment in anaphylaxis
0.5mg (0.5ml) 1:1000 Adrenaline
What should you try and do early on when treating anaphylaxis
Remove the source
How long should you monitor for after an anaphylactic reaction
6 hours in case theres a biphasic reaction
Treatment to a contact of a patient with meningococcal meningitis
Ciprofloxacin 500mg STAT
Ceftriaxone in preg
Gram negative diplococci on CSF gram stain
Neisseria meningitides
Encapsulated yeast on india ink staining of CSF
Cryptococcal meningitides (as seen in HIV)
First line investigation for meningitis
Lumbar puncture
First line investigation for sepsis
Lactate, cultures and urine output
How quickly do you have to do sepsis 6
Everything including Abx administration within 1hr
What to do if septic patient not responding to initial treatment
Consider ICU
Which antibiotic in neutropenic sepsis
Piperacillin Tazobactam
Flushed, dry, tachycardia and dilated pupils
Anticholinergic syndrome
Reduced GCS, pupillary changes and cardiorespiratory depression
Sedative syndrome- opioids, benzos, baclofen, barbituates
Confusion, autonomic instability and neuromuscular hyperactivity
Serotonin syndrome
First line investigation for overdose
Blood gas and ECG
First line treatment for TCA overdose
Sodium bicarbonate 8.4% and supportive measures
How to treat paracetamol overdose
N acetylcysteine according to nonogram
What do you have to be careful of when giving naloxone
Opioids have a longer half life than naloxone so might have to give as infusion
Facial nerve palsy following head injury
Basal skull fracture
What is mannitol
Hypertonic saline used to lower ICP
Unilateral ptosis and down and out eye and fixed dilated pupol
Surgical/ Traumatic 3rd nerve palsy
Inability to abduct eye after head injury
6th nerve palsy in raised ICP
1st line investigation in head injury
CT head
What to do if reduced GCS more than 2 hours since head injury
CT head within the hour
Where should you also assess if someone is coming in with a head injury
Cervical spine
Head injury + GCS 15 + no concerning clinical or imaging features
Discharged without supervision
When does an alcohol withdrawal seizure last
12-48 hours after last drink
Focal weakness after seizures
Todds Paralysis
Acute paralysis and dysarthria following treatment for hyponatraemia
Osmotic demyelination syndrome
Status epilepticus first line investigation
Clinical diagnosis (Elevated lactate, prolactin and creatine kinase can help distinguish true seizures)
What is a common and reversible cause of seizure
Hypoglycaemia
First line treatment for status epilepticus
IV lorazepam, Buccal Midazolam or Rectal Diazepam and repeat if needed
How long can you not drive for with a seizure of any type
6 months
Flexed internally rotated and ADducted hip
Posterior hip dislocation
Hypoxia, neurological signs and petechial rash after long bone fracture
Fat embolus syndrome
Pain out of proportion to the trauma
Compartment syndrome
First line investigation for hip fracture
AP pelvis XR and lateral XR of affected hip
Preoperative preparation for hip fracture surgery
Analgesia, fluid restriction, stop blood thinning medication, early surgery
How to treat intracapsular displaced fractures
Femoral head replacement, consider prior mobility
Postoperative preparation for hip fracture surgery
Thromboprophylaxis, early mobilisation
Hyperkalaemia ECG
Absent P waves, tall T waves, broad QRS
Sharp chest pain relieved by leaning forwards, saddle shaped ST segments
Pericarditis
Polyarthropathy, fractures and calcific skin lesions with CKD
Osteodystrophy
First line investigation for acute renal failure
U and Es
What determines the severity of AKI
Rise in basline creatinine
What are indications for renal replacement therapy in AKI
Refractory to treatment and
Hyperkalaemic, acidotic, encephalopathic or fluid overloaded
Post operative hypotension
Common side effect of epidural and spinal anaethesia
Pain associated with renal colic
Responds well to PR diclofenac
Trigeminal neuralgia first line medication
Carbamazepine
Diabetic painful neuropathy first line medication
Duloxetine
Why might you use several analgesics at once
Reduces total dose of each so less chance of side effects
When to avoid NSAIDs
Elderly, pregnancy, asthmatics and renal impairment
How to treat neuropathic pain
Non opioid analgesics
Which diabetes medication causes weight gain and fluid retention
Pioglitazone
Which diabetes medications cause weight gain and hypoglycaemic events
Sulphonylureas and IV insulin
How to manage insulin when diabetic patient started on NG feeding or TPN
Variable rate insulin infusion
What drugs to give after surgical resection of phaeochromocytoma
Alpha blockage then beta blockade
First line investigation for diabetes
Capillary blood glucose and HbA1c
How should you plan diabetics elective surgery
Delay until glucose control optimised (<69)
What should you do with basal insulin during surgery
Continue it all the way through at a low dose
How do you take someone off VRII
continue it 30 mins after first SC insulin
Acute worsening of infection after starting ART in HIV patient
IRIS- immune reconstitution inflammatory syndrome
Reduced visual acuity and perivascular infiltrates in HIV patient
CMV retinitis
Odonophagia and white mucosal plaques at endoscopy in HIV patient
Oesophageal candidiasis
HIV patient and desaturation on exertion
Pneumocystis jirovecii pneumonia
HIV patient and brain MRI demonstrating ring enhancing lesions
Toxoplasmosis encephalitis
HIV patient and violet plaques and human herpes virus 8
Kaposis sarcoma
First line investigation for HIV
Combined HIV antibodies and p24 antigen
What to do if positive HIV test
Repeat to confirm
What to do if negative HIV test
Repeat in 12 weeks
How to limit spread of HIV
Appropriate use of condoms, safe needle use and post exposure prophylaxis
Gential ulcer, acute fever, headache and myalgia just after starting treatment for syphilis
Jarisch Herxheimer reaction
Genital ulcer, painful unilateral inguinal lymphadenopathy and proctocolitis
Lymphogranuloma Venereum
Painful ulcer and lymphadenopathy
Chancroid
What should you always test for in a patient with STI
HIV
CSF with low glucose, high protein and lymphocytes
TB meningitis
Orange stained body fluids
Rifampicin therapy
Red green colour vision disturbance
Ethambutol induced optic neuritis
First line investigation for active TB
CXR and sputum
First line investigation for latent TB
Mantoux test or interferon gamma assay
How long treatment does active TB need
6-12 months
How long treatment does latent TB need
3-6 months
What should you test for if a patient has latent TB
HIV
Polyarthralgia, conjuncitivits and mouth ulcers
Reactive arthritis
Chronic abdominal pain, altered bowel habit with no identifiable cause
Post infectious IBS
Campylobacter, ascending bilateral limb weakness and loss of reflexes
Guillain Barre Syndrome
First line investigation for infectious diarrhoea
Stool sample
Whats the treatment for travellers diarrhoea
Supportive measures
General malaise, relative bradycardia and rose spots
Salmonella typhi
Fever, headache, retro orbital pain, myalgia and rash
Dengue
Bulls eye rash
Lyme disease
Fist line treatment for malaria
Prompt Artemisinin combination therapy
Why do travellers get more severe malaria
Low immunity
Things to consider in returning traveller
Could be something normal or malaria, influenza, hepatiis, HIV
Rheumatoid factor
Rheumatoid arthritis
Sjogrens
Anti cyclic citrullinated peptide
Rheumatoid arthritis
ANA positive
SLE SS Sjogrens Poly/Dermato-myositis AI Hepatitis
Anti dsDNA and Anti Smith
SLE
Anti centromere
Limited systemic sclerosis
Anti mitochondrial
Primary biliary cirrhosis
Anti-Scl-70 (anti topoisomerase)
Diffuse systemic sclerosis
Anti Ro and Anti La
Sjogrens
Anti Jo (synthetase) and AntiMi2
Poly/Dermatomyositis
Anti histone
Drug induced lupus
ANCA
Vasculitis
