Finals - Medicine + Surgery Flashcards
What is used to manage acute flares of RA when on maintenance DMARD treatment?
oral steroids or IM steroids such as methylpred or tramcinolone
What is the initial management of RA?
conventional DMARD monotherapy (usually methotrexate), often with short-term bridging corticosteroid. Methotrexate is given weekly.
What may TNF-alpha inhibitors reactivate? What should be checked first?
TB, CXR should be checked first for presence of Ghon focus (Latent TB)
Electrolyte abnormalities seen with thiazide like diuretics
hypercalcaemia, as well as hyponatraemia, hypokalaemia and hypomagnesaemia.
1st line treatment for trigeminal neuralgia
carbamazepine is the first-line treatment for trigeminal neuralgia. The starting dose is typically 100mg twice daily, gradually titrated up to an effective dose or maximum tolerated dose
Other anticonvulsants such as oxcarbazepine or lamotrigine may be used as second-line treatments.
What monitoring is required in HSP? Why?
lood pressure and urinanalysis should be monitored to detect progressive renal involvement
What is HSP a type of?
IgA vasculitis
Preceding influenza predisposes to what type of pneumonia
Staph Aureus
1st line treatment for chronic plaque psoriasis
Topical potent corticosteroid + vitamin D analogue
Calcipotriol can be increased to twice daily before referral to secondary care
1st line treatment for scalp psoriasis
topical potent corticosteroids
Postpartum contraception
POP is the only method of contraception that can be initiated at any time postpartum.
Although this patient is not breastfeeding, the COCP should not be initiated in the first 21 days after delivery due to the increased venous thromboembolism risk.
The IUD and the IUS can only be inserted within 48 hours of childbirth or after 4 weeks.
How long after pregnancy can a woman get pregnant?
21 days
Benzo OD medication
Flumazenil - GABA antagonist
Difference between histamine drugs
Histamine-1 Antihistamines (e.g. loratadine)
Histamine-2 Antacids (e.g. ranitidine)
1st line treatment for allergic bronchopulmonary aspergillosis
Pred
Definitive management of vestibular neuronitis
Vestibular rehabilitation
Is hearing affected in vestibular neuronitis?
No
How to differ between BPPV and vestibular neuritis in terms of spinnign?
In BPPV, spinning is triggered by head movement. In vestibular neuronitis, spinning is worsened by head movements.
Acute management of vestibular neuritis
Prochlorperazine is recommended to alleviate vertigo, nausea and vomiting associated with vestibular neuronitis - used acutely, not definitive
How do viral layrinthitis and vestibular neuritis differ in terms of presentation?
The presentation of viral labyrinthitis is similar to that of vestibular neuronitis; however, hearing loss and tinnitus are more likely to be present in viral labyrinthitis. In vestibular neuronitis only the vestibular nerve is involved; thus hearing is spared.
Formula for alcohol units
Alcohol units = volume (ml) * ABV / 1,000
When should a beta blocker be stopped in acute HF?
if the patient has heart rate < 50/min, second or third degree AV block, or shock
Treatment for acute pulmonary oedema
IV loop diuretic e.g. furosemide
Acute HF not responding to treatment…
CPAP
When may nitrates be useful in patients with acute HF?
nitrates may be useful if the patient has concomitant myocardial ischaemia or severe hypertension
When does infantile colic typically resovle by?
normally improves around 3-4 months of age and resolves around 6 months of age
Treatment for vaginal vault prolapse
sacrocolpoplexy
Treatment for cystocele
anterior colporrhaphyu
Treatment for rectocele
Posterior colporrhaphy
Investigations for acromegaly
1st line - serum IGF-1
In the investigation of acromegaly, if a patient is shown to have raised IGF-1 levels, an oral glucose tolerance test (OGTT) with serial GH measurements is suggested to confirm the diagnosis
What may be expected following a start of an ACEi? What are acceptable changes? When to consider swapping to an alternative hypertensive?
a rise in the creatinine and potassium may be expected after starting ACE inhibitors
acceptable changes are an increase in serum creatinine, up to 30% from baseline and an increase in potassium up to 5.5 mmol/l.
A potassium above 6mmol/L should prompt cessation of ACE inhibitors in a patient with CKD (once other agents that promote hyperkalemia have been stopped)
What is amaurosis fugax? Which artery does it affect? What does this arise from?
Amaurosis fugax is a form of stroke that affects the retinal/ophthalmic artery, arises from internal carotid ipsilaterally
What does an anterior cerebral artery stroke cause?
leg weakness but not face weakness or speech impairment
What does a posterior cerebral artery stroke cause?
Contralateral homonymous hemianopia with macular sparing and visual agnosia
What does an MCA stroke cause>
Contralateral hemiparesis and sensory loss with the upper extremity being more affected than the lower, contralateral homonymous hemianopia and aphasia
What does a basilar artery stroke cause?
Locked in syndrome
What is weber’s syndrome?
form of midbrain stroke characterised by the an ipsilateral CN III palsy and contralateral hemiparesis
(branches of the posterior cerebral artery that supply the midbrain)
What does an anterior inferior cerebellar artery stroke cause?
Ipsilateral: facial paralysis and deafness
Contralateral: limb/torso pain and temperature loss
Ataxia, nystagmus
AKA Lateral Pontine Syndrome
What does a pontine haemorrhage present with?
reduced GCS, paralysis and bilateral pin point pupils
most common cause of amaurosis fugax
Atherosclerosis of the internal carotid
How does wallenberg syndrome (posterior inferior cerebellar artery) present?
Ipsilateral: facial pain and temperature loss
Contralateral: limb/torso pain and temperature loss
Ataxia, nystagmus
how to differentiate between PICA and AICA stroke
Posterior inferior cerebellar artery (lateral medullary syndrome, Wallenberg syndrome) Ipsilateral: facial pain and temperature loss
Contralateral: limb/torso pain and temperature loss
Ataxia, nystagmus
Anterior inferior cerebellar artery (lateral pontine syndrome) Symptoms are similar to Wallenberg’s (see above), but:
Ipsilateral: facial paralysis and deafness
Risk of phototherapy as a treatment for psoriasis
SCC
Power equation
Power = 1 - the probability of a type II error
Can be increased by increasing the sample size
What tests are used to assess statistical correlation?
Correlation
parametric (normally distributed): Pearson’s coefficient
non-parametric: Spearman’s coefficient
Types of parametric tests
Student’s t-test - paired or unpaired*
Pearson’s product-moment coefficient - correlation
*paired data refers to data obtained from a single group of patients, e.g. Measurement before and after an intervention. Unpaired data comes from two different groups of patients, e.g. Comparing response to different interventions in two groups
Types of non-parametric tests
Mann-Whitney U test
compares ordinal, interval, or ratio scales of unpaired data
Wilcoxon signed-rank test
compares two sets of observations on a single sample, e.g. a ‘before’ and ‘after’ test on the same population following an intervention
chi-squared test
used to compare proportions or percentages e.g. compares the percentage of patients who improved following two different interventions
Spearman, Kendall rank - correlation
How are accoustic neuromas best visualsied?
MRI of the cerebellopontine angle
Gold standard for diagnosing contact dermatitis
Skin patch testG
Gold standard for diagnosing immediate hypersensitivity reactions
Skin prick testing
Who can be considered for a non-urgent referral with in women witha breast lump?
A woman < 30 years of age presenting with an unexplained breast lump with or without pain does not meet 2WW criteria but can be considered for a non-urgent referral
INAPPROPRIATE TO DIAGNOSE FIBROADENOMA ON CLINICAL EXAM ALONE
What is mondor’s disease of the breast?
localised thrombophlebitis of a breast vein.
What type of breast inflam is common in smokers? How is it treated?
Periductal mastitis is common in smokers and may present with recurrent infections. Treatment is with co-amoxiclav.
Types of mastitis
Non-lactational - periductal - common in smokers and treated with co-amox
Lactational - common postpartum and treated with fluclox
STEMI management if patient is having PCI (within 120 minutes of episode occuring)
Patients undergoing a PCI are given dual antiplatelet therapy prior to the PCI itself which involves aspirin and prasugrel (if the patient does not take an oral anticoagulant) or clopidogrel (if they do take an oral anticoagulant).
Preferred stent type for primary PCI
Drug eluting stents
What type of arterial access preferred for primary PCI?
Radial
If PCI cannot be delivered within 120 minutes of STEMI, what should be offered? What does this consist of?
Fibrinolysis
Need to give an antithrombin - fondaparinux
Ticagrelor is given following procedure
What ABG findings present with cushing’s syndrome
hypokalaemic metabolic alkalosis
loss of left heart border on CXR
left lingula consolidation
What can LMWH cause on electrolytes? Why?
Hyperkalaemia
Can suppress aldosterone
Triad for cardiac tamponade
muffled heart sounds, paradoxical pulse and jugular vein distension.
Following referral to ENT, patients with sudden onset sensorineural hearing loss are treated with what?
High dose oral corticosteroids
What do ground glass hepatocytes on light microscopy point towards in hepatitsis B?
Chronic infection
When should an MSU be sent for women with a suspected UTI?
If ASx with visible or non-visible haematuria
What drug class may be useful in patients with an overactive bladder (both voiding and storage symptoms)
antimuscarinic drugs - tolterodine
What can beta blockers exacerbate?
plaque psoriasis
What type of antihypertensive is asx with tiredness?
Beta blocker
Migraine management
acute: triptan + NSAID or triptan + paracetamol
prophylaxis: topiramate or propranolol
Transfusion threshold for patients with ACS
The transfusion threshold for patients with ACS is 80 g/L
What type of renal mass is seen in tuberous sclerosis?
angiomyolipoma - typically seen bilaterally - it is benign
What is seen in acute interstital nephritis?
an ‘allergic’ type picture consisting usually of raised urinary WCC and eosinophils, alongside impaired renal function
What is sampling bias?
When subjects are not representative of the population
What is drusen pathognomonic for?
Drusen = Dry macular degeneration - Presence of drusen on fundoscopy (referred to as ‘amber material under the retinal pigment epithelium in both eyes’)
What is a useful test in those with macular degeneration? Why?
Amsler grid testing (to check for distortion of line perception) may be useful in testing patients with suspected age related macular degeneration
What is wet macular degeneration characterised by?
Choroidal neovascularisation
What is a risk factor for macular degeneration
Smoking
How do macular degeneration and open-angle glaucoma differ in terms of vision loss?
Macular degeneration is associated with central field loss
Primary open-angle glaucoma is associated with peripheral field loss
What should decreasing vision over months with metamorphopsia (distorted vision) and central scotoma (dark spot) should cause high suspicion of?
wet age-related macular degeneration
Definitive treatment of wet AMD
anti-VEGF (Bevacizumab)
Medical treatment of dry AMD
There is no curative medical treatment for dry AMD. High dose of beta-carotene, vitamins C and E, and zinc can be given to slow deterioration of visual loss
What should patients with long saphenous vein superficial thrombophlebitis have?
an US scan to exclude DVT
Recommended management for supergicial thrombophlebitis
Compression stockings
1st line treatment for acute gout
NSAIDS
Colchicine should be used to treat acute gout if NSAIDs are contraindicated for example a peptic ulcer.
Should allopurinol be continued during an acute attack of gout?
only in pattients presenting with an acute flare of gout who are already established on treatment
What should be prescribing adjunct to allopurinol initiation?
NSAID or colchicine ‘cover’
Who should allopurinol be offered to?
All patients after their first attack of gout
Mackler triad for boerhaave syndromw
vomiting, thoracic pain, subcutaneous emphysema.
Inferior MI and AR murmur should raise suspicion of?
ascending (proximal) aorta dissection
What type of organism can cause immune mediated neurological diseases following a LRTI?
Mycoplasma
Is weight bearing reccomended following hip fracture?
Yes, immediately
How does the leg present following hip fracture? How does this differ in dislocation?
Shortened and externally rotated
Dislocation is internally rotated
General rule for management of intracapasular fractures
Intracapsular femoral fracture - hemiarthroplasty
extracapsular femoral fracture - dynamic hip screw
Patients with a GRACE score of >3% should undergo coronary angiography when?
within 72 hoyurs of admission
fundoscopy findings of anterior ischaemic optic neuropathy
swollen pale disc and blurred margins
What is polymyalgia rheumatica associated with?
GCA - can lead to anterior ischaemic optic neuropathy if left untreated
What can local anaethetic toxicity be treated with?
IV 20% lipid emulsion
Formula for number needed to treat
NNT = 1 / Absolute Risk Reduction
how can loop diuretics affect hearing?
May cause ototoxicity
When should FIT testing be offered?
FIT testing should be offered first-line to help exclude colorectal cancer for patients aged ≥ 50 years with any of the following:
rectal bleeding
abdominal pain
weight loss
What can occur following an inferior MI?
AV block
what is the most likely diagnosis in an uncircumcised man, who has developed a tight white ring around the tip of the foreskin and phimosis
lichen sclerosis
What type of referral should be made if querying parkinson’s disease?
Urgent referral to neurology
How may bell’s palsy affect the tongue?
With a Bell’s palsy loss of taste of the anterior two-thirds of the tongue (on the same side as the facial weakness) may occur
When should referral to ENT be made in bells palsy?
For a patient with a Bell’s palsy, if the paralysis shows no sign of improvement after 3 weeks, refer urgently to ENT
What to do if CT or MRI shows limited infarct core in an acute ischaemic stroke?
Thrombectomy
Can be done between 6-24 hourss
What should be done prior to thrombolysis in an acute ischaemic stroke?
Treatment of hypertension (>185/110)
1st line secondary prevention of stroke, if not tolerated give what?
If clopidogrel is contraindicated or not tolerated, give aspirin for secondary prevention following stroke
What to do if large artery acute ischaemic stroke?
Consider mechanical clot retrieval
Globus, hoarseness and no red flags
?laryngopharyngeal reflux
first line radiological investigation for suspected stroke
Non-contrast CT head scan
Cushing’s triad for raised ICP
hypertension, bradycardia, and irregular breathing
What movement is classically impaired in adhesive capsulitis
External rotation (on both active and passive movement) is classically impaired in adhesive capsulitis
Definitive diagnostic investigation for small bowel obstruction
CT abdomen
1st line investigation for small bowel obstruction
abdominal X-ray
Management of small bowel obstruction
initial steps:
NBM
IV fluids
nasogastric tube with free drainage
How can nerve root pain be distinguished from other pain in the leg?
by the dermatomal distribution and an associated neurological deficit
What’s seen on polarised light microscopy in pseudogout?
weakly positively birefringent rhomboid-shaped crystals
How to distinguish pseudogout from gout?
Chondrocalcinosis helps to distinguish pseudogout from gout - Linear calcification of the articular cartilage
Acute epididymo-orchitis in sexually active younger adults is most commonly caused by?
Chlamydia
Epididymo-orchitis in individuals with a low STI risk (e.g. married male in 50s, wife only partner) is likely due to?
enteric organisms (e.g. E. coli)
Distal sensory loss, tingling + absent ankle jerks/extensor plantars + gait abnormalities/Romberg’s positive?
Subacute combined degeneration of the spinal cord
Whipple’s triad of insulinoma
Symptoms and signs of hypoglycemia
Plasma glucose < 2.5 mmol/L
Reversibility of symptoms on the administration of glucose
Importantly C-peptide levels do not fall on the administration of insulin if the patient has an insulinoma as endogenous levels are not reduced.
If a patient with ulcerative colitis has had a severe relapse or >=2 exacerbations in the past year they should be given?
either oral azathioprine or oral mercaptopurine to maintain remission
If a mild-moderate flare of distal ulcerative colitis doesn’t respond to topical (rectal) aminosalicylates then what should be added?
oral aminosalicylates should be added - both topical and oral mesalazine
f a severe flare of UC has not responded to IV steroids after 72 hours, consider adding?
IV ciclosporin or surgery
Ethylene glycol toxicity management
fomepizole
Ethanol toxicity management
Haemodialysis
Ongoing loin pain, haematuria, pyrexia of unknown origin?
?Renal cell carcinoma
Metabolic alkalosis + hypokalaemia ?
?prolonged vomiting
What is the only test recommended for H. pylori post-eradication therapy?
Urea breath tes
Klumpke’s paralysis
Involving brachial trunks C8-T1. Classically there is weakness of the hand intrinsic muscles. Involvement of T1 may cause a Horner’s syndrome.
arm is hanging loose on the side. It is pronated and medially rotated.
Erb’s palsy - Brachial trunks C5-6
Investigating suspected PE: if the CTPA is negative then consider?
a proximal leg vein ultrasound scan if DVT is suspected
widespread rash with fluid-filled blisters, fever, and recent initiation of phenytoin strongly suggests?
Toxic epidermal necrolysis
Peptic ulceration, galactorrhoea, hypercalcaemia?
MEN type 1
What should be considered for Afro-Caribbean patients with heart failure who are not responding to ACE-inhibitor, beta-blocker and aldosterone antagonist therapy
Hydrazine and nitrate
What should patients with reduced LVEF should be given as first-line treatment
a beta blocker and an ACE inhibitor
When starting ACE-inhibitors and beta-blockers for heart failure with reduced ejection fraction, how should you start the drugs?
One drug at a time
Can prostate cancer be seen with a normal PSA?
Yes
key investigation in diagnosing early CKD
urinary albumin:creatinine ratio (ACR)
When should you stop a statin?
When patient is on a macrolide - erythro/clarithromycin
What can be used to avoid transfusion associated graft versus host disease?
Irradiation of blood products
What is oesophagael adenocarcinoma associated with?
GORD or Barrett’s
How does synringomyelia present?
with cape-like loss of pain and temperature sensation due to compression of the spinothalamic tract fibres decussating in the anterior white commissure of the spine
What is syringomyelia? What does it have a strong association with?
collection of cerebrospinal fluid within the spinal cord.
Causes include:
a Chiari malformation: strong association
areflexia, ataxia, ophthalmoplegia
Miller Fisher syndrome (subtype of GBS)
Exudative causes of pleural effusion
HIGH PROTEIN
infection
pneumonia (most common exudate cause),
connective tissue disease
rheumatoid arthritis
systemic lupus erythematosus
neoplasia
lung cancer
mesothelioma
metastases
pancreatitis
pulmonary embolism
Dressler’s syndrome
Transudative causes of pleural effusion
LOW PROTEIN
heart failure (most common transudate cause)
hypoalbuminaemia
liver disease
nephrotic syndrome
malabsorption
hypothyroidism
Meigs’ syndrome
Sudden deterioration with ventilation suggests?
Tension pneumothorax
Bleeding on dabigatran? What to reverse?
Idarucizumab
Persistent unexplained hoarseness in a patient aged >45 years old, consider what?
urgent referral to ENT and CXR to exclude apical lung lesion
Damage to which CN causes a RAPD
optic nerve - CN II
Useful for managing tremor in drug-induced parkinsonism
Procyclidine
Which anti-parkinson drug has been ASx with lung fibrosis?
Cabergoline
Which anti-parkinsonian drug has a reduced effectiveness over time?
Levodopa
tumour marker in breast cancer
CA15-3
mixed aortic valve disease, what examination finding?
Bisferiens pulse
Massive PE + hypotension, do what?
Thrombolyse with alteplase
holosystolic murmur, high-pitched and ‘blowing’ in character
mitral regurg
Horner’s syndrome features
miosis, ptosis, enophthalmos and anhidrosis
How to differ between horner’s and third nerve palsy
Ptosis + dilated pupil = third nerve palsy; ptosis + constricted pupil = Horner’s
What determines site of lesion in horner’s syndrome?
anhydrosis determines site of lesion:
head, arm, trunk = central lesion: stroke, syringomyelia
just face = pre-ganglionic lesion: Pancoast’s, cervical rib
absent = post-ganglionic lesion: carotid artery
Arterial/venous thrombosis, miscarriage, livedo reticularis
anticardiolipin antibody +ve
Uncontrollable splenic bleeding in trauma patients is an indication for what?
Splenectomy
Indications for splenectomy
Uncontrollable splenic bleeding
Hilar vascular injuries
Devascularised spleen
Woman aged > 30 years with dysmenorrhoea, menorrhagia, enlarged, boggy uterus
?adenomyosis
J waves on ECG
Hypothermia
what is given before endoscopy in patients with suspected variceal haemorrhage
Both terlipressin and antibiotics
What is used if uncontrolled variceal haemorrhage
Sengstaken-Blakemore tube
What is used as a last resort treatment following sengstaken blakemore tube in variceal haemorrhage? What can it cause?
Transjugular Intrahepatic Portosystemic Shunt (TIPSS) - connects the hepatic vein to the portal vein
exacerbation of hepatic encephalopathy is a common complication
What is the pattern of pyrexia in still’s disease?
Pyrexia in Still’s disease has a characteristic pattern. It typically rises in the late afternoon/early evening in a daily pattern and accompanies a worsening of joint symptoms and rash
What is contraindicated in V tach?
Verapamil
What lung pathology can methotrexate cause?
pneumonitis - typically presents with cough, dyspnoea and fever
What are the most common triggers of autonomic dysreflexia
Faecal impaction / urinary retention
presentation of hypertension, bradycardia and physical symptoms of sympathetic overdrive in a patient with a spinal cord injury above the level of T6 is typical of?
Autonomic dysreflexia
A man presents with central, pleuritic chest pain and fever 4 weeks following a myocardial infarction. The ESR is elevated
Dressler syndrome
widespread systolic murmur, hypotension, pulmonary oedema following MI
Rupture of the papillary muscle due to a myocardial infarction → acute mitral regurgitation
A patient is noted to have persistent ST elevation 4 weeks after sustaining a myocardial infarction. Examination reveals bibasal crackles and the presence of a third and fourth heart sound
left ventricular aneurysm
Bilateral, mid-to-lower zone patchy consolidation in an older patient
? Legionella
Chest drain swinging
Rises in inspiration, falls in expiration
Mx of minimal change disease
prednisolone
How to differ between syncopal episodes and seizures?
Syncopal episodes are associated with a rapid recovery and short post-ictal period. Seizures are associated with a far greater post-ictal period
What must be assessed in a patient with potential bilateral urinary tract obstruction?
Renal function
A history of Intravenous drug use coupled with a descending paralysis, diplopia and bulbar palsy is characteristic of
infection with Clostridium botulinum
When can you diagnose stage 1/2 CKD?
CKD: only diagnose stages 1 & 2 if supporting evidence to accompany eGFR
What is used in the management of Von Willebrand’s disease?
Desmopression
Electrolyte abnormality in T1DM
Metabolic acidosis with increased anion gap
most common site of metatarsal stress fractures is?
2nd metatarsal shaft
When may nerve blocks be considered in a rib fracture?
Nerve blocks may be considered if a rib fracture is not controlled by normal analgesia
Stages of shock
Class I shock would be completely compensated for.
Class II shock would cause tachycardia.
Class III shock causes tachycardia and hypotension as well as confusion.
Class IV shock causes loss of consciousness as well as severe hypotension.
Parkinsonism with associated autonomic disturbance (atonic bladder, postural hypotension) points towards
Multiple system atrophy
Which testicular tumours present with raised markers? What are they?
Yolk sac tumour - AFP
Teratoma - HCG, presents 20-30
Seminoma - normal, presents in 30+
What is hyperacute transplant rejection caused by?
pre-existing antibodies against ABO or HLA antigens
Usually occurs within 24-48 hours post-transplant
Severe life-threatening complication of C.Diff
Pseudomembranous colitis
Rosacea features
nose, cheeks and forehead
flushing, erythema, telangiectasia → papules and pustules
Soft, non-tender swelling on one side of the scrotum that transilluminates
Hydrocele
For type 2 diabetics requiring treatment, metformin is contraindicated in those with?
eGFR < 30
Early ultrasound imaging in acute pancreatitis is important to determine the aetiology as this may affect management (e.g. patients with gallstones/biliary obstruction). What would this be?
US abdo
Phaeo triad
triad of sweating, headaches, and palpitations in association with severe hypertension
Vision worse going down stairs? Think what
4th nerve palsy
when looking straight ahead, the affected eye appears to deviate upwards and is rotated outwards. What palsy?
4th nerve
triad for hepatorenal syndrome. Mx?
ascites, low urine output, and a significant increase in serum creatinine. Terlipressin is 1st line
What murmur seen in anaemia? How does it present?
Aortic flow murmur, soft ESM which doesn’t radiate
IgA nephropathy classically presents as?
visible haematuria following a recent URTI, 1-2 days after. A=Acute
Infant with bilious vomiting & obstruction?
?Intestinal malrotation
no association between P waves (atrial activity) and QRS complexes (ventricular activity)>
Complete heart block
Treated with transvenous pacing if ASx with brady
What is the most suitable management option for epistaxis where the bleed site is difficult to localise
Anterior packing
Measles is characterised by
prodromal symptoms, Koplik spots (white spots on buccal mucosa). maculopapular rash starting behind the ears and conjunctivitis
long-term prophylaxis of cluster headaches?
Verapamil
Cluster headache - acute treatment
subcutaneous sumatriptan + 100% O2
Symptom control in non-CF bronchiectasis
inspiratory muscle training + postural drainage
Bronchiectasis: most common organism
Haemophilus influenzae
Pneumonia in an alcoholic
Klebsiella
In those diagnosed with anal fistula, best Ix?
MRI is the best investigation to characterise the fistula course
For patients with rosacea with predominant flushing but limited telangiectasia, consider?
Bromonidine gel
What can SAH cause on ECG?
Torsades de pointes
All patients with severe hyperkalaemia (≥ 6.5 mmol/L) or with ECG changes:
IV calcium gluconate
insulin/dextrose infusion
pain on palpation of the tragus, itching, discharge and hearing loss
otitis externa
Firm and well-circumscribed mass that transilluminates on the dorsal aspect of the wrist ?
Ganglion cyst
most common cause of osteomyelitis?
staph aureus
Cause of raised serum NP besides HF
Renal dysfunction (eGFR < 60) can cause a raised serum natriuretic peptides
first-line medication for primary biliary cholangitis
Ursodeoxycholic acid
common features of meniscal lesions
Knee locking and giving-way
Pain out of proportion of clinical presentation, contact lens and recent freshwater swimming is classical of
acanthamoebic keratitis
first-line treatment for regular broad complex tachycardias without adverse features
IV amiodarone
What is key in determining the severity of C. difficile infection
white cell count
Patients with orbital cellulitis require?
admission to hospital for IV antibiotics due to the risk of cavernous sinus thrombosis and intracranial spread
DIlated pupil, females, absent leg reflexes
Holmes adie syndrome
first line for lower back pain
NSAIDs
Abdominal pain, constipation, neuropsychiatric features, basophilic stippling?
Lead poisoning
Fever, loin pain, nausea and vomiting ?
Acute pyelonephritis
standard for the diagnosis and screening of HIV?
Combination tests (HIV p24 antigen and HIV antibody)
After an initial negative result when testing for HIV in an asymptomatic patient, offer a repeat test when?
12 weeks
Bile-acid malabsorption may be treated with? often occurs after?
cholestyramine, after cholecystectomy
empirical antibiotic of choice for neutropenic sepsis?
Piperacillin with tazobactam (Tazocin)
Gas gangrene is caused by?
Clostridium Pefringens
Is digoxin monitored?
No, unless suspected toxicity
Recommend Adult Life Support (ALS) adrenaline doses
anaphylaxis: 0.5mg - 0.5ml 1:1,000 IM
cardiac arrest: 1mg - 10ml 1:10,000 IV or 1ml of 1:1000 IV
The first line investigation for children aged 5 to 16 with suspected asthma is?
fractional nitric oxide
1st line treatment for CO poisoning
100% high flow o2
potential complication of panretinal photocoagulation
Decrease in night vision
Spinal cord transection after trauma can present with? How to manage?
neurogenic shock, manage with vasopressors
sudden painless loss of vision, severe retinal haemorrhages on fundoscopy
Central retinal vein occlusion
Neuromuscular disorders result in what pattern on pulmonary function tests?
Restrictive
Pioglitazone - contraindicated by:
HF
Bladder cancer
Screening for an abdominal aortic aneurysm consists of
single abdominal ultrasound for males aged 65
Critical limb ischaemia presents as?
pain at rest for greater than 2 weeks, often at night, not helped by analgesia
What are generally used to induce remission of Crohn’s disease?
Pred
What is used first-line to maintain remission in patients with Crohn’s
Azathioprine or mercaptopurine
first line test for diagnosis of small bowel overgrowth syndrome
Hydrogen breath testing
What is the most likely SSRI to lead to QT prolongation and Torsades de pointes
Citalopram
Burning thigh pain? Dx? What nerve affected?
? meralgia paraesthetica - lateral cutaneous nerve of thigh compression
What is the most common cause of peritonitis secondary to peritoneal dialysis
Coagulase-negative Staphylococcus e.g. Epidermis
What nephropathy is frequently associated with malignancy
Membranous nephropathy
Patients who have had an episode of SBP require antibiotic prophylaxis with what?
Cipro
Unilateral glue ear in an adult needs evaluation for what?
Posterior nasal space tumour
What medication may be used in patients with raised ICP?
IV mannitol is an osmotic diuretic that may be used in patients with raised ICP
Peptic ulceration, galactorrhoea, hypercalcaemia
multiple endocrine neoplasia type I
In the treatment of anaphylaxis, adrenaline may be given every 5 minutes by the following doses
0-6 years old: 150micrograms (0.15ml 1 in 1,000).
6-12 years old: 300micrograms (0.3ml 1 in 1,000).
13+ years old: 500micrograms (0.5ml 1 in 1,000).
What Rate control medication can interfere with MG?
Beta blockers
Sjogren’s syndrome mX
pilocarpine - helps to stimulate saliva production
CXR finding on ank spond
Apical fibrosis
What nerve supplies the extensor muscle group of forearms?
Radial
What nerve supplies the interosseous muscles of hand (involved in adduction)?
Ulnar
Disseminated gonococcal infection triad
tenosynovitis, migratory polyarthritis, dermatitis
What blood test can rise in small bowel obstruction?
Serum amylase
Dermatophyte nail infection, mx?
oral terbinafine
Treatment of choice for essential tremor
Propanolol
What can essential tremor affect besides the hands?
While an essential tremor is classically associated with a tremor present with sustained muscle tone (i.e. postural tremor) in the hands, it can also affect the vocal cords
What is the most sensitive scan to diagnose diffuse axonal injury
MRI
Retro-orbital headache, fever, facial flushing, rash, thrombocytopenia in returning traveller
?Dengue
Patients with polymyalgia rheumatica typically respond dramatically to steroids, failure to do so should?
Prompt consideration of an alternative diagnosis
Proximal aortic dissections are generally managed with?
Surgical aortic root replacement
Strong suspicion of PE but a delay in the scan:
Start on treatment dose anticoag meanwhile
Medial epicondylitis is aggravated by?
wrist flexion and pronation
What should be done if needle aspiration of a pneumothorax is unsuccessful?
Insertion of a chest drain
Mx of acute bronchitis? When is this different?
NICE guidance does not recommend antibiotics for acute bronchitis in people who are not at high risk of complications and who are not systemically very unwell. However, if a patient is very unwell or at risk of complications, antibiotics should be offered.
Desmopression MOA
Vasopressin V2 receptor agonist
Mx of lung abscess
IV ABx
If no improvement, consider CT-guided percutaneous drainage
Subacute productive cough, foul-smelling sputum, night sweats
Lung abscess
If a hernia cannot be reduced it is referred to as?
an incarcerated hernia - these are typically painless
Most effective antipsychotic for negative Sx of schizo
Clozapine
What is a recognised respiratory complication of pancreatitis
ARDS
Are patients with pancreatitis given Abx?
Not routinely, fluids and analgesia are mainstay
Should patients with acute pancreatitis be kept NBM?
Patients with acute pancreatitis should not routinely be made ‘nil-by-mouth’
Enteral nutrition should be offered to anyone with moderately severe or severe acute pancreatitis
Which antihypertensive can cause peripheral oedema?
CCBs e.g. amlodipine
What happens to iodine uptate in subacute thyroiditis?
Decreased iodine uptake
Mx of BPH
First tamsulosin - alpha 1 antagonist
then Finasteride - 5alpha reductase inhibitors
What can be used in refractory pain for shingles?
Corticosteroids can be used in refractory pain in shingles if simple analgesia and neuropathic analgesia do not help, but only for acute shingles
If combination of storage and voiding Sx that persist following tamsulosin, trial what Mx?
antimuscaric (anticholinergic drug) e.g. tolterodine or darifenacin
Best anaesthetic agent in trauma? Why?
Ketamine. no drop in BP
How are patient’s diabetic medication managed during operations?
most patients taking only oral antidiabetic drugs may be managed by manipulating medication on the day of surgery, depending on the particular drug
How do episcleritis and scleritis differ?
In episcleritis, the injected vessels are mobile when gentle pressure is applied on the sclera. In scleritis, vessels are deeper, hence do not move. Scleritis is PAINFUL
Gold standard for diagnosing CSF, if not can use?
Beta-2-transferring, use glucose if not (would be positive)
chronic history of lower limb weakness characterised by a pyramidal distribution, where flexors are more affected than extensors in the lower limbs. This is accompanied by hyperreflexia and an upgoing plantar response, which are indicative of an upper motor neuron lesion.
MS
Mx of anal fissures that don’t respond to conservative management
sphincterectomy
Acute anal fissue (<1 week) Mx
soften stool, dietary fibre, analgesia and topical anaesthetic cream (e.g. lidocaine) if necessary
Lateral anal fissure?
LOOK FOR OTHER CAUSES
Chronic anal fissure Mx
topical GTN
Mx of simple rib fractures
Conservative
Most common cause of sudden onset sensorineural hearing loss
Idiopathic
What Mx is used to prevent vasospasm in aneurysmal SAH
Nimodipine
How much should once daily insulin dose be on day before and day of surgery?
reduced by 20%
Open and closed comedones, pustules and nodules
acne vulgaris
Liver failure following cardiac arrest think
Ischaemic hepatitis
Presbycusis presents qwith?
bilateral high-frequency hearing loss
Mx of diverticulitis flare
oral antibiotics at home. If they do not improve within 72 hours, admission to hospital for IV ceftriaxone + metronidazole is indicated
1st line treatment for pyoderma gangrenosum
Oral steroids
Hodgkin’s lymphoma - most common type
Nodular sclerosing
Which CCB most likely to precipitate HF
Verapamil (CONTRAINDICATED)
What medication to consider in all housebound patients?
Daily vitamin D supplements
Neonatal hypotonia: associated with
Prader Willi
What is Hutchinson’s Sign?
Hutchinson’s sign: vesicles extending to the tip of the nose. This is strongly associated with ocular involvement in shingles.
NB: Anterior Uveitis is the ocular involvement
patients with unilateral deafness or tinnitus, worry about?
Accoustic neuroma
Loss of corneal reflex with unilateral hearing loss
Accoustic neuroma
What CNs are affected by vestibular schwannoma?
CN V, VII, VIII
What is rhinitis medicamentosa?
a condition of rebound nasal congestion brought on by extended use of topical decongestants
How are most intracranial aneurysms now treated?
Coiling by an interventional neuroradiologist
What can raised platelets be an indicator of?
Lung cancer
Timeline for determining cause of postoperative fever
Day 1-2: ‘Wind’ - Pneumonia, aspiration, pulmonary embolism
Day 3-5: ‘Water’ - Urinary tract infection (especially if the patient was catheterised)
Day 5-7: ‘Wound’ - Infection at the surgical site or abscess formation
Day 5+: ‘Walking’ - Deep vein thrombosis or pulmonary embolism
Any time: Drugs, transfusion reactions, sepsis, line contamination.
What blood test result can heparin cause? What does this lead to?
Thrombocytopenia, prothrombotic state
management for subluxation of the radial head
Passive supination of the elbow joint whilst flexed to 90 degrees
(paradoxically) prolonged APTT + low platelets
Antiphospholipid syndrome
Pancreatic pseudocyst Mx?
Manage conservatively initially, then consider radiological fine-needle aspiration
When should a thoracic surgical opinion be sough when draining a pneumothorax?
f after 3-5 days there is persistent air leak (e.g. bubbling chest drain) or failure of the lung to re-expand
Discoid lupus erythematous Mx
topical steroids → oral hydroxychloroquine
raised, erythematous rash, most commonly seen on the face and scalp in young women.
Discoid lupus
Mx of HUS
supportive
What does metastatic bone pain respond to?
analgesia, bisphosphonates or radiotherapy
Trial these in order
Diverticulitis symptoms + pneumaturia or faecaluria?
?colovesical fistula
Common blood test results in alcoholic liver disease
Macrocytic anaemia and thrombocytopenia
the commonest extra-colonic malignancy of HNPCC?
Endometrial
first line investigations for patients with a suspected diagnosis of vestibular schwannoma are
audiogram and gadolinium-enhanced MRI head scan
What are the opioids of choice for pain relief in palliative care patients with severe renal impairment? Why?
Buprenorphine or fentanyl are the opioids of choice for pain relief in palliative care patients with severe renal impairment, as they are not renally excreted and therefore are less likely to cause toxicity than morphine
Mx of heparin induced thrombocytopenai
anticoagulation can be provided by direct thrombin inhibitor e.g. argatroban
Perioral dermatitis should be treated with?
topical or oral ABx
Leriche syndrome triad
Classically, it is described in male patients as a triad of symptoms:
- Claudication of the buttocks and thighs
- Atrophy of the musculature of the legs
- Impotence (due to paralysis of the L1 nerve)
Local complication of gonorrhoea in males
urethral stricture
visual hallucinations associated with eye disease.
Charles bonnet syndrome
What type of urinary incontinence is the most associated with amitriptyline?
Overflow
What may patients develop following catheterisation for acute urinary retention?
post-obstructive diuresis
incubation period of Ebola virus
2 - 21 days
‘pigment-laden macrophages within the mucosa on PAS staining’.
Melanosis coli - caused by prolonged laxative use
Syphyllis test results
Positive non-treponemal test + positive treponemal test
consistent with active syphilis infection
Positive non-treponemal test + negative treponemal test
consistent with a false-positive syphilis result e.g. due to pregnancy or SLE (see list above)
Negative non-treponemal test + positive treponemal test :
consistent with successfully treated syphilis
investigation of choice for a suspected pharyngeal pouch
Barium swallow combined with dynamic video fluoroscopy
IO access is attained at the?
Proximal tibia
What can be used to assess the presence of fluid in the abdomen and thorax
FAST scan
What exercises can be performed by the patient at home to treat BPPV
Brandt-Daroff
most common cause of occupational asthma
Isocyanates
Sildenafil MOA
phosphodiesterase type V inhibitor
What type of chest pain can arise secondary to malignancy?
Pericarditis
Immunocompromised patients with poor dentition can develop what?
airway compromise from cellulitis at the floor of the mouth known as Ludwig’s angina.
emergency medical management of acute angle-closure glaucoma
Alongside eye drops, IV acetazolamide
Ix for acute angle closure glaucoma
Both tonometry and gonioscopy
Sudden weight loss is associated with what liver conditiion?
NAFLDF
CCB SEs
headache, flushing, ankle oedema
In patients with non-alcoholic fatty liver disease, what is recommended to aid diagnosis of liver fibrosis?
enhanced liver fibrosis (ELF) testing
Primary open-angle glaucoma: What is first-line if the IOP is ≥ 24 mmHg
360° selective laser trabeculoplasty (SLT)
Fracture of the proximal ulna, with an associated dislocation of the proximal radioulnar joint.
A Monteggia fracture
a distal radial fracture with an associated dislocation of the distal radioulnar joint.
Galeazzi fracture
How to differ between galeazzi fracture and monteggia fracture
Galeazzi fracture: a distal radial fracture with an associated dislocation of the distal radioulnar joint.
A Monteggia fracture (1) is a fracture of the proximal ulna, with an associated dislocation of the proximal radioulnar joint.
A method to remember the difference between the two of these is by combining the name of the fracture with the bone that is broken:
Monteggia ulna (Manchester United), Galeazzi radius (Galaxy rangers)
distal radius fracture with dorsal displacement
Colles
distal radius fracture with volar displacement
Smiths
fracture of the neck of the fourth or fifth metacarpal with volar displacement of the metacarpal head.
Boxers
What may be considered if a rib fracture is not controlled by normal analgesia
Nerve block
Nausea and vomiting associated with chemotherapy or radiotherapy often respond to?
5-HT3-receptor antagonist (ondansetron) in combination with dexamethasone
What are chiari malformations often associated with? Why?
syringomyelia due to disturbed cerebrospinal fluid flow at the foramen magnum
Headache caused by raised intracranial pressure due to brain cancer (or metastases) can be palliated with?
Dex
What pneumonia is associated with cold sores?
Strep pneumoniae
Ix of lipoma
Clinical diagnosis, unless >5cm then do an US to check for liposarcoma
lump characteristics:
smooth
mobile
painless
Dx?
Lipoma
HIV + proctitis ?
? Lymphogranuloma venereum
A woman suddenly falls to the ground then lays motionless
Atonic seizure
An MRI of the brain and spinal cord reveals multiple white matter lesions, some of which are periventricular
MS
chronic, painful, inflammatory skin disorder is characterized by nodules, pustules, sinus tracts, and scars in intertriginous areas
Hidradenitis suppurativa
Mx of shingles
The majority of patients with suspected shingles should be treated with antivirals within 72 hours of onset
What can loop diuretics do to bone health?
Worsen due to hypocalcaemia
What is preferred to morphine in palliative patients with mild-moderate renal impairment
Oxycodone
How can Primary and secondary aldosteronism can be differentiated?
by looking at the renin levels. If renin is high then a secondary cause is more likely, i.e renal artery stenosis.
first line anti-emetic for intracranial causes of nausea and vomiting
Cyclizine
What blood test is useful for late presentations of acute pancreatitis (>24 hours)?
lipase
What are inflammatory markers in biliary colic?
Normal
SIADH MX
fluid restrict
Flashes and floaters?
vitreous/retinal detachment
Prolonged diarrhoea may result in what blood gas result?
metabolic acidosis associated with hypokalaemia
SVC obstruction can cause visual disturbances such as ?
blurred vision
bulging of the veins on the forehead (back pressure due to compression), the papilloedema which is a sign of raised intracranial pressure and Pemberton sign.
SVC obstruction
When is surgical excision given in fibroadenoma?
Breast fibroadenoma: surgical excision is usual if >3cm
shortened and internally rotated leg
Posterior hip dislocation
Normal pressure hydrocephalus neuroimaging findings:
ventriculomegaly in the absence of, or out of proportion to, sulcal enlargement
What can doxasosin cause?
postural hypotension
What blood test should be considered in women with recurrent vaginal candidiasis
HbA1c
Total anterior circulation infarcts - all 3 of the following:
unilateral hemiparesis and/or hemisensory loss of the face, arm & leg
homonymous hemianopia
higher cognitive dysfunction e.g. dysphasia
Haemodialysis can give a falsely low?
HbA1C
management of acute relapse of MS
High dose steroids
Should you use ABx in pressure ulcer treatment?
Do not routinely use antibiotics in pressure ulcer treatment, only if there are signs of infection
Treatment for herpes simplex keratitis
topical aciclovir
painful red eye with photophobia and epiphora. abnormal fluorescein staining, typical appearance is a linear branching corneal ulcer
Herpes simplex keratitis
Uncal herniation affects what cranial nerve?
3
Dilated pupil due to compression of the third cranial nerve
Chronic urinary retention is classed as high pressure urinary retention if
renal function is impaired or if there is hydronephrosis
What type of CXR is used to identify bowel perf
erect - shows pneumoperitoneum
Excessive use of breakthrough analgesia should raise suspicion for?
Compartment syndrome
Hartmann’s procedure
sigmoid colectomy and formation of end stoma
In patients with severe colitis, what should be used for Ix?
colonoscopy should be avoided due to the risk of perforation - a flexible sigmoidoscopy is preferred
Pulsus paradoxus, think?
Cardiac tamponade
30-40 year old with basal emphysema and abnormal LFTs
?A1AT
What can reactive arthritis cause in the hands?
Dactylitis
Common SEs of adenosine
Flushing and chest pain
When prescribing maintenance fluids, how much of water per day is typically requried?
25-30 ml/kg/day
Acronym for causes of upper zone fibrosis:
CHARTS
C - Coal worker’s pneumoconiosis
H - Histiocytosis/ hypersensitivity pneumonitis
A - Ankylosing spondylitis
R - Radiation
T - Tuberculosis
S - Silicosis/sarcoidosis
Lower zone fibrosis acronym:
ACID
A - asbestos.
C - connective tissue diseases.
I - idiopathic pulmonary fibrosis.
D - drugs e.g. methotrexate, nitrofurantoin.
malignant tumour that occurs most frequently in the metaphyseal region of long bones prior to epiphyseal closure, Codman triangle with a sunburst appearance
osteosarcoma
fixed dilated pupil with conjunctival injection
Acute closed-angle glaucoma
Neutrophil predominant leucocytosis with periumbilical pain?
think acute appendicitis
When is surgery indicated in patients with repeated endoscopic treatment?
Surgery is indicated in patients with ongoing acute bleeding despite repeated endoscopic therapy
What is the oral antibiotic of choice to treat erythrasma
Erythromycin
first-line treatment in opioid detoxification
Methadone or buprenorphine
Pneumothorax: persistent air leak or recurrent episodes . plan?
consider referral for VATS to allow for mechanical/chemical pleurodesis +/- bullectomy
What pain meds to avoid in Myeloma?
NSAIDs, can precipitate renal failure
What types of shock cause warm peripheries? What cause cold?
Neurogenic, septic, and anaphylactic shock (together are all distributive shock) will cause warm peripheries, with the others causing cool peripheries (cardiogenic and hypovolaemic)
Unilateral spastic paresis and loss of proprioception/vibration sensation with loss of pain and temperature sensation on the opposite side
Brown-Sequard syndrome
What does NAC commonly cause on administration?
an anaphylactoid reaction (non-IgE mediated mast cell release)
A non-healing painless ulcer associated with a chronic scar is indicative of
squamous cell carcinoma (SCC)
Mx of actinic keratosis
Fluorouracil crea,
C peptide levels in T1DM
Low
severe hypertension and bilateral retinal hemorrhages and exudates, think?
Malignant hypertension
What artery is at risk with duodenal arteries?
Gastroduodenal
itchy, violaceous papules on the flexor aspects of her wrists
Lichen planus - polygonal rash on flexor surgaces
sudden painless loss of vision, severe retinal haemorrhages on fundoscopy
Central retinal vein occlusion
What may indicate referred lumbar spine pain as a cause of hip pain
positive femoral nerve stretch test
Most common type of melanoma that has the typical diagnostic features of a changing mole
Superficial spreading melanoma
What can essential tremor also affect?
The vocal cords
Malignancy + raised CK?
Polymyositis
Salter Harris Classification
The classification can be easily remembered using the acronym ‘SALTR’:
I: Slipped (either side of the growth plate slipping past each other) - Physis only
II: Above growth plate (physis) - Physis and metaphysis
III: Lower than growth plate (physis) - Physis and Epiphysis
IV: Through (fracture through both above and below the growth plate) - Physis, Metaphysis and Epiphysis
V: Rammed (a crush injury)
1st line Ix for avascular necrosis of hip. Gold standard
X-ray, MRI
first-line for chronic plaque psoriasis
Topical potent corticosteroid + vitamin D analogue
Acute onset of atrial fibrillation: if ≥ 48 hours or uncertain (e.g. patient not sure when symptoms started). Mx
Rate control - Beta blockers, if asthmatic - verapamil
intervention of choice in patients with malignant distal obstructive jaundice due to unresectable pancreatic carcinoma
Biliary stenting
The Parkland formula for fluid resuscitation in burns is:
Volume of fluid = total body surface area of the burn % x weight (Kg) x 4ml
1st line Iv for CO poisoning
ABG
first-line investigation for a suspected osteoporotic vertebral fracture
X-ray spine
If subarachnoid haemorrhage is suspected but a CT head done within 6 hours of symptom onset is normal, plan?
do not do an LP, consider an alternative diagnosis instead
For patients with acute heart failure, what may be useful if the patient has concomitant myocardial ischaemia or severe hypertension
Nitrates
common cause of chronic wound infections
Pseudomonas, especially in diabetics
lemon tinge to the skin is associated with
Pernicious anaemia
pedunculated heterogeneous mass on echocardiogram
Atrial myxoma
pharmacological options for treatment of orthostatic hypotension
Fludrocortisone and midodrine
differential for chronic hepatitis B patients with acute flare up
Hep D superinfection
What is used as a vitamin D supplement in end-stage renal disease because it does not require activation in the kidneys
Alfacalcidol
What should be considered if a bradycardia doesn’t respond to drugs or transcutaneous pacing
Transvenous pacing
What important differential can present similarly to renal colic>
Symptoms of a ruptured AAA can present similarly to renal colic with loin to groin pain. However, it is a very important differential diagnosis, particularly in men aged above 50 years.
Adult patients with a hydrocele require what?
an ultrasound to exclude underlying causes such as a tumour
What is a common complication of Colles’ fracture? What may it result in?
Median nerve injury is a common complication of Colles’ fracture - may result in weakness or loss of thumb or index finger flexion
Most common causes of massive splenomegaly in UK
CML/myelofibrosis
After the first VTE, patients with antiphospholipid syndrome should be on?
Lifelong warfarin
Patients with anti-phospholipid syndrome who haven’t had a thrombosis previously are generally on?
low dose aspirin
Low serum calcium, raised serum phosphate, raised ALP and raised PTH
chronic kidney disease leading to secondary hyperparathyroidism
NOTE: This is different to osteomalacia where you would get low phosphate
An important adverse effect of aminoglycosides is
Ototoxicity
Aortic stenosis - most common cause:
younger patients < 65 years: bicuspid aortic valve
older patients > 65 years: calcification
What can be used to distinguish vestibular neuronitis from posterior circulation stroke? How does it work?
The HiNTs exam can be used to distinguish vestibular neuronitis from posterior circulation stroke
During the HiNTs examination for peripheral vertigo, the head impulse test will show a corrective saccade (positive result) if the vestibulo-ocular reflex is disrupted. This occurs when the head is turned toward the affected side, causing the eyes to make a saccade to re-fixate on the target. If the reflex is intact (in a healthy individual or on the unaffected side), the eyes will stay fixed on the target when the head turns toward the normal side.
In the early stages of vestibular neuronitis, horizontal nystagmus may also be present, unlike the direction-changing nystagmus seen in central vertigo cases.
The test of skew usually yields normal results in peripheral vertigo. When a patient focuses on their nose while their eyes are alternately covered, vertical misalignment may occur in central vertigo, leading to corrective movements. This finding is absent in peripheral causes
What does meformin increase the risk of?
lactic acidosis - suspend during intercurrent illness eg. diarrhoea and vomiting
Herpes zoster ophthalmicus requires?
urgent ophthalmological review and 7-10 days of oral antivirals
Mx of asymptomatic mitral stenossi
Mitral stenosis patients who are asymptomatic are generally monitored and given medical therapy rather than having percutaneous/surgical intervention
treatment of choice for Bowen’s disease
Topical 5-fluorouracil
Red, scaly patches that grow on sun-exposed sites in older patients should raise suspicion of
Bowen’s disease, which is a precursor to squamous cell carcinoma (SCC)
most commonly affected site in ischaemic colitis
Splenic flexure
Moderate/severe psoriatic arthropathy mx
methotrexate
plain abdominal film classically shows small bowel obstruction and air in the biliary tree
Gallstone ileus
Key SE of ciprofloxacin
Achilles tendon rupture
imaging of choice in suspected renal colic
Non-contrast KUB
A third heart sound is one of the possible features of
left sided HF
Most common form of prostate cancer
Adenocarcinoma
What is a useful test of exocrine function in chronic pancreatits
Faecal elastase
Status epilepticus: rule out what before thinking of other causes?
Hypoxia and hypoglycaemia
Pulmonary oedema is an indication for what in a patient with acute kidney injury
Haemodialysis
Thyrotoxicosis with tender goitre =
subacute (De Quervain’s) thyroiditis
Visual changes secondary to drugs
blue vision: Viagra (‘the blue pill’)
yellow-green vision: digoxin
What is a key investigation in patients with suspected encephalitis
PCR of cerebrospinal fluid for viruses
Joint aspirate in rheumatoid arthritis shows a
high WBC count, predominantly PMNs. Appearance is typically yellow and cloudy with absence of crystals
key differential for abdominal pain and fever in patients with cirrhosis and portal hypertension
Spontaneous bacterial peritonitis
WHat should be prescribed adjunct to methotrexate in RA?
Folate to prevent myelosuppression
dyspnoea, chest pain, cough, hypoxia and new pulmonary infiltrates seen on chest x-ray in a patient with a background of sickle cell
acute chest syndrome
Mx of acute chest syndrome
Analgesia, respiratory support and Abx, ?transfusion
Early Sx of MS
Lethargy
What movements are typically spared in MND
eye movements
What is Verapamil contraindicated in?
V tach and HF
Immediate Mx of suspected temporal arteritis
oral pred
refractory hypertension and reduced eGFR after starting ACE inhibitor
Renal artery stenosis
AF cardioversion drugs
amiodarone + flecainide
Recurrent otitis externa following numerous antibiotic treatment should raise suspicion of?
Candida
acute progression of visual loss, metamorphopsia (wavy distortion of straight lines), and retinal haemorrhages
Wet AMD
What is required in the investigation of all patients presenting with an AKI of unknown aetiology
an US
Crypt abscesses on histology?
UC
What should be corrected first before giving bisphosphonates?
Hypocalcemia/vitamin D deficiency should be corrected before giving bisphosphonates
investigation of choice for varicose veins/chronic venous disease? What does it show/
Venous duplex ultrasound is the investigation of choice for varicose veins/chronic venous disease - it will show retrograde venous flow
Unilateral, purulaent discharge from eye
bacterial conjunctivitis
Transferrin in IDA
Transferrin will be high BUT transferring saturation will be low
CT head findings on alzheimers
widespread cerebral atrophy mainly involving the cortex and hippocampus
Quinsy Mx
IV antibiotics and surgical drainage, and a tonsillectomy should be considered in 6 weeks
Toxic multinodular goitre Mx
radioactive iodine is the treatment of choice
Gold standard Ix for MS
MRI head
What Mx slows bone healing
NSAIDs
Bladder still palpable after urination, think?
Retention with urinary overflow
How to differentiate between femoral and iliac artery claudication
Claudication affecting the femoral vessels is likely to present with calf pain rather than iliac claudication which causes buttock pain
What hormonal therapy is reccomended in turners
Growth
Woman with bone mets, most likely to originate from?
Breast
Example of nephrotoxic medications that should be stopped in AKI
NSAIDs, diuretics, ACE inhibitors, and metformin
In cardiac tamponade, there will be an abnormally large drop in BP during inspiration, known as?
Pulsus Paradoxus
bilateral, conductive pattern hearing loss, sometimes with associated tinnitus
Otosclerosis
Difference between presbycusis and otosclerosis
Presbyacusis gives a sensorineural, high frequency hearing loss picture.
Otosclerosis - progressive conductive deafness, which typically presents in middle age. Tinnitus and vertigo may also be present, but are less common.
Which thyroid cancer has best prognosi
Papillary
most common reason total hip replacements need to be revised
Aseptic loosening of implant
1st line Mx for glaucoma
Latanoprost - prostaglandin analogue
SE of phenytoin
Peripheral neuropathy
Mx of diabetic gastroparesis
Metoclopramide
What is a common complication from intraventricular haemorrhages
Hydrocephalus
Following nebulised SABA, what should all patients with asthma be given?
Oral pred (40-50mg)
Pigmentation of nail bed affecting proximal nail fold suggests?
Acral lentiginous melanoma: Pigmentation of nail bed affecting proximal nail fold suggests melanoma (Hutchinson’s sign)
When should NIV be considered in COPD exacerbation?
NIV should be considered in all patients with an acute exacerbation of COPD in whom a respiratory acidosis (PaCO2>6kPa, pH <7.35 ≥7.26) persists despite immediate maximum standard medical treatment
What type of melanoma can arise in areas not associated with sun exposure e.g. soles of feet and palms
acral lentiginous
Gold standard investigation for mesothelioma
Thoracoscopic biopsy
Most likely cause of AKI if poor response to fluid challenge
ATN
CKD on haemodialysis - most likely cause of death is?
IHD
What electrolyte abnormality predisposes patients to digoxin toxicity
hypokalaemia
treatment of choice for all patients with a displaced hip fracture
Hemiarthroplasty or total hip replacement
General rule for hip fractures
Intracapsular femoral fracture - hemiarthroplasty
extracapsular femoral fracture - dynamic hip screw
Firm and well-circumscribed mass that transilluminates on the dorsal aspect of the wrist ?
Ganglion cyst
What is used to treat cerebral oedema in patients with brain tumours
Dex
How does myoglobulinuria cause renal failure?
By tubular cell necrosis
diagnostic investigation of choice is the investigation of choice for suspected Non-Hodgkin’s lymphoma?
Excisional node biopsy
low T3/T4 and normal TSH with acute illness
Sick euthyroid syndrome
Gold standard Ix for MS causing optic neuritis
MRI of the brain and orbits with gadolinium contrast is the investigation of choice
Isoniazid, an anti-TB medication, may induce?
Pellagra
Four D’s of pellagra (vitamin B3 deficiency):
Diarrhoea
Dermatitis
Dementia
Death
known cause of neutropenia and a temperature of > 38 degrees?
Think neutropenic sepsis
What type of medications cause a raised INR?
Inhibitors of cP450
Inducers cause a decreased INR - think D in induce for decrease
Creatinine level in tumour lysis syndrome
Raised
What is the acceptable upper limit of residual urine in patients < 65 years old?
<50ml
Small cell lung cancer with progressive confusion and lethargy
Think SIADH, hyponatraemia causing cerebral oedema
What artery affected in epistaxis
Sphenopallatine
pain on the radial side of the wrist
tenderness over the radial styloid process
abduction of the thumb against resistance is painful
De Quervain’s tenosynocitis
Carotid artery stenosis Ix
Carotid artery stenosis is diagnosed (and degree of stenosis assessed) via duplex ultrasound
Abdominal distension, absence of passing flatus or stool, late onset/no vomiting?
Large bowel obstruction
What medication doesn’t worsen AKI but should be stopped due to an increased risk of toxicity?
Metformin
Hypotension + melaena?
Bleeding peptic ulcer
keratoderma blennorrhagicum on the soles of his feet - a waxy yellow rash. Pathognomic for?
Reactive arthritis
SEs of GTN
Hypotension, tachycardia and headache
tender goitre, hyperthyroidism and raised ESR. The globally reduced uptake on technetium thyroid scan is also typical
Subacute thyroiditis
What type of anaemia can phenytoin cause?
Macrocytic anaemia
5 day history painful left sided neck swelling below the angle of the jaw. She also complains of a foul taste in her mout
Sialadenitis
intermittent dysphagia (difficulty swallowing), halitosis (bad breath), and nocturnal coughing are characteristic of
Pharyngeal pouch (Zenker’s diverticulum)
What anaesthetic drug can cause adrenal suppression
Etomidate
Common cause of bilateral carpal tunnell syndrome
RA
Hypotension, dyspnoea, wheezing, angioedema during a blood transfusion
Anaphylaxis
All men with a suspected UTI should have what sent before starting antibiotics?
Mid stream urine culture
What accounts for the majority of ocular complications in temporal arteritis
Anterior ischaemic optic neuropathy
‘Rheumatoid’-like joint problems but nail changes
Psoriatic arthritis
What should be used in palliative care for nausea and vomiting that is due to gastric dysmotility and stasis
Metoclopramide
What common drug used for IBD can cause drug induced pancreatitis?
Mesalazine
The most common malignancy associated with acanthosis nigricans
is
GI adenocarcinoma
What medication are beneficial in proteinuric CKD, regardless of diabetic status
SGLT-2 inhibitors
Deep ulcer on toe/heel
?Arterial ulcer
small (1-2cm) calcified nodule is visible in the lateral area of the right mid zone
Ghon complex - latent TB
Complication of discitis that can cause worsenining features
Epidural abscess
Indications for thoracotomy in haemothorax include
> 1.5L blood initially or losses of >200ml per hour for >2 hours
First line treatment for most patients with a pituitary tumour causing acromegaly
Transphenoidal surgery
Then octredotide (somatostatin anaologue) and bromocriptine (dopamine agonist)
Most common cause of chronic pancreatitis
Alcohol excess
How to differentiate acute cholecystitis and biliary colic
people with cholecystitis typically are systemically unwell
pain on hip extension in an IVDU
Psoas abscess
Failure to correct childhood squints may lead to what?
Ambylopia
Widened mediastinum on CXR
Think aortic dissection
Ix for Aortic dissection
CT angiography of CAP, if unstable doe transoesophagaeal echocardiography
Classification and Mx of aortic dissection
type A - ascending aorta, 2/3 of cases - surgery and control BP in meantime
type B - descending aorta, distal to left subclavian origin, 1/3 of cases - conservative mx with BP management (IV labetalol)
What is a key Sx adjunt to dyspepsia that warrants an urgent referral
Weight loss
Ethylene glycol toxicity management
fomepizole. Also ethanol / haemodialysis
respiratory secretions & bowel colic may be treated by
hyoscine hydrobromide, hyoscine butylbromide, or glycopyrronium bromide
What nerve is at risk in a shaft fracture of the humerus
Radial
Severe vomiting → haematemesis
Mallory weiss syndrome
What joint condition can cause pyoderma gangrenosum
RA
HIV, neuro symptoms, multiple brain lesions with ring enhancement
Toxoplasmosi
HIV, neuro symptoms, single brain lesions with homogenous enhancement
CNS lymphoma
Most appropriate anti emetic in parkinsons
Domperidone
Tamoxifen increases the risk of what?
VTE and endometrial cancer
1st line Mx of hyperhidrosis
Topical aluminium chloride
Rough guidance on which conditions are AD and AR inheritance
Autosomal recessive conditions are ‘metabolic’ - exceptions: inherited ataxias
Autosomal dominant conditions are ‘structural’ - exceptions: Gilbert’s, hyperlipidaemia type II
Sickle cell patients should be started on long term WHAT to reduce the incidence of complications and acute crises
Hydroxycarbamide
How may HOCM present
Exertional dyspnoea
tingling/numbness of the 4th and 5th finger. Dx?
Cubital tunnel syndrome is caused by compression of the ulnar nerve
What Dx should be considered in patients with portal hypertension and lower gastrointestinal bleeding
Rectal varices
posterior circulation symptoms, such as dizziness and vertigo, during exertion of an arm
Subclavian steal syndrome
flu like illness → brief remission→ followed by jaundice and haematemesis
Yellow fever
gold standard for diagnosis of OSA
Nocturnal polysomnography
GRACE score higher than 3% in an NSTEMI?
PCI within 72 hours
Right upper quadrant tenderness and bilious fluid in the intra-abdominal drain would suggest a WHAT following cholecystectomy
Bile leak
weak pulses and aortic regurgitation in an aortic dissection
Think type A, IV labetalol and surgery
Types of respiratory failure
Type 1 respiratory failure: Low pO2, no CO2 retention
Type 2 respiratory failure: Low pO2, high pCO2
What skin condition can cold sores trigger?
Erythema multifiorme
Urine osmolality levels in ATN
<350`
methotrexate toxicity Mx
Folinic acid
non-falciparum malaria Mx
Primaquine is used in non-falciparum malaria to destroy liver hypnozoites and prevent relapse
. Primary herpes simplex infection, caused by the Herpes Simplex Virus (HSV), can lead to a dermatological condition known as
Erythema multiforme
Why is nephrotic syndrome prothrombotic
Loss of antithrombin 3
slow-growing, flesh-coloured or pink lesions with a pearly appearance. The rolled edges, central depression and presence of telangiectasia (dilated blood vessels) are classic features of?
Basal cell carcinoma
When should a thrombolytic drug be considered in CPr?
If a PE is suspected
Prerenal disease is suggested by what blood test result
Urine sodium <20
What electrolyte abnormality can SAH cause? How?
Hyponatraemia, SIADH
At what FRAX score should a DEXA scan be arranged?
As a guide, a QFracture score ≥ 10% means a DEXA scan should be arranged
What Abx can cause IPF
Nitrofurantoin
red and watery right eye with mild photophobia, not painful but discomfort
Episcleritis
preferred way to support nutrition in patents with motor neuron disease
PEG tube
Difference between BPPV and vestibular neuronitis
in bppv vertigo is triggered by head movements, in vestibular neuronitis - its worsened
skin hypopigmentation and loss of sensation
Leprosy
classic features of irritable bowel syndrome
Abdominal pain, Bloating and Change in bowel habit
If a pleural effusion fluid protein/serum protein ratio is >0.5, the effusion is an?
Exudate
Mx of wilson’s disease
Penicillamine
What Ix should all adults with suspected asthma have?
a bronchodilator reversibility (BDR) test
recurrent painless haematuria, poor renal function and a sensorineural deafness
Alport syndrome
recommended treatment for post-thrombotic syndrome
Compression stockings
What murmur often occurs secondary to pulmonary htn
Functional tricuspid regurgitation often occurs secondary to pulmonary hypertension
Critical limb ischaemia presents as?
pain at rest for greater than 2 weeks, often at night, not helped by analgesia
STEMI management, what anticoagulants to give>
STEMI management: if patient is having PCI then prasugrel is given in addition to aspirin. If patient is on an anticoagulant then clopidogrel used instead
What type of nystagmus seen in BPPV?
Rotatory nystagmus is indicative of a positive Dix-Hallpike manoeuvre
benign, lateral, unilateral neck mass. acellular fluid with cholesterol crystals on aspiration
Branchial cyst
Mx of acetazolamide
Acetazolamide is a carbonic anhydrase inhibitor that is used to treat idiopathic intracranial hypertension
How can TB affect the joints?
Can cause a polyarthritis
Hyaline casts may be seen in the urine of patients taking?
Loop diuretics
Brain abscess Mx:
IV 3rd-generation cephalosporin + metronidazole
first-line test for HIV screening of asymptomatic individuals or patients with signs and symptoms of chronic infection
Combined HIV antibody/antigen tests
purplish, lace-patterned discolouration of the skin
Livedo reticularis
investigation of choice in genital herpes
NAAT
What is used to treat cerebral oedema in patients with brain tumours
Dexamethasone
Abdominal wound dehiscence should initially be managed with
coverage of the wound with saline impregnated gauze + IV broad-spectrum antibiotics
Sudden onset headache, visual field defects + evidence of pitutary insufficiency (e.g. hypotension)
Pituitary apoplexy
first step in mx of patient with pleural effusion
Pleural aspirate
preferred method of access for haemodialysis
AV fistula
right iliac fossa, spouted and has a liquid output
Loop ileostomy
Where may gallstones present following cholecystectomy?
Gallstones may be present in the CBD causing ongoing jaundice and pain after cholecystectomy
Mx of renal stones >20mm
Percutaneous nephrolithotoym
pulmonary, hepatic, cerebral and spinal AVMs
Hereditary haemorrhagic telengiectasia
Features of still’s disease
Pyrexia in Still’s disease has a characteristic pattern. It typically rises in the late afternoon/early evening in a daily pattern and accompanies a worsening of joint symptoms and rash
ntervention of choice in patients with malignant distal obstructive jaundice due to unresectable pancreatic carcinoma
Biliary stenting
Adrenaline induced ischaemia mx
Phentolamine
triad of sudden onset abdominal pain, ascites, and tender hepatomegaly
Budd-chiari syndrome
Whatshould be used as the first-line treatment in opioid detoxification
Methaodone or buprenorphine
Naloxone is used in emergency management
Low cortisol on 9am cortisol test implies
Addison’s, need to synchacth
Grades of hepatic encephalopathy
Grade I: Irritability
Grade II: Confusion, inappropriate behaviour
Grade III: Incoherent, restless
Grade IV: Coma
secondary prophylaxis of hepatic encephalopathy
Rifamixin and lactulose
ocular pain and pain on eye movements associated with redness and swelling around the eye suggests
Orbital cellulitis
net-like pattern of reddish-blue skin discolouration that is non-blanching affecting her legs
Livedo reticularits
Management of myasthenic crisis
intravenous immunoglobulin, plasmapheresis
definitive management for theophylline toxicity
Haemodialysis
Obesity with abnormal LFTs
?NAFLD
unilateral tremor that improves with voluntary movement
Parkinson’s disease
Acute sensorineural hearing loss is an emergency and requires
urgent referral to ENT for audiology assessment and brain MRI
Chronic fatigue syndrome, how long before diagnosis can be made?
3 months
first-line investigation for a suspected osteoporotic vertebral fracture
X ray spine
treatment of choice for Bowen’s disease
Topical 5-fluorouracil
What type of ABx can lower the seizure threshold
Ciprofloxacin
Mx of subacute thyroiditis
NSAIDs - simple analgesia and conservative management
initial hyperthyroidism, painful goitre and globally reduced uptake of iodine-131
Subacute thyroiditis
hyperdense, crescentic collection around the left parietal lobe.
Acute subdural haematoma
If hypodense - chronic
Migraine Mx
acute: triptan + NSAID or triptan + paracetamol
prophylaxis: topiramate or propranolol
Topiramate not preferred in a woman of childbearing age
What Mx can cause osteonecrosis of the jaw
Bisphosphonate use
In patients with both vitamin B12 and folate deficiencies, what must be treated first
In patients with both vitamin B12 and folate deficiencies, the vitamin B12 deficiency must be treated first to avoid subacute combined degeneration of spinal cord
Mx of mild varicoceles
Reassure and observe
most likely operation to be done for symptomatic chronic subdural bleeds
burr hole evac
Increased, homogenous uptake on a radioactive iodine uptake test suggests
graaves disease
Raised ALP in the presence of normal LFT’s should raise suspicion of
malignancy. Particularly bone cancer/ metastases
Mx of hyperacute transplant rejection
Removal of graft
anorectal pain and a tender lump on the anal margin
Thrombosed haemorrhoids
What medication provides symptomatic relief for MG
Pyridostigmine
long-acting acetylcholinesterase inhibitor that reduces the breakdown of acetylcholine in the neuromuscular junction, temporarily improving symptoms of myasthenia gravis
asthma + aspirin sensitivity + nasal polyposis
Samter’s triad
AVOID ASPIRIN AND NSAIDS IN ASTHMA
2.5mm coved ST elevation in leads V1 and V2 followed by an inverted T wave. Exaggerated when fleicanide is given. Dx? Mx?
Brugada syndrome. Definitive management for Brugada syndrome is implantable cardioverter-defibrillator
Is strangulated hernia an open or laparoscopic procedure?
Open
Mx of gonorrhoea if patient refuses injection
For patients with gonorrhoea, a combination of oral cefixime + oral azithromycin is used if the patient refuses IM ceftriaxone
BP med that can cause gingival hyperplasia
Amlodipine
What can Over rapid aspiration/drainage of pneumothorax ersult in?
Re-expansion in pulmonary oedema
Left lower quadrant pain, low-grade fever in elderly patient
Diverticulitis
Corneal abrasion Mx
topical antibiotics should be given to prevent secondary bacterial infection
Difference in abg between diarrhoea and vomiting
Diarrhoea - metabolic acidosis (normal anion gap)
Vomiting - metabolic alkalosis
Can Abx be used as monotherapy in acne?
No, typically used adjunt to benzoyl peroxide
How should severe cellulits be treated
co-amoxiclav, cefuroxime, clindamycin or ceftriaxone
fasciculations
THink MND - typically spares ocular muscles
Rate of insulin infusion for DKA in adults
Diabetic ketoacidosis: the IV insulin infusion should be started at 0.1 unit/kg/hour
Most common organism found in central line infections
Staph epidermidis
Scrotal swelling you can’t get above:
Inguinal hernia
crypt abscesses
UC
All cases of pneumonia should have a repeat WHAT at 6 weeks after clinical resolution
CXR
Otalgia, fever, protruding ear and post-auricular tenderness
?mastoiditis, admit and IV ABx
How to differentiate between NMS and SS
NMS is typically seen in younger patients within hours-days after starting an antipsychotic and is associated with decreased reflexes and normal pupils
Seretonin syndrome - hyperreflexia and dilated pupils
diagnostic investigation of choice is the investigation of choice for suspected Non-Hodgkin’s lymphoma
Excisional node biopsy
Subdural haemorrhage results from bleeding of damaged?
bridging veins between the cortex and venous sinuses
Timolol MOA in gluacoma
Reduces aqueous secretion by ciliary body - reduces aqueous production
What supplementation is required prior to surgery for patients taking prednisolone
Hydrocortisone
most likely cause of an irregular broad complex tachycardia in a stable patient
AF with BBB
Urinary incontinence + gait abnormality + dementia
Normal pressure hydrocephalus
What anti hypetensive can cause reflex tachy
Nifedipine causes peripheral vasodilation which may result in reflex tachycardia
What should be corrected before giving bisphosphonates
Hypocalcaemia, vit D deficiency
How to differentiate between spider naevi and telengiectasia
Spider naevi can be differentiated from telangiectasia by pressing on them and watching them fill. Spider naevi fill from the centre, telangiectasia from the edge
What electrolyte abnormality can precipitate digoxin toxicity
Hypokalaemia
All patients with suspected upper GI bleed require?
An endoscopy within 24 hours of admission
red eye, photophobia and gritty sensation
Keratitis
A raised SAAG (>11g/L) indicates that it is?
Portal HTN that has caused the ascites
What has been shown to reduce the rate of CKD progression in ADPKD (and is approved by NICE)
Tolvaptan
For a patient with a Bell’s palsy, if the paralysis shows no sign of improvement after 3 weeks, mx?
Urgent referral to ENT
presentation of dysentery after a long incubation period
Amoebiasis
Managed with oral metro
What anaesthetic agent is useful in patients with a high risk of post operative vomiting
Propofol
`Necrotising fasciitis: most commonly affected site is
Perineum
Complete heart block following a MI?
RCA lesion
Dx of BPPV
Dix-hallpike
Following weight loss, whatis the first-line treatment for moderate/severe obstructive sleep apnoea
CPAP
Negative non-treponemal test + positive treponemal test is consistent with
successfully treated syphilis
Positive non-treponemal test + negative treponemal test
consistent with a false-positive syphilis result e.g. due to pregnancy or SLE (see list above)
Positive non-treponemal test + positive treponemal test
consistent with active syphilis infection
What can uncal herniation secondary to subdural cause?
third nerve palsy - down and out eye
A man suddenly stares into space and is non-responsive. He then repeatedly smacks his lip and appears to be chewing. This lasts for around 1 minute
Focal impaired awareness seizure
Abdominal distension, absence of passing flatus or stool, late onset/no vomiting
?LBO - ?malignancy
low T3/T4 and normal TSH with acute illness
Sick euthyroid syndrome
most common cause of secondary hypertension
Primary hy-peraldosteronism
most common cause of puritus vulvae is
contact dermatitis
Migraine triggers mneomonic
CHOCOLATE: chocolate, hangovers, orgasms, cheese/caffeine, oral contraceptives, lie-ins, alcohol, travel, exercise
If there is clubbing with hyperthyroidism, think?
Graves
1st line drug in the management of ocular myasthenia gravis
Pyridostigmine
What is a potential, and serious, cause of new onset atrial fibrillation following gastrointestinal surgery. What is the Mx?
Anastomotic leak
An anastomotic leak is a surgical emergency and patients must be taken back to theatre as soon as possible
What cancer marker is elevated in breast?
CA-15-3
Mx of venous ulceration
Compression bandaging
‘Popeye’ deformity in the middle of the upper arm
Biceps rupture
What skin condition may carbamezapine cause?
Steven Johnsons syndrome
Surgery/metformin on day of surgery
OD or BD: take as normal
TDS: miss lunchtime dose
assumes only one meal will be missed during surgery, eGFR > 60 and no contrast during procedure
Diagnostic criteria for AKI
↑ creatinine > 26µmol/L in 48 hours
↑ creatinine > 50% in 7 days
↓ urine output < 0.5ml/kg/hr for more than 6 hours
What type of surgery is done in type A aortic dissection
Aortic root replacement, IV labetalol adjunt
What type of head injury can present several weeks after the accident?
Subdural haematoma
Mx of non-falciparum malaria
Primaquine is used in non-falciparum malaria to destroy liver hypnozoites and prevent relapse
Ix of accoustic neuroma
MRI of cerebellopontine angle
Mouth manifestation of EBV. What is indicative of
Hairy leukoplakia is an EBV-associated lesion on the side of the tongue, and is considered indicative of HIV
Medical causes of gingival hyperplasia
phenytoin, ciclosporin, calcium channel blockers and AML
1st line treatment for seborrhoeic dermatitis
Topical ketoconzole
rythematous, scaly patches in sebum-rich areas such as the face (particularly nasolabial folds, eyebrows) and upper chest
Seborrhoeic dermatitis - Malassezia Furfur
PDE 5 inhibitors (e.g. sildenafil) - contraindicated by?
Nitrates and nicorandil
Kussmaul’s sign? Feature of?
The JVP increasing with inspiration is known as Kussmaul’s sign and can be a feature of constrictive pericarditis.
What are used to detect occupational asthma
Serial peak flow measurements at work and at home
Common electrolyte abnormality in SAH
Hyponatraemia
What type of repair is done for symptomatic AAA
undergo endovascular repair (EVAR)
Solitary firm papule/nodule that dimples on pinching
Dermatofibroma
How to differentiate between TACO and TRALI
Transfusion Associated Circularory Overload: Hypertension, raised jugular venous pulse, afebrile, S3 present.
Transfusion Related Acute Lung Injury: Hypotension, pyrexia, normal/unchanged JVP
What type of surgeries can lead to B12 deficiency
Gastrectomy, ileocaecal ersection
What deficiency seen in coeliac?
Coeliac disease is associated with iron, folate and vitamin B12 deficiency
Mouth side effect of tetracyclines
Black hairy tongue
Ix for all patients with suspected acute pericarditis
Transthoracic echo
How to differentiate between bullous pemphigoid and pemphigus vulgaris
Blisters/bullae
no mucosal involvement (in exams at least*): bullous pemphigoid
mucosal involvement: pemphigus vulgaris
How does ATN respond to fluid challenges?
Poorly
hip/groin pain and a snapping sensation
Acetabular labral tears
Postural headache but normal imaging ->
IIH
How to differentiate between tetanus and botulism
Fever, facial spasms, dysphagia in an intravenous drug user → ?tetanus (botulism would cause a flacid paralysis)
Adrenaline induced ischaemia mx
Phentolamine
Disseminated gonococcal infection triad
tenosynovitis, migratory polyarthritis, dermatitis
What medication can make perioral dermatitis worse?
Steroids
Order of Mx for symptomatic bradycardia
IV atropine 500mcg
Transcutaneous pacing
Transvenous pacing
First line management of acute pericarditis involves combination of
NSAID and colchicine
Criteria for oxygen support in ACS
<94 percent
Medical Mx of ER +ve breast cancers
Pre-menopausal - tamoxifen
Post-menopausal (including POF) - aromatose inhibitors - ozole
Diarrhoea, fatigue, osteomalacia →
Coeliacl?
Visual loss, relative afferent pupillary defect, ‘red spot’ on the retina →
Central retinal artery occlusion
Normocytic anaemia, thrombocytopaenia and AKI following diarrhoeal illness
HUS
Ix of choice for optic neuritis
Suspected optic neuritis: MRI of the brain and orbits with gadolinium contrast is the investigation of choice
Best Ix for HIV
Combined antibody/antigen test
Bubbly urine and nephritc picture
Enterovesical fistula?
Most specific finding on ECG for acute pericarditis
PR depression
Deterioration in patient with hepatitis B
?hepatocellular carcinoma
Ix for diabetes insipidus
Water deprivation test
Mx of painful mouth that may occur at the end of life
Benzydamine hydrochloride mouthwash or spray may be useful in reducing the discomfort associated with a painful mouth that may occur at the end of life
Mx of vestibular neuronitis
Acute: Prochloprazine
Chronic: Vestibular rehabilitation
Hodgkin’s lymphoma - best prognosis + worst prognosis
Best prognosis - Lymphocyte predominant
Worst prognosis - lymphocyte depleted
Aims of treatment in glaucoma
Reducing aqueous secretion and inducing pupillary constriction
What should be managed in the setting of acute ischaemic stroke prior to thrombolysis
Hypertension (>185/110 mmHg) in the setting of acute ischaemic stroke should be treated prior to thrombolysis - use labetalol
What type of infection is indicated in contact lens wearers?
Acanthamoebic keratitis
Typically seen in those who swim/act as a lifeguard with contact lenses in
foreign body sensation, conjunctival injection, and hypopyon on slit-lamp examination
Contact lens associated keratitis - if no water based RFs, think pseudoonas
What prophylaxis is needed for patients with nephrotic syndrome
LMWH prophylaxis
Dysphagia, aspiration pneumonia, halitosis →
?pharyngeal pouch
Finkelstein’s test
the examiner pulls the thumb of the patient in ulnar deviation and longitudinal traction. In a patient with tenosynovitis this action causes pain over the radial styloid process and along the length of extensor pollisis brevis and abductor pollicis longus
Post splenectomy blood film features:
Howell- Jolly bodies
Pappenheimer bodies
Target cells
Irregular contracted erythrocytes
Mechanical valves - target INR
Mechanical valves - target INR:
aortic: 3.0
mitral: 3.5
Mx of nec fas
immediate surgical debridement nd IV antibiotics
Best antibody for pernicious anaemia
IF antibody, can use gastric parietal cell if not
Bilateral grittiness - think?
Blepharitis. Mx with hot compress and lid hygiene
Mx of myasthenic crisis
IVIG, plasmapharesis
What associated condition causes hallucinations with age related macular degeneration
Charles bonnet syndrome
Mx of proximal pole scaphoid fractures
Urgent surgical screw fixation
growing keratotic nodule in an immunosuppressed patient on a sun-exposed site points strongly to a diagnosis of
SCC - managed with excision and biopsy
What medication co-prescribed with SSRIs is a common cause of seretonin syndrome
Tramadol
abnormally large drop in BP during inspiration, known as? Seen in?
In cardiac tamponade, there will be an abnormally large drop in BP during inspiration, known as pulsus paradoxus
Key side effects of prostaglandin analogues include
increased eyelash length, iris pigmentation and periocular pigmentation
Transcutaneous pacing AKA
External pacing
Generalised tonic clonic seizure Mx
Generalised tonic-clonic seizures
males: sodium valproate
females: lamotrigine or levetiracetam
Focal seizure Mx
first line: lamotrigine or levetiracetam
second line: carbamazepine, oxcarbazepine or zonisamide
Absence seizures Mx
Absence seizures (Petit mal)
first line: ethosuximide
second line:
male: sodium valproate
female: lamotrigine or levetiracetam
carbamazepine may exacerbate absence seizures
Myoclonic seizures Mx
Myoclonic seizures
males: sodium valproate
females: levetiracetam
Tonic or atonic seizure Mx
Tonic or atonic seizures
males: sodium valproate
females: lamotrigine
treatment of choice for SLE
Hydroxychloroquine
Difference in cauess of oral and genital herpes
Oral - HSV 1
Genital - HSV 2
Long term management of diverticular didsease
Increased dietary fibre intake
Breakthrough dose
1/6th dose of morphine
codeine to morphine
divide by 10
morphine to subcut morphine
divide by 6
Increase morphine doses by how much if pain not controlled
30-50%
Recurrent episodes of natal cleft pain with discharge
?Pilonidal disease
Important differential between viral labyrinthitis and vestibular neuronitis
VIRAL LABYRINTHITIS HAS HEARING LOSS
Mx of otitis media with perf
ABx and review in 6-8 weeks (5 day course of amox)
A description of the contents for amoebic liver abscesses is described as ‘anchovy sauce’
E. histolytica is known to digest hepatic tissue
As well as xanthochromia, CSF findings consistent with subarachnoid haemorrhage include
Normal or raised opening pressure
Myeloma aspirate
Plasma cells
EBV: associated malignancies:
Burkitt’s lymphoma
Hodgkin’s lymphoma
nasopharyngeal carcinoma
Hypoglycaemia with impaired GCS: give
IV glucose if there is access
Aim for a break of how long in between courses of topical corticosteroids in patients with psoriasis
4 week
speech fluent, comprehension abnormal, repetition impaired
Wernicke’s (receptive) dysphasia
Due to a lesion of the superior temporal gyrus. It is typically supplied by the inferior division of the left MCA
Speech is non-fluent, laboured, and halting. Repetition is impaired
Comprehension is normal
Broca’s (expressive) aphasia
Due to a lesion of the inferior frontal gyrus. It is typically supplied by the superior division of the left MCA
Speech is fluent but repetition is poor. Aware of the errors they are making
Comprehension is normal
Conduction aphasia
Arcuate fasciculus affected in stroke
Following weight loss, WHAT is the first-line treatment for moderate/severe obstructive sleep apnoea
CPAP
Adverse skin reaction that carbamezapine can cause
Steven Johnson’s syndrome
Contralateral homonymous hemianopia with macular sparing and visual agnosia
posterior cerebral artery
Stevens-Johnson syndrome exhibits Nikolsky sign in erythematous areas. What is this?
blisters and erosions appear when the skin is rubbed gently
What nerve lesion can cause weakness of foot dorsiflexion and foot eversion
Common peroneal nerve
treatment of choice for essential tremor
Propanolol
undoscopy typically shows a swollen pale disc and blurred margins
Anterior ischaemic optic neuropathy
What anti hypertensive can ause increased HR?
Nifedipine - peripheral vasodilation - reflex tachycardia
What is used for long-term prophylaxis of cluster headaches
Verapamil
Greek boy develops pallor and jaundice after having a lower respiratory tract infection. He has a history of neonatal jaundice. The blood film shows Heinz bodies
G6Pd
first line investigation for stable chest pain of suspected coronary artery disease aetiology
Contrast-enhanced CT coronary angiogram
What is the most sensitive and specific lab finding for diagnosis of liver cirrhosis in those with chronic liver disease
Thrombocytopenia
Addison’s disease/adrenal insufficiency can cause what acid base disturbance
Hyperkalaemic metabolic acidosis
Target saturations in COPD are WHAT if CO2 is normal on ABG
94-98%
Nicorandil SE
ulceration of GI tract
The most common site of metatarsal stress fractures is the?
2nd metatarsal shaft
diagnostic investigation of choice for pancreatic cancer
High resolution CT scan
Isolated lateral hip/thigh pain with tenderness over the greater trochanter
Trochanteric bursitis
How may uraemia present in AKI? What is it an indication for?
Encephalopatny or pericarditis, indication for dialysis
COPD - LTOT if 2 measurements of pO2
<7.3kPa
Patients who are allergic to aspirin may also react to what drug?
Sulfasalazin e
Localised headache, neck pain, and neurological signs (e.g. Horner’s) are indicative of
Carotid artery dissection
empirical treatment of choice in native valve endocarditis
IV amox
Diabetic ketoacidosis: the IV insulin infusion should be started at
0.1 unit/kg/hour
What are curlings ulcers
acute gastric ulcers that develop in response to severe physiological stress, such as burns
thrombophlebitis of the internal jugular vein following an anaerobic oropharngeal infection.
Lemierre’s syndrome
Pagets Mx
IV bisphosphonates
Genital wart treatment
multiple, non-keratinised warts: topical podophyllum
solitary, keratinised warts: cryotherapy
Autonomic dysreflexia can only occur if the spinal cord injury occurs above the level of?
T6
Which duct can be blocked by gallstones without causing jaundice?
Cystic
Facial rash plus lymphadenopathy think?
Sarcoidosis
Retinal haemorrhages, subdural haematoma and encephalopathy is the triad of
shaken baby syndrome
How to differentiate between anterior and posterior shoulder dislocation
Anterior shoulder dislocation is associated with FOOSH; while posterior shoulder dislocation is more likely associated with seizures and electric shock
What medication can make clopidogrel less effective?
Omeprazole
Infective exacerbation of COPD: first-line antibiotics are
Amox, clarithro, or foxy
When to use cryoprecipitate in bleeding
Low fibrinogen
Dysplasia on biopsy in Barrett’s oesophagus requires
Endoscopic mucosal therapy
What medications are useful in patients with T2DM who are obsese?
Sitagliptin
Severe diarrhoea, particularly in elderly patients may results in what blood gas
renal impairment, hypokalaemia and hyponatraemia - metabolic acidosis
What may lower lobe pneumonia present with?
Upper quadrant abdo pain
Mx for post LP headache
Caffeine and fluids
Marker for carcinoid tumours
Urinary 5-HIA
Haptoglobin level in haemolysis
Low - Haptoglobin binds to free haemoglobin
What contraceptive method can cause drug induced cholestasis
COCP
first-line investigation in suspected prostate cancer
Multiparametric MRI
first-line for spasticity in multiple sclerosis
Baclofen and Gabapentin
inferior myocardial infarction and AR murmur should raise suspicions of
Ascending aorta dissection
False positive VDRL/RPR:
‘SomeTimes Mistakes Happen’ (SLE, TB, malaria, HIV)
As well as Horner’s syndrome, Pancoast tumours may also present with
shoulder pain and upper limb neurological signs due to local extension of the tumour
Dermatitis, diarrhoea, dementia/delusions, leading to death
Pellagra
The presence of an elevated prolactin level along with secondary hypothyroidism and hypogonadism is indicative o
stalk compression is consistent with a non-functioning pituitary adenoma
Prostatitsi Mx
quinolone for 14 days e.g. cipro
Systemic lupus erythematosus with proteinuria on urinalysis
Lupus nephritis
What type of tumours can secrete pituitary hormones
Carcinoid tumours
What is INO? Why does it occur? WHat does it result in?
Internuclear ophthalmoplegia (INO) occurs due to a lesion of the medial longitudinal fasciculus (MLF), a tract that allows conjugate eye movement. This results in impairment of adduction of the ipsilateral eye. The contralateral eye abducts, however with nystagmus.
abdominal pain, diarrhoea and flushing which are the classical features
Carcinoid syndrome
‘Global’ T wave inversion (not fitting a coronary artery territory) -
think non-cardiac cause of abnormal ECG
Best ABx for MRSA
Vanco
A double pulse felt in systole is called a
bisferiens pulse or pulsus bisferiens
Caused by mixed aortic valve disease
Mx to prevent relapse in MS
Natalizumab
Ix for Takayasu’s
Vascular imaging is required to make a diagnosis of Takayasu’s arteritis - either magnetic resonance angiography (MRA) or CT angiography (CTA)
What strain HPV RF for oropharyngeal cancer
16/18
f shown a skull x-ray in an exam, think what condition?
Paget’s
Most important causes of VT clinically
Hypokalaemia, then hypomagnesaemia
Mx of small cell lung cancer
Surgery plays little role in the management of small cell lung cancer, with chemotherapy being the mainstay of treatment. Adjuvant radiotherapy is also now given in patients with limited disease.
n a child with sickle cell disease presenting with fever (temperature >38°C), do what
urgent hospital admission
DKA resolution is defined as
pH >7.3 and
blood ketones < 0.6 mmol/L and
bicarbonate > 15.0mmol/L
GCS - motor response
- Obeys commands
- Localises to pain
- Withdraws from pain
- Abnormal flexion to pain (decorticate posture)
- Extending to pain
- None
To be counted as localising, the arm must be brought above the clavicle, else it should be scored as ‘flexing’
GCS - Verbal
- Orientated
- Confused
- Words
- Sounds
- None
GCS - Eye
- Spontaneous
- To speech
- To pain
- None
A transaminitis (elevated ALT and AST) in the 10,000s is most commonly caused by
Paracetemol OD
Pigmented gallstones are associated with
Sickle cell anaemia
Mx of autonomic dysreflexia
emoval/control of the stimulus and treatment of any life-threatening hypertension and/or bradycardia e.g. removal of faecal matter
Schistosomiasis Mx
Praziquantel
What side of the heart can carcinoid syndrome affect? what does it cause
Carcinoid syndrome can affect the right side of the heart. The valvular effects are tricuspid insufficiency and pulmonary stenosis
LP findings for GBS
Protein risen, normal WCC
firm, smooth, tender and pulsatile liver edge
RHF
Mx of botulism
Botulism antitoxin
What metaboli distrubance can cholera present with
Hypoglycaemia
Parkland formula
4ml * % body surface area * weight (kg) = ml of Hartmann’s to be given in first 24 hours
The Parkland formula is used to calculate the amount of fluid to give in the first 24 hours after burns, with half being given in the first 8 hours
Dermatitis in acral, peri-orificial and perianal distribution
?Zinc deficiency
initial management of acute limb ischaemia
analgesia, IV heparin and vascular review
Mx of acute bronchitisi
The management is usually supportive, but if available it can be guided by the CPR levels. If the patient has a CRP of 20-100mg/L they should be offered a delayed prescription or if they have a CRP >100mg/L you should offer antibiotics immediately. The antibiotic of choice is usually doxycycline.
Intermittent limb claudication, absent or weak peripheral pulses in a young woman,
Takayasu’s arteritis
eGFR variables
CAGE - Creatinine, Age, Gender, Ethnicity
What Ix may be useful for diagnosing and monitoring the severity of liver cirrhosis
Transient elastography
Laughter → fall/collapse
?cataplexy
Recognised complication of NG feeding
Diarrhoea
Widened Qrs
> 100ms
first line test for diagnosis of small bowel overgrowth syndrome
Hydrogen breath testing
Facial rash plus lymphadenopathy think
Sarcoidosis
Features and Mx of anterior dislocation of shoulder
most common type of dislocation
may follow a fall on arm or shoulder
always check pulses and nerves (particularly AXILLARY - as commonly injured)
Always do a radiograph
Treatment: reduction (many methods), analgesia and sling
Features and Mx of posterior shoulder dislocation
rare, caused by seizure or electrocution
‘lightbulb sign’ on x-ray
refer to orthopaedic surgeons
Multiple sclerosis patient with bladder dysfunction. What Ix?
get an ultrasound KUB first to assess bladder emptying
Knee osteo pain ladder
Topical NSAIDs
Oral NSAID + PPi
Mx of MRSA
Vanco 1st
Linezolid 2nd
In children the most common site where osteomyelitis occurs in a long bone is the
Metaphysis
What urinary Ix done for phaeo
Metanephrines NOT catecholamines
What are common complications of seborrhoeic dermatitis
Otitis externa and blepharitis
The universal donor of fresh frozen plasma is
AB RhD negative blood
New onset AF is considered for electrical cardioversion if
it presents within 48 hours of presentation
Definition of upper GI bleed
haemorrhage with an origin proximal to the ligament of Treitz
Cellulitis (near the eyes or nose) Mx
Co-amox
Mechanism of controlled ventilation in raised ICP
hyperventilation –> reduce pCO2 → vasoconstriction of the cerebral arteries → reduced ICP
persistent sensation of having a ‘lump in the throat’, when there is none.
Globus
What endocrine abnormality can cause a euvolaemic hyponatraemia
Hypothyroidism
widespread cerebral atrophy mainly involving the cortex and hippocampus
Alzheimer’s
What should be used for standard-release ISMN to prevent nitrate tolerance
Asymmetric dosing regimes
What type of pill is best in women with acne
COCP, swap from POP if on this
Moderate-severe aortic stenosis is a contraindication to which anti hypertensice
Ace inhibitors
Pulmonary embolism and renal impairment. What Ix
V/Q scan is the investigation of choice
Renal colic. Mx of pain if NSAIDs contraindicated
Renal colic: if NSAIDs are contraindicated or not giving sufficiency pain relief NICE recommend IV paracetamol
first-line imaging of choice when investigating thyroid nodules
Ultrasonography
most common and important viral infection in solid organ transplant recipients
CMV
White cells present on urine dip and AKI
think AIN
Defunctioning the bowel indicates what type of stoma
Loop ileostomy
triad of encephalopathy, jaundice and coagulopathy
Liver failure
Mx of euvolemic and hypervolemic hyponatraemic patients who don’t have severe symptoms
Fluid restrict
How does airway management differ in spinal cord injury?
n adults where there is no concern for a cervical spine injury, a head-tilt chin-lift manoeuvre is appropriate but in the setting of major trauma like this patient where cervical spine injuries are unknown, a jaw-thrust is more appropriate
What Ix must be done regularly post op
Electrolyte panel to check for post operative ileus
Young adult with sore throat, fever, lethargy, cervical lymphadenopathy persisting > 1 week
Infectious mononucleosis
What is the most common cause of hypernatraemia in the elderly
Dehydration, either due to decreased intake or increased GI loss (eg. diarrhoea or vomiting)
Compartment syndrome is most commonly associated with what fractures?
Supracondylar and tibial shaft
What therapy is avoided if there is thyroid eye disease
Radioactive Iodine
Important SEs of penicillins
Toxic epidermal necrolysis
Urinary prioblems in a man with a history of gonorrhoea may be due to
Urethral stricture
What is the commonest cause of viral encephalitis in the adult population
Herpes simplex
Enteroviruses are most common cause of viral meningitis
Metabolic ketoacidosis with normal or low glucose:
Think alcohol
If a pituitary incidentaloma is found within the sellar, what must be done?
Lab investigation must be done to determine if it is functional or non functional
Best anaesthetic agent for haemodynamically unstable patients
Ketamine
Mx of salicyclate OD
IV sodium bicarb
What Sx are a red flag for patients with chronic rhinosinusitis
Unilateral
red eye and reduced vision following intraocular surgery.
Endophthalmitis
How many days before surgery is warfarin stopped
5
Ongoing diarrhoea in Crohn’s patient post-resection with normal CRP. Mx?
cholestyramine
Patients with type I diabetes and a BMI > 25 should be considered for WHAT in addition to insulin
metformin
Target-shaped lesion in the right upper lobe with air crescent sign present
Aspergilloma
reatment of choice for small bowel bacterial overgrowth syndrome
Rifamixin
hypochromic microcytic anaemia
high ferritin iron & transferrin saturation
- basophilic stippling of red blood cells
Sideroblastic anaemia
Ix for mycoplasm
Serology
Cardiac deformity associated with ADPKD
Mitral valve prolapse
Women with breast cancer and no palpable axillary lymphadenopathy at presentation should have a WHAT before their primary surgery
Pre operative axillary US
What can CLL transform to? What is this known as?
CLL can transform to high-grade lymphoma (Richter’s transformation) making patients suddenly unwell
SE of vincristine
Periphereal neuropathy
Strongest association of H.pylori
Duodenal ulcer
SE of ciclosporin
Hepatotoxicity + nephrotoxicity
An itchy rash affecting the face and scalp distribution is commonly caused by
Seborrhoeic dermatitis
Restless leg syndrome - management includes
opamine agonists such as ropinirole
The patient’s symptoms of ‘antsy’ legs, a creeping sensation, and relief with movement are suggestive of
restless legs syndrome (RLS), also known as Willis-Ekbom disease
What condition should metformin be stopped in?
MI, risk of lactic acidosis
What should be used to treat AF if there is coexistent heart failure, first onset AF or an obvious reversible cause
Rhythm e.g. amiodorone
Grave’s disease, orange peel shin lesions
Pretibial myxoedema
Thin, intracystic eggshell calcification throughout the bladder.
Schistosomiasis –> think SCC of bladder
How to start fluid resus in children
Start IV fluid resuscitation in children or young people with a bolus of 10 ml/kg over less than 10 minutes
What pulse is HOCM associated with
Bisfieriens - double pulse
If a patient with AF has a stroke or TIA, the anticoagulant of choice should be
warfarin or a direct thrombin or factor Xa inhibitor
If not, clopi
Type of melanoma that invades aggressively and metastasies early
Nodular
electrolyte abnormality that PPis can cause
Hyponatraemia
Difference in menorrhagia with thyroid issues
Hyperthyroidism is associated with oligomennorhoea, or amennorhoea, whereas hypothyroidism is associated with menorrhagia
Mx of toxoplasmosi
Immunocompetent patients with toxoplasmosis don’t usually require treatment
Pyrimethamine and sulphadiazine are management options for immunocompromised patients.
Ank spond Xray findings
subchondral erosions, sclerosis
and squaring of lumbar vertebrae
Bilateral conjunctivitis, bilateral calf pains and high fevers in a sewage worker suggests
Leptospirosis
aynaud’s phenomenon with extremity ischaemia
Buerger’s disease - Thromboangiitis obliterans
What is a RAPD
when the affected and normal eye appears to dilate when light is shone on the affected eye
Management of SCC in cosmetically important sites
MOHS
Management of SCC of skin
Surgical excision with 4mm margins if lesion <20mm in diameter. If tumour >20mm then margins should be 6mm
In aortic dissection, a pulse deficit may be seen: What may this include?
weak or absent carotid, brachial, or femoral pulse
variation in arm BP
Septic arthritis ABx therapy duration
4-6 weeks
Most important prognostic factor in melanoma
Invasion depth of the tumour
Asthma Mx pathway for >12
Low dose ICS/formoterol
Low dose MART
Moderate dose MART
Check Feno and eosinophils (if raised) –> refer to respiratory specificaly
If not raised –> Add LTRA or LAMDA
What can alcohol bingeing lead to in terms of endocrinological picture?
Alcohol bingeing can lead to ADH suppression in the posterior pituitary gland subsequently leading to polyuria
branching linear lesion with terminal bulbs seen on fluorescein staining is characteristic of
Herpes simplex keratitis
Treat with topical aciclovir
What should patients be screened for before starting rituximab treatment
Hep B
Constipation - if symptoms don’t respond to a bulk-forming laxative such as isphagula husk, try an
Osmotioc laxativev such as a macrogol
Which opioid is licensed for neuropathic pain
Tramadol
Patients who have varicose veins and an active or healed venous leg ulcer should be referred to
Secondary care for treatment
What should be considered in patients with ches wall trauma who have elevated JVP, persistent hypotension and tachycardia despite fluid resuscitation
Cardiac tamponade - pericardiocentesis
Patients with ascites (and protein concentration <= 15 g/L) should be given WHAT as SBP prophylaxis
oral ciprofloxacin or norfloxacin as prophylaxis against spontaneous bacterial peritonitis
Red eye - glaucoma or uveitis?
glaucoma: severe pain, haloes, ‘semi-dilated’ pupil
uveitis: small, fixed oval pupil, ciliary flush
What is recommended after a woman has had a wide-local excision as this may reduce the risk of recurrence by around two-thirds
Whole breast radiotherapy
Adults with asthma who are poorly controlled on SABA prn + regularly ICS
regular low-dose regular ICS/formoterol combination inhaler (MART therapy)
ST elevation and acute pulmonary oedema in a young patient with a recent flu-like illness
Myocarditis
For children aged 5 to 16, if the FeNO level is not raised, or if FeNO testing is not available then measure
bronchodilator reversibility (BDR) with spirometry
What may topical steroids cause in patients with darker skin
Patchy depigmentation
What ytpe of lung cancer is most likely to cause cavitating lesions
Squamous cell
Achilles tendonitis Mx
rest, NSAIDs, and physio if symptoms persist beyond 7 days
Ix of choice for gastric cacner
Oesophago-gastro-duodenoscopy with biopsy
Prosthetic heart valves - antithrombotic therapy:
bioprosthetic: aspirin
mechanical: warfarin + aspirin
Mirror image nuclei
Hodgkin’s lymphoma
Red or black lump, oozes or bleeds, sun-exposed skin
Nodular melanoma
blood in the eye anterior chamber known as
Hyphema –> urgent referral to on call opthal
Most common organism causing cholangitis
E.coli
Infective endocarditis causing congestive cardiac failure is an indication for WHAT
Emergency valve replacement surgery
Most common primary site of brain mets
Lung
What clotting time does warfarin prolong
PT
Most likely SSRI to lead to QT prolongation and torsades
Citalopram
What is Simmond’s triad? What is it used for?
Use Simmonds triad (palpation, examining the angle of declination at rest and the calf squeeze test) to assess for evidence of Achilles tendon rupture
what type of oesophagael cancer does achalasia increase risk of
SCC
Progressively worsening headache with higher cognitive function impaired. What is required
Urgent imaging
Ix of choice for suspected psoas
CT abdo
Definitive Mx of sickle cell crisis
Exchange transfusion
Mx of HAP
Co-amox
Mx of polycythaemia Vera
aspirin
reduces the risk of thrombotic events
venesection
first-line treatment to keep the haemoglobin in the normal range
chemotherapy
hydroxyurea - slight increased risk of secondary leukaemia
phosphorus-32 therapy
Dx that can result in both corneal opacities and optic neuritis
Amiodarone
When to treat subclinical hypothyroidism
if the TSH level is > 10 mU/L on 2 separate occasions 3 months apart
Mx of amiodarone induced hypothyroidism
Keep amiodarone and add levo
Returning traveller with fever/flu-like symptoms, anaemia/jaundice/renal impairment
Falciparum malaria
When dealing with heart failure not responding to ACE-inhibitor, beta-blocker and aldosterone antagonist therapy, a widened QRS complex favours what Mx
Cardiac resynchronisation therapy
Pancytopaenia 5 years post-chemotherapy/radiotherapy →
Myelodysplastic syndrome
In patients with breast cancer undergoing breast conserving surgery with adjuvant radiotherapy if, at sentinel node biopsy, more 3 or more involved nodes are found then WHAT is indicated
axillary node clearance
If a diagnosis of acute cholecystitis remains uncertain after ultrasonography, what Ix may be done
technetium-labelled HIDA scan may be done
abdominal X-ray shows multiple dilated loops of bowel with air-fluid levels and prominent haustra.
LBO
Hiccups in palliative care
chlorpromazine or haloperidol
Quinine can cause what
Hypoglycaemia
What type of CP450 medications increase warfarin
INhibitors INcrease warfarin
How does NMS typically present on blood tests
Raised CK and WCC
What is the key parameter to monitor in patients with hyperosmolar hyperglycaemic state
Serum osmolality
Anisocoria worse in bright light implies a problem with which pupil
the dilated pupil
Cardiac catheterisation results - jump in oxygen saturation from right atrium to right ventricle
VSD?
treatment option for patients with metastatic HCC
Sorafenib
SE of sulfasalazine in men
Low sperm count
Painless genital pustule → ulcer → painful inguinal lymphadenopathy → proctocolitis
Lymphogranuloma Venereum
Classical presentaiton of cauda equina? Late signs include?
Cauda equina syndrome classically presents with lower back pain, sciatica, reduced perianal sensation. Late signs include urinary incontinence
Mx of refractory anaphylaxis
IV adrenaline + IV fluids
Avoid what anti emetic in bowel obstruction
metoclop
Isolated rise in GGT in the context of a macrocytic anaemia suggests
Alcohol XS
combination of HIV + chest symptoms + unremarkable auscultatory findings in an exam are highly suggestive
Pneumocystitis jiroveci
Ciclosporin side-effects
everything is increased - fluid, BP, K+, hair, gums, glucose
screening test for APKD
US
oral ulcers, genital ulcers and uveitis
Behcets
proportion of patients with the condition who have a positive test result
Sensitivity
Proportion of patients without the condition who have a negative test result
Specificity
Acute heart failure with hypotension Mx
inotropes be considered for patients with severe left ventricular dysfunction who have potentially reversible cardiogenic shock
In beta-thalassaemia, what is given adjunt to repeat transfusions? Why?
In beta-thalassaemia major, iron chelation therapy (e.g. desferrioxamine) is important to prevent the complications of iron overload due to repeat transfusions
Mx of Paracetemol OD if presentation >8 hours
Paracetamol overdose: if presentation 8-24 hours after ingestion of an overdose of more than 150 mg/kg start acetylcysteine even if the plasma-paracetamol concentration is not yet available
Mx of paracetemol OD if presentation >24 hours
if presentation > 24 hours after an overdose start acetylcysteine if the patient is jaundiced, has hepatic tenderness or an elevated ALT
What should patients on SGLT-2 inhibitors be monitored for?
Closely monitor legs and feet of patients taking canagliflozin for ulcers or infection - possible increased risk of amputation
A wide-based gait with loss of heel to toe walking is called an
Ataxic gait
Mx of servere AI hepatitis
Steroids
How long of a break to take between topical steroid uses in psoriasis?
4 weeks
How to differ between radial tunnel syndrome and lateral epidondylitis
Radial tunnel syndrome presents similarly to lateral epicondylitis however pain is typically distal to the epicondyle and worse on elbow extension/forearm pronation
muscle relaxant of choice for rapid sequence induction for intubation
Suxamethonium
Risk of 0.9% NaCL in large columes
Hyperchloraemic metabolic acidosis
Spontaneous bacterial peritonitis: most common organism found on ascitic fluid culture is
E.Coli
Mx of prolactinoma
Dopamine agonist
Then surgery if indicated
exquisitely tender red-eye in a patient with SLE
Scleritis
Biggest risk of hyphema
Glaucoma
Which nerve damaged in wrist drop?
Radial, often caused by fracture of shaft of humerus
Slow growing, painless, mobile lump in the parotid gland of older female →
?Pleomorphic adenoma
Alcoholic ketoacidosis is managed with
Saline infusion and thiamine
Should morphine always be given in patients with ACS?
No, only to patients with severe pain - otehrwise paracetemol may be given
What antihypertensive can worse glucose tolerance
Thiazides
A patient develops acute heart failure 5 days after a myocardial infarction. A new pan-systolic murmur is noted on examination
VSD
Flashers and floaters in vision without vision loss
Posterior vitreous detachment
If with vision loss, retinal detachment
What may a raised CRP in SLE indicate
Underlying infection
Latent tuberculosis treatment options:
3 months of isoniazid (with pyridoxine) and rifampicin, or
6 months of isoniazid (with pyridoxine)
What Mx should all patients with PAD takeq
Clopi and statin
High uric acid + renal impairment following chemotherapy. Dx? Mx?
Tumour lysis syndrome. Mx is rasburicase
lump in the midline between umbilicus and the xiphisternum
Epigastric hernia
Mx of suspected neutropenic sepsis
If neutropenic sepsis is suspected (i.e. recent chemo + fever) IV antibiotics must be started immediately - do not wait for WBC
What airway management is preferred if concerned about cervical spine injury?
Jaw thrust
Complication of Klebsiella
Empyema
Ix of choice for avascular necrosis of the hi[
MRI
Alternative to spirinolactone if gynaecomastia troublesome in HF
Eplerenone
Recommend Adult Life Support (ALS) adrenaline doses
anaphylaxis: 0.5mg - 0.5ml 1:1,000 IM
cardiac arrest: 1mg - 10ml 1:10,000 IV or 1ml of 1:1000 IV
Correcting sodium levels rapidly is dangerous: What can it lead to
Hyponatraemia correction - osmotic demyelination syndrome
Hypernatreamia correction - cerebral oedema
Types of AKI
Pre-renal:
Caused by inadequate renal perfusion e.g. dehydration, haemorrhage, heart failure, sepsis
Kidneys act to concentrate urine and retain sodium - urine osmolality high, urine sodium low
Renal:
Most common = acute tubular necrosis
Damage to tubular cells due to prolonged ischaemia or toxins
Kidneys can no longer concentrate urine or retain sodium - urine osmolality low, urine sodium high
Rarer causes = acute glomerulonephritis, acute interstitial nephritis
Post-renal:
Obstruction of urinary tract
Usually identified with hydronephrosis on renal ultrasound
1st line treatment for compacted ear wax
Olive oil drops
1st line treatment for digoxin toxicity
Digibind
What antibodies in drug induced lupus
anti-histone
Renal tubular acidosis leads to what ABG picture
hyperchloraemic, normal anion gap metabolic acidosis
t SCC is associated with what infection
HPV
What Mx for prevention of calcium stones
Potassium citrate
HerpesVirus FAmily
Herpes simplex type I (HSV-1).
Herpes simplex type II (HSV-2).
Varicella-zoster virus (VZV/HHV-3).
Epstein-Barr virus (EBV/HHV-4).
Cytomegalovirus (CMV/HHV-5).
Herpesvirus type 6 (HBLV/HHV-6) - Roseola Infantum
Herpesvirus type 7 (HHV-7) - Roseola Infantum
Kaposi’s sarcoma herpesvirus (KSHV/HHV-8).
Persistent mouth ulcer
?SCC
Alterntative to atropine in symtpomatic brady
Adrenaline
Earliest and most common Sx of spinal cord compression
Back pain
Medical Mx of raynauyd
Nifedipine
Renal transplant + Infection?
CMV
What is diclofenac contraindicated in?
IHD
In type 1 diabetics, blood glucose targets:
5-7 mmol/l on waking and
4-7 mmol/l before meals at other times of the day
continuous dribbling incontinence after prolonged labour
Vesicovaginal fistula
most common complication of thyroid eye disease
Exposure keratopathy
Isolated fever in well patient in first 24 hours following surgery?
Physiological reaction to surgery
treatment for acute clot retention
Continuous bladder irrigation via a 3 way urethral catheter
Unruptured sigmoid volvulus is primarily managed by
Flatus tube insertion
HOCM Auscultation
HOCM may present with ejection systolic murmur, louder on performing Valsalva and quieter on squatting
Criteria for LTOT
Offer LTOT to patients with a pO2 of < 7.3 kPa or to those with a pO2 of 7.3 - 8 kPa and one of the following:
secondary polycythaemia
peripheral oedema
pulmonary hypertension
Alternative to amiodorane in ALS
Lidocaine
For patients with rosacea with predominant flushing but limited telangiectasia, consider prescribing
Bromonidine gel
referred and most effective mode of treatment for achalasia in a young patient without multiple comorbidities
Pneumatic dilatation
What is the technique to stop variceal bleeding if it is oesophageal
Endoscopic band ligation
What % reduction aimed for in HDL cholesterol
40%
ASymmetrical spreading lymphadenopathy
Hodkin’s
Widespread convulsions without conscious impairment is likely to represent a
Pseudoseizure
Lymph node pain when drinking alcohol is very specific
Hodgkin’s lymphoma
Plucking of clothes is typically seen in WHAT lobe seizures
Temporal
Triad for insulinoma
Whipple’s triad of symptoms of 1) hypoglycaemia with fasting or exercise, 2) reversal of symptoms with glucose, and 3) recorded low BMs at the time of symptoms is hallmark for an insulinoma
Combination of alcohol + what ABx can lead to a strange hangover like reaction
Metro
What is the ulnar paradox
proximal lesions of the ulnar nerve produce a less prominent deformity than distal lesions
When the ulnar nerve is damaged at the wrist, the medial two lumbrical muscles are affected (the lateral two being supplied by the median nerve). Denervation of the lumbricals, which flex the metacarpal phalangeal joints (MCPJ) and extend the interphalangeal joints (IPJ), causes unopposed extension of the MCPJ by extensor digitorum longus and flexion of the IPJ by flexor digitorum profundus and superficialis. This gives the hand a claw like appearance.
When the ulnar nerve is damaged at the elbow, the ulnar half of flexor digitorum profundus is also affected resulting in a less marked clawing due to reduced unopposed flexion at the IPJ.
Sudden heart failure, raised JVP, pulsus parodoxus, recent MI
left ventricular free wall rupture
What are cotton wool spots in diabetic retinopathy
Areas of infarction
NSTEMI (managed with PCI) antiplatelet choice:
if the patient is not taking an oral anticoagulant: prasugrel or ticagrelor
if taking an oral anticoagulant: clopidogrel
The main components for managing sickle cell crisis should be
analgesia, oxygen, and IV fluids. You can also consider antibiotics if you suspect an infection, and transfusion if the Hb is low
most common cause of hypopituitarism
non secreting pituitary macroadenomas
HIV, diarrhoea, Ziehl-Neelsen stain showing protozoa
Cryptosporidium parvum
‘empty delta sign’ seen on venography
Saggital sinus thrombosis
treatment of choice for facial hirsutism
Topical eflornithine
The transfusion threshold for patients without ACS
70g/L
Motion sickness Mx
hyoscine > cyclizine > promethazine
What is a high stepping gait? Why does it develop? Unilateral and bilateral causes?
A high-stepping gait develops to compensate for foot drop. If found unilaterally then a common peroneal nerve lesion should be suspected. Bilateral foot drop is more likely to be due to peripheral neuropathy.
The causes of massive splenomegaly are as follows:
myelofibrosis
chronic myeloid leukaemia
visceral leishmaniasis (kala-azar)
malaria
Gaucher’s syndrome
Pulse pressure in AS vs AR
AS - narrow
AR - widefned
Mx of perforated eardrum
no treatment is needed in the majority of cases as the tympanic membrane will usually heal after 6-8 weeks. It is advisable to avoid getting water in the ear during this time
What is a positive straight leg raise suggest?
A positive straight leg raise is performed by raising the leg whilst it is straight if this causes pain in the distribution of the sciatic nerve then the test is positive.
Squints may be classified as to where the eye deviates toward
the nose: esotropia
temporally: exotropia
superiorly: hypertropia
inferiorly: hypotropia
night blindness + tunnel vision
Retinitis pigmentosa
Mx of allopurinol if recurrent episodes of gout
Continue
Howvever, should not start allopurinol in first episode of gout - need NSAID cover
How to remember skewed distributions
alphabetical order: mean - median - mode
‘>’ for positive, ‘<’ for negative
CN6 palsy manifesting as diplopia could be the first sign of
Brain mets
nvestigation of choice for suspected Boerhaave’s syndrome
CT contrast swallow
Rotator Cuff muscles
Subscapularis - positioned anteriorly on your chest, helps with internal rotation of shoulder
Supraspinatus - positioned on top of your shoulder and runs parallel to your deltoid. Needed for the first 20° of shoulder abduction, then the rest of abduction is done by the deltoid
Infraspinatus - positioned posteriorly on the superior aspect of your back, helps with external rotation of shoulder
Teres minor - positioned posteriorly on the superior aspect of your back, helps with external rotation of shoulder
In hypothermia, what can rapid rewarming lead to?
Peripheral vasodilation and shock
CT abdomen is arranged, which demonstrates simultaneous dilatation of the common bile duct and pancreatic ducts.
Double duct sign - pancreatic cancer
Avoid what antiemetic in bowel obstruction
Metaclopramide
Mx of renal stones
watchful waiting if < 5mm and asymptomatic
5-10mm shockwave lithotripsy
10-20 mm shockwave lithotripsy OR ureteroscopy (pregnant)
> 20 mm percutaneous nephrolithotomy
Mx of uretic stoens
shockwave lithotripsy +/- alpha blockers>< 10mm shockwave lithotripsy +/- alpha blockers
10-20 mm ureteroscopy
Gold standard Ix for cerebral venous sinus thrombosis
MR venogram
What medication presdisposes to vitreous haemorrhage
Blood thinning agents
What is the main neurovascular structure that is compromised in a scaphoid fracture
Dorsal carpal branch of the radial artery
subtype of eczema characterised by an intensely pruritic rash on the palms and soles
Pompholyx eczema
After 5 shocks, what dose of amiodarone should be given in ALS
150
How to diagnose orthostatic hypotension/
when there is a drop in SBP of at least 20 mmHg and/or a drop in DBP of at least 10 mmHg after 3 minutes of standing
‘unrecordable’ blood sugar measurement with confusion and abdominal pain
DKA
What can be used to shrink nasal polyps
Topical corticosteroids
how to differentiate between PAD and spinal stenosis
eatures in the history that point more towards to spinal stenosis over peripheral arterial include
Pain improving on sitting down or crouches down
Weakness of the leg
Lack of smoking history
Lack of cardiovascular history
Risk factors for thrombosis, headache, reduced consciousness, vomiting →
?intracranial venous thrombosis
Acute onset of tear-drop scaly papules on trunk and limbs
Guttate psoriasis
Retro-orbital headache, fever, facial flushing, rash, thrombocytopenia in returning traveller
Dengue
Initial Mx of open fractures
Administration of intravenous antibiotics, photography of wound and application of a sterile soaked gauze and impermeable film
most effective treatment for prominent telangiectasia in rosacea
Laser therapy
Ix for budd chiari
US doppler flow
Pagets Mx
Bisphosphonates
Normal/raised total gas transfer with raised transfer coefficient:
Asthma
Consider WHAT in young female patients who develop AKI after the initiation of an ACE inhibitor
Important for m
fibromuscular dysplasia
Blood stained discharge from nipple is likely to be associated with
Intraductal papilloma
What nerve is at risk during total hip replacement
Sciatic nerve
What value of schobers test is suggestive of AS
Schober’s test <5cm is suggestive of ankylosing spondylitis. This is an indication of reduced lumbar flexion.
Renal impairment, respiratory symptoms, joint pain, systemic features
ANCA associated vasculitis
Mx of ramsay hunt
oral aciclovir and steroids
Hypokalaemia, osteomalacia
T2 RTA
Samter’s triad
aspirin sensitivity, asthma and nasal polyps
What endocrine abnormality can haemochromatosis cause?
Cranial DI
How does lithium cause nephrogenic DI
lithium desensitizes the kidney’s ability to respond to ADH in the collecting ducts
What type of ABx lowers seziure threshold
Quinolones
Ix of choice for bladder cancer
Flexi cysto
Options for pharmacological cardioversion in AF
‘f pharmacological cardioversion has been agreed on clinical and resource grounds for new-onset atrial fibrillation, offer:
flecainide or amiodarone if there is no evidence of structural or ischaemic heart disease or
amiodarone if there is evidence of structural heart disease.’
Clinical features of psoas abscessses
Psoas irritation is evidenced when the position of comfort is the patient lying on their back with slightly flexed knees. Inability to weight bear or pain when moving the hip is usually evident.
Visual defect in craniopharyngioma compared to pituitary adenoma
Craniopharyngioma - Inferior bitemporal hemianopia
Pituitary adenoma - Superior bitemporal hemianopia
First line Mx of suspected laryngopharyngeal reflux
A trial of PPi
abdominal, neurological and psychiatric symptoms. Think?
Acute intermittent prophyria
What ovarian tumour can cause endometrial hyperplasia?
Granulosa cell tumours
Urethritis in a male, negative for Gonorrhoea and Chlamydia
Mycoplasma genitalium
What does cryoprecipitate contain
factor VIII, fibrinogen, von Willebrand factor and factor XIII
Where is the lesion for Wernicke’s aphasia? Broca’s?
Superior temporal gyrus, inferior
HIV, neuro symptoms, single brain lesions with homogenous enhancement
CNS Lymphoma
Anterior uveitis is most likely to be treated with a
steroid eye drops (such as prednisolone acetate) and mydriatic eye drops (such as cyclopentolate). The steroid treats the underlying infection and the mydriatic eye drop dilates the pupil and reduces the pain.
Elderly patient dizzy on extending neck
Vertebrobasilar ischaemia
Ankylosing spondylitis - x-ray findings
subchondral erosions, sclerosis
and squaring of lumbar vertebrae
Refeeding syndrome metabolic picture
hypophosphataemia
this is the hallmark symptom of refeeding syndrome
may result in significant muscle weakness, including myocardial muscle (→ cardiac failure) and the diaphragm (→ respiratory failure)
hypokalaemia
hypomagnesaemia: may predispose to torsades de pointes
abnormal fluid balance
bilateral leg pain on walking that is relieved by forward flexion (such as leaning on a shopping trolley), improved symptoms when cycling (as this involves spinal flexion), and worsening with extension (such as walking downhill). Dx?
Lumbar canal stenosis - pathophysiology involves narrowing of the spinal canal, typically due to age-related degenerative changes, causing compression of the cauda equina nerve roots particularly when standing erect or extending the spine.
Most common cause of wound infection post op
Staph Aureus
presence of a cardiac tamponade is suggested by Becks Triad
Hypotension
Muffled heart sounds
Raised JVP
Medical Mx of NMS
Bromocriptine
What electrolyte abnormalities suggest dehydration
Urea raised disproportionately compared to creatine
The absence of a carotid pulse in the presence of sinus tachycardia indicates
Non shockable rhythm
Man returns from trip abroad with maculopapular rash and flu-like illness
HIV seroconversion
Carotid artery stenosis is diagnosed (and degree of stenosis assessed) via
Duplex US
Blood test results for wilson’s
reduced serum caeruloplasmin
reduced total serum copper (counter-intuitive, but 95% of plasma copper is carried by ceruloplasmin)
free (non-ceruloplasmin-bound) serum copper is increased
increased 24hr urinary copper excretion
What may exacerbate orthostatic hypotension
y venous pooling during exercise (exercise-induced), after meals (postprandial hypotension) and after prolonged bed rest (deconditioning)
Reynold’s pentad
Charcot’s triad (RUQ pain, jaundice, fever) plus hypotension and confusion
Erysipelas is localised skin infection caused b
Strep Pyogenes
Abdominal pain, constipation, neuropsychiatric features, basophilic stippling
Lead poisoning
Treatment of choice for scavies
Permethrin
inverted P wave in lead I, right axis deviation, and loss of R wave progression
Dextrocardia
Mx of achalasia
pneumatic (balloon) dilation is increasingly the preferred first-line option
less invasive and quicker recovery time than surgery
patients should be a low surgical risk as surgery may be required if complications occur
surgical intervention with a Heller cardiomyotomy should be considered if recurrent or persistent symptoms
HIV, neuro symptoms, widespread demyelination
PMFL
What type of CVD can present with neurological complaints
Aortic dissection
AS management
AVR if symptomatic, otherwise cut-off is gradient of 40 mmHg
Recurrent chest infections + subfertility
think primary ciliary dyskinesia syndrome (Kartagener’s syndrome)
Multiple rib fractures with > or = 2 rib fractures in more than 2 ribs is diagnosed as a
Flail chest
Difference in emphysema distribution in COPD and A1AT
Emphysema is most prominent in the lower lobes in A1AT deficiency and the upper lobes in COPD
Most common complication following meningitis
Sensorineural hearing loss
Avoid cyclizine in what chronic heart condition
Heart failure - can cause a drop in CO
Medical causes of AIN
drugs: the most common cause, particularly antibiotics
penicillin
rifampicin
NSAIDs
allopurinol
furosemide
Thyrotoxic storm is treated with
beta blockers, propylthiouracil and hydrocortisone
Axillary freckles are indicative of
NF type 1
ECG finding of deeply inverted or biphasic waves in V2-3 in a person with the previous history of angina is characteristic of
Wellen’s syndrome. This is highly specific for a critical stenosis of the left anterior descending artery
Pneumonia, peripheral blood smear showing red blood cell agglutination
Mycoplasma
Hypocalcaemia: prolonged QT interval is an indication for
urgent IV calcium gluconate
What should be performed in patients with suspected acute limb ischaemia
Handheld arterial doppler examination
Headache linked to Valsalva manoeuvres. What is this until proven otherwise?
raised ICP until proven otherwise so LP is contraindicated
What is prescribed adjunt to methotrexate in RA
Folate to prevent myelosuppression
Clinical findings in ankylosing spondylitis include
reduced chest expansion, reduced lateral flexion and reduced forward flexion (Schober’s test)
What organ toxicity is common in trastuzumab? What investigation is done prior to commencing treatment?
Cardiac toxicity, echo
When to offer spironolactone in HF
Offer a mineralcorticoid receptor antagonist, in addition to an ACE inhibitor (or ARB) and beta-blocker, to people who have heart failure with reduced ejection fraction if they continue to have symptoms of heart failure
first-line for spasticity in multiple sclerosis
Baclofen and gabapentin
triad of vomiting, pain and failed attempts to pass an NG tube
Gastric volvulus
Blurring of optic disc margin on fundoscopy
Papilloedema
Reversible Causes of cardiac arrest
The ‘Hs’
Hypoxia
Hypovolaemia
Hyperkalaemia, hypokalaemia, hypoglycaemia, hypocalcaemia, acidaemia and other metabolic disorders
Hypothermia
The ‘Ts’
Thrombosis (coronary or pulmonary)
Tension pneumothorax
Tamponade - cardiac
Toxins
combination of a high reticulocyte count and severe anaemia indicates
SCA
GI complication of radiotherapy for prostate cancer
Proctitis
1st line for lower back pain
NSAIDs
Psoas abscess Mx
Percutaneous drainage and IV ABx
What diabetic medication is associated with UTI
SGLT-2
Diastolic murmur + AF. Dx?
Mitral Stenosis
Persistent productive cough +/- haemoptysis in a young person with a history of respiratory problems
?Bronchiectasis
Prior to discharge, following an acute asthma attack, PEF should be
> 75% of best or predicted
triad of CVD, high lactate and soft but tender abdomen
Mesenteric ischaemia
Mx of mild to moderate Sx in carpal tunnel syndrome
Carpal tunnel syndrome: a trial of conservative treatment (wrist splint +/- steroid injection) should be tried initially for patients with mild-moderate symptoms
How to differentiate between macular degeneration and primary open angle glaucoma in terms of vision loss?
Common eye disorders affecting vision:
Macular degeneration is associated with central field loss
Primary open-angle glaucoma is associated with peripheral field loss
Empyema Mx
Prompt drainage alongside ABx therapy
Children and young people with unexplained bone swelling or pain: consider very urgent
direct access X-ray to assess for bone sarcoma
Fetor hepaticus, sweet and fecal breath, is a sign of
Liver failure
Mx of suspected myxoedema coma
IV thyroid replacement and IV hydrocortisone
What is required in the investigation of all patients presenting with an AKI of unknown aetiology
An USS
Fever/back pain with pain on extension of the hip
Iliopsoas abscess
Post-tonsillectomy haemorrhage Mx
Primary, or reactionary haemorrhage most commonly occurs in the first 6-8 hours following surgery. It is managed by immediate return to theatre.
Secondary haemorrhage occurs between 5 and 10 days after surgery and is often associated with a wound infection. Treatment is usually with admission and antibiotics.
Sterile pyuria and white cell casts in the setting of rash and fever should raise the suspicion of
AIN, commonly caused by ABs
initial period of recovery followed by a sudden worsening of symptoms. What condiiton is associated with this?
Bacterial sinusitis - double sickening
Alcoholic ketoacidosis is Mx with
IV fluids and thiamine
Osteomalacia Mx
Vit D supplements
Mx of Crohn’s
Inducing remission - glucocorticoids, 2nd line - mesalazine
Maintaining remisdsion - azathioprine or mercaptopurine
Is insluin used in HHS?
No, Insulin is only used in hyperosmolar hyperglycaemic state if the glucose stops falling while giving IV fluids - otherwise risk of central pontine myelinolysis
Brown sequard syndrome cause? Features?
caused by lateral hemisection of the spinal cord
Features
ipsilateral weakness below lesion
ipsilateral loss of proprioception and vibration sensation
contralateral loss of pain and temperature sensation
Dx of SBP
paracentesis. Confirmed by neutrophil count >250 cells/ul
muscle wasting of the hands, numbness and tingling and possibly autonomic symptoms
Neurogenic thoracic outlet syndrome
What can be inserted to reduce the risk of sudden cardiac death in HOCM
implantable cardioverter-defibrillator
Binocular vision post-facial trauma is suggestive of
Depressed fracture of the zygoma
pepperspot appearnce on skull X ray
Primary hyperparathyroidism
Axillary node clearance is associated with
arm lymphedema and functional arm impairment
n acute asthma, the BTS guidelines only recommend ABGs for
Patients with o2 sats <92
ECG finding in cardiac tamponade
Electrical alternans
How to differentiate causes of bitemporal hemianopia
lesion of optic chiasm
upper quadrant defect > lower quadrant defect = inferior chiasmal compression, commonly a pituitary tumour
lower quadrant defect > upper quadrant defect = superior chiasmal compression, commonly a craniopharyngioma
Mobitz II is an indication for what long term management
Pacemaker
If a perforated tympanic membrane doesn’t heal, mx?
Myringoplasty
Empyema aspirate features
Turbid effusion with pH<7.2, Low glucose, High LDH
Non-resolving unilateral discharge suggests
Cholesteatoma
Triad of Sx for Fat embolism
Triad of symptoms:
Respiratory
Neurological
Petechial rash (tends to occur after the first 2 symptoms)
What type of retinopathy is treated with panretinal laser photocoagulation
Proliferative retinopathy
potential complication of total hip replacement, presenting acutely with a ‘clunk’, leg shortening and internal rotation
Posterior hip dislocation
Persistent PUO and lymphadenopathy with high WCC?
Look for lymphoma
thickening and distortion in the region of the fovea, Hx of diabetes
Diabetes maculopathy
Decrease in pO2/FiO2 in poorly patient with non-cardiorespiratory presentation
ARDS
first-line treatment for magnesium sulphate induced respiratory depression
Calcium gluconate
Lactational amenorrhoea is a reliable method of contraception as long as
amenorrhoeic, baby <6 months, and breastfeeding exclusively
painful arc of shoulder abduction
Subacromial impingement
What may periureteric fat stranding indicate?
recent stone passage, if a ureteric calculus is not present.
central scotoma and there are well-demarcated red patches on the retina on fundoscopy.
Wet AMD
Mx of acromegaly
if patients are not suitable for trans-sphenoidal surgery, or have residual symptoms, then octreotide may be used
Medication overuse headache Mx
simple analgesia + triptans: stop abruptly
opioid analgesia: withdraw gradually
Diagnostic criteria for ARDS;
Clinical + CXR + pO2/fiO2 < 40kPa (300 mmHg)
First line management of acute pericarditis involves combination of
NSAID and colchicine
Electrolyte abnormality seen in chronic alcoholism
hypomagnasaemia
Eczema herpeticum is a primary infection of the skin caused by
HSV and uncommonly coxsackie
Signs of systemic sepsis with changing lower limb neurology
Possible epidural abscess
Mining occupation, upper zone fibrosis, egg-shell calcification of hilar nodes
Silicosis
Myoedema coma typically presents with?
Confusion and hypothermia
What type of NSAID is contraindicated in CVD
Diclofenac
What is the most useful initial diagnostic test in haemolytic uraemic syndrome
Blood film
What Ix is required in all patients with unknown AKI aetiology
US
How to differentiate between aplastic and sequestration crisis in SCA
Aplastic crisis has reduced reticulocytes, whereas sequestration crisis has increased reticulocytes
Intestinal angina (or chronic mesenteric ischaemia) is classically characterised by a triad of
severe, colicky post-prandial abdominal pain, weight loss, and an abdominal bruit - by far the most common cause is atherosclerotic disease in arteries supplying the GI tract
What to give before beta blockade in phaeo
PHaeochromocytoma - give PHenoxybenzamine before beta-blockers
What to do if patient undergoing major bleeding when on warfarin
It should be remembered that irrespective of the patient’s INR levels, all patients on warfarin who have major bleeding are advised to stop warfarin and are administered intravenous vitamin K 5mg and PCC.
What can be seen on fundoscopy in a fat embolism
Retinal haemorrhages and intra-arterial fat globules on fundoscopy can be assoicated with fat embolsim
Most common cause of SVCO
Lung cancer - specifically small cell
Useful marker for re-infarction in MI
Creatine kinase (CK-MB) remains elevated for 3 to 4 days following infarction. Troponin remains elevated for 10 days. This makes CK-MB useful for detecting re-infarction in the window of 4 to 10 days after the initial insult
Prodrome symptoms of sweating, pallor and nausea/vomiting before a transient loss of consciousness are suggestive of
reflex (neurally mediated) syncope. This is further supported by quick recovery after the syncope.
antisynthetase syndrome
Subtype of dermatomyositis, characterised by a combination of myositis and interstitial lung disease. This syndrome is caused by antibodies against anti-Jo1, also known as tRNA synthetase.
Which malignancy’s can progress to AML.
Myelodysplasia and polycythaemia vera
crescent sign on hip X ray
Avascular necrosis of hip - caused by csteroids
A chest X-ray shows bilateral bronchial dilatation with a tram-line appearance.
Bronchiectasis
When is ABG warranted in acute asthma
in patients with o2 sats <92%
what joint involvement is characteristic of hand osteoarthritis
Carpometacarpal and distal interphalangeal joint involvement is characteristic of hand osteoarthritis
What is the most appropriate investigation for patients with increased urinary cortisol and low plasma ACTH levels
CT adrenal glands
Best Mx for renal colic
IM diclofenac if no GI bleeed
DIlated pupil, females, absent leg reflexes
Holmes ADIe
What is the most common underlying cause of a vitreous haemorrhage
Proliferative diabetic retinopathy
Mx of severe urticaria
A short course of an oral corticosteroid may required in addition to a non-sedating antihistamine
Medical Mx of IBS
First-line pharmacological treatment - according to predominant symptom
pain: antispasmodic agents
constipation: laxatives but avoid lactulose
diarrhoea: loperamide is first-line
2nd line: Amitriptylline
Enzyme deficiency in gilbert’s
UDP glucoronyl transferase
Medical Mx of pyelonephritis in pregnancy
Cefalexin
Irregular pattern on fluoroscein staining of eye
Dendritic ulcer - Herpes simplex - topical aciclovir and urgent opthal assessment
Cancers associated with SIADH
Lung, prostate, thymus, lymphoma
How to differentiate between aplastic and sequestration crisis in SCD?
Aplastic crisis has reduced reticulocytes, whereas sequestration crisis has increased reticulocytes
How to identify cause of visual field defects based on presentation?
left homonymous hemianopia means visual field defect to the left, i.e. lesion of right optic tract
homonymous quadrantanopias: PITS (Parietal-Inferior, Temporal-Superior)
incongruous defects = optic tract lesion; congruous defects= optic radiation lesion or occipital cortex
A patient develops acute heart failure 10 days following a myocardial infarction. On examination he has a raised JVP, pulsus paradoxus and diminished heart sound. Dx?
Left ventricular free wall rupture
empirical antibiotic of choice for neutropenic sepsis
Piperacillin with tazobactam (Tazocin)
muscle wasting of the hands, numbness and tingling and possibly autonomic symptoms
Neurogenic thoracic outlet syndrome
Does campylobacter always require treatment?
NO, can be managed supportively unless severe - then mcrolide
Symptomatic aortic stenosis Mx
surgical AVR for low/medium operative risk patients
transcatheter AVR for high operative risk patients
Middle-aged, personality changes, involuntary movements
Hungtington’s disease
Fever, loin pain, nausea and vomiting
acute pyelonephritis
Ix for gout
Measure uric acid levels in suspected gout (i.e. in the acute setting)
a uric acid level ≥ 360 umol/L is seen as supporting a diagnosis
if uric acid level < 360 umol/L during a flare repeat the uric acid level measurement at least 2 weeks after the flare has settled
Which cancer has high risk of tumour lysis syndrome? How does it present? How to Mx?
Burkitt’s lymphoma
Rasburicase (a recombinant version of urate oxidase, an enzyme which catalyses the conversion of uric acid to allantoin*) is often given before the chemotherapy to reduce the risk of this occurring. Complications of tumour lysis syndrome include:
hyperkalaemia
hyperphosphataemia
hypocalcaemia
hyperuricaemia
acute renal failure
Sudden deterioration with ventilation suggests
Tension pneumothorax
What ECG finding can SAH cause
Torsades du Pointes
Ix for cardiac tamponade
Echo
Secondary amenorrhoea: low-level gonadotrophins indicate
a hypothalamic cause e.g. excess exercise
Causes of optic neuritis
MS, diabetes, syphillis
Eye complication of sarcoid
Anterior uveitis
If both menorrhagie and dysmenorrhoea present, what should be prescribed?
NSAIds should be prescribed in preference to transexamic acid
What should all patients who have had an acute MI be treated with?
ACEi, beta blocker, DAPT, statin
Medications to avoid in HF
Verapamil, Flecainide, Thizaolidinediones, NSAIDs, glucocorticoids
What Mx can cause discolouration to vision? What colour
Sildenafil - blue
Digoxin - yellow/green
What mx can cause cataracts
Steroids
What mx can cause corneal opacities
Amiodarone, indomenhacin
What Mx can cause optic neuritis
Amiodarone, metro, ethambutol
Mnemonic for cP450 enzyme inhibitors
Inhibitors INcrease INR
The mnemonic SICKFACES.COM can be used to easily remember common CYP450 inhibitors.
Sodium valproate
Isoniazid
Cimetidine
Ketoconazole
Fluconazole
Alcohol & Grapefruit juice
Chloramphenicol
Erythromycin
Sulfonamides
Ciprofloxacin
Omeprazole
Metronidazole
Mnemonic for cP450 enzyme inducers
The mnemonic CRAP GPs can be used to easily remember common CYP450 inducers.
Carbemazepines
Rifampicin
Alcohol
Phenytoin
Griseofulvin
Phenobarbitone
Sulphonylureas
What Mx can sildenafil not be given adjunct
Nitrates and nicorandil
What is Lhermitte’s sign?
shock like sensation radiating down the spine induced by neck flexion
What is Uhthoff’s phenomenon
Worsening multiple sclerosis symptoms during rising body temperature
Difference between swan neck and boutonniere deformity
In swan neck deformity, the PIP joint is hyperextended and the distal interphalangeal (DIP) joint is bent. In boutonnière deformity, the PIP joint can’t be straightened.
PSP triad
early dysphagia, recurrent falls, gaze palsy
Organisms causing post splenectomy sepsis
Think NHS:
Neisseria
Haemophilus
Streptococcus
Difference in optic disc between CRVO and vitreous haemorrhage
CRVO has optic disc swelling, VH doesn’t
What is used to treat cerebral oedema in patients with brain tumours
Dexamethasone
What combination of eye drops used in the management of acute angle closure glaucoma?
Direct parasympathomimetic eyedrops, such as pilocarpine, cause pupillary constriction thus widening the iridocorneal angle and allowing for humour to drain. Beta-blocker eye drops, such as timolol, reduce aqueous humour production. These two actions in combination work to reduce intraocular pressure.
Worsening FVC in a patient with MG, what medication may have predisposed to this?
Beta blocker
Mx of euvolemic and hypervolemic hyponatraemic patients who don’t have severe symptoms
Fluid restrict
Prior to discharge, following an acute asthma attack, PEF should be what?
> 75% of best or predicted
What is required to diagnose dementia?
Neuroimaging
What does COPD standby medication consist of?
Short course of oral corticosteroids and oral ABx to keep at home
What makes lateral epicondylitis worse?
resisted wrist extension/suppination whilst elbow extended
Supraspinatus tendonitis. How does it present?
Rotator cuff injury
Painful arc of abduction between 60 and 120 degrees
Tenderness over anterior acromion
Sudden hypoxia and increased ventilation pressure following intubation and ventilation, Dx?
Tension pneumothorax
Long term mechanical ventilation in trauma patients can result in what? What does this result in?
Tracheo-oesophageal fistula (TOF) formation, which increases the risk of ventilator-associated pneumonias and aspiration pneumonias - the latter caused by aspirated stomach contents
Perforated tympanic membrane Mx
If done by barotrauma, reassure and advise will likely resolve in 6-8 weeks
If done by otitis media, give amox
What do T and Z score mean?
The T score is your bone density compared to a healthy 30-year-old. The Z score compares your bone density to someone your age and body size. The Z score is adjusted for age, gender and ethnic factors.
DIC typical blood picture
↓ platelets
↓ fibrinogen
↑ PT & APTT
↑ fibrinogen degradation products
Important to check what blood test result in post operative ileus?
U+E
Useful anaesthetic agent in trauma
Ketamine, doesn’t count a drop in BP
Hyoscine hydrobromide or hyoscine butylbromide MOA
muscarinic antagonist
How long before surgery to stop HRT?
4 weeks
first line anti-emetic for intracranial causes of nausea and vomiting
Cyclizine
Best test for ACL injury
Lachman’s test (knee at 20-30 degrees) is superior to the anterior draw test
What transfusion can be used to help in acute chest crises in SCD
Exchange transfusions are a way of reducing the number of sickle red cells and increasing the number of normal red cells, in order to improve oxygenation
Mx of SCFE
Internal fixation
Risk of tamoxifen
pre and perimenopausal (VTE)
Risk of anastrazole
Osteoporosis
Mx of pseudomonas in CF
Oral cipro
Rivaroxaban and apixaban can be reversed by
Andexanet alpha
Warfarin can be reversed by
Vitamin K
Heparin can be reversed by
Protamine sulphate
Dabigatran can be reversed by
Idaricizumab
painless haematuria and HTN ina young patient
APKD
What test can be used to confirm Gilbert’s?
bilirubin rises post IV nicotinic acid
DIfference between chalazion and stye
Chalzion - cyst - painless
Stye - abscess - painful
BOTH USUALLY CAUSED BY STAPH AUREUS
Treated with hot compresses, and only topical ABx if associated conjunctivitis
Brown-squard syndrome
paralysis and loss of proprioception ipsilaterally, loss of temperature and pain contralaterally
Lesion at mid-thoracic level
Hoow to differentiate between blepharitis and conjunctivitis
Blepharitis - bilateral grittiness, asx with seborrhoeic dermatitis, NO discharge
Conjunctivitis - discharge
Ix for AAA
Ultrasound is the usual initial investigation for establishing the diagnosis.
CT angiogram gives a more detailed picture of the aneurysm and helps guide elective surgery to repair the aneurysm.
What is hypermetropia a risk factor for?
acute angle glaucoma
What is myopia a risk factor for?
Retinal detachment, open angle glaucoma
Initial emergency Mx for acute angle closure glaucoma
IV acetazolamide
What glaucoma medication can cause change in colour of the eye or increase eyelash length?
Prostaglandin analogues - latanoprost
Adverse effects include brown pigmentation of the iris, increased eyelash length
Pharamcology summary of glaucoma
How to differentiate between episcleritis and scleritis clinically
phenylephrine drops may be used to differentiate between episcleritis and scleritis
phenylephrine blanches the conjunctival and episcleral vessels but not the scleral vessels
if the eye redness improves after phenylephrine a diagnosis of episcleritis can be made
wber syndrome affects ther
midbrain
Lateral medullary syndrome affects the
medulla
What can untreated neck goitre lead to?
Tracheomalacia, sudden onset shortness of breath
amber material under the retinal pigment epithelium in both eyes
Drusen, between Bruchen’s membrane and retinal pigment epithelium
What nerve affected in collesf racture
Media
How long to continue iron tablets for once it has been correectewd?
3months after correction
gallstones in the gallbladder
cholecyystolithiasis
Gallstones in the CBD
choledocholithiasis
Jaundice, pruritus, dark urine and pale stool suggest
bile duct obstruction
Differentiating bronchitis and pneumonia
History: Sputum, wheeze, breathlessness may be absent in acute bronchitis whereas at least one tends to be present in pneumonia.
Examination: No other focal chest signs (dullness to percussion, crepitations, bronchial breathing) in acute bronchitis other than wheeze. Moreover, systemic features (malaise, myalgia, and fever) may be absent in acute bronchitis, whereas they tend to be present in pneumonia.
What can be used to guide decision making process regarding ABx therapy in bronchitis?
CRP
What Mx can be used for persistent dry cough in palliative care
humidified air, codeine, morphine, oral corticosteroids
Meckels diverticulum can be a risk factor for what?
Intusussception
Criteria to admit in new onset A fib
Tachycardic (>150), hypotensive
Relative bradycardia compared to temperature
Faget’s sign
Think Typhoid
Hypertrophic pulmonary osteoarthropathy triad
Periostitis, clubbing and painful arthropathy of large joints
Asx with lung cancers
Recurrent otitis media resistant to ABx, deep retration pocket in tympanic membrane noted o/e
Cholesteatoma
Mx that can be used in Meniere’s prevention
Betahistine
When should pred be considered in bell’s palsy
If presentaiton within 72 hours
Which anti-epileptics cause thrombocytopenia
Carbamezapine and sodium valproate
When to double dose of levonorgestrel?
Obese or on anti epileptic medications - becomes 3mg instead of 1.5
What should be given prior to colonoscopy?
Magnesium citrate prep
What arrythmias can cause canon A waves? what are they?
V tach, complete heart block, junctional tach
Cannon A waves are large jugular vein pulsations that occur when the right atrium contracts against a closed tricuspid valve.
Extra-renal manifestations of ADPKD
Liver cysts
ovarian cysts
Berry aneurysm - SAH
Mitral valve prolapse
Diverticular disease
Recurrent steatorrhoea, weight loss and gallstones. Hx of diabetes. O/E - jaundice
Somatostatinoma
Mx of postpartum thyroiditis
Propanolol
Damage to hypoglossal nervse causes tongue to deviate which way?
Towards lesion e.g. ipsilaterally. Right hypoglossal nerve lesion, tongue deviates towards the right.
Garden spade deformity
Smith’s fracture
Humeral shaft fracture causes damage to which nerve
Radial
What Mx can be used acutely for Mx of nausea in meniere
Cyclizine, good for ENT causes of N&V
Positive valgus stess test
MCL
Positive varus stress test
LCL
Difference in location radial fractures between adult and children
Children - radial neck
Adult - radial head
What is Nelson’s syndrome?
an enlargement of an adrenocorticotropic hormone-producing tumour in the pituitary gland, following surgical removal of both adrenal glands in a patient with Cushing’s disease.
Bilateral sciatica?
?Cauda equina
IVC obstruction triad. Caused by?
oedema below level of obstruction, lower limb oedema, tachycardia. Caused by renal cancer
Leriche syndrome triad
claudication, impotence and decreased pulses due to aortoiliac occlusion
What Ix if suspecting abscess secondary to PID?
USS
second line to chloramphenicol for bacterial conjunctivitis
Fusidic acid
At what Hb threshold can you operate?
> 100, if <100 postpone operation and investigation, if <80 needs transfusion
Mx of entamoeba
Metro
Mx of campylobacter
Macrolide, if not - cipro
Mx of salmonella
Cipro
Mx of shigella
Cipro
Oral candidiasis Mx
Localised: Oral miconazole
Extensive: Oral Fluconazole
DIC blood results
A typical blood picture includes:
↓ platelets
↓ fibrinogen
↑ PT & APTT
↑ fibrinogen degradation products
schistocytes due to microangiopathic haemolytic anaemia
Antihistamine creasm
Calamine lotion, topical menthol 1%
Winging of scapula. What nerve affected?
Long thoracic
What electrolyte abnormality can trimethoprim cause?
Folate
What can predispose to ovarian torsion?
Malignancy
What Ix for suspected SVCO
Contrast CT
Most common cause of UTI in immunosuppresssed
Pseudomonas
Initial Mx of cardiac tamponade
CHECK BP
IF UNSTABLE, oxygen and fluids
THEN pericardiocentesis
Pregnant patient with stones with renal stones. Ix?
USS
First line Mx for restless leg syndrome
Dopamine agonist e.g. pramipexole or ropinirole
Difference between bulbar and pseudobulbar palsy
A bulbar palsy is a lower motor neuron lesion of cranial nerves IX, X and XII.
A pseudobulbar palsy is an upper motor neuron lesion of cranial nerves IX, X and XII.
Pt with phaeo triad. Initialy Ix in GP?
Refer to see specialist on same day
Pt with malignant HTN but no signs of end organ damage. Mx?
Review and remeasure BP in 1 week
If pt high risk of bleeding, alternative to fondaparinux for NSTEMI Mx?
Unfractionated heparin
STEMI Mx
NSTEMI Mx
Bone pain/swelling in children. Potential Dx?
Bone sarcoma, urgent X ray within 48 huours
Lump that is increasing in size children and adults. Potential Dx?
Soft tissue sarcoma. Consider USS within 48 hours and 2 weeks respectively.
Samter’s triad
Asthma, aspirin sensitivit and nasal polyps. Polyps typically present with obstruction, rhinorrhoea and anosmia
Mx of sigmoid volvlulus
Flexible sigmoidoscopy
Which of measles or rubella has conjunctivitis
Measles
What CTD can cause menorrhagia
Ehler Danlos
For patients with strong family Hx of colorectal cancer (<50), Mx?
Offer colonoscopy as likely a strong genetic basis
Bounding pulse
Acute CO2 retention
How to treat metabolic causes of hypercalcaemia in end of life?
Haloperidol
Best antiemetic in parkinsons
DomperidoneBe
Best class of medication in parkinsons to treat tremor
Antimuscarinics
What cancer can cause thrombocytosis?
Lung cancer
Options for rhythm control in AF
<48 hours of presentaiton
Fleicanide or amiodarone if no evidence of structural heart disease
How to differentiate biliary colic and acute cholecystitis?
Acute cholecystitis has raised inflammatory markers, biliary colic has normal
Diagnostic feature of empyema
Loculated pleural effusion on ultrasound
MEN 1 is associated with
parathyroid, pancreatic, pancreatic, islet cell, and pituitary tumours.
MEN 2a is characterised by
thyroid medullary carcinoma, pheochromocytoma, and parathyroid tumours
MEN 2b is associated with
thyroid medullary carcinoma, pheochromocytoma, and mucocutaneous ganglioneuromas.
Mx of post-herpetic neuralgia
TCA
ipsilateral weakness below lesion
ipsilateral loss of proprioception and vibration sensation
contralateral loss of pain and temperature sensation
Brown-sequard syndrome
best Ix for mesenteric ischaemia
Abdo CT
CHADSVASC score
The CHA2DS2-VASc was designed to assess stroke risk in patients with atrial fibrillation. Clinicians should consider anti-coagulating males with a CHA2DS2-VASC score greater than 0 and females with a score greater than 1. Anti-coagulation is recommended in anyone with a score greater than 2:
C - Congestive cardiac failure (1)
H - Hypertension >140/90, or on anti-hypertensives (1)
A2 - Age >75 years (2)
D - Diabetes mellitus (1)
S2 - Stroke, TIA or thromboembolism in the past (2)
V – Vascular disease (1)
A –Age 65–74 years (1)
Sc – Sex – female (1).
Diagnostic Ix for achalasia
Oesophagael manometry
Stroke in a young person with recent Hx of immobility think?
PFO, do an echo
Mx of gastrinoma
Somatostatin analogue - Octreotide
Weber classification of fractures
The most common classification used, especially within the Emergency Department, is the Weber classification, which classifies lateral malleolus fractures:
Type A = below the syndesmosis
Type B = at the level of the syndesmosis
Type C = above the level of the syndesmosis
dilated pupil, which shows a delayed and incomplete constriction to light
Holmes-adle pupil.
Ix for holmes-adle pupil
To confirm the diagnosis, testing with low-dose pilocarpine can be carried out. There is usually no response to a dilute pilocarpine solution in a normal pupil. In a Holmes–Adie pupil, there is hypersensitivity to the solution due to degeneration of post-ganglionic neurones (denervation hypersensitivity).
What type of disorders can manifest with bleeding problems?
CTD
Where does a direct inguinal hernia protrude? How does it present? WHat is it associated with?
protrudes through a weak point in the inguinal canal’s posterior wall, typically in Hesselbach’s triangle and medial to the inferior epigastric vessels. It presents as a groin lump and can extend into the scrotum if untreated. ASsociated with heavy lifting
What anti parkinson medication can cause compulsive behabiours
Dopamine agonists e.g. ropinirole
What artery likely affected in bleeding duodenal ulcer
Gastroduodenal
Small, numerous opacities in upper lung zones with hilar lymphadenopathy
Silicosis
presence of probable pancreatitis (raised amylase, epigastric pain, vomiting), alongside the radiographic findings of bilateral pulmonary infiltrates, is suggestive of
ARDS
Mx of hyperkalaemia
immediate treatment with 30 ml of 10% calcium gluconate by slow intravenous injection to protect the cardiac myocytes from excess potassium. Following this, you should give ten units of Actrapid® in 100 ml of 20% glucose; this helps to draw potassium intracellularly. Salbutamol nebulisers can also help. Finally, calcium resonium 15 g orally or 30 g rectally is used to mop up excess potassium in the gastrointestinal tract.
Post-bone marrow transplant, the clinical features of respiratory disease and obstructive spirometry suggest
Bronchiolitis obliterans
What excess vitamins can cause kidney stones?
C/D
What artery affected in temporal arteritis?
Superficial temporal artery
What artery affected in peptic (gastric) ulcer?
Left gastric
Normocytic anaemia. What Ix?
EPO
An acoustic neuroma is associated with an over-proliferation of which type of cell?
Over-proliferation of Schwann cells forms the pathological basis of an acoustic neuroma.
Malignant cartilaginous tumour which most often arises from long bones and typically gives the appearance of ‘popcorn’ or ‘cotton wool’ calcification
Chondrosarcoma
What to do if major bleeding on warfarin?
Major bleeding:
stop warfarin sodium
give phytomenadione (vitamin K1) by slow intravenous injection
give dried prothrombin complex (factors II, VII, IX, and X); if dried prothrombin complex is unavailable (fresh-frozen plasma can be given but is less effective)
recombinant factor VIIa is not recommended for emergency anticoagulation reversal.
What to if minor bleeding on warfarin?
INR > 8.0, minor bleeding:
stop warfarin sodium
give phytomenadione (vitamin K1) by slow intravenous injection
repeat the dose of phytomenadione if INR is still too high after 24 h; restart warfarin sodium when INR < 5.0.
INR 5.0–8.0, minor bleeding:
stop warfarin sodium
give phytomenadione (vitamin K1) by slow intravenous injection
restart warfarin sodium when INR < 5.0.
What to do if no bleeding on warfarin?
INR > 8.0, no bleeding:
stop warfarin sodium
give phytomenadione (vitamin K1) by mouth using the intravenous preparation orally [unlicensed use]
repeat the dose of phytomenadione if INR is still too high after 24 h; restart warfarin when INR < 5.0.
INR 5.0–8.0, no bleeding:
withhold 1 or 2 doses of warfarin sodium and reduce subsequent maintenance dose.
An unwell child with an unhealed burn must be treated for WHAT until proven otherwise
toxic shock syndrome
What nerve is associated with tear formation?
Intermediate nerve, branch of facial nerve
Mx of cataract
phacoemulsification
definitive treatment in PSC
Liver transplanatation
Mx of scleritis
oral NSAIDs
What drug can be trialled in chronic plaque psoriasis if no response to other medications?
Methotrexate
hypertension in young women with a ‘string of beads’ appearance of the renal artery on CT. Dx? Mx?
Fibromuscular dysplasia, managed with antihypertensives and renal artery balloon angioplasty
Echo findings on HOCM
Characteristic ‘banana-shaped’ left ventricular cavity. This shape results from septal hypertrophy, which reduces the size of the left ventricular cavity. HOCM is commonly associated with left ventricular diastolic dysfunction, which impairs the heart’s ability to relax and fill properly during the resting phase. Over time, this can enlarge the left atrium as it accommodates the increased blood volume and works harder to maintain normal cardiac function.
What electrolyte abnormality can cause peptic ulcer disease?
Hypercalcaemia
What sided varicocele is worrying? Why?
A varicocele is a dilatation of the pampiniform plexus of the spermatic cord; this network of veins is dependent on the spermatic vein. A left-sided varicocele is associated with a left renal malignancy in a small proportion of patients. The anatomy of the testicular (gonadal) veins is asymmetrical. The right drains directly into the inferior vena cava. The left drains into the left renal vein. A large left renal tumour may compress/invade into the left renal vein, causing an obstruction to venous return, which results in a varicocele. Assessment with an ultrasound of the kidneys is recommended.
presence of alopecia with abnormal scalp skin must raise the possibility of
tinea capitis
What can be given after a fluid challenge to improve urine output?
Vasopressor, e.g. noradrenalien
What antihypertensive can cause angioedema?
Ramipril
Best Ix for sialadenitis
US guided fine needle aspiration
What is suspected in post-bone marrow transplant patients presenting with obstructive spirometry after 100 day
bronchiolitis obliterans
history of hereditary haemorrhagic telangiectasia and his presentation of exertional dyspnoea
pulmonary AV malformation
Mx of sepsis in ascending cholangitis
urgent decompression of the common bile duct with ERCP is the preferred and least risky approach for source control in this critically ill individual.
In major trauma, best support for hypotension?
Packed red blood cells (through a fluid warmer)
Mx of toxic shock syndrome
IV clindamycin and vancomycin
What bone affected in otosclerosis?
Stapes
triad of pain, tingling, and numbness radiating from the buttocks to the calf and foot. Dx? Mx?
likely diagnosis is sciatica caused by a herniated disc, spondylolisthesis, or spinal stenosis. Diagnosis is confirmed with a positive straight leg raise test. Treatment involves analgesia, physiotherapy referral, and specialist consideration if symptoms persist beyond 6-8 weeks.
Sx of carpal tunnel syndrome following FOOSH?
Lunate bone dislocation
NOTE: Scaphoid most common fracture, lunate most common dislocation
What location of gallstone is an ERCP appropriate?
CBD
A mnemonic to learn the degrees of burns could be
“S.P.F” which stands for Superficial (first degree), Partial thickness (second degree), and Full thickness (third degree)
patient with an unimpressive focus of infection (e.g. a small patch of infection) who is in multiorgan failure
toxic shock syndrome
What should be prescribed adjunt to retinoids in women?
Contraception
What murmur in proximal aortic dissection
Aortic regurgitation is heard as an early diastolic murmur, loudest at the right second intercostal space.
primary anticoagulation recommended in acute limb ischaemia
IV unfractionated heparin
If something is methicillin sensitive, what ABx do u give?
Fluclox
Normal QT interval
<420 seconds
What dermatological emergency can psoriasis lead to? MX?
Erythroderma, urgent treatment as a dermatological emergency - urgent admission to the hospital is necessary. There is a significant risk of infection and dehydration, requiring intravenous fluids and ample use of topical emollients and steroids.
keratin pearls on biopsy
SCC
1st line Mx for AIH
Azathioprine and prednisolone
What can large fibroids cause?
Urinary retention - think if there is suprapubic tenderness
Initial Mx of hypocalcaemia
Observe, if symptomatic or <1.95 then give calcium gluconate
Gold standard Ix for salivary gland stoens
Sialography
Bat wing pattern on CXR, history of immunodeficiency
PCP
first like Ix for suspected hypocalcaemia
ECG - prolonged QT
Mx of acute cholecystitis
Analgesia, IV fluids, IV abx, abdo USS
Above what spinal level are metastatic lesions more common for back pain than osteoporosis?
T4
Mx of diabetic retinopathy with maculopathy
Anti-VEGF injection
exudates forming a ring around a dot haemorrhage near the fovea
Diabetic retinopathy with maculopathy
Mx of proliferative diabetic retinopathy
Panretinal photocoagulation
Suddent onset breathless in CF?
Pneumothoraces, PE not common
Acutely painful visual loss, proptosis, conjunctival injection and a firm, tender and pulsatile eyeball
carotid cavernous fistula
It results from abnormal communication between the cavernous sinus’s carotid artery and the venous system. Management is with endovascular surgery to obliterate the fistula.
multiple petechiae and ecchymoses, IDA whilst on blood thinner. Ix?
GI endoscopy - look for causes of bleeding
1st line Ix for carotid artery stenosis
US carotid
Constipation secondary to opiate use? Mx?
Senna - stimulant
anaemic, with tachycardia and a gallop rhythm
HF due to anaemia
Ix for giardiasis
SMall bowel biopsy
Most common composition of gallstones
Cholesterol
all patients with confirmed PE who are haemodynamically unstable should be started on a continuous infusion of
unfractionated heparin, and thrombolysis should be considered
Causes of toxic shock syndrome
Retained tampon, packing in epistaxis
What management in PAD when an ulcer has developed?
Angioplastyu
Grading of diabetic retinopathy
Diabetic retinopathy is graded based on the findings on fundus examination:
Background – microaneurysms, retinal haemorrhages, hard exudates and cotton wool spots
Pre-proliferative – venous beading, multiple blot haemorrhages and intraretinal microvascular abnormality (IMRA)
Proliferative – neovascularisation and vitreous haemorrhage
Diabetic maculopathy also exists separately and involves:
Exudates within the macula
Macular oedema
NOTE: MACULA MAY BE DESCRIBED AS NEAR THE FOVEA
TOM TIP: The main distinction is between non-proliferative (which includes background and pre-proliferative) and proliferative diabetic retinopathy. The key feature of proliferative diabetic retinopathy is the development of new blood vessels (neovascularisation).
Mx of diabetic retinopathy
Non-proliferative diabetic retinopathy requires close monitoring and careful diabetic control.
Treatment options for proliferative diabetic retinopathy are:
Pan-retinal photocoagulation (PRP) – extensive laser treatment across the retina to suppress new vessels
Anti-VEGF medications by intravitreal injection
Surgery (e.g., vitrectomy) may be required in severe disease
An intravitreal implant containing dexamethasone is an option for macular oedema.
TOM TIP: Look up pictures of a retina treated with pan-retinal photocoagulation so you can spot it in exams.
Abrupt drop in urine output in a catheter is caused by? Opposed to a gradual drop? Mx?
abrupt - urinary clot, flush
Gradual - dehydration and hypovolaemia, fluid bolus
Supracondylar fracture of the humerus most likely to cause damage to which nerve?
Median
First Ix for retinoblastoma
US of affected eye
What antibodies are in HDN
IgG
Men with recurrent bacteriuria, consider what Dx?
Chronic bacterial prostatitis
first line Ix in someone with delayed puberty
Skeletal X ray - make sure their bone age is same as chronological age
Isolated gross motor delay in a child with otherwise normal development must raise the question of
muscular dystrophy
typical signs of a patient with an anastomotic leak
atrial fibrillation, increasing confusion and signs of sepsis
Mx of portal hypertension
Propanolol
Long term treatment of choice for oesophogael varices
Band ligation of large varices
ECG features of right ventricular strain, what may this indicate?
Pulmonary hypertension
What can sinusitis predispose to?
Cerebral abscess
aortic dissection, spontaneous pneumothorax and upward lens dislocation
Marfans
cough that is worse at night. Dx?
Acute bronchitis
Cavitating lesions. What vasculitis?
cANCA - Wegners
tender, pea-sized nodule in the upper pole of the testis over 24 hours is characteristic of
testicular appendage
first line Mx for aspiration pneumonia
Co-amox
facial nerve palsy and a lump at the angle of the jaw is highly suggestive of
Parotid gland adenocarcinoma
Best drug for MND
Riluzole
What vitamin deficiency can tuberculosis medication cause?
Vit D
revious and recent history of a viral upper respiratory tract infection, in combination with enlarged neck nodes and high temperature, should point to a diagnosis of
mesenteric adenitis in children presenting with right iliac fossa pain. Appendicitis tends to present with a low grade fever
1st line Ix in someone with amenorrhoea
Pregnancy test
What must be ruled out before Dx of hyperprolactinaemia?
Hypothyroidism
Chronic renal failure
Pregnancy
When is surgical drainage needed in orbital cellulitis? What is medical management otherwise?
If invading ethmoidal sinus, medical management is cef and mtro
Peripheral, spiculated lung mass
Adenocarcinoma (also most common lung cancer)
Mx of sliding hiatus hernia
Initial lifestyle management and PPI
Then fundoplication
Paraoesophagael surgery done for paraoesophagael hernia
Toxin cause of hypomagnasaemia
Alcohol
dry cough, low-grade fever, headache, general malaise and interstitial infiltrates on chest X-ray is consistent with
Mycoplasma
How to differentiate between TEN, staphylococcal scaled skin syndrome
Stevens–Johnson syndrome (SJS) is characterised by a severe mucocutaneous reaction, typically involving less than 10% of the total body surface area, with significant mucosal involvement. Although this patient has extensive mucosal involvement seen in SJS, the total body surface area affected (greater than 30%) indicates that TEN is a more likely diagnosis. and SJS
SSSS usually has minimal to no mucosal involvement
First line Ix for salivary gland stones
US neck
alpha synuclein
Parkinson’s/Lewy body
Neurofibrillary tangles
Alzheimers
Spongioform complexes
CJD
Which dopamine agonist best for prolactinoma
Cabergoline
Abx options for COPD infective exacerbations
Amox, clarithro and doxy - give if sputum is colored, or clinical signs of pneumonia
Abx threshold in tonsilitis
CENTOR score >3
CENTOR:
Cough Absent
Exudate present
Nodes (Cervical) palpable
Temperature
Common causes of drug induced lupus? Antibody?
isoniazid (used for TB), procainamide, hydralazine, minocycline and phenytoin
Anti-histone antibody
sensorineural deafness and a desquamating rash in a newborn. Dx? Prevention?
Congenital syphillis, use ben pen
If appendicitis self resolves, but an appendix mass seen on USS. WHen should appendicectomy be carried out?
6-8 weeks
Abx for pseudo aeruginosa
Cipro
Alternative pain medication to IM diclofenac in patients with PUD
IV paracetamol
SE of doxorubicin
Dilated cardiomyopathy
SE of cyclophosphomide
Haemorrhagic cystitis
Pericarditis Sx or signs on ECG with raised creatinine. Mx?
Haemodialyse, this is an AKI that is leading to uraemia
white patch on the side of his tongue that he is not able to rub off in a patient with HIV. Dx? Mx?
?oral hairy leukoplakia, reger to secondary care
Mx of ascending cholangitis
if septic, ERCP for biliary drainage and IV ABx
Risk factors for Idiopathic intracranial HTN. What condition often associated with it?
Obesity, tetracyclines
Acne often associated with it as tetracyclines used for that
What dose of dex in metastatic spinal cord comrpession
16mg
Indications for acute dialysis include
refractory hyperkalaemia, fluid overload, toxin ingestion, and uraemia.
Suspect in anyone with high creatinine, think AKI being the cause first
Ix for IIH
CT head, if normal do LP - shows raised opening pressur
What sign means that mastitis requires ABx
nipple fissure - give fluclox
What UTI medication can cause a fasely low GFR
Trimethoprim inhibits tubular creatinine secretion, leading to an increase in serum creatinine independent of the true glomerular filtration rate (GFR).
What are antibodies in bullous pemphigoid directed against
antibodies (IgG and C3) against hemidesmosome proteins in the epithelial basement membrane
euglycaemic metabolic acidosis with high anion gap in a patient with T2DM. Think?
SGLT-2 causing DKA. Check meds
Medication for steroid induced diabetes
Sulphonylurea e.g. gliclazide
Management of persistent hyperglycaemia in someone who has just started enteral feeding
Insulin
Mx of someone on a mab who presents with fever
Admit for further investigations
Mnemonic to remember KCC for liver transplanatation
“PHLaSH”:
P: pH < 7.3
H: Hepatic encephalopathy (Grade III or IV)
L: Lactate > 3.5 mmol/L (early) or > 3.0 mmol/L (after resuscitation)
S: Serum creatinine > 300 µmol/L
H: Prothrombin Time (PT) > 100 seconds
Best Ix to do prior to initiation for acetylcholinesterase inhibitors
ECG, for QT
What is useful in patients for whom the diagnosis of prosthetic valve endocarditis remains uncertain following echocardiography
PET CT
Best anticoagulant for cavernous sinus thrombosis
LMWH
immediate management of ACAG
Pilocarpine eye drops, carbonic anhidrase inhibitors
When are carbonic anhidrase inhibitors contraindicated
SCD
Anti epileptic that can cause pancreaitits
VAlproate
Mx of MRSA infectivite endocarditis
Vanco and rifamp
erythematous rash, hot to touch and associated scaling. Dx?
Erythroderma, think background of eczema or psoriasis
Delayed presentation of viral thyroiditis
Euthyroid
Best initial Ix for cushings
Overnight dexamethasone suppressiont est
Mastits in a patient that has swapped from breast to bottle feeding over the last few weeks. Dx? Mx?
Non-lactational mastitis, give co-amox and review in 48 hours
Mx of colicky pain due to peristalsis in malignant obstruction
Hycosine butylbromide
hyponatraemia and hyperkalaemia in a neonate. Dx?
CAH, may have a fused labia and urogenital sinus
scaphoid abdomen and a barrel chest.in a neonate. Dx?
Congenital diaphragmatic hernia
Yawning in a neonate. Potential Dx?
Opioid withdrawal due to maternal drug use
fever and foul smelling discharge following invasive testing for antenatal conditions
Chorioamnionites
What is haemotympanum a sign of? Ix?
Basal sjull fracture, urgent CT head within an hour
In the case of confirmed malignancy, what Ix is advised to check for metastatic spread and help stage disease
CT CAP
What should be screened for prior to initiation of infliximab?
TB - can either do CXR to check for ghon focus, or IGRA to test for latnet TB
Mx of overflow diarrhoea due to constipation in an adult
Phosphate enema
What drugs to avoid in alzheiemrs
Anticholinergiics - e.g. oxybutynin
Best blood test for rheumatic
Anti-streptolysin O test
Common SE of nebulised salbutamol
Tachycardia
What reflex may be absent on someone with a vitreous haemorrahge
red reflex
Best marker for re-infarction
CK-MB
Best Ix for infective endocarditis
TOE
Surgical management of cauda equina syndrome
Surgical decompression and laminectomy
Mx of non-epileptic seizures
Refer for psychotherapy
Ix for mesenteric ischaemia
CT angiography, do lactate too
What medication can be used for aspirin overdose?
Sodium bicarbonate
Oesophogael candidias. Do what testing?
HIV
Most important management of acute chest crises
Pain management
What blood marker may be low in haemolysis?
Haptoglobin
RBC is broken down into LDH and Hb
Hb is carried in the blood by haptoglobin
Low levels of haptoglobin imply it’s saturated by Hb
What Ix before trastuzumab?
Echo
What can recurrent episodes of otitis media lead to?
Tympanosclerosis - characterised by chalky white patches on tympanic membrane and conductive hearing loss
Most common cause of intracerebral haemorrhage
Hypertensive vasculopathy
inguinal lymphadenopathy following painless penile ulcer, think?
Lymphogranuloma venerum - give doxy
anticoag not working with DOAC, swap to?
Warfarin
Four day history of sore throat, fever and inability to swallow her own saliva., tender swelling over the lateral aspect of her neck and targetted ultrasound reveals a thrombus in her jugular vein.
Lemierre syndrome - infective thrombophlebeiutis, can lead to septic emboli and stroke
history of chronic pancreatitis presents with post-prandial vomiting and abdominal pain
Pseudocyst
Pseudocysts can be asymptomatic or present with signs of biliary obstruction (abdominal pain, jaundice) or gastric outlet obstruction (post-prandial vomiting) due to mass effect of an enlarging pseudocyst on adjacent structures
If become infected, can become an abscess and cause fevers etc
If IgA deficient, test for coeliac?
IgG TTG, then duodenal biopsy
Medical management of acute limb ischaemia is with
High flow o2 and unfractionated heparin infusion
Mx of acute breathlessness post thyroidectomy
urgent return to theatre to open the stitches and evacuate the haematoma
Neck haematoma is a life-threatening complication of thyroid surgery and can present with signs of airway obstruction (e.g. stridor, respiratory distress), dysphagia, hoarseness and a painful neck mass.
Significant AKI with Hx of intraabdominal malignancy, what ix?
US renal tract
How to differ between medical and surgical third nerve palsys?
Medical third nerve palsies spare the pupil, just causibng ptosis and double vision. An example would be diabetes causing vasculopathic iscahemia to the optic nerve
Thyroid eye disease with visual disturbance. Mx?
Surgical decompression of the optic nerve
Ix for leprosy? Mx? AKA?
Skin swab, rifampicin (monthly) and dapsone (daily), AKA hansen’s disease
Fluid management for insulinoma
Dextrose and potassium supplement
Metabolic acidosis ina patient with CKD
Could be progression to end stage CKD, causes low bicarboante and increased resp rate and hypocarbia to compensate partially
Worsening renal function with dark brown urine should raise suspicion of
ATN
Peripheral nuropeathies in different locations across the body randomly with background of ischaemia, inflammatory or infection. Dx? Mx?
Mononeuritis multiplex. Check for cause
Low grade Barrets Mx? High grade Mx?
Low grade - high dose PPi and surveillance
High grande - endomucosal resection
Most important spirometry measure for restrictive conditions e.g. GBS and MG
FVC
Little to no improvement when started on co-benyldopa in PD. Think?
Parkinson plus syndrome - do lying and standing BP for MSA, do vertical gaze test for PSP
What should be given after dexamethasone in metastatic spinal cord compression?
Radiotherapy given within 24 hours to prevenet premanent neurological damage
What CN’s are within the cavernous sinus?
3,4,5,6
Cranial nerves and brainstem
Midbrain - 3,4
Pons - 5,6,7,8
Medulla - 9-12
history of reduced sensation to the left side of her face, double vision and is struggling with pain in her left eye. Extensive left sided periorbital oedema and proptosis. Dx?
Caervnous sinus syndrome, likely due to a thrombus secodnary to cavernous sinus infection
Best first Ix for ?diabetes insipidus
Serum and urine osmolality
no clinical features suggestive or urge or stress incontinence, recent Hx of radiotherapy to the pelvis. Constant urinary leakage. Dx?
Vesicovaginal fistula
Best marker of prognostic function of liver damage
PT or INR, APTT usually spared
Dorsal column
Fine touch, vibration and proprioception
Spinothalamic
Pain and temperature
What to give in UTI if trimethoprim or nitrofurantoin contraindicated?
Pivmecillinam
Diagnostic test for strep pneumoniae
urinary antigen
1st line treatment for allergic conjunctivitis
topical mast cell stabilizer (sodium cromoglycate) and topical antihistamine (antazoline).
Best malaria prophtylaxis
atovaquone-proguanil
What HTN cut off is required before giving BP control instead of aleteplase?
185/110
1st line Mx for otitis externa
Topical cirpo and hydrocortisone
100 mg of oral morphine per 24 hours is approximately equivalent to WHAT dose of transdermal fentanyl
25 μg/hour of transdermal fentanyl
What tests required for brain death diagnosis
Clinical neuro examination and apnoea test
Gene affected in FAP
APC
Gene affected in lynch syndrome
MLH2
Gene affected in Li-fraumeni
TP53
1st line test for Tb
Gold standard
1st line - sputum acid fast b acilli smear
Gold standard - sputum culture
Symptomatic Mx of large fibroids
First line - transexamic acid/mefenamic acid
Then GnRH
Alternative to HRT for patients with vasomotor Sx
Clonidine or SSRI
1st line Mx for uncomplicated malaria
ACT - artemisin combination therapy
Features of mild NPDR
Microaneurysms onlyF
Features of moderate NPDR
microaneurysms, intraretinal haemorrhages and hard exudates.
Features of severe NPDR
microaneurysms, intraretinal haemorrhages, hard exudates and the ‘4–2–1 rule’: severe intraretinal haemorrhages in four quadrants, venous beading in at least two quadrants and intraretinal microvascular abnormalities (IRMAs) in at least one quadrant.
Features of proliferative diabetic retinopathy
neovscularisation - panretinal photocoagulation
Diffuse bilateral interstitial infiltrates following immunosuppression. Think?
PCP
What anatomical feature increaes risk of primary acute angle closure gaucom
Narrow anterior chamber angle
etinal whitening in a sector of the retina, scattered flame-shaped haemorrhages and venous dilatation and tortuosity in the affected area are consistent with
Branch retinal vein occlusion
painless, firm plaque on the dorsal side of the penis and penile curvature during erections are characteristic of
Peyronie’s disease
new neurological deficits and increased intracranial pressure in post operative period for neurosurgery
Think cerebral oedeam
Best short term feeding approach if patient struggling with dysphagia
NG tube feedin
initial management for this patient with complex maxillofacial fractures involving the maxilla and zygomatic bones
Open reduction and initial fixation
Initial Mx for ASD
applied behaviour analysis therapty
Best graft for cosmetic results
Full thickeness skin graft
Mx of arteriovenous malformation
Emobolisation of the malformation, eliminationg the abnormal connection between artery and vein
Ideal medication for a depressed patient who wants to stop smoking
Buproprion, it is an atypical antidepressant
Gold standard for bariatric surgery
Roux en Y gastric bypass
Mx of obesity
> 35 BMI with no co-morbidities and motivation to lose wight - orlistat and dietary/exercise advice
35 with comorbiditis or >40 - gastric bypass
Urinary Sx with PMHx of STIs
Urethral stricture
Who should be referred for consideration of an Aortic valve replacement
Aortic stenosis with LVEF or <55
dry cough, increasing shortness of breath on exertion, hypoxia, finger
clubbing and bibasal crepitations. Hx of smoking. Dx?
IPF
lower back pain, pain in the left leg,
and tingling in the left big toe. What dermatome? What sign also seen,
L5 dermatome, foot drop also seen
most likely
causative organism for diarrhoea in an HIV positive patient with protozoa seen on microscopy
Cryptosporidium Parvum
Damage to the hypoglossal nerve on one side will cause the tongue to deviate
towards which side?
Towards the lesion, e.g. if tongue deciates to right, right hypoglossal affected
zig-zagging and flashing lights, headache, nausea,
and vomiting are typical features of
Migraine with aura
Mx of severe, acute urticaria
Oral Corticosteroids e.g prednisolone, NOT TOPICAL
Signs of optic neuritis with no optic disc swelling on fundoscopy. Cause?
Retrobulbar cause
Initial Mx of nephrotic syndrome
Loop diuretic, then consider pred
Mx of postpartum thyroiditis
Thyroid phase - propanolol
Hypothyroid phase - levo
Anti diabetic drug that needs stopping before CT scan with contrast
Mettformin, nephrotoxic
Inital Mx of post operative low urine output, tachycardia and hypotension
Fluid challenge - likely due to hypovolaemia
presence of bilateral pleural
effusions and upper lobe blood vessel diversion on chest X-ray suggests WHAT is causing breathlessness
Cardiac cause
sudden onset of visual loss, the
presence of an afferent pupillary defect, and red spot (the cherry red spot) on
fundoscopy are all consistent with
Central retinal artery occlusion
symptoms of a painful red eye without
discharge and a diffuse area of redness on the sclera are suggestive of ? Mx
Scleritis, urgent assessment by opthalmologist
When to use amitriptyline over duloxetine for neuropathic pain
Renal impairment (<30)
e symptoms of tiredness, bloating and weight loss along with flattened villi
and increased lymphocytes in the lamina propria and surface epithelium on
duodenal biopsy suggest
Coeliac
copious sputum production, and the history of childhood pneumonia and
recurrent chest infections. Dx>
Bronchiectasis due to CF
What Sx can bronchiectasis cause in an exacerbation
Haemoptysis
severe
left-sided abdominal pain, blood mixed in with her stools, and tenderness on
palpation in the left lower quadrant, the most likely cause of her symptoms is?
Diverticulitis
broad complex ectopic beats suggest what as the origin?
Ventricular ectopics
Long history yet small size of the lesion, together with the description of a
raised, pale border. Most likely Dx?
BCC
What indicates the need to start Abx in a patient with a long term catheter?
Systematic unwellness e.g. fever and mild confusion - suggestive of UTi
bilateral renal masses, reduced renal function and
haematuria.
PCKD. Do an US
Worrying feature of a migraine
Abrupt onset
elevated blood pressure,
radiofemoral delay, and chest X-ray findings of notching of the ribs in the midclavicular line are suggestive of
Aortic coarctation
e history of sinusitis, oral ulceration and
haemoptysis and the bilateral pulmonary nodules on chest X-ray
Granulomatosis with polyangiitis
sore throat, malaise, intermittent fever, swollen
tonsils, yellow-tinged sclerae, and tender lymph nodes
Infectious mononucleosis
How to reduce risk of oral candidiasis with beclometasone
Use a large volume spacer
Mx of empyema
Chest drain insertion
Gold standard treatment for OSA
CPAP
Histological
examination of testicular mass shows areas of mature cartilage and columnar epithelium.
Teratoma
low testosterone and low LH and
FSH levels, the most likely cause of hypogonadotrophic hypogonadism
Pituitary adenoma
Acute HF after recent MI, likely due to?
Papillary muscle rupture
upper temporal defect in both visual fields.
Optic chiasm compression from an inferior approach
Most common cause of non-bullous impetigo
Staph auresu
presence of a rash with folliculitis on the chest. What immunosuppressive disease can cause this?
HIV serovoncersion - late stage
Gram-positive cocci arranged in
pairs
Strep pneumoniae
What part of memory is affected most in alzheimers’
Short term
Mx of neuropathic bladder due to multiple sclerosis
Intermittent self catheterisation
What feature of C diff makes it hard to destroyq
Spore formation
multiple tender ulcers on the
preputial skin following recent sexual intercourse is suggestive of
HSV infection
crampy
abdominal pain, poor appetite, sore throat, fever, cervical lymphadenopathy,
and tenderness in the right iliac fossa, suggest
Mesenteric adenitis
exaggerated lumbar lordosis and the palpable depression above L5
can be clinical findings of
Spondylololisthesis, where one vertebra slips out of line with the one above it. Usually occurs in lumbar spine. Neurological examination usually noraml
h large for gestation uterus and severe early onset pre-eclampsia
Molar pregnancy
Most likely route of spread of lung cancer
Haematogenosu
facial swelling, fullness, and
prominent chest veins are consistent with s
SVCO
lymphocytosis with
normal Hb, neutrophil count and near normal platelet count and the film
appearances (small mature lymphocytes and smear cells are common) are also
consistent with what
CLL
Persistent painless lymphadenopathy. Think?
CLL or Non-hodgkin’s. Non-hodgkin’s will not have a significant lymphocytosis
1st line treatment for children and adolescents with anorexia
Family therapy
Standard treatment for hepatic encephalopathy. How does it work
Latulose, works by reducing the ammount of ammonia in the blood
Best method of IOL if bishop’s score low?
vaginal prostaglandin gel
What can be used for slowly progressing labour
Membrane sweep, NOT USED FOR INDUCTION
history of chronic sinusitis and unresolving
headaches. When he bends forward, purulent fluid pours from his nose. Dx? What anatomical structure is most likely the source of this fluid?
Chronic maxillary sinusitis, maxillary sinus most commonly involved
symptoms of pain worsened by movement and difficulty sleeping,
along with a normal X-ray and pain on shoulder abduction between 80° and
120° are consistent with
Subacromial bursitis
What virus is associated
with squamous cell carcinoma of the oropharynx, which includes the tonsils
(typically palatine tonsils and lingual tonsils)
HPV
What can be used to reduce breathlessness in end stage heart failure with metastases?
Morphine
1st line Mx of hodgkin’s
Chemo
Most appropriate strategy to prevent colon cancer in someone with GAP
Panproctocolectomy
fear of public speaking,
avoidance behaviour, and recognition that his fears are irrational are
consistent with a diagnosis of
Social phobia
weak grip, cough and shallow breathing
following laryngoscopy and vocal chord biopsy which was carried out under general
anaesthetic. What does this suggest? Reversal agent?
suggest residual effects of neuromuscular blockade, use neostigmine to reverse
What procedure can provide palliation of dysphagia in patients with oesophagael cancer?
Placement of an oesophagael stent
Particularly useful in those with advanced or metastatic disease who aren’t candidates for curative treatment
back pain, fatigue, normocytic
anaemia, thrombocytopenia and renal failure. Dx?
Myeloma
What can be given in septic shock to maintain blood pressure
Noradrenaline/epinephrine infusion, increases SVR and maintains blood pressure
duct-like
structures lined by regular, low columnar cells separated by loose fibrous
tissue, with well-defined margins is consistent with what breast lump
FIbroadenoma
Pulling the pinna, or pressure on the tragus often
exacerbates the pain of what condition
Otitis externA
Only reccomended treatment for asystole
Adrenaline/epinephrine
Best airway device to protect lungs from regurgitated stomach contents
Tracheal tube
Most common pathogen in leg cellulitis
Strep pyogenes
Breast condition that characteristically causes pain associated with the menstrual cycle
Fibrocystic disease
Test for what if recurrent candidiasis
Diabetes
In chronic lithium use, what test shouold be done prior to water deprivation if complaints of polyuria/polydipsia
Serum calcium, rule out hypercalcaemia as a cause due to hyperparathyroidism
What can be given prior to a contrast scan in a patient with existing CKD?
IV saline
Best Ix for cervical spine fracture
CT scan of the neck
Benign arrhtyhmia seen in women aged 20-30 years, asx with s feeling as if the heart stops for a second followed by a pounding sensation
Supraventricular premature beats
Most common cause of prosthetic joint infections
Staph aureus
Mx of paralytic ileus post op
Drip and suck - NG tube and IV fluids
Proctitis and lymphadenopathy in MSM
Lymphogranuloma vnereum
increased ratio of LH:FSH along with
oligomenorrhoea and BMI in the overweight range indicates
PCOS
Best treatment option for metastatic spinal cord compression to preserve neurological function
External beam radiotherapy
Difference between inflammatory and mechanical back pain
Inflammatory back pain (IBP) is typically
improved with activity and not relieved by rest, as opposed to mechanical pain
which is worse with activity and is relieved by rest.
Septic shock, still hypotensive with IV fluids, give?
Vasopressors - adrenaline
pain on abduction of the right shoulder that is worse with the arm in internal
rotation and when abduction is resisted. Dx?
Supraspinatus tendiopathy, can be diagnosed clincially - NSAIDs and physio is Mx
Terminal restlessness should be
managed with
Midazolam
Drug causes of IPF
Nitrio, Bleomycin, Methotrexate, amiodarone
What arrythmia can safely be excluded if patient is conscious?
VF
Post ictal weakness following a focal seizure
Todd’s paresis, seen in focal frontal lobe seizures
Painful shin rash + cough
?sarcoid
Mx of TEN
Supportive, move to ICU
Mxx of hyperthyroidism in pregnancy
1st trimester: Propyl
2nd trimester: Carbimazole
