Friday 1st October Flashcards
What is claudication? [1]
Pain in your thigh, calf or buttock when you walk
Key differential in patient presenting with claudication [1]
Spinal stenosis
Differentiate between spinal stenosis and peripheral arterial disease [4]
Pain improving on sitting down or crouches down
Weakness of the leg
Lack of smoking history
Lack of cardiovascular history
What is the most common presenting Sx in AS? [1]
Back pain
What is lumbar spinal stenosis? [1]
Lumbar spinal stenosis is a condition in which the central canal is narrowed by tumour, disk prolapse or other similar degenerative changes.
How to differentiate true claudication [1]
Sitting is better than standing and patients may find it easier to walk uphill rather than downhill. T
What is the most common underlying cause for spinal stenosis? [1]
Degenerative disease is the commonest underlying cause.
Best way of Dx spinal stenosis [1]
MRI scanning is the best modality for demonstrating the canal narrowing.
What is the Tx for spinal stenosis? [1]
Laminectomy
When is the postmenopausal period? [1]
This woman has entered the postmenopausal period as she has not had a period for 12 months
Does a 47 y/o F with amenorrhoea for 12m require contraception and why? [2]
‘Women using non-hormonal methods of contraception can be advised to stop contraception after 1 year of amenorrhoea if aged over 50 years, 2 years if the woman is aged under 50 years.’
Best contraceptive option for a women with PMH of breast cancer [1]
A copper coil is the best option for this woman because of her past history of breast cancer
Which contraceptives are UKMEC1 for women over 40? [2]
All methods are UKMEC1 except for the combined oral contraceptive pill (UKMEC2 for women >= 40 years) and Depo-Provera (UKMEC2 for women > 45 years)
Why might a COPD be useful for women in peripmenopuasal period? [2]
COCP use in the perimenopausal period may help to maintain bone mineral density
COCP use may help reduce menopausal symptoms
Dose altering of COCP in women over 40? [1]
a pill containing < 30 µg ethinylestradiol may be more suitable for women > 40 years
What should women be warned about when taking Depot Provera over 40? [2]
women should be advised there may be a delay in the return of fertility of up to 1 year for women > 40 years
use is associated with a small loss in bone mineral density which is usually recovered after discontinuation
Can COPD be continued over the age of 50? [1]
No, switch to non-hormonal or progestogen-only method
Can implant/POP/IUS be continued past the age of 50? [3]
Continue
If amenorrhoeic check FSH and stop after 1 year if FSH >= 30u/l or stop at 55 years
If not amenorrhoeic consider investigating abnormal bleeding pattern
Can HRT be relied upon for contraception? [1]
As we know hormone replacement therapy (HRT) cannot be relied upon for contraception so a separate method of contraception is needed
What should mothers be offered if they have a PMH of a baby with GBS? [1]
Prescribe intrapartum IV benzylpenicillin
Why should benzylpenicillin not be given straight away to child? [1]
Administer intravenous benzylpenicillin to the child at birth is incorrect. Antibiotics should only be administered to the child if they present signs and symptoms of neonatal sepsis.
What is the most common cause of early-onset severe infection int he neonatal period? [1]
GBS
How many mothers are carriers of GBS? [1]
It is thought around 20-40% of mothers have GBS present in their bowel flora and may therefore be thought of as ‘carriers’ of GBS
RFs for GBS [4]
prematurity
prolonged rupture of the membranes
previous sibling GBS infection
maternal pyrexia e.g. secondary to chorioamnionitis
What is the risk of GBS carriage in new pregnancy if they’ve already had it previous one? [1]
women who’ve had GBS detected in a previous pregnancy should be informed that their risk of maternal GBS carriage in this pregnancy is 50%
When should women have swabs for GBS? [1]
if women are to have swabs for GBS this should be offered at 35-37 weeks or 3-5 weeks prior to the anticipated delivery date
when should women be given IAP? [1]
women with a pyrexia during labour (>38ºC) should also be given IAP
Positive p24 and antibody test for HIV, what should happen? [2]
- started on anti-retroviral treatment today
- repeat HIV p24 and antibody in 12w time
When can post-exposure prophylaxis be commenced? [1]
Can only be started 72 hours after possible exposure [i.e. recent high risk sex]
How common is HIV seroconversion symptomatic in HIV patients? [1]
60-80%
Typical presentation of HIV seroconversion [1]
Glandular type fever illness
When does HIV seroconversion typically occur? [1]
3-12w after infection
Features of HIV seroconversion [3]
sore throat lymphadenopathy malaise, myalgia, arthralgia diarrhoea maculopapular rash mouth ulcers rarely meningoencephalitis
When do HIV antibodies develop? [1]
may not be present in early infection, but most people develop antibodies to HIV at 4-6 weeks but 99% do by 3 months
When does p24 antigen become testable? [2]
a viral core protein that appears early in the blood as the viral RNA levels rise
usually positive from about 1 week to 3 - 4 weeks after infection with HIV
When should a HIV test be offered for possible exposure? [1]
testing for HIV in asymptomatic patients should be done at 4 weeks after possible exposure
What is the standard for HOV diagnosis and screening? [2]
combination tests (HIV p24 antigen and HIV antibody) are now standard for the diagnosis and screening of HIV
Most common CXR finding in PE? [1]
normal CXR
How common are tachypnea, crackles, tachycardia, fever in PE? [4]
The relative frequency of common clinical signs is shown below:
Tachypnea (respiratory rate >20/min) - 96%
Crackles - 58%
Tachycardia (heart rate >100/min) - 44%
Fever (temperature >37.8°C) - 43%
What is recommended as initial lung-imaging modality for non-massive PE? [1]
CTPA scan
Advantages of CTPA over V/Q scan [3]
Advantages compared to V/Q scans include speed, easier to perform out-of-hours, a reduced need for further imaging and the possibility of providing an alternative diagnosis if PE is excluded
If CTPA negative, are further tests required?
No, also no need Ix
When is V/Q scanning appropriate? [4]
V/Q scanning may be used initially if appropriate facilities exist, the chest x-ray is normal, and there is no significant symptomatic concurrent cardiopulmonary disease. V/Q scanning is also the investigation of choice if there is renal impairment (doesn’t require the use of contrast unlike CTPA)
Think could also be CI in pregnancy?
Sensitivity and specificity of D-dimers [1]
95-98%
Poor specificity
ECG changes in PE [3]
- the classic ECG changes seen in PE are a large S wave in lead I, a large Q wave in lead III and an inverted T wave in lead III - ‘S1Q3T3’.
- right bundle branch block and right axis deviation are also associated with PE
- sinus tachycardia may also be seen
How common is S1Q3T3? [1]
20% only of PE patients
Why is CXR ordered in PE? [1]
to r/o other causes
What might be found CXR in PE? [2]
Wedge-shaped opacification
Typically normal though
Sensitivity and specificity of V/Q scan [2]
sensitivity of around 75% and specificity of 97%
What type of brain injury is a lucid interval associated with? [1]
EDH
Types of primary brain injury [2]
Focal [contusion/haematoma] or diffuse [diffuse axonal injury]
How can diffuse axonal injuries occur? [1]
diffuse axonal injury occurs as a result of mechanical shearing following deceleration, causing disruption and tearing of axons
Where do contusions occur? [1]
contusions may occur adjacent to (coup) or contralateral (contre-coup) to the side of impact
When do secondary brain injuries occur? [4]
secondary brain injury occurs when cerebral oedema, ischaemia, infection, tonsillar or tentorial herniation exacerbates the original injury
What happens to the brain in secondary brain injuries? [2]
The normal cerebral auto regulatory processes are disrupted following trauma rendering the brain more susceptible to blood flow changes and hypoxia
What is Cushing reflex and when does it occur? [3]
the Cushings reflex (hypertension and bradycardia) often occurs late and is usually a pre terminal event
Where do EDH typically occur? [2]
The majority of epidural haematomas occur in the temporal region where skull fractures cause a rupture of the middle meningeal artery.
Features of EDH [2]
Raised ICP
Some patients have lucid interval
When do EDH typically occur? [1]
Often results from acceleration-deceleration trauma or a blow to the side of the head
Where do SDH typically occur? [1]
Most commonly occur around the frontal and parietal lobes.
RFs for SDH [3]
Risk factors include old age, alcoholism and anticoagulation.
Compare SDH to EDH [2]
Slower onset of symptoms than a epidural haematoma. There may be fluctuating confusion/consciousness
Classically, how does a subarachnoid haemorrhage present? [1]
Classically causes a sudden occipital headache.
When does SaH commonly occur? [2]
Usually occurs spontaneously in the context of a ruptured cerebral aneurysm but may be seen in association with other injuries when a patient has sustained a traumatic brain injury
What is a intracerebral haematoma? [1]
An intracerebral (or intraparenchymal) haemorrhage is a collection of blood within the substance of the brain
Causes/RF of ICH [5]
Causes / risk factors include: hypertension, vascular lesion (e.g. aneurysm or arteriovenous malformation), cerebral amyloid angiopathy, trauma, brain tumour or infarct (particularly in stroke patients undergoing thrombolysis).
Why is it crucial to obtain a CT in head in all stroke patients prior to thrombolysis? [2]
Patients will present similarly to an ischaemic stroke in ICH
Or will present with decreased LOC
Blood profile of a patient with anaemia of chronic disease [4]
A normocytic anaemia with low serum iron, low TIBC but raised ferritin in a patient with a chronic illness is typical of anaemia of chronic disease
Three distinct pathological processes in iron profile of anaemia of chronic disease [3]
reduced iron release from marrow, inadequate secretion of EPO for erythropoiesis and reduced red cell survival
Why is ferritin raised in chronic inflammation? [1]
Ferritin is an acute phase reactant and therefore raised in states of chronic inflammation, as is likely to be the case in this patient.
Why are platelets raised in chronic anaemia? [1]
The platelets are raised due to a reactive thrombocytosis in the presence of inflammation.
Blood profile of iron defieicny anaemia [3]
Iron deficiency anaemia causes a microcytic anaemia, low ferritin and a raised TIBC
Hereditary haemochromatosis blood picture [3]
Hereditary haemochromatosis can cause a raised ferritin and low TIBC however iron levels are unlikely to be normal and ferritin would usually be much higher than in this case.
What does sidroblastic anaemias typically cause blood profile? [2]
Sideroblastic anaemia usually causes a microcytic anaemia with raised serum iron levels.
Causes of normocytic anaemias [5]
anaemia of chronic disease chronic kidney disease aplastic anaemia haemolytic anaemia acute blood loss
What should be offered to patients with intrahepatic cholestasis and why? [2]
Intrahepatic cholestasis of pregnancy increases the risk of stillbirth; therefore induction of labour is generally offered at 37-38 weeks gestation
how common is intrahepatic cholestasis in pregnancy? [1]
1% in the UK
Features of intrahepatic cholestasis of pregnancy [3]
pruritus - may be intense - typical worse palms, soles and abdomen
clinically detectable jaundice occurs in around 20% of patients
raised bilirubin is seen in > 90% of cases
Mx of cholestasis of pregnancy [3]
induction of labour at 37-38 weeks is common practice but may not be evidence based
ursodeoxycholic acid - again widely used but evidence base not clear
vitamin K supplementation
How common is recurrence of intrahepatic cholestasis of pregnancy? [1]
Recurrence of intrahepatic cholestasis of pregnancy is 45-90% in subsequent pregnancies.
Presentation of biliary colic vs cholecystitis [4]
The pain becomes worse after eating but she is generally well, afebrile and her abdomen is soft. In cholecystitis, you would expect evidence of infection (e.g. fever, tachycardia). You might also be able to palpate the gallbladder, and she may be Murphy’s sign positive.
What is ERCP procedure used for? [1]
ERCP is a procedure that can be used to remove obstructing gallstones from the common bile duct or pancreatic duct, so has no role in simple biliary colic
Signs of an obstructing stone include what? [1]
Signs of an obstructing stone would include jaundice, of which there is no mention here
What is biliary colic caused by? [1]
Biliary colic is caused by gallstones passing through the biliary tree.
RFs for biliary colic [4]
it is traditional to refer to the ‘4 F’s’:
Fat: obesity is thought to be a risk factor due to enhanced cholesterol synthesis and secretion
Female: gallstones are 2-3 times more common in women. Oestrogen increases activity of HMG-CoA reductase
Fertile: pregnancy is a risk factor
Forty
Other notable RFs for biliary colic [4]
diabetes mellitus
Crohn’s disease
rapid weight loss e.g. weight reduction surgery
drugs: fibrates, combined oral contraceptive pill
Simple PP of biliary colic [3]
occur due to ↑ cholesterol, ↓ bile salts and biliary stasis
the pain occurs due to the gallbladder contracting against a stone lodged in the cystic duct
Features of biliary colic [3]
colicky right upper quadrant abdominal pain
worse postprandially, worse after fatty foods
the pain may radiate to the right shoulder/interscapular region
nausea and vomiting are common
Ix for biliary colic [1]
ultrasound
Mx of biliary colic [1]
- elective laparoscopic cholecystectomy
How common is it to have gallstones in the common bile duct? [1]
Around 15% of patients are found to have gallstones in the common bile duct (choledocholithiasis) at the time of cholecystectomy, This can result in obstructive jaundice in some patients
Possible Cx other than biliary colic of a gallstone [5]
acute cholecystitis: the most common complication ascending cholangitis acute pancreatitis gallstone ileus gallbladder cancer
What is most likely to be observed in the synovial fluid taken from a patients knee with reactive arthritis? [2]
Sterile synovial fluid with a high WCC
24 y/o painful right knee, lethargy, feverish Sx, PMH includes chlaydia infection 2w previously. Dx? [1]
Septic arthritis
Define reactive arthritis [3]
The patient’s presentation is suggestive of reactive arthritis, a HLA-B27 seronegative spondyloarthritis classically associated with oligoarthritis of the lower limbs following a gastrointestinal or urogenital infection 1-4 weeks previously
What type of WBCs will be seen in synovial fluid of patient with reactive arthritis? [1]
The pathological process is aseptic, does not involve salt crystal formation, but is likely to cause increased white blood cells in the fluid (mostly polymorphonuclear leukocytes).
When are negatively birefringent crystals seen in pts? [2]
commonly seen in calcium pyrophosphate deposition (pseudogout).
Positively birefringent crystals seen commonly when? [1]
Gout
What are smears done to test? [1]
Cervical cancer
What should happen if 2 consecutive inadequate samples taken cervical smear? [1]
Refer to colposcopy
Which system does the cervical cancer screening employ currently? [2]
The NHS has now moved to an HPV first system, i.e. a sample is tested for high-risk strains of human papillomavirus (hrHPV) first and cytological examination is only performed if this is positive.
If patient has negative hrHPV, what should you do? [5]
return to normal recall, unless
the test of cure (TOC) pathway: individuals who have been treated for CIN1, CIN2, or CIN3 should be invited 6 months after treatment for a test of cure repeat cervical sample in the community
the untreated CIN1 pathway
follow-up for incompletely excised cervical glandular intraepithelial neoplasia (CGIN) / stratified mucin producing intraepithelial lesion (SMILE) or cervical cancer
follow-up for borderline changes in endocervical cells
If hrHPV is positive and cytology is abnormal, what should be next line Mx? [1]
if the cytology is abnormal → colposcopy
If cytology is normal, but hrHPV is abnormal, what should be done? [1]
if the cytology is normal (i.e. hrHPV +ve but cytologically normal) the test is repeated at 12 months
If cervical sample is inadequate [2]
repeat the sample within 3 months
if two consecutive inadequate samples then → colposcopy
Inherited causes of thrombophilia [5]
Gain of function polymorphisms
- factor V Leiden (activated protein C resistance): most common cause of thrombophilia
- prothrombin gene mutation: second most common cause
Deficiencies of naturally occurring anticoagulants
- antithrombin III deficiency
- protein C deficiency
- protein S deficiency
Prevalence and RR of VTE in factor V Leiden [heterozygous]
prevalence 5%, relative risk of VTE is 4
Prevalence and RR of VTE in protein C deficiency
0.3% and RR is 10
Acquired causes of thrombophilia [2]
Antiphospholipid syndrome
Drugs
the combined oral contraceptive pill
What is Hodgkins lymphoma? [2]
Hodgkin’s lymphoma is a malignant proliferation of lymphocytes characterised by the presence of the Reed-Sternberg cell
When is Hodgkin’s lymphoma most common? [1]
It has a bimodal age distributions being most common in the third and seventh decades
What is the most common type of HL? [1]
nodular sclerosing
Features of nodular sclerosing HL [3]
More common in women. Associated with lacunar cells
Good prognosis
Which HL type has best prognosis, which has the worst prognosis? [2]
Lymphocyte predominant [5%] best prognosis, lymphocyte depleted [rare] worst prognosis
What is HSP? [2]
HSP is a IgA mediated small vessel vasculitis
When is HSP seen? [1]
Usually seen in children following an infection
Features of HSP [4]
palpable purpuric rash (with localized oedema) over buttocks and extensor surfaces of arms and legs
abdominal pain
polyarthritis
features of IgA nephropathy may occur e.g. haematuria, renal failure
Tx for HSP [2]
analgesia for arthralgia
treatment of nephropathy is generally supportive. There is inconsistent evidence for the use of steroids and immunosuppressants
Prognosis of HSP [2]
usually excellent, HSP is a self-limiting condition, especially in children without renal involvement
around 1/3rd of patients have a relapse
Where is Legionnaire’s disease typically contracted from? [1]
It typically colonizes water tanks and hence questions may hint at air-conditioning systems or foreign holidays.
Is Legionaires transmittable? [1]
No not person-to-person
