From the Modules Flashcards
1
Q
WHO criteria for T2DM diagnosis?
A
- fasting plasma glucose >/= 7mmol/L
- plasma glucose >/= 11.1mmol/L 2hrs after 75g oral glucose
- HbA1c >/= 6.5%
- in a symptomatic patient, a random plasma glucose of >/= 11.1mmol/L is diagnostic of T2DM under the WHO criteria
2
Q
Features of diabetic retinopathy on opthalmoscopy?
A
micro-aneurysm or haemorrhage
hard exudates
neovascularisation
pre-retinal hemorrhage
cotton wool spots
3
Q
Beck’s triad for cardiac tamponade + three other signs?
A
Beck’s triad = distended jugular veins, reduced heart sounds + hypotension.
Along with increased RR, tachycardia, and pulsus paradoxus.
4
Q
3 signs of a PE?
A
suddenSOB
pleuritic chest pain
hyoptension
tachypnea
pleural rub on chest auscultation
low O2 saturations
possible calf tenderness
5
Q
Differentials for vertigo?
A
Peripheral causes:
- benign paroxysmal positional vertigo
- vestibular neuritis (include ramsay hunt syndrome)
- meniere’s disease (too much endolymph causing an increase in pressure in the semicircular canals)
Central causes:
- stroke -> posterior circulation including cerebella, lateral medullary syndrome, vertebrobasilar)
- migraine
- demyelination -> MS
6
Q
Interpret HINTs exam
A
- Head Impulse test:
- peripheral cause = corrective saccade (inability to maintain central fixation on a stationary target during head rotation → their eyes will ‘catch-up’
- central = normal head impulse test (no corrective saccade)
- Nystagmus:
- peripheral cause = unidirectional horizontal nystagmus (typically beats away from the side of the lesion)
- central cause = bidirectional nystagmus aka gaze evoked
- Test of skew:
- peripheral = skew deviation is absent (eye remains fixed on central gaze when uncovered)
- central = skew deviation
7
Q
What is pernicious anaemia?
A
A rare autoimmune disorder that causes diminishment in dietary vitamin B12 (cobalamin) absorption, resulting in B12 deficiency and subsequent megaloblastic anemia.
Occurs due to autoimmune destruction of parietal cells, leading to a decreased production of intrinsic factor, this impaired vB12 absorption.
Blood work will show a high mean cell corpuscular volume and hypersegmented neutrophils (macrocytic anemia)
8
Q
Differentials for haematuria plus proteinuria?
A
Nephritic syndrome
- post-strep glomerulonephritis
- Goodpasture syndrome (anti-GBM antibody disease)
- Thin basement membrane disease
- Alport syndrome (chronic)
- fx → usually X-linked, can be autosomal recessive or dominant though
- leads to a defected basement membrane in the kidneys → results in kidney damage
- recurrent haematuria, can also have hearing loss
- can progress to nephritic syndrome → will have some proteinuria
- IgA nephropathy (chronic)
- symptoms often during or immediately after a respiratory or gastrointestinal infection → infection triggers IgA antibodies to for immune complexes that deposit in the renal mesangium → can progress to nephritic syndrome which will involve protein deposition
9
Q
DDx for haematuria with flank pain?
A
- uroliathesis
- polycystic kidney disease with cystic rupture (blood clot in the ureter)
- fx, ballotable kidneys
10
Q
Which part of the spine does RA affect?
A
the cervical spine (the rest of the spine is typically spared)
11
Q
What is terlipressin used for?
A
treatment of bleeding from oesophageal varices
12
Q
3 anti-emetics recommended in the management of migraines?
A
metoclopramide (maxalon)
promethazine (phenergen)
prochlorperazine (stemetil)
13
Q
Triptan MOA and indication
A
Used in abortive treatment of migraines.
5-HT(1B/1D) receptor agonist → causes vasoconstriction of painfully dilated cerebral blood vessels, inhibition of the release of vasoactive neuropeptides by trigeminal nerves (substances involved in pain transmission), and inhibition of nociceptive
14
Q
Headache red-flad symptoms
A
SNOOP10
systemic symptoms (fever, signs of meningitis)
neoplasm hx
neurological deficits (e.g. altered mental state, seizures)
onset is abrupt
older age >50ys
pattern changes to headache hx
positional headache
presipitated by sneezing, coughing or exercise
papilledema/signs of raised ICP
pregnancy or postpartum period
pain of the eye with autonomic features an visual deficits
post-traumatic onset
pathology of immune system
painkiller overuse
15
Q
Treatment for mastitis?
A
Commence on ABx e.g. flucloxacillin 500mg orally, every 6hrs for 5-10 days (depending on results), or dicloxacillin 500mg orally, every 6hrs for 5-10 days.
Review in 1 week or re-assess earlier if symptoms worsen.
If penicillin allergy, then use cefalexin 500mg 6hrs for 5-10 days.
16
Q
Outline NEXUS criteria for the assessment of neck injuries
A
If yes to any of the following, then refer for imaging. If no to all of them, then the C-spine can be cleared clinically.
- focal neurologic deficit present → motor weakness, impaired sensation, facial droop, absent reflexes
- midline spinal tenderness present
- altered level of consciousness → confusion, decreased GCS
- intoxication present
- distracting injury present - e.g. long bone fracture, significant visceral injury, large laceration, extensive burns
17
Q
Predicted ALT and AST levels/ratio in alcohol induced hepatitis?
A
AST often >2x ALT
GGT also raised in binge drinking
18
Q
LFT picture for intra vs post-hepatic jaundice
A
Raised ALT and AST in hepatic dysfunction
Raised ALP and GGT in cholestasis
19
Q
two phases of measles?
A
Prodromal phase - conjunctivits, cough, coryza
Exanthem phase - widespread maculopapular rash, fever, malaise
20
Q
Which paediatric rash typically comes after the fever subsides?
A
roseola infantum (human herpesvirus 6)
21
Q
Describe features pf a fibroadenoma?
A
- is the most common type of breast mass in women <35 years
- usually a well-defined, non-tender, rubbery, and mobile mass → generally do not increase in size
- on US/mammography → well defined mass with possible popcorn-like calcification.
- requires confirmatory studies such as a core needle biopsy.
- expectant management or surgical excision
22
Q
Which type of breast lump typically has popcorn-like calcification on mammography?
A
fibroadenoma
23
Q
Which breast lump is associated with premenstrual hormone changes?
A
fibrocystic condition of the breast - patients will typically present with premenstrual bilateral multifocal breast pain with or without palpable nodules → these may be tender
24
Q
Which benign breast lesion can be associated with bloody or serous nipple discharge?
A
Intraductal papilloma
25
duodenal atresia sign on xray?
Double bubble sign -> large gastric bubble proximal to an air-filled first part of duodenum. Nil air distally.
26
DDx for patient presenting with dysphagia
- osophageal stricture
- peptic → use dilation and PPI
- radiation → use dilation
- malignant → biopsy and surgery discussions
- web
- viral causes of oesophagitis (commonly HSV or CMV)
- fungal oesophagitis (candida)
- GORD → causes oesophagitis if severe
- Eosinophilic oesophagitis (EoE) → associated with atopy (asthma, eczema)
- eosinophils deposit within the oesophagus
- non-structural causes:
- achalasia
- dysmotility
- rumination syndrome
- neurological causes -> e.g. stroke
27
GORD DDx
lifestyle related - smoking, alcohol
hiatus hernia
oesophageal stricture insufficiency
Zollinger-Ellison syndrome -> tumours call gastrinomas that secrete gastrin which stimulate stomach acid release
h.pylori
28
Signs and symptoms of GORD
waterbrash
saliva on pillow
hoarse voice
heart burn
regurgitation
dysphagia
nausea
chronic productive cough
epigastric pain
belching/bloating
aspiration pneumona
29
name for painful swallowing?
odynophagia
30
Review HINTS exam and differentiating peripheral vs central vertigo:
Look up
31
Which domains are impaired in dementia according to DSM-5?
PLLECS:
Perceptural motor
Language
Learning and memory
Executive function
Complex attention
Social cognition
One or more domains affected in dementia
32
Link between anticholinergics and dementia? What medications are important to consider?
ACh is an important neurotransmitter for memory and cognitive processing. Anticholinergic medications linked to dementia risk.
Medications include:
Some antiparkinson meds, antidepressants (amitriptyline), bladder antimuscarinics, antipsychotics
33
Features of pancytopenia?
low RBC, platelets, and WBC
34
Treatment of acute gout?
NSAIDs or colchicine -> then use allopurinol for prevention
**Allopurinol contraindicated for treatment of acute flare as it can exacerbate symptoms
*be mindful using NSAIDs if renal impairment
35
What lymphoma are Reed-Sternberg cells pathognomonic for?
Hodgkin lymphoma
36
Hodgkin lymphoma clinical features?
- painless lymphadenopathy
- B-symptoms: night sweats, weight loss, fever
- Pel-Ebstein fever → intermittent fever with periods of high temperature for 1-2 weeks, followed by afebrile periods for 1-2 weeks (rare by specific for HL)
- alcohol induced pain → pain in lymph nodes after consuming alcohol
37
Clinical features of Q fever?
fever, myalgia, headache and granulomatous hepatitis
38
Q-fever organism?
Q fever is an infection caused by the bacteria Coxiella burnetii
39
Q-fever ABx treatment?
tetracycline (first line) or azithromycin
40
Duct ectasia features?
Milk duct becomes swollen and/or blocked - the duct walls thicken, and the duct fills with fluid. Can get nipple retraction and mucousy discharge
41
ABx to treat chlamydia?
doxycycline (7 day treatment) or azithromycin (single dose)
42
What 21 day progesterone level is indicative of annovulation?
<30 nmol/L
43
How does metaclopramide cause hyperprolactinemia?
It is a dopamine antagonist -> thereby increases prolactin secretion
44
What is Sheehan syndrome?
Pituitary necrosis following blood loss (commonly postpartum haemorrhage)
45
What is Felty's syndrome?
splenomegaly and neutropenia in a patient with rheumatoid arthritis
46
What is the corticosteroid of choice administered for premature labour? (for premature lung development)
Betamethasone
47
Hypochondriasis vs somatisation disorder?
Hypochondriasis: preoccupation with a having a disease despite negative tests and reassurance
Somatisation disorder: preoccupation with symptoms, despite no underlying cause
48
How to prevent vertical hep B transmission in women who are pregnant and Hep B positive?
Neonatal hep B immunisation. Consider hepatitis B immunoglobulin (HBIG) immediately after birth is recommended for infants born to mothers with chronic HBV infection
49
What to start child on with asthmatic symptoms not well controlled by ventolin?
Commence on an inhaled corticosteroid inhaler e.g. flixotide.
Not on a corticosteroid with a LABA -> make treating acute exacerbations harder
50
Another name for EBV?
Infectious mononucleosis
51
Barriers to GP ABx stewardship
- perceptions of patient expectations or ABx prescriptions
- GP clinical routines
- Consultation time pressures
- Clinical uncertainty
- Fear of adverse outcomes with non-prescribing
52
Normal resting HR for babies and toddlers?
babies (birth to 3 months of age): 100–150 beats per minute.
kids 1–3 years old: 70–110 beats per minute.
kids by age 12: 55–85 beats per minute
53
pyloric stenosis vs duodenal atresia?
Stenosis = partial blockage -> may not be detected for a few weeks.
Atresia = total blockage -> sometimes detected on prenatal US or due to polyhydramnios. Otherwise detected in the first 24hrs of life as baby will vomit any oral intake. Double bubble sign is when there is fluid in the baby's stomach and first part of the duodenum, but not fluid beyond that.
54
DDx for vomiting in infant
- pyloric stenosis
- CF
- gastroenteritis
- midgit volvulus or intestinal malrotation
- intussusception
- reflux or GORD
- intolerance → e.g cow’ milk protein
- cyclic vomiting syndrome
55
Management for splenic rupture?
Haemodynamically stable: aim for conservative management (hospital observation, angiographic embolisation of injured blood vessels)
Haemodynamically unstable: laparotomy, if salvageable then try splenic suturing and ligation of injured vessel/s. If not salvageable then require splenectomy or partial splenic resection.
56
Causes of splenic rupture?
Traumatic:
- blunt abdo trauma
- left sided rib fractures
- penetrating abdo trauma
Atraumatic splenic rupture:
- infection (malaria, mononucleosis, HIV)
- leukemia
- inflammation (e.g. pancreatitis)
- medications (anticoagulation)
- pregnancy (exact reason unknown)
57
Signs and symptoms of HSP? (IgA vasculitis)
- a skin rash, which looks like small bruises or small reddish-purple spots – it's usually seen on the bottom, legs and around the elbows
- peripheral oedma, particular hands, feet, and legs
- pain in the joints, such as the knees and ankles
- stomach pain
- blood in the faeces (poo) or urine (wee) (haematuria), caused by the blood vessels in the bowel and the kidneys becoming inflamed
- may have high BP secondary to nephritis
58
HSP pathophysiology?
Hypothesized pathophysiological mechanism: exposure to allergen/antigen (e.g., infection, drugs) → stimulation of IgA production → deposition of IgA immune complexes in vascular walls (e.g., in the skin, GI tract, joints, kidneys) → activation of complement → vascular inflammation and damage
get:
- abdo pain
- purpuric rash
- nephritis
- peripheral oedema
- HTN
- arthralgia (painful joints)
59
Causes of 'floaters' in vision?
- Eye infections
- Eye injuries
- Uveitis (inflammation in the eye)
- Bleeding in the eye
- Vitreous detachment (when the vitreous pulls away from the retina)
- Retinal tear (when vitreous detachment tears a hole in the retina)
- Retinal detachment (when the retina gets pulled away from the back of the eye)
60
S&S of Wernicke-Korsakoff syndrome?
Wernicke encephalopathy (acute and reservible):
- confusion
- oculomotor dysfunction (nystagmus, diplopia)
- gait ataxia
*Improves with thiamine administration
Korsakoff syndrome (chronic, irreversible)
- confabulation
- anterograde and retrograde amnesia
- personality changes
- disorientation to time, place, person
- hallucinations
61
Pharmacological management for alcohol misuse disorder?
- Naltrexone (first line) → reduces cravings for alcohol
- Disulfiram (antabuse) → exacerbates intoxication symptoms and induces negative conditioning
- Acamprosate → reduces cravings for alcohol
- thiamine and folic acid supplementation
62
management of hepatic encephalopathy?
- avoid any toxins that will contribute to liver impairment
- lactulose → decreases ammonia absorption within the bowel
- rifaximin → reduced the number of ammonia producing intestinal bacteria
- liver transplant
63
most common viral cause of pericarditis?
Coxsackie B virus infection (different from Coxsackie A which causes hand, foot and mouth).
Coxsackie B is associated with flu like symptoms and sudden thoracic and abdo pain caused by irritation of the pleura and muscles.
64
Triad for pericarditis?
Sudden onset positional pleuritic chest pain + pericardial rub + global ST elevation & PR depression
65
What do the right supraclavicular nodes drain?
Breast, lung, and oesophagus
66
Outline the four components of persistent pelvic pain?
1. Pelvic pain from organs
2. The musculoskeletal response to pain
3. Central sensitisation of nerve pathways
4. The psychological sequelae of persistent pain
67
Abnormal premenopausal bleeding DDx?
- polyps
- leiomyoma (fibroids)
- adenomyosis
- malignancy (cervical cancer)
- coagulopathy
- ovarian disorder (PCOS, ruptured cyst)
- endometriosis
- trauma
- STI
- cervical ectropion
- hypothyroidism (irregular, heavy periods)
68
Two ovulation induction medications?
letrozole and clomiphene
69
Diagnostic criteria for miscarriage on US?
- absence of foetal cardiac activity in embryo when crown to rump length (CRL) is > 7mm
- absence of a foetal pole when the mean sac diameter is > 2.5cm which corresponds to a gestational age of 6 weeks
Then there are some cases where the criteria is not met. In which case, follow up US is required.
70
DDx for PV bleeding in early pregnancy?
- miscarriage:
- threatened, incomplete, complete, inevitable
- ectopic pregnancy
- molar pregnancy
- normal pregnancy with unknown cause of bleeding (could be subchorionic haemorrhage present)
- infection or trauma co-existing with pregnancy
- implantation bleeding
71
placenta previa classifications?
- marginal → lies within 2-3cm of the internal os
- partial → implants near and partially covers the os
- total → completely covers the os
71
S&S of placenta previa?
Two classic presentations:
- antepartum haemorrhage:
- painless, bright red bleeding
- spontaneous, in third trimester and ceases spontaneously
- fetal malpresentation:
- remain high in uterus
- increased risk of transverse, oblique, or
breeched presentation
72
RA serology?
Antinuclear antibodies (ANA)
Anti-citrullinated peptide antibodies (ACPA)
Rheumatoid factor (RF)
73
DDx for joint pain?
Psoriatic arthritis
OA
Fibromyalgia
Reactive arthritis
Gout
Septic arthritis
Rheumatoid arthritis
74
What is the FAST imaging approach to blunt force trauma patients?
FAST scan (focused assessment with sonography for trauma) → assess for pericardial fluid, RUQ fluid (Morison’s pouch), LUQ fluid (splenorenal recess), suprabubic fluid
*helps to indicate the need for emergency laparotomy
75
Outline delirium tremens?
persistent alteration of consciousness and sympathetic hyperactivity due to alcohol withdraw
- symptoms include:
- disorientation
- tremor
- tachycardia
- HTN
- sweating
- nausea
- alcohol withdrawal seizures → tonic clonic seizures occurring 8-48hrs after withdrawal
76
Why use benzodiazepines for alcohol withdrawal?
Acute use of alcohol produces CNS depression because of an increased GABAergic neurotransmission and reduced glutamatergic activity. However, in patients with chronic heavy alcohol use, because of neuro-adaptation, there is a down regulation of Gamma-Amino Butyric Acid (GABA) and up-regulation of the glutamate (NMDA receptor) neurotransmission. In alcohol withdrawal, this neurotransmitter imbalance gets unmasked and there is an unopposed glutamate activity which leads to excitotoxicity as a result of intracellular calcium influx and oxidative stress. This is precisely the reason that benzodiazepines which are GABAergic drugs reduce the excitetoxicity by restoring the neurotransmitter balance and are considered to be the drug of choice in alcohol withdrawal syndrome.
77
management of hepatic encephalopathy?
- avoid any toxins that will contribute to liver impairment (especially proteins)
- lactulose → decreases ammonia absorption within the bowel
- rifaximin → reduced the number of ammonia producing intestinal bacteria
- liver transplant
- avoid unnecessary medications that are metabolised by the liver
- treat precipitating factors
78
What are uterine fibroids?
aka leiomyomas
benign tumours of the myometrium -> can be subserous, intramural or submucosal
79
4 typical features of uterine fibroids/leiomyoma?
menorrhagia
abdominal mass
pressure effect from pressure on the bladder, stomach or bowel (feeling full, frequent urination)
80
3 cardinal symptoms of fibromyalgia?
Widespread muscle pain
Fatigue
Unrefreshing sleep/sleep disturbance
81
Management for osteporosis?
Non-pharmacological:
- discuss fall prevention strategies → identify and manage risk factors
- encourage physical activity that focuses on strength and balance
- consider physiotherapy and/pr occupational therapy
Pharmacological:
- oral bisphosphonates e.g. alendronate, risedronate
- can be taken daily or weekly
OR
- denosumab (prolia)
- taken as a subcutaneous injection 6mthly
Plus vitamin D and calcium supplementation.
82
Major adverse effects of bisphosponates and prolia (denosumab)
Bisphosphonates - osteonecrosis of the jaw and oesphagitis (take 30mins before food and stay upright)
Prolia: osteonecrosis of the jaw
83
Cardinal signs of psychosis:
delusions
hallucinations
thought disorder
agitation/agression
84
Key features of each particular non-sinister headache:
- migraine
- cluster headache
- sinusitis
- tension-type
- TMJ syndrome
Migraine:
unilateral, few times a year, photophobia, pulsatile, sound sensitivity, +/- aura
Cluster:
occur in clusters (6-12 weeks every 1-2 years), focused around one eye, intense pain, lasts 20-30mins, may have red, watery eye and Horner's syndrome
Sinusitis:
often following coryzal symptoms
Tension type:
most common, stress anf fatigue are a trigger, described as a tightening band around head, nil other features (no photophobia or nausea).
TMJ:
associated with teeth grinding or jaw clenching
85
Sinister causes of headache:
VIVID
Vascular - SAH, subdural or extradural, cerebral venous sinus thrombosis, cerebellar infarct
Infection - meningitis, encephalitis
Vision-threatening - temporal arteritis, acute glucoma
Intracranial pressure (raised) - SOL, cerebral oedema, malignant HTN
Dissection - carotid dissection
86
Features of Kallmann syndrome?
Can affect males and females (46XX and 46XY).
Defective migration of GnRH neurons within the hypothalamus -> results in decreased GnRH production -> decreased FSH and LH secretion of the pituitary gland -> decreased testosterone production in males, decreased estrogen & progesterone production in females.
Results in absent or decreased pubertal changes. Can result in infertility without hormone treatment.
Also results in loss of smell (anosmia).
Other complications include osteoporosis, mental health complications.
87
Causes of delayed bone age in children/adolescents?
Hypothyroidism
Constitutional delay in growth
Growth hormone deficiency
88
Order of male puberty changes?
Testicular enlargement, then pubic hair, then growth spurt
89
Review Apgar scoring
90
Features of growing pains?
* never present at the start of the day after the child has woken
* no limp
* no limitation of physical activity
* systemically well
* normal physical examination
* motor milestones normal
* symptoms are often intermittent and worse after a day of vigorous activity
91
Hormone serology features of Turner syndrome?
Elevated FSH and LH, but decreased estrogen and androgen (due to impaired ovarian development)
92
Central vs peripheral precocious puberty? Give examples
Central - gonadotropin (FSH and LH) dependent. Will have an increase in FSH and LH (may also have increase in GnRH depending on the cause).
e.g. idiopathic, pituitary tumors, hypothalamus haemartoma, trauma, obesity related precocious sexual development.
Peripheral - gonadotropin independent. Will not have increase in GnRH or FSH/LH. Will have increase in testosterone/estradiol levels.
e.g. congenital adrenal hyperplasia, adrenal tumor, McCune-Albright syndrome (increase in estrogen production), ovarian/testis tumor
93
Differentiating between central vs peripheral precocious puberty?
Central: high FSH, LH, estrogen/progesterone/testosterone
Peripheral: low FSH & LH, raised estrogen/testosterone
GnRH stimulation test - administer GnRH and test FSH and LH.
Central will have raised FSH and LH.
Peripheral will have unchanged FSH and LH.
94
How does congenital adrenal hyperplasia cause precocious puberty?
Genetic deficit in enzyme involved in cortisol production. Results in negative feedback to the pituitary gland -> increased ACTH -> caused adrenal hyperplasia -> results in decreased cortisol and aldosterone production, but increase in androgen production.
95
Clinical features of congenital adrenal hyperplasia?
hypoglycemia (lack of cortisol)
adrenal crisis
hyperpigmentation esp. mucous membranes.
96
Workup for someone presenting with precocious puberty?
Labs:
- FSH, LH (particularly), estrogen/testosterone
- GnRH stimulation test (if LH is increased then indicative of central cause - perform brain MRI)
Imaging:
- x-ray non-dominant hand (within 1yr of child's age = puberty likely not started. If >2yr of child's age then puberty has been present for a year or longer)
- MRI of brain if LH raised (basal or following GnRH test)
- consider US of the pelvis and adrenal glands if suspecting peripheral cause
**Important to perform neurological examination - particularly looking at visual fields
97
Triad of McCune- Albright syndrome?
Cafe-au-lait spots
Polyostotic fibroud dysplasia
Endocrinopathies - peripheral precocious puberty, cushing syndrome, acromegaly
98
Initial examination of someone presenting with a headache?
Vitals - temp for infection, BP for malignant HTN
Head and neck examination - msk tenderness/stiffness (tension headache). Feel for temporal/scalp tenderness.
Neurological exam - focal neurological signs - SOL, haemorrhage
Fundoscopy - to exclude raised intracranial pressure
History should guide diagnostic suspicion but still perform exam to rule out other causes.
99
What is homonymous hemianopia?
Think and look up - consider where the lesion is
100
What is a heterotopic pregnancy?
a rare condition involving multiple gestations, in which one is intrauterine and another is ectopic. Occurs more frequently in patients undergoing infertility treatments, e.g., in vitro fertilization.
101
List some symptoms of lithium toxicity?
Tremor
Confusion
Ataxia
Renal impairment - diabetes insipidus (polyuria), uremia
Hypothyroidism
Diarrhoea
102
Treatment of lithium toxicity?
Acute (e.g. overdose) - forced diuresis
Chronic - hemodialysis
103
Formula for calculating predicted PCO2 in metabolic acidosis?
Winters formula: Anticipated pCO2 = 1.5 x [bicarb] + 8 (±2)
104
Treatment of bleeding in mild haemophillia A?
Factor VIII + desmopressin
Desmopressin can also be used in von willebrand disease - works to release von Willebrand's antigen from the platelets and the cells that line the blood vessels where it is stored
105
A high pitched, crescendo-decrescendo systolic murmur, loudest over the left sternal border and augmented by Valsalva, with a palpable double impulse apex beat, is most consistent with....
hypertrophic obstructive cardiomyopathy
**Manoeuvres that decrease left ventricular volume (Valsalva, standing from a squatting position) will augment a HOCM murmur.
**Manoeuvres which increase preload (rapid squatting) or afterload (hand-grip) will decrease the intensity of a HOCM murmur.
106
Management of CO poisoning?
If airway not a problem and ok GCS, then hyperbaric oxygen therapy.
If airway a concern then intubate and 100% oxygen delivery.
107
Medication used to prevent varice's bleeding
A non-selective beta-blocker such as propranolol is the drug of choice for primary prophylaxis of varices in patients with decompensated cirrhosis. The non-selective beta-blockers cause reduced splanchnic blood flow and splanchnic vasoconstriction, resulting in reduced portal pressure.
e.g. propanolol
108
Review side effects of red belly, brown, and tiger snake bites.
Think bleeding/VICC, myotoxicity, neurotoxicity, systemic symptoms
https://www.rch.org.au/clinicalguide/guideline_index/Snakebite/
109
Treatment for febrile non-haemolytic transfusion reaction
The immediate management is to stop the blood transfusion, administer an antipyretic (e.g. panadol), exclude serious adverse events (especially acute haemolytic reaction, transfusion associated sepsis and transfusion-related acute lung injury) and send a reaction form to the transfusion lab.
Usually patients just experience fever and chills. If there are more systemic symptoms then need to rule out more serious reaction.
110
First step for snake bite management?
The first step in management should always be to apply a broad pressure immobilisation bandage to the affected limb starting from the bite site. The joints on either side of the bite site should then be immobilised using a splint, and the entire patient immobilised.
Then can administer antivenom
111
Not appropriate investigation/management strategies for CO poisoning:
a.
CT scan of the brain
b.
Putting the patient in a hyperbaric chamber.
c.
Oxygen therapy via a non rebreather mask.
d.
A measure of the patient’s carboxyhemoglobin level.
e.
Pulse oximetry investigation
e.
Pulse oximetry investigation
HbCO absorbs light almost identically to that of oxyhemoglobin. Although a linear drop in oxyhemoglobin occurs as HbCO level rises, pulse oximetry will not reflect this change and is therefore a useless investigation in this scenario.
112
A serum creatinine increase < 30% is acceptable following commencement of an ACE inhibitor
113
List 3 conditions associated with seronegative spondyloarthropathies:
Seronegative spondyloarthropathies (SpA) are a family of rheumatologic disorders that classically include: Ankylosing spondylitis (AS), Psoriatic arthritis (PsA), Inflammatory bowel disease (IBD) associated arthritis
114
What is the following condition and what is the management?
- unwell
- sudden severely painful red eye
- blurred vision
- severe headache, nausea, vomiting
- experiencing halos in visual field
Acute angle closure glaucoma
Requires emergency ophthalmology referal to relieve pressure in the eye. Pressure build up from impaired aqueous humour drainage in the anterior and posterior chambers of the eye
115
optic neuritis three main features
sudden loss of vision (unilateral) (blurred, washed out, colour blindness), pain of eye movement, feeling pain behind the eye
116
Which eye condition is ankylosing spondylitis associated with?
anterior uveitis.
Symptoms include:
* acute onset
* ocular discomfort & pain (may increase with use)
* pupil may be irregular and small
* photophobia (often intense)
* blurred vision
* red eyes
* lacrimation
* ciliary flush
* visual acuity initially normal → impaired
117
Three causes of optic neuritis?
multiple sclerosis
diabetes
syphilis
118
Two appropriate management options for acute angle closing glaucoma?
reducing aqueous secretions with acetazolamide and
inducing pupillary constriction with topical pilocarpine
119
Are mydriatic drops a known precipitant of acute angle closure glaucoma?
Yes
120
What does Hordeolum externum refer to?
A stye on the eyelid
121
Review entropion and ectropion of the eye
122
Key feature differentiating scleritis and episcleritis?
Scleritis is painful, episcleritis is not painful
123
Sudden painless unilateral loss of vision in one eye + relative afferent pupillary defect + cherry spot seen on ophthalmoscope?
Central retinal artery occlusion
124
Two clinical features of retinitis pigementosa?
Night blindness (loss of rods)
Tunnel vision
125
Two syndromes associated with retinitis pigmentosa?
Alport’s syndrome, Hereditary ataxia
126
Review what papilloedema on fundoscopy looks like
127
What are reed sternberg cell a hallmarker of?
Hodgkin lymphoma
128
Prognostic factors for melanoma?
* thickness (Breslow classification)
* level or depth (worse in level IV or V)
* site (worse on head and neck, trunk)
* sex (worse for men)
* age (worse >50 years)
* amelanotic melanoma
* ulceration
129
What is achalasia?
A disorder of oesophagus motility where the oesophagus does not effectively propel food downward.
130
PPI for GORD management plan?
If there are no features of serious disease, suspected gastro-oesophageal reflux disease can be initially managed with a trial of a proton pump inhibitor for **4–8 weeks**. This should be taken 30–60 minutes before food for optimal effect.
Once symptoms are controlled, attempt to withdraw acid suppression therapy. If symptoms recur, use the minimum dose that controls symptoms. Patients who have severe erosive oesophagitis, scleroderma oesophagus or Barrett’s oesophagus require long-term treatment with a proton pump inhibitor.
Don't forget in conjunction with lifestyle therapy.
131
What is Agoraphobia?
Agoraphobia is a type of anxiety disorder. A person with agoraphobia is afraid to leave environments they know or consider to be safe. In severe cases, a person with agoraphobia considers their home to be the only safe environment.
132
A 50 year old man presents with tiredness, dyspnoea and paraesthesia. On examination he showed extensor plantar reflexes, brisk knee jerks and absent ankle jerks. His blood film shows macrocytic anaemia.
What is the most likely underlying cause?
Pernicious anemia
133
What is the philadelphia chromosome associated with?
CML
134
Because of the ease with which carbon dioxide diffuses across the alveolar membranes, PCO2 is a highly reliable indicator of alveolar ventilation. In this postoperative patient with respiratory acidosis and hypoxia, the hypercarbia is diagnostic of alveolar hypoventilation. Acute hypoxia can occur with pulmonary embolism, pulmonary oedema and significant atelectasis, but in all those situations the CO2
partial pressures should be normal or reduced as the patient hyperventilates to improve oxygenation. The absorption of gas from the peritoneal cavity may transiently affect PCO2, but should have no effect on oxygenation.
135
Which rash has the characteristic 'delta sign'?
Scabies
136
Most likely syndrome associated with jaundice, high billirubin, but normal liver function tests?
Gilbert syndrome
137
When do fetal movements usually start to occur?
Around 16 and 24 weeks of pregnancy
138
Imaging choice for suspected MS?
MRI with gadolinium
139
Which are the most common benign parotid tumours?
Pleomorphic adenomas.
They are slow growing, smooth and mobile.
140
What thyroid condition are anti-thyroid peroxidase antibodies indicative of?
Hashimotos thyroiditis
141
What are the antibodies that are suggestive of Graves disease?
Antithyroglobulin and TSH receptor antibodies (the TSH receptor antibodies are veyr specific)
142
How does a radioisotope scan aid in the diagnosis of hyperthyroidism?
It enables the diagnosis of Graves disease as the scan shows the uniform uptake of the radioisotope by the thyroid. There would be an increased but irregular uptake of the isotope if a toxic nodular goitre, while poor or no uptake in se Quervain thyroiditis and thyrotoxicosis factitia (thyroxine overdose).
143
Causes of hyperthyroidism?
Grave’s disease
Iodine overload
toxic multinodular goitre
subacute thyroiditis (de Quervain thyroiditis) → usually viral origin
amiodarone
144
COPD O2 saturation target range?
88-92%
145
pesticide poisoning antidote?
atropine - an anticholinergic
146
features of hypercalcemia?
Features of hypercalcaemia can be memorised via the mnemonic “stones, bones, moans, and psychiatric overtones”. Patients with hypercalcaemia are more likely to develop renal stones due to high calcium levels (although this is dependent on the chronicity of the hypercalcaemia), have bony tenderness (bones), abdominal (moans) symptoms including constipation and anorexia due to reduced smooth muscle GI function and may suffer from neurocognitive symptoms including confusion, lethargy, anxiety and depression (psychiatric overtones).
147
How long should malaria prophylaxis be continued for when travelling to malaria-endemic countries?
Chemoprophylaxis should be started one week before travelling to a malaria-endemic
country and continued for one month after returning.
148
Outline management plan for patient with ulcerative colitis
Non-pharmacological:
- education and support
- maintain healthy balanced diet with adequate fibre
- follow up and review to check how symptoms are managed and whether any complications are a concern
Pharmacological:
- 5-aminosalicyclic acid derivatives (e.g. sulfasalazine, olsalazine)
- immunomodifying drugs (azathioprine, methotrexate) and biological agents (infliximab) for severe disease
- corticosteroids mainly used for acute flares
Surgery:
- surgical resection of affected bowel may be considered in patients with UC that is not controlled on meds
Treatment similar for Crohn disease
149
What is the modified centor criteria?
The Centor criteria is used to determine the likelihood of group A streptococcal (GAS) infection in adults. The modified Centor criteria includes:
fever > 38C
tonsillar exudate
absence of a cough
cervical lymphadenopathy
also includes age
150
Stroke driving restriction period?
You must not drive a private vehicle for at least four weeks after a stroke. Commercial drivers must not drive for at least three months. Need to be cleared by a specialist.
151
What is HbA1c and how does it related to BGL control?
The level of glycated hemoglobin → occurs over prolonged period of raised BGL → therefore is a biomarker used to assess long-term glycemic control.
152
3 symptoms of pagets disease?
hearing loss
bone pain (esp in legs with bowing)
headaches
153
Normal ankle-brachial index range?
Normal cut-off values for ABI are between 0.9 and 1.4. An abnormal ankle-brachial index- below 0.9-is a powerful independent marker of cardiovascular risk.
154
Paget disease of the bone first line treatment?
Bisphosphonates - single IV dose Zoledronate (aka zoledronic acid)
155
Appropriate management plan for asymptomatic provoked DVT? In patient with normal renal function.
DOAC (e.g. Apixaban) for 6 weeks
156
TCA’s (tricyclic antidepressants) MOA?
Block the reuptake of noradrenaline and serotonin in the presynaptic cleft -> attenuates their effects for longer
157
MAOI - monoamine oxidase inhibitors MOA?
Prevent the breakdown of serotonin
158
Mirtazapine (NaSSa) MOA
block presynaptic Alpha 2 receptors -> attenuate serotinergic and noradrenergic effects
159
SSRIs and SNRIs adverse effects?
* Common: nausea, dry mouth, insomnia, somnolence, agitation, diarrhoea, sweating, sexual
dysfunction
* Hyponatraemia -10% of patients (more common in elderly)
* Hypertension - dose dependent (SNRI)
* Liver effects: cholestatic jaundice - raised transaminase enzyme activities
* Falls - elderly
* GI bleeds
* Dangerous side effects: rare, seizures
160
TCA adverse effects?
- Anticholinergic: Blurred vision, constipation, urinary retention, increased appetite, dry mouth, nausea,
diarrhoea, heartburn, weight gain,
- Fatigue, weakness, dizziness, sedation, headache, anxiety, agitation, sweating.
- Sexual dysfunction
- Dangerous side effects: QTc prolongation, hypotension, arrhythmias, sudden death, lowered seizure, threshold, Paralytic ileus, raised intraocular pressure.
- Dangerous in overdose
- Not usually used first line due to these adverse effects
- Get baseline ECG in patients over 50
161
Which medication is associated with the tyramine cheese reaction? (i.e. hypertensive crisis)
MAOIs - monoamine oxidase inhibitors
162
Symptoms of serotonin syndrome?
Three of: Change in mental status (such as the onset of delusions, change in level of consciousness),
myoclonus, hyperreflexia, tremor, diarrhoea, sweating, shivering, incoordination, fever
163
Adverse effects of antipsychotics?
Movement disorders- extra pyramidal side effects, dystonia, tardive dyskinesia- especially first
generation
Anticholinergic- dry mouth, confusion, urinary retention
Antiadrenergic – postural hypotension, impotence
Histaminergic- sedation, weight gain
Metabolic syndrome- weight gain, dyslipidaemia, diabetes, - especially second generation
antipsychotics.
Hyperprolactinaemia, galactorrhoea, amenorrhoea
Clozapine- agranulocytosis, seizures, myocarditis
Increased risk of death and CVA’s in elderly patients with dementia
164
Which medication is NEUROLEPTIC MALIGNANT SYNDROME associated with?
Antipsychotics
165
What are the symptoms of NEUROLEPTIC MALIGNANT SYNDROME?
Fever
Muscular (lead pipe) rigidity
Autonomic system instability - unstable hypertension, tachycardia
Altered consciousness, confusion
Sweating, pallor
166
Investigation findings for neuroleptic malignant syndrome?
Elevated Creatinine Kinase (CK), and elevated White Cell Count (WCC)
167
Antipsychotic with the lowest risk of neuroleptic malignant syndrome?
Low affinity agent such as quetiapine has least risk.
168
List 3 main pharmacologic classes of mood stabilisers?
Anti-epileptic
Lithium
Second generation antipsychotics
169
Discuss the adverse effects of using sodium valproate as a mood stabiliser/anti-epileptic?
Polycystic ovaries, Teratogenic, Avoid in young women of childbearing age
170
How often should you monitor lithium levels and renal function in patients taking the medication?
≥ 2 x wkly initially, wkly for the next mth, then mthly for the next year, then quarterly
Should also monitor thyroid and parathyroid function yearly
171
What should be discussed with a patient taking lithium regarding pregnancy?
the increased risk of congenital malformations is uncertain; discuss risks v benefit: harm
to the baby and maternal mood instability in considering whether to stop lithium therapy
172
2 significant side effects of lithium use?
nephrogenic diabetes insipidus and hypothyroidism
173
At what concentration does lithium toxicity occur?
>2mmol/L (some texts say >1.5mmol/L)
174
List some signs of lithium toxicity?
Signs include loss of balance, increasing diarrhoea, vomiting, anorexia, weakness, ataxia, blurred
vision, polyuria, coarse tremor, muscle twitching, irritability and agitation, psychosis.
Remember signs of hypothyroidism as a SE.
Disorientation, seizures, coma and renal failure may occur
175
List some maladaptive listening styles:
Selective attention, (selecting negative aspects of a situation) - one person rated my lecture badly, I am
a useless lecturer
Overgeneralisation – I got that question wrong therefore I am useless at this subject
Personalisation - my colleague is grumpy I must have done something to upset him
Black and white thinking - if I can’t be the best runner there is no point in trying
Catastrophisation – ‘my boss was a bit critical of a job I did at work so I will get the sack and lose my
house because I can’t pay the mortgage, I can’t do anything right’
Shoulds and oughts
176
Outline some psychological interventions within psychiatry:
CBT
psychoeducation
motivational interviewing
dialectical behaviour therapy (DBT) - used in
borderline personality disorder
mentalisation
177
What are the four major skills focused on in DBT?
mindfullness
distress tolerance
effective interpersonal skills
emotional regulation
178
Modes of treatment in DBT?
individual therapy
group therapy
phone contact
therapist consultation
179
Management of acute dystonia following use of antipsychotics?
Benztropine (2mg IM) initially followed by 2mg oral dosing once dystonia has stopped.
Benztropine is used for treating extrapyramidal symptoms.
180
Describe the features of schizoaffective disorder
is characterised by episodes of major mood disturbances (mania or depressive disorders) with concurrent symptoms of schizophrenia and when the major mood symptoms abate there are persisting schizophrenic symptoms that last for at least two weeks without any mood disturbance being present
181
Bipolar I vs bipolar II?
- Bipolar I: at least one manic episode
- Bipolar II: cyclic episodes of major depression and hypomanic episodes
182
Pharm treatment for:
acute mania
acute bipolar depression
bipolar prevention/maintenance
acute mania = antipsychotics such as olanzapine
acute bipolar depression = some controversial opinions -> evidence for quetiapine and fluoxetine
maintenance = mood stabiliser (lithium)
183
Outline the three main management options for anxiety?
psychoeducation,
psychological treatments (particularly cognitive behaviour therapy)
pharmacological treatments (SSRSs and SNRIs are first line).
184
List some medical conditions that can be associated with anxiety (i.e. masquerades)
hypo/hyper-thyroidism
hypoglycemia
cardiac conditions
pulomonary disorders/chronic respiratory disease
inner ear conditions/tinnitis
withdrawal from benzodiazepines
vit B deficiency
**Should consider these conditions on hx and ex of patient presenting with anxiety
185
Outline management options for someone with PTSD
Psychotherapy:
- CBT
- cognitive processing therapy → trauma-focused CBT
- written exposure therapy
- eye movement desensitization and reprocessing therapy
Pharmacotherapy:
- SSRIs (e.g. sertraline, fluvoxamine)
- SNRIs (e.g. venlafaxine)
- Prazosin for reducing nightmares
- Naltrexone for reducing flashbacks
186
DSM5 for MDD?
DSIGECAPS:
depressed mood
sleep disturbance
lack of interest
guilt
decreased energy
impaired concentration
appetite changes
psychomotor changes
suicidality
**Must experience depressed mood or anhedonia
**Must experience at least four of the other symptoms
**Symptoms for at least 2 weeks
187
DDx for MDD?
dysthymic disorder (less severe symptoms, but persist for >2yrs) (also known as persistent depressive disorder)
adjustment disorder
bereavement
bipolar disorder
188
Outline the difference between:
factitious disorder
somatic symptom disorder
conversion disorder
Factitious disorder aka Munchausen syndrome - patient knows they don't have a disorder but will fake their symptoms.
Somatic symptom disorder - patient will have a preoccupation with their symptoms. Present for >6mth. Often will have an injury or illness but they will have a severe preoccupation with their symptoms. Often attend to their symptoms religiously.
Conversion disorder akak FND - patient has neurological symptoms (sensory or motor) that are not explained by evident neurological damage/pathology. Symptoms do not involve pain.
189
List some important questions to ask to clarify the risk of suicide in a patient?
suicidal thoughts
plan
means
lethality
past hx
suicide in the family or peers
190
Serotonin discontinuation syndrome features
Clinical features
- Flu-like symptoms (fatigue, lethargy, malaise, muscle aches, headaches, diarrhea, sweating)
- Insomnia (vivid dreams, nightmares)
- Nausea
- Imbalance (gait instability, dizziness, lightheadedness, vertigo)
- Sensory disturbances (paresthesias, electric shock sensations)
- Hyperarousal (anxiety, agitation)
- Dysphoria, irritability
- Psychosis (especially with MAOI discontinuation)
Timing
- Typically occurs within 3 days after drug cessation
- Symptoms usually subside within 1–2 weeks
Treatment: Restart antidepressant therapy at the original dose and begin tapering slowly.
191
Revise the FINISH mnemonic for serotonin discontinuation syndrome
Flu like symptoms
Insomnia
Nausea
Imbalance
Sensory disturbance
Hyperarousal
192
Antipsychotics of choice for older people?
risperidone
193
S&S of dementia vs delirium?
Look at notion under the 'older patient' tab
194
Common symptoms of acute grief vs integrated grief:
ACUTE GRIEF
*Last most of the day, everyday for up to 6mths
* Recurrent, strong feelings of yearning, wanting very much to be reunited with the person who died;
possibly even a wish to die in order to be with deceased loved one
* Pangs of deep sadness or remorse, episodes of crying or sobbing, typically interspersed with periods of
respite and even positive emotions
* Steady stream of thoughts or images of deceased, may be vivid or even entail hallucinatory experiences
of seeing or hearing deceased person
* Struggle to accept the reality of the death, wishing to protest against it; there may be some feelings of
bitterness or anger about the death
* Somatic distress, e.g. uncontrollable sighing, digestive symptoms, loss of appetite, dry mouth, feelings
of hollowness, sleep disturbance, fatigue, exhaustion or weakness, restlessness, aimless activity,
difficulty initiating or maintaining organized activities, and altered sensorium
* Feeling disconnected from the world or other people, indifferent, not interested or irritable with others
SYMPTOMS OF INTEGRATED GRIEF THAT ARE WITHIN NORMAL LIMITS
*Does not dominate the thoughts of the day. More in the 'background'
* Sense of having adjusted to the loss. Interest and sense of purpose, ability to function, and capacity for
joy and satisfaction are restored
* Feelings of emotional loneliness may persist. Feelings of sadness and longing tend to be in the
background but still present
* Thoughts and memories of the deceased person accessible and bittersweet but no longer dominate the
mind
* Occasional hallucinatory experiences of the deceased may occur
* Surges of grief in response to calendar days or other periodic reminders of the loss may occur
195
What are the signs of complicated grief?
The symptoms of grief last longer than 6mths
There is excessive rumination on the circumstances of the loss/death.
Also excessive avoidance of any circumstances that remind them of the person.
196
Outline the stages of change model?
precontemplation
contemplation
preparation
action
maintenance
197
What does the Hepatitis B e antigen indicate?
Viral load - Indicates active viral replication and thus high transmissibility and a poor prognosis.
Indicates long-term clearance of HBV and thus low transmissibility.
198
Wolf Parkinson White features (3)
narrow PR, wide QRS, delta waves
199
Torsades de pointe management
IV magnesium
200
Proliferative vs non-proliferative retinopathy?
Proliferative includes neovascularisation.
Non-proliferative includes cotton wool spots, hard exudates, aneurysms, haemorrhages
201
Schizoaffective vs schizophreniform disorder?
Schizoaffective disorder includes symptoms of mania and schizophrenia.
Schizophreniform is essentially same symptoms as schizophrenia, just symptoms are less than 6mths.
202
What are the 4Hs and 4Ts in an A-E assessment?
Hypo/hyperthermia, hypoglycemia, hypoxia, hypovolemia
Tension pneumothorax, tamponade, thrombis, toxins
203
Adult fluid resusc and maintenance
Fluid resuscitation 500ml 0.9% NaCl over 15mins
Then commence on maintenance fluid (25-30ml/kg/day). Patients typically require 1mmol/kg sodium, potassium, and chloride throughout the day. Also require 50-100g glucose per day (~5% glucose).
204
treatment of gonorrhea?
ceftriaxone (500mg IM) single dose PLUS azithromycin (1g oral) single dose
205
SSRIs not recommended in pregnancy?
fluoxetine, paroxetine
206
Which SSRI not recommended in pregnancy?
fluoxetine
207
What is an escharotomy?
Escharotomy is the surgical division of the nonviable eschar, the tough, inelastic mass of burnt tissue that results from full-thickness circumferential and near-circumferential skin burns. The eschar, by virtue of its inelasticity, gives rise to the burn-induced compartment syndrome.
208
What are the features of Cushing triad/reflex? What does it signify?
irregular respiratory rate
bradycardia
increased pulse pressure
Sign of raised ICP and brain herniation
209
What are the 6p's
6Ps -> pain, pallor, pulseless, paraesthesia, poikilothermia, paralysis
210
Name for spoon shaped nails and what is the common cause.
Koilonychia
Iron deficiency anemia
211
criteria used to determine pneumonia severity?
CURB-65 (confusion, urea >7mmol/L, RR >30, SBP <90mmHg/DPB < 60mmHg)
212
Which lung lobe is aspiration pneumonia most likely to occur in?
R lower lobe
213
organism most commonly responsible for COPD exacerbation?
Haemophilus influenza
214
ABx used for GBS prophylaxis in pregnancy?
intravenous penicillin G (benzylpenicillin)
215
Which two test can be used for prenatal testing diagnosis and at how many weeks gestation are they performed?
chorionic villus sampling (11-12 weeks)
amniocentesis (15-18 weeks)
216
What does HELLP stand for?
hemolysis, elevated liver enzymes, low platelets
217
Why should women with T1DM take low dose aspirin from 12 weeks of pregnancy?
At higher risk of developing pre-eclampsia
218
What are these symptoms of:
Typically history of 6-8 weeks amenorrhoea with lower abdominal pain
(usually unilateral) initially and vaginal bleeding later. Shoulder tip pain and
cervical excitation may be present
ectopic pregnancy
219
PID management
IM ceftriaxone (500mg single dose), oral metronidazole (400mg BD 14 days), oral azithromycin (1g single dose) or doxycycline (100mg BD 14 days).
220
MOA of oxybutynin
Oxybutynin works through competitive acetylcholine antagonism at postganglionic muscarinic receptors, leading to the relaxation of the smooth muscles of the bladder
221
Review the difference between androgen insensitivity syndrome & Mullerian agenesis.
222
What medication is often used in the prevention of migraines?
propanolol
223
Which diabetic medication ends in 'ide'
Sulfonylureas
e.g. glibenclamide, gliclazide, glipizide
224
What diabetic medication ends in 'gliptin'?
DPP-4 inhibitors - linagliptin, sitagliptin
225
What diabetic medication ends in 'gliflozin'?
SGLT-2 inhibitors - dapagliflozin, empagliflozin
226
What diabetic medication ends in 'glutide'?
GLP-1 agonists - dulaglutide, liraglutide, semiglutide
227
Indications for AAA surgical repair
male > 5.5 cm
female > 5 cm
rapid diameter growth of >1cm per year
symptomatic AAA - back/abdo pain/tenderness
228
Absolute contraindications for using the COCP?
< 6 wks postpartum
smoker over the age of 35 (>15 cigarettes per day)
hypertension (systolic > 160mmHg or diastolic > 100mmHg)
current of past histroy of venous thromboembolism (VTE)
ischemic heart disease
history of cerebrovascular accident
complicated valvular heart disease (pulmonary hypertension, atrial fibrillation, histroy of subacute bacterial endocarditis)
migraine headache with focal neurological symptoms
breast cancer (current)
diabetes with retinopathy/nephropathy/neuropathy
severe cirrhosis
liver tumour (adenoma or hepatoma)
Obesity BMI >40
229
Relative contraindications for using the COCP?
smoker over the age of 35 (< 15 cigarettes per day)
adequately controlled hypertension
hypertension (systolic 140 - 159mmHg or diastolic 90 - 99mmHg)
migrain headache over the age of 35
currently symptomatic gallbladder disease
mild cirrhosis
history of combined OCP-related cholestasis
users of medications that may interfere with OCP metabolism
230
Treatment for acute angle glaucoma?
Timolol eye drops - reduces aqueous humour production
Acetazolamide - reduces aqueous humour production
Mannitol - decreases volume of vitreous humour
Laser peripheral iridotomy (LPI) involves using a laser to create a small hole in the peripheral iris, allowing for the flow of aqueous humor from the posterior chamber to the anterior chamber, bypassing the blocked angle. Treatment of choice by ophthal
231
List 5 main symptoms of complex regional pain syndrome
Pain excessive in duration or severity given the inciting event
Sensory: hyperesthesia and/or allodynia
Vasomotor: hypo-/hyperthermia and/or hypo-/hyperpigmentation of the skin
Sudomotor/edema: hypo-/hyperhidrosis and/or edema
Motor/trophic: ↓ range of motion and/or strength, tremors, and/or changes in nail and hair growth
232
Salicyclate toxicity
Nausea, vomiting, diaphoresis, and tinnitus are the earliest signs and symptoms of salicylate toxicity. Other early symptoms and signs are vertigo, hyperventilation, tachycardia, and hyperactivity. As toxicity progresses, agitation, delirium, hallucinations, convulsions, lethargy, and stupor may occur
233
Review drug withdrawal symptoms
Opiate withdrawal is well-characterised, and although not life-threatening in otherwise healthy adults, can cause severe discomfort. Symptoms from short-acting opiates like heroin can occur within just a few hours. Withdrawal from longer-acting opiates may not cause symptoms for days. Early symptoms include lacrimation, rhinorrhoea, yawning, and diaphoresis. Restlessness and irritability occur later, with bone pain, nausea, diarrhoea, abdominal cramping, and mood lability occurring even later.
Cocaine does not have a significant physiologic withdrawal syndrome, but craving is intense. Marijuana withdrawal syndrome is also not physiologically significant. Ecstasy can be considered a hallucinogen or a stimulant, and withdrawal is often associated with depression, but not the symptoms described above. Benzodiazepine withdrawal mimics alcohol withdrawal, and is associated with hypertension, tachycardia, and possibly seizures
234
Absolute contraindications for thrombolytic therapy?
Any prior intracranial hemorrhage (ICH)
Structural cerebral vascular lesion
Intracranial neoplasm
Ischemic stroke within three months
Possible aortic dissection
Active bleeding or bleeding diathesis (excluding menses)
Significant head injury or facial trauma within three months
Recent Intracranial or spinal surgery
Severe uncontrolled hypertension
235
Two pathologies acetazolamide can be used to manage?
acute angle glaucoma -> decrease aqueous humour production
idiopathic intracranial hypertension -> decreases CSF production
236
what leukemia are smudge cells present in?
CLL
237
Which leukemia are auer rods present in?
AML
238
Which leukemia is the Philadelphia chromosome associated with?
CML
239
Pathological/complicated grief symptoms?
Psychosis
suicidality
disproportionate guilt
out of context for cultural norms
persistent depressive symptoms
difficulty with reintegration
feeling that life is meaningless
240
Some reversible causes of dementia in older patients
drugs (anticholinergics)
emotional - depression
metabolic (hypothyroid)
eyes and ears declining
normal pressure hydrocephalus
tumour and other space-occupying lesions
infections (syphilis, AIDS)
anemia
241
What congenital conditions is hypogonadism and anosmia associated with?
Kallmann syndrome
242
Features of growing pains?
never present at the start of the day (on waking)
no limp
no limitation of physical activity
systemically well
normal physical examination
motor milestones are normal
symptoms are often intermittent and worse after vigorous physical activity
243
Orthostatic hypotension definition
Orthostasis is defined as a drop in systolic blood pressure >20 mmHg with or without a drop in diastolic blood pressure >10 mmHg, or an increase in heart rate >20 beats per minute (bpm) upon standing
244
Why order amylase when investigating an eating disorder case?
Amylase is usually elevated due to enlargement of the parotid and salivary glands. This occurs in bulimia nervosa and is an indicator of severity of disease. Amylase in non-specific (i.e. does not always indicate pancreatitis. If 3x upper limit then suspect pancreatitis).
245
Anorexia nervosa types?
Restrictive subtype and binge-purge subtype
246
Recommended ED treatment for children and adolescents?
Maudsley Family Based Therapy
247
Definition of binge eating disorder?
BED is characterised by recurrent
episodes of a loss of control and
overeating without the associated
inappropriate compensatory behaviour
248
BED criteria?
* recurrent episodes of binge eating
– once or more a week, over three
months or more
– eating within a two-hour period
– features of loss of control
* eating a large amount of food or an
inability to stop eating
* eating while full
* embarrassment, disgust and distress
* the absence of inappropriate
compensatory mechanisms to prevent
weight gain (eg laxative use, vomiting,
exercise, eating restriction)
* symptoms not better accounted for
by another medical condition, mental
health condition or substance use
* the exclusion of a diagnosis of bulimia
nervosa or anorexia nervosa
249
What does the SCOFF screening tool for EDs stand for?
Do you make yourself sick
Do you lose control around food
Have you lost one stone or more over the last 3mths (6kg)
Do you see yourself as fat when other say you're thin?
Preoccupation with food
250
Management approach to EDs (medically stable)?
Psychoeducation
Psychotherapy -> enhanced CBT, FBT, DBT, interpersonal behavioural therapy
Dietician involvement (allied health)
Medication -> SSRIs (fluoxetine) - not first line but can be used in conjunction with non-pharm
251
What should be included in initial examination of a patient with a suspected ED?
* Height, weight, body mass index (BMI;
adults), BMI percentile for age (children)
* Pulse and blood pressure, with postural
measurements
* Temperature
* Assessment of breathing and breath (eg
ketosis)
* Examination of periphery for circulation
and oedema
* Assessment of skin colour (eg anaemia,
hypercarotenaemia, cyanosis)
* Hydration state (eg moisture of mucosal
membranes, tissue turgor)
* Examination of head and neck (eg
parotid swelling, dental enamel erosion,
gingivitis, conjunctival injection)
* Examination of skin, hair and nails (eg
dry skin, brittle nails, lanugo, dorsal
finger callouses [Russell’s sign])
* Sit-up or squat test (ie a test of muscle
power)
252
Women with vulva leichen sclerosis need to be monitored for what complication?
SCC on the vulva
253
- foul smelling, frothy, yellow-green, purulent discharge
- vulvovaginal pruritis, burning sensation, dyspareunia, dysuria, strawberry cervix
- pH of the vaginal discharge will be >4.5
What is the likely diagnosis?
trichomonas vaginalis - treatment is oral metronidazole
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What are clue cells present in?
Bacterial vaginalis (Gardnerella vaginalis)
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Gleason scoring - what range is of concern?
6 or less is considered low grade
lowest grade is 2 which is normal
greater than 7 is considered concerning
highest score is 10 (5+5)
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What is goserelin?
A medication that reduces testosterone production by the testes. Results in reduced testosterone levels. Used in prostate cancer.
257
Which cancer is Schistosoma haematobium linked to?
Bladder squamous cell carcinoma
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What are three curative options for localised prostate cancer?
external beam radiation
brachytherapy
radical prostatectomy
259
How would genetic vs environmental cause of COPD present on lung imaging?
Central lung damage = smoking
Peripheral lung damage = a1 anti-trypsin deficiency
260
Criteria for ABx use in AECOPD?
- increased sputum purulence and
- increase in dyspnea or
- sputum volume
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Name 3 bacterial pathogens that can cause AECOPD?
H-influenzae
Strep pneumoniae
Pseudomonas aeruginosa (advanced COPD)
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ABx used in AECOPD?
Bacterial cause of AECOPD is more likely if there is an increase in sputum production or change in colour/purulence.
Use either amoxicillin (1mg BD for 5 days) or doxycycline (100mg daily for 5 days)
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A suspected bacterial infection of the throat is treated with amoxicillin and the patient develops a rash. What is the most likely diagnosis?
EBV -> rash occurs when mistreated with ABx
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What is Whipple's triad in relation to hypoglycemia?
BGL < 2.8mmol
Symptoms of hypoglycemia
Symptoms/signs relieved when patient is given glucose
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Approach to diabetic foot ulcer management:
BGL control (lifestyle & meds)
Assess the ulcer severity
Debridement of necrotic tissue (& slough)
Antibiotics (broad spectrum, then targeted based on biopsy)
Dressing
Offloading
Referral to specialist foot clinic/team
Education - self care, lifestyle
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ABx recommended of AOM in high risk groups?
Augmentin
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what sedating medication is used in people showing aggression? (last resort)
droperidol
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bHCG and PAPP-A for trisomy 13, 18, 21
trisomy 21 = high bHCG
trisomy 13 and 18 = low for both
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ASD - three main areas of impairment:
* social interaction
* communication, and
* behaviour with restricted and stereotyped interests
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Four main target areas of DBT?
Mindfulness
Distress Tolerance
Interpersonal Effectiveness
Emotion Regulation
271
Definition of low birth weight and the two main causes?
less than 2500g
IUGR or prematurity --> these need to be the targets for reducing LBW globally
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non-HRT medication for hot flushes associated with menopause?
gabapentin
273
Which cancer is most likely to cause hypercalcemia?
Squamous carcinomas are the most common malignancies that cause humoral-mediated hypercalcemia of malignancy.
"stones, bones, abdominal groans, thrones and psychiatric overtones"
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ABx therapy for diverticulitis?
Mild-moderate: augementin
Severe: gent + met + amp (or ceft + met)
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Crohn disease pharm management?
Acute flares:
- corticosteroids
Management/remission:
- thiopurines
- biologics (mabs)
- DMARD therapy → methotrexate
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UC pharm management?
- 5-aminosalicyclate therapy +/- corticosteroids to manage flares/exacerbations and induce remission (may need to add biologic therapy as well)
- 5-aminosalicylate or thiopurines or biologic therapy (mabs) for maintenance/remission
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What are some first rank symptoms of schizophrenia?
Auditory hallucinations
Thought withdrawal, thought broadcasting, interruption
Thought broadcasting
Somatic hallucinations
Delusional perception
Passivity phenomenon
(look up more)
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Which PV disorder are clue cells present?
Bacterial vaginalis
279
Home BGL and HbA1c targets for DM?
- HbA1c:less than 6.5%** for non-insulin dependent or less than 8% in insulin dependent.
- Home BGL monitoring:
- before meals: 4.0 - 7.0mmol/L
- after meals: 5.0 - 10.0mmol/L
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Diabetic retinopathy management?
- blood glucose control via antihyperglycemic agents
- medications including anti-VEGF (vascular endothelial growth factor) therapy can slow down diabetic retinopathy → use in proliferative
- can use laser treatment to treat the growth of new blood vessels in the back of the eye in cases of haemorrhages
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Pharm management of alcohol withdrawal?
- Naltrexone (first line) → reduces cravings for alcohol
- Acamprosate → reduces cravings for alcohol
- Disulfiram (antabuse) → exacerbates intoxication symptoms and induces negative conditioning (only give highly motivated patients)
- thiamine and folic acid supplementation
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normal pressure hydrocephalus triad of symptoms?
- dementia
- ataxia
- incontinence
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pathophysiology of alzheimers disease?
- characterised by **amyloid plaque deposits and neurofibrillary tangles** (due to abnormalities in tau protein)
- get cell apoptosis → neurodegeneration → brain atrophy (characterised by narrow gyri, enlarged sulci, enlarged ventricles)
- beta-amyloid plaque → biochemical markers
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What is Pick's disease?
- a subtype of frontotemporal dementia where nerve cells become abnormal and swollen before they die. These swollen neurons are a hallmarks of the disease.
- behaviour changes may include: apathy, poor personal hygiene, lack of judgement or inhibition, inappropriate actions, lack of empathy or interpersonal skills, changes in eating habit
- language changes: speaking slowly, difficulty finding words, jumbling words
285
What anticholinergic medications are commonly used among elderly patients?
Some parkinson disease medication
antipsychotics
anti-depressants
bladder anti-muscarinics
286
Clozapine monitoring guidelines?
WCB and ANC weekly for the first 18 weeks - then monthly thereafter
287
general principles of managing acute pancreatitis?
- identify and manage the cause e.g. gallstone
- hydration
- analgesia
- antiemetic
- manage hyperglycemia
- manage hypocalcemia
ABx not indicated unless signs of an infection
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What staining is used in eye examinations?
fluorescein staining - shows areas of abrasions or ulceration
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Type of tumour most likely to cause bitemporal vision loss?
Craniopharyngioma
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TCA overdose symptoms:
Myocardial Sodium channel antagonism: Reduced cardiac contractility and hypotension, widened QRS predisposing to VT and VF, Prolonged QT
Inhibition of noradrenalin and serotonin reuptake: CNS depression/coma, seizures
Anticholinergic: Sinus tachycardia, Vomiting, Blurred vision, Ataxia, Delirium, Urinary retention, Ileus
Antiadrenergic: Vasodilation
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What ABx are used for bacterial tracheitis?
Cefotaxime and Flucloxacillin
The most commonly involved organism is S.
aureus, but other common respiratory bacteria, such as S. pneumoniae and H influenza are
also often isolated.
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What is the cushing triad/reflex?
raised pulse pressure, bradycardia, irregular RR
indicative of raised ICP and cerebral oedema
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recommended guidelines for meningococcal prophylaxis following exposure?
household contacts or close contacts who were around the patient up to 7 days prior to symptom onset.
Typically give ciprofloxin or rifampicin
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Complicated hernia types:
incarcerated
strangulated
reduction en mass
incarcerated - can't be reduced
strangulated - ischemic
reduction en mass - reduced contents remained incarcerated or strangulated
295
At what age should UDT be referred for surgical evaluation?
3 mths -> some will still descend prior to this age
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Specific behaviour questions when assessing for ADHD in someone?
- **Inattention:**
forgetfulness, difficulty completing tasks, difficulty following instructions, losing items, difficulty listening, easily distracted, careless mistakes
- **Hyperactivity:**
restless, unable to wait, unable to play quietly, ‘on-the-go’, fidgeting, blurting out answers, talking excessively, interrupting people.
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Behavioural management options for children/families?
**Psychoeducation and support for ALL**
**Behavioural treatments for MOST**
**Medication for SOME** (stimulant and non-stimulant therapy)
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Cells that are CD30 positive are pathognomonic for?
Hodgkin lymphoma
299
What is the Ann Abor stating of lymphoma?
Review
300
APO management acronym?
Lasix
Morphine (decrease respiratory drive)
Nitrates
Oxygen
Posture
301
Define sepsis and septic shock
Sepsis: a severe, life-threatening condition that results from a dysregulation of the patient's response to an infection, causing tissue and organ damage and subsequent organ dysfunction [1]
Septic shock: a sepsis syndrome accompanied by circulatory and metabolic abnormalities that can significantly increase mortality [1]
Diagnostic criteria
Persistent hypotension: Vasopressors are required to maintain mean arterial pressure (MAP) ≥ 65 mm Hg.
Persistent lactic acidosis: lactate > 2 mmol/L (18 mg/dL) despite adequate fluid resuscitation
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What is alport syndrome?
genetic defect in type IV collagen -> kidney damage (glomerulonephritis), sensorineural hearing loss, ocular abnormalities
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What is Good pasture syndrome?
Type II hypersensitivity reaction where autoantibodies attack the renal and pulmonary capillary basement membrane. Results in hemoptysis and nephritic syndrome.
Will have anti-GBM antibodies present
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Which ABx should not be mixed with alcohol?
Metronidazole
305
General management of nephrotic syndrome in children (presume minimal change disease)?
usually high dose steroids, anticoagulation*, statin therapy*, fluid restriction, diuretic therapy, ACEi (reduces proteinuria and manages HTN), avoid a high protein diet, vaccination (due to immune suppression), albumin replacement (children)
**Children: fluid restriction, frusomide + albumin, prednisolone, daily weight
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What are three important questions to ask on a risk assessment?
1. Past behaviour is predictive of future behaviour (therefore thorough past history is
needed and can be gathered from patient, family, carers and past medical records).
2. What was the lethality of past self-harm or suicide attempts ?
3. Meaning to the patient (what did the patient think would happen
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ABx for gonorrhea infection?
ceftriaxone and azithromycin
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ABx for epididymo-orchitis
ceftriaxone and azithromycin
309
What is pneumocystis pneumonia treated with? (common among patients with unmanaged HIV)
Trimethoprim-sulfamethoxazole
310
4 treatment options for reduced menstrual heaviness?
tranexamic acid
mirena
primolut
endometrial ablation
hysterectomy
COPD
311
definition of PUO?
Fever ≥38.3° for at least 3 weeks with no identified cause after three days of hospital
evaluation or three outpatient visits
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DSM-5 criteria for ADHD
Symptoms of inattention or hyperactivity (6 or more symptoms).
Present prior to the age of 12yrs.
Present in more than 2 areas/environments.
Disrupts function.
Not explained by another mental disorder.
Present for at least 6mths.
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autism definition
neurodevelopmental disorder characterized by: (1) persistent impairments in reciprocal social communication and social interaction, and (2) restricted, repetitive patterns of behaviour, interests, or activities.
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What is Guttate psoriasis?
Guttate psoriasis is a distinct variant of psoriasis that is classically triggered by streptococcal infection (pharyngitis or perianal) and is more common in children and adolescents than adults. Patients present with several small drop-like lesions that respond well to topical and phototherapies.
315
Main overview of prostate cancer treatment options?
watchful waiting
active surveillance
androgen deprivation (e.g. GnRH agonist - goserelin)
radiation (brachytherapy or external beam)
prostatectomy
chemotherapy
Immunotherapy
316
What is TRALI?
Transfusion related acute lung injury
Can be an adverse reaction to blood transfusion. Results in non-cardiogenic pulmonary oedema.
responds to oxygen and ventilatory support. Good prognosis
317
What is TACO?
transfusion related acute cardiac overload --> results in ARDS, dyspnoea, raised JVP
responds to diuretics
high mortality
318
Main side effects/complications of blood transfusions
alergic reaction
febrile non-hemolytic transfusion reaction
hemolytic transfusion reaction
TACO
TRALI
319
Two epileptic disorders in children?
lennox-gastaut syndrome
west syndrome
320
which type of testicular cancer often has raised AFP and bhcg, and spread to the lungs and brain more rapidly?
teratoma
aka NON SEMINOMATOUS GERM CELL
TUMOR
responds well to chemo
321
Pasteurella multocida
cat bite
322
clozapine SE and monitoring?
agranulocytosis
hypersalivation
myocarditis
metabolic
constipation
arrhythmias
ECG and bloods weekly for 18 weeks, then monthly
323
4 cluster symptoms of PTSD?
- Hyperarousal
- Re-exposure/intrusion
- Cognitive/functional impairment
- Avoidance
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