Gen Med Flashcards
T2DM Diagnostic Criteria
- HbA1c
- Fasting blood glucose
HbA1c > 6.5 (48mmol)
Fasting glucose > 7
Where is B12 absorbed?
Ileum
Where is folate absorbed?
Duodenum & Jejunum
Reference ranges for Anaemia
FBC <130 in men, <120 in women AND children 12-14
MCV <80 = Microcytosis (iron deficiency more likely)
MCV >100 = Macrocytic
Ferratin - correlates to total body iron stores. Low ferritin suggests low iron except in pregnant people (2nd&3rd trimester)
Serum ferritin <30 = iron deficiency
however it is an inflammatory marker so can be raised despite iron deficiency in acute or chronic inflammation.
Term that describes velocity dependent increased tone?
Spasticity
Term that describes increased tone not dependent on velocity?
Rigidity
what visual disturbance is likely to be reported in acromegaly?
Pituitary adenoma –> Impinges on optic chasm causing bitemporal hemianopia
Symptoms of Horners syndrome
ptosis - drooping eyelid
miosis - constricted pupil
anhrdrosis - can’t sweat
ON IPSILATERAL SIDE
Biochemistry suggestive of AKI?
Increase in serum creatinine >26.4
or increase >50%
or reduced urine output
within 48 hour period and after fluid resuscitation
Indications for acute dialysis
Acidosis Electrolytes (raised K+) Intoxication (Salicylic acid, Lithium, isopropanol, magnesium laxative, ethylene glycol)
Overload (fluid)
Uraemia complications
Muddy brown casts
acute tubular necrosis
H.Pylori eradication?
PPI + Amox + Clarithromycin
PPI + Met + clarithromycin if PA
What is smoking protective for?
UC
pseudopolyp & crypt abscess
UC
Cobblestoning & skip lesions
Crohns
Radio-lucent stones
urate + xanthine stones
Radio-dense stones
Cystine stones
Does raised urea favour upper GI or lower GI pathology?
Upper
Major inspiratory muscles
Diaphragm (C3,4,5) and external intercostals
Accessory muscles of inspiration
SCM, scalene’s,pectoral
Muscles of ACTIVE expiration
Abdominals and internal intercostals
Side effect of isoniazid
Drug induced lupus
Side effect of ethambutol
Optic neuritis
Side effects of rifampicin
Hepatitis
Orange secretions
Flu like symptoms
When is methyldopa contraindicated
Depression
What is hairy leukoplakia associated with?
EBV
Rotterdam criteria
Oligo/amenorhoea
Hyperandrogenism
Polycystic ovaries (TVUS)
2 required for diagnosis of PCOS
Drug management of peripheral arterial disease
Atorvastatin
Clopidogrel
What is treatment with pyrazinamide associated with?
Gout
ECG changes in PE
S wave in lead I, a large Q wave in lead III and an inverted T wave in lead III - ‘S1Q3T3’
RBBB
RAD
Sinus tachy
Commonest cause of ascending cholangitis?
E.coli
Differentiating between seizures/pseudoseizures
Prolactin raised after genuine seizure
What causes Scarlet fever?
GAS
Are statins contraindicated in pregnancy
yes
Side effects of nitrates
Hypotension
Headaches
Tachycardia
Drug that reduced INR?
Pheonobarbital
What should be prescribed with goserelin and why?
Anti androgen for first 2 weeks
prevents flare of symptoms
Peripheral Arterial Disease management
QUIT SMOKING
Exercise training - claudication
Atorvastatin 80mg
Clopidogrel 75mg
BP targets > 80 y/o
Clinic 150/90 mmHg
ABPM 145/85 mmHg
Cutaneous signs in dermatomyositis?
Gottrons papules, shawl sign, heliotrope rash
Lab findings for polymyositis/dermatomyositis
Raised CK
Anti Jo-1
Definitive investigation and treatment of poly/dermatomyosisis
Muscle biopsy = definitive investigation
Prednisolone 40mg plus MTX or AZT
Which drugs exacerbate psoriasis?
Propanolol
What is secreted from zone glomerulosa of adrenal?
Mineralocorticoids
What is secreted from zone fascicularis of adrenal?
Glucocorticoids
What is secreted from zone reticularis of adrenals?
Androgens
What is secreted from the adrenal medulla?
Adrenaline and noradrenaline
Function of mineralocorticoid?
Increase BP by retaining fluid
Example of mineralocorticoid?
And antimineralocorticoid?
Fludrocortisone
Sprironolactone and eplerenone
Inheritance of MODY
AD
Early diastolic murmur post endocarditis - worse when making a fist and collapsing pulse
Aortic regurgitation
On HRT but needing contraception - period control
Progestogen only methods
COCP increases risk of ….. and …. cancer but is protective against … and …. cancer
Increased risk of breast & cervical
Decreased risk of endometrial & ovarian
Inverted t waves =
Ischaemia
e.g. inverted t waves and no raised trop then angina
Management of heart block
- 500micrograms atropine up until 3mg
- Transcutaneous pacing
- Adrenaline
1st line treatment for prolactinoma?
cabergoline
What tumours is MEN2 associated with?
Medullary thyroid
Parathyroid
Phaeochromocytoma
What drug is contraindicated in VT?
Verapamil
What differentiates diffuse and limited systemic sclerosis?
Trunk only affected in diffuse
Antibodies:
Limited = anti centromere antibody
Difffuse = anti scl-70
Treatment for raynauds?
CCB/iloprost
Warfarin his teratogenic.
True or false?
True
LMWH instead
Risk factors for gout
Genetics, diet high in red meat, alcohol and seafood
Acid build up in gout
Uric acid
Pseudogout =
Calcium pyrophosphate
Knee jerk nerves
L2-4
Malignancy + raised CK?
Polymyositis
Hypertension in systemic sclerosis with renal complications?
ACEi
How long is antibiotic therapy in septic arthritis?
4-6 weeks
Hoffman’s test
suggests ms
cannot close his left eye or wrinkle the left side of his forehead
Left CN VII LMN
CN VII lower face =
Contralateral
Location & function of brocas area
Inferior frontal gyrus
Motor function of speech
Location and function of wernickes area
Superior temporal gyrus
Comprehension and planning of speech - cannot understand
Murphys sign
Pain on palpation of right subcostal area on expiration after deep inspiration due to inflamed gallbladder coming into contact with body wall
Diagnosis = acute cholecystitis
Anticoagulant of choice in AKI
Warfarin
Contraindication to triptans
CVD
RA, splenomegaly and low WCC
Feltys syndrome
Shortened, adducted and internally rotated leg.
What’s the diagnosis and which nerve is most at risk of damage?
Posterior hip dislocation
Sciatic nerve
Pneumothorax <2cm
Discharge and review - normally self limiting
Biceps reflex nerves
Triceps reflex nerves
Supinator reflex nerves
C5/6
C6/7
C5/6
4 most common causes of liver cirrhosis?
Alcohol
NAFLD
Hep B
Hep C
Antidote for opioid overdose?
Naloxone
100micrograms at a time up to 1200mcg
Antidote for benzos?
Activated charcoal if within 1 hour
Flumazenil (caution)
Antidote for MDMA/cocaine (uppers)
None - slow them down with benzos
Pupils in MDMA/cocaine OD?
Dilated
Pupils in opiate OD?
Pinpoint
Pupils in benzo OD?
Normal/dilated
Presentation in anticholinergic OD?
and examples of common causes?
Everything is dry - Dry skin
Antihistamines, TCAs
Presentation of cholinergic OD (organophosphates/nerve agent)
Salivation Lacrimation Urination Diarrhoea GI Emesis
Manage with atropine
Antidote for b-blocker OD?
Glucagon/insulin
Antidote for CCB OD?
Ca chloride or Ca gluconate
Antidote for iron OD?
Desferrioxamine
antidote for digoxin?
Digibind
Cholecystitis vx cholangitis
Inflammation of gallbladder vs inflammation of the bile ducts
tinkling bowel sounds
obstruction
Haustra vs valvular conniventes
Haustra - large bowel - lines do not cross width
Valvulae conniventes - small bowel - visible lines across entire width
3 main causes of bowel obstruction
Adhesions
Hernias
Malignancy
Classification of haemorrhoids?
1st degree: no prolapse
2nd degree: prolapse when straining and return on relaxing
3rd degree: prolapse when straining, doesn’t return on relaxing, but can be pushed back
4th degree: prolapsed permanently
Classification of haemorrhoids?
1st degree: no prolapse
2nd degree: prolapse when straining and return on relaxing
3rd degree: prolapse when straining, doesn’t return on relaxing, but can be pushed back
4th degree: prolapsed permanently
What is required for thorough examination of haemorrhoids?
Proctoscopy
Differentials for rectal bleeding?
Anal fissures Diverticulosis Inflammatory bowel disease Colorectal cancer Haemorrhoids
When would you consider admission for thromboses haemorrhoids?
within 72 hours
Management of haemorrhoids?
increase fibre and fluid intake
topical therapy - anusol
Non surgical - Rubber band ligation
- Injection sclerotherapy (injection into the haemorrhoid to cause sclerosis and atrophy) - Infra-red coagulation - Bipolar diathermy
Surgery - Haemorrhoidal artery ligation
- Haemorrhoidectomy - Stapled haemorrhoidectomy
teardrop RBCs?
Myelofibrosis
anticoagulant in PE/DVT
rivaroxiban, apixaban, dabigatran, edoxaban, lmwh
What is JAK2 associated with?
Myelofibrosis
3 signs of polycythaemia vera?
Ruddy complexion
Splenomegaly
red conjunctiva (plethora)
Which type of anaemia occurs in aplastic anaemia?
Which type of anaemia occurs in aplastic anaemia?
Normocytic
When is irradiated and CMV negative blood required
Intrauterine transfusion
Granulocyte transfusion
Neonates up to 28 days post due date
When is irradiated blood required?
Immunocompromised - chemo/radio
Current or previous Hodgkins lymphoma
Bone marrow/stem cell transplants
When is prothrombin complex concentrate used?
Emergency reversal of anticoagulant in severe bleeding or suspected intracranial haemorrhage
What does cryoprecipitate replace?
Fibrinogen & factor VIII
Universal donor for FFP?
AB
What is the transfusion threshold for anaemia?
70 or 80 if acute coronary syndrome
How long is a unit of RBCs transfused over?
Non emergency
90-120 minutes
Warfarin reversal
Vitamin K - takes 6 hours
FFP - need a lot of fluids
Human prothrombin complex - much quicker (60 mins) but short half life so given with bit k
What initial investigations may you perform for suspected myeloma?
What is required for definitive diagnosis?
B – Bence–Jones protein (request urine electrophoresis)
L – Serum‑free Light‑chain assay
I – Serum Immunoglobulins
P – Serum Protein electrophoresis
bone marrow biopsy
What is the child-pugh classification used to assess?
Liver cirrhosis
ECG features of WPW
short PR interval
wide QRS complexes with a slurred upstroke - ‘delta wave’
Causes and symptoms of SVCO?
Lung cancer - medical emergency, lymphoma,
Presentation
- Dyspnoea is the most common symptom
- Swelling of the face, neck and arms - conjunctival and periorbital oedema may be seen
- Headache: often worse in the mornings
- Visual disturbance
- Pulseless jugular venous distension
Which thyroid cancer secretes calcitonin?
Medullary thyroid cancer
What are the 3 types of colon cancer?
Sporadic (95%)
Hereditary non polyposis colorectal cancer (5%)
Familial adenamatous polyposis (<1%)
what is the most common hereditary cause of colon cancer?
HNPCC - Lynch syndrome
Autosomal dominant
What is the next most common cancer associated with HNPCC?
endometrial
Tumour marker for colorectal cancer?
CEA
Most common cause of spontaneous bacterial peritonitis?
E.coli
What conditions must you inform the DVLA of?
Epilepsy
Stroke
Mania
insulin dependent diabetes
Most common benign tumour of bone?
Osteochondroma
Immature bone surrounded by sclerotic halo
Osteoid osteoma
What is the most common age for presentation of sarcoma?
50-70
patchy sclerosis
AVN
Presentation of achondroplasia
Disproportionately short limbs
Prominent forehead
Widened nose
Normal mental status
Main features of marfans
Autosomal dominant Pectus excavatum Long bones - ligament laxity Aortic aneurysm/dissection/regurgitation Mitral valve: prolapse/regurgitation
Beckers muscular dystrophy
Mild version of DMD
Boys can walk in their teens
Survival to 30s
Is a positive babinski an UMN or LMN sign?
UMN
mildest form of spina bifida
Spina bifida occulta
- tuft of hair or dimple
What is associated with spina bifida?
Hydrocephalus
What is the more sever form of spina bifida?
Spina bifida cystica
- meningocele normally no motor impact
- myelomeningocele affects nerves below area
What is the most common congenital malformation of the limbs?
Sclerodactyl
two digits fused
When should you suspect primary amenorrhoea?
No period by 13 if no secondary sexual characteristics.
No period by 15 if sexual characteristics present
What is required for home O2 therapy to be allowed?
2x pO2 <7.3
What drug class is ipatropium?
SAMA
Antibiotic in bacterial infective exacerbation of COPD?
Amox
Doxy or clarithromycin if PA
Management of PBC?
Ursodeoxycholic acid is the first-line medication for primary biliary cholangitis
Investigation for PSC?
MRCP
Metabolic alkalosis + hypokalaemia ?
→ prolonged vomiting
How do you diagnose spontaneous bacterioalperitonitis?
Pericentesis
Medical cardioversion in AF?
Amiodarone or flecanide
Murmur most associated with connective tissue disease (Marfans etc)
Mitral regurgitation
Pansystolic
What is the ligament of Treitz
Junction between upper and Lower GIT
Duodenal jejunal junctiom
Antibody in GPA?
cANCA
Antibody in goodpastures?
Anti GBM
Linear IgG
Antibody in microscopic polyangitis?
pANCA
Features of nephrotic syndrome?
Proteinuria > 3.5g/24 hours
Peripheral oedema
Hypoalbuminaemia
Hypercholesterolaemia
4 infrarenal causes of acute renal failure
- Acute glomerulonephritis
- Acute tubular necrosis
- Acute interstitial nephritis
- Vascular
What is the difference between acute renal failure and AKI?
AKI doesn’t require reduced urine output
When should a statin be taken?
More effective at night
spike wheel on CT
Oncocytoma - benign renal tumour
indications for dialysis?
eGFR<7
Urea >40
Resistant hyperkalaemia/acidosis
What is required to make a diagnosis of CKD?
Two samples, 90 days apart
eGFR = 50
What stage CKD?
3a (45-59)
eGFR 15-29
What stage CKD?
4
eGFR measurement in CKD 5
<15
how long should patients be monitored after AKI?
2-3 years as risk of CKD
Treatment of hyperkalaemia?
10ml 10% calcium gluconate (stabilises myocardium)
10 units insulin + 50ml 50% dextrose (moves K into cellss decreasing serum K)
Treatment of chronic hyperkalaemia?
Calcium resonium
Why do ACEi/ARBs/NSAIDs cause AKI/CKD?
Renal hypoperfusion
What is the most common cause of AKI?
Acute tubular necrosis
Triad seen in HUS?
Haemolytic anaemia
Low platelets
AKI
How high is CK in rhabdo?
1000s
Treatment of rhabdomyolysis?
IV fluids
Treat hyperkalaemia
Side effect of tamsulosin?
HYPOtension
Treatment of ascites
Spironolactone
Aldosterone antagonist
ABG in hyperaldosteronism?
Metabolic alkalosis due to increased acid secretion
Low K+
High Na+
What is cord prolapse commonly associated with?
Artificial rupture of membranes
Commonest type of ovarian cancer?
Serous
Fever + Jaundice + RUQ pain
Charcots triad - ascending cholangitis
Most common causative organism in pneumonia after influenza?
staph aureus
inguinal hernias in children ?
urgent surgery - risk of strangulation
Hyper or hypocalcaemia in severe pancreatitis
HYPOCALCAEMIA
- lipase leaks from damaged pancreas and mops up calcium to make soap –> decreased serum calcium
Outcome of Na valproate and warfarin?
Na Val is an enzyme inhibitor which Increases warfarin efficacy
How is metformin excreted?
Renally
What should not be prescribed with methotrexate?
Trimethoprim
Co-trimoxazole
Encephalopathy + jaundice + coagulopathy?
acute liver failure
Where to check for pulse on child < 1y/o
Brachial or femoral
electrolyte abnormality that would give prolonged QT?
Hypocalcaemia
Electrolyte abnormality that would give prolonged PR
Hypermagnesemia
Electrolyte abnormality that would give a shorted QT or ST segment?
Hypercalcaemia
Contraindictaions to a laryngeal airway?
Not fasted
Obese
Management of reactive arthritis ?
NSAIDs
Initial management of spinal cord compression
8mg dexamethasone
What can be used if treatment with haloperidol causes dystonia?
Procyclidine should reverse
Fluid resus in children?
20ml/kg NaCl over <10mins
Management of an acute exacerbation of COPD?
- 30mg Prednisolone daily
- Consider antibiotic therapy
Amox/doxy/clarithromycin 1st line
If no response within 2 days then send sputum sample - consider co-amox if high risk of treatment failure (prev resistance etc)
Treatment of cor pulmonale?
Loop diuretic
Home oxygen if suitable
What is the criteria for LTOT?
pO2 <7.3
or 7.3-8 with oedema, anaemia, pulmonary hypertension
Name some LABAs
Salmeterol
Formoterol
Name a SAMA
Ipatropium
Name some LAMAs
Tiotropium
Glycoperonium
Non invasive ventilation in COPD
BiPAP
Jelly like stool
Intusussception
Management of thyrotoxic storm?
Propanolol
Propylthiouracil
Hydrocortisone
Management of phaeochromocytoma
A blocker - phenoxybenzamine
B-blocker after initiated on a-blocker
Adrenalectomy = definitive however medical management 1st reduces risk from surgery
what is conn’s
primary aldosteronism
When should a GLP-1 be added to diabetes management?
If triple therapy unsuitable/ineffective or contraindicated and BMI >35
GLP-1 causes weight loss
What is the pathophysiology of metabolic acidosis in DKA?
Increased glucose causes increased urination
Increased urination results in increased electrolyte loss
Electrolyte loss = acidosis
Kaussmaul breathing to reduce CO2 in blood
Difference between DKA and hyperglycaemic hyperosmolar syndrome
HHS more likely to be T2DM
Associated with diuretics/fizzy drinks/steroids resulting in hypovolaemia and resultant hyperglycaemia
Less acidotic - ketones not raised
How do you calculate insulin dose?
0.3 units/kg
Divide 50% basal and 50% meals
The 50% meals further divided by 2/3
What is Addisons disease?
Primary adrenal insufficiency
Decreased aldosterone - decreased Na&H20 retention = decreased BP
Decreased glucocorticoid (cortisol) = weight loss, hyperpigmentation
Decreased androgens
Management of primary adrenal insufficiency?
15-25mg Hydrocortison
50-200micrograms fludrocortisone
Diagnostic test for Cushings?
DST
Diagnostic test for acromegaly?
OGTT
IGF-1
Diagnostic test for adrenal insufficiency/addisons?
Short synACTHen
Diagnostic test for Conns/aldosteronism?
aldosterone:renin ration
High aldosterone : low renin
what’s diabetes insidious?
Lack of ADH
= unconcentrated urine
= lots of dilute urine
= hypernatraemia because salt not excreted in urine
Causes of nephrogenic diabetes insidious?
Lithium
Kidney disease
Genetic
Management of SIADH?
Fluid restriction
Tolvaptan (ADH receptor blocker) - 6hr sodium required
What is the action of PTH?
Increases Ca2+
Decreases PO4-
Which diabetes medication should not be used in heart failure?
Pioglitazone
Difference between primary and secondary prevention for lipid modification?
Primary = Qrisk>10% = Atrovastatin 20mg Secondary = known CVD/IHD/PAD = Atorvastatin 80mg
What type of pain do c-fibres produce?
Dull, difffuse pain
What type of pain do a-delta fibres produce?
Fast, sharp, localised pain
First line options for neuropathic pain?
Amitriptyline
Duloxetine
Gabapentin
Pregabalin
all 4 can be tried in turn but only 1 at a time
Daily requirement of K+, NA+ and H2O?
k+ = 1mmol/kg Na+ = 4-5mmol/kg H2O = 25-30ml/kg
T score for osteoporosis?
<-2.5
T score for osteopenia?
-1 to -2.4
Movement affected by de quervains tenosynovitis?
thumb & wrist abduction
DAS 28 <2.6?
Remission
DAS 28 >5.1?
Active disease
Consider biologic if already on MTX
Onion skin appearance?
Ewings sarcoma
Loss of red reflex?
Retinal detachment
cataracts
retinoblastoma (children)
Normal cup:disc ratio?
0.3-0.5
cup:disc ratio >0.5
Glaucoma
No cup visible (ophthalmoscopy)
What must you do?
Papilloedema
Examine the other eye - raised iCP?
central vision loss
ARMD
Optic neuritis
Painful eye movements, colour destination, RAPD,central scotoma
Optic neuritis
High dose steroids
cycloplegic or mydriatic eye drops?
They will dilate the pupil –> relieves pain
e.g. used in uveitis
Management of diabetic retinopathy?
- non proliferative
- proliferative
Non proliferative - good glycemic control and frequency montoring
Proliferative - pan retinal photocoagulation +/- anti VEGF
Peripheral vision loss + haloes around lights
worse at night
Glaucoma
How is intraocular pressure measured?
Non contact tonometry (screening)
Goldmann applanation tonometry - gold standard
Drug treatment of glaucoma (prostaglandin analogue)
Latanoprost - increases uveoscleral outflow
SE - browning of iris,eyelash growth
Timolol
Carbonic anhydrase
Causes of RAPD
Optic neuritis
retinal. detachment
What is papilloedema?
cupping of dic due to raised ICP - always bilateral
Long term treatment of SBP?
Antibiotic prophylaxis with ciprofloxacin
Signs of lung cancer + gynaecomastia?
Adenocarcinoma