Gen Med 3 Flashcards
How does duodenal atresia present?
Non projectile bilious vomiting in the first few days of life
What condition is duodenal atresia associated with?
Downs
In a patient with longstanding diabetes (T1) what is most likely to cause decreased hypothyroidism awareness?
Autonomic neuropathy
What can you use to treat tardive dyskinesia?
Tetrabenazine
What can you use to treat tremor in drug induced parkinsons?
Procyclidine
What is coarctation of the aorta associated with?
Turner’s syndrome
bicuspid aortic valve
berry aneurysms
neurofibromatosis
How do you differentiate a prerenal AKI from an intra renal one?
Pre-renal will result in:
- High urine osmolality
- Low urine sodium
Renal (most common is acute tubular necrosis)
- High urine sodium
- Low urine osmolality
What bacteria is commonly associated with acne?
Propionibacterium acnes
How might a myxoedema coma present? What is it a complication of?
A complication of hypothyroidism
Presents with:
- Bradycardia
- Hypothermia
- Hypotensive
How do you treat myxoedema coma?
Hydrocortisone and levothyroxine
What electrolyte abnormalities can lead to a long QT?
Hypomagnesaemia
Hypokalaemia
Hypoclacaemia
Management of otitis externa?
If non severe
- Topical acetic acid
If more severe
- Topical antibiotic and steroid
ACE inhibitors and statins in pregnancy?
Not good
Major and Minor criteria for rheumatic fever?
Major:
- Erythema marginatum (pink, ring shaped)
- Sydenham’s chorea
- Polyarthritis
- Carditis and valvulitis (eg, pancarditis)*
- Subcutaneous nodules
Minor:
- Raised ESR or CRP
- Pyrexia
- Arthralgia (not if arthritis a major criteria)
- Prolonged PR interval
Persistent sterile pyuria and negative culture is suspicious of what?
Renal TB
Also look for recent travel history
Warfarin in breastfeeding?
Okay
Two main rashes in pregnancy? How do you tell them apart?
Polymorphic eruption of pregnancy
- Last trimester often
- Pruritic
- Small erythematous maculopapular
HTN treatment for diabetics?
ACEI first line regardless of age
What hormones change in a stress response?
Increased
- GH
- Cortisol
- Renin
Decreased
- Insulin
- Testosterone
- Oestrogen
What is Samters triad?
Association between asthma, nasal polyps and aspirin
Sick day rules for diabetes?
- Increase frequency of blood glucose monitoring to four hourly or more frequently
- Encourage fluid intake aiming for at least 3 litres in 24hrs
If unable to take struggling to eat may need sugary drinks to maintain carbohydrate intake - It is useful to educate patients so that they have a box of ‘sick day supplies’ that they can access if they become unwell
- Access to a mobile phone has been shown to reduce progression of ketosis to diabetic ketoacidosis
Insulin:
- Normal regime, with correcting doses (one sixth of normal, max 15 units)
Oral:
- Continue all, apart from metformin which you can consider taking off.
How do you manage diabetes post MI?
Stop oral drugs, start IV insulin infusion
What is the mechanism of nephrogenic diabetes insipidus, how do you treat?
Inability of the kidneys to respond to ADH, treated with thiazides
At what INR do you need to cover someone being treated for PE with immediate cover LMWH?
INR <2
First line management for mild acne?
Topical benzyl peroxide
Loop and Thiazide diuretics effects on electrolytes?
Loop - less (looss?) of everything
- Hyponatraemia
- Hypocalcaemia
- Hypokalaemia
- Hypomagnesaemia
Thiazide
- Hypokalaemia
- Hyponatraemia
- Hypercalcaemia
Special investigation for reflux nephropathy?
Micturating cystography
What is kussmauls sign?
Raised JVP that DOESN’T fall with inspiration
What bugs are most likely to cause endocarditis?
Gram positive cocci
Staph aureus
Staph viridans
Staph epidermidis
What is used to calculate the volume of IV fluid required post burn over the first 24hrs?
Parkland formula
What diuretic should be prescribed to patients after Beta blocker and Calcium channel antagonist? examples?
Thiazide-like (NOT thiazide)
e.g. Indapamide, chlortalidone
How can you differentiate spider naevi from telangiectasia?
If pressed naevi fill from the middle
Telangiectasia fill from the outside
What are the two GLP-1 mimics?
Exenatide
Liraglutide
What criteria for continuing GLP-1 mimic therapy do NICE have?
NICE like patients to have achieved a 11 mmol/mol (1%) reduction in HbA1c and 3% weight loss after 6 months to justify the ongoing prescription of GLP-1 mimetics.
How long do you watch and wait a perforated eardrum?
6 weeks
What medications can falsely lower BNP?
ACE inhibitors, angiotensin-II receptor antagonists, beta-blockers and diuretics can all falsely lower BNP levels, as can obesity.
Basically all the HTN drugs apart from Calcium channel antagonists
CXR findings for constrictive pericarditis?
Pericardial calcification
Bilateral and unilateral high stepping gait causes?
Bilateral
- peripheral neuropathy
Unilateral
- Common peroneal nerve injury
What is autonomic dysreflexia?
This clinical syndrome occurs in patients who have had a spinal cord injury at, or above T6 spinal level
The features are due to excessive sympathetic response below the level of injury without a coordinated parasympathetic counter-response resulting in excessive hypertension with flushing and sweating above the level of injury.
Features of inflammatory arthropathy?
Early morning stiffness (>20mins)
Stiffness that is worse after resting, eased by movement
Raised ESR CRP
Which of the hand joints are classically affected in RA and OA?
RA the more proximal MCP
OA the More distal Interphalangeal joints
What is the boutonniere deformity in RA?
Tendon splits like a button-hole
What is the swan neck deformity in RA?
Proximal interphalangeal joint is extended
Investigations for RA?
BOXES
Bloods
- FBC, CRP
- Renal and LFT
- Rheumatoid factor, Anti-CCP
O
- nil
XRAY
- Hands
- Feet
What is the treatment in Rheumatoid Arthritis?
DMARDS
- Methotrexate
- Leflunomide
- Sulfasalazine
In first presentation episode add in oral pred.
CRP and DAS 28 each visit
Biological
- Adalimumab
If not winning:
- First increase dose
- If not winning after 6 months DUAL DMARD
- High level of disease activity - biological
Prior to prescribing a biological what tests do you need to run?
Check for TB
- Tuberculin skin test
- OR IGRA
(treat latent TB first)
CXR
Hep B, C and HIV serology
What condition is atlanto-axial subluxation associated with?
What are the risks?
RA
Sudden compression can cause cardiac arrest
- e.g. in theatre
Chronic
- cervical compression - resulting in spastic quadraplegia
Main differentials with RA?
RA
Psoriatic arthropathy
SLE
Osteoarthritis with inflammatory component
What is the series of colour changes in raynauds?
White, blue, then brick red.
What is the spectrum of disease in systemic sclerosis?
CREST is mild
- Calcinosis
- Raynauds
- Esophageal involvement
- Sclerodactyly (hands)
- Telangiectasia
Diffuse cutaneous scleroderma - more extensive
- Includes internal organs
- Microstomia
- Tethering of skin over nose
- Interstitial pulmonary fibrosis
- Renal involvement
- Atonic oesophagus
Three questions to ask in a possible systemic sclerosis history?
Do your hands change colour in the cold
Do you get breathless
Do you get indigestion or heartburn
Management of systemic sclerosis?
Nifedipine for raynauds
Methotrexate for skin
PPI for GI
ACEI for renal crisis
Bosentan or sildenafil for pulmonary hypertension
What are the different seronegative arthritis’?
Psoriatic
Reactive
Ankylosing spondylitis
Behcets and Juvenile idiopathic
Post dysenteric and enteropathic
What is HLA B27 associated with?
Ank spond
treatment for Pagets?
Bisphosphonate
What is the aetiology of polyarteritis nodosa?
Polyarteritis nodosa (PAN) is a vasculitis affecting medium-sized arteries with necrotizing inflammation leading to aneurysm formation.
What HLA is associated with RA?
HLA-DR4
What HLA is associated with ank spond and reiters syndrome?
HLA-B27
What is the most common join gout affects?
The most common joint that gout affects is the first metatarsophalangeal joint.
Classic clinical examination signs associated with ankylosing spondylitis?
Reduced lateral flexion
Reduced chest expansion
Reduced forward flexion (Schobers test)
What medication is predisposed to toxicity in Thiopurine methyltransferase (TPMT) deficiency?
Azathioprine
Genetic inheritance of marphans?
Autosomal dominant
What is osteogenesis imperfecta?
Brittle Bone Disease.
Autosomal dominant
Abnormality in type 1 collagen due to decreased synthesis of pro-alpha 1 or pro-alpha 2 collagen polypeptides
Neuroleptic malignant syndrome treatment?
Dantrolene
What is the main immunoglobulin in breast milk?
IgA
What is the advice for taking bisphosphonates?
30 mins before brekkie with lots of water and sit upright 30 mins after
Management steps for osteoarthritis?
Education, weight loss, muscle strengthening and aerobic fitness
Paracetamol or topical NSAIDS (hand or knee)
Oral NSAIDS/COX-2 inhibitors (with PPI)
Supports, braces, TENS and shock absorbing soles/insoles
Periarticular erosions in psoriatic arthritis are given what name?
Pencil-in-cup
What is dermatomyositis? Antibody? Presentation?
An inflammatory disorder causing symmetrical, proximal muscle weakness and characteristic skin lesions.
May be idiopathic or associated with connective tissue disorders or underlying malignancy
Anti-Jo1 antibody, also ANA
Advice for women wanting to conceive who are on methotrexate?
Must wait for 3 months after stopping methotrexate to conceive
Anticentromere antibodies positive in which condition?
CREST
Erythema marginatum associated most strongly with?
Rheumatic fever
CXR signs in late Ankylosing Spondylitis?
Apical fibrosis
Azathioprine would interact with what to produce severe bone marrow suppression?
Allopurinol
- Both inhibit xanthine oxidase
Scleroderma antibody?
Anticentromere
What is liddles syndrome?
Autosomal Dominant
hypertension and hypokalaemic alkalosis
Anyone who’s started on long term steroids osteoporosis risk management?
If >65 or previous fragility fracture:
- Offer alendronate and adcal
If <65 then offer DEXA
- Less than -1.5 then offer bone protection
Management of hepatic encephalopathy?
NICE recommend lactulose first-line, with the addition of rifaximin for the secondary prophylaxis of hepatic encephalopathy.
Glasgow scale of pancreatitis severity?
PaO2< 7.9kPa Age > 55 years Neutrophils (WBC > 15) Calcium < 2 mmol/L Renal function: Urea > 16 mmol/L Enzymes LDH > 600IU/L Albumin < 32g/L (serum) Sugar (blood glucose) > 10 mmol/L
Antibody associated with drug induced lupus?
Antihistone
What is pellagra?
Pellagra is a caused by nicotinic acid (niacin) deficiency. The classical features are the 3 D’s - dermatitis, diarrhoea and dementia.
Key features of Multiple systems atrophy to distinguish it/
Autonomic dysfunction
Unilateral symptoms
Distinguishing feature between secondary and tertiary hyperparathyroidism?
High calcium and extremely high PTH in Tertiary. (hyperplasia of all glands following secondary hyperparathyroidism)
Classic presentation of NF2? (neurofibromatosis)
Bilateral acoustic schwannoma
What is Stills disease? (adults)
Typically affects 16-35 year olds
Arthralgia
Classic salmon pink rash
Fluctuating pyrexia (late afternoon/evening)
Causes of Gout?
Causes of Gout= DART D- iuretics A- lcohol R- enal disease T- rauma
What is Felty’s syndrome?
Felty’s syndrome is a condition characterized by splenomegaly and neutropenia in a patient with rheumatoid arthritis.
DKA classic triad of signs?
Acidosis
Ketosis
Hyperglycaemia
Clinical features of DKA?
Dehydration - Tachycardia and Hypotension
Kussmaul breathing
Smell of ketones
Vomiting and abdo pain
Some precipitating causes e.g. MI, Infection
Priniciples of DKA treatment?
Rehydration
Gastric aspiration (if vomiting or reduced GCS)
Insulin replacement
Potassium replacement
PANICS:
Potassium - measure hourly (omit if >5.5 or anuria)
Acidosis: check venous pH and Ketones
Normal saline - 500ml over 15mins if systolic <90, otherwise 1L in first hour
Insulin by infusion
Catheter and cultures, urine, blood etc.
Stomach aspiration if drowsy
What are the stages of diabetic retinopathy?
Background - Maculopathy (location rather than severity) Pre-proliferative Proliferative End-stage
What are the features of Background retinopathy?
- Microaneurysms (dot haemorrhages)
- Hard exudates (lipid leaking from microaneurysms)
Blot haemorrhages
<3 Blot haemorrhages (like thumbprints)
Features of Pre-proliferative retinopathy?
Cotton wool spots (infarcts)
> 3 blot haemorrhages
Venous bleeding and looping
Features of proliferative retinopathy?
New vessels round disc
Peripheral new vessels
New vessels on iris
Features of end-stage proliferative retinopathy?
Vitreous haemorrhage (from fragile vessels)
Scarring
Retinal detachment
Blindness
What are the different Neurological manifestations of diabetic damage?
Peripheral neuropathy
Mononeuropathy (e.g III nerve palsy)
Mononeuropathy multiplex (more than one individual nerve trunk affected)
Diabetic femoral neuropathy - sudden onset wasting of quads
Autonomic neuropathy
Cerebrovascular disease
Peripheral thyroid status examination?
Lid retraction/Lid Lag
Clubbing and onycholysis
Fine tremor, moist palms
Tachycardia, AF
Biceps reflex - slow relaxation (hypo)
Proximal myopathy (stand from sitting)
Pretibial myxoedema
Graves disease Triad?
Goitre
Eye disease
Thyrotoxicosis
Graves disease treatment options?
Carbimazole low dose for 18 months then recheck
Block and replace
Surgery
Radioiodine
SWEDISH mnemonic for Cushings features?
Spinal tenderness Weighty central obesity Easy bruising Diabetes Interscapular fat pad Striae Hypertension
Hypothyroidism examination findings?
Gruff voice, slow cerebration
Coarse facial features
Dry, cold, scaly skin
Slow pulse and slow relaxation
Goitre in hashimoto’s
Myxoedema - hands, swelling of subcutaneous tissue
Special tests for diagnosis of cushing’s?
- 24hr urinary free cortisol
2. Dexamethasone test
Causes of cushings syndrome?
Exogenous steroids
Pituitary adenoma (cushings disease)
Adrenal adenoma or carcinoma
Ectopic ACTH syndrome (paraneoplastic)
What type of tumours cause cushings and what type cause acromegaly?
Microadenoma - Cushings
Macroadenoma - Acromegaly
Hand examination findings in acromegaly?
Increased size of hands
Thenar eminence wasting in carpal tunnel syndrome
- Check median nerve distribution sensation
Sweating increased
Bogginess of palms
Skin fold increased in active disease
Face examination findings in acromegaly?
Prominent supraorbital ridges, big ears, nose and lips
Tongue may be big on protrusion
Prognathism - Protrusion of jaw (look from the side)
Wide separation of teeth - ‘show me your gums’
Features of Acromegaly acronym?
ABDCEF
Arthropathy BP high Carpal tunnel syndrome Diabetes Enlarged tongue, heart, thyroid Fields (bitemporal hemianopia)
What is the medical treatment for Acromegaly (in prep for surgery)
Octreatide/Lanreotide
Features of addisons (chronic)?
Non specific
- Fatigue
- Nausea
- Abdo pain
- Diarrhoea
Dizziness (postural hypotension)
Hyperpigmentation
- Buccal
- Hand creases
Hypoglycaemia
Questions to ask in acromegaly history?
Headaches
Vision problems
Tingling in hands, at night
Tingling in feet (diabetic nephropathy)
Sweat easily?
Difficulty with sex - erectile dysfunction
Any increase in shoe, hat or glove size
Pancoasts tumour features?
Horners syndrome
Upper lobe carcinoma
Wasting of small muscles of the hand
Pain felt in the axilla
Pleural effusion findings on examination?
Reduced expansion on the side of the lesion
Stony dull percussion
Trachea normal
Air entry and tactile vocal fremitus reduces
Common causes of pleural exudates?
Carcinoma of the bronchus
Infection: lobar pneumonia and TB
Pulmonary emboli
Rheumatoid arthritis
Common causes of pleural transudates
HF
Nephrotic syndrome
Liver failure
Main differences between an effusion and a collapse on examination?
Collapse
- Loss of lung volume
- Trachea deviated
Effusion
- Stony dullness
- Trachea central
What can cause loss of lung volume?
(trachea is deviated towards affected side)
Pneumonectomy
TB and old treatments for TB
Unilateral fibrosis
Collapse of a lobe
4 signs of severe asthma?
Unable to complete sentences in one breath
RR > 25
HR > 110
Peak Flow <50% predicted (or best)
7 signs of life threatening asthma?
33-92 CHEST
- Less than 33% Peak flow
- <92% sats
CHEST
Cyanosis Hypotension Exhaustion Silent chest Tachycardia (or brady)
What are the findings of FEV1/FVC and transfer factor in restrictive lung disease?
FEV1 and FVC reduced, the ration is normal or increased
Transfer factor reduced in a pulmonary cause
Transfer factor normal if extra-pulmonary
Extrapulmonary causes of restrictive lung disease?
Guillain barre
Respiratory depression
Flail chest
Kyphoscoliosis
Scleroderma of chest wall
Causes of pulmonary fibrosis?
Upper causes: TB SPACE
- TB
- Sarcoid
- Pneumoconiosis
- Ank spond
- CF
- Extrinsic allergic alveolitis
Lower causes: Acid
- Asbestosis
- Connective tissue disease
- Idiopathic pulmonary fibrosis
- Drugs
Drugs: AMEN
- Amiodarone
- Methotrexate
- Ergot derivatives (cabergoline)
- Nitrofurantoin
Drug causes of pulmonary fibrosis?
Drugs: AMEN
- Amiodarone
- Methotrexate
- Ergot derivatives (cabergoline)
- Nitrofurantoin
Causes of clubbing and basal crackles?
Idiopathic pulmonary fibrosis
Bronchiectasis
Asbestosis
Common organisms causing CAP?
Most common is strep pneumoniae
Haemophilus influenzae
Atypicals
- Mycoplasma
- Chlamydia
- Legionella (rare)
Signs and symptoms of pneumonia?
Symptoms
- Fever
- Cough - may be productive
- Breathlessness
- Pleuritic pain
- In elderly may be confused
Signs (of consolidation)
- Reduced expansion
- Increased vocal resonance (fremitus)
- Dullness to percussion
- Reduced air entry
- Bronchial breathing
- Coarse crackles
CURB 65 score made up of?
Confusion
Urea (>7)
RR >30
BP low
> 65 y/o
Management of infective exacerbation of COPD?
24% O2 initially
(evidence of significant acidosis or rising CO2 level may indicate need for ventilation)
Salbutamol and ipratropium via air-driven nebuliser
Steroids - IV or orally
Repeat nebulisers
Consider IV aminophylline if still struggling and not on oral theophylline
IV fluids and Abx
What is extrinsic allergic alveolitis?
Exposure to organic antigens in microbial spores. Presents acutely with fever SOB and crackles
Chronic exposure may lead to pulmonary fibrosis.
Either Framers lung (mouldy hay) or bird fanciers lung.
Typical sequelae of asbestos exposure?
Pleural plaques, pleural thickening
Asbestosis (pulmonary fibrosis)
Carcinoma of bronchus (50x risk if also smoker)
Mesothelioma
Presentation of Sarcoidosis?
Either acute (self-limiting) or chronic
Acute:
- Erythema nodosum
- Arthralgia
- Fever
- Hilar lymphadenopathy
Chronic
- Hilar lymphadenopathy
- Pulmonary fibrosis
- Tender swellings of fingers
- Facial rash
- Hypercalcaemia
- Facial nerve palsy, parotitis
- Anterior uveitis
Causes of erythema nodosum?
Sarcoidosis Strep infection TB IBD Drugs - Sulphonamides. OCP
Suspected lung cancer, CXR or similar investigations?
NICE recommends that patients with known or suspected lung cancer are offered a contrast-enhanced CT scan of the chest, liver and adrenals.
Biopsy after CT scan
Features of Kartagener’s syndrome?
Primary ciliary dyskinesia
Dextrocardia Quiet heart sounds Bronchiectasis Sinusitis Subfertility
What is Varenicline, what is it used for?
Nicotinic receptor partial agonist
Used to help stop smoking
Why do you use inhaled corticosteroids in COPD?
Reduce the frequency of exacerbations
Factors for Long term oxygen therapy?
- Very severe airflow obstruction (FEV1 < 30% predicted).
- Cyanosis
- Polycythaemia
- Peripheral oedema
- Raised jugular venous pressure
- Oxygen saturations less than or equal to 92% on room air
Factors that determine whether chest drain should be placed in pulmonary effusion?
Frankly purulent/cloudy aspirate
Organisms identified
pH <7.2
First things to rule out in status epilepticus?
Hypoxia and hypoglycaemia
Most common complication following meningitis?
Sensorineural hearing loss
Antiemetic for parkinson’s disease?
Domperidone - doesn’t cross BBB
Can you take inhaled asthma drugs in pregnancy?
Yes, no problem
Non-small cell cancer contraindications for surgery?
SVC obstruction
FEV < 1.5
MALIGNANT pleural effusion
Vocal cord paralysis
Mets
Features of Wernicke’s encephalopathy?
CAN OPEN
Confusion Ataxia Nystagmus Ophthamoplegia PEripheral Neuropathy
Cannonball lung tumours are mets from what cancer?
Renal Cell Carcinoma
Symptom control in non-CF bronchiectasis?
Inspiratory muscle training + postural drainage
What three interventions may improve survival in COPD patients?
Smoking cessation - the single most important intervention in patients who are still smoking
Long term oxygen therapy in patients who fit criteria
Lung volume reduction surgery in selected patients
COPD criteria for LTOT on ABG?
LTOT if 2 measurements of pO2 < 7.3 kPa
How do you classify the severity of COPD?
Done on the FEV1 freading, mild is normal (>80% with symptoms)
Moderate is FEV1 50-79%
Severe is 30-49%
Very severe is <30%
How do you diagnose asthma in de=ifferent age groups?
Patients >= 17 years:
- Patients should be asked if their symptoms are better on days away from work/during holidays. If so, patients should be referred to a specialist as possible occupational asthma.
- All patients should have spirometry with a bronchodilator reversibility (BDR) test
- All patients should have a FeNO test.
Patients 5-16 years;
- All patients should have spirometry with a bronchodilator reversibility (BDR) test.
- A FeNO test should be requested if there is normal spirometry or obstructive spirometry with a negative bronchodilator reversibility (BDR) test.
Patients < 5 years:
- Diagnosis should be made on clinical judgement
When should you use BIPAP and CPAP roughly speaking?
CPAP in Type One resp failue
BiPAP in Type two
One way to differentiate microscopic polyangiitis and Churg-Strauss syndrome/Polyangiitis with granulomatosis?
Churg/Wegeners have sinusitis
What is pott’s disease? How does it present?
TB in the bone
Back pain
Night sweats
Kyphosis
Weight loss
Signs and symptoms of asthma?
Symptoms
cough: often worse at night
dyspnoea
‘wheeze’, ‘chest tightness’
Signs
expiratory wheeze on auscultation
reduced peak expiratory flow rate (PEFR)
All patients with suspected/confirmed TB must also be tested for what?
HIV
What COPD patients with exacerbations require abx?
Purulent sputum or signs of pneumonia
What percentage increase in FEV1 is indicative of asthma?
An increase in the FEV1 of 12% or more after inhalation of a short-acting bronchodilator is indicative of asthma.
Prescription and course length to settle an acute exacerbation of asthma (non severe, in community)?
Salbutamol nebs initially
Then Oral Pred for 5 days plus beclometasone inhaler.
Two most common causes of bilateral hilar lymphadenopathy?
sarcoidosis and tuberculosis
COPD patients with frequent exacerbations should be given what?
Home prednisolone and abx
Causes of Acute Pancreatitis?
GET SMASHED
Gallstones
Ethanol
Trauma
Steroids
Mumps (other viruses include Coxsackie B)
Autoimmune (e.g. polyarteritis nodosa), Ascaris infection
Scorpion venom
Hypertriglyceridaemia, Hyperchylomicronaemia, Hypercalcaemia, Hypothermia
ERCP
Drugs (azathioprine, mesalazine*, didanosine, bendroflumethiazide, furosemide, pentamidine, steroids, sodium valproate)
What is Whipple’s disease?
Whipple’s disease is a rare multi-system disorder caused by Tropheryma whippelii infection.
Causes of metabolic alkalosis?
Diuretics Vomiting / aspiration Hypokalaemia Cushing's syndrome Primary hyperaldosteronism Bartter's syndrome
What is Peutz Jeghers syndrome?
Peutz-Jeghers syndrome is an autosomal dominant condition characterised by numerous hamartomatous polyps in the gastrointestinal tract. It is also associated with pigmented freckles on the lips, face, palms and soles. Around 50% of patients will have died from a gastrointestinal tract cancer by the age of 60 years.
What is FAP and gardners syndrome?
FAP is a rare autosomal dominant condition which leads to the formation of hundreds of polyps by the age of 30-40 years. gardeners syndrome is a variant that can lead to osteomas, thyroid cancers, retinal pigmentation and epidermoid cysts.
How does BUdd-Chiari syndrome present, what is the pathophysiology?
Abdominal pain: sudden onset, severe
Ascites
Tender hepatomegaly
Hepatic vein thrombosis
Metabolic consequences of refeeding syndrome?
Hypophosphataemia
Hypokalaemia§
Hypomagnesaemia
Abnormal fluid balance
What do you need to give to patients prior to large-volume paracentesis for the treatment of ascites? Why?
Albumin infusion to prevent circulatory dysfunction
Typical carcinoid presentation?
Flushing, diarrhoea, bronchospasm, hypotension, and weight loss
What is the main investigation for carcinoid syndrome?
Urinary 5-HIAA
What antibiotic do you give to cover for spontaneous bacterial peritonitis?
Ciprofloxacin
What would lead you to want to give cover for spontaneous bacterial peritonitis with a patient with ascites?
Protein concentration <15g/L
Most prominent symptom of Crohn’s disease in children and in adults?
Children - Abdominal pain
Adults - Diarrhoea
Diagnostic requirements for Wilson’s disease?
Reduced serum caeruloplasmin
Reduced serum copper (counter-intuitive, but 95% of plasma copper is carried by ceruloplasmin)
Increased 24hr urinary copper excretion
Three notable foods that are gluten free?
rice
potatoes
corn (maize)
Notable foods with gluten in it?
wheat: bread, pasta, pastry
barley*: beer
rye
oats**
Antibodies in autoimmune hepatitis?
Anti-nuclear and/or anti-smooth muscle antibodies.
What is a serum-ascites albumin gradient (SAAG) used to determine?
If the ascites is caused by portal hypertension or not
If it is above 11g/L then it is portal hypertension
What is the iron study profile in haemochromatosis?
Raised transferrin saturation and ferritin, with low TIBC.
In iron studies what do transferring, ferritin and TIBC represent?
Transferrin binds iron in the blood. If there is more iron in the body the saturation (of iron bound to transferrin) increases, and vice versa.
Ferritin is the iron store intracellularly. If there is more iron then there will be more ferritin.
TIBC (total iron binding capacity) the available binding sites on transferrin, this will decrease in iron overload.
What are the factors that contribute to the Modified glasgow score (for severity of pancreatitis)?
PANCREAS
paO2 Age (55) Neutrophilia Calcium Renal function Enzymes Albumin Sugar
Treatment for C.Diff?
first line - Metronidazole
Second - Oral Vanc
If life-threatening then oral vanc and iv Metronidazole
What investigations do you need before fundoplication surgery?
Endoscopy
Barium swallow
pH monitoring
Manometry studies
What is the surgical management of GORD?
Fundoplication - when medical management has failed
How do you classify the severity of Ulcerative colitis flare ups?
Mild
- fewer than four stools a day (with or without blood)
Moderate
- 4-6 stools a day
- Minimal systemic disturbance
Severe
- > 6 stools a day
- Evidence of systemic disturbance
Why are coeliac disease patients given immunisations?
Functional hyposplenism
What are the common types of oesophageal cancer?
Most common is now adenocarcinoma
- Commonly have history of Barretts
Squamous
- Achalasia
Time in which patients with UGIB need an endoscopy?
If unstable then immediate
If stable then within 24 hours
Triad of symptoms in intestinal angina (chronic mesenteric ischaemia)?
Severe, colicky post-prandial abdominal pain, weight loss, and an abdominal bruit.
Pseudomembranous colitis is associated with what bug?
C.Diff
What cancers are patients at risk of developing with HNPCC?
Colorectal most common
Endometrial second most common
What is the investigation of choice to detect liver cirrhosis?
Transient elastography
What are the extra-intestinal manifestations of IBD?
Iritis
Arthritis
Erythema nodosum
Pyoderma gangrenosum
Classic features of Crohn’s disease?
Both crohns and UC:
- Extra intestinal manifestations
- Diarrhoea
Crohns:
- Non-bloody diarrhoea
- Weight loss
- Abdo pain
- Skip lesions
- Inflammation all the way to the muscularis layer
- Granulomas
- Goblet cells
- Rose thorn ulcers
Classic features of UC?
Both crohns and UC:
- Extra intestinal manifestations
- Diarrhoea
UC: - Bloody Diarrhoea - PSC - Uveitis - Colorectal cancer - Continuous disease, starts at rectum - Tenesmus - Tumbprinting - Leadpipe Pseudopolyps
Dr Clarke Mnemonic for Crohns disease presentation?
CAMPERS
Clubbing and cobblestone mucosa Apthous ulceration Mass in RIF Perianal disease Erythema nodosum Rose thorn ulcers Skip lesions
Findings that suggest a fatty liver?
Raised LFTs, especially GGT
Highly echogenic liver on USS
SIgns of Chronic liver disease and Liver cell failure?
Chronic Liver disease:
- Clubbing
- Palmar erythema
- Dupuytrens contracture
- Spider naevi
- Gynaecomastia
- Testicular atrophy
Liver cell failure
- Jaundice
- Leuconychia
- Bruising
- Ascites
- Encephalopathy
Signs of Portal hypertension?
VASC
Varices
Ascites
Splenomegaly
Caput medusae
How do you tell the difference between caput medusae and Vena cava obstruction?
In Caput medusae the veins flow outwards from the umbilicus
In Vena cava obstruction they all flow upwards
Causes of ascites?
Cirrhosis Hypoalbuminaemic states Peritoneal secondaries Constrictive pericarditis Severe biventricular failure Hepatic vein thrombosis TB Ovarian tumours
Rule of M in primary biliary cholangitis?
Most common presenting feature?
IgM
anti-Mitochondrial antibodies, M2 subtype
Middle aged females
Associated with lethargy and pruritis
What is Courvoisier’s sign?
A palpable enlarged gallbladder is unlikely to be due to gallstones, likely to be cancer of biliary tree or pancreas.
Cirrhosis changes seen in AST and ALT?
AST is >2.5 higher than ALT
What is the most sensitive blood test to assess cirrhosis in chronic liver disease?
Thrombocytopenia
Treatment for Wilsons?
Penicillamine
What are the two triple therapy regimes associated with H.Pylori eradication?
PPI + amoxicillin + clarithromycin, or
PPI + metronidazole + clarithromycin
Diagnostic test for PSC?
ERCP
Features of vitamin C deficiency?
Gingivitis, loose teeth
Poor wound healing
Bleeding from gums, haematuria, epistaxis
General malaise
What is the MAddrey discriminant function?
Used to determine whether alcoholic hepatitis needs steroids. >32 means it does.
In wilsons what happened to the levels of serum copper and serum caeruloplasmin?
Both are reduced
Most common causative bug in SBP?
E.Coli
Risk associated with a too fast correction of a chronic hypernatraemia?
Correction of chronic hypernatraemia too fast predisposes to cerebral oedema
What is the BRCA2 and BRCA1 mutation associated with asides from breast cancer?
BRCA2
- Ovarian in women
- Prostate Ca. in men
BRCA1
- Colorectal cancer
Hiccups in Palliative care treatment?
Chlorpromazine or haloperidol
Treatment of Nausea in chemotherapy?
Metoclopramide - First line
Ondansetron (5HT3) - second line, high risk
What LFT is significantly altered in Pregnancy?
ALP is raised significantly
WHich thyroid cancer causes a rise in Calcitonin
Medullary
Haemophilia aetiology?
Haemophilia A is due to a deficiency of factor VIII whilst in haemophilia B (Christmas disease) there is a lack of factor IX.
What is the key difference in gram negative and gram positive bacteria?
Gram-negative bacteria have a double membrane (outer membrane and cytoplasmic membrane).
How do you remember the classification of bacteria?
Gram positive Cocci
- Staph and strep (inc enterococci)
Gram Negative cocci
- Neisseria meningitides and neisseria gonorrhoea
- Moraxella
Gram positive rods (ABCD L)
- Actinomyces
- Bacillus
- Clostridium
- Diptheria
- Listeria
Ebola incubation period?
2-21 days
How would you describe erythema multiforme?
Symmetrical target rash with central blister
Scoring system specifically for sepsis?
qSOFA
What are the CT findings for cerebral toxoplasmosis?
Ring enhancing lesions
What are the Beta haemolytic streptococci responsible for causing?
Groups A, B and D are important in humans
group A
- Erysipelas, impetigo, cellulitis, type 2 necrotizing fasciitis and pharyngitis/tonsillitis
- Post strep GN
- Scarlet fever
Group B
- Neonatal meningitis and sepsis
Group D
- Enterococci
Treatment of Hep C?
Protease inhibitors +/- ribavirin
Treatment of Toxoplasmosis?
Sulfadiazine and pyrimethamine
PEP for Hep A, B and C?
Hep A
- Immunoglobulin
Hep B
- Booster vaccine if known responder
- immunoglobulin and booster if non-responder
Hep C
- PCR to monitor seroconversion
- If conversion then Inteferon +/- Ribavirin
Treatment for Tetanus?
Tetanus immunoglobulin
Diazepam and ventilator if needed
How to remember mechanism of Antiretrovirals?
Fusion inhibitors
- Rock and tide prevented from being fused
- MaraviROCK
- EnfuvirTIDE
Protease inhibitors
- Navir tease a pro
- drugs ending in Navir
Integrase inhibitors
- Grave to integrate
- Drugs ending in gravir
NNRTI (non-nucleoside reverse transcriptase inhibitors)
- vir in the middle
NRTI
- All the rest
Who needs the Tuberculin skin test prior to BCG vaccination?
Any person being considered for the BCG vaccine must first be given a tuberculin skin test. The only exceptions are children < 6 years old who have had no contact with tuberculosis.
What do you need to check before starting ethambutol?
Visual Acuity
What are the vaccines offered to pregnant women?
Flu (during flu season) and pertussis (whooping cough)
How many patients develop a chronic infection in Hep C?
55-85% become chronically infected
Erythema infectiosum is caused by?
Parovirus
Management of syphillis?
Intramuscular benzathine penicillin is the first-line management (e.g. penicilling G)
Alternatives: doxycycline
Antibiotic for legionella?
Clarithromycin
Second-line antibiotic for cellulitis?
Clarithromycin
How does dengue fever present?
Causes headache (often retro-orbital) Fever Myalgia Pleuritic pain Facial flushing (dengue) Maculopapular rash
Low platelets and raised ALT
How does yellow fever present?
Often comes in phases:
- May cause mild flu-like illness lasting less than one week.
- Classic description involves sudden onset of high fever, rigors, nausea & vomiting. Bradycardia may develop.
A brief remission is followed by jaundice, haematemesis, oliguria.
What conditions are spread by mosquito?
Japanese encephalitis
Yellow fever
Dengue fever
Malaria
Most common pathogen causing pyelonephritis?
e.coli
What is the post op management of splenectomy with regards to infectious diseases?
Vaccines (if elective should be done 2 weeks prior):
- Hib, meningitis A (and B?)
- Annual influenza vaccination
- Pneumococcal vaccine every 5 years
Abx
- Penicillin V, for 2 years or until 16 usually
Overgrowth of what bacteria cause BV?
Gardnerella vaginalis
Cholera presentation?
Profuse waery (‘rice water’) diarrhoea.
ALSO
Hypoglycaemia, dehydration.
TB treatment drugs?
Rifampicin
Isoniazid
Pyrazinamide
Ethambutol
What tests do you need prior to TB treatment?
Visual acuity for ethambutol
LFTs and FBC for all of them as hepatotoxic
Us&Es for creatinine rise and electrolyte disturbance
What is the normal presentation for aspergilloma?
Normally colonises an existing cavity and is usually asymptomatic, but may get cough and haemoptysis
What pneumonias also cause erythema multiforme?
Mycoplasma and pneumococcus
What bloods do you need before starting terbinafine?
LFTs
What is red man syndrome, waht is the management?
vancomycin related transfusion reaction, redness over trunk and face due to vanc infusion at too high a rate.
Stop the transfusion then start again at a lower rate
Causative organisms in meningitis?
- Streptococcus pneumoniae
- Neisseria meningitidis
- Mycobacterium tuberculosis
- Cryptococcus neoformans
India ink staining picks up what bug?
Cryptococcus
What is the Jarisch-Herxheimer reaction?
Reaction that sometimes occurs after initial treatment of syphillis. Fever. Rash and tachycardia.
Which are the strains of HPV that cause cancer and which are the ones that cause warts?
16 & 18 are cancer
6 & 11 are warts
What is the structure of a liver lobule?
Hexagon shape with central vein in the centre. Around it are hepatic triads made up of
- Bile duct
- Hepatic artery
- Portal vein
What are the indications for stool microscopy (3)?
Immunocompromised
Blood/mucus
Suspect Sepsis
What is the pneumonia that commonly presents with desaturations on exertion?
PCP
Management of PCP?
Co-trimoxazole
Abx for HAP?
Within 5 days of admission: co-amoxiclav or cefuroxime
More than 5 days after admission: piperacillin with tazobactam OR a broad-spectrum cephalosporin (e.g. ceftazidime) OR a quinolone (e.g. ciprofloxacin)
What is the pneumonia most associated with hyponatraemia/
Legionella (could also be mycoplasma)
Black hairy tongue associated with what class of antibiotics?
Tetracyclines
Common organism to cause a chronic wound infection in a neuropathic ulcer (diabetic pt).
Pseudomonas
In terms of non-response to Hep B vaccine what is the recommended management?
If 10-100 then one more dose
If <10 then repeat the whole course
