General deck Flashcards
what are the types of trigeminal autonomic cephalgia?
- cluster headache
- paroxysmal hemicrania
- hemicrania continua
- short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT syndrome)
- short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA)
What is the initial tx for acute flare of UC?
1.) Intravenous fluid and electrolyte replacement
2.) Blood transfusion if required to maintain a haemoglobin >10g/dL
3.) Intravenous antibiotics ONLY if infection is considered or prior to surgery
4.) Subcutaneous heparin to reduce the risk of thromboembolism
5.) Intravenous corticosteroids (either hydrocortisone 100mg four times a day or methylprednisolone 60mg/day)
6.) Flexible sigmoidoscopy and biopsy within 72 hours to confirm diagnosis and exclude cytomegalovirus infection
7.) Daily monitoring with physical examination, recording of vital signs, stool chart, bloods (full blood count, c-reactive protein, serum electrolytes, serum albumin, liver function tests and glucose) and consider the need for daily abdominal X-ray.
What is the predictor for need of surgery in UC?
At day three a c-reactive protein >45 mg/l or a stool frequency of >8/day predicts the need for surgery in 85% of cases.
what is the tx of acute UC flare which has not responded to 72 hrs of IV steroids?
The National Institute for Clinical Excellence (NICE) recommends that if no improvement is seen after 72 hours of intravenous steroid treatment or if the patient deteriorates at any time despite corticosteroid treatment then an urgent surgical review is required ciclosporin (2mg/kg/day) should be added. NICE recommends that in this acute setting infliximab reserved for patients in whom ciclosporin is contraindicated or clinically inappropriate
How are patients within 24 hours of onset of TIA or minor ischaemic stroke and with a low risk of bleeding managed?
clopidogrel (initial dose 300 mg followed by 75 mg od) + aspirin (initial dose 300 mg followed by 75 mg od for 21 days) followed by monotherapy with clopidogrel 75 mg od
what are the causes of pulmonary eosinophilia?
Churg-Strauss syndrome
allergic bronchopulmonary aspergillosis (ABPA)
Loffler’s syndrome
eosinophilic pneumonia
hypereosinophilic syndrome
tropical pulmonary eosinophilia
drugs: nitrofurantoin, sulphonamides
less common: Wegener’s granulomatosis
what are special findings on pleural fluid and its associated diagnosis?
low glucose: rheumatoid arthritis, tuberculosis
raised amylase: pancreatitis, oesophageal perforation
heavy blood staining: mesothelioma, pulmonary embolism, tuberculosis
In T2Dm, what do you aim for Hba1c with just metformin and when do you add a second drug?
you can titrate up metformin and encourage lifestyle changes to aim for a HbA1c of 48 mmol/mol (6.5%), but should only add a second drug if the HbA1c rises to 58 mmol/mol (7.5%)
how do you convert percentage Hba1c to mmol?
11(HbA1c %)-24 = (HbA1c mmol/mol)
what are the CYP450 inducers and inhibitors?
CRAP GPS induce
Carbemazepines
Rifampicin
Alcohol (chronic)
Phenytoin
Griseofulvin
Phenobarbitone
Sulphonylureas
SICKFACES.COM inhibit
Sodium valproate
Isoniazid
Cimetidine
Ketoconazole
Fluconazole
Alcohol
Chloramphenicol
Erythromycin
Sulfonamides
Ciprofloxacin
Omeprazole
Metronidazole
Grapefruit juice
how is cocaine toxicity managed?
benzodiazepines are generally first-line
what drugs should be avoided in cocaine toxocity?
Beta-blockers should be avoided in cocaine-induced chest pain. The rationale is that beta-antagonism may result in unopposed alpha-mediated coronary vasospasm.
what are the rare causes of pappiloedema
Rare causes include
hypoparathyroidism and hypocalcaemia
vitamin A toxicity
what are factors that increase the risk of haemoptysis in goodpastures disease?
smoking
lower respiratory tract infection
pulmonary oedema
inhalation of hydrocarbons
young males
what lung nodules spotted on CT scans do not need any further follow up?
Solitary, solid and non-calcified lung nodules of less than 5mm in size do not warrant further investigations or monitoring
which lung nodules need follow up? and how do you follow up??
Nodule <5mm –> discharge
Nodule 5-6mm –> CT at 1 year
Nodule >6mm –> CT at 3 months
Nodule >8mm and/or high risk features (as per Brock model) –> Urgent CT PET +/- biopsy (if PET shows high uptake)
what medication is used for executive and visuospatial dysfunction on a background of PD?
rivastigmine
what are some acquired causes of Methaemoglobinaemia?
drugs: sulphonamides, nitrates (including recreational nitrates e.g. amyl nitrite ‘poppers’), dapsone, sodium nitroprusside, primaquine
chemicals: aniline dyes
How do you differentiate barter syndrome to gitelman’s syndrome?
Bartter’s syndrome presents early in life, with classical features of triangular facies, polyuria, polydipsia and renal failure. Serum renin and aldosterone levels are high despite a low or normal blood pressure. Urine calcium may be raised, and renal stones are a common feature.
In Gitelman’s syndrome patients may present later on in adulthood, but have a milder disease course or may be asymptomatic compared to patients with Bartter’s syndrome. Hypomagnesaemia and hypocalciuria differentiates Gitelman’s syndrome from Bartter’s syndrome.
what are the causes of Hypokalaemia with acidosis
diarrhoea
renal tubular acidosis
acetazolamide
partially treated diabetic ketoacidosis
what are the causes of Hypokalaemia with alkalosis
vomiting
thiazide and loop diuretics
Cushing’s syndrome
Conn’s syndrome (primary hyperaldosteronism)
what do you see on biopsy in polymyositis vs dermatomyosistis vs inclusion body myosistis?
- Endomysial CD8 positive T-cell mediated lymphocytic infiltrates that invade nonnecrotic muscle fibres = polymyositis
- Perimysial inflammation by CD4 positive T-lymphocytes and parafascicular atrophy = dermatomyositis
- Inflammatory infiltrates and inclusions within muscle fibres = inclusion body myositis
what is the kings college criteria for liver transplant?
Arterial pH < 7.3, 24 hours after ingestion
or all of the following:
prothrombin time > 100 seconds
creatinine > 300 µmol/l
grade III or IV encephalopathy
What is macrophage activation syndrome?
Macrophage activation syndrome is a rare disorder that is associated with rheumatological conditions such as juvenile idiopathic arthritis, rheumatoid arthritis or systemic lupus erythematosus. It commonly presents with a pancytopenia and intercurrent infection - particularly EBV - and is usually initially treated as neutropaenic sepsis.
Left untreated, the disease is often fatal after two months.
Diagnosis: bone marrow aspiration can reveal haemophagocytosis as the key feature.
Other features: excessive hyperferritinemia, elevated triglycerides, deranged LFTs, and hypofibrinogenemia.
Treatment: immunosuppression.
What drug interacts with azathioprine and enhances its toxicity?
Allopurinol enhances the effects and increases the toxicity of azathioprine
Allopurinol enhances the effects and increases the toxicity of azathioprine.
one should reduce the dose of azathioprine to one-quarter of usual dose
Because of our natural genetic variability, some healthy people will just naturally have a deficiency of TPMT (around three in a thousand). Such people are at a significant risk of developing severe, potentially life-threatening, bone marrow toxicity when treated with conventional doses of azathioprine.
Treatment used to induce remission in crohn’s disease?
Steroids
Steroids + enteral feeding with elemental diet (especially in young children)
2nd line - 5-ASAs (mesalazine)
3rd line - add on azathioprine/ mercaptopurine/ methotrexate
4th line - infliximab - for refractory disease and fistulating crohns
metronidazole - isolated perianal disease
Treatment for maintaing remission in crohn’s disease?
Stop smoking
1st line - azathioprine or mercatptopurine
2nd line - methotrexate
what tests need to be done before starting ergot derived dopaminde receptor agonists in
echocardiogram, ESR, creatinine and chest x-ray
what are the causes of hypernatraemia?
dehydration
osmotic diuresis e.g. hyperosmolar non-ketotic diabetic coma
diabetes insipidus
excess IV saline
what is the soft tissue complication that you can develop with chicken pox infections?
necrotising fasciitis
A common complication is secondary bacterial infection of the lesions
NSAIDs may increase this risk
whilst this commonly may manifest as a single infected lesion/small area of cellulitis, in a small number of patients invasive group A streptococcal soft tissue infections may occur resulting in necrotizing fasciitis
Multifocal motor neuropathy with conduction block vs motor neuron disease??
Multifocal motor neuropathy with conduction block (MMN-CB) is an acquired immune-mediated demyelinating neuropathy.
pure motor peripheral neuropathy with multifocal areas of demyelination and motor block, with f waves and H-reflexes suggestive of late motor responses to electrical stimuli,
Features of MMN-CB may resemble motor neuron disease but in contrast MMN-CB may respond well to intravenous immunoglobulin.
what are the causes of stevens johnson syndrome?
penicillin
sulphonamides
lamotrigine, carbamazepine, phenytoin
allopurinol
NSAIDs
oral contraceptive pill
what is the treatment for CMV retinitis?
IV ganciclovir
treatment used to be life-long but new evidence suggests that it may be discontinued once CD4 > 150 after HAART
alternative: IV foscarnet or cidofovir
How do you differentaite sigmoid volvulus vs caecal volulus on Xray?
This man has a sigmoid volvulus as confirmed on his abdominal x-ray which shows the classic coffee bean sign. Note that a sigmoid volvulus will not retain haustra and typically originate in the left lower quadrant and extend to the right upper quadrant as is the case here.
A caecal volvulus will typically originate in the right lower quadrant and extend to the left upper quadrant. Additionally, caecal volvuli retain haustra. As both of these features are not present here, a sigmoid volvulus is a more likely diagnosis.
What is the criteria for LTOT?
Offer LTOT to patients with a pO2 of < 7.3 kPa or to those with a pO2 of 7.3 - 8 kPa and one of the following:
secondary polycythaemia
peripheral oedema
pulmonary hypertension
what is the non-erosive arthritis linked with SLE called?
Jaccoud’s arthorpathy
Jaccoud arthropathy (JA), Jaccoud deformity or Jaccoud’s arthopathy is a chronic non-erosive reversible joint disorder that may occur after repeated bouts of arthritis.
caused by inflammation of the joint capsule and subsequent fibrotic retraction, causing ulnar deviation of the fingers, through metacarpophalangeal joint (MCP) subluxation,primarily of the ring and little-finger.
the deformities result mainly from soft-tissue abnormalities, such as laxity of ligaments, fibrosis of the capsule, and muscular imbalance, rather than from destruction of the bone of joints
How do you diagnose CLL?
Flow cytometery - immunophenotyping
most cases can be identified using a panel of antibodies specific for CD5, CD19, CD20 and CD23
How do you treat myxoedema coma?
Administration of both liothyronine (T3) and levothyroxine (T4)
who needs a reduced dose of levothyroxine?
initial starting dose of levothyroxine should be lower in elderly patients and those with ischaemic heart disease. The BNF recommends that for patients with cardiac disease, severe hypothyroidism or patients over 50 years the initial starting dose should be 25mcg od with dose slowly titrated. Other patients should be started on a dose of 50-100mcg od
how do you differentiate microscopic polyangiitis vs wegners granulamatosis?
WG is unlikely with the absence of upper and lower airway involvement. Also, the absence of granuloma formation in the kidneys would not favour it.
In MPA -
pANCA (against MPO) - positive in 50-75%
cANCA (against PR3) - positive in 40%
what is typical respiratory presentation of Granulamatosis with poluangiitis?
chest x-ray: wide variety of presentations, including cavitating lesions
what are the causes of lung fibrosis and which lobes do they affect
upper zone fibrosis:
CHARTS
C - Coal worker’s pneumoconiosis
H - Histiocytosis/ hypersensitivity pneumonitis
A - Ankylosing spondylitis
R - Radiation
T - Tuberculosis
S - Silicosis/sarcoidosis
Acronym for causes of lower zone fibrosis:
ACID
A- Asbestosis
C- Connective tissue disorders (except ankylosing spondylitis) e.g. SLE, RA
I- Idiopathic pulmonary fibrosis
D- Drug-induced: amiodarone, bleomycin, methotrexate
what are the complications of ankylosing spondylitis?
Apical fibrosis
atlanto-axial
aortitis
achilles tendonitis
anterior uveitis
what is the cause of Q fever and how does it present?
Q fever is caused by Coxiella burnetii, a rickettsia
Features
typically prodrome: fever, malaise
causes pyrexia of unknown origin
transaminitis
atypical pneumonia
endocarditis (culture-negative)
what is the tx for Q fever?
Coxiella burnetii
Management- doxycycline
what tests are used for monitoring recurrence of cancer in medullary, no medullary thyroid, melanoma, carcinoid syndrome ?
Chromogranin - marker for Carcinoid syndrome
Thyroid transcription factor 1 - marker for lung adenocarcinoma
S100 - melanoma
Thyroglobulin - non medullary thryoid cancer
Calcitonin - medullary thyroid cancer
what is given to prevent fractures in cases of bone mets?
Oral bisphosphonates - firts line
If eFR < 30 - Denosumab (Monoclonal Ab against osetoclast development - inhibits RANKL)
who gets prophylactic antibiotics in SBP?
patients who have had an episode of SBP
patients with fluid protein <15 g/l and either Child-Pugh score of at least 9 or hepatorenal syndrome
NICE recommend: ‘Offer prophylactic oral ciprofloxacin or norfloxacin for people with cirrhosis and ascites with an ascitic protein of 15 g/litre or less until the ascites has resolved’
How does HAS reduce mortality in SBP?
immune system uses the protein to bind to and fight infection.
Thus the IV albumin may promote immune function and defence against the infection
Intravenous albumin treatment has been shown to reduce in-hospital mortality of patients with uncomplicated SBP. Patients with associated renal dysfunction appear to derive the most benefit. Albumin decreases renal insufficiency, probably by increasing the circulatory volume and by binding pro-inflammatory molecules.
how is MS affected during pregnancy?
‘relapse rates may reduce during pregnancy and may increase 3 to 6 months after childbirth before returning to pre-pregnancy rates
what are the contrainidications for flecainide?
- post myocardial infarction
- structural heart disease: e.g. heart failure
- sinus node dysfunction; second-degree or greater AV block
- atrial flutter
what is the treatment for atrial flutter
Cardioversion should be used first line
In patients who are not suitable for cardioversion beta blockers and calcium channel blockers can be used to slow AV node conduction
Digoxin used to be first line treatment for ventricular rate control in flutter. Now it is used mostly in patients with heart failure alongside a beta blocker. It is also used in patients whose rate has not been adequately controlled by a calcium channel blocker, a beta blocker or both.
how do you differentiate ostium primum vs secundum on ECG?
Ostium secundum (70% of ASDs)
associated with Holt-Oram syndrome (tri-phalangeal thumbs)
ECG: RBBB with RAD
Ostium primum
present earlier than ostium secundum defects
associated with abnormal AV valves
ECG: RBBB with LAD, prolonged PR interval
As primum is first it is on the LEFT (LAD), secundum is second (RAD)
what test do you need to do regularly with patients on cabergoline?
Dopaminergic drugs are associated with fibrotic reactions including pulmonary, retroperitoneal and pericardial fibrosis, but cabergoline also assocaited with development of new valvulopathy.
What do you see on different microscopes for membranous nephropathy?
Light microscopy - diffuse thickening of glomerular basement membrane throughout all glomeruli in absence of significant hyper-cellularity
Immunofluorescence microscopy - diffuse granular patter of IgG with c3 along GBM
Electron microscopy - depends on stage of disease. but stage 2 is the classical exam description: sub-epithelial electron-dense deposits with small GBM extensions (spikes); GBM spikes seen with silver staining (segments of GBM between dense deposits)
what medications can be used in lew body dementia?
Acetylcholinesterase inhibitors (e.g. donepezil, rivastigmine) can help alleviate the features of Lewy body dementia
what is the difference between loffler syndrome and lofgren’s syndrome
Lofgren’s syndrome is an acute form sarcoidosis characterised by bilateral hilar lymphadenopathy (BHL), erythema nodosum, fever and polyarthralgia.
Loeffler syndrome is when ascaris lumbricoides infects the lungs. transient CXR shadowing and blood eosinophilia. presents with a fever, cough and night sweats which often last for less than 2 weeks. Self limiting generally
what drugs do you avoid in renal failure?
Drugs to avoid in renal failure
antibiotics: tetracycline, nitrofurantoin
NSAIDs
lithium
metformin
how do you classify severity of UC?
mild: < 4 stools/day, only a small amount of blood
moderate: 4-6 stools/day, varying amounts of blood, no systemic upset
severe: >6 bloody stools per day + features of systemic upset (pyrexia, tachycardia, anaemia, raised inflammatory markers)
what is the management of stills disaease?
NSAIDs
should be used first-line to manage fever, joint pain and serositis
they should be trialled for at least a week before steroids are added.
steroids
may control symptoms but won’t improve prognosis
if symptoms persist, the use of methotrexate, IL-1 or anti-TNF therapy can be considered
what is the tx for pseudomonas infections?
Intravenous anti-pseudomonal antibiotic plus inhaled aminoglycoside for 14 days
A prolonged course of oral Ciprofloxacin (e.g. 6 weeks)
IV ceftazidime and nebulised tobramycin for 14 days
what is primary CNS lymphoma in HIV associated with and how is it treated?
associated with the Epstein-Barr virus
CT: single or multiple homogenous enhancing lesions
treatment generally involves steroids (may significantly reduce tumour size), chemotherapy (e.g. methotrexate) + with or without whole brain irradiation. Surgical may be considered for lower grade tumours
what are the drugs that may exacerbate myasthenia?
penicillamine
quinidine, procainamide
beta-blockers
lithium
phenytoin
antibiotics: gentamicin, macrolides, quinolones, tetracyclines
How long do you continue VTE for PE in provoked vs unprovoked?
if the VTE was provoked the treatment is typically stopped after the initial 3 months (3 to 6 months for people with active cancer)
if the VTE was unprovoked then treatment is typically continued for up to 3 further months (i.e. 6 months in total)
what is the Ix and treatment for carcinoid syndorme?
Investigation
urinary 5-HIAA
plasma chromogranin A y
Management
somatostatin analogues e.g. octreotide
diarrhoea: cyproheptadine may help
which disease is commonly assocaited with carcinoid tumours?
pellagra can rarely develop as dietary tryptophan is diverted to serotonin by the tumour
Pellagra is a rare condition in the United Kingdom but it is seen in patients with carcinoid syndrome. It is caused by a deficiency in vitamin B3, (Niacin) and classically presents as the ‘4 Ds’ dermatitis, dementia, diarrhoea and death. Niacin can be absorbed through the diet or converted in vivo from tryptophan. Patients with carcinoid syndrome are at increased risk as tryptophan stores are metabolised to serotonin.
what is HIT?
immune mediated - antibodies form against complexes of platelet factor 4 (PF4) and heparin –> induce platelet activation by cross-linking FcγIIA receptors
usually does not develop until after 5-10 days of treatment
despite being associated with low platelets HIT is actually a prothrombotic condition
what are you worried about if some one presents with confusion along with valproate use?
hyperammonemic encephalopathy - L-carnitine may be used as treatement
what is an absolute contraindication of elctroconvulsive therapy for depression?
Raised ICP
what medication should be considered for T1Dm for over 10 years?
statins
what condition is assciated with sjogren’s syndrome?
Primary biliary cholangitis
Who can you give lumacaftor/ivacaftor to in cystic fibrosis?
Lumacaftor/Ivacaftor (Orkambi) can be used to treat cystic fibrosis patients who are homozygous for the delta F508 mutation
What medications induce seizures or worsen seizure control?
The following drugs may worsen seizure control in patients with epilepsy:
alcohol, cocaine, amphetamines
ciprofloxacin, levofloxacin
aminophylline, theophylline
bupropion
methylphenidate (used in ADHD)
mefenamic acid
Some medications such as benzodiazepines, baclofen and hydroxyzine may provoke seizures whilst they are being withdrawn.
what is used to reduce ophthalmological complications of methanol poisoning?
folinic acid along with fomepizole
what are the surgical contraindications for non-small cell lung ca management?
assess general health
stage IIIb or IV (i.e. metastases present)
FEV1 < 1.5 litres is considered a general cut-off point*
malignant pleural effusion
tumour near hilum
vocal cord paralysis
SVC obstruction
How often do you need monitor changes to TFTs after changing a dose?
8-12 weeks
what dose of levothyroxine do you start elderly patients and those with ischaemic heart disease on?
25mcg
while everyone else needs to be started on 50-100mcg
what changes to levothyroxine do you need to make during pregnancy?
women with established hypothyroidism who become pregnant should have their dose increased ‘by at least 25-50 micrograms levothyroxine’* due to the increased demands of pregnancy. The TSH should be monitored carefully, aiming for a low-normal value
what are the side effects of thyroxine therapy?
- hyperthyroidism: due to over treatment
- reduced bone mineral density
- worsening of angina
- atrial fibrillation
what are the interactions of levothyroxine with other medications?
iron, calcium carbonate
- absorption of levothyroxine reduced, give at least 4 hours apart
what is the treatment for neuropathic pain?
Pregabalin first line
amitriptyline, duloxetine and gabapentin
Tramadol - used as rescue tehrapy for exacerbations
topical capsaicin may be used for localised neuropathic pain
carbamezapine - trigeminal neuralgia
what are the possible CT findiings of a carbon monoxide poisoning?
The ischaemic change on CT head, particularly in the globus pallidus with haemorrhagic transformation, a classic neurological consequence of carbon monoxide poisoning
what are the prognostic meds to uptritrate and start for someone with HF?
ACEi
beta blockers
spironolactone - if ejection fraction < 35%
SGLT2 inhibitors
what is the topical treatment for basal cell carcinoma?
imiquimod, fluorouracil
what are the features of cholestrol embolisation?
eosinophilia
purpura
renal failure
livedo reticularis
what the work up for thyroid nodules?
- Check TSH
- TSH suppressed → Thyroid uptake scan → Cold/iso nodule → FNA cytology
- TSH suppressed → Thyroid uptake scan →Hot nodule → No FNA required
- TSH normal/elevated → Thyroid USS → Suspicious features → FNA cytology
- FNA cytology is then graded using the Royal College of Pathologist classification on a spectrum from benign → malignant.
what when prescribed with SSRIs can trigger serotonin syndrome?
tramadol
St John’s Wort, often taken over the counter for depression, can interact with SSRIs to cause serotonin syndrome
what are the nerves affected in SOF vs carvenous sinus syndrome vs orbital apex syndorme?
SOF- Affects CN III, CN IV, CN V(1), CN VI
Carvenous sinus syndrome- Affects CN III, CN IV, CN V(1 &2), CNVI
Orbital apex syndrome- Affects CN II, CN III, CN IV, CN V(1), CN VI
i.e. Orbital apex syndrome is SOF plus visual loss
what are the different antibodies of limbic encephalitis associated with the different cancers?
NMDA receptor antibodies = ovarian cancer
Voltage-gated potassium channel antibodies = Thymoma or small cell lung cancer
Anti-Hu antibodies = Small cell lung cancer
Anti-GAD = Thymoma
anti-Ma2 antibodies = Germ-cell tumours of testis, non-small cell lung cancer
what is some possible treatment options
All children in developing countries should receive two dose of vitamin A.
replenishes the low levels of vitamin A caused be measles which can lead on to diarrhoea, corneal perforation and secondary bacterial pneumonia
