General Med Flashcards
CURB-65 score and consequent Rx?
Confusion
Urea >7
RR >30
BP
Common causes of hypercalcaemia?
Name 4
+ 2 drugs that uncommonly cause it?
Primary parathyroidism
PTH-like peptide malignancy
Multiple myeloma (osteolytic lesions on xray)
Secondary malignancy/ leukaemia
Thiazides + Lithium
In osteoporotic individuals what must be checked before commencing treatment?
Make sure vit D and calcium are up to normal levels otherwise medication can deplete it causing profound hypocalcaemia
Patient is given Zoledronic acid (IV bisphosphonate, given once a year), what must be checked afterwards?
U+Es - causes profound hypocalcaemia
Kneeling in wet cement can give rise to what sign on the knees?
‘Pizza knee’- very toxic
Most important initial test to do if suspecting giant cell arteritis?
Rx?
ESR
Prednisolone 60mg OD
60 year old lady presents with 2 weeks of morning stiffness and tenderness bilaterally in her shoulders and thighs. She has some aching of the joints, fatigue and anorexia as well.
Creatinine kinase is normal (why is this important) and CRP is raised.
Diagnosis and differential?
Polymyalgia rheumatica
Drug causes of high potassium?
PAACH
potassium sparing diuretics (amiloride, spironolactone)
ACE inhibitors (reduces aldosterone)
angiotensin 2 receptor blockers (reduces aldosterone)
ciclosporin
heparin
Aldosterone upregulates Na/K exchanger and epithelial Na channels for uptake, so if renin decreases it will too.
Drug causes of hyponatraemia?
C- PIST?
Via increased ADH- little PISTING
Carbamazepine anti-Psychotics (haloperidol) nsaIds SSRI Thiazide diuretics
What are the sepsis six?
Three out:
Urine output- hourly
Blood cultures
ABG- Lactate + Hb
Three in:
High flow O2
Antibiotics
Fluids
Drugs to avoid in renal failure
Accumulate: D-FOAMS
Digoxin, furosemide, opioids, atenolol, methotrexate, sulphonylureas
Avoid: cycle trofar said the lithe met (police)
tetracycline, nitrofurantoin, nsaids, metformin, lithium
Which drugs increase in concentration in liver disease due to reduced albumin?
Less albumin, less protein to bind the drug
Higher levels: phenytoin + prednisolone
In hepatic failure, which drugs worsen hepatic encephalopathy? (Da sock)
Diuretics Analgesics Sedatives Opioids Constipators K+ low
Which drugs worsen fluid retention for those with ascites and oedema in chronic liver disease?
NSAIDs
Corticosteroids
Which drugs increase in concentration in liver disease due to reduced albumin?
Less albumin, less protein to bind the drug
Higher levels: phenytoin + prednisolone
In hepatic failure, which drugs worsen hepatic encephalopathy? (Da sock)
Diuretics Analgesics Sedatives Opioids Constipators K+ low
Which drugs worsen fluid retention for those with ascites and oedema in chronic liver disease?
NSAIDs
Corticosteroids
If someone has hypertension, how do you work out what drop in blood pressure indicates sepsis?
Baseline - 40mmHg
What’s the difference between SIRS (systemic inflammatory response syndrome) and sepsis?
SIRS can occur from non-infectious causes: burns or pancreatitis etc
Sepsis is SIRS because of infection
What pupil changes occur in patients who have suffered a brain-stem stroke?
Pin-point pupils
How does achalasia and oesophageal cancer present differently?
Achalasia- difficulty swallowing liquids and solids together
Carcinoma- difficulty with solids then liquids + weight loss
Achalasia- lack of inhibitory ganglion cells needed for a relaxed sphincter
Name for deep breathing in metabolic acidosis?
Kussmaul’s sign
Occurs in DKA or aspirin overdose
Black sputum is called what?
What is it caused by?
Melanoptysis
As silica dust is deposited (ie in coal-workers), immune reaction = granulomas accumulate to make a fibrotic lesion, in the centre necrotic areas form that may lead to coughing up of black tissue.
What defines progressive massive fibrosis?
The presence of fibrotic nodules greater than 1cm in size.
Which cancers does asbestosis predispose you to?
Squamous cell carcinoma of the bronchus
Mesothelioma
Pleural plaques in the lung are characteristic of?
Asbestosis
A man works as an arc-welder, if iron oxide is deposited in the lung what will be seen on xray?
Siderosis
Fine nodules throughout lung fields, no fibrosis
Doesn’t cause SOB
How does the likely differential change depending on whether someone is coughing up blood stained sputum of frank blood?
Frank blood suggests pulmonary infarction
Blood stained sputum is more suggestive of a bronchial carcinoma or bronchiectasis
If someone vomits without any nausea first, how does this impact the likely diagnosis?
Suggests a central cause like a tumour or meningitis
What test can be used to confirm suspected EBV-pharyngitis?
Heterophile antibody test (monospot)
Good for ruling in, less good for ruling out
Patient has enlarged exudative tonsils and an enlarged spleen. Likely cause?
EBV (infectious mononucleosis)
Patient gets back pain on walking or hurrying, relieved by rest. Some sensory loss in her legs also. How would you decide between the two differentials?
Spinal stenosis (causing mechanical compression and ischaemia)- pt’s perform better on cycling than walking as it opens out the spine
Intermittent vascular claudication (atherosclerosis)- pt’s may have absent pulses and no difference between cycling and walking
Name for the white lacy pattern found on the papules in lichen planus?
Wickham’s striae
45 year old man who is itchy with excoriations but no focal areas and a large spleen. Likely cause?
Polycythaemia rubra vera
Other less likely causes = primary biliary cirrhosis, hypothyroidism, iron-deficiency anaemia
Itchy groups of blisters on extensor surfaces, back and buttocks In a 60 year old who has had chickenpox. Possible cause?
Dermatitis herpetiformis
Why does low calcium levels cause tetany?
Low calcium increases permeability of neuronal membranes to sodium, (as less calcium ions means the voltage needed to open sodium channels is less) leading to progressive depolarisation and increased action potentials
Examining a man after some trauma you note shifting dullness on the right flank and fixed dullness on the left flank. What injury does this suggest?
Splenic rupture
Left = coagulated blood retroperitoneal
Right = fluid blood in intraperitoneal space
Spleen is an intraperitoneal organ
Kehr’s sign is?
Referred pain to the left shoulder caused by splenic rupture and diaphragmic involvement
What is the name for the phenomena where closure of an AV fistula leads to BRAdycardia?
BRAnham’s sign: may be that consequent rise in BP activates baroreceptors to slow HR
If you are unsure if abdominal pain is coming from the intra-abdominal area or the abdominal wall what test can you do?
Carnett’s test:
lifting head up leads to increased pain as the abdo wall muscles tense if the cause is the abdo wall (ie rectus sheath haematoma)
What is the name for the sign when palpating the size of the liver, if the patient breathes in and winces and catches their breath as you press in?
Murphy’s sign- suggests more likely to be cholecystitis (gall bladder infection)
Rather than choledocholithiasis (bile duct stones), pyelonephritis and ascending cholangitis (bile duct infection)
Doch = duct
In aortic stenosis and aortic regurgitation, which is associated with a large volume and a small volume pulse?
AS- small volume (high resistance to overcome)
AR- large volume (filling from two sides of ventricle)
Palpable lymph nodes and blood count with a lymphocytosis and 30% abnormal mononuclear cells, what is the likely cause?
Infectious mononucleosis
May get hepatosplenomegaly
Which types of leukaemias does hepatomegaly occur in?
Chronic rather than acute
Meig’s syndrome?
Ovarian fibroma/tumour
+ ascites
= pleural effusion
Is ulcerative colitis associated with primary sclerosing cholangitis or primary biliary cirrhosis?
uC =
primary sClerosing Cholangitis
(p-anCa)
Watch out for Carcinoma of bile duct
What are the different antibodies associated with primary sclerosis cholangitis and primary biliary cirrhosis?
psC = p-anCa (perinueclear myeloperoxidase anti-neutrophil cytoplasmic Ab)
pbc = AMA (anti-mitochondrial)
How does a lump’s position relative to the femoral artery help to identify the likely cause?
NAV (lat to med)
lumps lateral to the femoral artery:
Why can testicular tumour present with gynaecomastia?
Via the production of HCG
If an eye is down and out, how does the ability to accommodate and react to light suggest possible causes?
If parasympathetic intact, likely to be diabetes or giant cell arteritis (sparing the peripheral nerve fibres)
If parasympathetics wiped out, it’s likely to be a posterior communicating artery aneurysm
Difference between Trousseau’s sign and Chvostek’s sign?
Both due to hypocalcaemia from hypoparathyroidism causing decreased threshold of excitation (Ca modulates VG Na channels)
Trousseau's = BP cuff for 5 mins, painful carpal spasm and thumb adduction. +ve sign if spasm relaxes 5s after deflating cuff Chovstek's = tap pre-auricular area and corner of mouth twitches
Commonest form of glomerulonephritis (associated with IgA)
Berger’s disease- mesangial proliferation
A with coeliac, ank spond + HIV
What’s the difference between berger’s and buerger’s disease?
Berger's = IgA deposits in glomerulus leading to glomerulonephritis Buerger's = vasculitis of arteries and veins with thromboses leading to ischaemia, triggered by tobacco compounds
Name for the syndrome where tumour on one temporal lobe causes optic atrophy ipsilaterally (due to optic nerve iscahemia) and contralaterall papilloedema (due to raised intracranial pressure)?
Foster Kennedy Syndrome
Nelson’s disease?
Pituitary tumour causing bitemporal hemianopia + Cushing’s syndrome (excess ACTH)
What is the name of the disease where there is blockage of the aorta as it forms common iliac arteries leading to reduced femoral pulses and claudication of buttocks and thigh?
Leriche’s syndrome
Finding TB in the vertebrae of the spine is known as what disease?
Pott’s disease
What is vincent’s angina?
Acute necrotizing infection of the pharynx caused by bacteria (spirochete + fusiform bacilli) that lead to ulceration and pain, requires debridement
Drugs causing long QT?
As MESH
Amiodarone (class 1a anti-arrhythmic) Sotolol (class 1a anti-arrhythmic) Methadone Erythromycin SSRI Halopreidol
Which drugs might you consider prescribing gout prophylaxis for, aka allopurinol?
Cytotoxics or diuretics
What does B3 deficiency cause?
3 things, that are not nice (niacin = B3)
Dermatitis
Diarrhoea
Dementia
What does B1 deficiency cause?
Beriberi (or should I say ber1ber1)
Is this thigh mine? (B1 = thiamine) they get peripheral neuropathy
Wet = heart failure Dry = neuropathy, Wernicke's (cerebellar damage), Korsakoffs (memory impairment)
What does B6 deficiency cause?
Six = sux = pyridoXine
S for seizures
I for irritability
X for 0 Hb
Causes of low glucose on a tap of pleural effusion?
low glucose: rheumatoid arthritis, tuberculosis
Causes of a high amylase on a tap of a pleural effusion?
raised amylase: pancreatitis, oesophageal perforation
Causes of heavy blood staining of a tap of pleural effusion?
heavy blood staining:
mesothelioma,
pulmonary embolism,
tuberculosis
HACEK organisms causing endocarditis rarely, that will be culture -ve?
Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella
The combination of right upper quadrant pain in the abdomen, jaundice (raised bili) and temperature suggests what diagnosis?
Charcot's triad: Ascending cholangitis (infection of bile duct)
LUQ pain after a road traffic accident, what is the most likely serious diagnosis to consider?
Splenic rupture
Commonest malignant cause of para-neoplastic ADH production?
Small cell lung cancer
How does management of pneumothorax differ if you are over or under 50?
If under 50 aspirate if rim of 2cm air on Xray or SOB
If over 50 aspirate any pneumothorax, but if rim of 2cm on xray or SOB put in a chest drain.
How do you stratify severity of aspirin overdose?
Serum levels 150mg/kg = mild 250mg/kg = moderate 500mg/kg = severe 700mg/kg = likely fatal
What can cause a more mildly raised amylase than pancreatitis?
Cholecystitis
Mesenteric infarction
GI perforation
What features are used to determine severe pancreatitis?
After 48 hours, presence of 3 of these: PaO2 55 years Neutrophilia WBC >15 Calcium 16mmol Enzymes- LDH >600iU or AST >200 Albumin 10mmol
Most useful investigation for abdominal masses?
Abdo CT
Which 3 signs indicate appendicitis?
- Rovsing’s sign- greater pain in RIF when LIF is pressed
- Psoas sign- pain on extending hip (if retrocaecal appendix)
- Cope sign- pain on flexion and int rotation of right hip
How does appendicitis present in over 80s?
Confusion and shock
Rather than pain
What features in the history make an acute abdomen be more likely to be mesenteric adenitis over appendicitis?
Recent viral illness + lymphadenopathy
Abx to give prior to appendectomy?
Cefuroxime + metronidazole
Where is pain somatically referred in the different divisions of the gut?
Up to 2nd part of duodenum- epigastrium
To 2/3rd of transverse colon- periumbilical
After 2/3rd of tranverse colon- suprapelvic
Medical Rx for thyrotoxic storm?
Propranolol (if no asthma or poor CO)
Digoxin
Carbimazole
Hydrocortisone (blocks T4 to T3 conversion)
Phaeochromocytoma Rx?
a-blocker (Phentolamine IV) to control BP
Switch to long acting a-blocker when BP is controlled (phenoxybenazime)
Then b1-blocker for tachycardia or dysrhythmias
Surgery
What triggers each fever paroxysm in malaria?
Flocks of merozoites released from mature schizonts in the liver
What are the 5 grim signs in malaria?
Coma Convulsions Co-existing chronic illness ACidosis Crash of the kidneys (Renal failure)
Rx for uncomplicated benign malaria (P ovale, vivax, malariae)?
Chloroquine
Primaquine for ovale or vivax, CI: pregnancy
Uncomplicated falciparum malaria Rx?
Artemesinin derivatives (Artesuante, artemether...) \+ another drug (amodiaquine, napthoquine)
Severe falciparum malaria Rx?
IV artesunate
Or quinine
Mutation in sickle cell causing the abnormalities?
Glutamine to valine at position 6 = HbS rather than HbA
Definitive IHx for sickle cell and the different types of Hb variants?
Hb electrophoresis
Blood film will show sickle cells and target cells but not whether someone is homozygous, heterozygous or has other Hb variants
In children under what age can a vaso-occlusive crisis of the hands or feet lead to dactylitis (swelling of digit)?
Under 3s
IHx to determine if a child with sickle cell is at risk of a stroke and Rx if so?
Doppler ultrasound
Rx: blood transfusions
Common trigger of aplastic crisis in sickle cell patients?
Parvovirus B19
What paO2 would prompt referral to ITU in someone with acute chest syndrome secondary to sickle cell?
IHx to diagnose typhoid infection (salmonella typhi or paratyphi)?
Blood culture (10+ve for 10 days of infection) Urine + stool culture
Marrow culture
Rx for typhoid (salmonella typhi- fever, relative bradycardia, cough…)
Ciprofloxacin
Ceftriaxone if not working
Difference between true aneurysm and pseudoaneurysm?
True- involves all the layers of the wall
Pseudo- blood collects in the outer layer (adventitia)
The AAA screening programme is for what age of men?
65 years
How big does a vessel need to be to classify as an AAA?
> 3cm across
What criteria make an AAA qualify for elective surgery?
> 5.5cm
Symptomatic
Expanding >1cm/year
IHx for TB?
Lung TB: 3 sputum samples (one early morning) for MC+S for Ziehl- Neelsen stain
May need bronchoscopy + lavage
PCR for rifampicin resistance
Non lung TB: culture samples on Lowenstein-Jensen medium
What do different skin reactions to the Tuberculin test indicate in TB?
+ve = immunity, past exposure or BCG
Strong +ve = active TB infection
-ve = immunosupressed
Which TB drug causes reversible ocular toxicity (so it’s worth checking colour vision before starting)?
Ethambutol (begins with an e for eye)
For TB meningitis, how long should you vontinue treatment for?
12 months
Which TB drug causes peripheral neuropathy (responsive to vit B6)?
Isoniazid
Also drug-induced lupus
Rx of meningitis in community, a+e and prophylaxis for contacts?
Community- benzylpenicillin IM
A+E- ceftriaxone IV
Contacts- rifampicin 2ds or ciprofloxin
How does Rx differ for meningitis in over or under 55s?
Under 55- cefotaxime IV
Over 55- cefotaxime + ampicillin IV (for listeria)
Which infections can trigger a Guillain Barre syndrome?
Campylobacter jejuni
CMV, EBV
Mycoplasma, zoster
HIV
IHx to determine MRSA status?
Swabs from nose and groin
Rx for MRSA infection?
Teicoplanin or Vancomycin (glycopeptides- inhibit cell wall peptidoglycan synthesis)
Which medication can cause achilles tendonitis, putting as risk of rupture?
Ciprofloxacin
When can’t you give nitrofurantoin for a UTI?
Renal impairment
Pregnancy 3rd trimester
Can cause pulmonary fibrosis
Which form of hepatitis can you not be vaccinated against?
Hepatitis C
Which hepatitis is a DNA virus?
Hepatitis B
All the others are RNA
Hep D is incomplete RNA
Hep C is an RNA flavivirus
How can you monitor response to therapy in hepatitis b?
HBV PCR
What proportion of those with hepatitis C develop chronic infection?
85%
Leading to cirrhosis and hepatocellular cancer
Hepatitis C Rx?
Serine protease inhibitors (end in -previr)
+ ribavirin
+ PEG interferon a
ST elevation and +ve troponin in a young patient with recent hepatitis and chest pain/fever?
Acute myocarditis-
Which valve tends to get infected in endocarditis in IV drug users?
Tricuspid valve- following venous route into the heart following injections
In the peripheral stigmata of endocarditis, which is due to immune complex deposition and which is due to emboli?
Osler’s nodes (painful pulp infarcts) due to immune complex deposition
Janeway lesions (painless palmar) due to emboli
Which type of echo is most sensitive for detecting valve vegetations?
Transoesophageal is more sensitive and specific than transthoracic and better if prosthetic valves
Rx for blind native valve infective endocarditis compared to prosthetic valve?
Native: Amoxicillin + gentamycin
Prosthetic: Vancomycin + gentamycin + rifampicin
Likely gram -ve: meropenem + gentamycin
(Gent is ear and renal toxic)
Difference between Rx for a staph infection on a native valve Vs prosthetic valve?
What about for MSRA?
Infective endocarditis
Native: flucloxacillin IV
Prosthetic: flucloxacillin + rifampicin + gentamycin
MRSA native: vancomycin + rifampicin
MRSA prosthetic: vancomycin + rifampicin + gentamycin
IHx and Rx for a patient who has been getting muscle weakness and diplopia at the end of the day despite being cleared in a recent optician’s test?
IHx: single fibre electromyography
+ CT thorax to exclude thymoma (15%)
Rx:
Long-acting anticholinesterase (pyridostigmine)
How many +ve samples are needed for a diagnosis of ‘persistent non-visible haematuria’?
2/3 urine samples taken at least 2 weeks apart
Gold standard for diagnosing osteomyelitis in someone with a tender red area?
gold: Bone biopsy + culture
MRI is more sensitive and specific than isotope bone scan
Blind Rx and pseudomonas Rx of osteomyelitis?
Debride necrotic fragments then:
Vancomycin + cefotaxime IV for 6 weeks
Pseudomonas: ciprofloxacin
Best imaging to identify bone TB?
PET scan
Abx causing cholestasis and jaundice?
From my pen, I flew in a pro flux nit-so-far
Penicillins
Flucloxacillin
Ciprofluxacillin
Nitrofurantoin
Abx causing prolonged QT
+ what is the risk of?
Long QT > torsades de pointes
From macrolides + quinolones
Organism implicated in endocarditis and colorectal cancer?
Strep bovis
Which TB drug may precipitate gout?
Isoniazid
What renal and rheum problems is hepatitis B associated with?
Rheum- polyarteritis nodosa (aneurysms + thrombosis = infarction, rash + ulcers)
Renal- membranous glomerulonephritis (nephrotic syndrome)
Inferior nSTEMI looks like what on ECG?
ST depression in leads II, III, aVF
Why not give O2 if a patient has 02 sats above 96%?
May cause coronary angiospasm
What would you be concerned about if a patient was on Metformin and had an acute coronary syndrome?
Lactic acidosis due to poor perfusion from heart
Two main causes of congestive cardiac failure?
Low output- damage to muscle (MI, viral myocarditis, amyloid, dilated CM)
High output- too much fluid for the heart to pump out (kidney disease, transfusion)
Patient is in acute heart failure, if you want to give nitrates what should you consider (can be a CI)?
That systolic BP > 100mmHg
In acute heart failure, what investigations would be useful?
BNP- check ventricular strain
TTE- check if its systolic, diastolic, EF etc
Which electrolytes need to be corrected in Digoxin overdose?
K+ and Mg2+
What is the main problem in Digoxin overdose?
Bradyarrhythmias- need IV atropine to up heart rate
What blood levels of Digoxin warrants Digibind (antibody) in overdose?
13nmols = severe
What dose of paracetmol when taken is potentially fatal?
More than 12g
Depends on body weight
Which kind of people might have lower glutathione stores making paracetamol toxicity worse in overdose?
Malnutrition, cachexia
Alcoholic liver disease
HIV
P450 inducers (phenytoin, carbamazepine, st johns wort etc)
Which single investigation in most appropriate to indicate liver failure?
Prothrombin time (synthetic function of the liver)
But
ALT over 1000IU indicates toxicity
Inferior nSTEMI looks like what on ECG?
ST depression in leads II, III, aVF
Why not give O2 if a patient has 02 sats above 96%?
May cause coronary angiospasm
What would you be concerned about if a patient was on Metformin and had an acute coronary syndrome?
Lactic acidosis due to poor perfusion from heart
Two main causes of congestive cardiac failure?
Low output- damage to muscle (MI, viral myocarditis, amyloid, dilated CM)
High output- too much fluid for the heart to pump out (kidney disease, transfusion)
Patient is in acute heart failure, if you want to give nitrates what should you consider (can be a CI)?
That systolic BP > 100mmHg
In acute heart failure, what investigations would be useful?
BNP- check ventricular strain
TTE- check if its systolic, diastolic, EF etc
Which electrolytes need to be corrected in Digoxin overdose?
K+ and Mg2+
What is the main problem in Digoxin overdose?
Bradyarrhythmias- need IV atropine to up heart rate
What blood levels of Digoxin warrants Digibind (antibody) in overdose?
13nmols = severe
What dose of paracetmol when taken is potentially fatal?
More than 12g
Depends on body weight
Which kind of people might have lower glutathione stores making paracetamol toxicity worse in overdose?
Malnutrition, cachexia
Alcoholic liver disease
HIV
P450 inducers (phenytoin, carbamazepine, st johns wort etc)
Which single investigation in most appropriate to indicate liver failure?
Prothrombin time (synthetic function of the liver)
But
ALT over 1000IU indicates toxicity
Name the effects of PTH on bone, intestine and kidneys?
Bone- increases # osteoclasts
(Although if giving recombinant PTH, a sudden burst activates osteoblasts more than osteoclasts for bone deposition)
Kidneys- increases Ca reabsorption, inhibits P04 reabsorption
Intestine- no direct effects, but increases Vit D production
Name the effects of Vit D on bone, kidney and intestine:
Bone- increases #osteoclasts
Kidney- increases Ca and + P04 reabsorption
Intestine- increases Ca and P04 absorption
Name the effects of Calcitonin on bone, kidney and intestine:
From C cells in the thyroid
Bone- shrinks osteoclasts
Kidney- increases Ca excretion at supra-physiological levels
Intestine- no effect
Low magnesium prevents release of which hormone?
PTH
=hypocalcaemia
Calcium is high, P04 is normal, how does PTH level impact your suggested diagnosis?
If high it is likely to be primary or tertiary (CKD) hyperparathyroidism
If low, it is being suppressed by something- like PTHrP and is more likely to be malignancy (bone mets, myeloma, sarcoid, thyrotoxicosis)
To rule out familial benign hypocalciuric hypercalcaemia, what IHx should be done?
24 hour urinary Ca excretion
= defect in calcium-sensing receptor means the body’s baseline is naturally higher
