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General Medicine Flashcards

1
Q

What diseases does Raynaud’s present in?

A

SLE
Poly myosotis
Dermatologists

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2
Q

What diseases are associated with ankylosing spondylitis?

A

Crohn’s

Ulcerative colitis

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3
Q

What are the differentials for a monoarthritis?

A

Septic
Crystal
OA
Trauma

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4
Q

Which conditions can cause an asymmetrical arthritis?

A

Reactive

Psoriatic

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5
Q

When should you aspirate a joint?

A

Any monoarthritis

Apart from inflamed/potentially infected skin e.g. Psoriatic plaque

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6
Q

How does a diagnosis of RA affect lifespan?

A

Women - 7y decrease

Men - 4y decrease

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7
Q

Why is RA associated with a decreased lifespan?

A

Cardiovascular risk
Infections
Lymphoma

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8
Q

What is the genetic link of RA?

A

Increased incidence in 1st degree relatives

Polymorphism of HLA Class II genes

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9
Q

How does RA lead to inflammatory arthritis?

A

Immune response triggers inflammation
Local production of inflammatory cytokines (esp. TNF-alpha and IL-1) causes amplification of inflammation
Synovial tissue proliferates and erodes the joint causing pannus formation
Activated macrophages in pannus produce collagenases & proteinases
Cartilage is eroded and this leads to joint instability and deformity

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10
Q

In what order are joints commonly affected in RA?

A

Small joints first - hands and feet

Larger joints later

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11
Q

What does the presence of rheumatoid nodules indicate?

A

Severe arthritis and risk of extra-articulate disease

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12
Q

What are the X-Ray features of RA?

A

Symmetrical. Spares DIPJs
Early: soft tissue swelling and osteopenia
Strophic bone erosions - peri articulate bare areas
Later: joint space narrowing

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13
Q

What is the imaging method of choice in early arthritis?

A

Ultrasound or MRI

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14
Q

What is DAS in RA?

A

Disease Activity Score

Incorporates ESR/CRP, counts of swollen/tender joints, fatigue, radio graphic findings and limitation of function

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15
Q

What are the diagnostic criteria for RA?

A 
Need at least 4 of...
Morning stiffness
Arthritis of 3 or more joints
Arthritis of hand joints
Symmetrical
Rheumatoid nodules
Serum Rheumatoid Factor
Radiographic changes
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16
Q

What is Rheumatoid Factor?

A

Antibody directed against IgG

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17
Q

What is anti-CCP?

A

Antibody, binds to CCPs in synovial and has a pathogenic role

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18
Q

What are the principles of management of RA?

A

Symptomatic relief
Modification of underlying disease
Adjunctive therapy with steroids (flare-ups)
Biological agents

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19
Q

What are the indications for DMARD use?

A

Persistent/progressive disease despite regular NSAIDs

Erosive disease on X-Ray

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20
Q

How long do DMARDs take to work?

A

2-3 months

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21
Q

What is the range of doses of methotrexate?

A

7.5 - 25mg per week

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22
Q

What are the side effects of methotrexate?

A 
Myelosuppression
Pneumonitis
Pulmonary fibrosis
Mucositis
Diarrhoea, nausea, vomiting
Hepatotoxicicity
Teratogenic
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23
Q

What is the diagnosis when TSH is raised but T4 is low?

A

Hypothyroidism

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24
Q

What is the differential when TSH and T4 are both raised?

A

Thyroid-secreting tumour

Thyroid hormone resistance

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25
What is the diagnosis when TSH is low but T4 & T3 are both normal?
Sub clinical hyperthyroidism
26
What is sick euthyroidism?
Thyroid tests may be abnormal
27
What monitoring is required with methotrexate?
Regular FBC, LFT, UEs and creatinine | Baseline CXR
28
What are the effects of sulfasalazine on T cells?
Inhibits proliferation | Inhibits IL-2 production
29
What are the effects of sulfasalazine on neutrophils?
Reduced chemotaxis and degranulation
30
What are the side effects of sulfasalazine?
``` Nausea Headache Dizziness Rash Infrequent: myelosuppression and heptatoxicity ```
31
Which DMARDs are safe in pregnancy?
Sulfasalazine | Hydroxychloroquine
32
What conditions is hydroxychloroquine used to treat?
RA and SLE
33
What is hydroxychloroquine?
Anti-malarial | Inhibits toll-like receptors to reduce inflammation
34
What are the side effects of azathioprine?
Myelosuppression Infrequent hepatotoxicity Flu-like illness at onset of therapy
35
Name 2 anti-TNF agents
Infliximab | Etanercept
36
Name an anti B cell agent
Rituximab
37
Which patients are currently eligible for treatment with biological agents?
Clinically active RA Failure of standard therapy with at least 2 DMARDs Withdrawn if ADR or no response at 6 months
38
How does psoriatic arthritis present?
Asymmetrical large joint oligoarthritis Skin lesions/psoriatic nail changes Dactylitis
39
How is the Achilles affected in psoriatic arthritis?
Enthesitis seen on USS or MRI
40
How is psoriatic arthritis managed?
NSAIDs Physio/OT Dermatologists - methotrexate may be helpful when skin is badly affected Anti-TNF
41
What is the epidemiology of ankylosing spondylitis?
Typically
42
How does ankylosing spondylitis present?
Low back pain & stiffness, improved with exercise and not relieved by rest SIJ tenderness Fatigue, weight loss & low grade fever
43
What are the key investigations for ankylosing spondylitis?
CRP/ESR - raised in half of patients HLA B27 - Not a screening test as 8% all British makes carry it. Only 20% of those with B27 have ank spond MRI, CT or x-Ray affected area
44
How is ankylosing spondylitis managed?
Exercise and physio NSAIDs DMARDs if peripheral synovitis
45
What are the types of diabetic retinopathy?
Macular Pre-proliferation Proliferative
46
What is a reactive arthritis?
An aseptic inflammatory arthritis | Precipitated by a distant infection
47
What infections commonly cause reactive arthritis?
``` Non-bonobo cal urethritis/cervicitis Acute diarrhoea Chlamydia trachomatis Campylobacter Salmonella ```
48
What is Reiter's syndrome?
Classic triad... Urethritis Conjunctivitis Arthropathy
49
How do you manage reactive arthritis?
Bed rest Intra-articulate steroids NSAIDs
50
Define osteoporosis
Quantitative decrease in bone matrix components | I.e. Too little bone, but what there is is normal
51
What are the risk factors for osteoporosis?
``` Smoking Alcohol Steroid use Sedentary lifestyle Family history Lean body type ```
52
What endocrine disorders cause osteoporosis?
``` Gonadal insufficiency Hyperparathyroidism Hyperthyroidism T1DM Crushing's ```
53
What GI disease can cause osteoporosis?
``` IBD Chronic liver disease Eating disorders Coeliac disease Malabsorption ```
54
When is bone protection required with steroids?
Prednisolone >5mg daily for >3 months | & either over 65 or T score
55
What are the indications for DEXA scanning?
Predict fracture risk Confirm diagnosis of osteoporosis where there is evidence of osteopenia on radiographs Planned steroid use >5mg for >3 months and age >65
56
What is the T score?
Number of standard deviations away from the mean of a young person of the same gender and ethnicity Measures risk of future fractures
57
How is the T score used to define osteoporosis?
58
What is the Z score?
Number of standard deviations away from an age, gender and weight-matched population
59
What is the FRAX tool?
Gives probability of hip/major osteoporotic fractures integrating clinical factors and Bone mineral density
60
What is the action of bisphosphonates?
Reduce osteoclasts function and ultimately cause their apoptosis
61
What is Fosamax?
Alendronate (bisphosphonate)
62
How can you pharmacologically stimulate bone formation?
Give synthetic PTH analogue e.g. Teriparatide
63
What is the most common cause of osteomalacia in the UK?
Calcium or Vitamin D deficiency
64
What are the causes of calcium and vitamin D deficiency?
Dietary Poor sun exposure Gastrectomy Malabsorption
65
What are the biochemistry results like for someone with osteomalacia?
``` Low phosphate Low calcium Raised alk phos Low vit D High PTH ```
66
What is responsible for Gout?
Monosodium urate monohydrate crystals
67
How does urate affect gout?
Hyperuricaemia increases risk of attacks Normal urate levels during an attack don't exclude gout
68
What are the risk factors for gout?
``` Family history Excess alcohol Diuretics Renal disease Ciclosporin and tacrolimus Chemotherapy for malignancy Diet ```
69
What joints does gout commonly affect?
``` MTPJs Mid foot Ankles Knees Olecranon bursa ```
70
What are the diagnostic criteria for gout?
``` At least 2 of... Typical history Tophi Raised serum urate Crystals in joint during attack ```
71
What do urate crystals look like?
Needle-shaped | Strongly negatively birefringent
72
What are the X-Ray features of gout?
Soft tissue swelling | Opacities due to Tophi
73
How do you treat acute attacks of gout?
NSAIDs Colchicine - reduces neutrophil chemotaxis Corticosteroids
74
What are the indications for prophylaxis of attacks in gout?
2-3 acute episodes per year Tophi and erosions present Renal impairment/stones
75
What is used as prophylaxis in gout?
Allopurinol
76
What is the mechanism of action of allopurinol?
Xanthippe oxidase inhibitor - prevents conversion of purine to uric acid
77
What is responsible for pseudogout?
Calcium pyrophosphate dehydrate
78
What areas are commonly affected in pseudogout?
Knees Wrists Shoulders Hips
79
How do you manage pseudogout?
``` Aspiration Injection NSAIDs Colchicine No prophylaxis ```
80
What comprises mixed connective tissue disease?
Systemic sclerosis & SLE & vascular disease
81
What does systemic sclerosis consist of?
Scleroderma (skin fibrosis) & vascular disease
82
What is CREST syndrome?
``` Calcinosis Raynaud's oEsophageal & gut dysmotility Sclerodactyly Telangiectasia ```
83
What is diffuse cutaneous systemic sclerosis?
Whole body may be involved Organ fibrosis occurs early Lots of skin fibrosis
84
How do you manage systemic sclerosis?
No cure Immunosuppression if there is organ involvement or progressive skin disease Control BP Monitor renal function
85
What is Sjögren's syndrome?
Inflammation and fibrosis of exocrine glands Affects tear production, salivation plus other systemic features
86
What are the systemic features of Sjögren's syndrome?
``` Polyarthritis Raynaud's Lymphadenopathy Vasculitis Lung, liver and kidney involvement Peripheral neuropathy Myosotis Fatigue ```
87
What are the signs of dermatomyositis?
``` Macular rash Heliotrope rash Nail fold erythema Gottron's papules on knuckles and elbows Subcutaneous calcification ```
88
How does polymyositis present?
Progressive symmetrical proximal muscle weakness Myalgia & arthralgia Can lead to dysphagia, dysphonia or resp muscle weakness
89
How does SLE typically present?
Non-specific: malaise, fatigue, myalgia and fever | Can mimic other systemic diseases
90
What parameters are used to monitor SLE disease activity?
Anti-dsDNA titres Decreased C3 and C4 ESR raised (CRP normal in SLE)
91
How do you diagnose fibromyalgia?
Pain >3 months, both left and right sides occurring above and below the waist
92
What are the symptoms of giant cell arteritis?
``` Headache Temporal artery and scalp tenderness Jaw claudication Amaurosis fugax Sudden blindness ```
93
What is the treatment for GCA?
Mostly steroids - start immediately if GCA suspected to prevent irreversible blindness
94
What is Wegener's granulomatosis?
Granulomatosis with polyangitis | Vasculitis of small/medium sized vessels
95
In what disease are anti-Jo antibodies found?
Polymyositis
96
What disease is found in 50% of patients with GCA?
Polymyalgia rheumatica
97
What are the features of Polymyalgia rheumatica?
>50y Shoulders and proximal limb muscles: aching, tenderness, morning stiffness NO weakness Fever, weight loss, fatigue, anorexia and depression
98
What are the blood results like in PMR?
Raised CRP and ESR | CK levels normal
99
What are the 5Rs of IV fluid therapy?
``` Resuscitation Routine maintenance Replacement Redistribution Reassessment ```
100
What is fluid resuscitation?
Fluids given urgently to restore circulation in hypovolaemia or fluid and electrolyte loss E.g. Bleeding, dehydration, sepsis
101
When if IV fluid used for routine maintenance?
When patients can't take fluids orally or enterally but have no deficits or ongoing losses
102
When is fluid replacement needed?
Not urgent but required on top of routine maintenance to correct losses or meet abnormal ongoing losses E.g. GI losses, fever, burns
103
When is IV fluid required for redistribution?
When there are marked internal distribution changes or abnormal fluid handling E.g. Sepsis, post-op, cardiac, liver or renal comorbidity
104
What proportion of body weight is water?
60%
105
How is total body water affected by obesity?
Lower % of body weight is water as adipose contains less water than lean tissue
106
How is body fluid divided between intra- and extra cellular compartments?
One thirds extracellular | Two thirds intracellular
107
What ions are mainly responsible for ECF osmolality?
Sodium Chloride Bicarbonate
108
What proportion of the ECF is intravascular?
A quarter
109
What is the intravascular volume dependent on?
Plasma on comic pressure - mainly due to albumin
110
What is the normal range for plasma albumin?
35-52g/L
111
What is the starling effect?
Hydrostatic pressure in capillaries drives fluid out | Oncotic pressure of plasma proteins draws fluid back in
112
What is the internal fluid balance?
Constant flow of fluid and electrolytes between the ECF and the GI tract
113
How much water is required per kg per day?
25 ml / kg / day
114
What is the physiological osmolality of plasma?
280 - 290 mOsm/kg
115
What is the volume obligatoire?
The minimum amount of urine needed to excrete waste products About 500ml
116
How much does ECF need to be expanded by before oedema becomes an issue?
2 - 3 L
117
What is the urine : plasma urea ratio?
Osmolality ratio | Measure of the concentrating capacity of the kidney, in the presence of a water deficit
118
What is the normal range for plasma potassium?
3.5 - 5.3 mmol/L
119
How does hypokalaemia lead to further electrolyte disturbances?
Renal H+ reabsorption impaired to increase K+ Causes alkalosis Decreased ability to excrete Na+ causes hypernatraemia
120
How is ADH affected by disease?
Levels increased Retention of water
121
How much sodium is in normal saline?
154mmol/L
122
By what proportion does normal saline expand blood volume?
A quarter to a third
123
What are glucose solutions useful for doing?
Providing free water as it is distributed throughout total body water
124
What is the risk with giving too much glucose solution?
Hyponatraemia if too much given too quickly
125
Name a commonly used synthetic colloid
Hydroxymethyl starch (HES)
126
How do you give fluid resuscitation?
Rapid infusion (in less than 15mins) of 500ml boluses Repeat as necessary until markers of volume status improve
127
How much glucose is used for routine maintenance?
50-100g per day
128
Who should you prescribe 20-25ml/kg/day fluid to?
Elderly/frail Renal impairment/cardiac failure Malnourished - at risk of referring syndrome
129
How do you assess fluid status clinically?
``` Blood pressure Fluid balance chart Peripheral/pulmonary oedema CRT Skin turgor Heart rate Resp rate Mucous membranes UEs JVP Thirst EWS ```
130
What are the indications for fluid resuscitation?
Systolic 90 Cap refill >2s RR >20 EWS >5
131
How should you calculate fluid requirements for an obese patient?
Based on their ideal weight not their actual weight
132
How should you aim to increase sodium in a hyponatraemic patient?
No more than 3-5mmol/day
133
What is the normal range for blood glucose?
3.3 - 6 mmol/L
134
What is melaena?
Passage of black, tarry, foul-smelling stools
135
What is haematochezia?
Blood in the stools
136
What are the causes of pale stools?
Hepatitis Gallbladder disorders Malabsorption conditions
137
What is steatorrhea?
Fatty stool Sticky and difficult to flush Malabsorption syndromes
138
How should you investigate iron deficiency anaemia?
1st colonoscopy - more sinister potential causes Upper GI endoscopy next if nothing found
139
What are the indications for an abdominal X-ray?
Acute abdominal pain Small or large bowel obstruction Acute exacerbation of IBD Renal colic
140
What diameters show bowel obstruction?
Small bowel >3cm Large bowel >6cm Caecum >9cm
141
What is the difference between Haustra and valvulae conniventes?
Haustra are in the large bowel and only go part way across the wall VCs are small bowel and go all the way across the wall
142
What is the main cause of small bowel obstruction?
Adhesions
143
What is the main cause of large bowel obstruction?
Colorectal cancer
144
How do you tell if the ileocaecal valve is competent on AXR and why is it significant?
If there is gas in the small bowel as well when the large bowel is obstructed Perforation more likely if valve is competent: pressure higher in the large bowel if gas can't flow back into the small bowel too
145
What is the coffee bean sign on abdominal X-ray?
Sigmoid volvulus starting in left iliac fossa and extending towards the right upper quadrant
146
What is the main indication for AXR in inflammatory bowel disease?
Suspected toxic mega colon
147
What is lead-pipe colon?
Chronic ulcerative colitis leading to loss of normal architecture
148
What is thumb-printing on abdominal X-ray?
Really thick haustra Can result from anything causing oedema of the colon, but is classic of IBD
149
What is the flaciform ligament sign?
Indicates perforation - you only ever see the flaciform ligament when there's gas either side of it
150
How many calories are there in 1g of protein?
4kcal
151
How many calories are there in 1g of carbohydrate?
4kcal
152
How many calories are there in 1g of fat?
9kcal
153
What is the daily calorie requirement per kg?
25kcal per kg
154
What does vitamin A deficiency lead to?
Blindness - vit A needed for retina
155
What is vitamin C needed for?
Immune system | Collagen synthesis
156
What is vitamin D needed for?
Calcium absorption Bones
157
How does starvation cause malnutrition?
Hormone levels drop and lipase levels rise Burn fat for energy - so lose fat
158
How does illness cause weight loss?
No time to adjust and increase lipase levels All glucose and glycogen used first Muscle broken down to provide glucose So you lose muscles
159
What are the daily fluid requirements for an average person?
25 ml/kg/day
160
What does TPN provide?
Macro and micronutrients Minerals Fluid
161
How many calories does 1unit of alcohol provide?
56kcal
162
What are the causes of scurvy?
Vitamin C deficiency Poor, pregnancy or strange diet
163
What are the signs of scurvy?
``` Anorexia & cachexia Gingivitis Loose teeth Smelly breath Bleeding from gums, nose, hair follicles Muscle pain and weakness Oedema ```
164
What is Beriberi disease?
Vitamin B1 / thiamine deficiency
165
How do you treat beriberi?
Give thiamine urgently May lead to wernicke's encephalopathy
166
What is pellagra disease?
Lack of nicotinic acid Triad: diarrhoea, dementia, dermatitis
167
What is xerophthalmia?
Vitamin A deficiency Dry conjunctivae Corneas cloudy and soft
168
How does malabsorption present?
``` Diarrhoea Weight loss Lethargy Steatorrhea Bloating ```
169
What are the main causes of malabsorption in the UK?
Coeliac disease Chronic pancreatitis Crohn's disease
170
What is the prevalence of coeliac disease?
1 in 300-1500
171
What is the pathophysiology of coeliac disease?
T-cell mediated autoimmune Affects small bowel Prolamin intolerance Causes villous atrophy and malabsorption
172
When are the peaks in incidence of coeliac disease?
Infancy | 50-60y
173
How do you diagnose coeliac disease?
Low Hb, B12 and ferritin Antibodies: alpha-gliadin, transglutaminase, anti-endomysial Duodenal biopsy
174
What are the complications of coeliac disease?
``` Anaemia Lactose intolerance GI T-cell lymphoma Increased risk of malignancy Myopathies/neuropathies Hyposplenism Osteoporosis ```
175
What are the causes of chronic pancreatitis?
``` Alcohol Haemochromatosis Pancreatic duct obstruction Hyperparathyroidism Congenital ```
176
How does chronic pancreatitis present?
``` Epigastric pain radiating to back Relieved by sitting forward or hot water bottles Bloating Steatorrhea Weight loss ```
177
What is the medical management of chronic pancreatitis?
``` Analgesia Lipase Creon (enzymes) Fat-soluble vitamins ? Insulin requirements ``` Diet: no alcohol and low fat
178
When is surgery indicated for chronic pancreatitis?
Unremitting pain Narcotic abuse Weight loss
179
What are the complications of chronic pancreatitis?
``` Pseudocyst Diabetes Biliary obstruction Aneurysm Splenic vein thrombosis Gastric varices Pancreatic carcinoma ```
180
What is the most common cause of upper GI bleeding?
Peptic ulcer disease
181
What are the common causes of upper GI bleeding?
``` Peptic ulcer disease Gastroduodenal erosions Oesophagitis M-W tear Varices Malignancy ```
182
How can you tell if a patient is shocked following upper GI bleed?
Cool/clammy with decreased capillary refill Pulse over 100 Systolic BP lower than 100 Urine output less than 30ml/h
183
What is the mortality rate from upper GI re bleeding?
40%
184
What are the alarm symptoms related to dyspepsia?
``` Anaemia Loss of weight Anorexia Rapid onset Melaena/haematemesis Swallowing difficulty ```
185
What are the risk factors for developing a duodenal ulcer?
H.pylori infection | Drugs e.g. NSAIDs, steroids, SSRIs
186
When is pain from a duodenal ulcer worst?
Before meals or at night, i.e. When the stomach is empty
187
How do you manage peptic ulcers?
1. Lifestyle - reduce smoking, alcohol and aggravating foods 2. H.pylori eradication (triple therapy) 3. Drugs to reduce acid secretion: PPIs or H2 antagonist 4. Surgery
188
What are the potential complications of peptic ulcers?
Bleeding Perforation Malignancy Gastric outflow obstruction
189
Define GORD
Reflux of stomach contents causing symptoms of heartburn, with more than 2 episodes per week
190
Give some causes of GORD
``` Hiatus hernia Abdo obesity Smoking or alcohol Overeating H.pylori Gastric acid hypersecretion Pregnancy ```
191
What are the potential complications of GORD?
``` Oesophagitis Ulcers Benign stricture Iron deficiency Barrett's oesophagus ```
192
What can cause oesophagitis?
``` Corrosives NSAIDs Herpes Candida Duodenal or gastric ulcer Cardiac disease ```
193
What are the conservative management measures for GORD?
``` Raise whole bed Weight loss Smoking cessation Small, regular meals Avoid hot/fizzy drinks, spicy food Don't eat within 3hours of going to bed ```
194
What is a sliding hiatus hernia?
Gastro-oesophageal junction slides up into chest Acid reflux may accompany
195
What is a rolling hiatus hernia?
Junction remains in abdomen Bulge of stomach herniated into chest alongside oesophagus Acid reflux uncommon (junction remains competent)
196
What type of hiatus hernia should be surgically repaired?
Rolling This can strangulate so repair prophylactically
197
What is the treatment for C.difficile colitis?
Metronidazole 400mg/8h Stop causative antibiotics
198
When is colectomy required for c.diff colitis?
Toxic megacolon Raised LDH Rapidly deteriorating
199
Define extensive UC
Extending beyond the splenic flexure
200
How does smoking affect ulcerative colitis?
Decreases incidence | May induce remission
201
How does smoking affect Crohn's?
Increases incidence
202
What are the cardinal symptoms of ulcerative colitis?
Bloody diarrhoea Urgency Tenesmus
203
Define mild ulcerative colitis
Fewer than 4 stools per day No systemic features
204
Define severe ulcerative colitis
More than 6 stools per day + blood + systemic features
205
What are the extra-intestinal features of UC that are related to the disease activity?
Erythema nodosum Aphthous ulcers Episcleritis Acute Arthropathy
206
What are the extra-intestinal features of UC that are unrelated to the disease activity?
Sacroileitis Ank spond PSC
207
What are the aims of treatment in ulcerative colitis?
Induce remission in acute disease Maintain remission Improve quality of life Decrease risk of colorectal cancer
208
Why do UC patients get heparin?
IBD flares cause a prothrombotic state which can be severe
209
How are steroids used in UC?
Induce remission No role in long term therapy due to side effects
210
Why is important to slowly weane off steroids in UC?
Doing it too quickly can cause flare up
211
How is azathioprine used in UC?
Steroid-sparing Maintenance of remission Takes at least 6 weeks to work
212
What are the side-effects of azathioprine?
``` Flu-like GI upset Leukopenia Hepatitis Pancreatitis Rash Infections ```
213
How is ciclosporin used in UC? What is its mechanism of action?
Salvage therapy in severe refractory colitis Calcineurin inhibitors
214
When are laxatives used in UC?
Proximal constipation Relieving this can induce remission in left-sided disease
215
What are the indications for surgery in UC?
Perforation Massive haemorrhage Toxic dilatation Failed medical therapy
216
How are platelet measurements useful in IBD?
High platelets indicates severity of disease
217
What is the prevalence of Crohn's disease?
0.5-1 per 1000
218
When is the peak age for Crohn's to present?
20 - 40y and 60 - 70y
219
What are the symptoms of Crohn's?
``` Diarrhoea and urgency Abdo pain Weight loss Fever Malaise Anorexia ```
220
What are the examination signs of Crohn's?
``` Apthous ulcers Abdo tenderness Perinatal abscess, fistulae Clubbing Skin, joint and eye problems ```
221
Why is albumin low in Crohn's?
The liver switches protein synthesis to favour inflammatory proteins eg CRP
222
What are the indications for surgery in Crohn's?
``` Failure of medical management Perforation Obstruction by stricture Fistula Abscess ```
223
What is the incidence of IBS?
10-20% population
224
What symptoms should make you think of something other than IBS?
``` Older than 40 Less than 6 month history Anorexia and weight loss Waking at night with pain or diarrhoea Mouth ulcers Abnormal CRP, ESR, Hb or coeliac serology ```
225
Why is ispaghula better than lactulose to relieve constipation in IBS?
Lactulose ferments so can exacerbate bloating
226
How do you treat bloating?
Mebeverine 135mg QDS This is an antispasmodic
227
At what point does hyperbilirubinaemia cause visible jaundice?
> 60umol/L
228
Why do you get dark urine and pale faeces alongside jaundice?
Conjugated bilirubin enters urine, darkening it Less conjugated bilirubin reaches the gut, so there is less in faeces and they are pale
229
What do pale stools and dark urine commonly indicate?
Chile stasis
230
How does drug-induced jaundice present?
DRESS: | Drug Rash with Eosinophilia and Systemic Symptoms
231
What does decompensated liver disease mean?
Signs and symptoms present and patient generally unwell
232
What are the 2 main pathological processes leading to the clinical features of chronic liver disease?
Reduced hepatocyte mass Portal hypertension
233
What clinical features are caused by reduced hepatocyte mass?
Encephalopathy Loss of lean body mass Coagulopathy
234
What clinical features are caused by portal hypertension?
Varices Ascites Splenomegaly
235
What are the features of hepatic encephalopathy?
``` Reduced attention span Reversed sleep pattern Metabolic flap Constructional dyspraxia Coma ```
236
What does cirrhosis mean?
Irreversible liver damage | Loss of normal architecture plus modular regeneration
237
What are the causes of cirrhosis?
``` Chronic alcohol abuse HBV or HCV infection Genetic disorders Non-alcoholic fatty liver Autoimmune eg PBC Drugs ```
238
How does cirrhosis lead to kidney problems?
Reduced hepatic clearance of immune complexes Means they become trapped in the kidney Commonly IgA nephropathy
239
What are the signs of chronic liver disease found in the hands?
Clubbing Palmar erythema Leuconychia
240
What are the causes of decompensation of chronic liver disease?
``` Drugs (eg alcohol) Electrolyte disturbance Sepsis GI bleed Hepatoma ```
241
How is encephalopathy graded?
I altered mood II drowsy III stupor IV coma
242
What is fulminant hepatic failure?
Massive necrosis of liver cells | Leads to severe liver function impairment
243
What is the most common cause of fulminant hepatic failure?
Paracetamol
244
What emergencies should you look out for in hepatic failure?
Sepsis Hypoglycaemia GI bleeds/varices Encephalopathy
245
How do you treat cerebral oedema?
20% mannitol IV
246
How do you treat Ascites?
Fluid restriction Low salt diet Diuretics
247
What drugs should be avoided in hepatic failure?
Constipation drugs Oral hypoglycaemics Saline IV All drugs with hepatic metabolism NB warfarin's effects are enhanced in hepatic failure
248
Name 5 hepatotoxic drugs
``` Paracetamol Isoniazid Methotrexate Azathioprine Oestrogen Salicylates Tetracycline 6-MP ```
249
How does ammonia cause cerebral oedema?
Ammonia builds up as liver fails Passes into brain - taken up by astrocytes Convert glutamate to glutamine to clear ammonia Glutamine has osmotic effect and draws water into astrocytes Leads to cerebral oedema
250
Define hepatorenal syndrome
Cirrhosis + Ascites + Renal Failure
251
Name a screening tool for alcoholism
CAGE
252
What is the prognosis for an alcoholic with cirrhosis who keeps drinking?
48% 5yr survival
253
What type of anaemia is seen in alcoholism and why?
Macrocytic Marrow depression, GI bleeds, folate deficiency and haemolysis
254
What are the CVS complications of alcoholism?
Arrhythmias Hypertension Cardiomyopathy Sudden death due to binges
255
What are the symptoms of alcohol withdrawal?
``` Tachycardia Hypotension Tremor Convulsions Fits Hallucinations ```
256
How do you manage alcohol withdrawal?
Beware of hypotension Chlordiazepoxide 10-50mg QDS PO for 3 days & gradually wean over 7-10days Vitamin supplements eg pabrinex
257
What is the effect of disulfiram?
Causes acetaldehyde build-up and unpleasant effects when alcohol is consumed Used to treat chronic alcohol dependence
258
What is Charcot's triad?
Fever, pain and jaundice Cholangitis
259
Describe the typical pain of biliary colic
Central, severe and constant Radiates to back Lasts for as long as the stone is stuck Doesn't have to be everyday, can be any frequency NB no abdominal tenderness
260
What are the alarm symptoms related to dyspepsia?
``` Anaemia Loss of weight Anorexia Rapid onset Melaena/haematemesis Swallowing difficulty ```
261
What are the risk factors for developing a duodenal ulcer?
H.pylori infection | Drugs e.g. NSAIDs, steroids, SSRIs
262
When is pain from a duodenal ulcer worst?
Before meals or at night, i.e. When the stomach is empty
263
How do you manage peptic ulcers?
1. Lifestyle - reduce smoking, alcohol and aggravating foods 2. H.pylori eradication (triple therapy) 3. Drugs to reduce acid secretion: PPIs or H2 antagonist 4. Surgery
264
What are the potential complications of peptic ulcers?
Bleeding Perforation Malignancy Gastric outflow obstruction
265
Define GORD
Reflux of stomach contents causing symptoms of heartburn, with more than 2 episodes per week
266
Give some causes of GORD
``` Hiatus hernia Abdo obesity Smoking or alcohol Overeating H.pylori Gastric acid hypersecretion Pregnancy ```
267
What are the potential complications of GORD?
``` Oesophagitis Ulcers Benign stricture Iron deficiency Barrett's oesophagus ```
268
What can cause oesophagitis?
``` Corrosives NSAIDs Herpes Candida Duodenal or gastric ulcer Cardiac disease ```
269
What are the conservative management measures for GORD?
``` Raise whole bed Weight loss Smoking cessation Small, regular meals Avoid hot/fizzy drinks, spicy food Don't eat within 3hours of going to bed ```
270
What is a sliding hiatus hernia?
Gastro-oesophageal junction slides up into chest Acid reflux may accompany
271
What is a rolling hiatus hernia?
Junction remains in abdomen Bulge of stomach herniated into chest alongside oesophagus Acid reflux uncommon (junction remains competent)
272
What type of hiatus hernia should be surgically repaired?
Rolling This can strangulate so repair prophylactically
273
What is the treatment for C.difficile colitis?
Metronidazole 400mg/8h Stop causative antibiotics
274
When is colectomy required for c.diff colitis?
Toxic megacolon Raised LDH Rapidly deteriorating
275
Define extensive UC
Extending beyond the splenic flexure
276
How does smoking affect ulcerative colitis?
Decreases incidence | May induce remission
277
How does smoking affect Crohn's?
Increases incidence
278
What are the cardinal symptoms of ulcerative colitis?
Bloody diarrhoea Urgency Tenesmus
279
Define mild ulcerative colitis
Fewer than 4 stools per day No systemic features
280
Define severe ulcerative colitis
More than 6 stools per day + blood + systemic features
281
What are the extra-intestinal features of UC that are related to the disease activity?
Erythema nodosum Aphthous ulcers Episcleritis Acute Arthropathy
282
What are the extra-intestinal features of UC that are unrelated to the disease activity?
Sacroileitis Ank spond PSC
283
What are the aims of treatment in ulcerative colitis?
Induce remission in acute disease Maintain remission Improve quality of life Decrease risk of colorectal cancer
284
Why do UC patients get heparin?
IBD flares cause a prothrombotic state which can be severe
285
What is the normal range for blood glucose?
3.3 - 6 mmol/L
286
What are the symptoms of hyperglycaemia?
``` Polyuria Polydipsia Weight loss Visual blurring Genital thrush ```
287
What are the normal actions of insulin on glucose metabolism?
Inhibits liver glycogen breakdown Enhances glucose uptake by liver Enhances glucose uptake by muscle and adipose
288
What is the pathophysiology of type 1 diabetes?
Autoimmune destruction of beta cells | Causes absolute insulin deficiency
289
What proportion of all diabetes is type 1?
5-10%
290
Why are ketones produced?
Ketone production normally suppressed by insulin In starvation or insulin deficiency, ketone production is activated
291
What hormones antagonise the action of insulin?
Cortisol Growth hormone Glucagon Adrenaline
292
How do you manage cardiovascular risk in diabetics?
``` Target other risk factors e.g. Hypertension Smoking Obesity Hyperlipidaemia ```
293
What is DAFNE?
Dose adjustment for normal eating Course to educate diabetics on insulin doses
294
What is the most effective time for lifestyle intervention in type 2 diabetes?
Phase of impaired glucose tolerance
295
What does HbA1c measure?
Average glucose levels over the past 8 weeks
296
What are the microvascular complications of diabetes?
Nephropathy Neuropathy Retinopathy
297
What are the macrovascular complications of diabetes?
Cerebrovascular Peripheral vascular Cardiovascular
298
What is the mechanism of action of metformin?
Decreases hepatic gluconeogenesis Increases muscle glucose metabolism Mild anorexic
299
What are the side effects of Metformin?
GI upset Rarely lactic acidosis
300
What are the contraindications for Metformin?
Renal failure | Hepatic impairment
301
Give an example of a sulfonylurea
Gliclazide
302
What is the mechanism of action of sulfonylureas?
Increased insulin release from beta cells Binds and closes K+ channels to depolarise the cell
303
What are the side effects of sulfonylureas?
Weight gain | Hypoglycaemia
304
Give an example of a thiazolidinedione
Pioglitazone
305
What is the mechanism of action of Pioglitazone?
Activates PPAR-alpha to stimulate transcription of glut-1 and -4
306
What is the mechanism of action of acarbose?
Inhibits carbohydrate digestion to reduce glucose absorption
307
What are the side effects or acarbose?
Bloating | diarrhoea
308
What is exenatide?
GLP-1 receptor analogue Stimulates insulin release Inhibits glucagon release
309
What is the mechanism of action of dapagliflozin?
Inhibits SGLT2 to inhibit renal glucose reabsorption
310
What are the side effects of dapagliflozin?
UTI Genital thrush Hypoglycaemia Increased urination
311
Give 2 examples of ultra-fast insulin
Humalog Novorapid
312
Give an example of a mixed insulin preparation and its content
NovoMix 30% short acting 70% long acting
313
Give 2 examples of long-acting insulin
Glargine Insulin detemir
314
When is glargine taken?
Bedtime
315
What is a QDS insulin regime?
Before meals: ultrafast Bedtime long-acting
316
What is a good starter regime for T2 diabetics switching from tablets to insulin?
Once-daily long-acting insulin at bedtime Can retain Metformin
317
How are insulin requirements affected by illness?
Insulin requirement increases despite eating less
318
What is the target blood pressure for diabetics?
Less than 140/80mmHg
319
What is the target BP for diabetics with CKD?
Less than 125/75 mmHg
320
What is the pathophysiology of diabetic retinopathy?
Capillary basement membrane thickening leads to leaky vessels, occluded vessels and macular oedema
321
Why are diabetics screened for retinopathy?
Allows laser photo coagulation to be used Stops production of angiogenesis factors from is ischaemic retina Blindness is preventable!
322
How does pre-proliferative retinopathy look?
Cotton-wool spots Haemorrhages Venous bleeding
323
How does proliferative retinopathy look?
New vessels have formed (they are likely to bleed) | Haemorrhages
324
How do you treat macular oedema?
Intra-vitreal steroids | Prompt laser treatment
325
Why do diabetics get cataracts?
Acute hyperglycaemia induces osmotic changes in the lens Reversed when blood glucose returns to normal
326
What is the increased cardiovascular risk for diabetics?
MI 4 times more likely Stroke twice as likely
327
What is the pathophysiology of diabetic foot disease?
Peripheral vascular disease Peripheral neuropathy Increased susceptibility to infection
328
What are the consequences of diabetic foot?
Ulceration Infection Gangrene Charcot's foot
329
What are the features of diabetic ketoacidosis?
``` Gradual drowsiness Vomiting Dehydration Abdo pain Polyuria/polydipsia/weight loss Ketotic breath Coma Deep breathing ```
330
How do you diagnose DKA?
Blood pH
331
What are the potential complications of DKA?
Cerebral oedema Aspiration pneumonia Hypokalaemia/magnaesemia/phosphataemia Thromboembolism
332
How do you treat DKA?
50units actrapid insulin in 50ml 0.9% saline | Continue their long-acting insulin
333
What is the target decrease in blood ketones in DKA?
0.5mmol/L/h
334
What are the common triggers of DKA?
``` Infection Surgery MI Pancreatitis Chemotherapy Antipsychotics Poor insulin dosing or non-compliance ```
335
What is HONK?
Hyperosmolar non-ketotic syndrome Dehydration + blood glucose >35mmol/L
336
How do you treat HONK?
Slow rehydration: 110-220mmol/Kg deficit Use 0.9% NaCl
337
Why should blood glucose be maintained between 10 and 15 mmol/L for the first 24h in HONK?
To avoid cerebral oedema
338
How do you treat hypoglycaemic coma?
20-30g glucose IV (Eg 200-300ml 10% dextrose) Give sugary drinks and meal once conscious
339
Define hypoglycaemia
Plasma glucose
340
What are the autonomic symptoms of hypoglycaemia?
``` Sweating Anxiety Hunger Tremor Palpitations Dizziness ```
341
What are the neuroglycopenic symptoms of hypoglycaemia?
``` Confusion Drowsiness Visual disturbance Seizures Coma ```
342
What is the main cause of fasting hypoglycaemia?
Insulin or sulfonylurea treatment Increased activity, missed meal or an overdose
343
What are the causes of hypoglycaemia in non-diabetics?
``` EXPLAIN: EXogenous drugs Pituitary insufficiency Liver failure Addison's disease Islet cell tumours Non-pancreatic neoplasms ```
344
How do you manage hypoglycaemia?
Oral sugary drink and long-acting starch (eg sandwich) If can't swallow: IV 25-50ml 50% glucose If no IV access: 1mg IM glucagon
345
What are the risks of gestational diabetes?
``` Miscarriage Pre-term labour Pre-eclampsia Congenital malformations Macrosomia ```
346
What are the risk factors for gestational diabetes?
``` Older than 25 Family history Overweight Non-Caucasian HIV Previous GDM ```
347
What proportion of patients with gestational diabetes go on to develop T2DM later in life?
50%
348
What % of pregnancies are complicated by gestational diabetes?
3.5%
349
What blood glucose level should be maintained in the peri operative period?
6-11mmol/L
350
How long should VRII be maintain postop?
Until eating and drinking normally
351
How is blood glucose affected by being acutely ill?
Blood glucose higher due to: Cortisol, adrenaline and growth hormone release Physical inactivity Alteration in diet
352
What is the initial management for Hyperlipidaemia?
Diet modification Address other CVS risk factors: smoking, hypertension, excess weight
353
What are the target levels for cholesterol?
Total
354
What drugs are used to treat hypercholesterolaemia?
Statins Ezetimibe/fibrates Bile acid-binding resins
355
What drugs are used to treat hypertriglyceridaemia?
Fibrates Nicotinic acid Fish oil capsules
356
What are the indications for starting statin therapy?
Diabetes mellitus and over 40y Total cardiovascular disease risk >20% over 10y 2 of: family history, albuminuria, hypertension and smoking Men with LDL>6.5 despite dietary change Familial hypercholesterolaemia
357
When are statins indicated for secondary prevention?
Coronary artery disease TIA or strike Peripheral artery disease
358
What is low dose dexamethasone suppression test used for?
Screening for cushing's
359
What is the high dose dexamethasone suppression test used for?
Determining pituitary vs adrenal cause of Cushing's syndrome
360
What is the synacthen test?
Normal response is to cause cortisol release form the adrenals Test of primary adrenal failure
361
What is the insulin stress test?
Should cause cortisol release to >600 Insulin-induced hypoglycaemia Good test for hypopitutarism as it tests ACTH and GH reserve
362
What are the contraindications for the insulin stress test?
Epilepsy | Ischaemic heart disease
363
What is the glucose tolerance test?
Should suppress growth hormone Test for acromegaly Bonus of glucose will suppress GH in normal people, failure to suppress in acromegaly
364
What are the effects of pituitary tumours?
Excess hormone production Physical effects of lump on surrounding structures
365
What are the features of acromegaly?
``` Growth of hands and feet Coarse features Headache Sweating Carpal tunnel syndrome ```
366
Which hormones are affected by something blocking the pituitary stalk?
Increase in all pituitary hormones | EXCEPT prolactin as this is mainly under inhibitory control by dopamine
367
What is IGF-1?
Released from the liver in response to growth hormone | This is the main way growth hormone takes its effect
368
What is the treatment for acromegaly?
Somatostatin analogues eg ocreotide Growth hormone receptor blockers eg pegvisomant
369
How do you distinguish between active and inactive acromegaly?
Active: headaches, sweating Inactive means they have already had treatment, but may still have big features
370
What are the features of Cushing's syndrome?
``` Moon fancies Thinning of skin Easy bruising Buffalo hump Central obesity Abdominal striae Hypertension/diabetes ```
371
How do you do a low dose dexamethasone suppression test?
0.5mg dexamethasone QDS for 48h If cortisol decreases to less than 30nmol/L, it is not true Cushing's syndrome
372
What are the physical effects of a pituitary tumour?
Hypopitutarism Visual field disturbance (bitemporal hemianopia) Headache
373
What effect does compression of the pituitary stalk have on prolactin?
Causes hyperprolactinaemia
374
What are the features of primary adrenal insufficiency?
Hyponatraemia Hyperkalaemia Postural hypotension Increased pigmentation
375
What are the causes of primary adrenal insufficiency?
``` Autoimmune TB Iatrogenic Sepsis Infiltrative disease ```
376
What is the management of a hypo adrenal crisis?
``` Fluid resuscitation Glucose Steroids Treat sepsis Find cause ```
377
What can Addison's disease mimic clinically?
Depression Often not diagnosed until they have a crisis
378
What are the symptoms of hypothyroidism?
``` Bradycardia Slow reflexes Goitre Carpal tunnel Weight gain Depression Fatigue Cold intolerance Constipation ```
379
What are the symptoms of hyperthyroidism?
``` Weight loss despite good appetite Tremor Palpitations Heat intolerance Diarrhoea Irritability Tachycardia Proptosis Hyperreflexia Lid lag Goitre ```
380
In what order are hormones affected by hypopituitarism?
``` Growth hormone Gonadotrophins Prolactin TSH ACTH ```
381
What are the usual causes of panhypopituitarism?
Irradiation Surgery Pituitary tumour
382
What is the most common type of pituitary tumour?
Benign adenoma
383
What cranial nerves are affected by pituitary tumours?
CN III, IV and VI
384
What is the management of a prolactinoma?
Medical therapy with dopamine agonist
385
What is pituitary apoplexy?
Rapid bleed into a pituitary tumour | Causes rapid expansion
386
Why does hyperprolactinaemia present earlier in females than males?
Causes menstrual disturbance in females | Erectile dysfunction in males
387
Why does hyperprolactinaemia cause hypogonadism, infertility and osteoporosis?
Inhibits secretion of gonadotrophin releasing hormone
388
Where is dopamine released from?
Hypothalamus
389
What are the causes of hyperprolactinaemia?
Excess pituitary production eg prolactinoma Disinhibition eg compression of pituitary stalk causes reduced local dopamine levels Dopamine antagonist use
390
What drugs can cause hyperprolactinaemia?
Metoclopramide Haloperidol Antipsychotics (Dopamine antagonists)
391
Name a dopamine agonist
Bromocriptine
392
Why are free T3 and T4 levels a more useful test than total hormone levels?
Total levels are affected by TBG levels, which are increased in pregnancy or HRT
393
What are thyroid function tests like in hyperthyroidism?
Raised T4 | Low TSH
394
At what time of day are TSH levels lowest and highest?
Lowest about 2pm Highest in the dark
395
What is 'sick euthyroidism'?
Thyroid function tests may be deranged with any systemic illness Typically all results are low Retest when recovered
396
Name the thyroid autoantibodies implicated in grave's and hashimoto's disease
Anti thyroid peroxidase | Antithyroglobulin
397
Which patients should be screened for thyroid abnormalities?
``` AF Hyperlipidaemia DM Gestational diabetes Those on lithium and amiodarone Down's/turner's syndrome Addison's disease ```
398
What proportion of thyrotoxicosis is due to Grave's disease?
Two thirds
399
What is the male:female ratio for hyperthyroidism?
1:9
400
What is the pathophysiology of Grave's disease?
Circulating IgG antibodies bind to TRH receptors and cause thyroid enlargement and increased hormone production
401
What proportion of patients with Grave's disease get thyroid eye disease?
25-50%
402
Define proptosis
Eyes protruding beyond the orbit Have to look from above to see this
403
How do you treat symptoms of hyperthyroidism?
Beta blockers
404
How do you prescribe carbimazole?
1. Titration: start with 20-40mg/day PO for 4 weeks. Reduce depending on TFTs every 1-2 weeks 2. Block-replace: give carbimazole and thyroxine together
405
What are the side effects of carbimazole?
Agranulocytosis: see GP if they get an infection, need FBC
406
What are the contraindications of radio-iodine treatment?
Pregnancy | Lactation
407
What structures may be damaged during thyroidectomy?
Recurrent laryngeal nerve | Parathyroid glands
408
What are the potential complications of thyrotoxicosis?
``` Heart failure Angina AF Osteoporosis Ophthalmopathy Gynaecomastia ```
409
What is myxoedema?
Hypothyroidism
410
What are the causes of hypothyroidism?
Primary atrophic hypothyroidism (common) Hashimoto's thyroiditis Iodine deficiency
411
What is primary atrophic hypothyroidism?
Lymphocytic infiltration of thyroid leads to atrophy No goitre
412
What diseases is hashimoto's disease related to?
Type 1 diabetes Addison's disease Pernicious anaemia
413
What problems can hypothyroidism cause in pregnancy?
``` Eclampsia Anaemia Premature birth Low birthweight Stillbirth Post-Partum haemorrhage ```
414
What is the treatment for hypothyroidism?
Levothyroxine 50-100ug/day
415
What is sub clinical hypothyroidism?
TSH raised but T3 and T4 are normal Asymptomatic
416
What is the effect of amiodarone on the thyroid and why?
Can cause hyper or hypothyroidism Amiodarone is structurally similar to T4 (contains lots of iodine)
417
What types of hormone does the adrenal cortex produce?
Steroids: Mineralocorticoids Glucocorticoids Androgens
418
How is cortisol excreted?
Urinary free cortisol
419
What is the most common cause of Cushing's syndrome?
Oral steroids
420
What is the most common endogenous cause of Cushing's syndrome?
80% due to increased ACTH Pituitary adenoma (Cushing's disease) is the most common cause of this
421
What is the normal range for blood glucose?
3.3 - 6 mmol/L
422
What are the symptoms of hyperglycaemia?
``` Polyuria Polydipsia Weight loss Visual blurring Genital thrush ```
423
What are the normal actions of insulin on glucose metabolism?
Inhibits liver glycogen breakdown Enhances glucose uptake by liver Enhances glucose uptake by muscle and adipose
424
What is the pathophysiology of type 1 diabetes?
Autoimmune destruction of beta cells | Causes absolute insulin deficiency
425
What proportion of all diabetes is type 1?
5-10%
426
Why are ketones produced?
Ketone production normally suppressed by insulin In starvation or insulin deficiency, ketone production is activated
427
What hormones antagonise the action of insulin?
Cortisol Growth hormone Glucagon Adrenaline
428
How do you manage cardiovascular risk in diabetics?
``` Target other risk factors e.g. Hypertension Smoking Obesity Hyperlipidaemia ```
429
What is DAFNE?
Dose adjustment for normal eating Course to educate diabetics on insulin doses
430
What is the most effective time for lifestyle intervention in type 2 diabetes?
Phase of impaired glucose tolerance
431
What does HbA1c measure?
Average glucose levels over the past 8 weeks
432
What are the microvascular complications of diabetes?
Nephropathy Neuropathy Retinopathy
433
What are the macrovascular complications of diabetes?
Cerebrovascular Peripheral vascular Cardiovascular
434
What are the causes of decreased ACTH levels?
Adrenal adenoma/cancer Adrenal modular hyperplasia Oral steroids
435
What are the symptoms of Cushing's?
``` Weight gain Depression, lethargy, irritability Psychosis Proximal weakness Gonadal dysfunction Acne Recurrent Achilles rupture ```
436
What are the signs of Cushing's?
``` Central obesity Moon face Buffalo hump neck Supraclavicular fat distribution Skin and muscle atrophy Bruises, purple abdo striae Osteoporosis Hypertension Hyperglycaemia Increased infection risk and poor healing ```
437
Why are random cortisol levels not reliable?
Cortisol is a stress hormone so can be increased due to the situation eg illness
438
What are incidentalomas?
Non-functioning masses found on imaging Not the actual cause of Cushing's 5% have adrenal incidentalomas 10% have pituitary incidentalomas
439
What are the causes of pseudo-Cushing's?
Alcohol excess Obesity Depression
440
What is the treatment for Cushing's disease?
Transphenoidal removal of adenoma
441
When can adrenal insufficiency suddenly develop?
In those on long-term steroids Septic individuals Malignancy
442
What is the main cause of adrenocortical insufficiency?
Autoimmune
443
What are the symptoms of Addison's disease?
``` Tearful Tired, weakness Abdo pain Vomiting Anorexia Dizziness, faints Flu-like arthralgias/myalgias Postural hypotension Pigmented palmar creases ```
444
How does an Addisonian crisis present?
Shock: hypotensive and tachycardic Fever Coma
445
What are the electrolyte abnormalities found in Addison's disease?
Hyponatraemia Hyperkalaemia Hypoglycaemia Uraemia Hypercalcaemia
446
What is the short synacthen test?
Do plasma cortisol before and after 250ug IM synacthen Not Addison's if cortisol is less than 550nmol/L at 30min
447
What is the treatment for Addison's disease?
Steroids: 15-25mg hydrocortisone daily Give early in the day to avoid insomnia Fludrocortisone for postural hypotension and to decrease sodium and increase potassium
448
What are patients with Addison's given for emergencies?
Syringes of IM hydrocortisone | Inject 100mg if vomiting prevents oral intake
449
What is primary hyperaldosteronism?
Excess production of aldosterone with no increase in RAAS activity Leads to increased sodium and water retention and decreased renin release
450
What are the features of primary hyperaldosteronism?
Hypertension Hypokalaemia Alkalosis Sodium slightly raised or normal
451
What is Conn's syndrome?
Single aldosterone-producing adenoma | Causes primary hyperaldosteronism
452
How are renin and aldosterone levels affected by primary hyperaldosteronism?
Suppressed renin Raised aldosterone
453
When should the adrenals be MRId?
After hyperaldosteronism confirmed Due to high incidence of incidentalomas
454
What is used to medically manage hyperaldosteronism?
Spironolactone
455
What is secondary hyperaldosteronism?
High renin levels caused by reduced renal perfusion
456
What is a phaeochromocytoma?
Rare tumour usually found in adrenal medulla Produces catecholamines
457
What is the triad of features found in phaeochromocytoma?
Episodic headache Sweating Tachycardia
458
Name an alpha blocker and a use
Phenoxybenzamine Preop medical management of phaeochromocytoma
459
What are the actions of parathyroid hormone?
Increased osteoclast activity Increased calcium/decreased phosphate resorption in kidney Increased production of 1,25-dihydroxyvitamin D
460
What is the overall effect of parathyroid hormone?
Increased serum calcium Decreased serum phosphate
461
What is the main cause of primary hyperparathyroidism?
Single adenoma
462
What are the features of hypercalcaemia?
``` Weak Tired Depression Thirsty Renal stones Abdo pain Pancreatitis Ulcers ```
463
Why is alk phos raised in hyperparathyroidism?
Increased bone resorption
464
What is the treatment for mild hyperparathyroidism?
Increase fluid intake to avoid stones | Avoid thiazides and high calcium/vit D intake
465
What are the complications of removing a parathyroid adenoma?
Hypoparathyroidism Recurrent laryngeal nerve damage Symptomatic hypocalcaemia
466
How does Cinacalcet work?
Increases sensitivity of parathyroid cells to Ca2+ Increases negative feedback effect Decreases PTH secretion
467
What are the causes of secondary hyperparathyroidism?
Reduced Vit D intake Chronic renal failure
468
What is PTHrP commonly produced by?
Squamous cell lung cancers Breast cancer Renal cell carcinoma
469
What is the acute management of hypercalcaemia?
Correct dehydration with 0.9% saline Bisphosphonate (max dose 90mg) Diagnose and treat underlying cause
470
What is primary hypoparathyroidism?
Primary gland failure causing decreased PTH secretion and hence hypocalcaemia
471
What are the causes of secondary hypoparathyroidism?
Surgery Radiation Hypomagnesaemia (needed for PTH production)
472
What are the features of hypocalcaemia?
``` Spasms Anxious, irritable, irrational Seizures Hypertonic smooth muscle (colic, wheeze, dysphagia) Dermatitis Impaired orientation & confusion ```
473
What is the treatment of mild hypocalcaemia?
Calcium 5mmol/6h PO
474
What is the treatment of severe hypocalcaemia?
10ml 10% calcium gluconate IV over 30mins
475
What are the causes of hypocalcaemia with increased phosphate levels?
``` CKD Hypoparathyroidism Acute rhabdomyolysis Vit d deficiency Hypomagnaesemia ```
476
What are the causes of hypocalcaemia with normal or decreased phosphate levels?
Osteomalacia Acute pancreatitis Over hydration Respiratory alkalosis
477
What are the levels of FSH and LH like in primary Hypogonadism?
High
478
What are the levels of FSH and LH like in secondary hypogonadism?
Normal or low
479
What chromosomal abnormalities cause hypogonadism?
Klinefelter | Turner
480
What are the causes of primary hypogonadism?
``` Klinefelter/Turner syndrome Autoimmune eg Addison's Infection Haemochromatosis Surgery on gonads ```
481
What are the causes of secondary hypogonadism?
Hypothalamic or pituitary defect: Hypothalamic eg kallmann syndrome Pituitary eg hypopituitarism PCOS
482
What is the treatment for secondary hypogonadism?
Men: testosterone replacement therapy Women: oestrogen and progesterone replacement
483
How can morbid obesity be managed medically?
Orlistat - prevents absorption of fats by inhibiting lipase
484
What are the indications for bariatric surgery?
BMI over 40kg/m2 Non-surgical measures failed for at least 6 months Intensive specialist management Fit for surgery Patient commits to need for long-term follow-up
485
When is surgery the 1st line treatment for obesity?
Adults with BMI > 50
486
What is MEN?
Multiple endocrine neoplasia Functioning hormone-producing tumours in multiple organs Autosomal dominant inheritance
487
What are the features of MEN-1?
Parathyroid hyperplasia or adenoma Pancreas endocrine tumours Pituitary prolactinoma
488
What are the features of MEN-2a?
Thyroid carcinoma Adrenal eg phaeochromocytoma Parathyroid hyperplasia
489
How is genetic testing used in MEN?
MEN-2 gene is a proto-oncogene Test for it and do prophylactic thyroidectomy before 3 years of age
490
What is the normal range for GFR?
70-140ml/min
491
How much of the cardiac output do the kidneys receive?
20%
492
How much urine do the kidneys normally produce?
50-100ml per hour
493
Where is the urine made acidic?
Collecting ducts: whatever sodium resorption that occurs is accompanied by an equivalent excretion of H+ and K+
494
Where does sodium resorption occur?
60-70% proximal tubule 20-30% loop 5-8% distal tubule
495
Why is GFR better than creatinine at measuring renal impairment?
Creatinine also dependent on muscle mass - so if muscle mass is low, creatinine can be normal despite GFR being reduced
496
What is the MDRD equation?
``` Estimates GFR from 4 parameters: Serum creatinine Age Gender Race ```
497
What is the normal range for pCO2?
4.7 - 6 kPa
498
What is the normal range for HCO3-?
22-28mmol/L
499
What is the equation for anion gap?
(Na+ + K+) - (Cl- + HCO3-)
500
What is the normal range for the anion gap?
10-18mmol/L
501
What is the anion gap useful for?
Determining the cause of metabolic acidosis
502
What are the causes of metabolic acidosis with an increased anion gap?
Lactic acid eg shock, infection, ischaemia Urate ie renal failure Ketones (DKA, alcohol) Drugs/toxins
503
What are the causes of metabolic acidosis with a normal anion gap?
``` Renal tubular acidosis Diarrhoea Drugs Addison's disease Pancreatic fistula Ammonium chloride ingestion ```
504
Why does the anion gap increase in some metabolic acidosis?
Increased production or reduced excretion of organic acids Causes HCO3- to fall Other organic anions rise
505
What are the causes of metabolic alkalosis?
Vomiting Potassium depletion eg diuretics Burns Ingesting base
506
What causes respiratory acidosis?
Type 2 respiratory failure of any cause Most commonly COPD
507
What causes respiratory alkalosis?
Hyperventilation Eg stroke, asthma, anxiety, pregnancy, PE, drugs
508
Give 2 examples of loop diuretics
Furosemide | Bumetanide
509
What is the mechanism of action of loop diuretics?
Block Na/K/Cl cotransporter in thick ascending limb Prevent reabsorption of sodium, chloride and potassium Increases amount of solute in filtrate Reduces water reabsorption
510
What are the uses of loop diuretics?
``` Acute pulmonary oedema Peripheral oedema Ascites Heart failure Severe hypercalcaemia ```
511
What are the side effects of loop diuretics?
Hypokalaemic metabolic alkalosis (because they cause H+ and K+ excretion) Hypovolaemia Ototoxicity Allergies
512
Give 2 examples of thiazides
Bendroflumethiazide | Metolazone
513
What is the mechanism of action of thiazides?
Inhibit NaCl transporter in distal tubule Decrease NaCl reabsorption to increase water loss
514
How do thiazides affect serum potassium?
Cause hypokalaemia | Due to excessive potassium loss
515
What are the uses of thiazides?
Hypertension Long-term oedema eg heart failure Reduce renal stone formation in hypercalcuria
516
What are the side effects of thiazides?
``` Hypokalaemia Hyponatraemia Hypomagnaesemia Metabolic alkalosis Hyperglycaemia Increased serum lipid Increased uric acid level ```
517
Name 2 aldosterone antagonists
Spironolactone Eplerenone
518
Name 4 potassium sparing diuretics
Spironolactone and Eplerenone Amiloride and triameterene
519
What is the mechanism of action of amiloride?
Block ENaC in distal tubule to prevent sodium reabsorption
520
What potassium abnormality is common with potassium-sparing diuretics?
Hyperkalaemia They reduce potassium excretion
521
Which works more quickly, Spironolactone or amiloride?
Amiloride works in hours Spironolactone takes days for full effect
522
How can you prevent hyperkalaemia when using potassium sparing diuretics?
Use in combination with loop or thiazides diuretic
523
What are the side effects of Spironolactone?
Gynaecomastia GI upset Hyperkalaemia
524
Name an osmotic diuretic and its mechanism of action
Mannitol | Freely filtered but not reabsorbed - stays in lumen and causes less water to be reabsorbed from the proximal tubule
525
What are the uses of mannitol?
Reduce brain volume/ICP Haemolysis Rhabdomyolysis Reduce intraocular pressure
526
What are the side effects of mannitol?
Headache Nausea Vomiting Hypernatraemia
527
Define hypokalaemia
K+
528
What is the most common cause of hypokalaemia?
Diuretic therapy
529
What ECG changes appear in hypokalaemia?
``` Flat T wave U waves Long PR Depressed ST Tachyarrhythmias ```
530
What are the symptoms of hypokalaemia?
``` Weakness Intestinal ileus Hypotonia and hyporeflexia Cramps Tetany Palpitations Light-headedness Cardiac arrest ```
531
How do you manage mild hypokalaemia?
Oral K+ supplement Consider changing to potassium-sparing diuretic
532
How do you treat severe hypokalaemia?
IV KCl cautiously No more than 20mmol/h Not more concentrated than 40mmol/L
533
What is the maximum rate and concentration of potassium that it is safe to give?
20mmol per hour 40mmol/L
534
What potassium concentration is an emergency?
Above 6.5 mmol/L
535
What are the causes of hyperkalaemia?
``` Oliguric renal failure Potassium-sparing diuretics Rhabdomyolysis Metabolic acidosis Excess K+ therapy Addison's disease Massive blood transfusion Burns Drugs eg ACEi Artefactual result ```
536
Why do you get artefactual results stating hyperkalaemia?
Commonly from primary care causing delayed analysis Difficult venue puncture causing haemolysis Contamination with EDTA in FBC bottle - do UEs first
537
What are the concerning signs in hyperkalaemia?
``` Fast irregular pulse Chest pain Weakness Palpitations Light-headedness ```
538
What are the ECG changes in hyperkalaemia?
Tall tented T waves Small P waves Wide QRS VF
539
How do you manage non-urgent hyperkalaemia?
Treat underlying cause Stop precipitating medications Calcium resonium: binds to K+ in gut to prevent its absorption
540
How do you treat severe hyperkalaemia?
>6.5mmol/L get senior help IV calcium gluconate 10ml 10% over 2min Insulin + dextrose IV Dialysis
541
What is the pathophysiology of rhabdomyolysis?
Skeletal muscle breakdown | Release of contents into circulation (myoglobin, potassium, urate, CK)
542
What are the consequences of rhabdomyolysis?
Hyperkalaemia | AKI as myoglobin is filtered at glomerulus then obstructs renal tubules
543
What are the causes of rhabdomyolysis?
``` Post-ischaemia Prolonged immobilisation Burns Crash injury Excessive exercise Uncontrolled seizures Myosotis Infections Drugs ```
544
What is plasma CK like in rhabdomyolysis?
Very raised, over 1000iU/L
545
How do you distinguish between rhabdomyolysis and MI?
Troponin negative in rhabdomyolysis
546
How do you treat rhabdomyolysis?
Treat hyperkalaemia urgently IV fluids to prevent AKI Maintain urine output of 300ml/h until myoglobinuria has stopped
547
What is the normal range for plasma sodium?
135-145 mmol/L
548
What are the features of hyponatraemia?
``` Anorexia, nausea, malaise Headache Irritability Confusion Weakness Reduced GCS and seizures Cardiac failure/oedema ```
549
What are the causes of hyponatraemia with hypovolaemia?
Renal loss of sodium : diuretics, Addison's | Extra renal loss: vomiting, diarrhoea, burns, sweat
550
What are the causes of hyponatraemia with normovolaemia?
``` Inappropriate IV fluid (eg 5% dextrose) Hypothyroidism SIADH Sickle cell Drugs eg carbamazepine ```
551
What are the causes of hyponatraemia with Hypervolaemia?
``` Renal failure Cardiac failure Hepatic failure Nephrotic syndrome Inappropriate IV fluid eg excess 0.9% saline ```
552
How should sodium be replaced in hyponatraemia?
Replace sodium and water at the same rate they were lost
553
How do you manage Asymptomatic, chronic hyponatraemia?
Restrict fluid intake Demeclocycline (ADH antagonist) may be needed
554
What are the dangers of correcting hyponatraemia too quickly?
Central pontine myelinolysis
555
What is the maximum rate of increase in acute hyponatraemia?
1 mmol/h
556
What is the action of vasopressor receptor antagonists?
Cause water excretion without losing electrolytes Effective for hyper/euvolaemic hyponatraemia
557
Define clinical criteria for SIADH
Concentration of urine >20mmol/L Na+ Hyponatraemia Low plasma osmolality
558
What are the causes of SIADH?
``` Malignancy CNS disorders Chest disease eg TB or pneumonia Endocrine disease eg hypothyroid Drugs Porphyria Trauma Major abdo/thoracic surgery ```
559
How do you treat SIADH?
Restrict fluid intake and treat cause If severe, may require salt and loop diuretic
560
Define hypernatraemia
Plasma sodium > 145mmol/L
561
What are the features of hypernatraemia?
``` Lethargy Thirst Weakness Irritability Confusion Coma Fits Signs of dehydration ```
562
What is the mechanism of action of cyclizine?
H2 receptor antagonist Used to treat GI causes of vomiting
563
What is the action of metoclopramide?
D2 receptor antagonist
564
What is the mechanism of action of ondansetron?
5HT3 receptor antagonist
565
How do bulking agents work? Give an example
Increase faecal mass to stimulate peristalsis Ispaghula husk eg fybogel
566
How do stimulant laxatives work? Give an example
Increase intestinal motility Senna
567
How do osmotic laxatives work?
Retain fluid in the bowel Also retain ammonia so used in hepatic encephalopathy
568
Give two examples of osmotic laxatives
Lactulose | Macrogol (movicol)
569
What dose of codeine phosphate is used to treat diarrhoea?
30mg TDS PO
570
What is the dose of loperamide?
2mg PO after each loose stool Max 16mg per day
571
Define AKI
Rapid reduction in renal function over a period of hours to days
572
How is AKI measured?
Serum urea and creatinine
573
What are the risk factors for AKI?
``` Age over 75 CKD Heart failure PVD Chronic liver disease Diabetes Drugs Sepsis Low fluid intake/increased losses History of urinary symptoms ```
574
How is urine output used to diagnose AKI?
Less than 0.5ml/kg/h for 6h - stage 1 12h - stage 2 24h - stage 3
575
How is serum creatinine used to define AKI?
Stage 1 - >26umol/L increase or 1.5x baseline
576
What are the common causes of pre-renal AKI?
Hypo perfusion Hypotension Renal artery stenosis ACE inhibitors

Phase 2 (21 decks)

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