General Medicine Flashcards
Causes of hepatitis? (VADAM)
Viral - CMV/EBV/Hepatitis Alcohol Drugs - Paracetamol, Phenytoin, Sulfonamides Autoimmune hepatitis Metabolic
Main electrolytes intracellularly?
Magnesium, Calcium and Potassium
Main electrolytes extracellularly?
Sodium and Chloride
Plasma level to be defined as hyperkalaemia?
> 5.5mmol/L
Causes of Hyperkalaemia?
Impaired kidney excretion
- AKI/CKD
- Drugs (ACEI, Spironolactone)
- Hypoaldosteronism
- Addison’s
Release from cells
- Tumour-lysis syndrome
- Rhabdomyolysis
- Lactic acidosis
- Massive haemolysis
- DIgoxin
- B Blockers
- Insulin deficiency
DREAD
- Drugs (ACEI, Spironolactone)
- Renal failure
- Endocrine (addisons)
- Artefact
- DKA
Hyperkalaemia presentation? (ECG findings)
Palpitations or chest pain.
ECG changes:
- Tall T waves
- Flattened p waves
- Prolonged PR
- Widened QRS
- idioventricular rhythms
- Sine waves
- VF/Asystole
Hyperkalaemia management?
ABCDE
Immediate ECG (any change then treat)
Treatment:
- Protect heart
- Lower serum K+
- Waste body K+
- Prevent future reoccurence
- Clacium Gluconate - 10ml 10% in 10mins
- Lower serum:
- Insulin w/ Dextrose: 10-15units in 50ml@50%.
- Nebulised salbutamol - Waste:
- Furosemide (Dialysis if no GFR)
- Calcium resonium (bad compliance) - Prevent
- Monitor & repeat ECG
- Low K+ diet
- Treat cause
Serum level of potassium in hypokalaemia?
<3.5mmol/L
Calcium Gluconate dose in hyperkalaemia?
10 ml of 10% in 10 min
Presentation of hypokalaemia?
Lethargy and weakness
Muscle cramps
Palpitations
Causes of hypokalaemia?
Poor intake:
- Anorexia Nervosa
- Crohns
Increased gut loss:
- Vomiting (Loss of H+ ions and alkalosis offset by bicarb excretion in the kidneys forces K+ excretion)
- Diarrhoea (loss of bicarb)
Redistribution (into cell)
- Insulin OD
- Salbutamol
- Theophylline
Renal losses
- Furosemide
- Renal tubular acidosis
- Genetic renal pathologies
Endocrine (hyperaldosteronism)
- Primary: Conns syndrome
- Secondary: Kidney, renal, heart
Other:
- Hypomagnesaemia (can’t replace K+ without.)
Management of Hypokalaemia?
- ECG (flat t waves, U waves)
- Mild:
- Oral Sando K for 3 days - Severe:
- IV 20-40mmol KCl in N saline over 6 hrs (no faster than 20mmol/hr)
- Never as a bolus
What electrolyte disturbance is small cell lung cancer associated with?
SIADH (hyponatraemia)
Serum sodium in hyponatraemia?
<133 mmol/L (life threatening <120mmol/L)
Hyponatraemia presentation?
Hallucinations Headache Dizziness N&V If more serious: fits, coma, death
Causes of hyponatraemia?
Have to consider hyponatraemia in relation to fluid status:
Hypovolaemic:
- Dehydration (Excess sweating, burns, fistulas)
- D&V
- Diuretic excess (Addison’s, osmotic diuresis)
Euvolaemic
- SIADH
- Hypothyroidism
Hypervolaemic:
- HF, Kidney Failure, Liver failure
- Nephrotic syndrome
Small cell Lung Ca.
DRugs
- SSRIs, TCAs, Antipsychotics, Antiepileptics, omeprazole
SIADH causes?
Hypoxia
- Respiratory failure
- COPD
- Pneumonia
- Small cell ung ca.
CNS diseases
- Meningitis
- Stroke
- SAH
- Trauma
- Tumour
Hyponatraemia management?
- Assess fluid status
- Do Bloods
- U&Es
- 8am Cortisol
- TFT
- Serum osmolality - Urine tests
- Dip
- Osmolality (w/ serum)
- Sodium (off diuretics, if >40mmol/L then SIADH)
If Hypovolaemic:
- Treat cause
- Rehydrate w/ N saline
If Euvolaemic
- Treat cause
- If SIADH :
1. stop precipitating drug
2. fluid restrict
3. Tolvaptan
4. Furosemide
If hypervolaemic:
- Treat cause
- Fluid restrict
Serum level of sodium in hypernatraemia?
> 145mmol/L
Presentation of hypernatraemia?
Headache, Nausea and Vomiting, Seizures, Confusion.
Causes of hypernatraemia?
Excess loss (fluid):
- Diabetes insipidus**
- Osmotic Diuresis** e.g. DKA, HHS
- Diarrhoea
- Vomiting
- Sweating
Excessive hypertonic fluid
- IV infusion
- TPN
- Enteral feeds
Decreased Thirst*
Management of hypernatraemia?
- If severe consider ITU
- Treat underlying cause
- If mild
- Encourage oral intake of fluid - If hypervolaemic from inappropriate IV fluid then IV 5% dextrose and furosemide.
- N saline if hypovolaemic
Features of Hyperparathyroidism, what’s the usual patient?
Bones, stones, abdominal groans and psychic moans:
- Bone pain/fracture
- Renal stones
- Peptic ulceration/constipation/pancreatitis
- Polydipsia, polyuria
- Hypertension
- Depression
Normally elderly female, with unquenchable thirst and raised or inappropriately normal PTH
Normal (most common) cause of Hyperparathyroidism
Solitary parathyroid adenoma
Investigations in Hyperparathyroidism?
- Calcium - Raised (suppresses PTH)
- Phosphate low
- Pepperpot skull on XR
- Technetium-MIBI subtraction scan
Management of hyperparathyroidism?
Parathyroidectomy
If low level disease could manage conservatively
U&E (and pH) changes associated with cushings syndrome?
Hypokalaemic metabolic alkalosis
What main two types of steroid hormone activity do exogenous corticosteroids have and what are their main activities?
Glucocorticoid
- Anti-inflammatory
Mineralocorticoid
- Fluid retention
A patient presents with lethargy, hyponatraemia and hyperkalaemia, what’s the most likely diagnosis?
Addison’s disease
How do you diagnose addison’s disease?
Short synacthen test (ACTH stimulation). It will show no rise in cortisol if the pt has Addison’s.
Two most common causes of hypercalcaemia?
Malignancy and primary hyperparathyroidism
Common presentation of primary hyperaldosteronism?
Hypernatraemia, Hypokalaemia and hypertension
Addison’s disease management?
Hydrocortisone and fludrocortisone
What are you looking for when ordering an ultrasound in urosepsis/UTI?
Rule out urinary obstruction or renal stone disease
Causes of pulmonary oedema?
Cariogenic
- Left sided HF
Non-cardiogenic
- ARDS
- Lymphatic insufficiency
- Hypoalbinaemia
- HAPE
What is gastroparesis?
Delayed gastric emptying, often caused by autonomic neuropathy in poorly controlled diabetes. Presents with persistent nausea and vomiting, feeling full quickly and loss of appetite.
Pathophysiological changes in AKI?
Abrupt decline in GFR
Often oliguria (<400ml/day)
Raised Urea & Creatinine
If a diabetic pt is going to theatre what blood sugars are you aiming for? What might you do to achieve this?
7-10 could use an insulin sliding scale
What Abx can you use to treat C diff?
Metronidazole or vancomycin
What is a tissued cannula?
When the cannula has been pulled out of a vein (or wasn’t in one in the first place) and fluid is collecting around the cannula site.
What test may you do to differentiate T1DM and T2DM?
C-Peptide
What is Bronchiectasis, what does it present with, what is it caused by?
Bronchiectasis is a permanent dilatation and thickening of the airways presenting with chronic cough, sputum production, recurrent infection, haemoptysis, SOB, chest pain, crackles & wheeze
Bronchiectasis is caused by chronic inflammation of the airways. It can be associated with lots of diseases causing inflammation.
- Post lung infection
- HIV
- Connective tissue disorders such as RA, SLE.
- Asthma
What is pemberton’s sign testing for? What is it?
SVC obstruction - red face when both arms held up
Treatment for SVC obstruction?
O2
Dexamethasone
Invasive - Stenting/radiotherapy
What is lambert eaton syndrome?
A paraneoplastic syndrome seen in lung cancer, consists of proximal muscle weakness, and difficulty contracting muscles initially (but getting better on repeated use)
How would you treat lambert eaton syndrome?
IV immunoglobulins, prednisolone, azothiaprine or pyridostigmine
Confusion bloods?
FBC - (WCC, Neutrophils), anaemia Us&Es - Renal function B12, Folate TFTs LFTs
SIADH treatment?
Fluid restrict <1L Demeclocycline if fluid restricting is not working Hypertonic saline (1-2mmol/Hr) no more as risk of demyelination.
Common Lung Ca. symptoms?
Cough (present in 80%)
Haemoptysis, weight loss, lymphadenopathy
Causes of clubbing?
ABCDE
Abscesses Bronchiectesis Carcinoma Don't say COPD Empyema Fibrosis
Types of lung Ca?
Small cell
- Rapid growing lesion
- Associated with SIADH and cushings
- Bad prognosis
Non-Small cell
- Adenocarcinoma (non-smokers)
- Squamous (raised calcium) - Smokers
- Large (secrete B-HCG)
Types of drugs that affect coagulation?
Anticoagulants (Warfarin, Heparin, rivaroxaban, LMWH)
Fibrinolytics (streptokinase, alteplase)
Antiplatelet drugs (Aspirin, Clopidogrel)
Types of anticoagulants?
Vit K antagonist
- Warfarin
DOACs
- Xa inhibitors (Rivaroxaban, Apixaban)
Thrombin inhibitor:
- Dabigatran
Heparins (antithrombin activator)
- Unfactionated Heparin
- LMWH (dalteparin, enoxoparin)
Features of the heparins?
Heparins:
- Must be given by injection (SC or IV)
- Reversible with protamine
UFH (Heparin)
- V short half life
- Can cause thrombocytopaenia
LMWH e.g. enoxaparin
- Longer half life
- Less rate of thrombocyopenia
Features of Warfarin & the newer Factor inhibitors?
Warfarin
- Can give orally
- Full anticoagulant effect is delayed (4-5days)
- Long half-life
- Needs levels monitoring
Dabigatran (anti-thrombin), and Rivaroxaban (anti-Xa)
- Oral
- Acts rapidly
- Does not require monitoring
- Less reversibility available
In Liver disease what causes the pancytopenia?
Portal hypertension leads to splenomegaly and inhibits spleen function
What three veins contribute to the portal vein?
Superior and inferior mesenteric and splenic.
What is the function of the portal system? What is it’s pathway?
Drains blood from the GI tract, spleen, pancreas and gallbladder to the liver (to metabolise) then this is drained by the hepatic veins into the IVC.
What varices do you get in portal hypertension
Why do you get them in portal HTN?
Lower oesophageal
Anal wall
Caput medusa (on abdominal wall)
They are portal-systemic anastomoses and these engorge with increased pressure.
What are the different types of insulin and examples of them?
Rapid acting insulin analogues (act faster, and have shorter duration), often bolus in regimes:
- Novorapid
- Humalog
Short acting insulins: (can be bolus in regime)
- Actrapid
- Humulin S
Long acting insulins
- Levemir
- Lantus
There are also premix solutions available, e.g. Novomix
Relationship between steroids and insulin control?
Steroids induce hyperglycaemia and therefore insulin may need to be increased.
What is the difference in vertigo and dizziness?
Vertigo
- Experience of movement of self +/- the environment (especially rotation)
Dizziness
- Non-specific, light headed feeling, feeling faint (funny turns)
What are pleural plaques?
Plaques usually in the parietal pleura, caused by asbestos exposure, benign in themselves.
What is thyrotoxicosis?
Hyperthyroisim
What is diabetes insipidus? What are it’s causes?
Condition caused by hyposecretion or insensitivity of ADH:
- Cranial: hyposecretion
- Nephrogenic: resistance
Cranial: inherited or some kind of lesion
Nephrotoxic: acquired through metabolic disorders or congenital.
Acute alcoholic Tx?
Pabrinex, chlordiazepoxide
Paracetamol OD investigations and Tx?
Paracetamol levels
N-acetyl cystine
Pattern of spirometry changes in obstructive and restrictive lung disease?
Obstructive
- FEV1 reduced
- FVC normal
- Ratio reduced
Restrictive
- FEV1 reduced
- FVC reduced
- Ratio Normal
Examples of obstructive and restrictive lung disease?
Obstructive (obstruct airways)
- COPD
- Asthma
- Bronchiectasis
Restrictive (decrease lung vol.)
- Pulmonary fibrosis (scarring, e.g. drug treatment/radiotherapy)
- TB
- ARDS
On an ECG If leads 1 and 3 are positive what does this show?
Normal axis
On an ECG if leads 1 and 3 are facing away from each other what does this mean?
Leaving = L for Left
Left axis deviation
On an ECG if leads 1 and 3 are facing towards each other what does this mean?
Returning = R for Right
Right axis deviation
Asthma exacerbation treatment?
O SHIT M
Oxygen hi-flo 100%
Salbutamol neb (if over 5y/o, 5mg)
Hydrocortisone - IV 200mg
Ipratropium bromide neb 500mg
Magnesium
Types of haematuria and their causes?
Visible (painful/not):
Painful
- Infection/stones/thrombosis/cysts/trauma
Painless
- Cancer/exercise induced
Non Visible
Glomerular (usually w/ protein)
- IgA nephropathy/Glomerularnephritis
- Hereditary Alports/benign/familial
Non-glomerular:
- Infection, BPH, Stones, Polyps, Ca., Cysts, sickle cell, necrosis
Normal fluid output for an adult?
0.5ml/kg/hr for an adult
Why is urinary retention such an emergency?
UTIs - urine hanging about
AKI - reflux of urine into the kidney
Bladder damage - stretch on the bladder itself
Points of anaphylaxis immediate management? (adult)
- Rapid A-E
A- Look for and relieve obstruction, remove any traces of allergen left
B- Look for and treat bronchospasm and signs of respiratory distress
C- Colour, pulse and BP
D- AVPU/GCS
E- Assess skin
- Give HiFlo oxygen
- Lay patient flat
- Give 0.5mg 1:1000 IM adrenaline
- Repeat after 5 mins if no improvement - Establish airway
- IV fluid challenge
- Crystalloid (0.9% NaCl, Hartmans, plasmolyte) - 10 mg IV Chlorphenamine
- 200mg IV/IM hydrocortisone
- If still needing respiratory resus then can use salbutamol, ipratropium, aminophylline or mag sulf
- Continue to monitor:
- BP
- ECG
- Sats & Pulse - Make sure you have removed allergen, recorded on the drug chart replace with alternative, do a tryptase to see if it was a true allergic reaction.
What are the reversible 4 H’s and T’s cause of cardiac arrest?
Hypoxia
Hypovolaemia (shock)
Hyperkalaemia (and other metabolic causes)
Hypothermia
Thrombosis
Tension pneumothorax
Tamponade
Toxins
Immediate treatment for MI? Mnemonic?
MONARCH
Morphine O2 Nitrate - GTN Aspirin Reduced risk - Beta Blockers, ACEI, Statin Clopidogrel Heparin (LMW)
What are the different types of laxative?
Stimulants
- Senna
- Bisacodyl - dolculax
- Docusate (also softener)
- Glycerol
Bulk forming
- Bran
- Ispaghula - fybogel
Osmotic
- Macrogol - movicol/laxido
- Lactulose
Softener
Arachis oil (enema)
Docusate (also stimulant)
Risks of a fall in the elderly?
Long lie
- Rhabdomyolysis - AKI
- Pressure sores
- Malnutrition etc
Bony fracture
- NOF
- Wrist
- Clavicle
- Vertebra
What level of protein:creatinine ratio would indicate nephrotic syndrome
> 300
How would you investigate HHS to confirm or refute your diagnosis?
Plasma Osmolarity - Usually above 300
What is ITP?
Immune thrombocytopenia
Autoimmune disorder causing reduced circulating platelets, due to increased destruction and decreased production. The most common presentation is petechiae or bruising, can cause larger bleeds, in children in normally occurs following a viral infection.
What is hepatorenal syndrome (HRS)?
A complication of end-stage liver disease, occurs in pts with :
- Chronic liver dysfunction
- Cirrhosis
- Ascites
- Acute liver failure
This leads to impaired RENAL function, often precipitated by lowered BP
About 35-40% of pts with end-stage liver failure will develop this.
What is the pathophysiology of hepatorenal syndrome?
What other hepatic failure complications is it associated with?
Associated with GI bleeds, Spontaneous bacterial peritonitis other infection e.g. Pneumonia
Splanchnic vasodilatation leading to system circulatory dysfunction and intrarenal arterial vasoconstriction - renal dysfunction.
Differing symptoms of Crohns and UC? What symptoms are common between the two?
UC:
- Bloody diarrhoea more common
- Abdominal pain in the left lower quadrant
- Tenesmus
Crohns
- Diarrhoea usually non-bloody
- Weight loss more prominent
- Upper gastrointestinal symptoms, mouth ulcers, perianal disease
- Abdominal mass palpable in the right iliac fossa
UC pharmacological management?
Aminosalicylates such as messalizine good for induction and maintenance of remission in UC
Corticosteroids for flare ups
Azathioprine
- when corticosteroids don’t cut it
Infliximab and other biologics to treat flare ups and induce remission
Crohns pharmacological management?
Initially glucocorticosteroid
What is the AFP tumour marker for?
Hepatocellular carcinoma and testicular ca.
What is a PTC procedure (gastro) and why would you perform it
Percutaneous transhepatic cholangiogram
Interventional radiological technique where cotrast is injected into the biliary tree to visualise it and can also be used to stent the biliary tree (Mr Cooms)
What is the proportion of inheritance in Dominant, recessive and X-linked disorders?
Autosomal dominant
- 50% affected
- 50% unaffected
Autosomal Recessive
- 25% affected
- 25% unaffected
- 50% carrier
X-Linked recessive disorders
- Only affect males
- Inherited from mother
- 50% chance males will be affected, 50% chance unaffected
- 50% chance females carrier, 50% unaffected
What is the relationship between gout and furosemide?
Furosemide may increase levels of uric acid to rise, and could lead to gout.
When do you measure troponin?
At presentation and at 10-12 hours after.
What are the types of atrial fibrillation and how long do they last?
Paroxysmal <1 week
Persistent >1 week (self terminates or cardioverted)
Permanent - can’t be terminated
What are the different classifications of diverticular disease?
Diverticulosis - Asymptomatic diverticulae
Diverticular disease - intermittent problems occurring due to diverticulosis - Intermittent abdo pain
Diverticulitis - Inflammation due to lodged stool and possible infection - Constant abdominal pain and fever
What are the Z and T scores in osteoporosis? What do the values mean for diagnosis?
T - In comparison to healthy population
Z - In comparison to age matched population
Osteopenia - T score of less than -1
Osteoporosis is a T score
What area of the body do DEXA scans generally measure?
The hip and spine
Management of osteoporosis?
Lifestyle advice:
- Nutrition
- Exercise
- Smoking
- Alcohol
Adcal if necessary
If postmenopausal and no #
- Bisphosphonates, first line is alendronate. Only recommended in postmenopausal women < 65 w/ confirmed osteoporosis and no fragility fractures.
- Second line includes risedronate and may be considered if >65 and unable to take alendronate - Denosumab reduces osteoclast activity, 6 monthly SC injections
- Strontium ranelate only if all other options fail
If Postmenopausal and ##
- Bisphosphonates - alendronate
- Raloxifen
- Strontium, Denosumab or Teriparatide
Some combination for premenopausal/Men - but should investigate why osteoporotic first
Features of liver failure as opposed to stable chronic liver disease?
Liver failure (acute or decompensated chronic disease) is characterised by:
- Raised PT time (coagulopathy)
- High bilirubin
- Hepatic encephalopathy
Also, may have ascites and jaundice
Chronic cirrhosis is often asymptomatic, and may present with vague lethargy e.t.c. AST/ALT rise, portal hypertension, ascites, hepatomegaly, jaundice e.t.c.
For breath/stool H.Pylori test to be most effective what can’t you have taken, and for how long?
PPI for past 2 weeks and Abx for past 4 weeks
Criteria for diagnosis of malnutrition?
BMI <18.5
BMI <20 and unintended Weight loss of >5% for last 3-6Months
Unintended Weight loss >10% in last 3-6Months
What are the types of bowel ischaemia, and the features of each?
Mesenteric ischaemia
- Small bowel
- Abdo pain
- Embolism
- Sudden onset & severe
- High mortality - needs urgent surgery
Ischaemic colitis
- Large bowel
- Abdo pain
- Multifactorial
- transient, less severe symptoms
- ‘Thumbprinting’
- Conservative management
What is achalasia?
Lower oesophageal sphincter dysfunction (stays contracted) shown on barium swallow with dilated upper oesophagus and very small lower oesophagus
How does achalasia present?
Difficulty swallowing solids and liquids equally
Some heartburn
Some regurgitation of food
How does haemochromatosis classically present?
Fatigue, erectile dysfunction and arthralgia Bronze skin Diabetes Liver pathology e.g. hepatomegaly Hypogonaodism Arthritis
What does Gamma GT bloods test for?
Raised GGT in chronic alcohol use, bile duct scarring and non-alcoholic liver disease.
How does autoimmune hepatitis present (inc. bloods)
Young females
- Raised antinuclear/anti smooth-muscle antibodies
Children
- LKM1 raised
Middle aged adults
- Soluble liver-kidney antigen
Generally:
- May present with signs of chronic liver disease
- Acute hepatitis: fever, jaundice etc (only 25% present in this way)
- Amenorrhoea (common)
- ANA/SMA/LKM1 antibodies, raised IgG levels
- liver biopsy: inflammation extending beyond limiting plate ‘piecemeal necrosis’, bridging necrosis
- ALT/AST rise
How do you interpret Hep B antigen/antibody bloods?
Previous immunisation: anti-HBs positive, all others negative
Previous hepatitis B (> 6 months ago), not a carrier: anti-HBc positive, HBsAg negative
Previous hepatitis B, now a carrier: anti-HBc positive, HBsAg positive
Way to remember:
HBsAg = ongoing infection, either acute or chronic if present > 6 months, OR prev. infection, now a carrier
anti-HBc = caught, i.e. negative if immunized OR IgM Anti-HBc - chronic
What is cardiomyopathy and what are the types?
Definition:
- ‘myocardial disorder in which heart muscle is structurally and functionally abnormal without coronary artery disease, hypertension, valvular or congenital heart diseases’.
Dilated cardiomyopathy:
- Most common
- Left or both ventricles are dilated
- Reduced ejection fraction
- Causes: ischaemic, alcoholic, genetic, idiopathic
Hypertrophic cardiomyopathy:
- Usually familial
- Preserved ejection fraction
Normal LVEF (L ventricular Ejection fraction)?
55-70%
What are the dose conversion rates for the different steroids?
20 - 5 - 4 - 1
Hydrocortisone - Prednisolone - Methylprednisolone - Dexamethasone
How do you calculate the CURB 65 score, what is it used for?
Pneumonia
Confusion Urea (>7) RR >30 BP <90 Systolic Above 65 age ?
What is a transudate and exudate pleural effusion? What can cause each?
Transudate is fluid pushed through capillary beds due to high pressure (oncotic or hydrostatic)
- Heart failure
- Cirrhosis
- Hypoalbuminaemia
Exudate is when fluid as leaked around cells in inflammation
- Pneumonia
- Malignancy
Sound of a fourth heart sound?
Le Lub dub
What causes a fourth heart sound?
HF, MI Cardiomyopathy, HTN (pressure overload)
Pressure overload causes what in terms of apex beat?
Powerful, non-displaced beat
Volume overload causes what in terms of apex beat?
Displaced beat (dilated heart)
Sound of a third heart sound?
Lub de dub
Causes of a third heart sound?
Normal in children and young adults (up to 30)
HF, MI, Cardiomyopathy and Hypertension
Mitral and aortic regurgitation (in volume overload)
Constrictive pericarditis
Signs of infective endocarditis?
2 in the hands (clubbing and splinters)
Rare: Oslers nodes, Roth spots and Janeway lesions
1 in the heart (changing murmurs)
2 in the abdomen (Splenomegaly, microscopic haematuria)
Types of tremor, and their findings on examination?
- Parkinsonian:
- Most obvious at rest.
- Usually unilateral
- Pill rolling quality
- Cog wheeling (on rapid flexion and extension)
- Better on movement - Fine tremor (Physiological)
- Thyrotoxicosis. anxiety, alcohol withdrawal
- Fine tremor
- Bilateral, symmetrical and non-progressive over time - Benign essential tremor
- Most obvious when doing something (although present at rest)
- Head nodding
- Symmetrical
- Amplitude is highly variable depending on emotional and physiological state. - Cerebellar (intention tremor)
- Most obvious at the end of an inaccurate movement (finger to nose)
Essentially
- Rest tremor - parkinsons
- Action tremor - benign essential
- Fine tremor, the same - physiological
- Intention tremor - cerebellar
How would you examine a tremor?
- Inspect
- Resting tremor?
- parkinsonian features
- Hyperthyroidism features
- Head nodding (benign essential)
- Tardive dyskinesia (e.g. lip smacking) - Arms outstretched - fingers spread
- Fine tremor (thyroid, anxiety, alcohol)
- Clubbing (acropachy)
- Sweating
- Pulse for tachycardia and fibrillation - Arms outstretched, wrists cocked back
- CO2 retention, hepatic encephalopathy - Finger-nose test
- Intention tremor (at end of movement - cerebellar)
- Tremor worse on movement (benign essential tremor)
Features of Renal bone disease, pathophysiology?
Osteoporosis
Hyperparathyroidism
Osteomalacia (not common)
Osteosclerosis
Renal damage leads to reduced activation of Vit D (loss of 1-alpha enzyme) and therefore less Ca++ absorption from the gut. Renal damage also leads to phosphate retention.
Decreased Ca++ leads to increased PTH
Increased PTH increases Osteoclast activity - resorbing bone
Increased PTH also increases Osteoblast activity causing increased sclerotic lesion laid down at bone end plates.
What are the three groups of thyroid antibodies and in what conditions are they raised?
Antithyroid peroxidase (TPA Ab) - raised in Hashimoto’s (thyroid cells destroyed) - Hypothyroidism.
Antithyroglobulin (TG Ab) - Raised in Hashimotos’s too.
Thyroid stimulating immunoglobulin Ab (TSI Ab) - Activate TSH receptors in the thyroid - Causing Graves disease - Hyperthyroidism.
What are the characteristics of small cell lung Ca., what medical pathologies is it associated with?
Rapid growing lesion with bad prognosis
Associated with Cushing’s disease and SIADH
Do smokers or non smokers get Adenocarcinoma of the lung?
Non-smokers
What medical abnormalities is squamous lung cancer associated with?
Raised calcium
What medical abnormality is large cell lung cancer associated with?
B-HCG raised
What is Interstitial lung disease what causes it?
Term for restrictive lung diseases caused by damage to the pulmonary interstitium (Connective tissue surrounding the alveoli and other structures).
Caused by many things, including idiopathic pulmonary fibrosis, inhalation of asbestos, Systemic inflammatory disorders, reactions to drugs (e.g. Amiodarone and methotrexate) and infections.
What is polymyalgia rheumatica? How does it present?
Inflammatory condition
Severe bilateral pain and morning stiffness (>45mins) of:
- Shoulder
- Neck
- Pelvic girdle
Raised CRP/ESR and Over 50, lasting for >2 weeks
What is Lichen Planus and Lichen Sclerosus?
Lichen Planus
- T cell mediated autoimmune disease
- Purple Polygonal Papules and Plaques
- All over body including mouth (often wrist ankles and back
Lichen sclerosus:
- Genital and perianal areas
- More common in women
- May be autoimmune - unknown
- in women can cause itching, bleeding (from microtrauma) and loss of vulval architecture
- In men penis may become white, firm and scarred.
- Can be extragenital (rare) - firm white plaques
How is B12 absorbed and what is pernicious anaemia?
B12 is mostly absorbed in terminal ileum and requires Intrinsic Factor (IF), secreted by parietal cells.
Pernicious anaemia is an autoimmune condition that causes loss of the mucosa of the body and fundus of the stomach resulting in the loss of parietal cells and therefore IF - B12 deficiency.
What type of anaemia does B12 deficiency cause?
Megaloblastic anaemia (macrocytic) - High MCV
What are the causes of megaloblastic (macrocytic anaemia)?
Deficiency of:
- Folate
- Folic acid
- B12
What are the causes of B12 deficiency?
- Gastrectomy, H-Pylori, congenital deficiency
- Inadequate intake e.g. Vegan/Vegetarian
- Malabsorption e.g. coeliac/crohns
- Drugs e.g. colchicine
Presentation of B12 deficiency?
Fatigue Lethargy SOB Faintness Headache Palpitations
Neurology
- Parasthesia
- Peripheral neuropathy
How does cauda equina syndrome present?
Variable clinical presentation, can be sudden onset or more insidious.
Typically :
- Bladder/bowel dysfunction
- Saddle anaesthesia
- Sexual dysfunction
- Motor or sensory dysfunction of the lower limb
What causes type 1 respiratory failure and type 2 resp failure?
Type 1
- COPD (both)
- Pneumonia
- Pulmonary fibrosis
- PE
- Pneumothorax
Type 2
- COPD (both)
- Severe asthma (getting very bad here)
- Myasthenia gravis
- Poly neuropathy
- Polio
- muscle disorders/skeletal abnormalities
What is cyclical vomiting syndrome?
Repeated episodes of severe nausea, vomiting and physical exhaustion.
No known cause, associated with migraines.
Severe nausea and sudden vomiting lasting from hours to days. Typically after a warm shower. Can be cannabis induced.
What is the Glasgow-Blatchford Score used for, what does a score above 6 indicate?
Used for Upper GI bleeds, above 6 needs an endoscopy.
Where are the three common regions of the bowel that Crohns affects?
40% in terminal ileum
30% in colon
20% have small and large disease
Management of decompensated liver disease?
Drain ascites - rule out spontaneous bacterial peritonitis
Aggressively treat issues that arise
Two cardinal features of osteoporosis?
Reduced bone mass
Disrupted bone architecture
Osteoporosis R/Fs?
White and Asian women Old Early menopause Smoking Reduced Ca++ intake
What are the risks associated with bisphosphonates?
Atypical fractures
- Often wrist
- Due to over-strengthened brittle bone
- Only a small risk, 130 fractures saved for every one it causes
- Reduce risk by having breaks in taking it
OsteoNECROSIS of the jaw
What is Teriperatide how does it work?
Most effective way of building bone
- Raises PTH
- Expensive, and only used in risky pts
What is the cardinal feature of osteomalacia
Loss of calcification (e.g. low Vit D)
Rickets in young
Management of Osteomalacia?
Diet, sunlight, Vit D/Ca++ supplements, treatment of underlying cause.
How does Denosumab work in the treatment of osteoporosis?
Inhibits osteoclasts
How long should you put a blood transfusion on for?
90mins - 4 hours
What is TACO?
Transfusion associated Circulatory Overload
How can you prevent the occurrence of TACO in infusions?
Take Hx and Exam - for R/Fs
- Low Albumin
- CVD
- GFR
- SIze of pt
Lifestyle advice for the management of reflux disease?
Quit smoking
Stop drinking Alcohol
Dietary changes:
- Less spicy foods
- Less fatty foods
- Eat smaller meals
- Eat meals earlier
Long term risks of Omeprazole?
Hyponatraemia
Glomerulonephritis
Gastroenteritis
Osteoporosis
What level of faecal calprotectin suggests pathology?
150 more convincing, but can be NSAIDS/Small bowel disease
What tests should you run before starting azothioprine?
HIV, EBV, CMV, Hep B and C
TPNT - enzyme that breaks it down
Differentials for pulmonary cavity?
CAVITY
Cancer
- SCC
Autoimmune
- GPA (granulomatosis with polyangiitis)
Vascular
- Pulmonary embolus/infarction
Infection
- Abscess (TB, Staph A)
Trauma
Youth
- Bronchogenic cysts
Who gets pseudomonas chest infections?
Immunocompromised pts only.
What sats do you aim for in a CO2 retainer?
88-92
Features of parkinsonism?
Cardinal:
TRAP
Tremor.
Rigidity.
Akinesia (bradykinesia).
Postural instability.
Also (less important)
- Asymmetric onset
- One side predominant
- Dyskinesia
- Fine tremor
- COgwheeling
Causes of parkinsonism?
80% - parkinsons disease
Others
- CVD
- Parkinsons plus
- Other brain disorders: post-HIV etc.
Symptoms of autonomic neuropathy?
Dry Skin
Dry mouth/Excessive
Bowels - constipated
Postural hypotension
Non-motor symptoms of Parkinsonism?
Depression/Anxiety Behavioural problems Sleep disarrangement/REM disorders Hallucinations Anosmia Anergia
What causes the first and second heart sound?
First is the Atrio-Ventricular valves closing at the end of atrial systole (diastole) = Lub
Second is the Aortic and pulmonary valves closing at the end of ventricular systole/start of diastole - Dub
Common causes of splinter haemorrhages?
Most common - Microtrauma
Can also be
- Vasculitis
- Infective Endocarditis§
What are the five common signs of endocarditis?
2 in the hands
- Clubbing
- Splinter haemorrhages
1 in the heart
- Changing murmurs
2 in the abdomen
- Splenomegaly
- Microscopic haematuria
Also rare: oslers nodes, janeway lesions, roth spots
Why do ventricular ectopics disappear when exercising?
They occur in diastole, when exercising daistole is shorter and so there is less of a window of opportunity.
How do ventricular ectopics appear on the ECG?
Broad complex premature beat with compensatory pause
What is the physiological difference between VT (with pulse) and Pulseless VT?
(Dr Clarke)
Pulseless VT is ‘loss of diastolic filling time with fast ventricular rates’
Basically the cardiac output increases with pulse up to about 160 BPM - it then falls from there (supra-ventricular tachycardia) and at about 180 BPM it becomes pulseless VT
Three main causes of AF (Dr Clarke)?
IHD, Rheumatic Heart Disease, Hyperthyroidism
Two possible explanations of an irregularly irregular pulse, how do you differentiate?
AF, Multiple Ventriclar Ectopics
- Exercise (Ventricular ectopics will disappear)
How do you assess whether the AF is well rate controlled?
Time the apical rate with stethoscope (<80 is good)
Rate control management in AF?
Do CHA2DS2VASC2 score (AF stroke risk)
Do HASBLED (major bleeding risk, to see if you can anticoagulate)
- Consider DOAC/Warfarin
First line:
- Betablocker
Second-line:
- Diltiazem, or digoxin is pt is sedentary
Third-line:
Dual therapy with two of the above
Rhythm control management in AF?
Paroxysmal AF (<48hrs) - spontaneous termination
- Pill in pocket e.g. Flecanide
- Rhythm control prophylaxis (below)
Indications for rhythm control
- New onset AF, last 48hrs
- LVH due to AF
- Reversible cause
- Young
- Symptoms despite rate control
- Acutely unwell
Rhythm control first step:
- Electrical/chemical cardioversion
Rhythm control prophylaxis
- Betablocker
- Amiodarone in LV dysfunction
- Droperadone if no LV dysfunction
- Flecanide is fo CHD or LV dysfunction
Warfarin INR target? With and Without mechanical prosthetic valve?
2-3 without
3-4 with a valve
Causes of Aortic stenosis?
Degenerative calcified valve
Congenitally bicuspid (will be <3y/o)
Rheumatic heart disease
Why does the left ventricle thicken in aortic stenosis
PRESSURE overload
What happens in pressure overload in the left ventricle?
LV thickens - inwards
Causes of Pressure overload to the left ventricle?
HTN
Aortic Stenosis
Coarctation of the Aorta
Hypertrophic cardiomyopathy
Management of Aortic Stenosis?
Check severity
- Syncope
- Angina
- SOB
Depending on severity, valve replacement (TAVI) is definitive treatment.
Classic changes seen in osteoarthritis on XRAY?
- Decreased joint space
- Osteophytes
- Subchondral cysts
- subchondral sclerosis
Motion sickness treated with what?
Hyoscine
Cyclizine
Promethazine
Way to remember the presenttaion of Argyll-robertson pupil?
Argyll-Robertson-Pupil (ARP)
ARP = accommodation reflex present PRA = Pupillary reflex (to light) absent
What are the little red papules commonly seen on the trunk in older adults called?
Cherry haemangiomas
What is the difference between spine myelopathy and radiculopathy?
Myelopathy - commonly seen in cervical spine myelopathy is actual reduction in function due to compression of the cord. (like cauda equina in the base)
Radiculopathy is a ‘pinched nerve’, it is when a spinal nerve is compressed resulting in parasthesia, numbness and can have weakness
What Infusion of glucose should you administer in an unconscious patient with hypoglycaemia?
80ml 20% glucose or 150/160ml 10% glucose
When would you use DPP-4 inhibitors in diabetic pts? Give an example of one?
Sitagliptin
Used in obese pts - no weight gain S/Es
Becks triad suggesting cardiac tamponade?
Hypotensive
Muffled heart sounds
Raised JVP
In pt’s with Myasthenia Gravis who are going to undergo General Anaesthesia what two drugs do you need to be aware will have different effects compared to the normal patient?
The Neuromuscular blocking drugs Suxamethonium and Rocuronium
Suxamethonium:
- Works by binding to Acetylcholine receptors in the NMJ and depolarising. In MG there are less receptors and so suxamethonium does not work as effectively, and pts need a higher dose
Rocuronium:
- Works by antagonising post-synaptic receptors at the NMJ and in MG as there are less receptors works more effectively than normal and pts will require a lower dose.
Difference in voluntary and involuntary guarding?
Voluntary
- when the patient is tensing because they are in pain
Involuntary (True guarding - do not say guarding unless you think it is this)
- When the patient’s abdo muscle is reflexively going into spasm because of peritonitis = acute abdomen
Features of an acoustic neuroma, (nerves?
Divided up into the cranial nerves it affects:
CN VIII (vestibulocochlear)
- Hearing loss
- Vertigo
- Tinnitus
CN V (trigeminal) - Loss of corneal reflex
CN VII
- Facial palsy (ipsilaterally)
What investigation is gold standard for acoustic neuroma?
MRI of cerebellar pontine angle
What malignancy are patients on long-term immunosuppressive treatment at risk of?
SCC
What type of pleural effusion is an empyema? What would you find on analysis of the fluid in an empyema?
It is an exudate
Low Glucose, Low pH (<7.2) and High LDH
What are the dermatological complications you get with reactive arthritis?
- keratoderma blenorrhagica (waxy yellow/brown papules on palms and soles)
- Circinate balanitis (painless vesicles on the coronal margin of the prepuce - foreskin or clitoris)
What type of blood cancer causes splenomegaly?
CML - Chronic myeloid leukaemia
Mnemonic for remembering the live attenuated vaccines?
MOOBY (PT)
MMR Oral (Pertussis) Oral (Typhoid) BCG Yellow fever
What causes subacute combined degeneration of the cord and how does it present?
Often caused by B12 deficiency where folate is being replaced but B12 is not in a macrocytic anaemia.
Presents with damage to posterior columns (Proprioception, light touch and vibration) - DCML
Also has mixed UMN and LMN signs
- UMN due to damage to lateral columns
- LMN due to peripheral nerve damage
What does stranding of the paranephric fat represent?
Spontaneously passed renal stone(s)
What medication would you use to replace Vit D in a CKD bone disease p?
Alfacalcidol
Presentation of an asymmetric, non-contiguous (non-adjacent) neuropathy affecting some motor and some sensory functions is likely…?
Mononeuritis multiplex
What are the two nephrology complications that can present after an URTI, how do you differentiate?
IgA Nephropathy - A - FIRST - 1/2 days after URTI
Post-strep glomerulonephritis - 1-2 weeks after URTI
What medication can you use to suppress lactation if required?
Cabergoline
First and second line treatment for MRSA?
First: Vancomycin or teicoplanin
Second: Linezolid
How does salicylate overdose present?
Initial mixed respiratory alkalosis
Then Metabolic acidosis
Other symptoms include hyperventilation, N&V, tinntus etc.
What is Adult Respiratory Distress Syndrome (ARDS)?
Two stages
First stage:
- You get bilateral pulmonary infiltrates (substance in the parenchyma of the lung - in this case exudative fluid). Without any evidence of cardiac generated pulmonary oedema.
Later stage
- Fibroproliferative changes - scarring which may reduce respiratory function.
Caused by:
- Sepsis
- Direct lung injury
- Trauma
- Acute pancreatitis
- Long bone fracture or multiple fractures (through fat embolism)
- Head injury
Presentation:
- Acute dyspnoea and hypoxaemia hours/days after event
Multi organ failure
Management of ARDS?
- Treat the underlying cause
- Antibiotics (if signs of sepsis)
- Negative fluid balance i.e. Diuretics
- Recruitment manoeuvres such as prone ventilation, use of positive end expiratory pressure
- Mechanical ventilation
What are the two hyoscine drugs used in bowel colic and in respiratory secretions, what one is used for what?
Hyoscine Butylbromide = Bowel colic
- Think of the Bs
Hyoscine Hydrobromide
- Respiratory secretions
Gas gangrene presents how? Normal causative organisms?
Black blisters, Fever, dehydration.
Normally Clostridium i.e. C diff etc.
Types of testicular cancers?
Seminomas or non-seminomas
For long term feeding what is the best option?
PEG feed
Acute management of AFib in three steps?
- If unstable then DCCV
- Treat sepsis (if has)
- Rate control with beta-blocker and NOAC
Most common types of leukaemia in adults and kids?
Kids (acute)
- ALL (by far)
- AML
Adults
- CLL
- AML
How do you remember xray changes in RA and in OA?
RA: ‘LESS’- Loss of joint space, Erosions, Soft bones (osteomalacia), Soft tissue swelling.
OA: ‘LOSS’- Loss of joint space, Osteophytes, Subchondral sclerosis, Subchondral cysts.
What are the blood abnormalities associated with SLE?
Anti-dsDNA and anti-smith are specific
ANA is positive, but not specific
You get low C3 and C4
Features of CREST syndrome?
CREST syndrome:
Calcinosis Raynaud's phenomenon oEsophageal dysmotility Sclerodactyly Telangiectasia
What drugs may cause polymorphic VT (torsades des pointes)?
Clarithromycin tricyclic antidepressants antipsychotics chloroquine terfenadine erythromycin
What is polymorphic VT (torsades des pointes)?
A rare arrythmia associated with a long QT
Dermatitis herpetiformis is associated with what condition?
Coeliac disease
Common causes of Mitral Regurg?
- Congenital
- Endocarditis
- Degeneration
Mitral Regurgitation signs found on examination?
Apex beat displacement
Quiet first heart sound
Pansystolic murmur radiates LOUDLY to the axilla
What are the main systolic and diastolic murmurs?
Systolic
- Aortic Stenosis
- Mitral regurgitation
Diastolic
- Mitral stenosis
- Aortic regurgitation
Signs of mitral stenosis?
Loud first heart sound (high atrial pressure keeps valve open until systole pushes it shut).
Malar flush (pulmonary HTN) JVP not raised until late
No displaced apex beat
Signs of aortic regurgitation?
Collapsing pulse
JVP not raised
Displaced apex beat
‘lub taar’
Sound of mitral stenosis and aortic regurgitation?
Mitral Regurgitation
- Lub de de or lub de durr
Aortic regurgitation
- Lub taaar
ECG changes in ACS?
T wave inversion
Q waves
New LBBB
ST elevation and reciprocal depression
Three cardinal signs of ACS
Cardiac chest pain
Troponin change
ECG changes
What ACS is troponin negative in?
Unstable Angina
What investigations do you do in ACS and why?
FBC - Anaemia associated with Cardiac ischaemia
U&Es - Hypo/hyperkalaemia & Renal function (baseline for ACEI)
LFTs - Baseline for statins, ticagrelor
Lipids
Troponin
Serial ECG
Glucose
A-E for management post MI?
Ace-inhibitor Beta blocker Cholesterol lowering statin Dual antiplatelet (Clopidogrel or ticagrelor & Aspirin) Echo - left ventricle dysfunction
What is the dual antiplatelet therapy given post-MI?
Clopidogrel/Ticagrelor - atl a year
Aspirin - lifelong
Mnemonic for complications post-MI?
sudden death on PRAED street
Sudden death Pump failure Rupture of papillary muscles of septum Aneurysm or arrhythmias Emobolism Dresslers syndrome (late pericarditis) and Acute pericarditis (more common)
Qualities of pericardial pain?
Sharp and worse on inspiration (like pleurisy)
Retrosternal and radiates to left (like angina)
Worse lying flat and better sitting forward (it’s own)
What is PTH’s effect on phosphate?
Increases renal excretion of phosphate
Tumours in Men 1 and Men 2a?
Men 1
- 3 Ps, named after organs
- Pancreatic, pituitary, parathyroid hyperplasia
Men 2a
- Not all Ps
- Medullary thyroid, Phaeochromocytoma, parathyroid hyperplasia
What is the rate of insulin infusion in DKA?
0.1ml/kg/hr
What is used to treat gastroparesis?
Metoclopramide
What does sarcoidosis do to the PR interval?
Prolongs the PR interval
What effect on heart sounds would a short PR interval have?
Loud S1
What is brugada syndrome?
Autosomal dominant condition, more common in asians, Ion channel dysfunction.
Presents with:
- Sudden death
- ST elevation V1-3, followed by neg, T wave
- Partial RBBB
What is a penis?
dunno but Matt Olney’s massive
ECG changes in Hypokalaemia?
U waves
Prolonged PR
ST depression
Small T waves
ECG changes in hyperkalaemia
tall tented T waves Flat p wave Broad bizarre QRS Slurring into ST segment eventually VF
Causes of a LBBB?
IHD
HTN
Aortic Stenosis
Cardiomyopathy
Effect of hypercalcaemia on the ECG?
Shortened QT interval
What factor is deficient in Haemophilia A?
Factor VIII
ECG changes in SAH?
ST elevation and depressed T waves
ECG changes in digoxin toxicity?
a short QT interval
ST depression
a prolonged PR interval
inverted T waves
ECG changes in cor pulmonale?
Increased P wave amplitude
Right bundle branch block
Right axis deviation
Which are the dihydropyridine calcium channel blockers and the non ones?
NON
- Verapamil
- Diltiazem
Dihydropyridine
- Amlodipine
- Nifedipine
- All others
How to remember the ECG changes in Cor pulmonale and in PE?
cor Pulmonale
P = Peaked P waves
PE
T wave inversion
Both have RBBB and Right axis deviation
What anticoagulant strategy is used in AF?
DOAC or Warfarin - Pt choice
Posterior MI ECG changes?
Tall R waves in V1 - 2
In carotid sinus hypersensitivity, when doing carotid sinus massage (and ECG monitoring) what would you expect to see?
Ventricular pause >4 seconds.
What are the changes in ECG that warrant immediate PCI?
ST elevation of > 2mm (2 small squares) in 2 or more consecutive anterior leads (V1-V6) OR
ST elevation of greater than 1mm (1 small square) in greater than 2 consecutive inferior leads (II, III, avF, avL) OR
New Left bundle branch block
When do you thrombolyse in PE?
Circulatory failure - Hypotension
What cardiac drug cis associated with angioedema
ACEI
How does an ASD present in adults?
Ejection systolic murmur radiates to the back (and split S2)
Can cause paradoxical stroke
Anticoagulant treatment following stroke with AF?
Aspirin 300mg for 2 weeks, then anticoagulation lifelong (warfarin recommended)
How can you differentiate Cardiac tamponade and Constrictive pericarditis?
Kussmauls sign in constrictive pericarditis
BP target for diabetics? What factor do you need to consider?
End organ damage, if no damage then
- 140/80
IF damage then
- 130/80
What timing of murmurs are Aortic Regurg and Mitral stenosis associated with?
Aortic regurg = EARLY
Mitral Stenosis = MID-LATE
Q RISK score for recommendation of statins?
> 10%
Main signs of VSD?
Ejection systolic murmur
Jerky pulse - Can be bisferiens
Others
Cardiac abnormality associated with polycystic kidney disease?
Mitral Valve prolapse
In what situations do you treat stage 1 hypertension?
< 80 yers old AND:
- Qrisk > 20%
- Diabetes
- End organ damage
- Renal disease
- Established cardiovascular disease
Definitive treatment of Wolff Parkinson White?
Ablation
How do you differentiate NSTEMI and Unstable angina?
Troponin rise in NSTEMI, not in Unstable angina
Management of Aortic dissection?
Type A (proximal) - surgical aortic root replacement
Type B (More distal) - Medically - BP reduction and analgesia
In anaphylaxis how often can you give adrenaline and salbutamol nebs?
Adrenaline every 5 mins
Back to Back salbutamol nebs if signs of respiratory distress still present
What is otosclerosis?
Autosomal dominant condition associated with hearing loss that is conductive at a young age, can be precipitated by pregnancy.
