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General Medicine (including COTE) Flashcards

1
Q

Renal causes of hypovolaemic hyponatraemia

A

Diuretics - thiazide + loop diuretics
Mineralocorticoid insufficiency e.g. Addison’s
Osmotic diuresis e.g. low glucose, urea
Nephropathy

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2
Q

Causes of euvolaemic hyponatraemia

A

SIADH
Abnormal ADH release e.g. hypothyroidism,
Psychogenic polydipsia
Other - high water, lower solute intake e.g. anorexia nervosa

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3
Q

Hypovolaemic causes of hyponatraemia

A

GI losses - diarrhoea, vomiting, pancreatitis
Skin losses - sweating, burns
Renal losses - diuretics, nephropathy
Other - Addison’s disease, sepsis

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4
Q

Hypervolaemic causes of hyponatraemia

A

Failures (heart, liver, renal)
Nephrotic syndrome

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5
Q

Clinical features of hyponatraemia

A

Headache
Confusion
N+V
Lethargy
Irritability
Seizures/LOC/Coma
Often asymptomatic

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6
Q

Outcome of urine tests in SIADH

A

High urine osmolality
High urine sodium
(Low serum sodium)

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7
Q

Management of SIADH

A

Stop offending medication if relevant (usualyl diuretics)
Fluid restriction
Tolvaptan - ADH receptor blocker

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8
Q

Potential complication of treating severe hyponatraemia too quickly

A

Central pontine myelinolysis (osmotic demyelination syndrome)

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9
Q

Medications that most commonly cause hyponatraemia

A

Diuretics - especially thiazide + loop diuretics
SSRIs esp citalopram
Antipsychotics e.g. haloperidol + phenothiazines
Carbamazepine
PPIs
ACE inhibitors

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10
Q

Blood tests in confusion screen

A

FBC: WCC for infection
CRP (infection)
U+Es (Uraemia + hyponatraemia)
Bone profile (hyper/hypocalcaemia)
B12/Folate (deficiency)
TFTs (hypothyroid)
Glucose
LFTs (hepatic encephalopathy)
Coagulation/INR (intracranial bleed)

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11
Q

What indicates a significant postural drop in hypotension

A

> 20 systolic drop
10 diastolic drop
Within 3 minutes from lying to standing

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12
Q

Post-ACS medications

A

Block An ACS
- Beta blocker
- ACEi
- Aspirin
- Clopidogrel
- Statin

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13
Q

Risk factors for dementia

A

Genetics - family history
Insulin resistance e.g. T2DM
Atherosclerosis
Hypothyroidism
Depression
History of head injury
HIV
PD

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14
Q

DSM-IV criteria for dementia

A

Decline in memory and learning (on tests)
One of:
- Aphasia
- Apraxia
- Agnosia
- Reduced executive function
Symptoms interfere with functioning
Gradual onset + continual decline
No known organic cause
Not due to delirium
Not due to mental health disorder e.g. depression

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15
Q

Differential diagnosis of dementia

A

Normal reduced cognition of advanced age
Delirium
Depression
Drug abuse/side effect
Medical disorders

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16
Q

Medical disorder differentials of dementia

A

Anaemia
Hypothyroidism
Cerebral tumours/metastases
Syphilis (neurosyphilis)
Amyloidosis
Creutzfeldt-Jakob disease
Poor nutrition

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17
Q

Features of Lewy-body dementia

A

Progressive cognitive impairment - persistent memory dysfunction not apparent in early stages
Cognition may be fluctuating, with lucid periods
Parkinsonism (typically develops after cognitive impairment)
Visual hallucinations (may have other symptoms e.g. delusions)
Depression + sleep disturbance

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18
Q

Pathology of Lewy-body dementia

A

Alpha-synuclein cytoplasmic inclusions (Lewy bodies)
In the substantia nigra, paralimbic + neocortical areas

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19
Q

Management of Lewy body dementia

A

Acetylcholinesterase inhibitors e.g. donepezil, rivastigmine
or Memantine (NMDA receptor amtagonist)

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20
Q

Medications to be avoided in Lewy body dementia

A

First generation antipsychotics - may develop irreversible parkinsonism
e.g. haloperidol

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21
Q

Risk factors for Alzheimer’s disease

A

Increasing age
FHx
5% cases inherited autosomal dominant
Caucasian ethnicity
Down’s syndrome
Apoprotein E allele E4

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22
Q

Macroscopic pathological changes in Alzheimer’s disease

A

Widespread cerebral atrophy
Particularly cortex + hippocampus

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23
Q

Microscopic pathological changes in Alzheimer’s disease

A

Cortical plaques due to deposition of type A-beta-amyloid protein
Intraneuronal neurofibrillary tangles
Caused by abnormal aggregation of the tau protein

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24
Q

Pharmacological management of Alzheimer’s disease

A

Acetylcholinesterase inhibitors e.g. donepezil, rivastigmine, and galantamine - for mild to moderate disease
2nd line: memantine (NMDA receptor antagonist)
- Moderate AD if intolerant of, or acetylcholinesterase inhibitors contraindicated
- Add on in moderate or severe
- Monotherapy in severe disease

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25
Contraindications/side effects of donepezil
Relatively contraindicated in bradycardia Adverse effects include insomnia
26
What is Pick's disease
Dementia caused by localised atrophy of the frontal and temporal lobes
27
Blood tests done in a patient with suspected dementia to exclude reversible causes
FBC U+E LFTs Calcium Glucose ESR/CRP TFTs Vitamin B12 + folate levels
28
Features of frontotemporal dementia/Pick's disease
Personality change Impaired social conduct Hyperorality Disinhibition Increased appetite Perseveration behaviours More common in patients under 65 Memory problems tend to occur later
29
Macroscopic changes in Pick's disease/FTD
Atrophy of the frontal and temporal lobes
30
Microscopic changes in Pick's disease/FTD
Pick bodies - spherical aggregations of tau protein Gliosis Neurofibrillary tangles Senile plaques
31
Assessment tool for frailty status
PRISMA-7
32
What is frailty
State of impaired homeostasis --> increased vulnerability to minor stressor events
33
Elements of PRISMA-7 assessment
Age Sex Health problems Help at home Mobility Social support
34
What is multimorbidity
The presence of two, or more, long-term health conditions
35
Causes of acute confusional state/delirium
PINCH ME: - Pain - Infection - Nutrition - Constipation - Hydration - Medication - Environment Metabolic causes Alcohol withdrawal
36
Features of delirium/acute confusional state
Memory disturbances (loss of short term > long term) May be very agitated or withdrawn Disorientation Mood change Visual hallucinations Disturbed sleep cycle Poor attention
37
Non-pharmacological management of delirium/acute confusional state
Treat underlying cause Modifcation of environment
38
Pharmacological management of delirium/acute confusional state
Oral haloperidol 0.5mg Oral olanzapine Except in parkinsonism/PD: atypical antipsychotics e.g. quetiapine + clozapine
39
Risk factors for vascular dementia
History of stroke/TIA AF Hypertension Diabetes mellitus Hyperlipidaemia Smoking Obesity Coronary heart disease FHx stroke or CVD
40
Presentation of cognitive decline in vascular dementia
Several months/years of a history of a sudden/stepwise deterioration of cognitive function
41
Features of vascular dementia
Focal neurological abnormalities Difficulty with attention + concentration Seizures Memory disturbance Gait disturbance Speech disturbance Emotional disturbance
42
Management of vascular dementia
Reduction of vascular risk factors: - Aspiring or warfarin therapy - Controlling BP - Anticholinesterases + memantine: may have some benefit
43
STOPP tool
Screening Tool of Older Person's Prescriptions Aims to improve appropriateness of prescriptions, reduce occurence of adverse events, and reduce drug costs Used to identify potentially inappropriate drugs in a patient >65 years
44
START tool
Screening Tool to Alert doctors to the Right Treatment
45
Tool used to assess risk of major bleeding in patients who are on anticoagulants
HAS-BLED
46
Medications that may cause constipation
Codeine Ondansetron
47
Required level of understanding in capacity assessment
It is enough to understand salient details - must ensure level of understanding is not set too high and that the information is only relevant to the decision itself
48
What is 6CIT
Six Item Cognitive Impairment test Used as a brief test of cognitive function
49
Medications that may cause delirium
Anticholinergic drugs e.g. TCAs, neuroleptics, oxybutynin Opioids Benzodiazepines Antiparkinsonian agents H2 receptor blockers Cardiovascular agents e.g. beta-blockers, digoxin, or diuretics
50
Anti-emetic for chemo-induced nausea
Ondansetron
51
Anti-emetic for intracranial causes of nausea e.g. raised ICP/direct effect of tumour
Haloperidol
52
Anti-emetic for vestibular causes of nausea
Prochlorperazine
53
Anti-emetic for gastrointestinal causes of nausea
Metoclopramide
54
Causes of primary hyperaldosteronism
Low renin due to high BP Bilateral adrenal hyperplasia Adrenal adenoma secreting aldosterone (Conn's syndrome) Familial hyperaldosteronism Adrenal carcinoma
55
Causes of secondary hyperaldosteronism
High renin --> more aldosterone Generally happens when kidney BP disproportionately lower than rest of the body Renal artery stenosis Renal artery obstruction Heart failure
56
Investigations in hyperaldosteronism
Renin/aldosterone ratio; - High aldosterone, low renin --> primary - High aldosterone, high renin --> secondary Serum electrolytes: - Hypokalaemia (increased excretion) - Hypernatraemia (increased absorption) CT/MRI for adrenal tumour Renal doppler USS, CT angioram or MRA for renal artery obstruction
57
Management of hyperaldosteronism
Aldosterone antagonists e.g. spironolactone Treat underlying cause: - Surgical removal of adenoma - Percutaneous renal artery angioplasty for renal artery stenosis
58
First-line investigation for diagnosis of kidney stones
CT KUB
59
Stage 1 of AKI
Creatinine 1.5-1.9x higher than baseline, or Urine output <0.5ml/kg for >6 consecutive hours
60
Stage 2 of AKI
Creatinine 2-2.9x higher than baseline, or Urine output ,0.5ml/kg for >12 consecutive hours
61
Stage 3 of AKI
Creatinine >3x higher than baseline, or Urine output <0.5ml/kg for >24 consecutive hours
62
Stage 1 of CKD
eGFR >90
63
Stage 2 CKD
eGFR 60-89
64
Stage 3 CKD
3a eGFR 45-59 3b eGFR30-44
65
Stage 4 CKD
eGFR 15-29
66
Stage 5 CKD
eGFR <15 End-stage renal failure
67
Features of steroid-responsive COPD
Asthmatic features Atopic illness Variation in FEV1
68
Management of steroid-responsive COPD
Step 1: SABA or SAMA Step 2: SABA + LABA + ICS (discontinue SAMA and start SABA if prev using) Step 3: SABA + LABA + ICS + LAMA
69
Features of non-steroid responsive COPD
No asthmatic features No atopic illness No variation in FEV1
70
Management of non-steroid responsive COPD
Step 1: SABA or SAMA Step 2: SABA + LABA + LAMA (discontinue SAMA and start SABA if using previously)
71
Features of multiple myeloma
Bone disease: pain, osteoporosis (+fractures), osteolytic lesions Lethargy Infection Hypercalcaemia Renal failure
72
What is genetic anticipation
Hereditary diseases have an ealrier age of onset through successive generations
73
Examples of diseases exhibiting genetic anticipation
Trinucleotide repeat disorders e.g. Huntington's disease Myotonic dystrophy
74
Score used to identify patients at risk of pressure sores
Waterlow score
75
First line pharmacological management of COPD
SABA e.g. salbutamol Short antimuscarinics e.g. ipratropium bromide
76
Why is heparin contraindicated in acute bacterial endocarditis
Patients are believed to be susceptible to haemorrhagic transformation of embolic lesions
77
Immediate management of cardiac event
MONA Morphine Oxygen therapy Nitrates Aspirin
78
Investigations in heart failure
BNP (brain natriuretic peptide) - raised CXR (ABCDE) - Alveolar oedema - kerley B lines - Cardiomegaly - Dilated pulmonary vessels - pulmonary Effusion Echocardiogram: reduced ejection fraction, LV dilation ECG: LV hyertrophy (tall QRS)
79
Management of heart failure
Diet Education Pneumococcal + flu vaccinations Diuretics = furosemida 20-40mg OD 1st line for LV systolic dysfunction = ACEi + beta-blocker + furosemide
80
End-organ damage in hypertension
Left ventricular hypertrophy - tall QRS on ECG CKD - creatinine on U+Es Hypertensive retinopathy - fundoscopy
81
Target BP in hypertension management
140/85 In diabetes, CKD or CVD --> 130/80
82
Antibiotic for exacerbation of chronic bronchitis
Amoxicillin, tetracycline or clarithromycin
83
Antibiotics for uncomplicated community-acquired pneumonia
Amoxicillin (doxycycline or clarithromycin if allergic to penicillin) Add flucloxacillin if staphylococci suspected
84
Antibiotic for potential atypical pneumonia
Clarithromycin
85
Antibiotics for hospital-acquired pneumonia
Within 5 days of admission: co-amoxiclav or cefuroxime >5 days after admission: - Piperacillin with tazobactam; OR - Broad-spectrum cephalosporin e.g. ceftazidime; OR - Quinolone e.g. ciprofloxacin
86
Presentation of malignant hypertension
Papilloedema - must be present Retinal bleeding Increased cranial pressure --> headache + nausea Chest pain (due to increased cardiac workload) Haematuria (kidney failure) Epistaxis
87
Definition of malignant hypertension
Hypertension with acute end-organ damage >/=180/120

Phase 3A Revision (12 decks)

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