General mix Flashcards
how to remember NMS
FALTER
- Fever
- Autonomic isntability
- Leucocytosis
- Tremor
- Elevated (CK)
- Rigor
Missing one pill (less than 72 hours since the last pill was taken): COCP
- Take the missed pill as soon as possible (even if this means taking two pills on the same day)
- No extra protection is required provided other pills before and after are taken correctly
Missing more than one pill (more than 72 hours since the last pill was taken):
COCP
- Take the most recent missed pill as soon as possible (even if this means taking two pills on the same day)
- Additional contraception (i.e. condoms) is needed until they have taken the pill regularly for 7 days straight
Missing more than one pill (more than 72 hours since the last pill was taken):
COCP
- Take the most recent missed pill as soon as possible (even if this means taking two pills on the same day)
- Additional contraception (i.e. condoms) is needed until they have taken the pill regularly for 7 days straight
May have to take emergency contraception (see below)
The best way to understand the rules is to consider that theoretically women will be protected if they perfectly take the pill in a cycle of 7 days on, 7 days off. This will prevent ovulation.
- If day 1 – 7 of the packet they need emergency contraception if they have had unprotected sex
- If day 8 – 14 of the pack (and day 1 – 7 was fully compliant) then no emergency contraception is required
- If day 15 – 21 of the pack (and day 1 – 14 was fully compliant) then no emergency contraception is needed. They should go back-to-back with their next pack of pills and skip the pill-free period.
Missed pills POP
A pill is classed as “missed” if it is:
- More than 3 hours late for a traditional POP (more than 26 hours after the last pill)
- More than 12 hours late for the desogestrel-POP (more than 36 hours after the last pill)
Action required, if needed:
1) take the missed pill as soon as possible. If more than one pill has been missed just take one pill. Take the next pill at the usual time, which may mean taking two pills in one day
2) continue with rest of pack
3) extra precautions (e.g. condoms) should be used until pill taking has been re-established for 48 hours
Under which age is a child not able to consent to sexual intercourse
A child under the age of 13 is always considered to be unable to consent for sexual intercourse.
drugs for ADHD in children
First line: Methylphenidate (ritalin)
Second line: Atomoxetine
Atomoxetine is another stimulant medication. It is recommended for ADHD refractory to Methylphenidate or in those who it is not appropriate due to risk factors or development of side effects. Development of facial tics is an indication to change medications
what to always give with steroids and long term use of NSAIDs
PPI
ECOG
0- normal functioning
II- slight reduced functioning
II- >50% of time up and about
III -> 50% of time in bed
IV - bedbound
v- dead
chemo man
Cisplatin: otoxocity and nephrotoxicity
Bleomycin: pulmonary fibrosis
Cyclophosphamide- haemorrhagic cystitis
Methotrexate: bone marrow suppression
Vincristine- peripheral neuropathy
Transtuzuman and Doxorubicin- cardiotoxicity
malignant melanoma usually treated with
Mohs surgery
Immunotherapy
PD-1/PD-L1 immune checkpoint example
e.g. Nivolumab, Pembrolizumab
Used in melanoma, lung, renal cancers
Monitoring lithium
- Lithium levels in first 12 hours
- After 1 week untill stable
- every 3 months
after a change in dose, lithium levels should be taken a week later and weekly until the levels are stable
Every 6 months
- Thyroid function test
- Renal function tests
Patients should be issued with an :
- information booklet
- alert card
- record book
adverse effects of lithium
- nausea/vomiting, diarrhoea
- fine tremor
- nephrotoxicity: polyuria, secondary to nephrogenic diabetes insipidus
- thyroid enlargement, may lead to hypothyroidism
- ECG: T wave flattening/inversion
- weight gain
- idiopathic intracranial hypertension
- leucocytosis
- hyperparathyroidism and resultant hypercalcaemia
Lithium toxicity
Lithium toxicity generally occurs following concentrations > 1.5 mmol/L.
Toxicity may be precipitated by:
- dehydration
- renal failure
- drugs: diuretics (especially thiazides), ACE inhibitors/angiotensin II receptor blockers, NSAIDs and metronidazole.
Features of toxicity
- coarse tremor (a fine tremor is seen in therapeutic levels)
- hyperreflexia
- acute confusion
- polyuria
- seizure
- coma
Management
- mild-moderate toxicity may respond to volume resuscitation with normal saline
- haemodialysis may be needed in severe toxicity
atypical antipsychotic monitoring
Adverse effects of clozapine
- agranulocytosis (1%), neutropaenia (3%)
- reduced seizure threshold - can induce seizures in up to 3% of patients
- constipation
- myocarditis: a baseline ECG should be taken before starting treatment
- hypersalivation
Dose adjustment of clozapine might be necessary if smoking is started or stopped during treatment.
Autism definition
pervasive developmental disorder characterised by impairment in social interaction, communication and repetitive, stereotyped behaviour
ADHD definition
is characterized by an early onset, persistent pattern of inattention, hyperactivity and impulsivity that are more frequent and severe than in individuals at a comparable stage of development, and are present in more than one situation. Children may present with difficulties at school and at home
4 types of melanoma
Superficial spreading
Nodular melanoma
Lentigo maligna
Acral lentiginous (black people, think feet and nails)
A 3-day-old neonate born prematurely at 34 weeks’ gestation has been slow to wean off the ventilator since birth. On examination, she has been found to have a continuous heart murmur.
An echocardiogram has detected a patent ductus arteriosus. No other structural heart abnormalities have been found. A chest x-ray shows cardiomegaly and mildly congested lung fields.
What initial treatment should be started to manage this condition?
Emergency surgery
Indomethacin
Beta-blockers
Intravenous fluids
Prostaglandins
Indomethacin or ibuprofen is used in patent ductus arteriosus to promote duct closure
A mother presents with her baby to the GP for review. She asks for advice regarding her milestones and explains that her son was born was born prematurely at 32 weeks gestation.
With the premature age in mind, when should this baby begin to show a responsive social smile?
5 to 7 weeks
8 to 10 weeks
11 to 13 weeks
14 to 16 weeks
17 to 19 weeks
14-16 weeks
The corrected age of a premature baby is the age minus the number of weeks he/she was born early from 40 weeks
The corrected age is taken into consideration when looking at milestones until the age of 2.
management of bed wetting
desmopressin last line
An 8-year-old boy is brought to the attention of a psychiatrist by his mother with complaints of difficulty concentrating at home and at school. He is reported by the teachers to be easily distracted which is adversely affecting his learning. He also shows repeated outbursts of anger and his mother thinks he has ‘too much energy’. The psychiatrist diagnoses him with attention-deficit hyperactivity disorder (ADHD) and starts him on methylphenidate (Ritalin).
Which of the following parameters must be monitored every 6 months in this patient?
Full blood count (FBC)
Urea and electrolytes (U+E)
Thyroid function test
Weight and height
Visual acuity
Methylphenidate - monitor weight and height every 6 months
Expectant management of an ectopic pregnancy can only be performed for
1) An unruptured embryo
2) <35mm in size
3) Have no heartbeat
4) Be asymptomatic
5) Have a B-hCG level of <1,000IU/L and declining
A 30-year-old lady presents to the gynaecological outpatient department after she presented to her GP complaining of inability to conceive despite attempting for 2 years.
A trans-vaginal ultrasound scan is performed, and the report is given below:
TV USS A single 5 cm by 7 cm septated cyst is seen on the superior aspect of the right ovary. The left ovary is normal in size and morphology.
What further management would you suggest for this patient?
Book for a bilateral salpingo-oophorectomy
Commence metformin
Perform a serum CA-125, αFP and βHCG, and book for elective cystectomy
Perform an ultrasound-guided fine needle aspiration of the cyst for cytology
Reassurance and review with repeat ultrasound in 8 weeks / 3 menstrual cycles’ time
Perform a serum CA-125, αFP and βHCG, and book for elective cystectomy
Complex (i.e. multi-loculated) ovarian cysts should be biopsied with high suspicion of ovarian malignancy
An obstetrician is preparing themselves to perform an emergency lower segmental caesarian section for a 24-year-old woman who is suffering from complications of pre-eclampsia. After making an incision through the skin and superficial and deep fascia, what layers will the obstetrician have to cut through/traverse to reach the fetus?
Linea alba - rectus abdominis muscle - transversalis fascia - extraperitoneal connective tissue - peritoneum - uterus
External oblique - internal oblique - transversalis fascia - extraperitoneal fat - parietal peritoneum - uterus
Rectus abdominis muscle - posterior rectus sheath - transversalis fascia - extraperitoneal connective tissue - peritoneum - uterus
Anterior rectus sheath - rectus abdominis muscle - transversalis fascia - extraperitoneal connective tissue - peritoneum - uterus
Rectus abdominis muscle - linea alba - transversalis fascia - extraperitoneal connective tissue - peritoneum - uterus
Anterior rectus sheath - rectus abdominis muscle - transversalis fascia - extraperitoneal connective tissue - peritoneum - uterus
A 34-year-old pregnant woman presents at 30 weeks gestation for a routine check. On examination she has a symphysis-fundal height of 25 cm. What is the next most important investigation to confirm the examination findings?
Ultrasound
Cardiotocography
Biophysical profile
Umbilical artery Doppler
Urinalysis
US
The measurement of the symphysis-fundal height in centimetres should closely match the foetal gestational age in weeks within 1 or 2 cm from 20 weeks gestation. Therefore it can be inferred that the woman in this case is small for dates. It is therefore important to perform an ultrasound to confirm whether or not the foetus is small for gestational age.
Discuss (3)
Improve
Management of umbilical cord prolapse
- keep cord warm
- push any presenting part of fetus back in
- tocolytics e.g. terbutaline
- all 4s until CS ready
A 26-year-old primigravida woman attends the maternity centre at the start of labour at 38 weeks. Her pregnancy was marked high-risk because she was diagnosed with HIV last year and started on regular antiretroviral therapy. Her viral load at 36 weeks is shown below:
HIV Viral Load 35 RNA copies/mL (0-50)
What is the most appropriate delivery plan for this woman?
Continue with normal vaginal delivery
Prepare for an emergency caesarean section
Prepare for non-emergency caesarean section
Re-test her HIV viral load
Start an antiretroviral infusion during vaginal delivery
HIV in pregnancy: vaginal delivery is recommended if viral load is less than 50 copies/ml at 36 weeks
medical management of PPH not controlled by catheterisation and rubbing up the uterus
- IV oxytocin: slow IV injection followed by an IV infusion
- ergometrine slow IV or IM (unless there is a history of hypertension)
- carboprost IM (unless there is a history of asthma)
- misoprostol sublingual
- there is also interest in the role tranexamic acid may play in PPH
CAT 1 and CAT 2 caesareans should be done in
CAT 1- 30 mins
CAT 2- 75 mins
Caesarean sections may be categorised by the urgency
Category 1
- an immediate threat to the life of the mother or baby
- examples indications include: suspected uterine rupture, major placental abruption, cord prolapse, fetal hypoxia or persistent fetal bradycardia
- delivery of the baby should occur within 30 minutes of making the decision
Category 2
- maternal or fetal compromise which is not immediately life-threatening
- delivery of the baby should occur within 75 minutes of making the decision
Category 3
- delivery is required, but mother and baby are stable
Category 4
- elective caesarean
ascreening for DM in pregnancy
- women who’ve previously had gestational diabetes: OGTT should be performed as soon as possible after booking and at 24-28 weeks if the first test is normal.
- NICE also recommend that early self-monitoring of blood glucose is an alternative to the OGTTs
- women with any of the other risk factors should be offered an OGTT at 24-28 weeks
Diagnostic thresholds
- fasting glucose is >= 5.6 mmol/L
- 2-hour glucose is >= 7.8 mmol/L
antenatal screening
A 26-year-old woman is seen in the maternity unit at 12 weeks gestation regarding antenatal testing for Down’s syndrome and undergoes a screening test.
The results of her screening are as follows:
b-hCG increased
PAPP-A decreased
Ultrasound thickened nuchal translucency
Chance 1/80
She states that if she requires testing, she would like whichever option carries the least risk of harm to her and her baby. She has no past medical history.
What is the most appropriate next step in her management?
Arrange quadruple test
Discuss decisions regarding continuing pregnancy
Down’s syndrome unlikely - no further tests necessary
Offer amniocentesis
Offer non-invasive prenatal screening test (NIPT)
Offer non-invasive prenatal screening test (NIPT)
66%
Results of combined or quadruple tests for chromosomal conditions are reported as ‘lower chance’ or ‘higher chance’, using a cut-off of 1 in 150 to differentiate
A 32-year-old female patient attends clinic. She is 33 weeks pregnant and so far has had no complications with the pregnancy. However, she is now worried as she feels that her baby’s usual kicking and moving has reduced over the past few days. She has not noticed any other symptoms of concern and otherwise feels well. She has no significant past medical history, nor family history. She has had two previous uncomplicated pregnancies.
Physical examination is unremarkable, and observations are stable and within normal parameters. A handheld Doppler scan is performed; no fetal heartbeat is detected.
What is the next step in management?
Fetal blood sampling
Ultrasound scan
Repeat Doppler in 1 hour
Cardiotocography for 10 minutes
Cardiotocography for 20 minutes
Ultrasound scan
If after 28/40 weeks, if a woman reports reduced fetal movements and no heart is detected with handheld Doppler then an immediate ultrasound should be offered
2 forms of emergencvy contraception
- 72h (3 days)- Levonogestrel (levonelle)
- 120 h (5 days) Ulipristal acetate (EllaOne)
PID
Pus cells
Management of PID
- A single dose of intramuscular ceftriaxone 1g (to cover gonorrhoea)
- Doxycycline 100mg twice daily for 14 days (to cover chlamydia and Mycoplasma genitalium)
- Metronidazole 400mg twice daily for 14 days (to cover anaerobes such as Gardnerella vaginalis)
VTE in pregnancy
DR C BRaVADO
DR C BRaVADO is a mnemonic often taught to assess the features of a CTG in a structured way. It involves assessing in order:
DR – Define Risk (define the risk based on the individual woman and pregnancy before assessing the CTG)
C – Contractions
BRa – Baseline Rate
V – Variability
A – Accelerations
D – Decelerations
O – Overall impression (given an overall impression of the CTG and clinical picture)
normal contractions in labour
4-5 in 10
> 5 = hyperstimulation
normal baseline
110-160
normal variability in HR
5-25
summary of normal baseline and variability
Decelerations
Decelerations are a more concerning finding. The fetal heart rate drops in response to hypoxia. The fetal heart rate is slowing to conserve oxygen for the vital organs. There are four types of decelerations to be aware of:
Early decelerations
Late decelerations
Variable decelerations
Prolonged decelerations
Early decelerations are gradual dips and recoveries in heart rate that correspond with uterine contractions. The lowest point of the declaration corresponds to the peak of the contraction. Early decelerations are normal and not considered pathological. They are caused by the uterus compressing the head the fetus, stimulating the vagus nerve of the fetus, slowing the heart rate.
Late decelerations are gradual falls in heart rate that starts after the uterine contraction has already begun. There is a delay between the uterine contraction and the deceleration. The lowest point of the declaration occurs after the peak of the contraction. Late decelerations are caused by hypoxia in the fetus, and are a more concerning finding. They may be caused by excessive uterine contractions, maternal hypotension or maternal hypoxia.
Variable decelerations are abrupt decelerations that may be unrelated to uterine contractions. There is a fall of more than 15 bpm from the baseline. The lowest point of the declaration occurs within 30 seconds, and the deceleration lasts less than 2 minutes in total. Variable decelerations often indicate intermittent compression of the umbilical cord, causing fetal hypoxia. Brief accelerations before and after the deceleration are known as shoulders, and are a reassuring sign that the fetus is coping.
Prolonged decelerations last between 2 and 10 minutes with a drop of more than 15 bpm from baseline. This often indicates compression of the umbilical cord, causing fetal hypoxia. These are abnormal and concerning.
CTG is reassuring when
there are no decelerations, early decelerations or less than 90 minutes of variable decelerations with no concerning features.
scarlet fever vs strep A pharyingitis
Bacteria called group A Streptococcus (group A strep) cause scarlet fever.
These bacteria are also the cause of strep throat.
The bacteria sometimes make a toxin (poison), which causes a rash — the “scarlet” of scarlet fever.
Presentation temporal arteritis
- Unilateral headache typically around temple and forehead
- Scalp tenderness when brushing hair
- Jaw claudication
- Blurred or double vision
- Associated: fever, muscle aches, fatigue, weight loss, lossof appetite, peripheral oedema
Can cause papilloedema
Pathophysiology congenital hydrocephalus
Most common cause is aqueductal stenosis ->Insuff drainage of CSF
Cerebral aqueduct which connect third and fourth ventricle is stenosed
describing mass on head imaging
- Patient and imaging technique used
- Intra or extra-axial
- Shape
- Location
o Supra or infratentorial
o Lobes/ part of brain involved - Density OR intensity
o Hypo/hyperdense used with CT
o Hypo/hyperintense used with MRI - Border
o How defined
o Oedema - Contrast enhancement
o Homogenous/heterogenous
o Rim enhancement - Mass effect
o Effacement of sulci : ipsilateral / contralateral
o Midline shift
o Ventricle compression
o Basal cisterns: obliterated/patent - Hydrocephalus
DVLA and epilepsy
Car/motorbike licence
- one off seizure (not diagnosed with epilepsy/ no EEG changes)= reapply in 6 months
- epileptic who has had seizure = reapply in 12 months
seizure following change in antiepileptic medications = reapply to drive if seizure was more than 6 months ago or you’ve been back on previous medication for 6 months
Bus/coach/lorry licence
- one off seizure - reapply in 5 years or if you haven’t taken anti epileptic medications for 5 years
- more than one seizure = reapply once you haven’t had a seizure for 10 years or you haven’t taken any anti-epileptic medication for 10 years
management of tumour lysis syndrome
- Vigrourous rehydration (fluid resus: 500ml normal saline over 15 mins)
- Rasburicase to lower uric acid levels
- Calcium gluconate for hyperkalaemia
- Allopurinal to prevent i.e. give to patients at risk
Margins for BCC or SCC
- Surgical excision with 4mm margins if lesion <20mm in diameter.
- If tumour >20mm then margins should be 6mm.
margins for melanoma
Full assessment in Eye Casualty
- Visual acuity testing
- Near vision and colour vision
- Pupillary defects
- Visual fields and blind spot
- Oculomotor testing (H)
- Slit lamp (fluoresceine stain and Mydriatics (tropicamide, atropine)
- Fundoscopy
- Optical coherence topography or US
management of acne roseacia
first line: topical ivermectin
second line: topical metronidazole
third line: topical + lymecycline
management of norweigon crusted scabies
ivermectin
(normal permethrin or malathion)
length of follicular phase vs luteal
follicular is variable - usually around 14
luteal- always 14 days
14+14 = 28 (average cycle lenght)
if cycle length 24 days, then follicular phase wuld be 24-14 therefor day 10
summarise GBS
flaccid paralysis with some sensory defects caused by peripheral nerve destruction by antibdoies produced by B cells against recent infection (mimicry)
e.g. Epstein-Barr virus, CMV, campylobacter
- symetrical
- ascending weakness
Management of GBS
- IV immunoglobulins- KEY
- Plasma exchange (alternative to IV IG)- *plasmapheresis *
- Supportive care e.g. nutrition and hydration
- VTE prophylaxis (pulmonary embolism is a leading cause of death)
- In severe cases with respiratory failure patients may need intubation, ventilation and admission to the intensive care unit.
management of MND
No effective treatments for halting or reversing progression of the disease
Drug
Riluzole
o Can slow progression and extend survival by a few months in ALS
Edaravone
o Used in US and not UK
o Potential to slow progression of disease
Supportive
Non-invasive ventilation at night
Palliative
Prognosis
Patient will die between 2-3 years after diagnosis
which neurological conidtions are assoicared with Type 2 respiratory failure
GBS and MG
management of cluster headache
- sumatripan subcut
- high flow oxygen
- ramipril
- lithium
- steroids
Bells palsy management
For those presenting within 72h of symptoms:
- Prednisolone
- In general antivirals not recommender by NICE, but may. Offer some benefit
- Supportive: lubricating eye drop/ tape eyelids at night to prevent exposure keratopathy
Prognosis
- Full recovery over several weeks, may take 12 months
MS only affects
CNS oligodendrites
-> motor
MS vs MND
MS -> destruction of myelination
- mixed motor and sensory
- CNS
- mainly UMN
- can be relapsing and remitting
MND -> destruction of neurone
- just motor
- UMN and LMN
Q
MS lesions
A
A characteristic feature of MS is that lesions vary in their location over time, meaning that different nerves are affected and symptoms change over time. The key expression to remember to describe the way MS lesions change location over time is that they are “disseminated in time and space”.
Presentation of MS
Symptoms progress over more than 24 hours. At first presentation symptoms last day to weeks and then improve.
- Optic neuritis
- Eye movement abnormalities
- Focal weakness
- Focal sensory symptoms
- Ataxia
diagnosis of MS
- Symptoms have to be progressive over a period of 1 year
- Imaging: MRI scans can demonstrate typical lesions
- Lumbar puncture an detect “oligoclonal bands” in CSF
Ataxia and MS
Ataxia is a problem with coordinated movement. It can be sensory or cerebellar:
- Sensory ataxia is the result of loss of the proprioceptive sense, which is the ability to sense the position of the joint (e.g. is the joint flexed or extended). This results in a positive Romberg’s test and can cause pseudoathetosis.
- Cerebellar ataxia is the result of problems with the cerebellum coordinating movement. This suggestions cerebellar lesions.
Eye movement abnormalities and MS
Background
Patients may present with double vision due to lesions with the sixth cranial nerve (abducens nerve).
There are two key phrases to remember to describe a sixth cranial nerve palsy:
1) Internuclear ophthalmoplegia
2) Conjugate lateral gaze disorder.
conjugate lateral gaze
think abducens nerve palsy
For example, in a lesion affecting the left eye, when looking to the left, the right eye will adduct (move towards the nose) and the left eye will remain in the middle as the muscle responsible for making it move laterally is not functioning.
internuclear ophthalmoplegia
think abducens again (not sure why)
feature
* impaired adduction of the eye on the same side as the lesion
* horizontal nystagmus of the abducting eye on the contralateral side
Focal weakness in MS
Bells palsy
Horners syndrome
Limb paralysis
Incontinence
Focal sensory symptoms and MS
- Trigeminal neuralgia
- Numbness
- Paraesthesia (pins and needles)
- Lhermitte’s sign is an electric shock sensation that travels down the spine and into the limbs when flexing the neck. It indicates disease in the cervical spinal cord in the dorsal column. It is caused by stretching the demyelinated dorsal column.
M
MS
1) Clinically Isolated Syndrome
- This describes the first episode of demyelination and neurological signs and symptoms.
- MS cannot be diagnosed on one episode as the lesions have not been “disseminated in time and space”.
- Patients with clinically isolated syndrome may never have another episode or develop MS. If lesions are seen on MRI scan then they are more likely to progress to MS.
2) Relapsing-Remitting
Most common pattern at initial diagnosis.
It is characterised by episodes of disease and neurological symptoms followed by recovery.
In MS the symptoms occur in different areas with different episodes. This can be further classified based on whether the disease is active and/or worsening:
Active: new symptoms are developing or new lesions are appearing on MRI
- Not active: no new symptoms or MRI lesions are developing
Worsening: there is an overall worsening of disability over time - Not worsening: there is no worsening of disability over time
cerebellar lesions
e.g. cerebellar stroke or MS
Can present with vomiting, vertigo, difficulty walking etc
ipsilateral face pain and temperature loss
*contralateral limb pain and temp loss**
**Classic symptoms and signs **(Danish pneumonic)
- Dysdiadochokinesis
- Ataxic gait
- Nystagmus (fast phase towards lesion side)
- Intention tremor
- Slurred speech
- Hypotonia in the limbs
Blood supply to cerebellum is from the vertebra basilar system
- Occlusion of the three cerebellar arteries produce similar syndrome (don’t forget the brainstem)
- Therefore should also examine cranial nerves in order to establish if brainstem involvement
Q
obstructive nephropathy in lymphoma and renal cancer
due to retroperitoneal mass which causes renal ureter obsturction -> hydronephrosis -> AKI
investigations: USS
management: nephrostomy
Q
side effects of monoclonal antibodies such as rituximab
reactivation of virus’ and drug reaction
chemotherapy used in Hodgkin lymphoma
ABVD
- Adriamycin
- Bleomycin
- Vinblastine
- Dacarbazine
chemotherapy used in non- hodgkins lymphoma
R-CHOP
- Rituximab
- Cyclophosphamide
- Doxorubicin hydrochloride (hydroxydaunorubicin)
- Vincristine sulfate (Oncovin)
- Prednisone
RF for Upper tract transitional cell carcinoma (UTTCC)
- Analgesic misuse
- Exposure to aniline dyes used in the industrial manufacture of dyes, rubber and plastics
- Smoking
- Male to female ratio is 3:1
RF for RCC
- smoking
- male
- industrial carcinogens e.g. cadium
- haemodialysis
- Obesity
- HTN
- Anatomical abnormalities such as polycystic kidneys and horseshoe kidney
- Genetic disorders: Hippel-Lindau disease, BAP1 mutant disease
A 12-year-old boy presents for review. He was diagnosed with asthma three years ago by his general practitioner. He is currently on a salbutamol inhaler which he is using 2 puffs 3 times daily, a paediatric low-dose beclomethasone inhaler and oral montelukast. He still has a night time cough and has to use his blue inhaler most days. Unfortunately, there appears to have been little benefit following the addition of montelukast. His chest is clear on examination today with no wheeze and a near-normal peak flow.
What is the next step in his management?
Stop montelukast and add salmeterol
Increase dose of beclomethasone
Add regular oral prednisolone until symptoms are controlled
Add tiotropium
Add theophylline
Stop montelukast and add salmeterol
Child aged 5-16 years with asthma not controlled by a SABA + paediatric low-dose ICS + leukotriene receptor antagonist asthma management in children 5-16 - add a LABA and stop the leukotriene receptor antagonist
A 25-year-old man is counselled regarding the genetics of Huntington’s disease. Which one of the following best describes the concept of anticipation?
The psychological effect of a patient knowing they will develop an incurable condition
Less severe disease in successive generations
Earlier age of onset in successive generations
Where there is a known history of inherited conditions, patients may attribute symptoms to the onset of the disease
Screening at risk families to allow early intervention and improve outcomes
Anticipation in trinucleotide repeat disorders = earlier onset in successive generations
Earlier age of onset in successive generations
Anticipation in trinucleotide repeat disorders = earlier onset in successive generations
A 68-year-old man is in hospital after suffering a stroke ten days ago. Focused history and neurological exam is taken in the rehabilitation ward.
You report to your senior doctor that the patient has ataxia, nystagmus, right-sided ptosis and miosis, and diminished sensation in his left arm and leg. The patient can raise his eyebrows and has a symmetrical smile.
Where is the lesion most likely located?
Basilar artery
Left anterior cerebral artery
Left anterior inferior cerebellar artery
Right posterior cerebral artery
Right posterior inferior cerebellar artery
Right posterior inferior cerebellar artery
Lateral medullary syndrome - PICA lesion - cerebellar signs, contralateral sensory loss & ipsilateral Horner’s
A lesion in this artery caused lateral medullary syndrome, caused by ischemia to the lateral part of the medulla, which is responsible for various tracts, cranial nerve nuclei and physiological centres. Damage to this part of the medulla results in the clinical manifestations seen in the question stem. These include ataxia, nystagmus, ipsilateral Horner’s syndrome (ptosis and miosis) and contralateral upper and lower limb sensory loss.
brainstem anatomy
A 38-year-old man is brought to the emergency department after falling down the stairs. His past medical history is unknown.
On examination, he has scalp bruises and lacerations, but no obvious external bleeding. He is not opening his eyes and when supraorbital pressure is applied, he makes groaning noises without distinct words and his right arm reaches to his eye and tries to pull the examiner’s hand away.
What is his Glasgow coma score?
8
GCS: Motor (6 points) Verbal (5 points) Eye opening (4 points). Can remember as ‘654…MoVE’
when to head CT
Question 11 of 670
A 63-year-old man is seen in the neurology clinic with a 4-month history of recurrent falls and feeling clumsy. His only history is gastroenteritis 6 months ago.
He has significant leg muscle atrophy and reduced power in both the upper and lower limbs which are more severe on the right. Spontaneous involuntary muscle contractions and relaxations are seen in the upper and lower limbs. Reflexes are absent in the upper limb but brisk in the lower limb. Sensation and coordination are intact. Upgoing plantar reflexes are present bilaterally.
What is the most likely diagnosis?
Amyotrophic lateral sclerosis
Charcot-Marie-Tooth disease
Guillain–Barré syndrome
Multiple sclerosis
Multiple system atrophy
‘Fasciculations’ - think motor neuron disease
Important for meLess important
The presence of neurological motor symptoms and fasciculations with mixed upper motor neurone (UMN), lower motor neurone (LMN) signs, and very few or absent sensory signs should raise suspicion of motor neurone disease (MND). Fasciculations (described as spontaneous involuntary muscle contractions and relaxations here), atrophy, and absent reflexes are LMN signs, and brisk reflexes and upgoing plantar reflexes are UMN signs. This patient’s symptoms are more severe on the right.
A 56-year-old man presents to the emergency department with sudden onset double vision and right-sided upper and lower limb weakness. He has a past medical history of a transient ischaemic attack 6 months ago and type 2 diabetes mellitus.
On examination, there is ptosis of the left eyelid and the left eye is shifted downward and laterally. There is reduced power and sensation in the upper and lower right limbs. A cerebellar examination is unremarkable however the patient reports feeling nauseated during past-pointing assessment due to his double vision.
What is the most likely diagnosis?
Horner’s syndrome
Lateral medullary syndrome
Lateral pontine syndrome
Middle cerebral artery stroke
Weber’s syndrome
Weber’s syndrome is a form of midbrain stroke characterised by the an ipsilateral CN III palsy and contralateral hemiparesis
Important for meLess important
This patient has presented with cranial nerve III palsy and right-sided hemiparesis. This is consistent with the midbrain stroke termed ‘Weber’s syndrome’. The most common locations for infarcts are the basilar paramedian mesencephalic branches and posterior cerebral artery peduncular perforating branches. Patients are most likely to have a previous history of hypertension, diabetes, or hypercholesterolaemia. If the insult is severe, there may be dilated unresponsive pupils.
An 81-year-old man presents to the emergency department complaining of visual disturbance and headache. The headache came on suddenly around an hour ago in the occipital region. On examination, his left eye is depressed and laterally deviated, and there is left-sided ptosis. The left pupil is dilated and he has diplopia at rest with pain on all movements of the left eye. His past medical history includes hypertension and polycystic kidney disease.
Given the most likely diagnosis which vessel is affected?
Anterior communicating artery
Bridging veins
Middle meningeal artery
Posterior cerebral artery
Posterior communicating artery
Painful third nerve palsy = posterior communicating artery aneurysm
causes of third nerve palsy
- diabetes mellitus
- vasculitis e.g. temporal arteritis, SLE
- false localizing sign* due to uncal herniation through tentorium if raised ICP
- posterior communicating artery aneurysm
pupil dilated
often associated pain - cavernous sinus thrombosis
- Weber’s syndrome: ipsilateral third nerve palsy with contralateral hemiplegia -caused by midbrain strokes
- other possible causes: amyloid, multiple sclerosis
A 51-year-old man presents to the GP complaining of frequent flushing of his face and neck, causing him embarrassment at work. His skin also feels generally thicker than previously and he describes getting occasional papules, which he manages with simple facial cleansers. On examination, there is moderate erythema across his cheeks and nose, very mild telangiectasia, and a small number of papules.
What first-line treatment would you offer this man?
Oral doxycycline once daily for 8-12 weeks
Topical brimonidine gel
Topical ivermectin gel
Topical metronidazole gel
Topical retinoid with topical clarithromycin
For patients with rosacea with predominant flushing but limited telangiectasia, consider prescribing brimonidine gel
Benzydamine hydrochloride mouthwash
or spray can reduce pain from a painful mouth in patients undergoing palliative care. Maintaining good oral hygiene and avoidance of alcohol, tobacco, and spicy or acidic foods is also helpful.
action of hyoscine hydrobromide,
respiratory secretions & bowel colic
A 76-year-old woman is being managed in a hospice for metastatic lung cancer. Her main symptoms have been pain and agitation.
She has been started on a syringe driver containing morphine sulphate and midazolam. She is receiving the morphine at a rate of 60 mg in 24 hours.
Despite this dose, she remains in pain and you decide to increase her dose of morphine.
Which of the following options is the most appropriate dose to give over the next 24 hours?
65 mg
78 mg
100 mg
120 mg
240 mg
In palliative patients increase morphine doses by 30-50% if pain not controlled
A 65-year-old man is seen in the lung cancer clinic for investigation of a lung nodule in close proximity to his left main bronchus. He has also had some weight loss over the past 3 months. He has no past medical history or family history. He is on no regular medications and has no allergies. He has 65 pack year smoking history. He has no occupational exposure to asbestos.
Which of the following is the most likely histological diagnosis of this mass?
Carcinoid tumour
Squamous cell carcinoma
Mesothelioma
Adenocarcinoma
Large cell carcinoma
Squamous cell lung cancer has the strongest association with smoking
Lung cancer: non-small cell
There are three main subtypes of non-small cell lung cancer:
Squamous cell cancer
- typically central
- associated with parathyroid hormone-related protein (PTHrP) secretion → hypercalcaemia
- strongly associated with finger clubbing
- cavitating lesions are more common than other types
- hypertrophic pulmonary osteoarthropathy (HPOA)
Adenocarcinoma
* typically peripheral
* most common type of lung cancer in non-smokers, although the majority of patients who develop lung adenocarcinoma are smokers
Large cell lung carcinoma
- typically peripheral
- anaplastic, poorly differentiated tumours with a poor prognosis
- may secrete β-hCG
A 54-year-old man is investigated for a chronic cough. A chest x-ray arranged by his GP shows a suspicious lesion in the right lung. He has no past history of note and is a life-long non-smoker. An urgent bronchoscopy is arranged which is normal. What is the most likely diagnosis?
Lung sarcoma
Squamous cell lung cancer
Lung adenocarcinoma
Small cell lung cancer
Lung carcinoid
Lung adenocarcinoma
most common type in non-smokers
peripheral lesion
most common type of thyroid cancer
Papillary (80%) - MEN 1
Follicular
Medullary -MEN2 (calcitonin)
Anaplastic
Lymphoma
bilateral acoutstic neuromas associated with
neurofibromatosis type II
syndrome associated with pharyngeal cancer
Trotters Syndrome is a triad of clinical features suggestive of nasopharyngeal malignancy, comprised of
(1) unilateral conductive deafness (secondary to middle ear effusion),
(2) trigeminal neuralgia (secondary to perineural invasion), and
(3) defective mobility of the soft palate
A 68-year-old woman has been investigated as an inpatient for a six month history of cough and weight loss. Following a CT scan of her chest she is diagnosed with lung cancer. Biopsy and further imaging confirm this to be metastatic small cell lung cancer. After discussion at the multi-disciplinary team meeting and subsequently with the patient it is agreed that her treatment be palliative.
On the ward she has been taking codeine sulphate 60mg four times a day for pain however this is still poorly controlled. The decision is made to convert this to oral morphine.
What is the equivalent dose of oral morphine daily?
6mg
20mg
24mg
80mg
120mg
24mg
/10
whi
which thyroid cancer produces calcitonin
medullary
lithium toxicity
levels need to be monitored regularly
- 12h following first dose
- Weekly until therapeutic level (0.5-1.0mmol/l) has been stable for 4 weeks
- Once stable check every 3 months
o U+Es every 6 months
o TFTs every 12 months
Jackie is a 33-year-old female who is on the psychiatric ward being treated for bipolar disorder. She is currently taking lithium after being started on it 3 weeks ago. The doctor needs to take bloods to check if her levels have stabilised. Her last dose was 9am this morning, it is currently 12pm.
When should the doctor take the bloods?
Immediately
In 3 hours
In 6 hours
In 9 hours
In 12 hours
9 h
When checking lithium levels, the sample should be taken 12 hours post-dose
Angela is a 32-year-old doctor who you referred to the mental health team with suspected bipolar disorder. The psychiatrist has written to you to confirm a diagnosis of bipolar disorder and the commencement of lithium. Her levels have been monitored and she is now stable on treatment, therefore they have requested that you take over the monitoring.
You call Angela and advise that she will need her lithium levels. Angela remembers that it is important that she has these tests at a certain time related to her medication, but cannot remember when.
How would you advise her medication levels to be checked?
Blood test immediately pre dose every month
Blood test 6 hours post dose every 3 months
Blood test 6 hours post dose every month
Blood test 12 hours post dose every 3 months
Blood test 12 hours post dose every month
Blood test 12 hours post dose every 3 months
acute stress reaction vs PTSD
Acute stress disorder is defined as an acute stress reaction that occurs in the 4 weeks after a traumatic event, as opposed to PTSD which is diagnosed after 4 weeks
Adverse effects of clozapine
- agranulocytosis (1%), neutropaenia (3%)
- reduced seizure threshold - can induce seizures in up to 3% of patients
- constipation
- myocarditis: a baseline ECG should be taken before starting treatment
- hypersalivation
A 45-year-old female complains of lower back pain, constipation, headaches, low mood, and difficulty concentrating.
Her presentation is likely due to which of the following medications?
Clozapine
Quetiapine
Olanzapine
Imipramine
Lithium
Long-term lithium use can result in hyperparathyroidism and resultant hypercalcaemia
A 45-year-old man with schizophrenia taking chlorpromazine develops a bilateral resting tremor. What side-effect of antipsychotic medication is this an example of?
Tardive dyskinesia
Parkinsonism
Acute dystonia
Akathisia
Neuroleptic malignant syndrome
Parkinsonism
SSRI + NSAID =
GI bleeding risk - give a PPI
Aripiprazole has the most
tolerable side effect profile of the atypical antispsychotics, particularly for prolactin elevation
dopamine and schizophrenia theory
- An excess of dopamine and overactivity in the mesolimbic system is believed to cause the positive symptoms of schizophrenia. Dopamine antagonists are therefore used to treat schizophrenia.
- There is also thought to be less dopamine activity in the mesocortical tracts, causing the negative symptoms in schizophrenia. This explains why dopamine antagonists are more successful at treating positive than negative symptoms.
- Psychotic symptoms are seen in people with Parkinson’s disease if they are overtreated with levodopa as this increases the amount of dopamine in the brain. Amphetamines and cocaine also increase dopamine release and lead to psychosis.
- Dopamine is not the only neurotransmitter implicated in schizophrenia. There is also an increase in serotonin activity and a decrease in glutamate activity
mood congruent
look sad, say they are sad
mood congruent
look sad, say they are sad
*
*
management of alcohol withdrawal
A
Alcohol withdrawal
- Alcohol detoxification regime
- High dose benzodiazepines (commonly chlordiazepoxide), are given initially, and the dose is tapered down over 5-9 days
- Thiamines (Vit B1) to prevent Wernickes encephalopathy
o Orally or IV as Pabrinex
*
management of alcohol withdrawal
Alcohol withdrawal
- Alcohol detoxification regime
- High dose benzodiazepines (commonly chlordiazepoxide), are given initially, and the dose is tapered down over 5-9 days
- Thiamines (Vit B1) to prevent Wernickes encephalopathy
o Orally or IV as Pabrinex
Long term
- Disulfiram: Works by causing a build-up of acetaldehyde on consumption of alcohol, causing unpleasant symptoms e.g. anxiety, flushing and headache.
- Acamprosate: Reduces craving by enhancing GABA transmission.
- Naltrexone: Blocks opioid receptors (antagonist) in
the body, thus reducing the pleasurable effects of alcohol
B1 vs B12
B1- thiamine
B12- cobalamin (related to pernicious anaemia)
Common features of PTSD
- re-experiencing e.g. flashbacks, nightmares
- avoidance e.g. avoiding people or situations
- hyperarousal e.g.hypervigilance, sleep problems
SSRIs and pregnancy
- BNF says to weigh up benefits and risk when deciding whether to use in pregnancy.
- Use during the first trimester gives a small increased risk of congenital heart defects
- Use during the third trimester can result in persistent pulmonary hypertension of the newborn
- Paroxetine has an increased risk of congenital malformations, particularly in the first trimester
A 14-year-old girl is diagnosed with anorexia nervosa. Her parents initially presented as they had noticed she was severely limiting her dietary intake and losing weight. What treatment is she most likely to be offered?
Family based therapy
Self-guided cognitive behavioural therapy
Individual cognitive behavioural therapy
Group cognitive behavioural therapy
Fluoxetine
Family based therapy
You are asked to review a patient with generalised anxiety disorder (GAD) who has been taking sertraline for the last 6 months. They have previously tried citalopram with little benefit. The patient reports that they are still struggling with anxiety, chest tightness and palpitations on a regular basis and would like to try a new medication.
What would be the most appropriate medication to prescribe?
Citalopram
Clomipramine
Diazepam
Duloxetine
Mirtazapine
Duloxetine
If a first line SSRI such as sertraline is ineffective or not tolerated, try another SSRI or an SNRI for GAD
Important for meLess important
SSRI of choice for children
fluoxetine
bells palys symtoms
facial paralysis (non-forehead sparing)
hyperacusis
coeliac disease investigation
Patient must remain on gluten diet when investigations are happening (otherwise inflammation and antibodies may be missing)
TEST:
- total immunoglobulin A levels to exclude IgA deficiency before checking for coeliac disease specific antibodies
- Raised anti-TTG antibodies (first choice)
- Raised anti-endomysial antibodies
pathophysiology of Hirschsprungs
Nerve cells of myenteric plexus (Auerbach’s) are absent in the distal bowel and rectum
- Auerbach’s forms the enteric nervous system – brain of the gut
Auerbach’s runs all the way along the bowel in the bowel war and is a complex network of neurones, ganglion cells, receptors, synapses and NT - Causes peristalsis of the large bowel
- Without this stimulation -> bowel loses motility and food cannot pass food along
Key pathology: absence of parasympathetic ganglion cells – responsible for peristalsis
- Foetal development of the parasympathetic ganglion cells
- During fetal development these start in the upper GI tract and gradually migrate down the distal colon and rectum -> in Hirschsprung’s these cells do not travel all the way down the colon- therefore a section of the colon is left without these parasympathetic ganglion cells
- Aganglionic sections of the colon cannot relax-> therefore become constricted
- Proximal bowel will become distended and full
A parent brings their 2-week-old boy, who was diagnosed prenatally with Down’s syndrome, to hospital. He has been feeding poorly and has been constipated.
On examination, his abdomen is distended.
A colonic biopsy shows absence of ganglion cells in the submucosa.
What is the initial management for this condition?
Conservative management with monitoring of disease progression
Course of high dose steroids
Immediate surgery
Medical management with laxatives
Rectal washouts/bowel irrigation
Rectal washouts/bowel irrigation
which cells found in FBC for erythroderma
erythroderma- inflammatory skin condition affecting >90% of the body
- Sezary cells found on blood film (could suggest T-cell lymphoma
medication to stop postural hypotension
fludrocortisone
head lice treatmet
dimeticone
scabies is causes by which parasitic mite
Sarcoptes scabiei
hyphaema
- Blunt trauma that compresses the globe can have a shearing effect on the blood vessels of the iris, ciliary body and trabecular meshwork
- Can lead to haemorrhage (blood) in the anterior chamber with a fluid level -> hyphaemia
presbyopia
long sightededness associated with getting older
Pathophysiology
is the irreversible loss of the accommodative ability of the eye that occurs due to aging - stiffening of ciliary muscles
- As we get older, our lenses lose elasticity and become unable to change shape, hence why older people need reading glasses, which are convex spherical ‘plus’ lenses to add refractive power
presbycusis
Age-related hearing loss
Prophylactic treatments to reduce severity for chronic migraine sufferers
- Propranolol (avoid in asthma)
- Pizotifen (often causes drowsiness)
- Topiramate (girls with child bearing potential need highly effective contraception as it is very teratogenic).
muscular dystrophy summary
- progressive muscles weakening and wasting: x-linked recessive
- more common in males
- dystrophin gene abnormality
- Key types: Duchennes and Beckers (less severe)
Signs
- Gowers sign
- Waddling gait
- Calf pseudohypertrophy (enlarged calf- fat and fibrosis)
Investigations
- High CK
- Genotyping: Mutations in dystrophin
- Muscle biopsy- stain for dystrophin
Spinal muscular atrophy
- Autosomal recessive condition caused by progressive loss of motor neurones -> leads to progressive muscular weakness
- Does not affect intelligence
Pathophysiology
- Mutations in survival motor neuron 1 gene (SMN1)
- Neurone degeneration affects lower motor neurones in the spinal cord
management of pyloric stenosis
- Rehydration to correct metabolic abnormalities
- Laparoscopic pyloromyotomy (Ramstedts operation)
- o Incision is made in the smooth muscle of the pylorus to widen canal allowing food to pass from stomach to duodenum as normal
- Excellent prognosis
when are corticosteroids and mag sulphate given
- Maternal corticosteroids: before 35 weeks
- IV magnesium sulphate: before 34 weeks
tocolysis for preterm labour
nifedipine (CCB)
tocolysis for preterm labour
nifedipine (CCB)
Non reassuring CTG
- Baseline tachycardia or bradycardia
- Reduced baseline variability (flat)
- Absence of accelerations (non-reactive)
- Presence of decelerations
location of spinal and epidural
spinal- subarachnoid
epidural- epidural
Classification of perineal tears
There are four degrees of perineal tear, each involving injury to tissue beyond the previous:
- First-degree – injury limited to the frenulum of the labia minora (where they meet posteriorly) and superficial skin
- Second-degree – including the perineal muscles, but not affecting the anal sphincter
- Third-degree – including the anal sphincter, but not affecting the rectal mucosa
- Fourth-degree – including the rectal mucosa
preventing HIV transmission during birth
The mother’s viral load will determine the mode of delivery:
- Normal vaginal delivery is recommended for women with a viral load < 50 copies / ml
- Caesarean section is considered in patients with > 50 copies copies / ml and in all women with > 400 copies / ml
- IV zidovudine should be given during the caesarean if the viral load is unknown or there are > 10000 copies / ml
Down’s syndrome: antenatal testing
The combined test is now standard
- these tests should be done between 11 - 13+6 weeks
- nuchal translucency measurement +
- serum B-HCG
- pregnancy-associated plasma protein A (PAPP-A)
if women book later in pregnancy the quadruple test should be offered between 15 - 20 weeks
quadruple test: alpha-fetoprotein, unconjugated oestriol, human chorionic gonadotrophin and inhibin A
saThe most common cause of PPH by far is
uterine atony
safe antidepressants for breast feeding
paroexetine or sertraline
bishops score
options for induction
- membrane sweep
- vaginal prostaglandins
- cervical balloon ripening
- artifical rupture of membranes with oxytocin infusion (beware with previous c-section)
The Bishop Score should be assessed prior to induction of labour
Important for meLess important
- Cervical position (posterior/intermediate/anterior)
- Cervical consistency (firm/intermediate/soft)
- Cervical effacement (0-30%/40-50%/60-70%/80%)
- Cervical dilation (<1 cm/1-2 cm/3-4 cm/>5 cm)
- Foetal station (-3/-2/-1, 0/+1,+2)
MS lumbar puncture
oligoclonal bands
