General Practice Flashcards

Question

What is the ICD-11 Criteria for Acute Stress Reaction?

Answer 1

* **Exposure:** Direct or indirect to a traumatic event, resulting in intense emotional distress. * **Symptoms:** Include dissociation, intrusive memories, negative mood, arousal, or avoidance. * **Duration:** Persists for a brief period, typically between 3 days to 4 weeks post-event.

Answer 2

intrusive thoughts e.g. flashbacks, nightmares dissociation e.g. 'being in a daze', time slowing negative mood avoidance arousal e.g. hypervigilance, sleep disturbance

Answer 3

**Adjustment Disorder:** * Adjustment disorder involves diverse maladaptive responses to stressors, leading to disproportionate mood disturbances, impaired functioning, and cognitive alterations persisting for up to six months. **Post-Traumatic Stress Disorder (PTSD):** * PTSD is marked by persistent intrusion symptoms, avoidance behaviours, negative alterations in mood and cognition, and heightened arousal following exposure to a traumatic event, with symptom duration extending beyond one month.

Answer 4

**First Line: Trauma-focused CBT** * Occasionally medication may be used for symptomatic management such as sleep disturbance (benzodiazepines)

Answer 5

An umbrella term for hypersensitivity of the immune system to allergens. Allergens are proteins that the immune system recognises as foreign and potential harmful, leading to an allergic immune response.

Answer 6

A term used to describe a predisposition to having hypersensitivity reactions to allergens. It refers to the tendency to develop conditions such as eczema, asthma, hayfever, allergic rhinitis and food allergies.

Answer 7

* Asthma * Atopic eczema * Allergic rhinitis * Hayfever * Food allergies * Animal allergies

Answer 8

IgE antibodies to a specific allergen trigger mast cells and basophils to release histamines and other cytokines. This causes an immediate reaction. Typical food allergy reactions, where exposure to the allergen leads to an acute reaction, range from itching, facial swelling and urticaria to anaphylaxis.

Answer 9

**Cytotoxic Mediated Immune Reaction** IgG and IgM antibodies react to an allergen and activate the complement system, leading to direct damage to the local cells. **Examples are haemolytic disease of the newborn and transfusion reactions.**

Answer 10

Immune complexes accumulate and cause damage to local tissues. **Examples are autoimmune conditions such as systemic lupus erythematosus (SLE), rheumatoid arthritis and Henoch-Schönlein purpura (HSP)**

Answer 11

Cell mediated hypersensitivity reactions caused by T lymphocytes. T-cells are inappropriately activated, causing inflammation and damage to local tissues. **Examples are organ transplant rejection and contact dermatitis**

Answer 12

* Timing after exposure to the allergen * Previous and subsequent exposure and reaction to the allergen * Symptoms of rash, swelling, breathing difficulty, wheeze and cough * Previous personal and family history of atopic conditions and allergies

Answer 13

There are three main ways to test for allergy: * Skin prick testing * RAST testing, which involves blood tests for total and specific immunoglobulin E (IgE) * Food challenge testing

Answer 14

* Establishing the correct allergen is essential * Avoidance of that allergen * Avoiding foods that trigger reactions * Regular hoovering and changing sheets and pillows in patients that are allergic to house dust mites * Staying in doors when the pollen count is high * Prophylactic antihistamines are useful when contact is inevitable, for example hayfever and allergic rhinitis * Patients at risk of anaphylactic reactions should be given an adrenalin auto-injector

Answer 15

* **Antihistamines** (e.g. cetirizine) * **Steroids** (e.g. oral prednisolone, topical hydrocortisone or IV hydrocortisone) * **Intramuscular adrenalin in anaphylaxis** Antihistamines and steroids work by dampening the immune response to allergens. Close monitoring is essential after an allergic reaction to ensure it does not progress to anaphylaxis.

Answer 16

Autosomal dominant

Answer 17

Spherocytosis (horizontal deformity) - more severe, present neonatal jaundice and haemolysis Elliptocytosis (vertical deformity)

Answer 18

Deficiency of red cell membrane proteins caused by genetic lesions leading to haemolytic anaemia.

Answer 19

Jaundice Anaemia Splenomegaly

Answer 20

Deficiency in structural membrane protein Spectrin Makes RBCs more spherical and rigid Mistaken to be damaged and therefore prematurely destroyed by the spleen Causes Splenomegaly

Answer 21

General Anaemia Neonatal Jaundice Splenomegaly 50% have Gallstones

Answer 22

**FBC and blood film:** Normocytic Normochromic Increased Reticulocytes + Spherocytes **Diagnostic Test:** EMA (Eosin-5 Maleimide) Binding Test

Answer 23

**acute haemolytic crisis:** * treatment is generally supportive * transfusion if necessary **longer term treatment:** * folate replacement * splenectomy

Answer 24

Glucose-6-Phosphate Dehydrogenase deficiency

Answer 25

X linked recessive enzymopathy causing 1/2 RBC lifespan and RBC degradation

Answer 26

G6PD is required for glutathione synthesis Glutathione protects Red blood cells against oxidative damage

Answer 27

Mostly asymptomatic unless precipitated by oxidative stressor causing an attack: * neonatal jaundice is often seen * intravascular haemolysis * gallstones are common * splenomegaly may be present

Answer 28

G6PD Enzyme Assay (Reduced Levels) FBC: * anaemia and raised reticulocytes **Blood film:** * Normal in between attacks * Increased reticulocytes * **HEINZ bodies and BITE cells**

Answer 29

Avoid Precipitants - Oxidative drugs Blood transfusions when attacks come on.

Answer 30

Naphthalene Anti-malarials Aspirin FAVA beans Nitrofurantoin

Answer 31

- Low level of haemoglobin in the blood - It is the result of an underlying disease, and not a disease itself

Answer 32

Men: Haemoglobin - 120-165 g/L MCV - 80-100 femtolitres Women; Haemoglobin - 130-180 g/L MCV - 80-100 Femtolitres

Answer 33

Size of the red blood cells

Answer 34

- <135 g/L for men - <115 g/L for women

Answer 35

- Microcytic anaemia (low MCV indicating small RBCs) - Normocytic anaemia (Normal MCV indicating normal sized RBCs) - Macrocytic anaemia (Large MCV indicating large RBCs)

Answer 36

Tiredness Shortness of breath Headaches Dizziness Palpitations Worsening of other conditions such as angina, heart failure or peripheral vascular disease

Answer 37

Pale skin Conjunctival Pallor Tachycardia Raised Respiratory Rate

Answer 38

Secondary anaemia due to underlying pathology. Commonest anaemia in hospitals Occurs in patients with inflammatory disease

Answer 39

Iron is required for the synthesis of Haemoglobin. Therefore in Iron deficiency there is impaired synthesis of haemoglobin leading to Microcytic anaemia.

Answer 40

Iron Deficiency anaemia

Answer 41

Iron is being lost (BLEEDING) Insufficient dietary iron Iron requirements increase (for example in pregnancy) Inadequate iron absorption

Answer 42

Duodenum and Jejunum

Answer 43

Transported - Transferrin Stored - Ferritin and Haemosiderin

Answer 44

Iron is kept in the soluble ferrous (Fe2+) form by the stomach acid. When it enters the intestines and the acid drops, it changes to Insoluble ferric iron (Fe3+) The ferric iron is required for absorption. PPIs will increase insoluble ferric iron in the stomach that cannot be absorbed.

Answer 45

GI tract Cancer Oesophagitis and Gastritis - GI bleeding IBD, Colitis and Coeliacs - Impaired absorption

Answer 46

General Anaemia Sx PICA Brittle hair and nails Koilonychia Angular Stomatitis, Cheilitis Atrophic Glossitis

Answer 47

FBC - MCV = Low (microcytic anaemia) Blood Film - Hypochromic RBC, Target cells, Howell Jolly Bodies Iron Studies - Low Ferritin (<15), Low transferrin Saturation (<15%), Increased Total Iron Binding Capacity (TIBC) Endoscopy/Colonoscopy if >60 yrs to look for GI bleed

Answer 48

Oral Fe - Ferrous Sulphate (Ferrous Gluconate if poorly tolerated) Blood Transfusion

Answer 49

Cause GI Upset Nausea Diarrhoea Constipation Black stools

Answer 50

A microcytic anaemia characterised by ineffective erythropoiesis due to having the inability to incorporate Iron into blood cells

Answer 51

Defective Hb synthesis within Mitochondria Often X linked inheritance A Functional Iron deficiency where there is increased Fe but it is not used in Hb Synthesis

Answer 52

FBC - Microcytic Blood film - Ringed Siderobasts

Answer 53

- Mainly supportive - Iron chelation (Desferrioxamine) - Consider B6 (Pyridoxine) if hereditary

Answer 54

- Autoimmune condition in which atrophic gastritis leads to a lack of intrinsic factor secretion from the parietal cells in the stomach - Dietary B12 remains unbound and cannot be absorbed at the terminal ileum - Therefore B12 deficiency leads to impaired maturation of RBCs and anaemia

Answer 55

- Macrocytic anaemia with peripheral neuropathy and neuropsych complaints - It is a megaloblastic anaemia, as well as folate deficiency anaemia

Answer 56

* **Pernicious anaemia:** most common cause * post gastrectomy * vegan diet or a poor diet * disorders/surgery of terminal ileum (site of absorption) * Crohn's: either diease activity or following ileocaecal resection * metformin (rare)

Answer 57

Autoimmune atrophic gastritis

Answer 58

- DNA synthesis cofactor and the production of red blood cells - required for cell division - Without it, cells remain large (megaloblast) - It is normally present in meat, fish and dairy, and it absorbed in the terminal ileum combined with intrinsic factor

Answer 59

B12 typically binds to Transcobalamin in the saliva (provides protection against stomach acid) Parietal cells release Intrinsic factor (IF) IF forms complexes with Vit B12 which is then absorbed in the ileum B12 is then used for RBC production

Answer 60

* antibodies to intrinsic factor +/- gastric parietal cells * intrinsic factor antibodies → bind to intrinsic factor blocking the vitamin B12 binding site * gastric parietal cell antibodies → reduced acid production and atrophic gastritis. Reduced intrinsic factor production → reduced vitamin B12 absorption * vitamin B12 is important in both the production of blood cells and the myelination of nerves → megaloblastic anaemia and neuropathy

Answer 61

General Anaemia Sx Signs: Lemon Yellow Skin Angular Stomatitis and glossitis Neurological SX - B12 def causes suactue combined degeneration of the Spinal chord. presents as loss of DCML, distal paraesthesia and neuropsych symptoms (mood disturbances)

Answer 62

**Subacute Combined Degeneration of the Spinal Cord** Impairment of the dorsal columns, lateral corticospinal tracts and spinocerebellar tracts. **dorsal column involvement** * distal tingling/burning/sensory * loss is symmetrical and tends to affect the legs more than the arms * impaired proprioception and vibration sense **lateral corticospinal tract involvement** * muscle weakness, hyperreflexia, and spasticity * upper motor neuron signs typically develop in the legs first * brisk knee reflexes * absent ankle jerks * extensor plantars **spinocerebellar tract involvement** * sensory ataxia → gait abnormalities * positive Romberg's sign

Answer 63

MCV Increased - macrocytic anaemia Blood film - Megaloblasts + Oval Macrocytes Low serum B12 levels Anti-IF antibodies and Anti-parietal Abs

Answer 64

**Vitamin B12 replacement** * usually given intramuscularly * no neurological features: 3 injections per week for 2 weeks followed by 3 monthly treatment of vitamin B12 injections * Neurological features require more frequent injections **Folic Acid Supplementation**

Answer 65

- A type of MACROcytic anaemia with absence of neurological signs - Folate is required for cell division and DNA synthesis. Without it maturing RBCs wont divide - Megalobastic

Answer 66

- Poor diet (poverty, alcohol, elderly) - Increased demand (Pregnancy, renal disease) - Malabsorption (Coeliac) - Drugs, alcohol and methotrexate

Answer 67

Headache Loss of appetite and weight

Answer 68

General Anaemia Sx Angular Stomatitis and Glossitis No Neurological Sx - distinguish between B12 Def.

Answer 69

FBC and Blood film - Macrocytic and Megaloblasts Decreased serum folate

Answer 70

Dietary advice - leafy greens and brown rice Folate supplements If pancytopenic then give packed RBC Transfusion

Answer 71

Autoimmune Abs against RBCs causing intra and extravascular haemolysis

Answer 72

- Enzyme defects (G6P dehydrogenase deficiency) - Membrane defects (Spherocytosis, elliptocytosis) - Haemoglobinopathies (Abnormal Hb production) (Sickle cell, thalassaemia)

Answer 73

**Warm AIHA** * IgG mediated * Commonly causes extravascular haemolysis (splee) **Cold AIHA** * IgM Mediated * Causes haemolysis at 4 degrees * Commonly causes intravascular haemolysis

Answer 74

Direct Coombs Test - Agglutination of RBCs with Coombs reagent

Answer 75

- Anaemia symptoms (Pallor, fatigue, dyspnoea) - Jaundice (Increase in bilirubin) - Splenomegaly (increased haemolysis) - Dark urine (PNH)

Answer 76

Low Hb FBC - Normocytic Anaemia Blood film - Shistocytes, increased reticulocytes' Jaundice features: Inc bilirubin, Inc urinary urobilin, High faecal stercobilin Direct coombs Test - positive for autoimmune

Answer 77

**Treatment of any underlying disorder** * Steroids (+/- rituximab) are generally used first-line **Severe Cases** * RBC transfusion and folic acid * Splenectomy

Answer 78

Decreased EPO causes reduced erythropoiesis Normocytic and Normochromic anaemia

Answer 79

A Pancytopenia where Bone Marrow fails and stops making haematopoietic stem cells from pluripotent cells..

Answer 80

Anaemia caused by haemolysis - early breakdown of RBCs

Answer 81

Microcytic - CMV <80 Normocytic - CMV 80-95 Macrocytic - CMV >95

Answer 82

An anaemia characterised by large (macrocytic) non-condensed chromatin due to impaired DNA synthesis. B12 deficiency Folate Deficiency

Answer 83

Infection Liver disease Autoimmune disease - SLE/RA Cancers (often haematological)

Answer 84

Increased Loss: BLEEDING Haemolysis Decreased Production: Iron deficiency B12 deficiency Folate deficiency BM failure

Answer 85

Pale cells due to less haemoglobin

Answer 86

Crohn’s RA TB SLE Malignant disease CKD

Answer 87

* Increased Hepcidin → Decreased iron absorption and release → Functional iron deficiency. * Inflammatory cytokines (IL-6, TNF-α, IFN-γ) → Reduced erythropoiesis and blunted response to erythropoietin. * Shortened RBC lifespan → Increased destruction of red blood cells. * Iron sequestration in macrophages → Impaired hemoglobin synthesis.

Answer 88

FBC and blood film Normocytic/microcytic and hypochromic (pale) Low serum iron and low total iron-binding capacity (TIBC) Increased or normal serum ferritin

Answer 89

Treat underlying cause Recombinant erythropoietin

Answer 90

G6PD vital in hexose monophosphate shunt which maintains glutathione in reduce state. Glutathione protects the RBC from oxidative crisis Therefore in deficiency the RBCs are easily damaged by oxidative stress.

Answer 91

Thalassaemia Anaemia of chronic disease

Answer 92

Folic acid supplements Whilst this would treat the anaemia, this could mask the neurological symptoms predisposing you to an irreversible neurological deficit

Answer 93

Heart failure Angina Neuropathy

Answer 94

Both macrocytic megaloblastic anaemias B12 presents with anaemia Sx and Neurological deficits. Folate has no neurological deficits.

Answer 95

Intravascular - within blood vessels Extravascular - within reticuloendothelial system (most common) By macrophages in spleen (mainly), liver and bone marrow

Answer 96

Autoimmune haemolytic anaemia Infections - malaria Secondary to systemic disease

Answer 97

Folate and iron supplementation Immunosuppressives - prednisolone/ciclosporin Splenectomy

Answer 98

A – Autoimmune conditions (e.g., lupus) P – Parvovirus B19 and other viral infections (like hepatitis, HIV, EBV) L – Lithium (or other drugs/medications like chemotherapy, antibiotics) A – Alcohol or Toxins (like benzene) S – Stem cell disorders (e.g., Fanconi anemia) T – Treatments with radiation or chemotherapy I – Idiopathic (unknown cause) C – Congenital causes (e.g., dyskeratosis congenita, Shwachman-Diamond syndrome)

Answer 99

Anaemia Increased susceptibility to infection Increased bruising Increased bleeding (especially from nose and gums)

Answer 100

FBC – would show pancytopenia (low levels of all blood cells i.e. RBCs, WBCS etc.) Reticulocyte count – low or absent BM biopsy – hypocellular marrow with increased fat spaces

Answer 101

Remove causative agent Blood/platelet transfusion BM transplant Immunosuppressive therapy – anti-thymocyte globulin (ATG) and ciclosporin

Answer 102

Linear tears or cracks in the mucosa of the distal anal canal, often causing severe pain and bleeding during or after bowel movements.

Answer 103

* **Constipation:** Hard stools can cause tearing in the distal anal canal. * **Pregnancy:** Increased risk during the third trimester and post-delivery.

Answer 104

* Severe anal pain or a tearing sensation during bowel movements, lasting for hours afterward. * Anal spasms reported by about 70% of patients. * Bright red PR bleeding typically noticed on the stool or the toilet paper.

Answer 105

* **Hemorrhoids:** Painful, swollen veins in the lower portion of the rectum or anus. Signs include painless bleeding during bowel movements, itching or irritation in the anal region, discomfort, swelling around the anus, and a lump near the anus. * **Anal abscess or fistula:** Symptoms include anal pain, rectal discharge, bleeding, irritation, and fever. * **Anal cancer:** Symptoms can include anal bleeding, anal itching, a lump or mass at the anal opening, pain or feeling of fullness in the anal area. * **Inflammatory bowel disease** (Crohn's disease or ulcerative colitis): Symptoms include diarrhea, rectal bleeding, abdominal cramps and pain, an urgent need to move the bowels, and weight loss.

Answer 106

**Clinical physical examination**

Answer 107

**Management of an acute anal fissure (< 1 week)** * soften stool is the aim * Dietary advice: high-fibre diet with high fluid intake * **Bulk-forming laxatives are first-line** - if not tolerated then lactulose should be tried * Lubricants such as petroleum jelly may be tried before defecation * Topical analgesia/anaesthetics - Lidocain ointment **Management of Chronic Anal Fissure** * Continue above management * **Topical GTN Ointment** is first line **Patients with atypical anal fissures or symptoms/signs suggestive of Crohn's disease should be referred to a gastroenterologist.**

Answer 108

Asthma is a chronic inflammatory airway disease leading to **reversible airway obstruction**. The smooth muscle in the airways is hypersensitive and responds to stimuli by constricting and causing airflow obstruction.

Answer 109

Environmental trigger against specific allergens leads to sensitisation reaction where IgE Abs against antigen bind to mast cells. Secondary exposure leads to an immune system activation and activation of Th2 cells. Th2 cells produce cytokines such as IL3, 4, 5, 13. IL-4 leads to IgE Crosslinking and degranulation of mast cells releasing histamine and leukotrienes. IL-5 leads to eosinophil activation and release of proteins This leads to a Hypersensitivity Rxn which causes Smooth muscle bronchospasm and increased mucus production leading to narrow airways and airway obstruction.

Answer 110

Initially asthma and inflammation of the airways is reversible. Over chronic asthma the inflammation in the airways causes irreversible damage such as scarring and fibrosis causing thickening of the epithelial BM causing permanent narrowing of the airways.

Answer 111

* Increased number of and hypertrophy of smooth muscle * Constriction of smooth muscle cells (bronchoconstriction) * Increased mucous production * Swelling and inflammation (of mucosa) * Thickened basement membrane * Airway hyperreactivity, cellular infiltration

Answer 112

Asthma caused by environmental triggers within the workplace

Answer 113

* Family history * Personal history of atopy * Maternal smoking * Viral infections * Lower socioeconomic status * Occupational settings: Dusts, moulds, sands

Answer 114

* Infection * Night time or early morning * Exercise * Animals * Cold, damp or dusty air * Strong emotions * NSAIDs and Beta blockers

Answer 115

**Symptoms:** * **Wheeze** * Dyspnoea * Cough (may be nocturnal) * Chest tightness * **Diurnal variation** (symptoms worse in the morning) **Note: symptoms may worsen following exercise, weather changes or following the use of nonsteroidal anti-inflammatory drugs (NSAIDs)/beta blockers.** **Signs:** * Tachypnoea * Hyperinflated chest * Hyper-resonance on chest percussion * Decreased air entry * Wheeze on auscultation

Answer 116

**Peak Flow Diary:** * Due to diurnal variation theres readings will be lower in the morning * Twice daily readings over 2-4 weeks * Variability of **20% is positive and supports diagnosis** **Spirometry with Reversibility Testing:** * FEV1/FVC < 0.7 is suggestive of **obstructive airway disease** * Bronchodilator reversibility testing should **increase FEV1/FVC by > 12% and 200ml** **Fractional Exhaled Nitric Oxide (FeNO):** * NO is a marker of airway inflammation * **>40 ppb in adults or >35 ppb in children** is a positive result and supports diagnosis

Answer 117

NICE 2020 Guidelines **Initial Investigations:** * FeNO * Spirometry + Bronchodilator Reversibility **Where there is diagnostic uncertainty:** * Peak Flow Variability is the next step **Still Uncertainty:** * Direct bronchial challenge test with histamine or methacholine

Answer 118

* Smoking cessation * Avoidance of precipitating factors (eg. known allergens) * Review inhaler technique * Regular exercise * Vaccinations/yearly flu jab

Answer 119

1. Start a short-acting beta 2 agonist inhaler (e.g. salbutamol) as required 2. Add a regular low dose corticosteroid inhaler **Assess Inhaler Technique** 3. Consider offering a leukotriene receptor antagonist (LTRA) in addition to the low dose ICS. Review the response to treatment in 4 to 8 weeks. 4. Add a long-acting beta-2 agonist inhaler (e.g. salmeterol). Continue salmeterol only if the patient has a good response. (Consider stopping LRTA) 5. If asthma uncontrolled, offer to change the person's ICS and LABA maintenance therapy to a maintenance and reliever therapy (MART) regimen with a low maintenance ICS dose. 5. Titrate the inhaled corticosteroid up to a moderate dose. 6. If asthma is uncontrolled on a moderate maintenance ICS dose with a LABA (either as MART or a fixed-dose regimen), with or without an LTRA, consider a trial of an additional drug (Theophylline). Alternatively change ICS to high dose

Answer 120

* **Acid Reflux/GORD** * **Churg-Strauss Syndrome (EGPA)** * **Allergic Bronchopulmonary Aspergillosis (ABPA)**

Answer 121

An acute exacerbation of asthma involves a rapid deterioration in symptoms.

Answer 122

* Progressively shortness of breath * Use of accessory muscles * Raised respiratory rate (tachypnoea) * Symmetrical expiratory wheeze on auscultation * The chest can sound “tight” on auscultation, with reduced air entry throughout

Answer 123

Moderate: PEF > 50% predicted Severe: PEF < 50% predicted Life threatening: PEF < 33% predicted

Answer 124

PEF > 50% predicted Normal speech

Answer 125

* PEF 33-50% predicted * O2 saturations < 92% * Incomplete sentences * Signs of respiratory distress **Respiratory rate:** >25 **Heart rate:** >110 bpm

Answer 126

**33, 92, CCHEST:** * PEF **< 33%** predicted * **<92%** - Oxygen Stats * **C**yanosis * **C**onfusion/Consciousness/AMS * **H**ypotension * **E**xhaustion and poor respiratory effort * **S**ilent Chest/no wheeze * **T**achycardia

Answer 127

* Routine blood tests * Chest X-ray to rule out pneumothorax or consolidation * **ABG** as respiratory alkalosis is likely

Answer 128

**Maintain oxygen saturations between 94-98% with high flow oxygen if necessary.** **All patients should receive steroids (Oral Prednisolone or IV hydrocortisone) given IV only if the patient is unable to take the dose orally** * Administer **inhaled salbutamol** via spacer: 10 puffs every 2 hours * Proceed to **nebulised salbutamol** if necessary * Add **nebulised ipratropium bromide** * If O2 saturations remain <92%, **add magnesium sulphate** * Add **intravenous salbutamol if no response to inhaled therapy** * If severe or life-threatening acute asthma is not responsive to inhaled therapy, add **IV aminophylline** **If the patient is not responding to salbutamol or ipratropium, consult with a senior clinician**

Answer 129

A type of glaucoma characterized by the blockage or narrowing of the drainage angle formed by the cornea and the iris, resulting in a sudden increase in intraocular pressure.

Answer 130

* Predominantly affects older individuals >40 years

Answer 131

* Increasing age * Family history * Female (four times more likely than males) * Chinese and East Asian ethnic origin * Shallow anterior chamber * Hyperopia (long-sightedness) and short axial length of the eyeball

Answer 132

* Adrenergic medications (e.g., noradrenaline) * Anticholinergic medications (e.g., oxybutynin and solifenacin) * Tricyclic antidepressants (e.g., amitriptyline), which have anticholinergic effects

Answer 133

* Occurs when the iris bulges forward and seals off the trabecular meshwork from the anterior chamber * This prevents aqueous humour from draining and leading to a continual increase in intraocular pressure. * The pressure builds in the posterior chamber, pushing the iris forward and exacerbating the angle closure. **It is an ophthalmological emergency requiring rapid treatment to prevent permanent vision loss.**

Answer 134

**Symptoms** * **Severely Painful Red Eye:** an extremely painful eye that develops rapidly, with pain spreading throughout the orbit * **Blurred vision:** Can progress to vision loss * **Halos:** patients will often describe coloured haloes around lights * **Systemically unwell:** nausea and vomiting are very common presenting symptoms **Signs** * **Red eye:** ciliary flush with a hazy cornea * **Mid-dilated or fixed pupil** * **Hazy Cornea** * **Closed iridocorneal angles** on gonioscopy * **Corneal oedema** **Hard Eyeball due to Raised IOP** (defined as >21 mmHg)

Answer 135

* **Open-angle glaucoma:** Gradual loss of peripheral vision, usually in both eyes, and tunnel vision in the advanced stages. * **Acute anterior uveitis:** Red, painful eye, blurred vision, photophobia, and a small, irregular pupil. * **Retinal detachment:** Sudden appearance of floaters, flashes of light in the periphery, and a shadow or curtain over a portion of the visual field.

Answer 136

**Gonioscopy** - assessing angle between iris and cornea **Tonometry** - measurement of intraocular pressure **Ophthalmological examination**

Answer 137

**Acute angle-closure glaucoma requires immediate admission and urgent referral to ophthalmology. Measures while waiting for an ambulance are:** * Lying the patient on their back without a pillow * A Parasympathetomimetic (**Pilocarpine**) eye drops (2% for blue and 4% for brown eyes) * **Acetazolamide 500 mg orally** * Analgesia and an antiemetic, if required

Answer 138

Pilocarpine acts on the muscarinic receptors in the sphincter muscles in the iris and causes pupil constriction (it is a miotic agent). It also causes ciliary muscle contraction. These two effects open up the pathway for the flow of aqueous humour from the ciliary body, around the iris and into the trabecular meshwork.

Answer 139

Acetazolamide is a carbonic anhydrase inhibitor that reduces the production of aqueous humour.

Answer 140

Surgical management o reduce the Intra-ocular pressure **Peripheral/laser iridotomy:** makes a hold in the iris allowing aqueous humour to flow from the posterior chamber to the anterior chamber to relieve the pressure

Answer 141

Blepharitis refers to inflammation of the eyelid margins. One of the most common reaons for eye related primary care visits

Answer 142

It may due to either: * **meibomian gland dysfunction** (common, posterior blepharitis) * **Seborrhoeic dermatitis/staphylococcal infection** (less common, anterior blepharitis). * Also can be caused by HSV/VZV infection * Blepharitis is more common in patietns with rosacea

Answer 143

**The symptoms of blepharitis include:** * Painful, gritty, itchy eyes * Eyelids sticking together upon waking * Dry eye symptoms (due to reduced meibomian gland oils) * Symptoms associated with the causative condition (e.g., seborrhoeic dermatitis, acne rosacea) **The signs of blepharitis include:** * Erythema of the eyelid margins * Crusting or scaling at the eyelid margin * Visibly blocked Meibomian gland orifices

Answer 144

Blepharitis is a chronic condition for which there is no cure, but it can be well controlled and is rarely sight-threatening. The main management strategies include: * Softening of the lid margin using **hot compresses** twice a day * **'lid hygiene'** - mechanical removal of the debris from lid margins: * cotton wool buds dipped in a mixture of cooled boiled water and baby shampoo is often used * an alternative is sodium bicarbonate, a teaspoonful in a cup of cooled water that has recently been boiled * artificial tears may be given for symptom relief in people with dry eyes or an abnormal tear film

Answer 145

Acute infection of a gland at the edge of the eyelid or under the eyelid causing a small painful lump **External hordeolum** * Infection of an Eyelash follicle * It is an infection of the **glands of Zeis or Glands of Moll** **Internal Hordeolum:** is an abscess of the **meibomian gland**

Answer 146

A chalazion (Meibomian cyst) is a retention cyst of the Meibomian gland. It presents as a firm painless lump in the eyelid. The majority of cases resolve spontaneously but some require surgical drainage

Answer 147

Presents as a painful, red hot lump on the eyelid that points outwards, causing localized inflammation.

Answer 148

Not usually painful, but evolves into a non-tender swelling that points inwards.

Answer 149

* **Blepharitis:** Chronic inflammation of the eyelid, symptoms include red, swollen eyelids, crusting of the eyelashes, and a gritty sensation in the eye. * **Dacryocystitis:** Infection of the tear sac, symptoms include pain, redness, and swelling in the inner corner of the eye. * **Cellulitis:** Infection of the skin, symptoms include redness, swelling, warmth, and pain.

Answer 150

**Stye** * Warm compresses to promote drainage. * Topical antibiotics if infected. * Incision and drainage in cases of large or persistent styes. **Chalazion** * Warm compresses to encourage the gland to drain. * Steroid injections or surgical removal if it does not resolve after several weeks. * Antibiotics are not typically needed unless there is secondary infection.

Answer 151

* Entropion refers to when the eyelid turns inwards with the lashes pressed against the eye. * Causes pain and can result in **corneal damage and ulceration** * Management is taping down the eyelid to prevent it turning inwards + regular lubrication to prevent the eye drying out. * **Definitive management is Surgical**

Answer 152

* Ectropion refers to when the eyelid turns outwards, exposing the inner aspect. * Usually affects the bottom lid resulting in **exposure keratopathy** due to poor lubrication and protection of the eye ball * Management is to regularly lubricate the eye

Answer 153

* Trichiasis refers to inward growth of the eyelashes. It results in pain and can cause corneal damage and ulceration. * Management involves removing the affected eyelashes. * Recurrent cases may require electrolysis, cryotherapy or laser treatment to prevent them from regrowing.

Answer 154

Benign prostatic hyperplasia (BPH) is a very common condition affecting men in older age (usually over 50 years). It is caused by hyperplasia of the stromal and epithelial cells of the prostate. It usually presents with lower urinary tract symptoms.

Answer 155

* Benign proliferation of the transitional zone of the prostate (in contrast to peripheral layer expansion seen in prostate carcinoma) * After 30, men produce ~1% less testosterone each year but 5a-reductase increases with age 🡪 increased dihydrotestosterone levels * Prostate cells respond by living longer and growing 🡪 hypertrophy * As the prostate gets bigger, it may squeeze or partly block: * The bladder 🡪 urine retention 🡪 bladder dilation and hypertrophy 🡪 urine stasis 🡪 bacterial growth 🡪 UTIs * The urethra 🡪 urination problems

Answer 156

Dihydrotestosterone is responsible for prostatic growth

Answer 157

**Lower Urinary Tract Symptoms:** **Storage:** * Frequency * Urgency * Nocturia * Incontinence **Voiding:** * Straining/ Stream Poor * Hesitancy * Incomplete Emptying * Terminal Dribbling

Answer 158

**international Prostate Symptom Score (IPSS)**

Answer 159

**Digital rectal examination** **Abdominal examination** **Urinary frequency volume chart**, recording 3 days of fluid intake and output **Urine dipstick** to assess for infection, haematuria **Prostate-specific antigen (PSA)** for prostate cancer, depending on the patient preference

Answer 160

**Trans-rectal Ultrasound Scan** **Biopsy** to rule out prostate cancer

Answer 161

* Prostate cancer * Benign prostatic hyperplasia * Prostatitis * Urinary tract infections * Vigorous exercise (notably cycling) * Recent ejaculation or prostate stimulation

Answer 162

**If Symptoms are minimal: Watch and Wait** **Lifestyle advice:** * Reduce caffeine * Relax when voiding **Medication:** if symptoms are not controlled or if experience complications of BOO * 1st Line - alpha blocker - Tamsulosin (act immediately) * 2nd Line - 5-alpha Reductase inhibitors - Finasteride (take 6-12 months) **Surgery (last resort)** * Transurethral resection of prostate (TURP)

Answer 163

Alpha blocker that will relax the bladder neck increasing urinary flow rate and improving obstructive Symptoms of BPH

Answer 164

Dizziness, postural hypotension, dry mouth, depression, drowsiness Retrograde ejaculation – bladder neck relaxes so sperm travels back into bladder

Answer 165

5-alpha reductase inhibitor that will block conversion of testosterone to dihydrotestosterone to reduce prostatic growth

Answer 166

* Fatigue, lethargy * Erectile Dysfunction * libido loss

Answer 167

* Bleeding * Infection * Impotence * Urinary incontinence * **Erectile dysfunction** * **Retrograde ejaculation** * Urethral strictures * Failure to resolve symptoms

Answer 168

* Auria - no urination * Retention * Hydronephrosis * UTI * Renal Stones

Answer 169

Inflammation and swelling of the olecranon bursa over the elbow. The olecranon is the bony lump at the elbow, which is part of the ulna bone.

Answer 170

* Bursae are sacs created by synovial membrane filled with a small amount of synovial fluid. * They are found at bony prominences (e.g., at the greater trochanter, knee, shoulder and elbow). * They act to reduce the friction between the bones and soft tissues during movement.

Answer 171

Bursitis is inflammation of a bursa. This causes thickening of the synovial membrane and increased fluid production, causing swelling.

Answer 172

* Friction from repetitive movements or leaning on the elbow (common in students, drivers, plumbers etc) * Trauma * Inflammatory conditions (e.g., rheumatoid arthritis or gout) * Infection – referred to as septic bursitis

Answer 173

The typical presentation is a young/middle-aged man with an elbow that is: * Swollen * Warm * Tender * Fluctuant (fluid-filled)

Answer 174

* Hot to touch * More tender * Erythema spreading to the surrounding skin * Fever * Features of sepsis (e.g., tachycardia, hypotension and confusion

Answer 175

**Management:** * Rest * Ice * Compression bandaging if tolerated * Elevation to reduce swelling * Analgesia (e.g., paracetamol or NSAIDs) * Protecting the elbow from pressure or trauma * Aspiration of fluid may be used to relieve pressure * Steroid injections may be used in problematic cases where infection has been excluded **When infection is suspected or cannot be excluded, management involves:** * Aspiration of the fluid for microscopy and culture: rule out crystal arthropathy and septic arthritis * Antibiotics

Answer 176

Trochanteric bursitis refers to inflammation of a bursa over the greater trochanter on the outer hip (femur). **It produces pain localised at the outer hip, referred to as greater trochanteric pain syndrome.**

Answer 177

* Friction from repetitive movements * Trauma * Inflammatory conditions (e.g., rheumatoid arthritis) * Infection – referred to as septic bursitis

Answer 178

* middle-aged patient with gradual-onset lateral hip pain (over the greater trochanter) that may radiate down the outer thigh. * Aching or burning pain * Worse with activity, standing/sitting for long periods/lying on affected side * May disrupt sleep * Tenderness on examination over the greater trochanter * Positive Trendelenburg gait * **Not usually any swelling compared to bursitis in other areas**

Answer 179

* **Hip osteoarthritis:** Characterised by chronic pain in the hip, morning stiffness, reduced range of motion, and pain that worsens with activity. * **Iliotibial band syndrome:** Presents with lateral knee pain, tenderness, and often a snapping or popping sensation on the outer knee. * **Hip fracture:** Acute, severe pain following trauma, inability to weight-bear, and physical examination may reveal shortening and external rotation of the leg. * **Lumbar radiculopathy:** Characterised by pain radiating from the lower back to the lower limb, often accompanied by numbness or weakness in the affected limb.

Answer 180

**Generally a clinical diagnosis** * Examination and palpation of the greater trochanter * Trendelenburg Test * **Resisted, abduction, internal and external rotation of the hip** (Pain on these resisted movements supports the diagnosis)

Answer 181

**Usually Self limiting** * **Reduce compressive forces:** Weight loss, avoidance of excessive hip adduction * Rest * Ice * Analgesia (e.g., ibuprofen or naproxen) * Physiotherapy * Steroid injections in some cases to reduce inflammation

Answer 182

Chronic kidney disease (CKD) describes a chronic reduction in kidney function where the GFR <60ml/min sustained over three months. It tends to be permanent and progressive.

Answer 183

CKD has an estimated prevalence of 9–13% worldwide.

Answer 184

**KDIGO Criteria gives a G score based on eGFR (ml/min/1.73m^) and A score (Albumin:creatinine ratio mg/mmol):** **Stage 1 (G1):** * eGFR >90 * A1: <3 mg/mmol **Stage 2 (G2):** * eGFR 60-89 * A2: 3-30 mg/mmol **Stage 3a (G3A):** * eGFR 45-59 * A3: >30 mg/mmol **Stage 3b (G3b):** eGFR 30-44 **Stage 4 (G4):** eGFR 15-29 **Stage 5( G5/End stage):** eGFR <15 **Patients are typically asymptomatic until stage 4 or 5 CKD**

Answer 185

**Kidney function naturally declines with age** * diabetic nephropathy * chronic glomerulonephritis * chronic pyelonephritis * hypertension * adult polycystic kidney disease

Answer 186

**Most patients with CKD are Asymptomatic until stage 4/5** * Fatigue * Pallor (due to anaemia) * Foamy urine (proteinuria) * Nausea * Loss of appetite * Pruritus (itching) * Oedema * Hypertension * Peripheral neuropathy

Answer 187

**C**ardiovascular disease **R**enal osteodystrophy **F**luid (oedema) **H**ypertension **E**lectrolyte disturbance (hyperkalaemia, acidosis) **A**naemia **L**eg restlessness (uraemia) **S**ensory neuropathy (uraemia)

Answer 188

Cardiovascular disease

Answer 189

CKD staging is based on the eGFR and Urine Albumin:Creatinine Ratio (ACR) * FBC: Anaemia (normocytic) * U&Es: Raised creatinine and urea, **Low eGFR** **(ACR > 3 is significant)** * Urine Dipstick: Proteinuria and Haematuria * Renal Ultrasound: **Bilaterally small kidneys in CKD** **Others:** * Blood pressure (for hypertension) * HbA1c (for diabetes) * Lipid Profile (for hypercholesterolaemia) * ECG: for hyperkalaemia

Answer 190

**Focuses on preserving kidney function, managing complications of CKD and preparing for RRT** **Lifestyle Interventions:** * Maintaining health weight * Health diet * Exercise * Smoking cessation **Hypertension:** * Blood pressure <140/90 mmHg in patients with CKD and ACR <70 mg/mmol * Blood pressure <130/80 mmHg in patients under 80 with CKD and ACR >70 mg/mmol **Diabetes:** Individualised targets but generally: * HbA1c <53 mmol/mol

Answer 191

**Slow disease progression** * ACE inhibitors * SGLT2 inhibitors (Dapagliflozin) **Reduce risk of complications:** * Exercise, maintain healthy weight and smoking cessation * Atorvastatin 20mg for primary prevention of CVD **Management of Complications:** * Oral sodium bicarbonate: for metabolic acidosis * Iron and erythropoietin replacement: to treat anaemia * Vitamin D, Low phosphate diet for Renal Bone Disease **End-stage Renal Disease:** * Special dietary advice * Dialysis * Renal Transplant

Answer 192

**Haemodialysis:** **Peritoneal Dialysis:** **Haemofiltration:**

Answer 193

* Healthy kidneys produce erythropoietin, a hormone that stimulates the production of red blood cells. **Reduced Erythropoietin Levels:** * CKD results in lower erythropoietin and a drop in red blood cell production. **Reduced Iron Absorption** * Inflammation and reduced renal clearance of **Hepcidin** * Decreased iron absorption from the gut * Reduced iron stores for erythropoiesis

Answer 194

* Iron deficiency if present is treated first (IV iron) * EPO stimulating agents such as recombinant EPO

Answer 195

**Basic problems in chronic kidney disease (CKD):** * 1-alpha hydroxylation normally occurs in the kidneys → CKD leads to low vitamin D * The kidneys normally excrete phosphate → CKD leads to high phosphate **This, in turn, causes other problems:** * The high phosphate level 'drags' calcium from the bones, resulting in osteomalacia * Low calcium: due to lack of vitamin D, high phosphate * Secondary hyperparathyroidism: due to low calcium, high phosphate and low vitamin D

Answer 196

* Low phosphate diet * Phosphate binders * Active forms of vitamin D (alfacalcidol and calcitriol) * Ensuring adequate calcium intake * Parathyroidectomy in certain cases

Answer 197

**Also known as Thrush/yeast infection** Vaginal infection with a Yeast of the Candida family **most commonly Candida albicans**

Answer 198

Recurrent vaginal candidiasis is defined as **4 or more symptomatic episodes within 1 year**

Answer 199

* Increased oestrogen (higher in pregnancy, lower pre-puberty and post-menopause) * Poorly controlled diabetes * Using SGLT2 inhibitors * Pregnancy * Immunosuppression (e.g. using corticosteroids) * Broad-spectrum antibiotics

Answer 200

Candida albicans - 85-90% of the cases. Transmission is typically **non-sexual**

Answer 201

**Symptoms:** * Itching * **Cottage cheese non-offensive discharge** * **typically does not smell but may have sour milk odour** * dysuria * superficial dyspareunia * tenderness, * Burning sensation. **Examination findings:** * Redness * Satellite lesions * fissuring, * swelling, * intertrigo, * thick white discharge.

Answer 202

* **Bacterial vaginosis:** Characterised by greyish-white discharge, fishy odour, and absence of significant inflammation. * **Trichomoniasis:** Presents with yellow-green, frothy discharge, dysuria, and itching. * **Chlamydia or Gonorrhoea:** These sexually transmitted infections can cause similar symptoms such as discharge, but often also present with pelvic pain or bleeding. * **Genital herpes:** Characterised by painful blisters or open sores in the genital area.

Answer 203

**Clinical Diagnosis and Routine investigations usually not required** * Testing Vaginal pH with a swab can help differentiate between Bacterial Vaginosis, Trichomonas (pH > 4.5) and candidiasis (pH < 4.5) * **Charcoal wab + microscopy** can confirm the diagnosis

Answer 204

**Antifungal Treatment:** * First Line: Oral Antifungal Tablets (**Fluconazole**, Itraconazole): **150mg capsule as a single dose** * Second Line: Antifungal pessary (Clotrimazole): 500mg as a single dose * Antifungal Cream (Clotrimazole): 10% 5g as a single dose if vuvlal symptoms **if pregnant then only local treatments (e.g. cream or pessaries) may be used - oral treatments are contraindicated**

Answer 205

Oral candidiasis is also called oral thrush. It refers to an overgrowth of candida, a type of fungus, in the mouth. This results in white spots or patches that coat the surface of the tongue and palate.

Answer 206

* Inhaled corticosteroids (particularly with poor technique, not using a spacer and not rinsing with water afterwards) * Antibiotics (disrupt the normal bacterial flora giving candida a chance to thrive) * Diabetes * Immunodeficiency (consider HIV) * Smoking

Answer 207

* **Miconazole gel** * **Nystatin suspension** * Fluconazole tablets (in severe or recurrent cases)

Answer 208

Conjunctivitis (**Pink Eye**) is inflammation of the conjunctiva. The conjunctiva is a thin layer of tissue that covers the inside of the eyelids and the sclera. * Conjunctivitis may be Infectious (bacterial, viral) or Non-infectious (allergic/irritant) * It may be unilateral or bilateral.

Answer 209

**Allergic Conjunctivitis:** * Type 1 hypersensitivity reaction * common triggers include pollen, dust mites, pet dander **Viral Conjunctivitis:** * **Most commonly caused by Adenoviruses** * May be caused by Herpes Simplex Virus * Highly Contagious * Often associated with URTIs or Colds **Bacterial Conjunctivitis:** * S. aureus, S. pneumoniae, H. influenzae, M. catarrhalis * May be caused by STIs such as Gonorrhoea or Chlamydia

Answer 210

**General Presentation:** * **Non-painful eye** * Red bloodshot eye * Itchy or Gritty sensation * Irritation * Excessive tearing * Discharge **Viral Presentation:** * Clear discharge * Associated with dry cough, sore throat and blocked nose **Bacterial Presentation:** * **Purulent discharge** * Complaints of eyelids being stuck together (often in morning)

Answer 211

* Acute angle-closure glaucoma * Anterior uveitis * Scleritis * Corneal abrasions or ulceration * Keratitis * Foreign body * Traumatic or chemical injury

Answer 212

* Conjunctivitis * Episcleritis * Subconjunctival haemorrhage

Answer 213

**Typically resolves in 1-2 weeks without needing treatment** * Hygiene measures to reduce the spread * Clean the eyes with cooled boiled water and cotton wool to help clear the discharge * **Antihistamines (oral/topical)** if allergic conjunctivitis * **Chloramphenicol or Fusidic acid** eye drops for bacterial conjunctivitis if necessary

Answer 214

Contact dermatitis is a skin condition marked by inflammation of the skin, **resulting from direct contact with substances** that irritate the skin (irritant contact dermatitis) or provoke an allergic response (allergic contact dermatitis).

Answer 215

* Exposure to irritants or allergens in the environment or workplace * Personal or family history of atopic dermatitis or other allergic conditions * Occupation involving frequent exposure to potential irritants or allergens * Use of certain skincare products or cosmetics containing allergenic ingredients * Previous episodes of contact dermatitis increase the risk of future occurrences

Answer 216

Non-allergic reaction: Occurs when the skin's natural barrier is disrupted by exposure to irritating substances, such as harsh chemicals, detergents, or solvents (**weak acids/alkalis**). This results in direct damage to the skin's cells and inflammation.

Answer 217

This is a **delayed type IV hypersensitivity reaction**. Exposure to an allergen (often a low-molecular-weight chemical) sensitizes the immune system over time. Upon re-exposure (e.g. after repeated hair dyes), an immune response is triggered, leading to inflammation and the characteristic skin rash.

Answer 218

* Eczema due to contact with an irritant. * There may be burning, pain, and stinging. * Erythematous * Eczematous rash appears localised to the direct area of contact

Answer 219

* Presents as an itchy, eczematous rash (vesicles, fissures, erythema), **typically 24-48 hours after exposure**. * The rash may extend beyond the boundaries of immediate contact

Answer 220

* **Nickle** found in jewellery, watches, metal buttons on clothing * Acrylates found in nail cosmetics * Fragrances * Rubber/plastics * Hair dye * Henna

Answer 221

**Contact dermatitis is a clinical diagnosis and investigations aren’t always needed. However, investigations may include:** * **Patch Testing:** used to identify allergens responsible for allergic contact dermatitis. * **Skin Biopsy:** rarely necessary, but it can help confirm the diagnosis or rule out other conditions.

Answer 222

* Avoidance of the irritant/allergen: 8-12 weeks avoidance may be needed before improvements are seen * **liberal emollient and soap substitutes** * Topical steroids (depends on severity of dermatitis) * Antihistamines for pruritis relief

Answer 223

Chronic obstructive pulmonary disease (COPD) is characterised by irreversible, progressive obstruction of the airways caused by long term damage to lung tissue. It comprises both: * **Chronic bronchitis –** involves hypertrophy and hyperplasia of the mucus glands in the bronchi * **Emphysema –** involves enlargement of the air spaces and destruction of alveolar walls

Answer 224

* Approximately 1.2 million people, or about 2% of the UK population, are living with diagnosed COPD. * Each year, COPD accounts for approximately 30,000 deaths or 26% of all lung disease-related deaths. * Majority of patients have a history of tobacco smoking

Answer 225

* **Tobacco smoking (active or passive)** * Occupational exposure to dust * Air pollution * Alpha-1 antitrypsin deficiency **Prognosis is worsened by:** * Advancing age * Ongoing smoking * Reduced body weight * Low FEV1

Answer 226

A inflammatory lung condition that develops over time in which the bronchi and bronchioles become inflamed and scarred **Chronic Bronchitis is a clinical term relating to a chronic productive cough for at least 3 months over 2 consecutive years.** Alternative explanations for the cough should also be excluded.

Answer 227

Refers to abnormal air space enlargement distal to terminal bronchioles with evidence of alveoli destruction and no obvious fibrosis. Damage to the alveolar sacs and alveoli decreases the gas exchange surface

Answer 228

* Chronic exposure to noxious particles such as smoking or air pollutants causes hypersecretion of mucus in the large and small bronchi. * Airway inflammation and fibrotic changes result in narrowing of the airways and subsequently chronic airway obstruction. * Cigarette smoke interferes with the action of cilia in removing noxious particles. * Cigarette smoke also dampens the ability of leukocytes in eliminating the bacteria in the airways.

Answer 229

* Abnormal irreversible enlargement of the airspaces distal to the terminal bronchioles, due to destruction of their walls. * This reduces the alveolar surface area thus impeding efficient gaseous exchange. * Cigarette smoke stimulates accumulation of neutrophils and macrophages which produce neutrophil elastase that destroys alveolar walls. * In a normal lung, α1-antitrypsin is responsible for inhibiting excessive activity of neutrophil elastase. However, in emphysema, the normal balance of proteases and antiproteases is lost. * The stimulated neutrophils release free radicals that inhibit the activity of α1-antitrypsin. * This results in loss of elastic recoil and subsequently airway collapse during expiration and air trapping.

Answer 230

**Centriacinar:** * The proximal part of the airways such as the respiratory bronchioles, mainly the upper lobes. * Caused by **cigarette smoking** **Panacinar:** * The entire acini from respiratory bronchioles to alveolar duct and alveoli, mainly the lower lobes. * Caused by **alpha1-antitrypsin deficiency** **Distal/Paraseptal Acinar:** * The distal part of the airways, mainly the paraseptal region * Caused by **Fibrosis, atelectasis**

Answer 231

* Productive cough * Recurrent respiratory infections (especially in winter) * Wheeze * Dyspnoea (shortness of breath) * Reduced exercise tolerance * Weight loss

Answer 232

* Accessory muscle use for respiration * Prolonged expiratory phase * Pursed lip breathing (Common in Emphysema) * Tachypnoea * Cachexia * Hyperinflation – reduction of the cricosternal distance (barrel chest) * Reduced chest expansion * Hyper-resonant percussion * Decreased/quiet breath sounds * Wheeze * Cyanosis (Common in Chronic bronchitis) * Cor pulmonale (signs of right heart failure)

Answer 233

* Clubbing * Haemoptysis * Chest Pain

Answer 234

**Grade 1:** Breathless on strenuous exercise **Grade 2:** Breathless on walking uphill **Grade 3:** Breathlessness that slows walking on the flat **Grade 4:** Breathlessness stops them from walking more than 100 meters on the flat **Grade 5:** Unable to leave the house due to breathlessness

Answer 235

**Clinical Diagnosis with Spirometry** **Spirometry:** * FEV1/FVC <0.7 * Little to no response with Bronchodilator reversibility testing **Other Investigations:** **Bloods:** FBC for polycythaemia, anaemia, infection **ABG:** Reduced PaO2 +/- Raised PaCO2 **ECG:** to assess for heart failure or Cor pulmonale **Chest X-ray:** To exclude other pathology such as cancer **Sputum Culture:** To assess for Chronic infections such as pseudomonas **Serum a1AT:** Look for alpha1-antitrypsin deficiency

Answer 236

* P-pulmonale showing Right Atrial Hypertrophy due to increased pulmonary pressures * Right ventricular Hypertrophy if there is Cor pulmonale

Answer 237

* Hyperinflated chest (>6 anterior ribs) * Bullae * Decreased peripheral vascular markings * Flattened hemidiaphragms

Answer 238

Post Bronchodilator when FEV1/FVC ratio < 70% **Stage 1:** Mild - FEV1 >80% of predicted **Stage 2:** Moderate - FEV1 50-79% of predicted **Stage 3:** Severe - FEV1 30-49% of predicted **Stage 4:** Very Severe - FEV1 <30% of predicted

Answer 239

* **Asthma:** Characterised by reversible airway obstruction, episodic symptoms and response to bronchodilators. * **Bronchiectasis:** Persistent productive cough, recurrent respiratory infections and abnormal bronchial dilatation on CT chest. * **Heart Failure:** Shortness of breath, orthopnea, paroxysmal nocturnal dyspnoea, and signs of fluid overload such as peripheral oedema and elevated jugular venous pressure. * **Pulmonary Fibrosis:** Progressive dyspnoea, non-productive cough, and inspiratory crackles on auscultation.

Answer 240

* Smoking cessation (significantly worsens lung function and prognosis) * Nutritional support * Flu and pneumococcal vaccinations * Pulmonary rehabilitation

Answer 241

**Initial Medical Treatment: Short Acting Bronchodilators:** * SABA: Salbutamol * SAMA: Ipratropium Bromide **Second Step when symptoms or exacerbations are problematic and is determined based on asthmatic/steroid responsive features:** **No Steroid Responsive Features:** * Offer LABA (Salmeterol) PLUS LAMA (Tiotropium). * **Anoro Ellipta, Ultibro Breezhaler, DuaKlir Genuair** * If no improvement then consider **3 month trial** of LABA Plus LAMA Plus ICS (to change back to LABA + LAMA in 3 months if not worked) **Has Steroid Response Features:** * Offer LABA Plus ICS * **Fostair, Symbicort, Seretide** * If day-day symptoms continue or pt has 1 severe/2 moderate exacerbations then offer LABA Plus LAMA Plus ICS **LABA + LAMA + ICS:** * **Trimbow, Trelegy Ellipta, Trixeo Aerosphere**

Answer 242

* **Raised blood eosinophil count** * Previous diagnosis of asthma or atopy * Variation in FEV1 of more than 400mls * Diurnal variability in peak flow of more than 20%

Answer 243

* Nebulisers (e.g., salbutamol or ipratropium) * Oral theophylline * Oral mucolytic therapy to break down sputum (e.g., carbocisteine) * Prophylactic antibiotics (e.g., azithromycin) * Oral corticosteroids (e.g., prednisolone) * Oral phosphodiesterase-4 inhibitors (e.g., roflumilast) * Long-term oxygen therapy at home * Lung volume reduction surgery (removing damaged lung tissue to improve the function of healthier tissue) * Palliative care (opiates and other drugs may be used to help breathlessness)

Answer 244

**Used in Severe COPD where there is:** * Chronic Hypoxia (Sats <92%) * polycythaemia * Cyanosis * Core pulmonale **Smoking is a contraindication due to the fire risk**

Answer 245

An acute COPD exacerbation presents rapidly worsening symptoms, such as cough, shortness of breath, sputum production and wheezing. Viral or bacterial infection often triggers it. (Often caused by **haemophilus influenzae**)

Answer 246

**ABG:** Showing Respiratory failure and Respiratory Acidosis **Others:** * **Chest X-ray:** Look for pneumonia or other pathology * **ECG:** Look for arrhythmias or evidence of heart strain * **FBC:** Look for infection (raised WCC) * **U&Es:** Check Electrolytes * **Sputum or blood cultures**

Answer 247

**Ensure Patent Airway:** **Ensure Oxygen Saturations of 88-92% (if pt has a history of CO2 retention)** **First-line medical treatment of an acute exacerbation of COPD involves:** * **Regular nebulisers** (e.g., salbutamol and ipratropium) * **Steroids** (e.g., prednisolone 30 mg once daily for 5 days) * **Antibiotics** if there is evidence of infection **Respiratory physiotherapy** can be used to help clear sputum. **Additional options in severe cases include:** * IV aminophylline * Non-invasive ventilation (NIV) * Intubation and ventilation with admission to intensive care

Answer 248

**respiratory Failure:** COPD patients are chronic retainers of CO2 and therefore their kidneys adapt to produce extra HCO3 to compensate the acidotic state. In acute exacerbations the kidneys cannot produce enough HCO3 quickly leading to respiratory failure * Low pH indicates acidosis * Low pO2 indicates hypoxia and respiratory failure * Raised pCO2 indicates CO2 retention (hypercapnia) * Raised bicarbonate indicates chronic retention of CO2

Answer 249

* **Cor pulmonale** * Recurrent Respiratory Tract Infections: S. pneumoniae/H. influenzae * Respiratory failure * Pneumothorax: rupture of bullous disease (in Emphysema) * Polycythaemia or anaemia * Depression

Answer 250

**Cor pulmonale refers to right-sided heart failure caused by respiratory disease.** * The increased pressure and resistance in the pulmonary arteries (pulmonary hypertension) limits the right ventricle pumping blood into the pulmonary arteries. * This causes back-pressure into the right atrium, vena cava and systemic venous system.

Answer 251

* **COPD (the most common cause)** * Pulmonary embolism * Interstitial lung disease * Cystic fibrosis * Primary pulmonary hypertension

Answer 252

**early Cor pulmonale is asymptomatic** * Shortness of breath * Peripheral oedema * Breathlessness of exertion * Syncope (dizziness and fainting) * Chest pain

Answer 253

* Hypoxia * Cyanosis * Raised JVP (due to a back-log of blood in the jugular veins) * Peripheral oedema * Parasternal heave * Loud second heart sound * Murmurs (e.g., pan-systolic in tricuspid regurgitation) * Hepatomegaly due to back pressure in the hepatic vein (pulsatile in tricuspid regurgitation)

Answer 254

**Symptom management and treating the underlying cause:** **Diuretics:** For oedema and fluid overload **LTOT** is often used

Answer 255

**Also known as Ringworm** A superficial fungal infection of the skin caused by dermatophytes, a group of fungi that invade and grow in dead keratin. The most common type of fungus that grows is **Trichophyton**

Answer 256

* Can affect anyone * Related to poor hygiene

Answer 257

**Tinea capitis** refers to ringworm affecting the scalp (caput meaning head) **Tinea pedis** refers to ringworm affecting the feet, also known as athletes foot (pedis meaning foot) **Tinea cruris** refers to ringworm of the groin (cruris meaning leg) **Tinea corporis** refers to ringworm on the body (corporis meaning body) **Onychomycosis** refers to a fungal nail infection **Tinea manuum** refers to ringworm on the hand

Answer 258

* Fungal infection in another part of their body * Poor Hygiene * Close contact with infected individuals or animas * Immunocompromised nature

Answer 259

* Itchy erythematous scaly rash that is well demarcated. * The rash has a central clearing giving it the appearance of a ring.

Answer 260

* **Psoriasis:** Characterised by silver-scaled plaques in typical locations such as elbows, knees, and scalp. * **Eczema (dermatitis):** Generally causes dry, itchy, and inflamed skin. * **Pityriasis rosea:** Features a herald patch followed by a 'Christmas tree' pattern of rash. * **Lyme disease:** Erythema migrans, the initial sign, is a red, expanding rash that sometimes presents with a bull's eye appearance.

Answer 261

**Clinical Diagnosis supported by good response to anti-fungal medications** * Green flourescence under Woods Lamp * May be supported with culture of skin/scalp scrapings

Answer 262

**General Hygiene Advice** **Anti-fungal medications:** * Anti-fungal creams such as clotrimazole and miconazole * Anti-fungal shampoo such as ketoconazole for tinea capitis * Oral anti-fungal medications such as fluconazole, griseofulvin and itraconazole * Fungal Nail infections are treated with **amorolfine nail lacquer for 6-12 months** * In resistance cases **oral terbinafine** may be required but this needs LFT monitoring before and after.

Answer 263

* Wear loose breathable clothing * Keep the affected area clean and dry * Avoid sharing towels, clothes and bedding * Use a separate towel for the feet with tinea pedis * Avoid scratching and spreading to other areas * Wear clean dry socks every day

Answer 264

An inflammatory condition of the skin folds, resulting from skin-on-skin friction, often exacerbated by heat, moisture, maceration, and lack of air circulation. It is frequently complicated by secondary bacterial or fungal infections.

Answer 265

* **Obese patients** * **Hyperhydrosis** * **Diabetes mellitus** * Infants, due to short necks, relative chubbiness, and flexed posture. Intertrigo in infants may be exacerbated by drooling. * Individuals who frequently wear closed-toe or tight-fitting shoes, which can induce toe web intertrigo. This commonly affects those participating in athletic, occupational, or recreational activities. * Those with other predisposing factors, including urinary and faecal incontinence, hyperhidrosis, diabetes, poor hygiene, and malnutrition.

Answer 266

The moist, damaged skin associated with intertrigo provides a fertile environment for the proliferation of various pathogens, leading to frequent secondary cutaneous infections: * **Bacterial infection:** Staphylococcus aureus, group A beta-haemolytic streptococcus, and various gram-negative organisms may occur alone or in combination. Proliferation may lead to keratinocytic necrosis. * **Fungal infection: Candida** is the fungus most commonly associated with intertrigo. In the toe webs, gram-negative bacteria often coexist.

Answer 267

* Itching, Burning and Pain in the affected areas * **Distribution:** The condition is most prevalent in the groin, axillae, and inframammary folds. It may also affect antecubital fossae; umbilical, perineal, or interdigital areas; neck creases; and folds of the eyelids. * **Morphology:** The condition is characterised by erythematous patches, often symmetrical. Erythema may progress to more severe inflammation with erosions, fissures, exudation, crusting, and maceration.

Answer 268

* **Seborrhoeic eczema:** Can present similarly but often has scalp involvement and lacks the typical satellite lesions of Candidal intertrigo. * **Psoriasis:** May appear similar, but psoriasis is often associated with nail changes and glistening, well-demarcated, symmetrical flexural lesions. * **Tinea cruris:** Lesions are often annular or polycyclic, and tend to have a leading erythematous scaly edge. * Erythrasma, atopic eczema, irritant contact dermatitis, allergic contact dermatitis, and scabies can all involve skin folds and therefore be mistaken for intertrigo. * **Hailey-Hailey disease** and pemphigus vegetans are less common conditions that can be mistaken for intertrigo.

Answer 269

**Clinical diagnosis based on examination and response to treatment:** **May require:** * Fungal culture to rule out fungal infection * Bacterial culture to identify secondary bacterial infection * Skin biopsy for histopathological examination in unclear or refractory cases

Answer 270

**Minimise moisture and friction:** Loose-fitting clothing, weight loss if necessary, and the use of barrier creams can all reduce skin-on-skin friction and moisture. **Promote skin hygiene:** Regular cleaning of the affected areas with mild soap and water. **Patient Education:** On the chronic and recurrent nature of the disease and importance of preventive measures **Topical agents:** * **Zinc oxide ointment** (reduces friction) * Application of topical antifungal, antibacterial, or corticosteroid agents, depending on the causative organisms and severity of inflammation. * **Clotrimazole**

Answer 271

* Gout * Pseudogout

Answer 272

**Gout:** * Needle Shaped monosodium Urate Crystals * Negatively Birefringent in polarised light **Pseudogout:** * Rhomboid Brick shaped Pyrophosphate crystals * Positively Birefringent in Polarised Light

Answer 273

Gout is a form of **Crystal arthritis** caused by the deposition of **monosodium urate crystals** in and around the joints leading to an acute inflammatory response

Answer 274

**Nonmodifiable** * Male sex * Age over 50 years * Family history of gout * Inherited syndrome with uric acid overproduction (eg. Lesch–Nyhan syndrome) **Modifiable** * Obesity * High purine diet such as meats and alcohol * Hypertension * Chronic kidney disease * Diabetes * Metabolic syndrome * Medications (eg. thiazide diuretics, ACE inhibitors and aspirin)

Answer 275

CKD Diuretics, ACEis Pyrazinamide Lead Toxicity

Answer 276

* Seafood/protein binges – eating lots of high-protein foods raises levels of uric acid * Chemotherapy – increases cell breakdown * Trauma and surgery – increases cell breakdown * Alcohol excess * Intercurrent illness * Medications that interfere with the handling of uric acid (eg. allopurinol)

Answer 277

High purine intake (food/alcohol) Is oxidised to Uric acid by Xanthine oxidase. Normally uric acid is then excreted by the kidneys But in hyperuricaemia this cannot occur fast enough and this can lead to kidney damage The Uric acid is converted to monosodium urate crystals that trigger intracellular inflammation. These deposit in joints and cause an inflammatory arthritis

Answer 278

* Excruciating, sudden, burning pain in the affected joint * Swelling, redness, warmth and stiffness in the affected joint * Asymmetric joint distribution * Gouty Tophi: Nodular masses of urate acid crystals subcutaneously commonly seen on the **hands, elbows and ears** * Mild fever * Tachycardia as a transient sympathetic response to the pain of an acute attack

Answer 279

* Base of the Big Toe (**Metatarsophalangeal joint/MTP Joint**) * Base of the Thumb (**Carpometacarpal join/ CMC Joint**) * Wrist

Answer 280

* **Pseudogout:** Typically affects the larger joints such as the ankle, knee, hips, wrist and shoulder * **Septic Arthritis:** Vital to rule this out so any suspicion of an acute onset arthritis should have this checked

Answer 281

**Joint Aspiration:** * **Negatively birefringent needle shaped Monosodium Urate Crystals** **Serum Uric Acid Level:** * Useful for long term management * Should be obtained at least 2 weeks after the attack as during this they may be falsely low or normal (Since all the uric acid is in the joint space) **X-ray of affected joints:**

Answer 282

* Maintained joint space (no loss of joint space) * Lytic lesions in the bone * Punched out erosions * Erosions can have sclerotic borders with overhanding edges

Answer 283

**First Line: NSAIDs** * Naproxen 500mg BD * Co prescribed with a PPI for gastric protection * Avoid if renal impaired, cardiac failure and IHD **Second Line: Colchicine** * Colchicine 500ug BD * Use with cation in liver or renal disease and can cause diarrhoea **Third Line: Oral Corticosteroids** * Prednisolone, 30mg OD for 5-7 days * Intra-articular corticosteroids is also an option

Answer 284

**Lifestyle Changes:** * Reduce alcohol consumption * Reduce purine based food consumption - Meat and seafood * Increase Dairy consumption and hydration * Regular Exercise and weight loss **Review Medications that may cause hyperuricaemia** **Urate Lowering Therapies: Xanthine Oxidase Inhibitors** * Allopurinol or Febuxostat * Should not be started until weeks after first acute attack. Once started then continued during further acute attacks

Answer 285

Pseudogout is a **crystal arthropathy caused by calcium pyrophosphate crystals** collecting in the joints. It is formally known as calcium pyrophosphate deposition disease (CPPD). It may also be called chondrocalcinosis.

Answer 286

* Advanced age * Female Gender * Osteoarthritis * Injury or previous joint surgery * Metabolic Diseases: Hyperparathyroidism, Haemochromatosis, Hypophosphataemia, Diabetes * Hypomagnesaemia * Acute attacks may be precipitated by intercurrent infection

Answer 287

**4 H's** H – Hyperparathyroidism (high calcium levels and surgery) H – Hemochromatosis (iron overload) H – Hypothyroidism (underactive thyroid and T4 replacement) H – Hydration issues (dehydration, illness, IV fluids, blood transfusions)

Answer 288

**Often Asymptomatic** * Acute Monoarthritic pain: **Shoulder, Wrist and Knee most common** * Affected joints are acutely inflamed, swollen, effusive, warm and tender * Patients may display acute systemic illness with fever and general malaise

Answer 289

**Joint Aspiration:** * **Positively birefringent rhomboid shaped Calcium Pyrophosphate Crystals** **X-ray of affected joints:** * **Chondrocalcinosis** * X-ray changes similar to Osteoarthritis (LOSS:) * Loss of joint space * Osteophytes (bone spurs) * Subarticular sclerosis (increased density of the bone along the joint line) * Subchondral cysts (fluid-filled holes in the bone) **Bloods:** It is important to consider secondary causes of pseudogout, particularly in younger patients: * Ferritin * Iron-binding studies * Bone profile * Alkaline phosphatase

Answer 290

**symptomatic treatment only - No disease modifying drugs:** **First Line: NSAIDs** * Naproxen 500mg BD * Co prescribed with a PPI for gastric protection * Avoid if renal impaired, cardiac failure and IHD **Second Line: Colchicine** * Colchicine 500ug BD * Use with cation in liver or renal disease and can cause diarrhoea **Third Line: Oral Corticosteroids** * Prednisolone, 30mg OD for 5-7 days

Answer 291

Common warts are elevated, round, hyperkeratotic skin papules with a rough greyish-white or light brown surface **Caused by HPV**

Answer 292

* Very common * More common in children then adults * Clearance rates in children are related to time of diagnosis

Answer 293

* Water immersion * Occupations involving the handling of meat and fish * Nail biting * Age < 35 years * Immunocompromised

Answer 294

Common warts are caused by the **Human Papillomavirus (HPV)** infection of keratinocytes. Various strains of the HPV virus are responsible such as HPV 1, 2, 4, 27, 57, 63

Answer 295

* Rough papule on the hand, finger, periungual, or other skin area * Filiform papule on the skin of the body or face * Flat pink, slightly scaly papule on the face or digits.

Answer 296

**Clinical Diagnosis based on appearance** **May consider:** * Skin Biopsy * Immunoperoxidase stain * Skin culture

Answer 297

* Seborrhoeic keratosis * Lichen planus * Melanoma * Squamous Cell Carcinoma

Answer 298

**Often Spontaneous regression of warts will occur** * Salicylic Acid and Debridement * Cryotherapy: using a liquid nitrogen spray to freeze the wart off

Answer 299

A term used to describe conditions related to the presence of diverticula, which are small, bulging pouches of mucosa that can form in the lining of the digestive system that leads to **the patient experiencing symptoms**

Answer 300

Refers to the presence of diverticula, without inflammation or infection where **the patient is asymptomatic**

Answer 301

is a pouch or pocket of mucosa in the bowel wall, usually ranging in size from 0.5 – 1cm that form from the lining of the bowel.

Answer 302

Lower part of the colon (**Sigmoid Colon**)

Answer 303

A subset of diverticular disease, occurs when these diverticula become inflamed or infected. This condition is typically characterized by severe abdominal pain, fever, and nausea.

Answer 304

* Common in individuals over the age of 50 * Common in those who consume a **western diet (Low Fibre)**

Answer 305

**High Pressures in the Colon:** * Age > 50 * Low Fibre Diet * Obesity/Sedentary Lifestyle * Smoking * Constipation * Connective Tissue Disorders * NSAIDs and Opiates

Answer 306

* Wall of large intestine has a layer of circular muscle. * The points where arteries enter are areas of weakness. * Increased pressure over time can cause the mucosa to herniate through the muscle layer and pouch causing a diverticulum. * If faecal matter of bacteria gather –> this can lead to inflammation and rupture of the vessels causing GI bleeding

Answer 307

* Pain and tenderness in the left iliac fossa / lower left abdomen * Fever * Diarrhoea * Nausea and vomiting * Rectal bleeding * Palpable abdominal mass (if an abscess has formed) * Raised inflammatory markers (e.g., CRP) and white blood cells

Answer 308

* Pain and tenderness in the left iliac fossa / lower left abdomen * Fever * Diarrhoea * Nausea and vomiting * Rectal bleeding * Palpable abdominal mass (if an abscess has formed) * Raised inflammatory markers (e.g., CRP) and white blood cells

Answer 309

**Blood Tests:** * FBC: inflammatory picture * U&Es: Urea increased * CRP/ESR: Elevated * WCC: raised leukocytes **Abdominal Imaging:** * CT abdo/Pelvis with contrast (**Gold Standard for Diverticular Disease**) * Colonoscopy/Endoscopy if acute bleeding

Answer 310

**No treatment is required**

Answer 311

* Patients advised to increase dietary fibre intake and hydration * Bulk forming Laxatives (**Ispaghula Husk**) * If evidence of Diverticulitis then patients are initially managed with oral antibiotics * Analgesia

Answer 312

* Oral Co-amoxiclav (5 days) * Analgesia (avoid opiates and NSAIDs) * Only taking clear liquids (avoid solid food) until symptoms improve * Follow-up within 2 days to review symptoms

Answer 313

**Patients with severe pain, complications or resistant to antibiotics should be admitted to hospital** * Nil by mouth or clear fluids only * IV Antibiotics * IV Fluids * Analgesia * Urgent Investigations (CT scan) * Urgent Surgery may be required for complications

Answer 314

**Short-term complications include:** * **Abscess formation:** Initially managed with bowel rest, broad-spectrum antibiotics ± CT-guided percutaneous drainage. Surgical management is considered if medical management fails. * **Perforation:** A surgical emergency suspected in cases of generalised peritonitis. Free air on the abdominal x-ray and high clinical suspicion necessitate urgent exploratory laparotomy. * **Large Haemorrhage requiring blood transfusions** **Long-term complications include:** * **Fistula formation:** Most commonly colovesical fistulas, presenting with pneumaturia, faecaluria, and recurrent UTIs. Diagnosed with cystoscopy or cystography and require surgical repair. Colovaginal, coloenteric, colouterine, and colourethral fistulas may also occur. * **Fibrosis:** Secondary to inflammation, resulting in strictures and large bowel obstruction.

Answer 315

A chronic, complex, and widespread pain syndrome. Patients experience body pain that occurs at specific tend anatomical sites over at least three months.

Answer 316

* More common in females * Presents between the ages of 20-40 * Has a familial predisposition

Answer 317

**Unknown but likely multifactorial**

Answer 318

* Females: Middle aged 30-60 yrs * Family history of Fibromyalgia * Depression * Stress * Poverty * IBS

Answer 319

**Pain features:** * Chronic widespread muscle pain > 3 months * Pain found at specific tender points: 11/18 (9 pairs of points) * Pain worse with stress and cold weather * Morning stiffness <1hr **Other features:** * Fatigue: and waking up fatigued despite sufficient sleep * Non-restorative sleep * Cognitive disturbances: Problems with focus and memory * Mood disorder: depression and anxiety * Sleep Disturbances: insomnia

Answer 320

**Specific tender points throughout body: (9 pairs)** * Occiput * Low cervical region * Trapezius * Supraspinatus * Second rib * Lateral epicondyle * Gluteal region * Greater trochanter * Knees

Answer 321

* **Rheumatoid arthritis:** Characterized by joint pain, swelling, and redness * **Chronic fatigue syndrome:** Marked by severe, unexplained fatigue * **Lupus:** Presents with rash, joint pain, and kidney problems * **Hypothyroidism:** Accompanied by weight gain, constipation, and cold sensitivity

Answer 322

**Primarily clinical diagnosis after exclusion of other causes** * Widespread pain and tenderness for **at least 3 months** at **11 of 18 tender points** * Other investigations reveal no acute findings

Answer 323

**Conservative Management:** * Lifestyle modifications: Regular Exercise, stress management, relaxation techniques * Patient education of condition * Cognitive Behavioural Therapy **Medical Management:** * Simple analgesia * Antidepressant medications

Answer 324

Folliculitis refers to the inflammation of a hair follicle that results in the formation of papules or pustules, commonly known as 'pimples'.

Answer 325

**Bacterial Infection** of hair follicles * Primarily Staphylococcus aureus

Answer 326

* Papules and pustules that can appear anywhere on the body specifically around hair growth regions. * Not found on palms of hands and soles of feet (no hair follicles here)

Answer 327

* **Acne Vulgaris:** Presents with comedones, papules, pustules, nodules and possible scarring. Mainly seen on face, chest, and back. * **Impetigo:** Characterised by honey-colored crusty sores, often beginning as small red papules. * **Contact Dermatitis:** Symptoms include erythema, pruritus, and vesicles. Occurs in areas of skin exposure to irritants or allergens. * **Herpes Simplex:** Characterised by grouped vesicles on an erythematous base, often with a history of recurrence and previous similar episodes. * **Rosacea:** Presents with erythema, telangiectasia, and inflammatory papules and pustules, predominantly on the face.

Answer 328

**Clinical diagnosis based on physical examination**

Answer 329

**Application of topical antibiotics**, with a suggested addition of antibacterial soaps (e.g. chlorhexidine-containing solutions like Hibiscrub). * Oral antibiotics may also be required in more severe cases or cases that don't respond to topical treatments. * Specific variants may require tailored antibiotic approaches

Answer 330

A clinical diagnosis based on the presence of typical symptoms (dyspepsia, ""heartburn"" or ""acid reflux"") resulting from the reflux of gastric contents into the oesophagus caused by a defective lower oesophageal sphincter.

Answer 331

* Obesity * Hiatus Hernia * Smoking * Alcohol use

Answer 332

Defective lower oesophageal sphincter which enables the reflux of gastric contents into the lower oesophagus causing irritation

Answer 333

* Greasy and spicy foods * Coffee and tea * Alcohol * Non-steroidal anti-inflammatory drugs * Stress * Smoking * Obesity * Hiatus hernia

Answer 334

* Dyspepsia (Heart burn) * Acid regurgitation * epigastric or chest pain * Bloating and Belching * Nocturnal Cough * Tooth Erosion

Answer 335

**A**naemia **L**oss of weight **A**norexia **R**ecent onset of progressive symptoms **M**assess/Melena - or bleeding from any part of GIT **S**wallowing Difficulties (Dysphagia) **+55yrs**

Answer 336

* **Dysphagia** (at any age gets an immediate TWW referral) * **Aged over 55 years with Unintentional weight loss plus** * Upper abdominal pain * Reflux * Treatment resistant dyspepsia * **rectal bleeding** with bowel habbit change for 3/52 over the age of 40

Answer 337

* **Gastric ulcers:** These may present with epigastric pain, nausea, vomiting, and weight loss. * **Oesophageal cancer:** This may present with dysphagia, weight loss, and potentially haematemesis. * **Zollinger-Ellison Syndrome:** This may present with severe dyspepsia, diarrhoea and peptic ulcers * **Functional dyspepsia:** This condition may present with similar gastrointestinal symptoms without a clear organic cause.

Answer 338

**8 week therapeutic trial of Proton Pump Inhibitor** **If symptoms don't improve or patient has alarm symptoms then** * Oesophagealgastroduodenoscopy (OGD): Usually normal in GORD * 24-hr oesophageal pH monitoring (the gold standard test for diagnosis) * Oesophageal Manometry

Answer 339

**Lifestyle interventions** * Weight loss * Dietary changes * Elevation of the head of the bed at night * Avoidance of late-night eating. **Proton pump inhibitor therapy**. * Omeprazole/Lansoprazole * For patients <40 years old who present with typical symptoms and no red flags, commence treatment with a standard-dose PPI for 8 weeks in combination with lifestyle changes. **Antacids** for symptomatic relief: Gaviscon, Rennie **H2 Receptor Antagonists:** Famotidine Anti-reflux surgery for refractory cases: **Laparoscopic fundoplication**

Answer 340

* Reduce tea, coffee and alcohol * Weight loss * Avoid smoking * Smaller, lighter meals * Avoid heavy meals before bedtime * Stay upright after meals rather than lying flat

Answer 341

* oesophagitis * ulcers * anaemia * benign strictures * Barrett's oesophagus * oesophageal carcinoma

Answer 342

A gram negative bacilli with a flagellum that is present in 50% of the populations gastric mucosa

Answer 343

* secretes urease → urea converted to NH3 → alkalinization of acidic environment → increased bacterial survival **Pathogenesis mechanism:** * Helicobacter pylori releases bacterial cytotoxins (e.g. CagA toxin) → disruption of gastric mucosa

Answer 344

Peptic Ulcer Disease (PUD) Gastritis Gastric carcinomas

Answer 345

**Urea Breath Test:**First Line **Stool Antigen Test:** **Rapid urease test: Performed during endoscopy (CLO Test)**

Answer 346

**Triple-therapy: For 7 days** * Proton Pump Inhibitor - Omeprazole * Clarithromycin * Amoxicillin (metronidazole if CI)

Answer 347

The constant reflux of acid into the lower oesophagus causes a change in the epithelium called **metaplasia.** **This is a change from the stratified squamous epithelium to the columnar epithelium from the stomach in the lower 3rd of the oesophagus.** Barrett's Oesophagus is **considered premalignant.**

Answer 348

Considered premalignant: predisposing the patient to adenocarcinoma.

Answer 349

* Endoscopic Monitoring: For progression to adenocarcinoma * Proton Pump Inhibitors: Omeprazole * Endoscopic Ablation: Can destroy abnormal cells which are then replaced with normal squamous epithelial cells. Only used in treating **high grade dysplasia to reduce cancer risk**

Answer 350

Defined as a pathophysiological condition characterised by the development of multiple ulcerations in the stomach and duodenum. This is the **result of an uncontrolled release of gastrin from a gastrinoma**, a type of neuroendocrine tumour that commonly presents in the pancreas or the duodenum.

Answer 351

Associated with Multiple Endocrine Neoplasia Type I (MEN-1)

Answer 352

**MEN 1:** 3 P's * Pituitary Adenoma * Parathyroid * Pancreatic tumours (Insulinoma, Gastrinoma (Zollinger-Ellison)) **MEN 2a** 2 P's +1 M * Parathyroid * Medullary Thyroid * Phaeochromocytoma **MEN 2B** 1 P + 2 M's * Phaeochromocytoma * Mucosal neuromas * Marfanoid habitus

Answer 353

* Abdominal pain, particularly in the epigastric region * Diarrhoea * Ulceration of the duodenum, which can often lead to gastrointestinal bleeding * Non-responsiveness to simple Proton Pump Inhibitors (PPIs)

Answer 354

**Fasting Gastrin Levels:** Best Screening test **Secretin Stimulation Test** an unusually large increase in gastric occurs following secretin administration confirms the diagnosis **Somatostatin Receptor Scintigraphy** for imaging of the Tumour **Endoscopy** to identify duodenal ulcerations

Answer 355

**Surgical resection of Gastrinoma** * Chemotherapy if Metastatic disease **Medical Management:** * Proton Pump Inhibitors * Somatostatin analogues

Answer 356

A disorder of carbohydrate metabolism characterised by hyperglycaemia

Answer 357

* Type 1 DM - Insulin dependent * Type 2 DM - Insulin Independent - Maybe be gestational or medication induced) * MODY (Maturity Onset Diabetes of Youth) * Pancreatic diabetes * Endocrine diabetes - Acromegaly, Cushing’s * Malnutrition related diabetes

Answer 358

4.4 - 6.1 mmol/l

Answer 359

Type 1 diabetes mellitus (T1DM) is an autoimmune condition characterized by the destruction of the insulin-producing beta cells within the pancreas, leading to insulin deficiency.

Answer 360

* Predominantly affects children and young adults but can occur at any age * Highest incidence over norther Europe * Lean males * Associated with Family History and other autoimmune diseases

Answer 361

Thought to be caused by **combination of genetic predisposition and environmental triggers** leading to a Type IV hypersensitivity reaction that destroys pancreatic beta cells. **Genes associated with T1DM:** HLA DR3 and HLA DR4 **Environmental Triggers:** Viral infections (such as Coxsackie B virus and Enterovirus)

Answer 362

* Type IV hypersensitivity reaction leads to destruction of pancreatic beta cells leading to Absolute insulin deficiency. * Lack of insulin leads to: * Unrestricted hepatic glucose output: Glycogenolysis + Gluconeogenesis * Impaired peripheral uptake of glucose into adipose and muscle tissue * Glucose concentration rises in the blood significantly causing **hyperglycaemia** * Cells cannot uptake glucose and thus become **metabolically starved** resulting in lipolysis and muscle breakdown to **undergo ketogenesis** * High glucose concentration in the blood leads to glycosuria as re-uptake mechanisms are saturated. Glucose is also osmotically active and thus draws more water into the urine leading to **polyuria** * Increased Polyuria can subsequently cause increased thirst and **polydipsia**

Answer 363

**2-6 week history** * **polyuria** * **Polydipsia** * **Weight loss** **Others:** * Fatigue

Answer 364

* **Diabetes insipidus:** Presents with polyuria and polydipsia, but without hyperglycaemia or glucosuria. * **MODY (Maturity Onset Diabetes of the Young):** * **Hyperthyroidism:** Can present with weight loss and increased appetite, but usually also includes symptoms such as tachycardia, tremor, and heat intolerance.

Answer 365

**If symptomatic, one of the following results is sufficient for diagnosis:** **If the patient is asymptomatic, two results are required from different days.** * Random blood glucose **≥ 11.1mmol/l** * Fasting plasma glucose **≥ 7mmol/l** * 2-hour Oral Glucose Tolerance Test (OGTT) **≥ 11.1mmol/l** * HbA1C **≥ 48mmol/mol (6.5%)** **To confirm T1DM, the following investigations can be done:** * **Autoantibody testing:** Identification of specific antibodies (e.g. anti-GAD, ICA, IAA) contributes to confirming the autoimmune nature of T1DM. * **C-peptide levels:** Evaluation of C-peptide production helps assess endogenous insulin secretion. * **Urine ketone testing:** Presence of ketones may suggest concurrent DKA.

Answer 366

**Insulin Therapy:** * Basal Bolus Regime: * Long acting Insulin (levemir) * Rapid acting insulin taken 30 mins before meals (Humalog) **Lifestyle Modifications:** * Guidance on nutrition and carbohydrate counting * Exercise * Reduce alcohol consumption * Blood Glucose Monitoring: Either self glucose monitoring (SMBG) or continuous glucose monitoring (CMG) **Hypoglycaemia management: Sugary drinks or snacks if they have a hypo** **Regular Follow-up from DSN and monitoring of HbA1c** **Monitoring for complications (short and long term)** **Reduce risk factors of complications:** * Blood pressure control if high

Answer 367

**Individualised to the patient** **Typically:** * Pre-meal blood glucose: 4-7 mmol/L (72-126 mg/dL) * Bedtime blood glucose: 6-10 mmol/L (108-180 mg/dL) * **HbA1c: Less than 7% (53 mmol/mol) for most adults**; individualised targets for children, elderly patients, and those at risk of hypoglycemia.

Answer 368

* Hypoglycaemia * Hyperglycaemia leading to **Diabetic Ketoacidosis (DKA)**

Answer 369

Hypoglycaemia is a metabolic condition characterized by an abnormally low blood glucose level, typically defined as less than 3.9 mmol/L.

Answer 370

* Advancing age * Cognitive impairment * Depression * Aggressive treatment of glycaemia * Impaired awareness of hypoglycaemia * Duration of multi dose insulin therapy * Renal impairment and other comorbidities

Answer 371

* Drugs: **Insulin, Sulphonylureas**, GLP-1 analogues, DPP-4 inhibitors, Beta-blockers * Alcohol * Acute liver failure * Sepsis * Adrenal insufficiency * Insulinoma * Glycogen storage disease

Answer 372

**Hormonal response:** * Decreased insulin secretion. * Increased glucagon secretion. * Growth hormone and cortisol are also released but later **Sympathoadrenal response:** * Increased catecholamine-mediated (adrenergic) and acetylcholine-mediated (cholinergic) neurotransmission * Activates the PNS and CNS

Answer 373

**Adrenergic Symptoms (Blood glucose concentrations <3.3 mmol/L):** * Trembling * Sweating * Irritability * Palpitations * Hunger * Headache **Neuroglycopenic Symptoms (Blood glucose concentrations below <2.8 mmol/L):** * Double vision * Difficulty concentrating * Slurred speech * Confusion * Coma

Answer 374

* **Diabetic ketoacidosis:** May cause hypoglycaemia due to insulin treatment. Symptoms include polydipsia, polyuria, fatigue, and abdominal pain. * **Adrenal insufficiency:** Lack of cortisol may lead to hypoglycaemia. Features include fatigue, weight loss, hyperpigmentation, and hypotension. * **Insulinoma:** Insulin-secreting tumour resulting in hypoglycaemia. Symptoms mimic hypoglycaemia but can occur after meals. * **Alcohol intoxication:** Alcohol can inhibit hepatic gluconeogenesis, leading to hypoglycaemia. Symptoms include confusion, ataxia, slurred speech, and coma.

Answer 375

**Mild Hypoglycaemia (Patient is conscious):** * ABCDE approach * Consume 15-20g of fast-acting carbohydrate (e.g., glucose tablets, non-diet soda, sweets, fruit juice). * Avoid chocolate due to slower absorption. * Follow up with slower-acting carbohydrates (e.g., toast). **Severe Hypoglycaemia (e.g. Seizures, Unconsciousness):** * ABCDE approach * Administer **1mg glucagon IM** if no IV access (Note: this won't work if alcohol ingestion is the cause due to its action blocking gluconeogenesis). Alternatively * Administer 20% dextrose solution IV. * Manage prolonged or repeated seizures. **Aftercare:** * Consider medication changes. * Investigate non-drug causes if necessary.

Answer 376

Diabetic ketoacidosis (DKA) is a severe medical emergency characterized by the triad of: * Hyperglycaemia (blood sugars >11 mmol/L) * Ketonemia (blood ketones >3 mmol/L) * Acidosis (pH <7.3 or bicarbonate <15 mmol/L) **Note: Patients on gliflozins can present with euglycemic DKA.**

Answer 377

DKA is most common in individuals with Type 1 diabetes but can occur in those with Type 2 diabetes under severe stress or illness. It is the leading cause of death among young individuals with diabetes.

Answer 378

* Infections * SGLT2 Inhibitors * Dehydration * Fasting * First presentation of Type 1 diabetes **It is vital to note that fever is not a typical part of DKA presentation; a raised temperature might indicate an underlying infection that precipitated DKA.**

Answer 379

* Nausea and Vomiting * Abdominal pain * Dehydration * Hypovolaemic shock * Drowsiness * Coma **Signs:** * Tachypnoea (**Kussmaul's respiration: a deep, sighing pattern of respiration, compensating for a metabolic acidosis by blowing off CO2**) * 'Fruity' ketotic breath

Answer 380

* **Alcoholic ketoacidosis:** History of chronic alcohol misuse, abdominal pain, nausea, vomiting, dehydration, similar lab findings as DKA. * **Starvation ketosis:** History of fasting or extremely low-calorie intake, dizziness, weakness, hypotension, mild ketonaemia. * **Lactic acidosis:** Shortness of breath, abdominal pain, lactate >5 mmol/L, and evidence of tissue hypoperfusion. * **Hyperosmolar hyperglycaemic state:** Severe hyperglycaemia (>30 mmol/L), severe dehydration, change in mental status, minimal ketonaemia.

Answer 381

* Blood glucose (>11.1mmol/L) * Blood ketones (>3mmol/L) * Blood gas analysis: pH <7.3 or Bicarbonate <15mmol/L * (expecting hyperglycaemic, hypokalaemic metabolic acidosis, low bicarb) * Urea and electrolytes * Urinary glucose and ketones * Blood cultures (if evidence of infection) * ECG (for any ischaemic changes or changes secondary to hypokalaemia)

Answer 382

**F**luids: IV fluid resuscitation with 1L 0.9% NaCl stat. Then 1L every 2 hours **I**nsulin: Fixed rate insulin infusion (Actrapid 0.1 units/kg/hour) **G**lucose: Monitor BMs until glucose is <14mmol/L and add glucose infusion **P**otassium: Potassium replacement (dependant on [K]) added to IV fluids **I**nfection: Treat underlying trigger such as infection **C**hart fluid balance **K**etones: Monitor blood ketones, pH and Bicarbonate **Resolution of DKA is when pH >7.3, blood ketones <0.6mmol/L and bicarbonate >15**

Answer 383

**Dehydration, Acidosis, Potassium imbalance (Low total body K+)** * Gastric stasis * Thromboembolism * Arrhythmias secondary to hypokalaemia * Acute respiratory distress syndrome * Acute kidney injury **Iatrogenic due to incorrect fluid therapy: cerebral oedema, hypokalaemia, hypoglycaemia**

Answer 384

A chronic metabolic condition characterized by inadequate insulin production from pancreatic beta cells, combined with peripheral insulin resistance. This leads to an elevation in blood glucose levels, causing hyperglycaemia.

Answer 385

* Onset older (>30 years). * Strong familial predisposition * Usually overweight. * More common in African/Asian. * Most common form of Diabetes Mellitus (90-95% of cases)

Answer 386

**Non-modifiable risk factors:** * Older age * Ethnicity (Black African or Caribbean and South Asian) * Family history **Modifiable risk factors:** * Obesity * Sedentary lifestyle * High carbohydrate (particularly sugar) diet

Answer 387

* Steroids * Tacrolimus * Thiazides * Protease inhibitors (HIV) * Antipsychotics

Answer 388

* Repeated exposure to glucose and insulin makes the cells in the body resistant to the effects of insulin. * More and more insulin is required to stimulate the cells to take up and use glucose. * Over time, the pancreas becomes fatigued and damaged by producing so much insulin, and the insulin output is reduced. * A high carbohydrate diet combined with insulin resistance and reduced pancreatic function leads to chronic high blood glucose levels (hyperglycaemia). * Chronic hyperglycaemia leads to microvascular, macrovascular and infectious complications

Answer 389

**Initially Asymptomatic but over time develop:** * Polyuria * Polydipsia * Unexplained weight loss * Fatigue * Slow wound healing * Opportunistic infections (Oral Thrush) * **Acanthosis nigricans** (associated with insulin resistance)

Answer 390

* HbA1c: **42-47 mmol/mol** **Impaired Fasting Glucose** 6.1-6.9 mmol/L **Impaired Glucose Tolerance** 7.8-11.0 mmol/L

Answer 391

**If symptomatic, one of the following results is sufficient for diagnosis: If the patient is asymptomatic, two results are required from different days.** * Random blood glucose ≥ 11.1mmol/l * Fasting plasma glucose ≥ 7mmol/l * 2-hour glucose tolerance ≥ 11.1mmol/l * HbA1C ≥ 48mmol/mol (6.5%) Typically repeated after 1 month to confirm diagnosis

Answer 392

**Lifestyle management:** * Patient education about their condition and lifestyle * Dietary modification * Exercise and weight loss * Smoking Cessation * Monitoring for macro and microvascular complications of DM **First Line Pharmacotherapy: (To keep HbA1c <48mmol/mol)** * **Metformin** * Once settled on metformin, add **SGLT2 inhibitor** if the patient has existing CVD, Chronic HF or a QRISK >10% **Second Line Pharmacotherapy: (HbA1c >58mmol/mol on Metformin)** Add one of: * Sulphonylurea: Gliclazide, Tolbutamide * Pioglitazone * DPP-4 Inhibitor: Sitagliptin, Linagliptin * SGLT2 Inhibitor if not already on one: Dapagliflozin, Empagliflozin, Canagliflozin **Third Line Pharmacotherapy: (HbA1c >58mmol/mol on Dual Therapy)** One of: * Triple Therapy: Metformin and 2 of the second line drugs * Insulin therapy (initiated by a diabetes specialist nurse (DSN)) * If triple therapy fails to control HbA1c and patients BMI >35kg/m2 then switch one of the second line drugs to a **GLP-1 mimetic:** * Exenatide, Liraglutide, Semaglutide

Answer 393

* Metformin increases insulin sensitivity and decreases glucose production by the liver. * It is a biguanide (the class of medication). * It does not cause weight gain (and may cause some weight loss). * It does not cause hypoglycaemia.

Answer 394

* Gastrointestinal symptoms, including pain, nausea and diarrhoea (depending on the dose) * Lactic acidosis (e.g., secondary to acute kidney injury)

Answer 395

* Sulfonylureas stimulate insulin release from the pancreas. * Acts on the SUR1 receptor

Answer 396

* Weight gain * Hypoglycaemia

Answer 397

* The sodium-glucose co-transporter 2 protein is found in the proximal tubules of the kidneys. * It acts to reabsorb glucose from the urine back into the blood. * SGLT-2 inhibitors block the action of this protein, causing more glucose to be excreted in the urine. * Loss of glucose in the urine lowers the HbA1c, reduces the blood pressure, leads to weight loss and improves heart failure. * They can cause hypoglycaemia when used with insulin or sulfonylureas.

Answer 398

* Glycosuria (glucose in the urine) * Increased urine output and frequency * Genital and urinary tract infections (e.g., thrush) * Weight loss * **Diabetic ketoacidosis**, notably with only moderately raised glucose * Fournier’s gangrene (rare but severe infection of the genitals or perineum)

Answer 399

Incretins are hormones produced by the gastrointestinal tract. They are secreted in response to large meals and act to reduce blood sugar by: * Increasing insulin secretion * Inhibiting glucagon production * Slowing absorption by the gastrointestinal tract The main incretin is glucagon-like peptide-1 (GLP-1). Incretins are inhibited by an enzyme called dipeptidyl peptidase-4 (DPP-4).

Answer 400

* DPP-4 inhibitors block the action of DPP-4, allowing increased incretin activity. * Examples of DPP-4 inhibitors are sitagliptin and Linagliptin. * They do not cause hypoglycaemia.

Answer 401

* Headaches * GI Tract upset * Low risk of acute pancreatitis

Answer 402

* Pioglitazone is a thiazolidinedione. * Activate PPAR-gamma receptor in adipocytes to promote adipogenesis and fatty acid uptake * It increases insulin sensitivity and decreases liver production of glucose. * It does not typically cause hypoglycaemia.

Answer 403

* Weight gain * Fluid Retention * Heart failure * Increased risk of bone fractures * A small increase in the risk of bladder cancer

Answer 404

* **Rapid-acting insulins (e.g., NovoRapid)** start working after around 10 minutes and last about 4 hours. * **Short-acting insulins (e.g., Actrapid)** start working in around 30 minutes and last about 8 hours. * **Intermediate-acting insulins (e.g., Humulin I)** start working in around 1 hour and last about 16 hours. * **Long-acting insulins (e.g., Levemir and Lantus)** start working in around 1 hour and last about 24 hours or longer. Combinations insulins contain a rapid-acting and intermediate-acting insulin. In brackets is the ratio of rapid-acting to intermediate-acting insulin: * Humalog 25 (25:75) * Humalog 50 (50:50) * Novomix 30 (30:70)

Answer 405

* **Hypoglycaemia** * Injection site - Lipodystrophy: May occur when a patient injects insulin into the same spot causing the subcutaneous fat to harden. This can lead to poorer absorption of insulin * Insulin resistance - mild and associated with obesity * Weight gain - insulin makes people feel hungry

Answer 406

* GLP-1 mimetics imitate the action of GLP-1. * Examples are exenatide and liraglutide. * They are given as subcutaneous injections. * Liraglutide can also be used for weight loss in non-diabetic obese patients.

Answer 407

* Reduced appetite due to making patient feel sick * Weight loss * Gastrointestinal symptoms, including discomfort, nausea and diarrhoea

Answer 408

Hyperglycaemia leading to Hyperosmolar Hyperglycaemic State (HHS)

Answer 409

A severe metabolic disorder that typically occurs in patients with type 2 diabetes, characterised by **extreme hyperglycaemia, hypotension, and increased serum osmolality without significant ketosis or acidosis.**

Answer 410

* Infection * Medications that cause fluid loss or lower glucose tolerance * Surgery * Impaired renal function

Answer 411

hyperglycaemia → ↑ serum osmolality → osmotic diuresis → severe volume depletion

Answer 412

* Polyuria, Polydipsia and weight loss with: * Nausea and vomiting * Lethargy * Weakness * Confusion * Dehydration * Coma * Seizure **They can be extremely unwell, demonstrating signs of hypovolaemia, tachycardia, hypotension, and exhaustion.**

Answer 413

* The main differential diagnosis for HHS is Diabetic Ketoacidosis (DKA). * Unlike HHS, DKA is characterised by significant acidosis (pH<7.3; bicarb <15mmol/L) and ketosis (ketones > 3mmol/L).

Answer 414

* Severe hyperglycaemia (>=30mmol/L) * Hypotension * Hyperosmolality (usually >320 mosmol/kg) **The absence of significant acidosis or ketosis differentiates HHS from DKA.**

Answer 415

**IV Fluid resuscitation** * 0.9% saline. * Patients may require subsequent fluid to correct dehydration. **Electrolyte Replacement** **Insulin** * Only if ketones >1mmol/L or glucose fails to fall. * Continue any long-acting insulin. **Venous thromboembolism (VTE) prophylaxis** * These patients are at high risk due to dehydration and hyperviscosity. **The management of HHS involves correcting serum osmolality, fluid deficit, and electrolyte deficits. These corrections need to occur over a slightly longer period of time than in DKA.**

Answer 416

**Cardiac Complications** Diabetes significantly increases the risk of cardiovascular disease, contributing to major morbidity and mortality. **Peripheral Arterial Disease (PAD)** Patients present with foot discolouration, gangrene, intermittent claudication, rest pain, night pain and absent peripheral pulses (confirmed on doppler). **Cerebrovascular disease** Patients with diabetes are at significantly increased risk of TIAs and stroke and as such it is paramount to address the main risk factors (lipids, BP, smoking, obesity) for these as a broader part of management

Answer 417

**Diabetic Retinopathy** Characterised by vascular occlusion and leakage in the retinal capillaries, leading to potential sight loss if unmanaged, it is the leading cause of visual loss in adults. See separate section. **Diabetic Nephropathy** A leading cause of chronic kidney disease, it is characterised by proteinuria. Prevention of this complication is achieved with ACE inhibitors/ARBs (by managing blood pressure) and SGLT-2 inhibitors. **Diabetic Neuropathy** The primary causative factor is chronic hyperglycaemia, which leads to several distinct types neuropathy. **Sexual Dysfunction** Caused by a combination of factors including poor glycaemic control, neuropathy, microvascular complications, obesity, hypertension, depression, medication side effects, etc.

Answer 418

* **Autonomic Neuropathy:** May lead to postural hypotension and associated symptoms like dizziness, falls, and loss of consciousness. * **Gastrointestinal Complications:** Gastroparesis - a result of poor glycaemic control leading to nerve damage of the autonomic nervous system. Characterized by delayed gastric emptying, early satiety, abnormal stomach wall movements, and morning nausea. * **Foot Complications:** Diabetic Foot Infections - patients with vascular and neuropathic complications are at high risk for diabetic foot ulceration and subsequent infection.

Answer 419

* Urinary tract infections * Pneumonia * Skin and soft tissue infections, particularly in the feet * Fungal infections, particularly oral and vaginal candidiasis

Answer 420

* Hyperglycaemia is thought to cause increased retinal blood flow and abnormal metabolism in the retinal vessel walls. * * This precipitates damage to endothelial cells and pericytes * * Endothelial dysfunction leads to increased vascular permeability which causes the characteristic exudates seen on fundoscopy. * * Pericyte dysfunction predisposes to the formation of microaneurysms. * * Neovasculization is thought to be caused by the production of growth factors in response to retinal ischaemia

Answer 421

* R0 - None detected * R1 - Background changes; screened once a year * R2 - Pre-proliferative; early changes screened 6-monthly * R3 - Proliferative; called into eye clinic to look at interventions to protect vision * M - Maculopathy; changes that happen close to the fovea * P - Photocoagulation; laser treatment has been done * U - Unclassifiable

Answer 422

* Hyperglycaemia leads to RBCs becomming sticky and can cause occlusion of the efferent arteriole. * Efferent arteriole is blocked leading to a build up of pressure and Hyperfiltration. * The hyperfiltration damages the filtration barrier and stimulates mesangial cells to secrete extracellular matrix * This leads to sclerosis and scarring (glomerulosclerosis) and subsequent nephropathy

Answer 423

T1DM - Around 10 years after diagnosis T2DM - Can be present at diagnosis

Answer 424

Weakening of the bones of the foot, they are more prone to fractures and the stress of walking leads to deformity of the foot

Answer 425

**Prevention of Cardiovascular Complications:** * ACE inhibitors are first line to manage Hypertension in Diabetes **Prevention of Diabetic Nephropathy:** * ACE inhibitors are also started in diabetics with CKD when the ACR >3mg/mol * SGLT2 inhibitors are started in diabetics with CKD when ACR >30 mg/mol **Management of Sexual Dysfunction in Diabetes:** * Phosphodiesterase-5 inhibitors may be started: **sildenafil, tadalafil** **Management of Gastroparesis in Diabetes:** * Prokinetic drugs: **Metoclopramide, Domperidone** **Management of Neuropathic pain in Diabetic Neuropathy:** * Amitriptyline: Tricyclic Antidepressant * Duloxetine: SNRI Antidepressant * Gabapentin: Anticonvulsant * Pregabalin: Anticonvulsant

Answer 426

A High Blood Pressure A 'normal' blood pressure ranges between 90/60mmHg to <140/90mmHg. **The definition of hypertension is a blood pressure above 140/90 in clinical setting that is confirmed with 24h ambulatory blood pressure average reading (ABPM) that is more than or equal to 135/85mmHg.**

Answer 427

**Essential hypertension accounts for 90% of hypertension. This is also known as primary hypertension.** It means a high blood pressure has developed on its own and does not have a secondary cause. **Secondary Causes of Hypertension:** **R**enal disease **O**besity **P**regnancy-induced hypertension or pre-eclampsia **E**ndocrine **D**rugs (e.g., alcohol, steroids, NSAIDs, oestrogen and liquorice)

Answer 428

**Renal disease is the most common cause of Secondary Hypertension** * **Chronic Kidney Disease** * Renal Artery Stenosis * Tubular Necrosis

Answer 429

* **Conn's Syndrome** * Cushing's Syndrome * Phaeochromocytoma * Acromegaly

Answer 430

* Family history * Old age * Male * Afro-Caribbean * Lack of physical activity * Unhealthy diet (high salt intake, alcohol, smoking) * Obesity * Diabetes mellitus * Stress

Answer 431

**Stage 1: (low risk)** * Clinical: >140/90 * ABPM: >135/85 **Stage 2: (high risk)** * Clinical: >160/100mmHg * ABPM: >150/95mmHg **Severe:** * Clinical systolic >180mmHg * Clinical diastolic >120 mmHg

Answer 432

**Asymptomatic**

Answer 433

Patients with a clinic blood pressure between 140/90 mmHg and 180/120 mmHg should have 24-hour ambulatory blood pressure or home readings to confirm the diagnosis. **This rules out White Coat Syndrome where there is a increased BP reading of 20/10 mmHg due to the clinical setting** **Assess for End Organ Damage in all newly diagnosed patients**

Answer 434

**Assessment for End Organ Damage:** * **Urine Albumin:Creatinine ratio (ACR):** For proteinuria and dipstick for microscopic haematuria to assess for kidney damage * **Bloods:** For HbA1c, Renal Function and Lipids * **Fundus Examination** For Hypertensive Retinopathy * **ECG:** For Cardiac Abnormalities such as LVH * **Calculate QRISK score:** Any patients >10% offered Statin (atorvastatin 20mg)

Answer 435

* Stage 1 - Treat if >80yrs or if signs of end organ target damage or QRISK2 score 10% * Stage 2 - start Treatment

Answer 436

* Weight loss * Reduce alcohol intake * Reduce salt intake * Stop smoking * Regular exercise * Stress reduction

Answer 437

**Under age of 55 or Diagnosed with Diabetes Mellitus:** 1. ACE inhibitor / ARB (**Ramipril**) 2. Add Calcium Channel Blocker (**Amlodipine**) 3. Add Thiazide Diuretic (**Indapamide**) 4. Resistant Hypertension 4a. If K+ < 4.5 - Add Spironolactone 4b. If K+ > 4.5 - Add alpha or beta blocker **Over age of 55 or Afro-Caribbean Origin:** 1. Calcium Channel Blocker (**Amlodipine**) 2. Add ACE inhibitor / ARB (**Ramipril**) 3. Add Thiazide Diuretic (**Indapamide**) 4. Resistant Hypertension 4a. If K+ < 4.5 - Add Spironolactone 4b. If K+ > 4.5 - Add alpha blocker (**Doxazosin**) or beta blocker (**Atenolol**)

Answer 438

* Increased risk of morbidity and mortality from all causes * Coronary artery disease * Heart failure * Renal failure * Stroke * Peripheral vascular disease * Vascular Dementia * Hypertensive retinopathy, Nephropathy

Answer 439

**Extremely High Blood Pressure Above 180/120 with signs of Retinal Haemorrhages or Papilloedema** **Fibrinoid Necrosis is a pathological hallmark** Patients admitted with Malignant hypertension are assessed for **secondary causes and end organ damage**

Answer 440

* Headaches * Visual Disturbances

Answer 441

**Hypertensive Urgency: (no end organ damage)** * Oral Nifedipine * Oral Nifedipine and Oral Amlodipine **Hypertensive Emergency (end organ damage):** * IV Sodium Nitroprusside * IV Labetalol * IV GTN

Answer 442

Haemorrhoids are a pathological condition where the vascular cushions become enlarged within the anal canal, abnormally expand and can protrude outside the anal canal.

Answer 443

* **1st degree:** no prolapse * **2nd degree:** prolapse when straining and return on relaxing * **3rd degree:** prolapse when straining, do not return on relaxing, but can be pushed back * **4th degree:** prolapsed permanently

Answer 444

* Constipation * Pregnancy * Increased intra-abdominal pressure due to causes like obesity, chronic cough or space-occupying lesions * Portal hypertension, particularly secondary to cirrhosis, due to increased pressure at the rectal porto-systemic anastomosis

Answer 445

**May be Asymptomatic** * Bright red PR bleeding, often associated with defecation and on wiping * Absence of pain, unless the patient has a thrombosed external haemorrhoid or another condition such as an anal fissure * Anal pruritus * A palpable or protruding mass in the anal region during examination

Answer 446

* **Anal fissure:** Characterised by severe anal pain during and after bowel movements, presence of bright red blood on toilet paper, and potentially a visible tear or lump of skin near the anal area * **Anal cancer:** May present with rectal bleeding, anal pain, the presence of an anal mass, and changes in bowel habits * **Perianal haematoma:** Presents with acute, severe pain and a tender, bluish lump near the anus. It can be mistaken for a thrombosed external haemorrhoid * **Rectal prolapse:** Identified by the protrusion of pink or red tissue from the anus, typically after a bowel movement, with potential rectal bleeding

Answer 447

**Clinical Examination** **Digital Rectal Examination** **Proctoscopy**

Answer 448

**Grade 1and 2:** * First Line: Conservative management, Analgesia and topical corticosteroids to alleviate pruritus * Second Line: Non-surgical treatments **Grade 3:** First Line: Rubber band ligation **Grade 4:** * First Line: Surgical haemorrhoidectomy may be necessary, **In all cases, patients should be advised to maintain a diet rich in fibre and fluids to reduce the risk of constipation, thereby limiting exacerbation of haemorrhoids.**

Answer 449

* Increasing the amount of fibre in the diet * Maintaining a good fluid intake * Using laxatives where required * Consciously avoiding straining when opening their bowels

Answer 450

* Anusol * Anusol HC (contains hydrocortisone) * Germoloids cream (contains lidocaine anaesthetic)

Answer 451

* Rubber band ligation (fitting a tight rubber band around the base of the haemorrhoid to cut off the blood supply) * Injection sclerotherapy (injection of phenol oil into the haemorrhoid to cause sclerosis and atrophy) * Infra-red coagulation (infra-red light is applied to damage the blood supply) * Bipolar diathermy (electrical current applied directly to the haemorrhoid to destroy it)

Answer 452

* Haemorrhoidal artery ligation * Haemorrhoidectomy * Stapled Haemorrhoidectomy

Answer 453

Occurs when abdominal contents (commonly the stomach) protrude through an enlarged oesophageal hiatus in the diaphragm.

Answer 454

* Obesity * Increasing age * Pregnancy * Prior hiatal surgery * Increased intra-abdominal pressure, such as from chronic cough, multiparity, or ascites

Answer 455

**Type 1: Sliding (80%):** Here, the gastro-oesophageal junction slides up into the chest. This results in a less competent sphincter and consequent acid reflux. Treatment is similar to Gastroesophageal reflux disease (GORD). **Type 2: Rolling (20%):** In this type, the gastro-oesophageal junction stays in the abdomen, but part of the stomach protrudes into the chest alongside the oesophagus. This type requires more urgent treatment since volvulus can lead to ischemia and necrosis. **Type 3: Combination of sliding and rolling** **Type 4: Large opening where additional abdominal organs enter the thorax**

Answer 456

* heartburn * dysphagia * regurgitation * chest pain

Answer 457

* **Gastroesophageal reflux disease (GORD):** Heartburn, regurgitation, difficulty swallowing * **Gastritis:** Abdominal pain, nausea, vomiting * **Peptic ulcer:** Abdominal pain, bloating, feeling of fullness * **Gallstones:** Severe abdominal pain, jaundice, fever

Answer 458

**Endoscopy** Often first line due to presentation **Barium Swallow** is most sensitive test **Chest X-ray:** Retrocardiac air bubble **CT Scan**

Answer 459

**Conservative Management:** * Weight loss * Elevating the head of the bed * Avoidance of large meals and eating 3-4 hours before bed * Avoidance of alcohol and acidic foods * Smoking cessation **Medical Management:** * Proton Pump Inhibitors: Omeprazole, Lansoprazole **Surgical Management:** * Laparoscopic Fundoplication

Answer 460

Refers to insufficient thyroid hormones, triiodothyronine (T3) and thyroxine (T4).

Answer 461

* Higher prevalence among females * Increases with age * Iodine deficiency is most prominent cause in developing world * Hashimoto's Thyroiditis is most prominent cause in developed world

Answer 462

Primary hypothyroidism is where the thyroid behaves abnormally and produces inadequate thyroid hormones. Negative feedback is absent, resulting in increased production of TSH. TSH is raised, and T3 and T4 are low.

Answer 463

Secondary hypothyroidism, also called central hypothyroidism, is where the pituitary behaves abnormally and produces inadequate TSH, resulting in under-stimulation of the thyroid gland and insufficient thyroid hormones. TSH, T3 and T4 will all be low.

Answer 464

* **Hashimoto's thyroiditis** Most common in developed world * **Dietary iodine deficiency** Most common in developing world * Subacute thyroiditis (de Quervain's) * Riedel thyroiditis * After thyroidectomy or radioiodine treatment * Drug therapy (e.g. lithium, amiodarone or anti-thyroid drugs such as carbimazole)

Answer 465

* Tumours (e.g., pituitary adenomas) * Surgery to the pituitary * Radiotherapy * Sheehan’s syndrome (where major post-partum haemorrhage causes avascular necrosis of the pituitary gland) * Trauma

Answer 466

Autoimmune destruction of the thyroid gland associated with anti-TPO antibodies and Anti thyroglobulin antibodies. It initially causes a goitre when then leads to atrophy of the gland

Answer 467

Post partum Thyroiditis De Quervain’s thyroiditis

Answer 468

**General features:** * Goitre: Depends on aetiology * Weight gain * Fluid retention * Fatigue * Heavy or irregular periods * Constipation * **Cold intolerance** **Peripheral Features:** * Dry skin * Coarse hair and hair loss * **Queen Anne's Sign:** loss of outer 1/3 eyebrows **Neurological features:** * Slow reflexes * Confusion/Delirium * Peripheral neuropathy **Cardiac Features:** * Bradycardia * Cardiomegaly

Answer 469

* **Iron deficiency anaemia:** fatigue, weakness, pallor, shortness of breath. * **Chronic fatigue syndrome:** persistent fatigue, unrefreshing sleep, cognitive impairment. * **Depression:** persistent low mood, lack of interest, feelings of guilt, sleep and appetite changes.

Answer 470

**Thyroid Function Tests:** * Primary Hypothyroidism: * TSH - High * T3/T4 - Low * Secondary Hypothyroidism: * TSH - Low * T3/T4 - Low **Investigations for Aetiology:** * Antibody testing (Anti-TPO, Anti-thyroglobulin, Anti-TSH receptor) is used to identify autoimmune causes. * Imaging and biopsy may be used to identify congenital and infiltrative causes. * Medication review * Iodine levels can be assessed to determine whether deficiency or excess is contributing to hypothyroidism.

Answer 471

* Anti-Thyroid Peroxidase (Anti-TPO) * Antithyroglobulin antibodies

Answer 472

**Oral Levothyroxine:** Synthetic T4 which metabolises to T3 in the body * Dose is titrated until TSH is normalised

Answer 473

Myxoedema coma - usually infection precipitated Rapid loss of T4 **Features** * Hypothermia * Loss of consciousness * Heart failure

Answer 474

* IV thyroid replacement * IV fluid * IV corticosteroids (until the possibility of coexisting adrenal insufficiency has been excluded) * electrolyte imbalance correction * sometimes rewarming

Answer 475

Hyperthyroidism: TSH - Low (except in a pituitary adenoma) T3/T4 - High Primary Hypothyroidism: TSH - High T3/T4 - Low Secondary Hypothyroidism: TSH - Low T3/T4 - Low

Answer 476

Anti-thyroid Peroxidase antibodies (Anti-TPO) - Graves disease and Hashimoto's Thyroiditis Antithyroglobulin antibodies - Graves disease, Hashimoto's Thyroiditis and thyroid cancer TSH Receptor antibodies (IgG) - Graves disease

Answer 477

Thyroid Ultrasound for Nodules Radioisotope Scan with radioactive iodine: Diffuse high uptake - Graves disease Focal high uptake - TMG/adenoma Cold areas (low uptake) - Thyroid cancer

Answer 478

Over production of Thyroid hormone from the thyroid gland

Answer 479

Abnormal/excessive quantity of thyroid hormone in the body.

Answer 480

An autoimmune condition where TSH receptor autoantibodies stimulate the TSH-R leading to increased production of T3/T4. Most common cause of hyperthyroidism (80-90% primary cause)

Answer 481

Nodules develop in the thyroid gland that act independently of the normal negative feedback system and therefore result in over production of T3/T4

Answer 482

Grave’s disease Toxic multinodular goitre Benign Adenoma (Solitary toxic thyroid nodule) Thyroiditis (e.g. De Quervain’s, Hashimoto’s, postpartum and drug-induced thyroiditis)

Answer 483

(EVERYTHING FAST) Sweating and heat intolerance Tachycardia Weight loss Fatigue Frequent loose stools Sexual dysfunction Anxiety and irritability

Answer 484

Diffuse goitre (without nodules) Graves eye disease Bilateral exophthalmos Pretibial myxoedema Acropachy All relate to the presence of TSH Receptor antibodies

Answer 485

bulging of eyeball out of the socket caused by Graves Disease. This is due to inflammation, swelling and hypertrophy of the tissue behind the eyeball that forces the eyeball forward.

Answer 486

Deposits of mucin under the skin on the anterior aspect of the leg (the pre-tibial area). This gives a discoloured, waxy, oedematous appearance to the skin over this area. It is specific to Grave’s disease and is a reaction to the TSH receptor antibodies.

Answer 487

Goitre with firm nodules Most patients are aged over 50 Second most common cause of thyrotoxicosis (after Grave’s)

Answer 488

A rare presentation of hyperthyroidism. It is also known as “thyrotoxic crisis”. It is a more severe presentation of hyperthyroidism with pyrexia, tachycardia and delirium.

Answer 489

Transient form of thyrotoxicosis caused by excessive stimulation of thyroid gland by hCG. This leads to raise free T4 but low TSH. Usually limited to the first 12-16 weeks of pregnancy

Answer 490

Transplacental transfer of thyroid stimulating autoantibodies from mother to fetus. These autoantibodies bind to the fetal thyroid stimulating hormone (TSH) receptors and increase the secretion of the thyroid hormones.

Answer 491

Carbimazole: Prevent thyroid peroxidase enzyme coupling and iodinating tyrosine residues on thyroglobulin → reduce T3 and T4

Answer 492

Propylthiouracil (PTU): inhibits the conversion of T4 to T3

Answer 493

PTU has high risks of severe hepatic reactions

Answer 494

Carbimazole Propylthiouracil Radioactive iodine Beta-Blockers Surgery

Answer 495

Drinking a single dose of radioactive iodine. This is taken up by the thyroid gland and the emitted radiation destroys a proportion of the thyroid cells. This reduction in functioning cells results in a decrease of thyroid hormone production and thus remission from the hyperthyroidism Patients are then on Levothyroxine replacement

Answer 496

Pregnant women

Answer 497

Used to block the adrenaline related symptoms Typically Propranolol (non-selective) would be used

Answer 498

To removed toxic nodules/adenomas The patient would likely be on Levothyroxine permanently

Answer 499

Graves Disease symptoms predate pregnancy (and are more prominent during pregnancy) N&V is greater in Gestational Thyrotoxicosis Graves disease will present with Goitres Graves disease ill have TSH-R antibodies

Answer 500

Agranulocytosis Presents as a sore throat

Answer 501

Myxoedema coma - usually infection precipitated Rapid loss of T4 Hypothermia, loss of consciousness, heart failure

Answer 502

ABCDE and fluids to correct volume 1st Line: Using Propylthiouracil AND hydrocortisone AND propranolol GS: Thyroidectomy Can also give Hydrocortisone

Answer 503

Levothyroxine Hydrocortisone until adrenal insufficiency has been ruled out

Answer 504

Carbimazole is teratogenic therefore give PTU

Answer 505

Graves' disease Hashimoto's disease Drugs (e.g. lithium, amiodarone) Iodine deficiency/excess De Quervain's thyroiditis (painful) Infiltration (e.g. sarcoid, haemochromatosis

Answer 506

Toxic solitary adenoma Non-functional thyroid adenoma Multinodular goitre Thyroid cyst Cancer

Answer 507

Subacute Granulomatous thyroiditis Self limited inflammation of the thyroid often following viral infection.

Answer 508

4 Phases: Phase 1 (3-6 weeks) Hyperthyroidism and painful goitre Phase 2 (1-3 weeks) Euthyroid - normal function Phase 3 (weeks-months) Hypothyroidism Phase 4 Thyroid structure and function return to normal

Answer 509

Neck pain (may radiate to jaw/ears) Difficulty eating Tender firm enlarged thyroid + goitre Fever Palpitations - often secondary to thyrotoxicosis

Answer 510

**thyroid scintigraphy: globally reduced uptake of iodine-131** All elevated Total T4, T3, T3 resin uptake CRP elevated Often follows viral infection

Answer 511

Hyperthyroid Phase - NSAIDs and corticosteroids Hypothyroid Phase - No Tx usually

Answer 512

**Also known as Glandular fever or "Mono"** Tthe most prevalent manifestation of Epstein-Barr virus (EBV) infection. as a classical traid of: * Sore Throat * Lymphadenopathy * Pyrexia

Answer 513

* Most commonly observed among young adults in developed countries. * Exhibits no seasonal variation. * Does not show sex-based differences. * Transferred via saliva (kissing, sharing cups, toothbrushes etc)

Answer 514

**Classical Features:** * Sore throat * Pyrexia * Lymphadenopathy **Other Features:** * malaise, anorexia, headache * palatal petechiae * **splenomegaly** * hepatitis, transient rise in ALT * lymphocytosis * haemolytic anaemia secondary to cold agglutins (IgM) * **Maculopapular, pruritic rash** develops in around 99% of patients who take ampicillin/amoxicillin whilst they have infectious mononucleosis

Answer 515

* **Streptococcal pharyngitis:** Presents with a sore throat, fever, and swollen lymph nodes. * **Influenza:** Characterized by fever, malaise, and sore throat. * **HIV seroconversion:** May present with symptoms similar to infectious mononucleosis. * **Cytomegalovirus (CMV):** Presents with similar symptoms, often with more prominent hepatosplenomegaly.

Answer 516

**Full Blood Count (FBC):** Typically shows elevated lymphocytes. **Monospot test (heterophile antibodies):** * This should be conducted in the 2nd week of illness. (Can be negative if undertaken early in the infection (first 2–6 weeks)) * If the result is negative, retesting should occur in 5-7 days. **EBV viral serology:** * Can be utilized if the patient is under 12, immunocompromised, * When the Monospot test continues to yield negative results despite high clinical suspicion. **Abdominal ultrasound:** Required if assessment of splenomegaly is necessary. **HIV Test:** Remember that a glandular fever-like presentation occurs in acute HIV

Answer 517

**Usually a self limiting disease where the acute illness lasts around 2-3 weeks** * Rest during the early stages, drink plenty of fluid, avoid alcohol * Analgesia to manage pain * Antibiotics: Ampicillin and Amoxicillin should be avoided as they can trigger an itchy maculopapular rash * Contact sports should be avoided for 3 weeks to prevent splenic rupture

Answer 518

An intensely itchy maculopapular rash

Answer 519

* Splenic rupture * Glomerulonephritis * Haemolytic anaemia * Thrombocytopenia * Chronic fatigue * Rarely EBV infection can cause **Hemophagocytic lymphohistocytosis (HLH)** **EBV infection is associated with Burkitt's Lymphoma**

Answer 520

Influenza or 'flu' is a **single-stranded RNA virus** and is the **most common cause of viral pneumonia** in immunocompetent adults.

Answer 521

* **Influenza A** – capable of causing pandemics and epidemics; no animal reservoir * **Influenza B** –capable of epidemics only, animal hosts include pigs and birds * **Influenza C** – only found in cattle The influenza serotype is determined by surface antigens haemagglutinin and neuraminidase, which are rearranged in host organisms such as birds and animals to produce different strains.

Answer 522

The influenza virus is highly contagious and transmitted via respiratory secretions.

Answer 523

The incubation period is typically **1–4 days**

Answer 524

Patients can remain infectious for **7–21 days**

Answer 525

* Fever ≥ 37.8°C * Nonproductive (dry) cough * Myalgia * Lethargy and Fatigue * Headache * Malaise * Sore throat * Rhinitis * Anorexia * Muscle and joint aches

Answer 526

* Flu tends to have an **abrupt onset**, * Whereas a common cold has a more gradual onset. * **Fever** is a typical feature of the flu but is rare with a common cold. * Finally, people with the flu are **“wiped out”** with **muscle aches and lethargy**. * Whereas people with a cold can usually continue many activities.

Answer 527

* **Rapid Polymerase Chain Reaction (PCR) Test** - Is now first line and can confirm the diagnosis. Nasal or Throat swabs are used to get a sample. * **Point of Care Tests** - Using swabs, detects viral antigens and can give a rapid result. However, they are not as sensitive as formal lab tests and do not give information about the subtypes.

Answer 528

* Healthy patients (who aren't at risk of complications) don't need treatment. The **infection will resolve with self-care measures** (such as adequate fluid intake and rest). **Treatment for patients at risk of complications**: * Oral oseltamivir (twice daily for 5 days) * Inhaled zanamivir (twice daily for 5 days) **Post-Exposure Prophylaxis** * Can be given to patients who meet specific criteria after exposure to someone with the flu. * Oral oseltamivir 75mg once daily for 10 days * Inhaled zanamivir 10mg once daily for 10 days

Answer 529

* It is **started within 48 hours** of close contact with influenza * **Increased risk** (e.g., chronic disease or immunosuppression) * **Not protected by vaccination** (e.g., it has been less than 14 days since they were vaccinated)

Answer 530

* **Pulmonary** Viral pneumonia, secondary bacterial pneumonia (particularly S. aureus) , worsening of chronic conditions (eg. COPD and asthma) * **Cardiovascular** Myocarditis, heart failure * **Neurological** encephalopathy * **Gastrointestinal** Anorexia and vomiting are common

Answer 531

Those at **higher risk of developing flu or flu-related complications**: * Aged 65 and over * Young children * Pregnant women * Chronic health conditions, such as asthma, COPD, heart failure and diabetes * Healthcare workers and carers

Answer 532

Irritable Bowel Syndrome (IBS) is a common, **chronic gastrointestinal disorder** characterized by abdominal pain or discomfort associated with altered bowel habits, **without any identifiable structural or biochemical abnormalities**.

Answer 533

* It occurs in up to 20% of the population. * Affects **women** more than men * More common in **younger adults**.

Answer 534

The precise cause of IBS remains unknown. It is considered a **multifactorial condition** potentially involving: * Genetic predisposition * Altered gut microbiota * Low-grade inflammation * Abnormalities in the gut-brain axis.

Answer 535

The Manning criteria for diagnosis of IBS includes: **At least 6 months of:** * Abdominal discomfort or pain * Relieved by defecation** OR * Associated with altered bowel frequency or stool form **PLUS two or more of the following:** * Altered stool passage (e.g., straining or urgency) * Abdominal bloating * Symptoms worsened by eating * Passage of mucus Additional symptoms such as lethargy, nausea, backache, and bladder symptoms may also be present. Physical examination typically reveals no abnormalities.

Answer 536

* Rectal bleeding * Unexplained/unintentional weight loss * Family history of bowel or ovarian cancer * Onset after 60 years of age

Answer 537

* Anxiety * Depression * Stress * Sleep disturbance * Illness * Medications * Certain foods * Caffeine * Alcohol

Answer 538

* **Inflammatory Bowel Disease (IBD)** Symptoms may include bloody diarrhea, weight loss, and fever. * **Coeliac Disease** Symptoms may include diarrohea, weight loss, and anemia. * **Colorectal Cancer** Symptoms may include rectal bleeding, weight loss, and changes in bowel habits.

Answer 539

The following investigations are often performed to rule out other organic diseases: * **Full blood count** for anaemia * **Inflammatory markers** (e.g., ESR and CRP) * **Coeliac serology** (e.g., anti-TTG antibodies) * **Faecal calprotectin** for inflammatory bowel disease * **CA125** for ovarian cancer

Answer 540

1st Line is **Lifestyle Advice** including: * Drinking enough fluids * Regular small meals * Adjusting fibre intake according to symptoms (more fibre if predominantly constipated, less with diarrhoea/bloating) * Limit caffeine, alcohol and fatty foods * Low FODMAP diet, guided by a dietician * Probiotic supplements may be considered over-the-counter (discontinuing after 12 weeks if there is no benefit) * Reduce stress where possible * Regular exercise 1st Line **Pharmocological options** (depends on symptoms) * pain: antispasmodic agents * constipation: laxatives but avoid lactulose * diarrhoea: loperamide is first-line Low dose TCAs are second line

Answer 541

* Lyme disease is an infectious condition caused by the **spirochaete Borrelia burgdorferi** * Its transmitted via the bite of **Ixodes ticks** predominantly found in wooded areas.

Answer 542

Most cases originate from northeastern regions of the USA and northern-eastern Europe.

Answer 543

* Lyme disease is caused by **transmission of Borrelia burgdorferi via the bite of an infected Ixodes tick**. * The diverse clinical manifestations of the disease are attributed to the variety of Borrelia species and the host immune response to the infection.

Answer 544

**Early Localized Stage (3-30 days after tick bite)** * Erythema migrans (EM): Bullseye-shaped rash at the site of the tick bite * Flu Like Symptoms (Fever, chills, headache, arthralgia) **Early Disseminated Stage (Weeks to months after bite)** * Multiple EM Rashes: May appear on other parts of the body as the infection spreads. * Neurological Symptoms: Facial Palsy * Cardiac issues: carditis * MSK Pain: Migratory joint pain **Late Disseminated Stage (Months to years after bite)** * Chronic Join Issues: Lyme arthritis * Neurological Complications: Neuropathy * Chronic Fatigue

Answer 545

**Other spirochaetal infections**: * **Borrelia recurrentis** Typically presents with recurring fever episodes * **Leptospirosis (Weil's disease)** Presents with jaundice, renal failure, and hemorrhage * **Treponema infections (syphilis, yaws, and pinta)** Present with distinct skin lesions and systemic symptoms **Other tick-borne diseases**: * **Rickettsia** (Rocky Mountain spotted fever or tick typhus) Presents with fever, headache, and a characteristic rash * **Babesiosis** Presents with fever, fatigue, and hemolytic anemia * **Tularaemia** Presents with ulcerative skin lesions and lymphadenopathy * **Tick-borne relapsing fever** (Caused by other Borrelia species) presents with recurring fever episodes * **Human monocytic ehrlichiosis and human granulocytic anaplasmosis** Present with non-specific flu-like symptoms * **Q fever** Presents with high fever, severe headache, and pneumonia

Answer 546

**If typical Erythema Migrans (target rash) is present, antibody testing is not nescesary for diagnosis** **Fist line is ELISA testing for Abs against borrelia burgdorfori** * If initial tests are negative but symptoms persist, retesting 3-4 weeks later is recommended * In cases presenting with **arthritis**, a **synovial fluid sample may be obtained for PCR Borrelia DNA testing**.

Answer 547

* Ensure complete removal of tick and monitor bite area for signs of infection (if asymptomatic, no antibiotics are required) **Antibiotic Management**: * **Oral Doxycycline for 3 weeks** 1st line for early disease * Oral Amoxicillin (if patient is pregnant) * **IV Ceftriaxone** in disseminated disease

Answer 548

* It is reaction that can develop within the **first 24 hours of treatment** with any antibiotic for Lyme disease. * It is a **systemic reaction** thought to be caused by the release of cytokines when antibiotics kill large numbers of bacteria, resulting in **worsening of fever, chills, muscle pains and headache**. * Its often mistaken for an allergic reaction, however if there are no features of anaphylaxis/allergy then the antibiotics can be continued. * There is usually complete **resolution within 48 hours**.

Answer 549

* Measles is a highly contagious disease caused by the Measles morbillivirus. * It is transmitted via droplets from the nose, mouth, or throat of infected persons.

Answer 550

* It is most common in unvaccinated children * It is still prevalent in areas with low vaccination rates and can cause large outbreaks.

Answer 551

* Measles is caused by the **Measles morbillivirus (a paramyxovirus)**, which is a single-stranded, enveloped RNA virus. * The virus is **transmitted by respiratory droplets or by direct contact with nasal or throat secretions** of infected individuals.

Answer 552

**Prodrome** * High fever above 40 degrees Celsius * Coryzal symptoms * Conjunctivitis **Other** * A rash appearing 2-5 days after onset of symptoms * **Koplik spots**: small grey discolourations of the mucosal membranes in the mouth, appearing 1-3 days after symptoms begin during the prodrome phase of infection. **These are pathognomonic for measles**. Symptoms usually develop 10-14 days post-exposure and last for 7-10 days.

Answer 553

* **Rubella** Similar to measles but often milder. The rash typically begins on the face and spreads to the rest of the body. Enlarged lymph nodes, particularly behind the ears and at the back of the skull, are common. * **Roseola** Characterized by a sudden high fever followed by a rash once the fever subsides. The rash usually starts on the chest, back, and abdomen, spreading to the neck and arms. * **Scarlet Fever** Presents with a characteristic sandpaper-like rash, a high fever, and a sore throat. The tongue may also become red and bumpy, giving it a 'strawberry' appearance.

Answer 554

* 1st: **Measles-specific IgM and IgG serology** (ELISA), most sensitive 3-14 days after onset of the rash. * 2nd: **Measles RNA detection by PCR**, best for swabs taken 1-3 days after rash onset.

Answer 555

Management of measles involves: * Supportive care, usually involving antipyretics. * Vitamin A administration for all children under 2 years. * Ribavirin may reduce the duration of symptoms but is not routinely recommended due to the potential side effects.

Answer 556

* Acute otitis media * Bronchopneumonia * Encephalitis

Answer 557

* Mumps is a viral infection caused by a paramyxovirus and spread by respiratory droplets. * Mumps is usually a self limiting condition that lasts around 1 week.

Answer 558

14 – 25 days

Answer 559

Its prevalence has decreased considerably due to the introduction of the MMR vaccine in the 1980s, but there have been a number of outbreaks in unvaccinated/partially vaccinated groups (mostly men over 19 years at University)

Answer 560

* Vaccination status (**unvaccinated**) * International travel * Exposure to a known case or outbreak.

Answer 561

Patients experience **generalised symptoms** like: * Fever * Muscle aches * Lethargy * Reduced appetite * Headache * Dry mouth Alongside the following organ involvement: * **Parotitis** The parotid glands are **almost always affected**, usually bilaterally (though can be unilateral). Swelling can be severe enough to prevent the mouth from being opened and usually lasts 3-4 days. * **Epididymo-orchitis** Presents as severely painful swelling of one or both testicles and/or backache. It usually develops 4-5 days after onset of parotitis. * **Aseptic meningitis** Is relatively common, but tends to be mild and self limiting * **Encephalitis** Rare complication presenting as headache, vomiting, seizures, unconsciousness. * **Deafness** Mumps can be a cause of acute or insidious sensorineural hearing loss (usually unilateral) in children.

Answer 562

* Need laboratory confirmation using **oral fluid sample (salivary IgM)** to confirm a diagnosis * Can use serum serology (IgM or IgG) * High-resolution **ultrasound** can differentiate orchitis from torsion.

Answer 563

* **Supportive, symptomatic treatment** only: fluids, analgesia, antipyretics * The disease is usually benign and self-limiting. Although Mumps encephalitis has a fatality of 1.5%. * Patients should be **isolated to prevent transmission** (usually until 5 days after onset of parotitis) * Mumps is a **notifiable disease**, meaning you need to **notify public health** of any suspected and confirmed cases.

Answer 564

* **Infection** STI, Mumps, TB, brucellosis * **Trauma** * **Torsion** * **Malignancy** Usually painless, or gradual onset of pain. * **Vasculitis** PAN, Henoch-Schonlein Purpura

Answer 565

**Underweight** < 18.49 **Normal** 18.5 - 25 **Overweight** 25 - 30 **Obese class 1** 30 - 35 **Obese class 2** 35 - 40 **Obese class 3** > 40

Answer 566

The management of obesity consists of a step-wise approach: * 1st Line - **conservative Management** including a healthy diet and more exercise **Pharmacological management**: * **Orlistat** - is a pancreatic lipase inhibitor. * **Liraglutide** - is a glucagon-like peptide-1 (GLP-1) mimetic that is used in the management of type 2 diabetes mellitus (T2DM) **Surgical Management** * Bariatric Surgery

Answer 567

* Faecal urgency/incontinence * Flatulence * fatty or oily poo * Oily discharge from the rectum

Answer 568

It should only be prescribed as part of an overall plan for managing obesity in adults who have: * BMI of 28 kg/m2 or more with associated risk factors (e.g. hypertension or T2DM), or * BMI of 30 kg/m2 or more * Continued weight loss e.g. 5% at 3 months Orlistat is usually **only used for less than a year**

Answer 569

* BMI of 35 or more * BMI of 32.5 or more (if patient is of south Asian, Chinese, Black African or African-Caribbean origin) * Non-diabetic hyperglycaemia * At high risk of heart problems such as heart attacks and strokes, for example because you have high blood pressure (hypertension) or high cholesterol

Answer 570

* BMI of 40 or more, or * BMI of between 35 and 40 and another health condition that could be improved with weight loss, such as type 2 diabetes or high blood pressure. * When all appropriate non-surgical measures have been tried, but the person hasn't achieved or maintained adequate, clinically beneficial weight loss * The person is fit enough to have anaesthesia and surgery * The person has been receiving, or will receive, intensive management as part of their treatment.

Answer 571

Osteoarthritis is a **chronic, degenerative joint disease** involving the breakdown and eventual **loss of the articular cartilage** in synovial joints.

Answer 572

* It is the most common form of arthritis * Its associated with ageing * More common in Females

Answer 573

* Increased **Age** * **Female** * **Obesity** * Previous joint injury (history of trauma) * Overuse of the joint * Genetics (family history) * Bone deformities

Answer 574

* Cartilage Breakdown: Loss of joint cushioning. * Joint Narrowing: Bones get closer, increasing friction. * Bone Spurs: Painful bone growths form. **Osteophytes** * Inflammation: Swelling of joint lining. * Muscle Weakness: Weak muscles worsen joint instability. * Chronic Pain & Stiffness: Ongoing damage limits movement

Answer 575

* Hips * Knees * Distal interphalangeal (DIP) joints in the hands * Carpometacarpal (CMC) joint at the base of the thumb * Lumbar spine * Cervical spine (cervical spondylosis)

Answer 576

* **Joint pain and stiffness** that is **worsened by activity** and tends to be worse at the end of the day. * No morning stiffness or **morning stiffness that lasts less than 30 mins** * Bulky, bony enlargement of the joint * Restricted range of motion * Crepitus on movement * Effusions (fluid) around the joint

Answer 577

* **Heberden’s nodes** (in the **DIP** joints) * **Bouchard’s nodes** (in the **PIP** joints) * Squaring at the base of the thumb (CMC joint) * Weak grip * Reduced range of motion

Answer 578

* **Rheumatoid arthritis** Involves pain, swelling, and stiffness in multiple joints, often symmetrically. It is often accompanied by systemic symptoms like fever and fatigue. * **Gout** Known for sudden, severe attacks of pain, swelling, redness, and warmth in a joint, usually the big toe. * **Lyme disease** May present with joint pain and stiffness along with other symptoms like fever, fatigue, and skin rash. * **Psoriatic arthritis** Presents with joint pain, stiffness, and swelling, and is usually accompanied by psoriasis skin lesions.

Answer 579

A diagnosis can be made without investigations if the patient is: * **Over 45** * Has typical **pain associated with activity** and * Has **no morning stiffness** (or stiffness lasting **under 30 minutes**). Although imaging is used to confirm the diagnosis: * **X-Ray** (1st Line imaging) * MRI (shows more detailed view of the joint and reveal changes in the early stages of the disease)

Answer 580

**LOSS**: * **L** – Loss of joint space * **O** – Osteophytes (bone spurs) * **S** – Subarticular sclerosis (increased density of the bone along the joint line) * **S** – Subchondral cysts (fluid-filled holes in the bone)

Answer 581

**Non-Pharmacological** * Therapeutic exercise to improve strength and function and reduce pain * Weight loss if overweight, to reduce the load on the joint * Occupational therapy to support activities and function (e.g., walking aids and adaptations to the home) **Pharmacological** * **Topical NSAIDs** (first-line for knee osteoarthritis) * **Oral NSAIDs** (co-prescribed with a **proton pump inhibitor** for gastroprotection) * Weak opiates and paracetamol are only recommended for short-term, infrequent use. NICE recommend against using any strong opiates for osteoarthritis. * **Intra-articular steroid injections** may temporarily improve symptoms (usually up to 10 weeks) **Surgical** * **Joint replacement** may be used in severe cases. The hips and knees are the most commonly replaced joints.

Answer 582

NSAIDs (like ibuprofen and naproxen) are very effective for musculoskeletal pain. However, they must be used cautiously, particularly in older patients and those on anticoagulants. Side effects include: * **Gastrointestinal side effects** Such as gastritis and peptic ulcers (leading to upper gastrointestinal bleeding) * **Renal side effects** Such as acute kidney injury (e.g., acute tubular necrosis) and chronic kidney disease * **Cardiovascular side effects** Such as hypertension, heart failure, myocardial infarction and stroke * **Exacerbating asthma**

Answer 583

* Osteoporosis is a **systemic skeletal disease** characterized by **reduced bone mass and altered microarchitecture of the bone tissue**. * It leads to increased bone fragility and a consequent increase in fracture risk. * It is typically defined by a **DEXA scan T-score of -2.5 or lower (Bone mineral density)**.

Answer 584

* Osteopenia is a **precursor to Osteoporosis**. * Its defined as a Bone mineral density (**T-Score**) of **-1 to -2.5**.

Answer 585

Osteomalacia is defined as **poor bone mineralisation**; leading to soft bones due to a lack of calcium.

Answer 586

* The T-Score is T-score is the number of standard deviations the patient's **bone mineral density** is from an average healthy young adult. * Its measured by a DEXA Scan at the Femoral Neck

Answer 587

**SHATTERED**: * **S** – Steroid use and Smoking * **H** – Hyperthyroidism, hyperparathyroidism * **A** – Alcohol * **T** – Thin (BMI < 22) * **T** – Testosterone deficiency * **E** – Early menopause * **R** – Renal/liver failure * **E** – Erosive/inflammatory bone disease * **D** – Diabetes * FAMILY HISTORY

Answer 588

* Osteoporosis primarily affects **postmenopausal women and elderly men**. * But it is more common in postmenopausal women compared to elderly men.

Answer 589

Bone Mineral Density and Bone mass is reduced however the mineralisatoin of bone is unchanged in Osteoporosis. **Bone remodelling imbalance** * Increased bone resorption from osteoclasts * Reduced bone formation by osteoblasts * Reduction in both bone mineral density and matrix density reducing bone mass. **Bones Brittle and Fragile** * Reduced bone density and mass * Causes brittle and fragile bones **Increased fracture risk**

Answer 590

It is usually **asymptomatic until a fracture occurs** But some clinical features include: * Back pain, caused by a fractured or collapsed vertebra * Loss of height over time * A stooped posture * A bone fracture that occurs much more easily than expected

Answer 591

* **Hip** - Femoral Neck Fracture (when someone falls on their side or back) * **Wrist** - Fracture of the distal radius (Collins/Smith fracture) after falling on an outstretched arm. * **Vertebrae** - Causes sudden onset severe back pain, often radiating to the front.

Answer 592

* **Metabolic bone diseases** Such as osteomalacia and hyperparathyroidism, which can present similarly with low bone mass and increased fracture risk. * **Malignancies** Like multiple myeloma or metastatic disease, which can lead to pathologic fractures similar to those seen in osteoporosis. * **Secondary causes of osteoporosis** Such as Cushing's syndrome, hyperthyroidism, and certain medications (e.g., glucocorticoids, anticonvulsants).

Answer 593

**DEXA Scan**: * with a T-Score of -2.5 is diagnostic for osteoporosis * Stands for Dual Energy X-Ray Absorbtiometry * It measures a patient's Bone mineral density at the femoral neck. **Other investigations** include: * X-rays for suspected fractures * MRI of the spine to assess vertebral fractures * Blood tests to exclude metabolic bone diseases and assess vitamin D, calcium, and hormone levels.

Answer 594

The FRAX (Fracture Risk Assessment Tool) score is used to estimate the **10-year probability of a major osteoporotic fracture**. Interpretation of FRAX scores: * **Normal**: 10-year probability < 10% * **Osteopenia**: 10-year probability 10-20% * **Osteoporosis**: 10-year probability >20%

Answer 595

**Non-Pharmacological**: * Reducing risk factors, such as quitting smoking and improving diabetic control, maintain healthy weight. * Ensuring adequate intake of vitamin D, calcium, and protein * Regular weight-bearing exercise * Use of hip protectors in nursing home patients **Pharmacological**: **Bisphosphonates** are the 1st line treatment for osteoporosis. Example regimes include: * **Alendronate** 70 mg once weekly (oral) * **Risedronate** 35 mg once weekly (oral) * **Zoledronic acid** 5 mg once yearly (intravenous) Other options (for when bisphosphonates aren't suitable): * **Denosumab** (a monoclonal antibody that targets osteoclasts) * **Romosozumab** (a monoclonal antibody that targets sclerostin – a protein in osteocytes that inhibits bone formation) * **Teriparatide** (acts as parathyroid hormone) * **Hormone replacement therapy** (particularly in women with early menopause) * **Raloxifene** (a selective oestrogen receptor modulator) * **Strontium ranelate** (a similar element to calcium that stimulates osteoblasts and blocks osteoclasts)

Answer 596

Oral bisphosphonates should be: * Taken on an **empty stomach** with a **full glass of water**. * Afterwards, the patient should **sit upright for 30 minutes** before moving or eating to reduce the risk of reflux and oesophageal erosions.

Answer 597

* **Reflux and oesophageal erosions** * Atypical fractures (e.g., atypical femoral fractures) * Osteonecrosis of the jaw (regular dental checkups are recommended before and during treatment) * Osteonecrosis of the external auditory canal

Answer 598

Increased risk of: * **Venous thromboembolism** * **Myocardial infarction**

Answer 599

* Otitis externa is **inflammation of the skin in the external ear canal** (external auditory meatus). * It's sometimes called **“swimmers ear”**, as exposure to water whilst swimming can lead to inflammation in the ear canal. * Its a common cause of otalgia (ear pain)

Answer 600

* infection: bacterial (Staphylococcus aureus, Pseudomonas aeruginosa) or fungal * seborrhoeic dermatitis * contact dermatitis (allergic and irritant) * recent swimming is a common trigger of otitis externa

Answer 601

* Pseudomonas aeruginosa * Staphylococcus aureus

Answer 602

* Ear pain * Discharge * Itchiness * Conductive hearing loss (if the ear becomes blocked) **Examination can show:** * Erythema and swelling in the ear canal * Tenderness of the ear canal * Pus or discharge in the ear canal * Lymphadenopathy (swollen lymph nodes) in the neck or around the ear

Answer 603

* **Otitis media**: Characterised by middle ear pain, fever, hearing loss and sometimes discharge. * **Furunculosis**: Presents with localised pain, swelling and redness, and occasionally fever. * **Eczema**: Features include itching, redness, and scaling of the skin.

Answer 604

* The diagnosis can be made **clinically with an examination of the ear canal** (otoscopy). * An ear swab can be used to identify the causative organism but is not usually required.

Answer 605

**Mild Otitis Externa** * Acetic acid 2% (drops in the ear) - Has both antifungal and antibacterial effect * Patients should keep their ear dry for 7-10 days **Moderate Otitis Externa** Is treated with topical antibiotics and steroids: * **Neomycin, dexamethasone and acetic acid** (e.g., **Otomize spray**) - is most common * Neomycin and betamethasone * Gentamicin and hydrocortisone * Ciprofloxacin and dexamethasone * Fungal infections can be treated with clotrimazole ear drops. **Severe Otitis Externa** * Oral antibiotics (**flucloxacillin** or **clarithromycin**) * IV antibiotics in very severe cases * An **Ear Wick** can be used if the if the canal is very swollen, and treatment with ear drops or sprays will be difficult. They contain antibiotics and steroids and are left in place for a prolonged period (e.g. 48 hours).

Answer 606

* It is essential to exclude a **perforated tympanic membrane** before using topical aminoglycosides in the ear. * This is because aminoglycosides are potentially **Ototoxic** (causing hearing loss) if they get past the tympanic membrane.

Answer 607

* It is a severe and potentially life-threatening form of otitis externa. * It is when the **infection spreads to the bones surrounding the ear canal and skull**. * It progresses to **osteomyelitis of the temporal bone** of the skull.

Answer 608

Found in **immunocompromised individuals or diabetics (90%)** * Most commonly caused by **pseudomonas aeruginosa**

Answer 609

* Diabetes (90%) or immunosuppression (illness or treatment-related) * Severe, unrelenting, deep-seated otalgia * Temporal headaches * Purulent otorrhea * Possibly dysphagia, hoarseness, and/or facial nerve dysfunction

Answer 610

**Diagnosis:** * **Granulation tissue** at the **junction between the bone and cartilage in the ear canal** (about halfway along) is a key finding of malignant otitis externa. * Diagnosis is typically made with a **CT Scan** **Management:** * Urgent referral to ENT * IV antibiotics (covering for pseudomonas): **Ciprofloxacin**

Answer 611

* Facial nerve damage and palsy * Other cranial nerve involvement (e.g., glossopharyngeal, vagus or accessory nerves) * Meningitis * Intracranial thrombosis * Death

Answer 612

* Otitis media is an **infection-induced inflammation of the middle ear**. * Frequently occurring after a viral upper respiratory tract infection.

Answer 613

* It is primarily caused by a **bacterial infection** * The bacteria are able to enter the middle ear **through the eustachian tube from the back of the throat**. This is why otitis media is usually preceeded by an Upper Respiratory Tract infection.

Answer 614

Predominantly affects young children

Answer 615

**Streptococcus pneumoniae** Other causes include: * Haemophilus influenzae * Moraxella catarrhalis * Staphylococcus aureus

Answer 616

* **Rapid onset of deep-seated ear pain** * **Reduced hearing** in the affected ear * Systemic symptoms, e.g. fever, irritability, anorexia, vomiting * Symptoms of an upper airway infection such as cough, coryzal symptoms and sore throat * When the infection affects the vestibular system, it can cause **balance issues and vertigo**. * When the tympanic membrane has perforated, there may be **discharge from the ear**. (After this, there will be a reduction of pain)

Answer 617

A dry tympanic membrane perforation without chronic infection

Answer 618

Also known as "Glue Ear". It presents with persistent pain lasting weeks after the initial episode with an abnormal-looking drum and reduced membrane mobility.

Answer 619

CSOM is defined as perforation of the tympanic membrane with purulent otorrhoea for > 6 weeks hearing loss labyrinthitis

Answer 620

* **“pearly-grey”, translucent and slightly shiny**. * You should be able to visualise the malleus through the membrane. * Look for a cone of light reflecting the light of the otoscope.

Answer 621

* Otitis media will give a **bulging, red, inflamed looking membrane**. * When there is a perforation, you may see discharge in the ear canal and a hole in the tympanic membrane.

Answer 622

* **Otitis externa** Characterized by pain exacerbated by tugging of the auricle, accompanied by otorrhea and possible hearing loss * **Mastoiditis** Presenting with postauricular pain, erythema, and swelling, as well as protrusion of the ear * **Temporomandibular joint disorder** Characterized by jaw pain, difficulty in opening the mouth, and clicking or popping sounds during jaw movement

Answer 623

Diagnosis of otitis media is **primarily clinical**, based on history and physical examination, notably the appearance of the tympanic membrane (with an **Otoscope**).

Answer 624

* Most cases will **resolve without antibiotics** within around **three days**, sometimes up to a week. * Simple analgesia (e.g., paracetamol or ibuprofen) can be used for pain and fever. * A **delayed prescription** of antibiotics can be given after three days if symptoms have not improved or have worsened at any time * Consider **Immediate antibiotics** in patients who have significant co-morbidities, are systemically unwell or are immunocompromised. Antibiotic options include: * **Amoxicillin for 5-7 days** first-line * Clarithromycin (in pencillin allergy) * Erythromycin (in pregnant women allergic to penicillin)

Answer 625

* Otitis media with effusion * **Hearing loss** (usually temporary) * **Perforated tympanic membrane** (with pain, reduced hearing and discharge) * Labyrinthitis (causing dizziness or vertigo) * Mastoiditis (rare) * Abscess (rare) * Facial nerve palsy (rare) * Meningitis (rare)

Answer 626

Pelvic inflammatory disease is **inflammation and infection of the organs of the pelvis**, caused by **infection spreading up through the cervix**. The terms for the individual affected organs include: * **Endometritis** - inflammation of the endometrium * **Salpingitis** - inflammation of the fallopian tubes * **Oophoritis** - inflammation of the ovaries * **Parametritis** - inflammation of the parametrium, which is the connective tissue around the uterus * **Peritonitis** - inflammation of the peritoneal membrane

Answer 627

Most cases of pelvic inflammatory disease are caused by one of the **sexually transmitted** pelvic infections: * **Neisseria gonorrhoeae** (tends to produce more severe PID) * **Chlamydia trachomatis** * Mycoplasma genitalium However less commonly, PID be caused by non-sexually transmitted infections, such as: * Gardnerella vaginalis (associated with bacterial vaginosis) * Haemophilus influenzae (associated with respiratory infections) * Escherichia coli (associated with urinary tract infections)

Answer 628

(The same as any other sexually transmitted infection): * Not using barrier contraception * Multiple sexual partners * Younger age * Existing sexually transmitted infections * Previous pelvic inflammatory disease * Intrauterine device (e.g. copper coil)

Answer 629

* Pelvic or lower abdominal pain * Abnormal vaginal discharge * Abnormal bleeding (intermenstrual or postcoital) * Dyspareunia * Fever * Dysuria **On Bi-manual examination:** * Adnexal tenderness * Cervical motion tenderness upon bi-manual examination **Right upper quadrant pain (Fitz-Hugh-Curtis Syndrome)**

Answer 630

* It's a complication of pelvic inflammatory disease where there is **inflammation and infection of the liver capsule** (Glisson’s capsule), leading to **adhesions** between the liver and peritoneum. * It presents with **right upper quadrant pain** that can be **referred to the right shoulder tip** if there is diaphragmatic irritation. * Laparoscopy can be used to visualise and also treat the adhesions by adhesiolysis.

Answer 631

* **Appendicitis** Presents with right lower quadrant abdominal pain, fever, nausea, and vomiting. * **Ectopic Pregnancy** Symptoms may include unilateral lower abdominal pain and vaginal bleeding. A positive pregnancy test is a key distinguishing factor. * **Endometriosis** Chronic pelvic pain, dysmenorrhea, and dyspareunia are common. Pain typically worsens during menstruation. * **Ovarian Cyst** Symptoms can include unilateral lower abdominal pain, bloating, and a palpable mass on examination. * **Urinary Tract Infection** Symptoms usually include dysuria, frequency, urgency, suprapubic pain, and possible fever.

Answer 632

**STI Screen** * NAAT swabs for gonorrhoea and chlamydia * NAAT swabs for Mycoplasma genitalium if available * HIV test * Syphilis test **A high vaginal swab**can be used to look for bacterial vaginosis, candidiasis and trichomoniasis. A microscope can be used to look for **pus cells on swabs from the vagina or endocervix**. The absence of pus cells is useful for excluding PID. A **pregnancy test** should be performed on sexually active women presenting with lower abdominal pain to exclude an ectopic pregnancy. **Inflammatory markers** (CRP and ESR) are raised in PID and can help support the diagnosis.

Answer 633

Management involves a **combination of antibiotics** managed in an outpatient setting. A common regime includes: * 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) **Empirical treatment** for PID is often initiated in **sexually active young women** presenting with bilateral lower abdominal pain and adnexal tenderness due to the substantial number of women with PID that remain undiagnosed. Analgesia may also be required In severe cases of PID, admission to hospital may be required for IV antibiotics.

Answer 634

* Chronic pelvic pain (in around 40% of cases) * Infertility (approximately 15%) * Ectopic pregnancy (about 1%) * Sepsis * Pelvic Abscess * Fitz-Hugh-Curtis syndrome

Answer 635

* (Also known as **peripheral vascular disease**) * It refers to the **narrowing of the arteries (distal to the aortic arch** (supplying the limbs and periphery), reducing the blood supply to these areas. * It usually affects the **lower limbs**.

Answer 636

Prevalence increases with age

Answer 637

* Smoking * Diabetes mellitus * Hypertension * Hyperlipidaemia, (characterised by high total cholesterol and low high-density lipoprotein (HDL) cholesterol levels) * Physical inactivity * Obesity * Increased age

Answer 638

* The most common cause is **Atherosclerosis** * Atherosclerosis involves both the formation of fatty deposits in the artery wall (**Atheroma**) as well as the hardening/stiffening of the artery wall (**Sclerosis**). * Atherosclerosis results in the **narrowing of the arteries**. As a result, this resricts blood flow through these ateries (usually in the leg. As a result of this reduced blood flow, the tissues that arteries supply **don't recieve enough oxygen**. * A reduction in oxygen, results initially in **muscle ischaemia** (presents as claudication); followed by **wide spread cell death, necrosis and gangrene** if it occurs for long enough.

Answer 639

* **Stage 1** - Asymptomatic * **Stage 2** - Intermittant Claudication This is like angina of the leg * **Stage 3** - Critical Limb Ischaemia Is the end-stage of peripheral arterial disease, where there is an inadequate supply of blood to a limb to allow it to function normally at rest. There is a significant risk of losing the limb. * **Stage 4** - Acute Limb Ischaemia Refers to a rapid onset of ischaemia in a limb. Typically, this is due to a thrombus (clot) blocking the arterial supply of a distal limb

Answer 640

**Intermittant Claudication** * **Crampy leg pain** that predictably **occurs after walking** a certain distance; that resolves with rest. * The most common location is the calf muscles, but it can also affect the thighs and buttocks. **Critical Limb Ischaemia** * Pain at rest * The pain is also **worse at night when the leg is raised**. * Non-healing ulcers * Gangrene **Acute Limb Ischaemia** (6 P's) * Pain * Pallor * Pulseless * Paralysis * Paraesthesia (abnormal sensation or “pins and needles”) * Perishing cold

Answer 641

**Arterial Ulcers** - Are caused by ischaemia secondary to an inadequate blood supply. * Are **smaller** than venous ulcers * Are **deeper** than venous ulcers * Have **well defined borders** * Have a **“punched-out”** appearance * Occur peripherally (e.g., on the toes) * Have reduced bleeding * Are **painful** **Venous Ulcers** - Are caused by impaired drainage and pooling of blood in the legs. * Occur after a minor injury to the leg * Are larger than arterial ulcers * Are more superficial than arterial ulcers * Have irregular, gently sloping borders * Affect the gaiter area of the leg (from the mid-calf down to the ankle) * Are less painful than arterial ulcers * Occur with other signs of chronic venous insufficiency (e.g., haemosiderin staining and venous eczema)

Answer 642

It is when there is **occlusion in the distal aorta or proximal common iliac artery**. There is a clinical triad of: * Thigh/buttock claudication * Absent femoral pulses * Male impotence

Answer 643

* **Lumbar spinal stenosis** Presents with neurogenic claudication, numbness, tingling, or weakness in the legs, and lower back pain. * **Deep vein thrombosis** Swelling, pain, warmth, and redness are commonly observed in the affected leg. * **Diabetic neuropathy** Presents with burning or shooting pain, increased sensitivity to touch, and numbness or reduced ability to feel pain or temperature changes.

Answer 644

* **Buerger’s Test** - Used to assess for used to assess for PAD clinically * **Ankle-brachial pressure index (ABPI)** - 1st Line A normal ABPI doesnt exclude PAD, so more investigations may be nescesary: * **Duplex ultrasound** – ultrasound that shows the speed and volume of blood flow * **Angiography (CT or MRI)** – using contrast to highlight the arterial circulation

Answer 645

* It is the **ratio of systolic blood pressure (SBP) in the ankle** (around the lower calf) compared with the **systolic blood pressure in the arm**. * The readings are taken using a doppler probe

Answer 646

* **Normal**: 0.9 – 1.3 * **Mild** peripheral arterial disease: 0.6 – 0.9 * **Moderate to severe** peripheral arterial disease: 0.3 – 0.6 * **Severe disease to critical ischaemic**: Less than 0.3 Above 1.3 can indicate calcification of the arteries, making them difficult to compress (more common in diabetics)

Answer 647

Buerger’s test is a clinical test used to assess for peripheral arterial disease. There are 2 parts to the test: The **first part** involves the patient lying on their back (supine). Lift the patient’s legs to an angle of 45 degrees at the hip. Hold them there for 1-2 minutes, looking for pallor. Pallor indicates the arterial supply is not adequate to overcome gravity, suggesting peripheral arterial disease. The **second part** involves sitting the patient up with their legs hanging over the side of the bed. Blood will flow back into the legs assisted by gravity. In a healthy patient, the legs will remain a normal pink colour. In a patient with peripheral arterial disease, they will go: * **Blue initially**, as the ischaemic tissue deoxygenates the blood * **Dark red** (Rubor) after a short time, due to vasodilation in response to the waste products of anaerobic respiration

Answer 648

Buerger’s angle refers to the angle at which the leg is pale due to inadequate blood supply

Answer 649

**Conservative Management** (1st Line) * **Lifestyle changes** - to manage modifiable risk factors (e.g., stop smoking). * Optimise medical treatment of co-morbidities (such as hypertension and diabetes). * **Exercise training**, involving a structured and supervised program of regularly walking to the point of near-maximal claudication and pain, then resting and repeating. **Medical Management** * **Atorvastatin** 80mg * **Clopidogrel** 75mg once daily (aspirin if clopidogrel is unsuitable) * **Naftidrofuryl oxalate** if poor quality of life (5-HT2 receptor antagonist that acts as a peripheral vasodilator) **Surgical Management** * Endovascular angioplasty and stenting * Endarterectomy – cutting the vessel open and removing the atheromatous plaque * Bypass surgery – using a graft to bypass the blockage

Answer 650

Patients require **urgent revascularisation**. This can be achieved by: * Endovascular angioplasty and stenting * Endarterectomy * Bypass surgery * Amputation of the limb if it is not possible to restore the blood supply

Answer 651

**Initial management** * ABC approach * analgesia: IV opioids are often used * intravenous unfractionated heparin is usually given to prevent thrombus propagation, particularly if the patient is not suitable for immediate surgery vascular review **Definitive management:** * intra-arterial thrombolysis * surgical embolectomy * angioplasty * bypass surgery * amputation: for patients with irreversible ischaemia

Answer 652

* Polymyalgia rheumatica (PMR) is an **inflammatory condition** that causes **pain and stiffness** in the **shoulders, pelvic girdle and neck**. * There is a strong association with **giant cell arteritis**, and the two conditions often occur together.

Answer 653

* It occurs **exclusively** in patients aged **over 50**. * It's most common in patients with **Northern European ancestry**.

Answer 654

The core symptoms are **pain and stiffness** of the: * **Shoulders**, potentially radiating to the upper arm and elbow * **Pelvic girdle** (around the hips), potentially radiating to the thighs * **Neck** Features of the pain and stiffness: * **Worse in the morning** * **Worse after rest** or inactivity * **Interfere with sleep** * Take **at least 45 minutes to ease** in the morning * Somewhat improve with activity Other associated features: * **Systemic symptoms** (e.g., weight loss, fatigue and low-grade fever) * Muscle tenderness * Carpel tunnel syndrome * Peripheral oedema There's a **relatively rapid onset of symptoms** over days to weeks. And the symptoms should be present for at least two weeks before its considered

Answer 655

Autoimmune rheumatic disease: * **Polymyositis** Myositis causes bilateral proximal muscle weakness, while pain is either absent or mild . Whereas in polymyalgia rheumatica, pain and stiffness are prominent, but there should not be muscle weakness on examination * **rheumatoid arthritis** * **SLE** **Infection**, such as tuberculosis or subacute bacterial **Endocarditis** **Malignancy** **Chronic fatigue syndrome** **Hypothyroidism**

Answer 656

Diagnosis is based on: * **clinical presentation** * **Response to steroids** - Improvement of symptoms * **Excluding differentials** **Investigations** that should be **done before starting steroids**: * Full blood count * Renal profile (U&E) * Liver function tests * Calcium (abnormal in hyperparathyroidism, cancer and osteomalacia) * Serum protein electrophoresis for myeloma * Thyroid-stimulating hormone for thyroid function * Creatine kinase for myositis * Rheumatoid factor for rheumatoid arthritis * Urine dipstick **Other investigations** to consider: * Anti-nuclear antibodies (ANA) for systemic lupus erythematosus * Anti-cyclic citrullinated peptide (anti-CCP) for rheumatoid arthritis * Urine Bence Jones protein for myeloma * Chest x-ray for lung and mediastinal abnormalities (e.g., lung cancer or lymphoma)

Answer 657

* **15mg prednisolone daily** initially * Follow up after 1 week * Patients will show a dramatic improvement in symptoms within one week. * A poor response to steroids suggests an alternative diagnosis. * Symptoms typically resolve within 3 weeks Treatment with **steroids typically lasts 1-2 years**. The following **Reducing regime** of **prednisolone** is recommeded: * **15mg** until the symptoms are fully controlled, then * **12.5mg** for 3 weeks, then * **10mg** for 4-6 weeks, then * **Reducing by 1mg** every 4-8 weeks

Answer 658

**DON'T STOP** mnemonic: * **Don't** - **steroid dependence** occurs after 3 weeks of treatment, and abruptly stopping risks adrenal crisis * **S** – **Sick day rules** (steroid doses may need to be increased if the patient becomes unwell) * **T** – **Treatment card** – patients should carry a steroid treatment card to alert others that they are steroid-dependent * **O** – **Osteoporosis** prevention may be required (e.g., bisphosphonates and calcium and vitamin D) * **P** – **Proton pump inhibitors** are considered for gastro-protection (e.g., omeprazole)

Answer 659

* Prostate cancer is a malignant tumour that arises from the cells of the prostate.

Answer 660

* It is the most common cancer in men * Prevalence increases with age

Answer 661

**Non-Modifiable** * African ethnicity * BRCA gene mutations * Family history of prostate cancer * Age (risk increases with advancing age) * Tall stature **Modifiable** * Obesity * Smoking * Diet rich in animal fats and dairy products * Anabolic steroids

Answer 662

Early prostate cancer is often **asymptomatic**. While later in the course of the disease it can present with **LUTs** (similar to BPH) including: * Hesitancy * Frequency * Weak flow * Terminal dribbling * Nocturia Other **symptoms** include: * Haematuria * Erectile dysfunction * Haematospermia (blood in semen) * Pelvic discomfort Symptoms of **advanced disease** (or metastasis): * Weight loss * Bone pain * Cauda equina syndrome

Answer 663

* Prostate cancers are almost always **androgen-dependent**, (meaning they rely on androgen hormones (e.g., testosterone) to grow). * The majority are **adenocarcinomas** and grow in the **peripheral zone of the prostate**. * They vary in how aggressive they can be; but most prostate cancers are very **slow-growing and do not cause death**.

Answer 664

**Lymph nodes** and **Bones**

Answer 665

* **Benign Prostatic Hyperplasia (BPH)**: Characterised by difficulty in urination, increased frequency of urination, nocturia, and potentially, haematuria. * **Prostatitis**: Acute or chronic inflammation of the prostate that can cause pelvic pain, urinary symptoms, and potentially, systemic symptoms such as fever and malaise. * **Urinary Tract Infection (UTI)**: Can cause dysuria, urinary frequency, urgency, and potentially, systemic signs of infection. * **Bladder cancer**: May present with haematuria, dysuria, and urinary frequency.

Answer 666

**Digital Rectal Examination** * A cancerous prostate may feel **firm or hard, asymmetrical, craggy or irregular, with loss of the central sulcus**. There may be a hard nodule. * Any of these findings require a 2 week urgent cancer referral **Multiparametric MRI** * Is the **1st line** investigation * The results are scored on the Likert scale (from 1 - very low suspicion to 5 - definite cancer) **Prostate Biopsy** * Establishes a **definitive diagnosis** * **Performed when the Likert scale of an MRI is 3 or above** * There are 2 types (**Transrectal ultrasound-guided biopsy** (TRUS) and **Transperineal biopsy**) * Due to the risk of a false negative result, (if the biopsy misses the cancerous area); multiple needles are used to take samples from different areas of the prostate. **Isotope Bone Scan** * Is also called a radionuclide scan or bone scintigraphy. * It is used to look for bony metastasis.

Answer 667

* **Pain** (particularly lower abdominal, rectal or perineal pain) * **Bleeding** (blood in the stools, urine or semen) * **Infection** * **Urinary retention** due to short term swelling of the prostate * **Erectile dysfunction** (rare)

Answer 668

* Gleason grading system is based on the histology from the prostate biopsies. * The **greater the Gleason score**, the **more poorly differentiated the tumour is** (the cells have mutated further from normal prostate tissue) and the **worse the prognosis is**. * The tissue samples are graded 1 (closest to normal) to 5 (most abnormal). Its made up of **two numbers added together**: * The first number is the grade of the most prevalent pattern in the biopsy * The second number is the grade of the second most prevalent pattern in the biopsy A score of: * 6 is considered **low risk** * 7 is **intermediate risk** (3 + 4 is lower risk than 4 + 3) * 8 or above is deemed to be **high risk**

Answer 669

**TNM staging system** - This rates the T (tumour), N (lymph nodes) and M (metastasis) of the cancer. **T for Tumour**: * TX – unable to assess size * T1 – too small to be felt on examination or seen on scans * T2 – contained within the prostate * T3 – extends out of the prostate * T4 – spread to nearby organs **N for Nodes**: * NX – unable to assess nodes * N0 – no nodal spread * N1 – spread to lymph nodes **M for Metastasis**: * M0 – no metastasis * M1 – metastasis

Answer 670

* PSA is a **glycoprotein** thats produced from **epithelial cells of the prostate** and is secreted in the semen (with a small amount entering the blood). * It helps to thin the semen after ejaculation * Its specific to the prostate and a **raised PSA is an indicator of prostate cancer**.

Answer 671

**Advantages** * PSA testing can lead to the early detection of prostate cancer, potentially resulting in effective treatment and preventing significant problems. **Disadvantages** * PSA testing is unreliable, with a high rate of **false positives** (75%) and **false negatives** (15% * There are various other causes of a raised PSA (other than prostate cancer) * **False positives** may lead to further investigations, including invasive prostate biopsies, which have complications and may be unnecessary. It may also lead to the unnecessary diagnosis and treatment of prostate cancer that would never have caused problems * **False negatives** may lead to false reassurance.

Answer 672

* **Prostate cancer** * **Benign prostatic hyperplasia** * Prostatitis * Urinary tract infections * Vigorous exercise (notably cycling) * Recent ejaculation or prostate stimulation

Answer 673

**Localised Cancer:** * Surveillance - Watch and wait * Radical Prostatectomy * Radiotherapy: External beam/brachytherapy **Localised Advanced Cancer:** * Hormonal * Radical Prostatectomy * Radiotherapy **Metastatic:** * Hormonal therapy * Chemotherapy

Answer 674

**Proctitis** - inflammation of the rectum * Proctitis can cause pain, altered bowel habit, rectal bleeding and discharge. * Prednisolone suppositories can help reduce inflammation.

Answer 675

* Inflammation in nearby organs, such as the bladder (cystitis) or rectum (proctitis). * Erectile dysfunction * Incontinence * Increased risk of bladder or rectal cancer

Answer 676

* **Androgen-receptor blockers** such as bicalutamide * **GnRH agonists** such as goserelin (Zoladex) or leuprorelin (Prostap) * **Bilateral orchidectomy** to remove the testicles (rarely used)

Answer 677

* Hot flushes * Sexual dysfunction * Gynaecomastia * Fatigue * Osteoporosis

Answer 678

**Erectile dysfunction** and **Urinary incontinence**

Answer 679

Psoriasis is a **chronic autoimmune disease** characterised by **well-demarcated, erythematous, scaly plaques**.

Answer 680

**plaque psoriasis:** * the most common sub-type resulting in the typical well-demarcated red, scaly patches affecting the extensor surfaces, sacrum and scalp **flexural psoriasis:** * in contrast to plaque psoriasis the skin is smooth **guttate psoriasis:** * transient psoriatic rash frequently triggered by a streptococcal infection. * Common in children * Multiple red, **teardrop lesions** appear on the body **pustular psoriasis:** * commonly occurs on the palms and soles

Answer 681

**Key Presentation**: Itchy, well-demarcated circular-to-oval bright red/pink elevated lesions (plaques) with overlying white or silvery scale, distributed symmetrically over extensor body surfaces and the scalp. **Other psoriatic specific signs**: * **Auspitz sign** - refers to small points of bleeding when plaques are scraped off * **Koebner phenomenon** - refers to the development of psoriatic lesions to areas of skin affected by trauma * **Residual pigmentation** of the skin after the lesions resolve **Nail Changes** in psoriasis: * **Nailbed pitting** - superficial depressions in the nailbed * **Onycholysis** - separation of nail plate from nailbed * **Subungual hyperkeratosis** - thickening of the nailbed

Answer 682

* Skin trauma (Koebner phenomenon) * Infection: Streptococcus, HIV * Drugs: B-blockers, Anti-malarials, Lithium, Indomethacin/NSAIDs (BALI) * Withdrawal of steroids * Stress * Alcohol + smoking * Cold/dry weather Other risk factors include: Family history, HIV infection and obesity

Answer 683

There are various differentials for a **scaly rash**: * Pityriasis rosea * Tinea * Seborrhoeic dermatitis * Bowen's disease * Discoid eczema * Mycosis fungoides * Discoid lupus * Scabies

Answer 684

The treatment of plaque psoriasis targets this pathology: * **Corticosteroids** to reduce inflammation and * **Vitamin D** to reduce keratinocyte proliferation. **Topical Treatment** - is first line * **All** patients should use an emollient to reduce scale and itch * **1st** - potent topical corticosteroid OD (eg Betnovate) + topical vitamin D OD (eg Dovonex) applied at different times (1 morn, 1 eve for 4 weeks) * **2nd**: stop the topical corticosteroid, apply topical vitamin D analogue twice daily for 4 weeks * **3rd**: stop the topical vitamin D, apply potent topical corticosteroid twice daily **Phototherpy** * With narrow band ultraviolet B light * Is useful in **extensive guttate psoriasis** **Systemic treatment** - when topical treatment fails * **1st** line: Methotrexate * **2nd** line: Ciclosporin (1st line if rapid disease control needed/palmoplantar pustulosis/are considering conception) * **3rd** line: Acitretin * **4th** line: Biologic therapy (e.g. Infliximab, Etanercept or Adalimumab)

Answer 685

**Methotrexate** * Can cause pneumonitis and hepatotoxicity (monitor LFTs). * It can also cause myelosuppression leading to pancytopenia. **Acitretin** * Is teratogenic * It can cause hepatotoxicity and elevated lipids **Anti-TNF biological drugs** * (such as adalimumab) * Associated with reactivation of latent tuberculosis (always do CXR before initiation of treatment) **Ciclosporin** * Side effects can can be remembered by the **5 H's**: * Hypertrophy of the gums, Hypertrichosis, Hypertension, Hyperkalaemia and Hyperglycaemia (diabetes)

Answer 686

* Spinal stenosis refers to the **narrowing of part of the spinal canal**, resulting in **compression of the spinal cord or nerve roots**. * This usually affects the cervical or lumbar spine.

Answer 687

* Lumbar spinal stenosis is the most common type of spinal stenosis * More common in patients older than 60 years (relating to degenerative changes in the spine)

Answer 688

* **Central stenosis** – narrowing of the central spinal canal * **Lateral stenosis** – narrowing of the nerve root canals * **Foramina stenosis** – narrowing of the intervertebral foramina

Answer 689

* **Congenital** spinal stenosis * **Degenerative changes**, including facet joint changes, disc disease and bone spurs * **Herniated discs** * **Thickening of the ligamenta flava** or posterior longitudinal ligament * **Spinal fractures** * **Spondylolisthesis** (anterior displacement of a vertebra out of line with the one below) * **Tumours**

Answer 690

* **Gradual symptom onset** (as opposed to cauda equina syndrome or sudden disc herniation with cord compression) **Central stenosis** * **Intermittent neurogenic claudication** is the key presentation. It involves typical symptoms involve: Lower back pain, Buttock and leg pain, Leg weakness. * Symptoms are absent at rest and when seated but occur with standing and walking. * Bending forward (flexing the spine) expands the spinal canal and improves symptoms. * Standing straight (extending the spine) narrows the canal and worsens the symptoms. **Lateral stenosis and Foramina stenosis** * Cause symptoms of **Sciatica** **Severe spinal stenosis** * Can present with features of **cauda equina syndrome** (saddle anaesthesia, sexual dysfunction and incontinence of the bladder and bowel).

Answer 691

* It refers to **compression of the nerve roots as they exit the spinal cord and spinal column**. * This leads to motor and sensory symptoms. * Caused by things like spinal stenosis

Answer 692

* **Peripheral Vascular Disease (PVD)**: Characterized by intermittent claudication, but with associated vascular risk factors, diminished or absent pulses, and skin changes * **Herniated Lumbar Disc**: Presents with radicular pain, but the pain is often exacerbated by flexion and relieved by extension, the opposite of the presentation in LSS * **Spinal Tumors**: Can cause similar neurological symptoms, but often associated with weight loss, night sweats, or other systemic symptoms * **Arthritis**: Although it can cause back pain, it's typically associated with morning stiffness and may involve other joints

Answer 693

* **Diagnostic** - MRI Scan * Physical examination is usually the first step; to examine the patient for neurological signs and vascular risk factors * **Electromyography** (EMG) - Can be used to evaluate nerve function in patients with LSS

Answer 694

**Conservative Management** - is first line * Exercise and weight loss (if appropriate) * Analgesia (NSAIDs, opioids, or nerve block injections) * Physiotherapy **Surgical Management** - when conservative measures fail or for patients with severe, disabling pain. Common procedures involve: * **laminectomy**, * **laminoplasty**, * **spinal fusion**.

Answer 695

* Reactive arthritis is a **sterile inflammatory arthritis** occurring **within 4 weeks of an infection**.

Answer 696

* **Male** * **Early adulthood**, commonly presents between the age of 20 and 40 * **HLA-B27** positive (it is a **seronegative spondyloarthropathy**)

Answer 697

A previous **Sexually transmitted** or **Gastrointestinal infection** occuring within a month of the reactive arthritis. * Most common infections include **Chlamydia, Shigella, Yersinia or Salmonella** * (**Gonorrhoea more commonly causes Septic arthritis instead**) * Sometimes this infection is asymptomatic, and is only identified half of the time

Answer 698

**Reiter's Triad**: * **Conjunctivitis** * **Urethritis** and Circinate balanitis (dermatitis at the head of the penis) * **Oligoarthritis** * *Can't see, Can't pee, Can't climb a tree* It typically presents as a **warm and painful swollen joint** (commonly affecting the large joints of the lower limb). It is typically an **Asymmetrical Oligoarthritis**.

Answer 699

Septic Arthritis

Answer 700

Septic arthritis needs to be excluded; and antibiotics are given until it is. To do this: * **Joint aspiration** is done * The **synovial fluid** obtained is sent off for **microscopy**, **culture** and **sensitivity** testing for infection, and crystal examination for gout and pseudogout. When **Septic Arthirtis has been excluded**: * Treatment of the triggering infection (e.g., chlamydia) * **Analgesia and NSAIDs** * **Steroid injection** into the affected joints * Systemic steroids may be required, particularly where multiple joints are affected Most cases **resolve within 6 months** and do not recur. However, recurrent cases may require **DMARDs** or **anti-TNF** medications.

Answer 701

* Rhinosinusitis is defined as **inflammation of the nose and paranasal sinuses**. * The diagnosis requires the presence of at least two symptoms, one of which must be either **nasal blockage/obstruction/congestion** or **nasal discharge** (anterior/posterior nasal drip).

Answer 702

It is a very common disorder affecting around 10% to 15% of the adult population globally.

Answer 703

Inflammation of the sinuses can be caused by: * atopy: hay fever, asthma * nasal obstruction e.g. Septal deviation or nasal polyps * recent local infection e.g. Rhinitis or dental extraction * swimming/diving * smoking

Answer 704

* Acute lasts less than 12 weeks * Chronic lasts more than 12 weeks

Answer 705

* facial pain: typically frontal pressure pain which is worse on bending forward * nasal discharge: usually clear if allergic or vasomotor. Thicker, purulent discharge suggests secondary infection * nasal obstruction: e.g. 'mouth breathing' * post-nasal drip: may produce chronic cough

Answer 706

* **Common cold**: Symptoms typically include runny or stuffy nose, sore throat, cough, and fatigue. Cold symptoms usually peak within 2-3 days and resolve within 7-10 days. * **Allergic rhinitis**: Presents with nasal itching, sneezing, rhinorrhea, and nasal congestion. Ocular symptoms such as tearing and itching of the eyes can also be present. * **Nasal polyps**: Commonly associated with a history of chronic sinusitis, asthma, or aspirin allergy. Symptoms include nasal obstruction, anosmia, and often a runny nose.

Answer 707

**Clinical Diagnosis** To Confirm: * **Nasal endoscopy** - Allows for the visual examination of the internal nasal passages and the sinus openings. * **Computed tomography** (CT) - Provides detailed images of the sinuses and can reveal evidence of sinus inflammation or obstruction. * **Cultures** - Can be useful when bacterial sinusitis is suspected and previous treatments have failed.

Answer 708

* Avoid allergen * Intranasal corticosteroids * Nasal irrigation with saline solution **Surgical Management:** where medical treatment fails * Intranasal polypectomy * Endoscopic nasal polypectomy

Answer 709

unilateral symptoms persistent symptoms despite compliance with 3 months of treatment epistaxis **Requires referral as suggests neoplasia, abscess or osteomyelitis**

Answer 710

* A tension headache is a cause of chronic recurring head pain. * It typically cause a **mild ache or pressure in a band-like pattern** around the head

Answer 711

* They are the most common cause of chronic recurring head pain * More likely to affect **women**

Answer 712

* Bilateral, non-pulsatile headaches * Tightness sensation, like a band around the head * Scalp muscle tenderness They develop and resolve gradually and do not produce visual changes.

Answer 713

**Triggers** include: * Stress * Depression * Alcohol * Skipping meals * Dehydration

Answer 714

**First Line**: * Reassurance * Lifestyle Advice * Simple Analgaesia (Ibuprofen and paracetamol) **Medication** - Used for chronic or frequent tension headaches * Amitriptyline is first line

Answer 715

* Tonsilitis refers to **inflammation of the tonsils**. * Its primarily caused by infection (either viral or bacterial)

Answer 716

It is a very common condition that predominantly affects **children** and **adolescents**

Answer 717

The most common cause is a **viral infection**. Common viruses include: * Epstein-Barr virus * Influenza virus * Adenovirus * Rhinovirus. It can also be caused by a **bacterial infection**: * Most common - Group A streptococcus (Streptococcus pyogenes). * 2nd most common - Streptococcus pneumoniae

Answer 718

* **Sore throat** * **Fever** (above 38°C) * **Pain on swallowing** **Examination** will show: Red, inflamed and enlarged tonsils, with or without exudates (small white patches of pus on the tonsils) There may be **anterior cervical lymphadenopathy**

Answer 719

The tonsillar lymph nodes are just **behind the angle of the mandible** (jawbone).

Answer 720

* The **Centor criteria** - estimates the probability that tonsillitis is due to bacterial infection and will benefit from antibiotics. * The **FeverPAIN score** is an alternative to the Centor criteria.

Answer 721

A score of **3 or more gives a 40 – 60 % probability** of bacterial tonsillitis, and it is appropriate to offer antibiotics. A point is given if each of the following features are present: * **Fever over 38ºC** * **Tonsillar exudates** * **Absence of cough** * **Tender anterior cervical lymph nodes** (lymphadenopathy)

Answer 722

A score of 2 – 3 gives a 34 – 40% probability, and 4 – 5 gives a 62 – 65% probability of bacterial tonsillitis: * **Fever** during previous 24 hours * **P** – Purulence (pus on tonsils) * **A** – Attended within 3 days of the onset of symptoms * **I** – Inflamed tonsils (severely inflamed) * **N** – No cough or coryza

Answer 723

* **Pharyngitis** Symptoms include sore throat, fever, and headache. Unlike tonsillitis, patients do not usually present with lymphadenopathy. * **Mononucleosis** Characterized by fatigue, sore throat, fever, and swollen lymph nodes. A key difference is the presence of severe fatigue and splenomegaly.

Answer 724

* Investigation for Tonsilitis typically involves **clinical examination** and **patient history**. * **Throat swabs** and **rapid antigen tests** are can be done if bacterial infection is suspected. * **Blood tests** are reserved for those with suspected immunodeficiency.

Answer 725

* Calculate the Centor Criteria or FeverPAIN Score **If Centor score is less than 3**: * **Simple analgesia** with paracetamol and ibuprofen to control pain and fever. * Advise to return if the pain has not settled after 3 days or the fever rises above 38.3ºC. * Delayed perscriptions (for antibiotics) are an option for if the symptoms get worse. **If Centor score is 3 or more**: * Consider Antibiotics * **Penicillin V** (phenoxymethylpenicillin) for a 10-day course is 1st line * **Clarithromycin** is first line in a patient with a penicillin allergy

Answer 726

* **Recurrent Tonsillitis** (most common) * **Peritonsillar abscess**, also known as quinsy * **Otitis media**, if the infection spreads to the inner ear * Scarlet fever * Rheumatic fever * Post-streptococcal glomerulonephritis * Post-streptococcal reactive arthritis

Answer 727

* Stress incontinence * Urge incontinence * Overflow incontinence * Functional incontinence * Mixed incontinence

Answer 728

**DIAPPERS** * **D** - Delirium * **I** - Infection * **A** - Atrophic vaginitis or urethritis * **P** - Pharmaceutical (medications) * **P** - Psychiatric disorders * **E** - Endocrine disorders (e.g. diabetes) * **R** - Restricted mobility * **S** - Stool impaction

Answer 729

* Stress incontinence involves the leaking of urine when **intra-abdominal pressure is raised** (e.g. when coughing, laughing or straining). * Its due to due to **weakness of the pelvic floor and sphincter muscles**.

Answer 730

* **advancing age** * **high body mass index** * **Childbirth** (especially **vaginal**) - This may be due to a combination of injury to the pelvic floor musculature and connective tissue (for example leading to prolapse), as well as nerve damage as a result of pregnancy and labor. * **family history** * **Hysterectomy**

Answer 731

Anything that can increase abdominal pressure sufficiently: * Coughing * Laughing * Sneezing * Exercising

Answer 732

**Conservative Management** * Avoiding caffeine, fizzy and sugary drinks * Avoiding excessive fluid intake * **pelvic floor exercises** (8 contractions x3 daily for at least three months before considering surgery) **Surgical Management** * **Tension-free vaginal tape** (TVT) - involves a mesh sling looped under the urethra and up behind the pubic symphysis to the abdominal wall. This supports the urethra, reducing stress incontinence. * **Autologous sling procedures** - work similarly to TVT procedures but a strip of fascia from the patient’s abdominal wall is used rather than tape * **Colposuspension** - involves stitches connecting the anterior vaginal wall and the pubic symphysis, around the urethra, pulling the vaginal wall forwards and adding support to the urethra * **Intramural urethral bulking** - involves injections around the urethra to reduce the diameter and add support **Medical Management** * **Duloxetine** is an SNRI antidepressant and is used second line where surgery is less preferred

Answer 733

* Urge incontinence involves the **sudden and involuntary loss of urine associated with urgency**. * It is caused by overactivity of the detrusor muscle and is often called an **Overactive Bladder**

Answer 734

* Recurrent urinary tract infections * High BMI * Advancing age * Smoking * Caffeine

Answer 735

**Conservative Management** * **Bladder retraining** (gradually increasing the time between voiding) for at least **six weeks** - is first-line * Avoiding caffeine, fizzy and sugary drinks; as well as avoiding excessive fluid intake. * Pelvic floor exercises (can also help) **Medical Management** - 2nd line when conservative management fails * **Anticholinergic medication** (e.g. oxybutynin, tolterodine and solifenacin) - work by inhibiting the parasympathetic action on the detrusor muscle. * **Mirabegron** (a beta-3 receptor agonist) is an alternative often used in older patients as it has less of an anticholinergic burden. **Surgical Management** * **Botulinum toxin type A** injection into the bladder wall * **Percutaneous sacral nerve stimulation** involves implanting a device in the back that stimulates the sacral nerves * **Augmentation cystoplasty** involves using bowel tissue to enlarge the bladder * **Urinary diversion** involves redirecting urinary flow to a urostomy on the abdomen

Answer 736

* Dry mouth * Dry eyes * Urinary retention * Constipation * Postural hypotension It can also lead to a **cognitive decline**, **memory problems** and **worsening of dementia**, which can be very problematic in older, more frail patients.

Answer 737

**Uncontrolled hypertension** As it works as a beta-3 agonist, stimulating the sympathetic nervous system, leading to raised blood pressure. This can lead to a hypertensive crisis and an increased risk of TIA and stroke.

Answer 738

Functional incontinence involves an individual having the urge to pass urine, but for whatever reason they're unable to access the necessary facilities and as a result are incontinent. **You cant get to or a toilet in time**

Answer 739

Functional incontinence is associated with: * Sedating medications * Alcohol * Dementias

Answer 740

* Overflow incontinence occurs when **small amounts of urine leak without warning**. * It can occur when there is **chronic urinary retention** due to an obstruction to the outflow of urine. * The chronic urinary retention results in an overflow of urine, and the **incontinence occurs without the urge to pass urine**.

Answer 741

* Anticholinergic medications * Fibroids * Pelvic tumours **Neurological conditions** such as: * Multiple sclerosis * Diabetic neuropathy * Spinal cord injuries.

Answer 742

**Medical History** - Should be able to distinguish between the different types of incontinence Assess the **modifiable lifestyle factors** that can contribute to symptoms: * Caffeine consumption * Alcohol consumption * Medications * Body mass index (BMI) Assess **severity** by asking: * Frequency of urination * Frequency of incontinence * Nighttime urination * Use of pads and changes of clothing An **Examination** to assess for pelvic tone, and should look for: * Pelvic organ prolapse * Atrophic vaginitis * Urethral diverticulum * Pelvic masses The **strength of pelvic muscle contraction** should be assesed and graded using the **modified Oxford grading system**

Answer 743

* **0** - No contraction * **1** - Faint contraction * **2** - Weak contraction * **3** - Moderate contraction with some resistance * **4** - Good contraction with resistance * **5** - Strong contraction, a firm squeeze and drawing inwards

Answer 744

* A **bladder diary** should be completed, tracking fluid intake and episodes of urination and incontinence over at least three days. There should be a mix of work and leisure days. * **Urine dipstick testing** should be performed to assess for infection, microscopic haematuria and other pathology. * **Post-void residual bladder volume** should be measured using a bladder scan to assess for incomplete emptying. * **Urodynamic testing** can be used to investigate patients with urge incontinence not responding to first-line medical treatments, difficulties urinating, urinary retention, previous surgery or an unclear diagnosis. It is not always required where the diagnosis is possible based on the history and examination.

Answer 745

* **Cystometry** measures the detrusor muscle contraction and pressure * **Uroflowmetry** measures the flow rate * **Leak point pressure** is the point at which the bladder pressure results in leakage of urine. The patient is asked to cough, move or jump when the bladder is filled to various capacities. This assesses for stress incontinence. * **Post-void residual bladder volume** tests for incomplete emptying of the bladder * **Video urodynamic testing** involves filling the bladder with contrast and taking xray images as the bladder is emptied. Theses are only performed where necessary and not a routine part of urodynamic testing.

Answer 746

Infection of the lower urinary tract from the urethra to the bladder.

Answer 747

* Upper urinary tract infections or Pyelonephritis refers to **inflammation of the kidney** resulting from bacterial infection. * The inflammation affects the kidney tissue (parenchyma) and the renal pelvis (where the ureter joins the kidney).

Answer 748

Much more common in **women** (as **urethra is alot shorter**, making it easier for bacteria to get into the bladde)r.

Answer 749

**Escherichia coli** (gram-negative, anaerobic, rod-shaped bacteria) - is most common Other causes: * **Klebsiella pneumoniae** (gram-negative, anaerobic, rod-shaped bacteria) * Enterococcus * Pseudomonas aeruginosa * Staphylococcus saprophyticus * Candida albicans (fungal) Bacteria can spread from faeces to the urinary tract through: * **Sexual Activity** * Faecal Incontinence * Poor Hygeine **Urinary catheters** are another possible source of infection

Answer 750

* Dysuria (pain, stinging or burning when passing urine) * Suprapubic pain or discomfort * Frequency * Urgency * Incontinence * Haematuria * Cloudy or foul-smelling urine * Confusion is commonly the only symptom in older and frail patients

Answer 751

Can present with the same symptoms as a lower UTI **Plus**: * **Fever** * **Loin or back pain** (bilateral or unilateral) * **Nausea or vomiting** * **Renal angle tenderness** If there is evidence of **Systemic Illness**, its much more likely to be Pylonephritis

Answer 752

**Urine Dipstick** - **Nitrites or leukocytes plus red blood cells** indicate that the patient will likely have a UTI. **Midstream urine (MSU) sample** sent for microscopy, culture and sensitivity testing. This will determine the infective organism and the antibiotics that will be effective in treatment. It is important in: * **Pregnant** patients * Patients with **recurrent UTIs** * **Atypical** symptoms * When symptoms do not improve with antibiotics

Answer 753

First Line Oral Antibiotics: * **Nitrofurantoin** (avoided in patients with an eGFR < 45) * **Trimethoprim** (often associated with high rates of bacterial resistance) Duration of Antibiotic Course: * **3 days of antibiotics** - for simple lower urinary tract infections in women * **5-10 days of antibiotics** - for immunosuppressed women, abnormal anatomy or impaired kidney function * **7 days of antibiotics** - for **men**, **pregnant women** or **catheter-related UTIs** Possible Alternatives: * Pivmecillinam * Amoxicillin * Cefalexin

Answer 754

**First-line antibiotics** for **7-10 days**: * Cefalexin * Co-amoxiclav (if culture results are available) * Trimethoprim (if culture results are available) * Ciprofloxacin (keep tendon damage and lower seizure threshold in mind) Patients require referral to hospital if there are features of Spesis. They then need the sepsis six.

Answer 755

Changing the catheter

Answer 756

* Management requires **7 days of antibiotics**. * All women should have an **MSU** for microscopy, culture and sensitivity testing. The **antibiotic options** are: * Nitrofurantoin (avoided in the third trimester) * Amoxicillin (only after sensitivities are known) * **Cefalexin** (the typical choice)

Answer 757

* Trimethoprim works as a **folate antagonist** * Folate is essential in early pregnancy for the normal development of the fetus * This means that trimethoprim can **cause congenital malformations**, particularly **neural tube defects** (e.g., spina bifida).

Answer 758

* Urticaria are also known as **hives**. * They are **small itchy lumps that appear on the skin**. * Urticaria can be classified as acute urticaria or chronic urticaria.

Answer 759

* Urticaria are caused the release of **histamine** and other pro-inflammatory chemicals by **mast cells in the skin**. * This may be part of an allergic reaction in acute urticaria or an autoimmune reaction in chronic idiopathic urticaria.

Answer 760

Acute urticaria is typically triggered by something that **stimulates the mast cells to release histamine**. This may be: * Allergies to food, medications or animals * Contact with chemicals, latex or stinging nettles * Medications * Viral infections * Insect bites * Dermatographism (rubbing of the skin)

Answer 761

Chronic urticaria is an **autoimmune condition**, where autoantibodies target mast cells and trigger them to release histamines and other chemicals. It can be sub-classified depending on the cause: * **Chronic idiopathic urticaria** - describes recurrent episodes of chronic urticaria without a clear underlying cause or trigger. * **Chronic inducible urticaria** - Describes episodes of chronic urticaria that can be induced by certain triggers * **Autoimmune urticaria** - describes chronic urticaria associated with an underlying autoimmune condition, such as SLE.

Answer 762

* Sunlight * Temperature change * Exercise * Strong emotions * Hot or cold weather * Pressure (dermatographism)

Answer 763

* **Antihistamines** are first line for urticaria. * **Fexofenadine** is usually the antihistamine of choice for chronic urticaria. * **Oral steroids** may be considered as a short course for severe flares. In very **problematic cases**, the following may be considerred: * Anti-leukotrienes such as montelukast * Omalizumab, which targets IgE * Cyclosporin

Answer 764

* **Human alpha-herpesvirus 3 (HHV-3)** * It is a member of the human herpes virus family

Answer 765

* Chickenpox is an **acute infectious disease** caused by the **varicella-zoster virus (VZV)**, a member of the human herpes virus family. * This **highly contagious illness**, predominantly seen in children, is characterised by a vesicular rash, mild fever, and malaise.

Answer 766

* It is a common global disease * The majority of cases occur in **children aged 1-9 years**. * The illness is typically **mild in children** but can be **severe in adults or immunocompromised individuals**. * Its highly contagious, with a 90% secondary infection rate in susceptible household contacts.

Answer 767

* Its caused by the VZV * The virus is **airborne** and spreads through **direct contact** with the rash or by **breathing in particles** from an infected person's sneezes or coughs.

Answer 768

The cardinal sign of chickenpox is a **distinctive rash** that: * Starts as **raised red, itchy spots**, primarily on the face or chest, before spreading to the rest of the body. * Progresses into **small, fluid-filled blisters** over a span of a few days. * Eventually **crusts over and heals**, typically leaving no scars unless the blisters have been scratched and infected. Other **accompanying symptoms** include: * Mild fever * Fatigue * Loss of appetite * General discomfort.

Answer 769

* **Herpes simplex**: Characterised by painful, grouped vesicles on an erythematous base, usually around the mouth or genital area. * **Hand, foot, and mouth disease**: Presents with a rash on the hands, feet, and inside the mouth, often alongside fever and malaise. * **Scabies**: Manifests as intense itching, especially at night, and a pimple-like rash.

Answer 770

* Diagnosis of chickenpox is usually made **clinically** due to the characteristic nature of the rash and a history of exposure. * Laboratory testing is reserved for severe cases, immunocompromised patients, or when the diagnosis is uncertain.

Answer 771

Management is **primarily conservative** as the condition is self limiting: * Keeping the patient's **fingernails short** to prevent scratching and subsequent infection * Encouraging the use of **loose, long-sleeved clothing** to limit skin exposure and scratching * **Cooling measures** like oatmeal baths or calamine lotion to reduce itching * **Analgesics** and **antipyretics** for symptom relief Management of **Immunocompromised patients** or **previously unexposed pregnant women**/neonate with peripartum exposure: * IV Aciclovir * Human varicella-zoster immunoglobulin (VZIG) It is recommended to **isolate the patient** to prevent the spread of the virus to others. NICE recommends **school exclusion** during the most infectious period.

Answer 772

**1-2 days before** the rash appears, until all of the lesions are dry and have crusted over (**usually 5 days after** the rash appears)

Answer 773

* Secondary bacterial skin infections due to scratching * Pneumonia (more common in adults) * Encephalitis (rare) * Reye's syndrome (a severe complication, primarily in children) * Congenital varicella syndrome (if infection occurs during early pregnancy) * Reactivation of the virus as herpes zoster (**shingles**) later in life

Answer 774

Shingles is a **reactivation of the varicella zoster virus** which can lie dormant in nerve ganglia following primary infection (chickenpox).

Answer 775

More common in the elderly

Answer 776

* It manifests first as a **tingling feeling** in a dermatomal distribution. * It then progresses to **erythematous papules** occurring along one or more dermatomes within a few days. * The erythematous papules then develop into **fluid-filled vesicles** which then crust over and heal. * There may also be **systemic symptoms** like fever, headache and malaise. * **NEVER CROSSES THE MIDLINE**

Answer 777

* **Herpes zoster ophthalmicus (HZO)** Presents with symptoms including a painful red eye, fever, malaise, and headache, followed by an erythematous vesicular rash over the trigeminal division of the ophthalmic nerve. A lesion on the nose, known as **Hutchinson's sign**, may suggest ocular involvement.

Answer 778

**Prevent Spread:** * may need to avoid pregnant women and the immunosuppressed * Should be advised that they are infectious until the vesicles have crusted ove * Covering lesions reduces the risk **Analgesia** * Paracetamol and ibuprofen are first line * Oral Corticosteroids may be considered in first 2 weeks if immunocompromised and severe pain not responding to the above * Amitriptyline for Severe pain **Antivirals: Started within 72 hours of onset** * **Aciclovir** * Are over 50 years old. * Have non-truncal involvement (e.g., the rash affects areas like the face, eyes, or limbs). * Have moderate to severe pain or rash. * Are immunocompromised (due to conditions like HIV, cancer, or medications like steroids). * **consider** for people: < 50 years with milder symptoms, if treatment can be started within 72 hours.

Answer 779

**post-herpetic neuralgia** * Most common complications **herpes zoster ophthalmicus** * (shingles affecting affecting the ocular division of the trigeminal nerve) is associated with a variety of ocular complications **herpes zoster oticus** * (Ramsay Hunt syndrome): may result in ear lesions and facial paralysis

Answer 780

Varicose veins are **dilated and tortuous superficial veins** measuring **more than 3mm in diameter**, usually affecting the legs.

Answer 781

Reticular veins are dilated blood vessels in the skin measuring **less than 1-3mm in diameter**

Answer 782

* They are very common affecting 1/3 of adults * More common with **increased age** * More common in **Women** (due to hormonal influences)

Answer 783

* Increasing age * Family history * Female * Pregnancy * Obesity * Prolonged standing (e.g., occupations involving standing for long periods) * Deep vein thrombosis (causing damage to the valves)

Answer 784

* Varicose veins develop when the **valves within perforating veins** (veins that connect the superficial and deep veins) become **incompetant**. * This allows blood to **flow backwards from the deep veins into the superficial veins**, and overloads them. * This leads to dilatation and engorgement of the superficial veins, forming varicose veins.

Answer 785

Varicose Veins present with **engorged and dilated superficial leg veins**. There may also be: * Heavy or dragging sensation in the legs * Aching * Itching * Burning **Chronic Venous Insufficiency Signs:** * Haemosiderrin staining * Venous ulcers * Lipodermatosclerosis * Venous Eczema

Answer 786

* **Brown discolouration of the lower legs** - This occurs as when blood pools in the distal veins, the pressure causes the veins to leak small amounts of blood into the nearby tissues. The haemoglobin in this leaked blood breaks down to haemosiderin, which is deposited around the shins in the legs (giving the brown colour). * **Venous Eczema** - The pooling of blood in the distal tissues results in inflammation; resulting in dry and inflamed skin. * **lipodermatosclerosis** - The skin and soft tissues also become fibrotic and tight, causing the lower legs to become narrow and hard.

Answer 787

* **Deep vein thrombosis**: Presents with pain, swelling, redness or discoloration, and warmth in the affected limb. * **Chronic venous insufficiency**: Characterized by chronic oedema, skin changes such as pigmentation or eczema, and venous ulcers. * **Superficial thrombophlebitis**: Presents with a firm, red, tender vein and may have associated systemic symptoms such as fever. * **Peripheral artery disease**: Presents with intermittent claudication, non-healing ulcers, and in severe cases, rest pain.

Answer 788

Investigation starts with a thorough history and physical examination (including special tests). **Venous Duplex Ultrasound** * Shows retrograde venous flow

Answer 789

* **Tap test** – apply pressure to the saphenofemoral junction (SFJ) and tap the distal varicose vein, feeling for a thrill at the SFJ. A thrill suggests incompetent valves between the varicose vein and the SFJ. * **Cough test** – apply pressure to the SFJ and ask the patient to cough, feeling for thrills at the SFJ. A thrill suggests a dilated vein at the SFJ (called saphenous varix). * **Trendelenburg’s test** – with the patient lying down, lift the affected leg to drain the veins completely. Then apply a tourniquet to the thigh and stand the patient up. The tourniquet should prevent the varicose veins from reappearing if it is placed distally to the incompetent valve. If the varicose veins appear, the incompetent valve is below the level of the tourniquet. Repeat the test with the tourniquet at different levels to assess the location of the incompetent valves. * **Perthes test** – apply a tourniquet to the thigh and ask the patient to pump their calf muscles by performing heel raises whilst standing. If the superficial veins disappear, the deep veins are functioning. Increased dilation of the superficial veins indicates a problem in the deep veins, such as deep vein thrombosis.

Answer 790

Treatment is typically not required unless symptoms like bleeding, pain, ulceration, thrombophlebitis arise or significant psychological morbidity is noted. Management can involve: **Conservative Management** * Weight loss if appropriate * Staying physically active (to promote venous return) * Keeping the leg elevated when possible to help drainage * Compression stockings * Reduction of long periods of standing **Surgical Management** * **Endothermal ablation** – inserting a catheter into the vein to apply radiofrequency ablation * **Sclerotherapy** – injecting the vein with an irritant foam that causes closure of the vein * **Stripping** – the veins are ligated and pulled out of the leg

Answer 791

* Prolonged and heavy bleeding after trauma * Superficial thrombophlebitis (thrombosis and inflammation in the superficial veins) * Deep vein thrombosis * All the issues of chronic venous insufficiency (e.g., skin changes and ulcers)

Answer 792

Syncope may be defined as a **transient loss of consciousness due to global cerebral hypoperfusion** with rapid onset, short duration and spontaneous complete recovery. * Syncopal episodes are also known as **vasovagal episodes**, or simply fainting.

Answer 793

* A vasovagal episode (or attack) is caused by a problem with the **autonomic nervous system** regulating blood flow to the brain. * When the vagus nerve receives a **strong stimulus**, such as an emotional event, painful sensation or change in temperature it can **stimulate the parasympathetic nervous system**. * Parasympathetic activation counteracts the sympathetic nervous system, (which keeps the smooth muscles in blood vessels constricted). * As the blood vessels delivering blood to the brain relax, the **blood pressure in the cerebral circulation drops**, leading to **hypoperfusion of brain tissue**. This causes the patient to lose consciousness and “faint”.

Answer 794

**Prodrome**: * Hot or clammy * Sweaty * Heavy * Dizzy or lightheaded * Vision going blurry or dark * Headache The **Vasovagal Episode** itself: * Suddenly losing consciousness and falling to the ground * Unconscious on the ground for a few seconds to a minute as blood returns to their brain * There may be some twitching, shaking or convulsion activity, which can be confused with a seizure * There can also be incontinence * The patient may be a bit groggy following a faint, however, this is different to the postictal period following a faint.

Answer 795

**Primary syncope** (simple fainting): * Dehydration * Missed meals * Extended standing in a warm environment, such as a school assembly * A vasovagal response to a stimuli, such as sudden surprise, pain or the sight of blood **Secondary Syncope**: * Hypoglycaemia * Dehydration * Anaemia * Infection * Anaphylaxis * Arrhythmias * Valvular heart disease * Hypertrophic obstructive cardiomyopathy

Answer 796

**Cardiovascular Examination** * **ECG** - particularly assessing for arrhythmia and the QT interval for long QT syndrome **Blood Pressure Lying and Standing** **Other Investigations if required** * **24 hour ECG** - if paroxysmal arrhythmias are suspected * **Echocardiogram** - if structural heart disease is suspected * **Bloods** - including a full blood count (anaemia), electrolytes (arrhythmias and seizures) and blood glucose (diabetes)

Answer 797

More common in children (particularly teenage girls)

Answer 798

Seizures or underlying pathology need to be managed by an appropriate specialist. Once a simple vasovagal episode is diagnosed, **reassurance and simple advice** can be given to: * Avoid dehydration * Avoid missing meals * Avoid standing still for long periods * When experiencing prodromal symptoms such as sweating and dizziness, sit or lie down, have some water or something to eat and wait until feeling better.

Answer 799

Venous ulcers, are a **form of skin ulcers** predominantly caused by **sustained venous hypertension**, resulting in **venous valve incompetence**.

Answer 800

* Obesity * Immobility * Presence of varicose veins * History of deep vein thrombosis (DVTs) * Advanced age * Prior trauma to the leg

Answer 801

* Predominantly found over the medial malleolus * Shallow and sloughy in nature * Presence of haemosiderin deposition in the lower leg * Oedema * Skin thickening * Eczema

Answer 802

**Ankle-Brachial Pressure Index (ABPI)** - Is the first line investigation in order to rule out any co-existing arterial disease that might be exacerbated if compression bandaging is applied. (As this would worsen arterial supply to the leg).

Answer 803

**Conservative Management** * Maintain cleanliness of the ulcer * Promote mobility * Suggest weight reduction * Recommend leg elevation at rest * **Emollient treatment** for the leg * **Compression bandaging** - This technique aims to improve venous return from the leg. **Medical Management** * **Pentoxifylline** (a peripheral vasodilator) may be considered if the ulcer fails to respond to initial treatment. **Surgical Management** * Though rarely necessary, options include debridement and skin grafting.

Answer 804

* Decreased mobility due to pain * Risk of infection, which can progress to sepsis * Possibility of osteomyelitis * Decreased quality of life due to persistent pain and disability

Answer 805

* Chronic venous insufficiency occurs when **blood does not efficiently drain from the legs back to the heart**. * This results in blood pooling in the legs, causing **venous hypertension** and the skin changes associated with chronic venous insufficiency. * Its often associated with Varicose Veins

Answer 806

* Chronic venous insufficiency usually occurs as a result of **damage to the valves inside the veins**. * These valves are usually responsible for ensuring blood flows in one direction as the leg muscles contract and squeeze the veins. * When they are damaged however, the **pumping effect** of the **leg muscles becomes less effective** in draining blood towards the heart; and blood pools in the veins of the legs, causing venous hypertension. * Chronic pooling of blood in the legs leads to skin changes. The area between the **top of the foot and the bottom of the calf muscle** is the area most affected by these changes. This is known as the **gaiter area**.

Answer 807

**Skin Changes**: * **Haemosiderin staining** (is a **red/brown discolouration to the legs**) - This occurs as small ammounts of blood leaks out of the veins into the nearby tissues (due to the venous hypertension). haemoglobin in this leaked blood breaks down to haemosiderin, which is deposited around the shins in the legs (giving the brown colour). * **Venous eczema** (or varicose eczema) - Is dry, itchy, flaky, scaly, red and cracked skin. These eczema-like changes are caused by a chronic inflammatory response in the skin in response to the pooled blood. * **Lipodermatosclerosis** - is hardening and tightening of the skin as well as the tissue beneath. This occurs as, chronic inflammation causes the subcutaneous tissue to become fibrotic. * **Atrophie blanche** - refers to patches of smooth, porcelain-white scar tissue on the skin, often surrounded by hyperpigmentation. **Other symptoms**: * Cellulitis * Poor healing after injury * Skin ulcers * Pain

Answer 808

**Management involves**: * Keeping the skin healthy * Improving venous drainage to the legs * Managing complications The skin is **kept healthy by**: * Monitoring skin health and avoiding skin damage * Regular use of emollients (e.g., diprobase, oilatum, cetraben and doublebase) * Topical steroids to treat flares of venous eczema * Very potent topical steroids to treat flares of lipodermatosclerosis **Improving venous drainage** to the legs involves: * Weight loss if obese * Keeping active * Keeping the legs elevated when resting * Compression stockings (exclude arterial disease first with an ankle-brachial pressure index) **Management of complications** involves: * Antibiotics for infection * Analgesia for pain * Wound care for ulceration

Answer 809

* An “exanthem” is an **eruptive widespread rash**. * Originally there were **six “viral exanthemas”** known as first, second, third, fourth, fifth and sixth disease.

Answer 810

* First disease: **Measles** * Second disease: **Scarlet Fever** * Third disease: **Rubella** (AKA German Measles) * Fourth disease: **Dukes’ Disease** * Fifth disease: **Parvovirus B19** * Sixth disease: **Roseola Infantum**

Answer 811

* (Also known as **fourth disease**), it has been mostly forgotten and is **never now used in clinical practice**. * No organism has been found that could explain a specific “fourth disease”. * Its likely the term fourth disease, was used to decribe the various non-specific viral rashes with no one specific viral cause.

Answer 812

It's caused by **human herpesvirus 6** (HHV-6) and less frequently by human herpesvirus 7 (HHV-7).

Answer 813

* It presents **1 – 2 weeks after infection** with a **high fever (up to 40ºC)** that comes on rapidly, **lasts for 3 – 5 days** and then disappears suddenly. * During this period, there may also be coryzal symptoms, sore throat and swollen lymph nodes. * When the fever settles, a **mild erythematous macular rash** across the arms, legs, trunk and face appears for 1 – 2 days. The rash is not itchy. * Children make a **full recovery within a week**

Answer 814

**Febrile convulsions** due to the high temperature

Answer 815

Acute gastritis is **inflammation of the stomach** and presents with nausea and vomiting.

Answer 816

Enteritis is **inflammation of the intestines** and presents with diarrhoea.

Answer 817

Gastroenteritis is **inflammation all the way from the stomach to the intestines** and presents with nausea, vomiting and diarrhoea.

Answer 818

The most common cause of gastroenteritis is **viral infection**: * **Norovirus** - most common cause of viral gastroenteritis overall * **Rotavirus** - most common cause of infantile gastroenteritis * Adenovirus - more commonly causes respiratory infection. But it can also cause gastroenteritis, especially in children.

Answer 819

* **Escherichia coli** (including E.coli 0157 which can cause haemolytic uraemic syndrome) * **Campylobacter Jejuni** - The most common cauase of bacterial gastroenteritis worldwide (is a common cause of travellers diahorrea) * Staph. aureus * Shigella * Salmonella * Bacillus Cereus

Answer 820

* Infection (gastroenteritis) * Inflammatory bowel disease * Lactose intolerance * Coeliac disease * Cystic fibrosis * Toddler’s diarrhoea * Irritable bowel syndrome * Medications (e.g. antibiotics)

Answer 821

**Prevent the spread**: * When patients develop symptoms they should immediately be **isolated** to prevent spread. * **Barrier nursing** and **rigorous infection control** is important for patients in hospital to prevent spread to other patients. * Children need to stay off school until 48 hours after the symptoms have completely resolved. **Faeces sample** with microscopy, culture and sensitivities to establish the causative organism **Rehydration**: * The key to managing gastroenteritis is to ensure they remain hydrated whilst waiting for the diarrhoea and vomiting to settle. * **Fluid challenge** - This involves recording a small volume of fluid given orally every 5-10 minutes to ensure they can tolerate it. * Oral **Rehydration solutions** (e.g. dioralyte) can be used if tolerated * If oral fluid isn't tolerated, then **IV fluid rehydration** may be nescesary **Antibiotics** * Antibiotics should only be given in patients that are at risk of complications once the causative organism is confirmed.

Answer 822

* Lactose intolerance * Irritable bowel syndrome * Reactive arthritis * Guillain–Barré syndrome

Answer 823

CRAP GPS Carbemazepines Rifampicin Alcohol Phenytoin Griseofulvin Phenobarbitone Sulphonylureas

Answer 824

SICKFACES.COM Sodium Valproate Isoniazid Cimetidine Ketoconazole Fluconazole Alcohol (binge drinking) Chloramphenicol Erythromycin Sulphonamides Ciprofloxacin Omeprazole Metronidazole

Answer 825

They're abnormal heart rhythms that result from an interruption to the normal electrical signals that coordinate the contraction of the heart muscle. There are several types

Answer 826

Ventricular tachycardia Ventricular fibrillation

Answer 827

Pulseless electrical activity (all electrical activity except VF/VT, including sinus rhythm without a pulse) Asystole (no significant electrical activity)

Answer 828

Narrow complex tachycardia refers to a fast heart rate with a QRS complex duration of less than 0.12 seconds.

Answer 829

Sinus tachycardia Supraventricular tachycardia Atrial fibrillation Atrial flutter

Answer 830

Synchronised DC cardioversion under sedation or general anaesthesia. IV amiodarone is added if initial DC shocks are unsuccessful.

Answer 831

Broad complex tachycardia refers to a fast heart rate with a QRS complex duration of more than 0.12 seconds.

Answer 832

* Ventricular tachycardia (or unclear cause) * Polymorphic ventricular tachycardia, such as torsades de pointes * Atrial fibrillation with bundle branch block * Supraventricular tachycardia with bundle branch block

Answer 833

IV Amiadorone

Answer 834

IV Magnesium

Answer 835

Synchronised DC cardioversion under sedation or general anaesthesia. IV amiodarone is added if initial DC shocks are unsuccessful. (Same as narrow complex )

Answer 836

Atrial flutter is a common supraventricular tachycardia (SVT) where there is succession of rapid atrial depolarisation It is characterised by an abnormal cardiac rhythm with an atrial rate of 300 beats/min and a ventricular rate that can be fixed or variable.

Answer 837

Usually 2:1 conduction (2 atrial contractions for every ventricle contraction) Thus the HR would be 150bpm Although the conduction rate can be 3:1 or even 4:1

Answer 838

As the electrical signal can't enter the ventricles on every lap due to the long refractory period of the atrioventricular node

Answer 839

**Sawtooth appearance** with repeated P waves occurring at around 300 per minute. In a regular rhythm). With a narrow complex tachycardia (narrow QRS Complex).

Answer 840

Normally the electrical signal passes through the atria once, stimulating a contraction, then disappears through the atrioventricular node into the ventricles. Atrial flutter is caused by a re-entrant rhythm in the right atrium. The electrical signal re-circulates in a self-perpetuating loop due to an extra electrical pathway in the atria. The signal goes round and round the atrium without interruption resulting in a very high atrial HR.

Answer 841

Its likely to occur with pulmonary disease such as: * COPD * Obstructive sleep apnoea * Pulmonary emboli * Pulmonary hypertension Other causes: SMITH Sepsis Myocardial Ischaemia Infection (IE) and intoxication (alcohol) Thyrotoxicosis Hypertension

Answer 842

Asymptomatic Palpitations Lightheadedness Syncope Chest pain

Answer 843

1st line = direct current synchronised cardioversion +/- amiodarone

Answer 844

Treat reversible causes e.g. fluid rehydration (in septic/dehydrated patients) **Rate and Rhythm control** * 1st line = **beta-blocker** (bisoprolol) OR calcium channel blocker (diltiazem, verapamil) * 2nd line = if rate control fails to control flutter than consider cardioversion (either electrical or pharmacological with drugs like **amiodarone**, sotalol, or digoxin) * 3rd line = recurrent or refractory flutter managed with **Radiofrequency ablation of arrhythmogenic foci at cavotricuspid isthmus**. **Anticoagulation** According to CHA2DS2VASc score due to increased risk of ischaemic stroke

Answer 845

* **CardiacEmboli** - Ischaemic stroke if not appropriately anticoagulated. * Tachycardia-induced cardiomyopathy leading to heart failure.

Answer 846

More than 440 milliseconds in men More than 460 milliseconds in women

Answer 847

A prolonged QT interval represents **prolonged repolarisation** of the heart muscle cells (myocytes) after a contraction. Waiting a long time for repolarisation **can result in spontaneous depolarisation** in some muscle cells. These afterdepolarisations spread throughout the ventricles, **causing a contraction before proper repolarisation.** When this leads to **recurrent contractions without normal repolarisation, it is called torsades de pointes.**

Answer 848

Depolarisation is the electrical process that leads to heart contraction.

Answer 849

Repolarisation is a recovery period before the muscle cells are ready to depolarise again.

Answer 850

Its type of polymorphic ventricular tachycardia. It translates from French as “twisting of the spikes”, describing the ECG characteristics.

Answer 851

It looks like standard ventricular tachycardia but with the appearance that the QRS complex is twisting around the baseline. The height of the QRS complexes gets progressively smaller, then larger, then smaller, and so on.

Answer 852

They will **terminate spontaneously and revert to sinus rhythm** or progress to ventricular tachycardia. Ventricular tachycardia can lead to cardiac arrest.

Answer 853

**Congenital:** * Jervell-Lange-Nieslen Syndrome (deafness) * Romano-Ward Syndrome (no-deafness) **Drugs: (ASTHMATiC)** * **A:** amiodarone * **S:** sotalol, SSRIs * **T:** terfenadine * **H:** haloperidol * **M:** methadone, macrolides (erythromycin) * **A:** antiarrythmics class Ia * **T:** tricyclic antidepressants * **C:** chloroquine **Other:** * Electrolyte imbalance: Hypocalcaemia, hypokalaemia, hypomagnesaeimia * Acute MI * Myocarditis * Hypothermia * SAH

Answer 854

* Stopping and avoiding medications that prolong the QT interval * Correcting electrolyte disturbances * Beta blockers (not sotalol) * Pacemakers or implantable cardioverter defibrillators

Answer 855

* Correcting the underlying cause (e.g., electrolyte disturbances or medications) * **Magnesium infusion** (even if they have normal serum magnesium) * Defibrillation if ventricular tachycardia occurs

Answer 856

They are premature ventricular beats caused by random electrical discharges outside the atria. Patients often present complaining of random extra or missed beats. They are relatively common at all ages and in healthy patients. (but are more common in those with pre-existing heart conditions).

Answer 857

They appear as isolated, random, abnormal, broad QRS complexes on an otherwise normal ECG.

Answer 858

Bigeminy refers to when every other beat is a ventricular ectopic. The ECG shows a normal beat, followed immediately by an ectopic beat, then a normal beat, then an ectopic, and so on.

Answer 859

**PR interval greater than 0.2 seconds** It occurs where there is delayed conduction through the atrioventricular node. Despite this, every atrial impulse still leads to a ventricular contraction, meaning every P wave is followed by a QRS complex.

Answer 860

Second-degree heart block is where some atrial impulses don't make it through the atrioventricular node to the ventricles. Thus, there are instances where P waves are not followed by QRS complexes. There are two types.

Answer 861

Mobitz type 1 (Wenckebach phenomenon) Mobitz type 2

Answer 862

It is where the conduction through the atrioventricular node takes progressively longer until it finally fails, after which it resets, and the cycle restarts. On an ECG, there is an increasing PR interval until a P wave is not followed by a QRS complex. The PR interval then returns to normal, and the cycle repeats itself.

Answer 863

This is where there is intermittent failure of conduction through the atrioventricular node, with the occasional absence of QRS complexes following P waves. There is usually a set ratio of P waves to QRS complexes, for example, three P waves for each QRS complex (3:1 block). **The PR interval remains Constant (either normal/prolonged)** There is a risk of asystole

Answer 864

Also called complete heart block. There is no observable relationship between the P waves and QRS complexes. There is a significant risk of asystole

Answer 865

Asystole refers to the absence of electrical activity in the heart (resulting in cardiac arrest).

Answer 866

* Mobitz type 2 * Third-degree heart block (complete heart block) * Previous asystole * Ventricular pauses longer than 3 seconds

Answer 867

**Commence ALS/PALS:** * **Intravenous Adrenaline 1mg every 3-5mins** (first line) * Inotropes (e.g., isoprenaline or adrenaline) * Temporary cardiac pacing * Permanent implantable pacemaker, when available

Answer 868

* Transcutaneous pacing, using pads on the patient’s chest * Transvenous pacing, using a catheter, fed through the venous system to stimulate the heart directly

Answer 869

Atropine is an antimuscarinic medication and works by inhibiting the parasympathetic nervous system.

Answer 870

pupil dilation dry mouth urinary retention constipation.

Answer 871

Atrial fibrillation (AF) is characterised by irregular, uncoordinated atrial contraction usually at a rate of 300-600 beats per minute. Delay at the AVN means that only some of the atrial impulses are conducted to the ventricles, resulting in an irregular ventricular response.

Answer 872

AF is the commonest sustained cardiac arrhythmia. (Atrial Flutter is second most common) The prevalence of AF roughly doubles with each advancing decade of age

Answer 873

* Acute: lasts <48 hours * Paroxysmal: lasts <7 days and is intermittent * Persistent: lasts >7 days but is amenable to cardioversion * Permanent: lasts >7 days and is not amenable to cardioversion It can also be classed as **fast** or **slow**: Fast AF : >100bpm Slow AF: <60bpm

Answer 874

**Cardiac** * Ischaemic heart disease: most common cause in the UK. * Hypertension * Rheumatic heart disease (typically affecting the mitral valve): most common cause in less developed countries. * Peri-/myocarditis **Non-cardiac** * Dehydration * Endocrine causes e.g. hyperthyroidism * Infective causes e.g. sepsis * Pulmonary causes e.g. pneumonia or pulmonary embolism * Environmental toxins e.g. alcohol abuse * Electrolyte disturbances e.g. hypokalaemia, hypomagnesaemia

Answer 875

Palpitations Chest pain Shortness of breath Lightheadedness Syncope

Answer 876

* Irregularly irregular pulse rate with a variable volume pulse. * A single waveform on the jugular venous pressure (due to loss of the a wave - this normally represents atrial contraction). * An apical to radial pulse deficit (as not all atrial impulses are mechanically conducted to the ventricles). * On auscultation there may be a variable intensity first heart sound.

Answer 877

**Atrial Flutter** Distinguishing between the two requires an ECG. **Supraventricular Tachycardia** Distinguishing between different types of SVT requires an ECG. **Ventricular Tachycardia** ECG patterns differ tremendously.

Answer 878

**12-lead ECG** Shows absence of p waves with an irregularly irregular rhythmn.

Answer 879

* Routine bloods: to look for reversible causes (e.g. infection (raised WCC and CRP), Hyperthyroidism (raised T3/T4)) * Echocardiography - To see if there is a cardoiac cause for the AF (e.g. left atrial dilatation secondary to mitral valve disease).

Answer 880

1st line = synchronised DC cardioversion +/- amiodarone

Answer 881

**Rate or rhythmn control** Either: * Rhythm control with DC cardioversion (+ sedation) * or pharmacological anti-arrhythmics (fleicanide if no structural heart disease, amiodarone if history of structural heart disease). If DC cardioversion is used then heparin will be required to anticoagulate the patient before DC cardioversion. If onset of AF is <48 hours then no further anticoag is required

Answer 882

**Rate control only** * Rate control with **beta-blockers or rate limiting CCBs (diltiAzeem, verapamil)** * Digoxin may be used does no/very little exercise * Need to anticoagulate for 3/52 prior to attempting cardioversion due to the risk of throwing off a clot. You can also perform a TOE to exclude a mural thrombus.

Answer 883

Management focusses on symptomatic relief and control of stroke risk * 1st Line = **Rate Control** (reduces patient's HR to control symptoms) * **Rhythem Control** is only appropriate in certain patients * **Anticoagulation** should be given to males who score 1 or more, and females who score 2 or more in CHADS2VASc

Answer 884

* **1st line**: beta-blocker (bisoprolol) or rate-limiting calcium channel blocker (diltiazem). * **2nd line**: dual therapy of beta blockers and rate limiting CCBs * **Digoxin monotherapy** may be considered in those with non-paroxysmal AF who are sedentary.

Answer 885

**RANCH** * Reversible cause of AF *Atrial Flutter Ablation * New onset (<48hrs) * Clinical Judgement * HF secondary to AF

Answer 886

* Electrical cardioversion * Pharmacological cardioversion: amiodarone, fleicanide or sotalol. * Catheter Ablation of the arrhythmogenic focus between the pulmonary veins and left atrium is a final option for rhythm control. But with this method, there is a high risk of reccurence.

Answer 887

* **1st Line**: Direct oral anticoagulants (DOACs) e.g. edoxaban, apixaban, rivaroxaban & dabigatran. These don't require monitoring. * Warfarin - Requires cover with LMWH for 5 days when initiating treatment; and regular INR monitoring. This is the only option for those with Valvular AF * Low Molecular Weight Heparin (LMWH) - e.g. enoxaparin. This is a rare option for those who can't tolerate oral treatment. Requires daily injections.

Answer 888

**Heart failure** **Systemic emboli**: * Ischaemic Stroke * Mesenteric ischaemia * Acute limb ischaemia **Bleeding**: * GI * Intracranial

Answer 889

Acute Self limiting rash caused by HHV-7

Answer 890

**Herald Patch** on the trunk. * 1-2 weeks later multiple erythematous scaly patches following the rib distribution (parallel to the line of Langer) (**Christmas tree appearance**) * Self limiting- disappears within 6-12 weeks

Answer 891

Self limiting condition caused by HHV-7 Will clear within 6-12 weeks.

Answer 892

**Guttate Psoriasis** * Prodrome: preceded by strep throat 2-4 weeks ago * Appearance: **tear drop** scaly papules on trunk and limbs * Management: Resolve within 2-3 months. Topical agents as per psoriasis treatment **Pityriasis Rosea** * Prodrome: often non- may have URTI (viral) * Appearance: Herald patch followed by christmas tree distribution of smaller scaly patches on ribs * Management: Self limiting - resolves in 6-12 weeks

Answer 893

Also called tinea versicolor, is a superficial cutaneous fungal infection caused by **Malassezia furfur**

Answer 894

* Most commonly affects trunk * Patches may be hypopigmented, pink or brown (hence versicolor). * May be more noticeable following a suntan * Scale is common * Mild pruritus

Answer 895

* Occurs in healthy individuals * Immunosuppression * Malnutrition * Cushing's

Answer 896

**Topical Antifungal** * Ketoconazole shampoo as this is more cost effective for large areas * If failure to respond to topical treatment then consider alternative diagnoses (e.g. send scrapings to confirm the diagnosis) + oral itraconazole

Answer 897

Scabies is caused by the mite **Sarcoptes scabiei** and is spread by prolonged skin contact. It typically affects children and young adults.

Answer 898

* The scabies mite burrows into the skin, laying its eggs in the stratum corneum. * The intense pruritus associated with scabies is due to a delayed-type IV hypersensitivity reaction to mites/eggs * Which occurs about 30 days after the initial infection.

Answer 899

* **Widespread Intense pruritus** * linear burrows on the side of fingers, interdigital webs and flexor aspects of the wrist * in infants, the face and scalp may also be affected * **secondary features** are seen due to scratching: excoriation, infection

Answer 900

**Permethrin 5% is first-line** **malathion 0.5% is second-line** pruritus persists for up to 4-6 weeks post eradication

Answer 901

* Avoid close physical contact with others until treatment is complete * All household and close physical contacts should be treated at the same time, even if asymptomatic * Launder, iron or tumble dry clothing, bedding, towels, etc., on the first day of treatment to kill off mites.

Answer 902

Scabies seen in immunosuppressed patients especially with HIV **Ivermectin and isolation is the treatment of choice**

Answer 903

Rosacea (sometimes referred to as acne rosacea) is a chronic skin disease of unknown aetiology.

Answer 904

* Typically affects nose, cheeks and forehead * Flushing is often first symptom * Sunlight may exacerbate symptoms * Telangiectasia are common * later develops into **persistent erythema with papules and pustules** * **rhinophyma** **ocular involvement: blepharitis**

Answer 905

**Simple Measures:** * Application of high-factor sun cream * Camouflage creams for redness concealment **Mild-Moderate papules/pustules** * **Topical Ivermectin** is first line **Moderate-Severe Papules/Pustules** * Combination of **Topical Ivermectin + Oral Doxycycline**

Answer 906

**Topical Brimonidine Gel** * Topical alpha-adrenergic agonist * Temporarily reduces redness

Answer 907

* Symptoms have not improved with optimal management in primary care * Laser therapy may be appropriate for patients with prominent telangiectasia * **Patients with a rhinophyma**

Answer 908

An enlargead red bumpy and bulbous nose due to granulomatous infiltration as a result of untreated rosacea

Answer 909

Fungal Nail infection involving any part of the nail or the entire nail unit

Answer 910

**Dermatophytes** * account for around 90% of cases * mainly Trichophyton rubrum **Yeasts** * account for around 5-10% of cases * Candida **non-dermatophyte moulds**

Answer 911

increasing age diabetes mellitus psoriasis repeated nail trauma

Answer 912

* 'unsightly' nails are a common reason for presentation * Thickened, rough, opaque nails are the most common finding

Answer 913

**nail clippings +/- scrapings of the affected nail** * Microscopy and culture * should be done for all patients if antifungal treatment is being considered * False-negative rate for cultures are around 30%, so repeat samples may need to be sent if the clinical suspicion is high

Answer 914

**Asymptomatic** * Does not require treatment if patient not bothered by appearance **Confirmed Candida/Dermatophyte infection (Limited Involvement)** * Topical Amorolfine 5% nail laquer * 6 months for finger nails * 12 months for toe nails **Extensive Dermatophyte infection** * Oral Terbinafine * 6-12 weeks for finger nails * 3-6 months for toe nails

Answer 915

an infection of the proximal and lateral fingernails and toenails folds, including the tissue that borders the root and sides of the nail

Answer 916

The persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance. It is a symptom and not a disease

Answer 917

**Factors Favouring an Organic Cause** * Gradual onset of symptoms * Lack of tumescence * Normal libido **Factors Favouring a Psychogenic Cause** * Sudden onset of symptoms * Decreased libido * Good quality spontaneous or self-stimulated erections * Major life events * Problems or changes in a relationship * Previous psychological problems * History of premature ejaculation

Answer 918

**Psychological** * Stress * Anxiety disorder * Depression * Performance Anxiety **Non-Psychological** * Vascular causes * Diabetes * Neurogenic - parkinsons/nerve damage * Alcohol * Meds - Beta blockers

Answer 919

* **Increased Age** * Cardiovascular disease risk factors: obesity, diabetes mellitus, dyslipidaemia, metabolic syndrome, hypertension, smoking * Alcohol use * Drugs: SSRIs, beta-blockers

Answer 920

**NICE recommend all men have their 10-year CVD risk assessed by calculating lipid and fasting glucose levels** **Free Testosterone:** * Measured in morning between 9-11am * If low or borderline then do LH. FSH and Prolactin * If these are abnormal then refer to Endocrinology **Blood tests:** * Testosterone * Lipid Profile * Prolactin * HBA1c

Answer 921

**PDE-5 inhibitors** * Sildenafil * Prescribed regardless of aetiology (if no CIs) * sildenafil can be purchased over-the-counter without a prescription. **Vacuum erection devices** are recommended as first-line treatment in those who can't/won't take a PDE-5 inhibitor. **Psychosexual Counselling** **Advice:** * Young man who has always had difficulty achieving an erection, referral to urology is appropriate * People with ED who cycle for more than three hours per week should be advised to stop

Answer 922

Actinic, or solar, keratoses (AK) is a common premalignant skin lesion that develops as a consequence of chronic sun exposure

Answer 923

* Small, crusty or scaly, lesions * May be pink, red, brown or the same colour as the skin * Typically on sun-exposed areas e.g. temples of head * Multiple lesions may be present

Answer 924

**Prevention** * Sun avoidance * Suncreams **Fluorouracil Cream** 2-3 week course **Topical Diclofenac** **Topical Imiquimod**

Answer 925

Type of precancerous dermatosis that is a precursor to squamous cell carcinoma. * It is more common in elderly patients. * There is around a 5-10% chance of developing invasive skin cancer if left untreated.

Answer 926

* Red, scaly patches * often 10-15 mm in size * slow-growing * often occur on sun-exposed areas such as the head (e.g. temples) and neck, lower limbs

Answer 927

**Topical 5-fluorouracil** * typically used twice daily for 4 weeks * often results in significant inflammation/erythema. **Topical steroids are often given to control erythema from 5-FU** Cryotherapy Excision

Answer 928

Post fracture, there is raised pressure causing muscles and blood vessels within a fascial compartment are compressed and inflamed. The fascia is not stretchy so leads to ischaemia and severe pain/

Answer 929

6Ps of acute limb ischaemia Extreme pain on passive movement of the limb. Pulses may be faint rather than absent

Answer 930

**History of crush injury or trauma** * Intra-compartmental manometry (increased by 40mmHg)

Answer 931

Fasciotomy