General stuff Flashcards
HLA-B27
- Ankylosing spondylitis
- Reactive arthritis
- Acute anterior uveitis
- Poor prognostic factor for pt with reactive arthritis (more sudden onset, more severe symptoms, more likely to develop chronic reactive arthritis)
HLA-B47
21-hydroxylase deficiency
HLA-DR2
SLE
Coeliac disease
HLA-DR3
- Autoimmune hepatitis
- T1DM
- SLE
- Sjogren syndrome
- Coeliac disease
HLA-DR4
- RA
- T1DM
HLA-DQ2
HLA-DQ8
Coeliac disease
Opiate antagonists
Methadone
Naltrexone
Buprenorphine
Causes of upper GIB
- Oesophageal tumour
- Mallory Weiss tear
- Oesophagitis
- Oesophageal varices
- Gastric carcinoma
- Gastritis
- Gastric ulcer
- Duodenal ulcer
- Angiodysplasia
look at diagram in epigastric pain
Emergency treatment of hyperkalaemia
- Calcium gluconate - FIRST STEP to protect the heart
- Insulin and dextrose –> They activate the co-transporters on cells which move potassium back into cells and lowers serum potassium for 30-45 minutes SECOND STEP
- Salbutamol nebulisers THRID STEP
Other answers are used in the treatment of hyperkalaemia but not during emergencies
- IV calcium gluconate/chloride can stabilise the myocardium in hyperkalaemia
- Calcium resonium is given orally with aperients (i.e. drugs used to relieve constipation) and will help reduce potassium chronically but takes >24hrs to have an effect. You cannot give it IV.(capsule)
Features of rhambomyolysis
Black/”Smokey” urine (colour of coca cola)
AKI causes
Hypocalcaemia [kidney cant retain it]
Hyperphosphataemia(capsule) [kidney cant excrete it]
How does myoglobin released from rhabdomyolysis (crush injury) damage the kidneys? (3 ways)
it causes renal vasoconstriction
it is toxic to tubular cells
precipitates in the tubules(capsule)
Contra-indication to MRI
Pacemaker(capsule)
How is renal anaemia treated?
Renal anaemia is treated with regular injections of recombinant erythropoeitin
This avoids the complications of repeated transfusion such as
- Iron overload
- Risk of infection with blood born agents
- Sensitisation to potential kidney donor HLA(capsule)
Why is a low phosphate diet recommended to patients with CKD?
With a low GFR phosphate excretion by the kidney is considerably reduced, hyperphosphataemia can cause itching, leads to reduced production of active calcitriol and contributes to hypocalcaemia and hyperparathyroidism
Increased levels of phosphate + FGF23 by osteocytes in bone decrease the activity of 1-alpha-hydroxylase* leading to decreased calcitriol production therefore less Ca is released from bones and this causes an increase in PTH release to try and increase the calcium
*The activity of the enzyme is stimulated by PTH, so decrease in its activity will also cause increased PTH release(capsule)
Sepsis 6
Give
o2
abx
ivf
take
urinary output
blood cultures
lactate + hb measurements
Diffference bn SIRS, sepsis, severe sepsis, shock, MODS
• SIRS (systemic inflammatory response syndrome) body’s response to a wide range of pro-inflammatory processes (not just infection but also pancreatitis, anaphylaxis, PE). Defined as 2 or more of:
o Pulse >90
o T >38 or <36
o RR >20 or PaCO2 <4.3 (hyperventilatory hypocapnia)
o WBC >12 or <4
• Sepsis is SIRS caused by a suspected/proven infection (SIRS + septicaemia)
• Severe sepsis - sepsis causing
o Hypotension – SBP <90mmHg or >40mmHg drop compared to normal for patient
o End organ hypoperfusion – VBGs shows lactic acidosis (e.g. oliguria (kidney hypoperfusion), confusion (brain hypoperfusion) or serum lactate >4 (muscle hypoperfusion))
- Septic shock – severe sepsis refractory to fluid resuscitation (+ therefore in need of vasopressors)
- MODS (multiorgan dysfunction syndrome)/multiorgan failure – evidence of >2 organs failing (e.g. confusion due to cerebral hypoperfusion, respiratory failure, liver failure, renal failure)
Altered organ function in acutely ill patients such that homeostasis cannot be maintained without intervention
It usually involves two or more organ systems
Condition usually results from infection, injury, hypoperfusion, hypermetabolism
Sepsis is the most common cause
SLE HLA assosciations
DR2
DR3
T1DM HLA assosciations
DR3
DR4
Light chain protein in urine
MM AL Amyloidosis (primary)
Causes of proximal myopathy
MND MG Idiopathic inflammatory myopathy (polymyositis, dermatomyositis) Hyperthyroidism Osteomalacia Cushing's
AMTS + MMSE scores that indicate cognitive impairement
AMTS <6/10
MMSE <26/30
Dilated vs pinpoint pupils vs asymmetrical pupils
Dilated - drug overdose (e.g. cocaine), TCA, severe hypoxia
Pinpoint- opiate overdose, barbiturate overdose, organophosphates
Asymmetrical - third nerve palsy, coning due to increased ICP, can be normal
CSF
Oligoclonal bands vs albuminocytological dissosciation + which part of the nervous system do they affect
Oligoclonal bands
- MS (affects CNS)
Albuminocytological dissosciation
- GBS (affects PNS)
Most likely cause of confusion in a man with a history of alcoholcim + a 4-day hospital stay + how would you treat
Alcohol withdrawal
Chlordiazepoxide - not intended for long term use (max 4 weeks)
Thiamine (to avoid progression to Wernicke’s encephalopathy)
Triad of Wernicke’s encephalopathy
- Confusion
- Ataxia
- Ophthalmoplegia
Reasons for post-operative confusion
- Hypoxia (anaemia, PE, basal ateletasis, opioids)
- Opioids
- Electrolytes (derangement due to intra + postoperative fluid replacement)
- Infection
- Sleep deprivation
- Alcohol withdrawal
What will you see on the gram stain of someone with meningococcal meningitis?
Gram -ve intracellular diplococci
Types of hyponatraemia, signs (S), causes (C) and how to differentiate (D)
Pseudohyponatraemia (C) - Hyperglycaemia - Hyperlipidaemia - Hyperproteinaemia (D) - High or normal serum osmolarity High serum osmolarity - hyperglycaemia Normal serum osmolarity - hyperlipidaemia, hyperproteinaemia
True hyponatraemia (D) low serum osmolarity - Hypovolaemic - Hypervolaemic - Euvolaemic
(S)
Hypovolaemic
- Dry mucous membranes, tachycardia, low + narrow BP, decreased skin turgor, low urine output
(C)
High urinary Na (>220 mM) or K - renal problem (diuretics, renal failure, addison’s)
Low urinary Na (<220 mM) or K - extra-renal problem (kidneys retain ability to concentrate urine) (V+D, sweating, burns, pancreatitis, SBO)
(S) Hypervolaemic - oedema, crackles, raised JVP (C) CHF, liver failure, nephrotic syndrome
(S)
Euvolaemic
- no signs of hypo or hypervolaemia
(C)
SIADH - urine osmolarity >500 mosmol/l (D)
Psychogenic polydipsia - urine osmolarity <500 mosmol/l(D)
Severe hypothyroidism - urine osmolarity <500 mosmol/l(D)
Adrenal insufficiency - urine osmolarity <500 mosmol/l (D)
look at “Hyponatraemia” table on pg 29 of oxford cases - LEARN
Acute management of hypoglycaemia
If the person can eat/drink - sweet drink, glucose tablets
If unconscious either
- Dextrose - in gel form rubbed into her mouth
- 50ml of 20% glucose or 100 ml of 10% glucose IV
Repeat if still unconscious after 10-15 mins
- Glucagon IM
confusion case oxford cases pg 31
Where are Broca’s and Wernicke’s areas found?
Broca’s - frontal lobe
Wernicke’s - temporoparietal lobe
What is hypertonic hyponatraemia?
- Hyperglycaemia
- Administration of an active osmolyte (e.g. mannitol)
Management of hyponatraemia
Hypovolaemic
Euvolaemic
Hypervolaemic
Severe acute hyponatraemia
Hypovolaemic
- Isotonic fluid infusion
- treat underlying cause
Hypervolaemic
- fluid restriction
- loop diuretic or spironolactone
- treat underlying cause
Euvolaemic
- fluid restriction
- treat underlying cause
Severe acute hyponatraemia symptoms/ cerebral oedema (altered mental status, seizure, coma)
- Slow IV hypertonic 3% saline
- Furosemide
Change in [Na+] must not exceed 10mmol/L in the first 24h (+aim to increase sodium by <2mM/h) and 18mmol/L in the first 48h - rapid correction can result in central pontine myelinolysis
What is the difference between loop diuretics and thiazide diuretics?
Thiazides are used to relieve oedema due to chronic heart failure and, in lower doses, to reduce blood pressure
Act in the distal tubule
• Block Na+/Cl- cotransporter
Loop diuretics are used in pulmonary oedema due to left ventricular failure and in patients with chronic heart failure.
Act on the ascending loop of Henley
• Blocks Na+/K+/2Cl- transporter
• Na+ retained in lumen
Management of hypernatraemia
- Treatment of cause
- Appropriate fluid replacement
- Normal saline can be used as it may have a lower osmolarity than the blood and will not abruptly lower the Na+ level
- Sodium level should be reduced no faster than 1mmol/L/h- to avoid rapid fluid shifts + cerebral oedema
Difference between a lipoma, dermoidcyst and a cystic hygroma
Lipoma is mobile, does not transilluminate
Dermoid cyst is not mobile, might transilluminate
Cystic hygromas
Posterior triangle of neck
People with genetic abnormalities e.g. Down’s
Features of hyperkalaemia on ECG
Clinical features
> 5.5 mM Tall tented T waves
6.5 mM Flattening of p waves
7.5 mM Prolonged PR + QRS intervals, bradycardia
severe hyperkalaemia (>9mM/L) - sinusoidal waves
Clinical features
muscle weakness
arrythmias
chest pain
Features of hypokalaemia on ECG and clinical features
Flattened T waves Long QT Long PR U waves ST depression
atrial and ventricular tachyarrhythmias
clinical features
muscle weakness + spasm
cardiac arrhythmia
polyuria + polydipsia –> nephrogenic DI
What might cause hyperkalaemia
Renal disease - HTN, DM
Low RAAS activity - ACEi, ARBs, aldostrone antagonists, adrenal failure
Systemic K + release - rhabmomyolysis, metabolic acidosis (DKA), burns, tumour lysis syndrome (any condition that causes increased tissue breakdown)
Damage to the DCT - renal tubular acidosis, NSAID toxicity
Mx of hyperkalaemia
10 10 10 50 50
10ml 10% calcium gluconate 10 U actrapid (insulin) + 50ml 50% glucose or 5U actrapid + 100ml 20% dextrose Nebulised salbutamol 12 lead ECG continuous
Things that act the fastest
- Salbutamol nebulisers
- Insulin and dextrose –> They activate the co-transporters on cells which move potassium back into cells and lowers serum potassium for 30-45 minutes
Other answers are used in the treatment of hyperkalaemia but not during emergencies
- IV calcium gluconate/chloride can stabilise the myocardium in hyperkalaemia
- Calcium resonium is given orally with aperients (i.e. drugs used to relieve constipation) and will help reduce potassium chronically but takes >24hrs to have an effect. You cannot give it IV.(capsule)
What might cause hypokalaemia
GI loss - vomiting, diarrhoea Diuretics Primary hyperaldosteronism Cushing's Steroids
Renal loss - hyperaldosternosim, excess cortisol, natriuresis
Redistribution of K+ into cells - insulin, b agonsits, metabolic alkalosis
Decreased K+ intake - anorexia nervosa
Hypokalaemia mx
always correct Mg
K 3.0-3.5 mmol/L
- Oral KCl (SandoK)
- recheck in 48h
K <3.0 mmol/L
- IV KCl
(max infusion rate 10 mmol/hr)
Treatment – for acute hypocalcaemia
Treatment – for acute hypocalcaemia
• IV calcium infusion (calcium gluconate)
Acute hypercalcaemia mx
Acute hypercalcaemia
• IVF (saline) [1st line]
• Bisphosphonates (if calcium remains high, good for cancer mets, Zolendronate) [2nd line]
• Avoid factors that can exacerbate hypercalcaemia including thiazide diuretics
Karim said don’t give bisphosphonates in patients who don’t have cancer
you would give bisphosphonates if PTH is suppressed as that would suggest cancer
Commonest cause of hypercalcaemia in
healthy people
sick patients
primary hyperparathyroidism
cancer
How do you treat
Staph aureus?
MRSA?
flucloxacillin
MRSA - Vancomycin
ECG on someone with hypothermia
J waves
A 32-year-old man presents with a 2-week history of frequent urination and excessive thirst. He has also noticed that he feels much weaker than usual, and is struggling to complete his usual gym routine. He has been to see his GP once before because his blood pressure was high on multiple occasions, however, he did not return to receive treatment. His blood pressure is measured again and it is 184/94 mm Hg. What would you expect to see on the ECG of this patient? A Tented T waves B Absent P waves C ST elevation D J waves E U waves
Answer: E
This patient has Conn’s syndrome – a condition in which an aldosterone-secreting adenoma leads to inappropriately elevated aldosterone levels. The excessive sodium reabsorption and potassium excretion caused by the high aldosterone leads to hypertension and hypokalaemia. Hypokalaemia induces nephrogenic diabetes insipidus, which, consequently, leads to polyuria and polydipsia. Furthermore, muscle weakness is another feature of hypokalaemia. The main ECG features of hypokalaemia are U waves, ST depression, flattened T waves and prolonged PR interval. In any young patient presenting with hypertension, consider secondary causes such as Conn’s syndrome, coarctation of the aorta and renal artery stenosis.
Tented T waves are a feature of hyperkalaemia. Absent P waves can be seen in several different conditions, most notably atrial fibrillation and supraventricular tachycardia. J waves (sometimes referred to as Osborn waves) are see in hypothermia.
Anaphylaxis mx
- Help
- Remove trigger
- Lie flat + raise legs
- IM adrenaline 0.5mg 1:1000
- ABC
- IV chlorphenamine (anti-histamine), IV hydrocortisone
Causes of onycholysis
- Trauma
- Thyrotoxicosis
- Fungal infection
- Psoriasis
A nervous 16-year-old college student attends the local A&E department with her boyfriend, complaining of an episode of sudden onset right-sided pain in her abdomen. Physical examination of the patient is unremarkable except from a small scar in the right lower quadrant. What is the most appropriate first line investigation in this case?
USS of the abdomen 𝞫-hCG test Full blood count CT scan of the abdomen No investigations, immediate surgery
𝞫-hCG test
exclude pregnancy
FLAWSV
Fever Lethargy Anorexia Weight loss Night sweats V+N
Causes of high urea vs causes of low urea
High urea
- UGIB (or large protein meal)
- Dehydration/AKI
Low urea
- Severe liver dysfunction (synthesised in the liver)
- Malnutrition
- Pregnancy
Why can girls with Turner’s syndrome inherit X linked disorders?
Because they only have one X chromosome
45XO
Rinne’s positive vs Rinne’s negative
Rinne’s positive = Louder in air
Rinne’s negative = Louder on the bone
Ototoxic drugs
- Aminoglycoside antibiotics e.g. gentamycin
- Loop diuretics e.g. furosemide
- Aspirin overdose
3 top global causes of blindness
vs
3 UK causes of irreversible blindness
Global causes of blindness
- Cataract
- Galucoma
- Macular degeneration
UK causes of irreversible blindness
- AMD (leading cause of visual loss in the UK)
- Glaucoma + optic nerve
- Diabetic retinoapthy
Leading causes of avoidable visual impairement vs leading causes of avoidable blindness
Avoidable visual impairement
- cataracts
- uncorrected refractive errors
Avoidable blindness
- Unoperated cataract
- Glaucoma
leading causes of blindness in children
- cataracts
- retinopathy of prematurity (ROP)
- vitamin A deficiency
Normal visual field
Normal field extends 60º nasal & superior, 70 º inferior & 90-100 º temporal to fixation
https://entokey.com/wp-content/uploads/2016/07/DA1-DB3-DC2-C49-FF1.gif
Features of rhabdomyalisis
Dark urine + High CK + Hyperkalaemia + fall
Anion gap equation
Generally used formula, K is excluded on the grounds that its value is small enough to be disregarded
Na - (Cl + HCO3)
Formula used when the value of the K is expected to vary significantly as in renal patients (+ is the one that is on bb)
(Na + K) - (Cl+ HCO3)
normal anion gap 4-12
Plasma osmolarity equation
2 (Na+K) + glucose + urea
Causes of a wide anion gap
Normal anion gap 4-12
KULT Ketones Uraemia Lactate Toxins (aspirin, paracetamol, isonazide, polythene glycol)
What is pyoderma gangrenosum?
complicaton of inflammatory diseases (e.g. Crohn’s, UC, RA) or haematological malignancies
Dark blue/purple halo around it
• European Pressure Ulcer Advisory Panel (EPUAP) – four grades of pressure ulcers
o Grade 1 – non-blanching erythema of intact skin
o Grade 2 – partial thickness skin loss or blistering
o Grade 3 – full thickness skin loss, SC may be visible, no underlying tendons/bone/muscles visible
o Grade 4 – full thickness tissue loss with involvement of muscle/bone/tendon. May be covered with thick slough or eschar
Coeliac trunk
SMA
IMA
Levels
T12
L1
L3
Which class of drugs increases risk of bleeding form diverticular disease?
NSAIDs
Metoclopramide indications and contraindications
Since metoclopramide is a prokinetic, it is
- Indicated in gastroparesis (delayed gastric emptying see in DM and cause vomiting with partially digested food)
- Contra-indicated in bowel obstruction
Anti- emetic for patients suffering with PD
Domperidone
Anti- emetic for chemo
Ondansendron
Anti-emetic for bowel obstruction, post-operative nausea, motion sickness, other labyrinthine aertiologies
Cyclizine (anit-histamine + anti-muscuarinic)
Anti-kinetic therefore can be used in Bowel obstruction
Anti-emetic for N+V induced by drugs + metabolic causes
Haloperidol
D2 antagonist, blocks D2 receptors found in CTZ
Anti-emetic for N+V induced by motion sickness
Need to block histamine and ach receptors
Promethazine - H1 antagonist
Hyoscine - Ach antagonist
signs of metastatic abdominal cancer
- Virchow’s node – Troisier’s sign
* Sister Mary Joseph node – metastatic nodule on umbilicus
Most common valves affected in rheumatic fever
mitral + aortic mostly affected
mitral > aortic
A female patient presents with a lateral neck lump that you think is a parotid mass. Which is the most important in your examination of this patient?
Examine the facial nerve
A facial nerve palsy is highly suggestive of an invasive and therefore malignant parotid tumour
How to classify haemorrhagic shock
Class 1-4 Blood loss ml Blood loss % of blood HR SBP DBP RR UO Mental state
https://www.researchgate.net/profile/Sam_Thomson2/publication/227027828/figure/tbl2/AS:393858908213258@1470914689653/Classification-of-hypovolemic-shock-68.png
Osteosclerotic lesions on XR found in
- Prostate ca mets
- Breast ca mets
- Paget’s disease of the bone
OSA - most common + hallmark symptom
excessive daytime sleepiness
HLA-DR1
HLA-DR4
RA
a1 antitrypsin deficiency casues…
Inheritance pattern
Chromosome
Emphsyema
Liver cirrhosis
AR inheritance, Chr 14
What is a Marjolin ulcer?
A squamous cell carcinoma
refers to an aggressive ulcerating squamous cell carcinoma presenting in an area of previously traumatized, chronically inflamed, or scarred skin
Long standing fungating venous ulcer = suggests malignancy or infection
chronic venous ulcer has transformed into a squamous cell carcinoma
• Signs
o Foul-smelling, overgrown, elevated edges
o Scarred surrounding skin, features of long-standing venous insufficiency (hemosiderin deposition (skin pigmentation), Lipodermatosclerosis, Atrophie blanche)
• Investigations
o Biopsies of the peripheral area of the ulcer in order to obtain histological confirmation (central area is likely to contain necrotic tissue which is hard to visualise for a histological diagnosis)
• Management
o Wide excision
o Split skin grafting
Give examples of the 5 types of hypersensitivities
Type I
- Asthma
- Hay Fever
- Peanut allergies
Type II
- Acute haemolytic reaction to ABO incompatibility
- ITP
Type III
- Post-strep glomerulonephritis
- Rheumatic fever
- SLE
Type IV
- Contact dermatitis
- Transplant rejection
- Hashimotos
Type V
- Grave’s
- MG
Staging systems
Duke's Ann Arbor Breslow Clark Gleason
Duke's - colorectal cancer Ann Arbor - lymphoma Breslow - malignant melanoma (thickness) Clark - malignant melanoma (depth of invasion into skin layers) Gleason - prostate cancer
How to differentiate between the different causes of back pain
Spinal stenosis
Spondylosis
Spondylolisthesis
Spinal tumours
Spinal stenosis
Pain relieved when sitting/leaning forwards
Caused by narrowing of the spinal canal due to spondylosis
Presents with: a)back pain + b) sciatica
Pain worse when spine is extended going downhill, walking
Pain better when spine is flexed going uphill, sitting
Spondylosis
Pain worse in the morning + following activity
Spondylolisthesis
Pain worse when standing
Spinal tumours
Pain is unremitting
Associated with systemic features e.g. weight loss, night sweats
List
Gram -ve cocci
Gram +ve cocci
Gram -ve rods
Gram +ve rods
Gram -ve cocci – Neisseria gonorrhoea, Neisseria meningitides
Gram +ve cocci – Staphylococci, Streptococci
Gram -ve rods – E. coli, Salmonella, Haemophilus influzeza, Pseudomonas aeruginosa, Enterobacter, H pylori
Gram +ve rods – C. difficile, Listeria
Patient on warfarin and
High INR (5-9) + no bleeding Significantly raised INR (>9) + no bleeding High INR + active bleeding
mx
High INR + no bleeding omit a dose of warfarin
Significantly raised INR + no bleeding omit a dose of warfarin + oral dose of vitamin K
High INR + active bleeding oral/IV vitamin K + prothrombin complex concentrate (contains F 2, 7, 9, 10)
How does alcohol cause hypoglycaemia?
It increases insulin secretion
NSAID contra-indications
Asthma – can cause bronchospasm
Hx of gastric/duodenal ulcers – can cause gastric erosions + ulcerations
Aspirin – severe risk of GIB from gastric erosions + ulcerations
Moderate/severe HF – can cause fluid retention
Diverticular disease - increases the risk of bleeding
Antidotes for
Antimuscarinic overdose Aspirin overdose Benzodiazepine overdose BB overdose CO poisoning Digoxin overdose Heparin overdose Iron overdose Methanol overdose Paracetamol overdose Warfarin overdose
Antimuscarinic overdose – Physostigmine Aspirin overdose – activated charcoal, sodium bicarbonate Benzodiazepine overdose – flumazenil BB overdose – atropine, glucagon CO poisoning – O2 Digoxin overdose – digibind Heparin overdose – protamine Iron overdose – desferrioxamine Methanol overdose – ethanol Paracetamol overdose – N-acetylcysteine Warfarin overdose – vitamin K
SE of abx
Co-amoxiclav Erythromycin (macrolides) Gentamicin Nitrofurantoin Ciprofloxacin (quinolones)
Co-amoxiclav – cholestatic jaundice, deranged LFTs
Erythromycin (macrolides) – diarrhoea (macrolides increase GI motility)
Gentamicin – nephrotoxicity
Nitrofurantoin – pulmonary fibrosis
Ciprofloxacin (quinolones) – tendon rupture
Tumour markers
AFP bHCG ca15-3 ca 19-9 calcitonin CEA Monoclonal IgG (paraprotein) Neurone specific enolase Placental ALP PSA S-100 Thyroglobulin
Tumour markers
AFP – HCC, 50-60% teratomas, not seminomas
bHCG – choriocarcinoma, 40-60% teratomas, 30% seminomas
ca15-3 – breast cancer
ca 19-9 – pancreatic cancer
calcitonin – medullary thyroid cancer
CEA – colorectal cancer
Monoclonal IgG (paraprotein) – multiple myeloma
Neurone specific enolase – small cell lung cancer
Placental ALP – ovarian carcinoma, testicular tumours
PSA – prostate cancer
S-100 – malignant melanoma
Thyroglobulin – thyroid tumours
Acute tumour lysis syndrome metabolic disturbances
Hyperuricaemia
Hyperkalaemia
Hyperphosphataemia
Hypocalcaemia
Commonest cause of hypocalcaemia
Renal failure
Universal recipient in blood transfusion
Universal donor in blood transfusion
Universal recipient in blood transfusion – AB+
Universal donor in blood transfusion – O-
Commonest organism for a short history of traveller’s diarrhoea
if longer history consider
short history - E. coli
longer history - Giardia
Valves affected in carcinoid syndrome vs valves affected in rheumatic fever
Carcinoid - tricuspid + pulmonary
Rheumatic fever - mitral>aortic>tricuspid
A 23- year old woman with CF complicated by chronic cholestasis presents to her GP with a 1-week history of muscle weakness and tremor in her hands
She admits that she has been non compliant with her medications
Neurological examination reveals diminished tendon reflexes throughout
What is the most likely diagnosis
Hypoglycaemia Vitamin K Vitamin E Vitamin B Vitamin D
Vitamin E deficiency (fat soluble, may become deficiect in the setting of cholestasis)
Vitamin B is water soluble so cholestasis is not a RF for deficiency
Vitamin B deficiency may cause ataxia, memory problems, paraesthesia
Tremor + hyporeflexia are not common findings
Hyponatraemia symptoms + signs
130-135 asymptomatic
125-130 non-specific symptoms (headaches, nausea, lethargy, muscle cramps)
<120 – neurological symptoms (seizures, hallucinations, confusion, memory loss)
If sodium drops acutely over 24-48h – cerebral oedema, coning, respiratory arrest
Causes of onycholysis
DR PITHS
Drugs (TCAs, COCP, DM drugs, tetracyclines)
Reactive arthritis, Reiter’s syndrome
Psoriasis Infection (esp fungal) Trauma Hyper/hypothyroidism Sarcoidosis, scleroderma
Tumour lysis syndrome biochemistry
Hyperkalemia
Hyperphosphatemia
Hypocalcemia
Hyperuricemia
Higher than normal levels of blood urea nitrogen (BUN) and other nitrogen-containing compounds (azotemia)
Breast cancer screening
50-70 every 3 years
Felty syndrome is a triad of
RA
Splenomegaly
Neutropenia
Occurs in pt w a hx of RA
Neutropenia – pt suffers frequent infections
Different stains
Ziehl Neelsen
Giemsa
India ink
Sudan black
Ziehl Neelsen – TB
Giemsa – Malaria
India ink – cryptococcus spp
Sudan black – AML
Breast cancer screening
50-70 every 3 years
Colorectal cancer screening
55 felx sig
60 - 74 FOBT every 2 years
if you’re 75 or over, you can ask for a home testing kit every 2 years by calling the free bowel cancer screening helpline on 0800 707 60 60
Fluids used for volume resuscitation
Colloid
or
Blood
Alport’s syndrome triad
Hereditary nephritis
Sensorineural deafness
Ocular abnormalities (cataracts, macular retinal flecks)
genetic defect in type 4 collagen
Effect on potassium
Acidosis
vs
Alkalosis
Acidosis - hyperkalaemia
(K+ moves from intracellular to extracellular compartment in exchange for H+ ions)
Alkalosis - hypokalaemia
(H+ moves from the intracellular to the extracelluar compartment in exchange for K+ ions)
How does Cushing’s syndrome / high levels of cortisol / steroids lead to increased risk of infections?
Decrease in circulating lymphocytes
Suppression of the innate immune + T cell responses resulting in lymphopenia
Causes of erythema nodosum
LOST BUSH Leprosy, lymphoma (NHL), leukaemia Oral contraceptive, pregnancy Sarcoidosis, sulphonamides, penicillins TB, toxoplasmosis
Bechet’s
UC, Crohn’s
Salmonella, Strep, Yersinia
Histoplasmosis
What is Pemberton’s test
Test for SVC syndrome/obstruction
Ask the patient to lift their arms over their head for 1 minute
Facia plethora
Raised non-pulsatile JVP
Inspiratory stridor
What is a Paradoxical embolism
Paradoxical embolism - DVT can cause a TIA by passing through a septal defect in the heart, thereby bypassing the lungs and travelling to the brain causing a stroke/TIA
fluid challenge
no hf
hf
no heart failure - 500 ml 0.9% saline STAT
heart failure - 250 ml of 0.9% saline
This does not put as much strain on their physiology and risk the patient devoting worsening cardiac failure
Fat embolism triad
Petechiae
Mental state changes
Dyspnoea
