GenMed Flashcards
List some scoring systems used in acute GI bleeding
Rockall score - predict risk of rebleeding and mortality (>6 is indication for surgery)
Glasgow Blatchford score - to consider admission
List the gastro red flag symptoms
ALARMS Anaemia Loss of weight Anorexia Recent onset Malaena Swallowing difficulty \+ recurrent vomiting, epigastric mass, >55 years old
What are the contraindications for liver transplantation
Extrahepatic malignancy Multiple tumours Severe CVS/Resp disease Systemic sepsis HIV infection Non compliance with drugs
What are some complications of liver transplantation?
Sepsis (G-ve, CMV) Hepatic artery thrombosis Chronic rejection Graft vs host Disease recurrence
Why is microalbuminuria relevant in people with diabetes?
30-300mg albumin/24h
Early warning of impending renal problems and progression of disease, strong risk factor for CVD
Patient should be started on ACEi/ARB irrespective of blood pressure
List the diabetic eye complications and their signs
Background - microaneurysms (dots), haemorrhages (blots), hard exudates (lipid deposits)
Pre-proliferative - cotton wool spots (infarcts), haemorrhages, venous bleeding
Proliferative - new vessels form
Suggest some retinopathy treatments
Laser
Intravitreal steroids
Antiangiogenic agents
Aspirin
Define diabetic neuropathy
Decreased sensation in ‘stocking’ distribution (test with a 10g monofilament fibre with just sufficient force to bend it)
Absent ankle jerks
Neuropathic deformity - pes cavus, claw toes, loss of transverse arch, rocker bottom sole)
Foot ulceration - painless, punched out ulcer in an area of thick callus +/- super added infection
How do you assess the diabetic foot?
- Neuropathy - clinically
- Ischaemia - clinically, doppler +/- angiogram
- Bone deformity - Charcot joint + X-ray
- Infection - swabs, blood culture, X-ray
What is a Charcot joint and how is it treated?
Loss of pain sensation leads to increased mechanical stress and repeated joint injury, collapse of medial longitudinal arch –> swelling, instability, deformity,
Treatment - offload all weight, immobilise, bisphosphonates
List some conditions associated with Charcot joint
Diabetic neuropathy, tabes dorsalis, spina bifida, syringomyelia, leprosy, paraplegia, spinal osteolysis/cord atrophy (systemic sclerosis)
Discuss the treatment of diabetic neuropathy
- Paracetamol
- TCA e.g. amitriptilline
- Duloxetine, gabapentine/pregabalin
- Opiates
Avoid weight bearing
Define IBS
Abdominal pain relieved by defecation/altered stool AND urgency/incomplete evacuation/bloating/worse after food
No organic cause
List the red flag symptoms of dyspepsia
Unintentional weight loss
Recurrent vomiting
Dysphagia
Evidence of GI bleeding
Describe Duke’s staging of cancer
A - limited to muscularis mucosae
B - extension through muscularis mucosae
C - involvement of regional lymph
D - distant metastases
List some diseases associated with hypothalamus and pituitary disorders
Hypothalamus - kallmann’s syndrome, tumour, inflammation, infection, ischaemia
Pituitary stalk - trauma, surgery, meningitis, carotid artery aneurysms
Pituitary - tumour, irradiation, inflammation, Sheehan syndrome
What hormones are released from the pituitary?
Anterior - FSH/LH, ACTH, TSH, GH, prolactin
Posterior - oxytocin, ADH
List some causes of hyperthyroidism
Graves' disease Toxic multinodular goitre Toxic adenoma Ectopic thyroid tissue Exogenous iodine Drugs (amiodarone, lithium)
List some causes of hypothyroidism
Primary trophic hypothyroidism Hashimoto's Iodine deficiency Post thyroidectomy/radioiodine Drugs (amiodarone, lithium)
What is the function of the parathyroid glands?
Secrete PTH in response to low calcium
–> increase osteoclasts activity in bones, increase calcium reabsorption in kidney
Describe different types of hyperparathyroidism
Primary - high calcium (stones, groans, bones, psychiatric overtones), high blood pressure. Treatment = increase fluid intake, excise adenoma/glands, cinacalcet
Secondary - low calcium, high PTH due to low vitD intake, CKD. Treatment = phosphate binders, vitD, cinacalcet
Tertiary - high calcium, very high PTH due to prolonged secondary, CKD
Malignant - high calcium, low PTH due to PTHrP produced by some squamous cell lung cancer/breast/renal cell carcinoma
Describe different types of hypoparathyroidism
Primary - low calcium, high phosphate due to gland failure (autoimmune/congenital DiGeorge). Treatment = calcium supplements, calcitriol
Secondary - low calcium, high phosphate due to radiation, surgery, hypomagnesaemia
Pseudo - failure of target cell response to PTH –> short metacarpals, round face, short stature, calcified basal ganglia, low IQ
Pseudopseudo - as pseudo but with normal biochemistry
List some causes, signs and symptoms and treatment of hyperkalaemia
Causes - oliguric renal failure, K+ sparing diuretics, rhabdomyolysis, metabolic acidosis, Addison’s disease, massive blood transfusion, burns, drugs (ACEi)
Signs and symptoms - fast irregular pulse, chest pain, weakness, palpitations
Treatment - treat underlying cause, calcium gluconate, IV insulin and dextrose, salbutamol, calcium resonium
List some causes, signs and symptoms and treatment of hypokalaemia
Causes - diuretics, diarrhoea and vomiting, pyloric stenosis, rectal colloid adenoma, intestinal fistula, Cushing’s syndrome/steroids/ACTH, Conn’s syndrome, alkalosis, liquorice abuse, renal tubular acidosis
Signs and symptoms - muscle weakness, hypotonia, hyporeflexia, cramps, tetany, palpitations, constipation
Treatment - oral K+ supplement (mild), IV K+ (severe)
Describe the ECG changes seen with potassium disturbance
Hyper - tall tented T wave, small P waves, wide QRS, VF
Hypo - small/inverted T waves, prominent U waves, increased PR interval, low ST segments
List signs of hypocalcaemia
Spasms Periorsl paraesthesia Anxious Seizures Muscle tone increase Orientation reduced Dermatitis Impetigo herpetiformis Chovstek's sign Cardiomyopathy
List some reasons for urgent dialysis
Hyperkalaemia unresponsive to treatment
Pulmonary oedema unresponsive to treatment
Uraemic complications (pericarditis, encephalopathy)
Severe metabolic acidosis (pH <7.2)
Drug overdose (BLAST - barbiturates, lithium, alcohol, salicylates, theophylline)
What cancers metastasise to bone?
Thyroid Breast Lung Kidney Prostate
Define AKI staging
Stage 1 - increase serum creatinine >26umol in 48h OR <0.5ml/kg/hr >6h
Stage 2 - increase serum creatinine 2-2.9x baseline OR <0.5ml/kg/hr >12h
Stage 3 - increase serum creatinine 3x baseline OR <0.3ml/kg/hr >24h OR anuria 12h
Define CKD staging
Stage 1 - GFR >90 + renal damage >3 months
Stage 2 - GFR 60-89 + renal damage >3 months
Stage 3a - GFR 45-59 +/- renal damage
Stage 3b - GFR 30-44 +/- renal damage
Stage 4 - GFR 15-29 +/- renal damage
Stage 5 - GFR <15 +/- renal damage
List some complications of CKD
Normocytic anaemia (treat with EPO)
Acidosis –> high urea, platelet dysfunction
Hyperkalaemia
CCF
Renal bone disease (osteitis fibrosa cystica)
Treatment - viD/calcium, bisphosphonates, parathyroidectomy/cinacalet
List the functions of the kidney
Regulatory - fluid, acid
Endocrine - EPO, vitD
Excretory - phosphate
Metabolism - drugs
What is nephrotic syndrome and what are some primary causes?
Oedema, proteinuria (>3.5g/24h), hypoalbuminaemia (<25g/L), hyperlipidaemia
Causes - membranous glomerulonephritis, minimal change, FSGS, mesangiocapillary glomerulonephritis
What is nephritic syndrome and what are some primary causes?
Haematuria, high BP, low GFR
Causes - IgA nephropathy, mesangiocapillary glomerulonephritis
What are some secondary causes of nephrotic/nephritic syndrome?
Diabetes SLE Amyloid Hepatitis (B/C) Post streptococcal Vasculitis Anti GBM disease
Describe the presentation and treatment of polycystic kidney disease
Presentation - pain, haematuria, E. coli infection, stroke (berry aneurysms)
Treatment - low BP, increase fluids, low salt diet, tolvaptan (vasopressin antagonist stops cyst growth)
What is Cushing’s syndrome?
Chronic glucocorticoid excess and loss of normal feedback mechanisms
List some causes is Cushing’s syndrome
ACTH dependent - pituitary adenoma (Cushing’s disease), small cell lung carcinoma, carcinoid tumour, thyroid/prostate cancer
ACTH independent - adrenal adenoma, adrenal nodular hyperplasia, iatrogenic (steroids)
What is Addison’s disease?
Destruction of adrenal cortex leading to glucocorticoid/mineralocorticoid deficiency
List some causes of Addison’s disease
Autoimmune, TB, adrenal metastases, lymphoma, long term steroid use
Define male and female hypogonadism and list some causes
Male:
Failure of testes to produce testosterone, sperm or both
Primary = testicular failure (local trauma, torsion, chemo, post orchitis, alcohol excess, kleinefelter’s, renal failure, cirrhosis)
Secondary = decreased LH/FSH (hypopituitarism, prolactinoma, Kallmann’s, COPD, HIV, Pradee-Willi)
Female:
Underactivity, developmental failure or absence of the ovaries –> low oestrogen
Primary (Turner’s, surgical removal, menopause)
Secondary = HP axis problem (pituitary adenoma, viral encephalitis, excessive exercise, sudden weight loss)
What is a multiple endocrine neoplasia (MEN)?
Autosomal dominant functional hormone producing tumours in multiple organs.
MEN 1 - parathyroid hyperplasia/adenoma, pancreas (insulinoma, gastrinoma, somatostatinoma), pituitary prolactinoma
MEN 2a - thyroid (medullary carcinoma), adrenal (phaeochromocytoma), parathyroid hyperplasia
MEN 2b - mucosal neuromas, marfanoid appearance
List the red flag symptoms of back pain
Age <20, >55 Acute onset (in elderly) Constants or progressive Nocturnal Worse when supine Fever, night swears, weight loss Malignancy history Abdominal mass Thoracic Morning stiffness Bilateral/alternating in legs Neurological disturbance Sphincter disturbance Current or recent infection Immunosuppression Leg claudication/exercise related weakness
List differentials for joint pain
Local + swelling + 1 joint = septic arthritis, gout, seronegative spondyloarthropathies, RA
Local - swelling = OA, tendonitis/bursitis
General = malignancy, SLE, fibromyalgia
Describe the presentation, signs and management of RA
Presentation - symmetrical, swollen, painful stiff small joints on hands/feet, worse in morning
Signs - swollen MCP, PIP, wrist, MTP joints, ulnar deviation of fingers, dorsal wrist subluxation, boutonnière/swan neck deformity of fingers, Z deformity of thumbs
Management - DAS28, DMARDs (methotrexate, sulfasalazine, hydroxychloroquine), biologics (infliximab), steroids for flares, NSAIDS, PT/OT, surgery
Describe the presentation, signs and symptoms and management of OA
Presentation - female:male 3:1, >50 years old, localised large joint, pain on movement, crepitus, worse at end of day, stiffness after rest <30 mins, heberden’s nodes at DIP, Bouchard’s nodes at PIP, decreased range of movement
Management - exercise, weight loss, paracetamol +/- topical NSAID, codeine/oral NSAID + PPI, topical capsaicin, intraarticular steroid injection, PT/OT (walking aids, hot/cold packs), surgery (replacement)
Describe the X-ray changes in RA and OA
RA - loss of joint spaces, erosions, soft tissue swelling, soft bones (osteopenia) = LESS
OA - loss of joint spaces, osteophytes, subarticular sclerosis, subchondral cysts = LOSS
Describe the presentation, investigations and management of ankylosing spondylitis
Presentation - male, young <30, Caucasian, lower back pain, worse at night, spinal morning stiffness relieved by exercise, radiates to hip/buttocks, enthesitis, acute iritis
Investigations - bamboo spine, sacroiliitis, erosions, sclerosis, ankylosis, calcification, modified Schober’s test (<5cm), wall tragus
Management - exercise, physiotherapy, NSAIDs, anti TNF, local steroid injection, bisphosphonates
Describe the presentation, investigations and management of psoriatic arthritis
Symmetrical polyarthritis (arthritis mutilans), asymmetrical oligoarthritis (dactylitis, nail changes) Management - NSAIDs, sulfasalazine, methotrexate, ciclosporin, anti TNF
Describe the presentation, investigations and management of reactive arthritis
A sterile arthritis precipitated by a distant infection e.g. chlamydia, shigella, salmonella typically affecting lower limb (knee)
*Reiter’s syndrome - can’t see (conjunctivitis), pee (urethritis) or bend the knee (arthritis)
Management - splint, NSAIDs/steroid injection, sulfasalazine, methotrexate
What rheumatoid antibodies do seronegative spondyloarthropathies have in common?
RhF -ve
HLA B27 +ve
Describe the causes, symptoms, diagnosis and treatment of gout
Causes - increased uric acid crystals in blood and decreased excretion by kidneys, alcohol, low vit.C, fructose drinks, medication (diuretics, aspirin, chemo), obesity, high BP, diabetes
Symptoms - attack acute,y develops over a few hours, severe pain in one joint (big toe = pedagra), swollen, red, inflamed joint
Diagnosis - -ve birefringence needle shaped under polarised light
Treatment - RICE, NSAID (diclofenac, naproxen), steroid tablet/injection, allopurinol, lifestyle (loss weight, less alcohol, less fructose intake, avoid dehydration)
Describe the causes, symptoms, signs and management of SLE
Causes - drug induced (isoniazid, procainamide, hydralazine, quinidine, phenytoin), EBV infection
Symptoms - malaise, fatigue, myalgia, fever, weight loss, migraine, alopecia, history of miscarriage, DVT/PE
Signs - lymphadenopathy, nail fold infarcts, reynauds, retinal exudates, mouth ulcers, malar/discoid/photosensitive rash
Management - NSAIDs (ibuprofen, naproxen, diclofenac), hydroxychloroquine, steroids, immunosuppressants (azathioprine, ciclosporin, cyclophosphamide, methotrexate, mycophenolate), belimumab
List some important things a patient with SLE should be informed of
Increased long term risk of CVD, osteoporosis
Beware of the sun (wear sunblock, long sleeves, hat)
Pregnancy counsel re methotrexate
Counsel re autoimmune conditions
Risk of bladder infertility with cyclophosphamide
Check retinal fields and acuity yearly with hydroxychloroquine
List the diagnosis criteria for SLE
A RASH POIN MD (4/11) Arthralgia Renal abnormality ANA +ve Serositis Haematological abnormality Photosensitivity Oral Ulcers Immunological abnormality Neurological abnormality Malar rash Discoid rash
Describe the presentation and management of Sjögren’s syndrome
Female:male 9:1, 40-50 years old
Dry eyes and mouth, vaginal dryness
Lymph enlargement, parotitis, increased risk of lymphoma
Investigations - schirmer’s test, ANA/ENA, gammaglobulinaemia, RhF +ve
Treatment - NSAIDs/hydroxychloroquine, artificial tears
Describe the presentation of Behçet’s disease
HLA B5
Mediterranean (Turkish) male
Recurrent oral/genital ulceration, uveitis, erythema nodosum, arthritis
Diagnosis - pathergy test, needle prick = papules (48h)
Describe the presentation and monitoring necessary for systemic sclerosis (Scleroderma)
CREST - calcinosis, raynaud’s, oesophageal/but dysmotility, sclerodactyly, telangiectasia
Monitor BP, renal function
Describe the presentation of polymyositis and dermatomyositis
Progressive symmetrical proximal muscle weakness, striated muscle inflammation, myalgia/arthralgia, paraneoplastic syndrome (lung, pancreas, ovarian, bowel) Macular rash (shawl sign), heliotrope rash, nail fold erythema, gottron's papules *beware malignancy (ovary, myeloma, prostate, bowel)
What is vasculitis?
Inflammatory disorder of blood vessel walls
Large - giant cell arthritis
Medium - polyarteritis nodosa
Small - wegeners granulomatosis aka granulomatosis with polyangiitis
Describe the features and treatment of giant cell arthritis and polymyalgia rheumatica
GCA - elderly, white, male, acute onset, headache, scalp tenderness, morning stiffness (of shoulders), jaw claudication, amaurosis fugax, sudden blindness
Temporal artery biopsy
Treatment - steroid (60mg if visual loss, 40mg if no visual loss)
PMR - no muscle involvement, very quick response to 15mg steroid (1 week)
Describe the features and treatment of Wegener’s granulomatosis
Necrotising granulomatous inflammation and vasculitis of small and medium vessels
ENT (saddle nose deformity), Resp (fluffy infiltrates), urinary (protein, blood +ve)
Treatment - steroids, cyclophosphamide/rituximab, azathioprine/methotrexate, co-trimoxazole prophylaxis against pneumocystis jiroveci, staph infections
Why is antiTNF given parenterally?
Degrades in stomach
How should bisphosphonates be taken?
Taken while standing >30 mins
Beware oesophagitis
What monitoring and caution in necessary with azathioprine
Measure TPMT
DDI with allopurinol
What should a patient be counselled anout when taking cyclophosphamide?
May cause infertility
Haemorrhagic cystitis
Bladder cancer
List some indications for an AXR
Suspected bowel obstruction Suspected perforation (+erect CXR) Moderate to severe undifferentiated abdo pain Suspected foreign body Renal tract calculi follow up
What is Rigler’s sign?
Gas on both sides of the bowel wall
What is a bowel sentinel loop?
Single dilated loop due to localised ileus from nearby inflammation causing local paralysis and accumulation of gas in the intestinal loop
What is Rigler’s triad?
Pneumobilia + SBO + gallstone RIF
What are the features of toxic megacolon on AXR?
Lower bowel dilatation >6cm (usually transverse) Inflammatory pseudopolyps (mucosal islands) Thumbprinting and mucosal oedema
List the likely conditions for different autoimmune antibodies
RhF ANA/ENA - SLE, sjogren's, polymyositis ANCA - vasculitis (system involvement) anti CCP - RA HLA B27 - seronegative spondyloarthropathies HLA B5 - behçet's
List some causes of osteoporosis
Increased age Menopause Low vitamin D Hypogonadism Liver/kidney failure
What is the Child-Pugh score used to determine?
Grading of cirrhosis and risk of variceal bleeding (>8)
Grade A = 5-6, grade B = 7-9, grade C >10
Can predict mortality and quantify need to liver transplantation
Bilirubin, albumin, PT time (s>normal), ascites, encephalopathy
What monitoring and caution is necessary with methotrexate
Once weekly dosing
Regular FBC monitoring
Importance of contraception/birth control (teratogenic)
CI - trimethoprim, aspirin/warfarin
ADR - nausea, convert to parenteral preparation, pneumonitis, oral ulcers, hepatotoxicity
