GP Flashcards
1
Q
AF
Presentation?
types?
A
Dyspnoea
IRREGULARLY IRREGULAR PULSE
Chest pain
Palpitations
Permanent- Cardioversion ineffective
Persistent - >7 days
Paroxysmal - <7 days
2
Q
AF
Investigations?
management?
A
ECG
1) Rate and rhythm control
2) Reduce stroke risk
3
Q
AF
Ways of controlling rhythm/rate?
A
Rhythm- Cardioversion
Rate- BB, Diltiazem (CCB), Digoxin
4
Q
AF
What is the risk of Cardioversion?
A
Increased risk of embolism,
Only attempt if there is symptoms for over 48 hours of symptoms and long period of anticoags
5
Q
AF
How to measure Stroke risk for patients with AF?
A
CHA2DS2VASc
CCF - 1
HTN - 1
Age 75 - 2
Diabetes- 1
Stroke or TIA previously - 2
Vascular disease - 1
Age 65-74= 1
Sc- Sex- Female - 1
6
Q
AF
Types of Cardioversion?
A
Electrical DC
Pharmacological- Amiodarone, Flecanide
7
Q
Tx for AF post CVA?
A
Warfarin
Thrombin or Factor 10A inhibitor
8
Q
HYPERTENSION
What is it?
A
Clinical reading persistently 140/90
24hr > 135/85
9
Q
HYPERTENSION
How to assess for end organ damage?
A
Fundoscopy- Hypertensive retinopathy
ECG - LVH or IHD
Urine dip - Renal disease
10
Q
Side effects of ACEi?
A
Cough
Angioedema
Hyperkalaemia
11
Q
Side effects of CCB?
A
ankle swelling
headache
flushing
12
Q
Side effects of thiazide diuretics?
A
Hyponatraemia
Hypokalaemia
Dehydration
13
Q
Side effects of ARB?
A
hyperkalaemia
14
Q
HYPERTENSION
Stages of HTN?
A
1 =
clinical- >140/90
ABPM - >135/85
2=
clinical- >160/100
ABPM - >150/95
3 =
clinical- >180/110
15
Q
HYPERTENSION
How to do ABPM?
A
2 per hour during usual waking hours
Average at least 14 readings a day
16
Q
HYPERTENSION
How to do HBPM?
A
Two consecutive measurements 1 minute apart
Patient seated
Twice a day (morning and evening)
for at least 4 days (prefer 7)
DO NOT INCLUDE 1ST DAY MEASUREMENTS (INACCURACY)
17
Q
HYPERTENSION
What to do if patient reaches stage 4 of management
A
Resistant HTN:
Confirm elevated BP
Assess for postural Hypotension
Discuss Adherence
Potassium <4.5 add low dose spironolactone
Potassium >4.5 add AB or BB
18
Q
Causes of paediatric HTN?
A
80% renal parenchymal disease
CoA
renal vascular disease
19
Q
Secondary causes of HTN?
A
5-10% primary hyperaldosteronism
Renal disease
- Glomerulonephritis
- Pyelonephritis
- Adult PKD
- Renal artery stenosis
Endocrine
- Pheochromocytoma
- Cushing’s
- Liddle’s
- Congenital adrenal hyperplasia
- Acromegaly
Drugs
- Steroids
- MAO-I
- Combined OCP
- NSAIDs
- Leflunomide
Pregnancy
CoA
20
Q
CHEST PAIN
Features of:
Myocardial Infarction?
A
Heavy central chest pain
Radiation to neck or left arm
Sweating
N/V
No pain in elderly or diabetics
CVD risk factors
21
Q
CHEST PAIN
Features of:
Pneumothorax?
A
History of asthma
Sudden dyspnoea
Pleuritic chest pain
22
Q
CHEST PAIN
Features of:
PE?
A
Sudden dyspnoea
Pleuritic chest pain
Calf pain/swelling
Combined OCP
Malignancy
23
Q
CHEST PAIN
Features of:
Pericarditis?
A
Sharp pain
RELIEVED BY SITTING FORWARDS
Pleuritic chest pain
24
Q
CHEST PAIN
Features of:
MSK?
A
Worse on movement
Worse on palpation
Precipitated by trauma or cough
25
CHEST PAIN
Features of:
GORD?
Burning retrosternal pain
Regurgitation
Dysphagia
26
CHEST PAIN
Features of:
Shingles?
Pain precedes rash
27
CHEST PAIN
Features of:
Dissecting aortic aneurysm?
Tearing chest pain
Radiation to the back
Unequal upper limb BP
28
Typical presentation of aortic dissection and how is it diagnosed?
Male 50-70 tearing intrascapular pain
Diagnosed by: Widened mediastinum, CT angiography
29
PE
Presentation?
```
Haemoptysis
Previous DVT
SOB
Chest pain sudden onset
Hypoxia
```
30
PE
Diagnosis?
CT pulmonary angiography
ECG:
1) S waves in Lead I
2) Q waves in lead III
3) Inverted T wave in lead III
31
How can be pathological Q waves be identified?
Pathological Q waves occur if they are 25% or more of the height of the partner R wave and/or they are greater than 0.04 seconds in width
32
PE
Management?
Anticoags
Thrombolysis
33
Typical MI presentation?
Px- Crushing chest pain radiating to arm/neck, Dyspnoea
34
MI Diagnosis?
Dx- ECG (NSTEMI/STEMI), Tall t waves, LBBB
Raised troponin/ creatine kinase
35
MI Management?
1) PCl in under 120 mins and Thrombolysis
2) Start GPIIb/IIIa antagonist (abciximab)
Long-Term: statin, aspirin, clopidogrel, B blocker, ACE-I, (for 12 months)
CABG/ Coronary Angioplasty
36
Immediate tx of suspected ACS?
GTN
Aspirin
O2 if sats <94
ECG ASAP
37
Referral Guidance for chest pain:
- Chest pain current or within 12 hours + abnormal ECG = EMERGENCY ADMISSION
- Chest pain 12-72 hours ago = REFERRAL FOR SAME DAY ASSESSMENT
- Chest pain > 72 hours ago = FULL ASSESSMENT, ECG + TROPONIN
38
Pathophysiology of ACS?
1) Endothelial damage (smoking, HTN)
2) Endothelial inflammation (macrophages, lymphocytes, phagocytes)
3) Foam cells produced
4) death of cells = further inflammation and smooth muscle proliferation (fatty plaque)
5) Formation of fibrous capsule over fatty plaque
6) reduced O2 and blood flow
7) Rupture of capsule = complete occlusion
39
ACS
STEMI ECG changes?
ST ELEVATION
▪ II, III, aVF = RIGHT CORONARY
▪ V1-V4 = LAD
▪ I, V5-V6 = LEFT CIRCUMFLEX
40
ACS Management?
```
M- Morphine
O- Oxygen
N- Nitrate
A- Aspirin
T- Clopidogrel/ Ticragelor (second antiplatelet for STEMI)
```
41
Secondary prevention of NSTEMI/STEMI?
```
Aspirin
ACE-I
Beta Blocker
Clopidogrel (2nd antiplatelet)
Statin
```
42
Cause of hyperglycaemia in
T1DM?
T2DM?
T1DM- AI disorder, insulin producing B-cells in Islets of Langerhan are destroyed- Absolute Insulin Deficiency
T2DM- Insulin resistance/deficiency due to XS adipose tissue
43
DM symptoms?
Polydipsia
Polyuria
Weight loss
DKA:
Abdo pain
vomiting
Reduced LOC
44
DM investigations?
1. Finger-prick
2. BM – Fasting or non-fasting
3. HbA1c – Average BM over 2-3 months
4. Glucose tolerance test
a. Fasting BM
b. 75g glucose
c. Second BM 2 hours later
45
DM diagnostic criteria?
1. Symptomatic…
a. Fasting BM > 7.0
b. Random or post GTT BM > 11.1
2. Asymptomatic…
a. Same as above on TWO SEPARATE OCCASIONS
46
Management of:
T1?
T2?
- TYPE 1
o Supplementary insulin to control BM
- TYPE 2
o FIRST LINE METFORMIN
o SECOND LINE…
▪ SULFONYLUREAS
▪ GLIPTINS
▪ PIOGLITAZONE
47
Dx of TB?
Ziehl- Neelsen Stain on Lowenstein Jensen medium
48
Screening of TB?
MANTOUX TEST - Screens for latent TB
o Inject 0.1ml of 1:1000 purified protein derivative intradermally
o Read result 2-3 days later
o < 6mm – Negative – No hypersensitivity – Give BCG
o 6-15mm – Positive – Hypersensitive – Do not give BCG
▪ May be due to TB infection or BCG
o > 15mm – Strongly positive – Strongly hypersensitive – TB infection
49
Management of active TB?
```
- INITIAL PHASE - FIRST 2 MONTHS = RIPE
o RIFAMPICIN
o ISONIAZID
o PYYRAZINAMIDE
o ETHAMBUTOL
```
- CONTINUATION PHASE – NEXT 4 MONTHS = RI
o RIFAMPICIN
o ISONIAZID
50
management of latent TB?
- 3 MONTHS ISONIAZID + PYRIDOXINE + RIFAMPICIN
| - 6 MONTHS ISONIAZID + PYRIDOXINE
51
Side effects of Rifampicin?
Hepatitis
orange secretions
flu-like symptoms
52
Side effects of isoniazid?
Hepatitis
| Agranulocytosis
53
Side effects of Pyrazinamide?
Hyperuricaemia – GOUT
Arthralgia
Myalgia
Hepatitis
54
Side effects of Ethambutol?
Optic Neuritis- check acuity
| Adjust dose in renal impairment
55
What is the BCG vaccine?
- Limited protection against TB
| - Protects against leprosy
56
Who is the BCG vaccine for?
- At-risk groups…
o Children in areas where TB incidence > 40/100000
o Children with a parent/grandparent born in a country where TB > 40/100000
o Unvaccinated contacts of respiratory TB patients
o Healthcare workers
o Prison staff
o Care home staff
o Those who work with the homeless
57
Contraindications of BCG vaccine
- Previous BCG vaccination
- PMH of TB
- HIV
- Pregnancy
- Positive tuberculin test
- NO EVIDENCE FOR EFFICACY >35
58
CROHNS VS UC
Features?
Crohns-
- Non bloody diarrhoea
- weight loss
- upper GI symptoms
- mouth ulcers
- perianal disease
- RIF mass
UC
- bloody diarrhoea
- LIF mass
- tenesmus
59
CROHNS VS UC
Extra-intestinal symptoms and complications?
Crohns-
Gallstones (reduced bile reabsorption)
obstruction, fistula, CR cancer
UC-
PSC
increased risk of CR cancer
60
CROHNS VS UC
Pathology?
Crohns-
Skip lesions and mouth to anus
UC-
Inflammation rectum to IC valve
61
CROHNS VS UC
Histology?
Crohns-
transmural, increased goblet cells, granulomas
UC-
```
submucosa only
inflammatory cells in lamina propria
crypt abscesses
goblet cell depletion
infrequent granulomas
```
62
CROHNS VS UC
Endoscopy?
Crohns-
deep ulcers
skip lesions
cobble stone
UC-
widespread ulceration
adjacent mucosa preserved
Pseudopolyps
63
CROHNS VS UC
Radiology?
Crohns-
```
Small bowel enema
High sensitivity and
specificity
Kantor’s string sign
Proximal bowel dilation
ROSE THORN ULCERS
Fistulae
```
UC-
```
Barium enema
LOSS OF HAUSTRATIONS
SUPERFICIAL ULCERATION
PSEUDOPOLYPS
Colon narrow and short –
‘Drainpipe colon’
```
64
Ix of Crohns?
- Inflammatory markers – CRP
- FAECAL CALPROTECTIN
- Anaemia
- B12 and folate
65
Extra-intestinal features of Crohns?
```
o ARTHRITIS
o Erythema nodosum
o Episcleritis
o Osteoporosis
o Uveitis
o Pyoderma gangrenosum
o CLUBBING
o Primary sclerosing cholangitis
```
66
Management of Crohns?
Inducing remission
- FIRST LINE = PREDNISONE
- SECOND LINE = MESALAZINE
- Add on – AZATHIOPRINE
- Refractory disease – INFLIXIMAB
- Peri-anal disease – METRONIDAZOLE
Maintaining remission
- FIRST LINE = AZATHIOPRINE
- SECOND LINE = METHOTREXATE
- Previous surgery = MESALAZINE
67
extra intestinal features of UC?
```
o ARTHRITIS
o Erythema nodosum
o Episcleritis
o Osteoporosis
o Uveitis
o Pyoderma gangrenosum
o CLUBBING
o PRIMARY SCLEROSING CHOLANGITIS
```
68
management of UC?
- TOPICAL AMINOSALICYLATE – MESALAZINE
- 4 weeks – ADD ORAL AMINOSALICYLATE
- No remission – TOPICAL OR ORAL CORTICOSTEROID
- Maintenance – TOPICAL AMINOSALICYLATE AND ORAL AMINOSALICYLATE
69
COELIAC
Presentation?
- Chronic or intermittent diarrhoea
- Failure to thrive
- Persistent unexplained GI symptoms
- N/V
- Fatigue
- Abdo pain
- Weight loss
- Iron-deficiency anaemia
- FHx
70
COELIAC
Immunology?
- TTG IgA – TISSUE TRANSGLUTAMINASE ANTIBODIES
| - Endomysial IgA
71
COELIAC
What will the duodenal biopsy show?
- Villous atrophy
- Crypt hyperplasia
- Intraepithelial lymphocytes
- Lamina propria infiltration
72
COELIAC
Associated conditions?
IBS
Dermatitis herpetiformis
DMT1
AI Thyroid Disease
73
COELIAC
Management and complications?
Management : Gluten free diet
```
Complications:
- ANAEMIA
o Iron
o Folate
o B12
- Hyposplenism
- Osteoporosis / osteomalacia
- LACTOSE INTOLERANCE
- Subfertility
```
74
HAEMATURIA
Causes of transient non visible haematuria?
- UTI
- Menstruation
- Vigorous exercise
- Sexual intercourse
75
HAEMATURIA
Causes of persistent non visible haematuria?
- Cancer
- Stones
- BPH
- Prostatitis
- Urethritis
- Renal – IgA nephropathy
76
HAEMATURIA
cause of Red/orange urine – but blood NOT PRESENT ON DIPSTICK
- Beetroot
- Rhubarb
- RIFAMPICIN
- DOXORUBICIN
77
HAEMATURIA
Tests?
- URINE DIP
- Persistent = 2/3 samples 2 weeks apart
- Renal function
- Albumin:creatinine ratio – ACR
- Protein:creatinine ratio – PCR
- Urine microscopy
78
HAEMATURIA
When should you urgently refer?
```
> 45 YEARS AND…
o Unexplained visible haematuria
o Visible haematuria persisting after UTI management
> 60 YEARS AND…
o Unexplained non-visible haematuria
o Dysuria
o ^^ WCC
```
79
HAEMATURIA
Give examples of causes due to trauma, infection or malignancy?
```
Trauma:
Direct injury to renal tract
Renal trauma due to blunt injury
Ureter trauma – iatrogenic???
Bladder trauma – RTA or pelvic fracture
```
Infection:
TB
```
Malignancy:
Renal cell carcinoma
Urothelial malignancies – 90% TCC
Squamous cell carcinoma
Adenocarcinoma
Prostate cancer
Penile cancers
```
80
HAEMATURIA
iatrogenic causes?
Catheterisation
| Radiotherapy
81
HAEMATURIA
Causes due to renal disease, stones or structural abnormalities?
Renal disease:
Glomerulonephritis
Stones:
Microscopic haematuria
```
Structural abnormalities:
BPH – Hypervascularity of prostate
Cystic renal lesions – PKD
Vascular malformations
Renal vein thrombosis due to RCC
```
82
HAEMATURIA
What drugs can cause this?
```
Aminoglycosides
Chemotherapy
Penicillin
Sulphonamides
NSAIDs
Anticoagulants
```
83
HEART FAILURE
Presentation?
- Dyspnoea
- Cough – PINK FROTHY SPUTUM
- Orthopnoea
- Paroxysmal nocturnal dyspnoea
- WHEEZE
- Weight loss
- BIBASAL CRACKLES
- Right sided…
o Raised JVP
o Ankle oedema
o Hepatomegaly
84
HEART FAILURE
What BNP ranges indicate referral?
```
>400 = high urgent 2 referral
100-400 = 6 week referral
<100 = normal
```
85
HEART FAILURE
Causes of increased BNP?
```
LVH
Ischaemia
Tachycardia
RV overload
Hypoxaemia – PE
GFR < 60
Sepsis
COPD
Diabetes
Age > 70
Liver cirrhosis
```
86
HEART FAILURE
Causes of decreased BNP?
```
Obesity
DIURETICS
ACE-I
BB
A2RB
ALDOSTERONE ANTAGONISTS
```
87
HEART FAILURE
Management?
1. ACE-I + BB
2. ALDOSTERONE ANTAGONIST (spironolactone)
3. DIGOXIN
88
HEART FAILURE
What does ABCDE stand for in treatment of HF?
Antiplatelet therapy (ACE-I, aldosterone antagonists)
BP control (Beta blockers)
Cholesterol lowering therapy (statins), cigarette cessation
Diet and diabetes prevention/ treatment, digoxin
Exercise and weight management
89
What is the cycle of the production of Thyroxine from the thyroid gland?
1) Hypothalamus secretes thyrotropin- releasing hormone (TRH)
2) Anterior pituitary secretes thyroid-stimulating hormone (TSH)
3) Thyroid releases T3 and T4
90
Most common cause of Hypothyroid?
Hashimoto's Thyroiditis
Autoimmune
Iodine deficiency
Drugs (Lithium/ Amiodarone)
91
Most common cause of Thyrotoxicosis?
Graves Disease
Thyroid Eye Disease
Amiodarone
92
Compare Hypothyroid features to Hyperthyroid features
(Hyperthyroid)
```
General
Cardiac
Skin
GI
Gynae
Neuro
```
General: Weight loss, manic restlessness, heat intolerance
Cardiac: Palpitations
Skin: Increased sweating, pretibial myxoedema, lesions above lateral malleoli, thyroid acropachy, clubbing
GI: Diarrhoea
Gynae: Oligomenorrhoea
Neuro: Anxiety, tremor
93
Compare Hypothyroid features to Hyperthyroid features
(Hypothyroid)
```
General
Cardiac
Skin
GI
Gynae
Neuro
```
General: Weight gain, lethargy, cold intolerance
Cardiac:
Skin: Dry, cold, yellow skin, non pitting oedema, dry coarse scalp hair, loss of eyebrows
GI: Constipation
Gynae: menorrhagia
Neuro: Decreased deep tendon reflexes
94
What antibodies can be found in:
Hashimoto's?
Grave's?
Hashimoto's - Anti-TPO
Grave's- TSH receptor
95
Management of Hypo/hyperthyroid?
Hypo- Levothyroxine
Hyper-
Propanolol (control symptoms),
Carbimazole (reduces thyroid production)
May cause agranulocytosis (acute&severely low neutrophils)
Radioiodine
96
CKD
What are the eGFR variables and what factors can affect the eGFR?
eGFR VARIABLES
- Serum creatinine
- Age
- Gender
- Ethnicity
Factors affecting eGFR
- Pregnancy
- Muscle mass
- Red meat
97
CKD
Causes?
- Diabetic nephropathy
- Chronic glomerulonephritis
- Chronic pyelonephritis
- HTN
- Adult PKD
98
CKD
Methods of renal replacement therapy?
haemodialysis
Peritoneal dialysis
Renal transplant
99
CKD
Symptoms of inadequate management?
- Breathlessness
- Fatigue
- Insomnia
- Pruritus
- Poor appetite
- Swelling
- Weakness
- Weight gain/loss
- Abdominal cramps
- Nausea
- Muscle cramps
- Headaches
- Cognitive impairment
- Anxiety
- Depression
- Sexual dysfunction
100
IDA
Causes?
- Excessive bleeding
(menorrhagia. GI bleed)
- Poor dietary intake
- Malabsorption
- Increased requirements (growth spurts, pregnancy)
101
IDA
Presentation?
- Fatigue
- SOBOE
- Palpitations
- Pallor
- Nail changes
- Hair loss
- Atrophic glossitis
- Post-cricoid webs
- Angular stomatitis
102
IDA
Investigations?
```
- HISTORY
o Dietary changes
o Medication
o Menstruation
o Weight loss
o Bowel habits
```
- FBC – HYPOCHROMIC MICROCYTIC ANAEMIA
- Serum ferritin – May be raised during inflammation
- ^^^ Total iron-binding capacity
- Endoscopy to rule out malignancy
103
IDA
Management?
- TREAT UNDERLYING CAUSE
- ORAL FERROUS SULPHATE
o May cause N/D/V, abdo pain, constipation
- Iron rich diet
o Meat and dark green vegetables
104
VTE
Risk factors?
- Medical patients – Significant reduction in mobility > 3 days
- Surgical/trauma patients
o Hip/knee replacement
o Hip fracture
o GA or surgery > 90 minutes
o Pelvic or lower-limb surgery under GA >60 minutes
o Acute surgical admission with inflammatory or intra-abdominal condition
o Surgery which leads to reduced mobility
```
- General
o Active cancer/chemotherapy
o Aged > 60
o Known clotting disorder
o BMI > 35
o Dehydration
o 1+ significant comorbidities
o Critical care admission
o HRT
o OCP
o Varicose veins
o Pregnant or < 6 weeks post-partum
```
105
Pharmacological prophylaxis of VTE?
- FONDAPARINUX SODIUM – Subcutaneous
- LMWH – ENOXAPARIN
- UNFRACTIONATED HEPARIN – with CKD
106
List the clinical features compromising the Well's Score
- Previous DVT
- Active cancer
- Paralysis/ immobilisation
- Bedridden (surgery)
- tenderness
- leg swelling
- unilateral calf swelling 3cm more
- pitting oedema
- collateral superficial veins
107
What investigations are done if the Wells score is:
2 or more
1 or less
>2 = USS within 4 hours + D-Dimer
<1 = D-dimer (if positive do USS within 4 hours)
108
What should be given if the USS is delayed when diagnosing a VTE?
LMWH
109
Management of a VTE?
- LMWH
o 5 days OR INR >2.0 for 24h
o 6 months if active cancer
- FONDAPARINUX
- WARFARIN
o 3 months then reassess
o 6 months if unprovoked
110
If the VTE is unprovoked what should be done?
Test for Malignancy:
CXR
Bloods (FBC,Ca,LFTs)
Urinalysis
Abdo CT or mammogram if >40
111
PE
Presentation?
- Pleuritic chest pain
- Dyspnoea
- Haemoptysis
- Tachycardia – 44%
- Tachypnoea – 96%
- Crackles – 58%
- Fever – 43%
112
PE
Investigations?
- PE likely…
o CPTA
▪ LMWH if delayed
- PE unlikely
o D-DIMER
▪ Positive – CPTA
● LMWH if delayed
- RENAL IMPAIRMENT = V/Q scan
113
PE
Signs on ECG?
SINUS TACHYCARDIA
(rare)
S1 Q3 T3
Large S in lead I
Large Q in lead III
Inverted T in lead III
114
What may affect a V/Q scan?
o Previous PE
o AV malformations
o Vasculitis
o Radiotherapy
115
PE
Management?
1. WARFARIN within 24h
Continue for 3 months
Continue for 6 months if unprovoked
2. LMWH for 5 days OR INR > 2.0
Continue for 6 months if active cancer
3. THROMBOLYSIS IF CIRCULATORY FAILURE
116
HODGKIN'S LYMPHOMA
Lab signs?
Lymphocyte proliferation
Reed-Sternberg cells
117
HODGKIN'S LYMPHOMA
Presentation?
30s and 70s
- Lymphadenopathy – 75%
o Painless
o Non-tender
o Asymmetrical
```
- Systemic – 25%
o Weight loss
o Pruritus
o Night sweats
o Fever
- Alcohol induced node pain
- Normocytic anaemia – Eosinophilia
- LDH raised
```
118
Name the types of Hodgkins Lymphoma
Rank their prognosis
State the percentage of frequency
Nodular Sclerosing- 70% - Good prognosis (mainly seen in women- lacunar cells)
Mixed Cellularity- 20%- Good prognosis (Reed-Sternberg cells)
Lymphocyte predominant- 5%- Best prognosis
Lymphocyte depleted- rare- worst prognosis
119
LYMPHOMA
What features may suggest a poor prognosis?
B-symptoms
- Weight loss >10%
- Fever >38
- Night sweats
Poorer:
- Age > 45
- Stage 4
- Haemoglobin < 10.5
- Lymphocytes < 600 or 8%
- Male
- Albumin
- WCC > 15000
120
What is Non-Hodgkin's Lymphoma?
Malignant proliferation of lymphocytes
more common than Hodgkin's
121
NON-HODGKIN'S LYMPHOMA
Risk factors?
- Elderly
- Caucasians
- History of viral infection
- FHx
- Chemical agents
- Past chemo or radiotherapy
- Immunodeficiency
- AI disease
122
NON-HODGKIN'S LYMPHOMA
Symptoms?
- Painless lymphadenopathy
o Non-tender
o Rubbery
o Asymmetrical
```
- Constitutional symptoms
o Fever
o Weight loss
o Night sweats
o Lethargy
```
```
- Extranodal disease
o Gastric
▪ Dyspepsia
▪ Dysphagia
▪ Weight loss
▪ Abdo pain
```
o Bone marrow
▪ Pancytopenia
▪ Bone pain
123
NON-HODGKIN'S LYMPHOMA
Signs?
- Weight loss
- Lymphadenopathy – Cervical, axillary, inguinal
- Palpable abdo mass – Hepatomegaly, splenomegaly, lymph nodes
- Testicular mass
- Fever
124
Difference between Hodgkin's and Non-Hodgkin's in terms of:
- Histology
B-symptoms
Extra-nodal disease
Hodgkins- Reed-Sternberg cells
B-symptoms-
Hodgkins = Early
Non-Hodgkins = Late
Extra-nodal disease-
Hodgkins = Less common
Non-Hodgkins = More common
125
LYMPHOMA
Investigations?
```
Investigations
- EXCISIONAL NODE BIOPSY
o Burkitt’s = Starry sky
- STAGING CT
- HIV test – RF for non-Hodgkin’s
- FBC
- ESR
- LDH
```
126
LYMPHOMA
Staging?
ANN-ARBOR SYSTEM
1. One node affected
2. More than one node
Same side of the diaphragm
3. One node either side of the diaphragm
4. Extra-nodal involvement
+ A if no B symptoms
+ B if B symptoms present
127
LYMPHOMA
Management?
- Chemo/radiotherapy
- Flu/pneumococcal vaccines
- Abx prophylaxis if neutropenic
128
LYMPHOMA
Complications?
```
- Bone marrow infiltration
o Anaemia
o Neutropenia
o Thrombocytopenia
- SVC obstruction
- Metastasis
- Spinal cord compression
```
129
Signs and Symptoms of Tonsillitis?
Symptoms
- Painful throat >48 hours
- Pain on swallowing
- Painful ears
- Abdominal pain in small children
- Headache
- Voice changes
```
Signs
- Red throat
- Tonsils inflamed
- Fever
- Swollen regional lymph glands
- STREP…
o Acute onset
o Headache
o Abdo pain
o Foul smelling breath
```
130
Signs on Examination of Tonsillitis?
- Erythema of tonsils and pharynx
- Yellow exudate
- Tender enlarged anterior cervical glands
131
Signs of Tonsillitis differentials:
Viral
Coxsackie's
EBV
Viral = milder symptoms
Coxsackie's = Blisters
EBV = unwell, lethargic teenagers
132
What is the Centor Criteria?
Cervical lymphodenopathy
Exudate (Tonsillar swelling)
No cough
Temperature (fever)
OR
133
Medication for Tonsillitis?
- Antipyretics – Paracetamol and Ibuprofen
```
- Abx indications…
o Marked systemic upset
o Unilateral peritonsillitis
o History of rheumatic fever
o ^^^ Infection risk
o CENTOR > 3
```
134
What is the Antibiotic treatment for Tonsillitis?
Phenoxymethylpenicillin
for 5-10 DAYS
- Clarithromycin or erythromycin are alternatives
135
Criteria for Tonsillitis referral?
```
Difficulty breathing
Clinical dehydration
Abscess
Systemic illness/ sepsis
Suspected sinister cause
```
136
When would a Tonsillectomy be considered?
After over 7 episodes of Tonsillitis
137
COPD
What is it?
Chronic bronchitis + Emphysema
138
COPD
Possible causes?
- Smoking
- Alpha-1 antitrypsin deficiency
- Cadmium, coal, cotton, cement, grain
139
COPD
Features?
Chronic productive cough with sputum
Dyspnoea
Wheeze
Right HF
140
COPD
Stages?
All FEV1/FVC ratio of <0.7
FEV1 (% of predicted)
```
>80 = Stage 1
50-79 = Stage 2
30-49 = Stage 3
<30 = Stage 4
```
141
COPD
Bronchodilator therapy?
1st- SABA or SAMA (Salbutamol/ Ipratropium)
2nd- Assess for asthmatic features or steroid responsiveness
No asthmatic features = Add LABA + LAMA
(Salmeterol/ Tiotropium)
Asthmatic features =
Add LABA + ICS (Salmeterol + Beclamethasone)
then add LAMA Tiotropium
142
COPD
Asthmatic features?
o PMH or asthma or atopy
o Higher eosinophil count
o Substantial variation in FEV1 (400ml)
o Substantial diurnal variation in PEF (20%)
143
COPD
What is cor pulmonale?
Management?
- Peripheral oedema
- ^^^ JVP
- Parasternal heave
- Loud P2
Management - Loop Diuretic Furosemide
Consider long term O2
144
COPD
Features of an acute exacerbation?
- ^^^ Dyspnoea
- ^^^ Cough
- ^^^ Wheeze
- ^^^ Sputum
- Hypoxia
- Confusion
145
COPD
Exacerbation organisms?
Haemophilus Influenzae
Strep Pneumoniae
Moraxella Catarrhalis
146
COPD
Management if acute exacerbation?
Increase Bronchodilator
Prednisolone for 7-14 days
Oral Abx if purulent sputum or signs of pneumonia
- Amoxicillin
- Tetracycline
- Clarithromycin
147
COPD
When should long term oxygen therapy be offered?
- pO2 < 7.3
- OR pO2 7.3 – 8 AND…
o Secondary polycythaemia
o Peripheral oedema
o Pulmonary hypertension
Dont offer to continuous smokers
148
GOUT
What is it?
Hyperuricaemia and intra articular sodium urate crystals
149
GOUT
Cause of hyperuricaemia?
Increased production- psoriasis, genetics, diet (shellfish, red meat, alcohol)
or
Decreased excretion from the kidneys - (CKD, NTN, thiazides, alcohol)
90% IS IDIOPATHIC
150
GOUT
Signs?
50% occurs at 1st MTPJ
Acute severe pain with swelling and redness
151
GOUT
Precipitants?
Diuretics
Cold
Alcohol
152
GOUT
Investigations?
What do the investigations show?
- Joint aspiration- shows urate crystals in synovial fluid
- X-ray shows:
1) Soft tissue swelling
2) Peri-articular erosions
3) Norma joint space
153
GOUT
Management?
- NSAIDs, Colchicine, Steroids (prednisolone injection)
| - Allopurinol
154
GOUT
Lifestyle Management?
Lose weight
stop drinking
avoid meats with high purines (red meat, shellfish)
155
Difference between pseudo-gout and gout?
Pseudogout = Positive birefringent
calcium pyrophosphate rhomboid crystals
(chondrocalcinosis typically in the knee treated with corticosteroid injection)
Gout = Negative birefringent urate needle shaped crystals
156
What Drugs can cause Hypothyroidism?
Lithium
Amiodarone
