Internal med Flashcards
What are things to consider as part of initial management in patinets with COPD?
- smoking cessation advice: including offering nicotine replacement therapy, varenicline or bupropion
- annual influenza vaccination
- one-off pneumococcal vaccination
- Pulmonary rehabilitation to all people who view themselves as functionally disabled by COPD (usually Medical Research Council [MRC] grade 3 and above)
Who is oral azithromycin prophylaxis useful for in COPD? 250mg 3 times a week
- Do not smoke and
- Have optimised non-pharmacological management and inhaled therapies, relevant vaccinations and (if appropriate) have been referred for pulmonary rehabilitation and continue to have 1 or more of the following, particularly if they have significant daily sputum production:
- Frequent (typically 4 or more per year) exacerbations with sputum production
- Prolonged exacerbations with sputum production
- Exacerbations resulting in hospitalisation.
What are some congenital causes of QT prolongation?
- Jervell-Lange-Nielsen syndrome (includes deafness and is due to an abnormal potassium channel)
- Romano-Ward syndrome (no deafness)
What are some medications that cause QT prolongation?
- amiodarone, sotalol, class 1a antiarrhythmic drugs
- tricyclic antidepressants, selective serotonin reuptake inhibitors (especially citalopram)
- methadone
- chloroquine
- terfenadine
- erythromycin
- haloperidol
- ondanestron
What are some miscellanous organic causes of QT prolongation other than congenital and drugs?
- electrolyte: hypocalcaemia, hypokalaemia, hypomagnesaemia
- acute myocardial infarction
- myocarditis
- hypothermia
- subarachnoid haemorrhage
What are the commonest bugs causing exacerbation of COPD?
Haemophilius influenzae
Strep pneumoniae
Moraxella catarrhalis
Bug that causes chest infection and often affects younger patients, frequently those living in crowded accommodation. It is associated with a number of characteristic complications such as erythema multiforme and cold autoimmune hemolytic anemia.
Mycoplasma pneumoniae
How do you differentiate typhoid from dengue and leptosperosis?
Dengue usually presents with fever and joint pains whilst leptospirosis follows a biphasic pattern of fever and headaches continuing with muscle and abdominal pain
Typhoid - erythematous rash on her trunk and back are known as rose spots which are irregular discrete spots measuring between 2-4mm. Non-productive cough, diarrhoea and constipation
What is the organism that causes typhoid?
Salmonella typhi and Salmonella paratyphi
A 25-year-old man with ulcerative colitis presents with new onset itching and fatigue. On examination you note that he is jaundiced and tender in the right upper quadrant with significant hepatomegaly. He reports that his ulcerative colitis is well controlled and he has not had a flare in over 6 months. However, he believes he has lost weight despite no change to his diet or exercise.
Which autoantibody tests would you expect to be positive?
p-ANCA
ulcerative colitis coupled with new clinical signs of hepatobiliary disease should make you think of primary sclerosing cholangitis.
What are some of the complications associated with blood transfusion?
- Non-haemolytic febrile reaction
- Allergic reaction
- Anaphylaxis
- Infective
- transfusion-related acute lung injury (TRALI)
- transfusion-associated circulatory overload (TACO)
other: hyperkalaemia, iron overload, clotting
what are the features of non-haemolytic febrile reaction? and management
Fever, chills
Thought to be caused by antibodies reacting with white cell fragments in the blood product and cytokines that have leaked from the blood cell during storage
Start paracetamol
How do you differentiate chronic renal failure from AKI?
Best way to differentiate is renal ultrasound - most patients with CRF have bilateral small kidneys
hypocalcaemia (due to lack of vitamin D)
What is the choice of antiplatelet therapy after NSTEMI?
DAPT:
1. Aspirin +
2.
if the patient is not taking an oral anticoagulant: prasugrel or ticagrelor
if taking an oral anticoagulant: clopidogrel
How do you treat a man with UTI?
Trimethoprim or nitrofurantoin are both appropriate first-line antibiotics for suspected lower urinary tract infections. However, whilst a 3-day course is acceptable in women, men must be treated for 7 days and may need to be referred to a Urologist if they get a recurrence.
What is the investigation of choice for suspected neoplastic spinal cord compression?
MRI whole spine
What is the management for suspected neoplastic spinal cord compression?
High dose PO Dexamethasone
What are the common side effects of 5-HT antagonists (ondensetron)?
constipation is common
prolonged QT interval
What are the side effects of erythropoietin treatment?
- Accelerated hypertension potentially leading to encephalopathy and seizures (blood pressure increases in 25% of patients)
- Bone aches
- Flu-like symptoms
- Skin rashes, urticaria
- Pure red cell aplasia* (due to antibodies against erythropoietin)
- Raised PCV increases risk of thrombosis (e.g. Fistula)
- Iron deficiency 2nd to increased erythropoiesis
What are some reasons patients do not respond to EPO treatment?
- iron deficiency
- inadequate dose
- concurrent infection/inflammation
- hyperparathyroid bone disease
- aluminium toxicity
What are the causes of DCM?
alcohol
Coxsackie B virus
wet beri beri
doxorubicin
cocaine abuse, hemochromatosis, sarcoidosis, and pregnancy
What are some live attenuated vaccines?
BCG MMR oral polio yellow fever oral typhoid
A 40-year-old patient with HIV was assessed in the neurology clinic after reporting worsening clumsiness over the past month; he regularly falls into door frames and this is not something that he has experienced before.
On physical examination, the patient had an unsteady gait and dysdiadochokinesia. Cranial nerve testing and speech were normal, and the rest of the examination was unremarkable.
The patient underwent extensive investigation and his MRI scan was found to show multifocal non-enhancing lesions.
What is the likely diagnosis and causative organism?
The scenario above suggests that the patient has developed progressive multifocal leukoencephalopathy, which is a rare viral disease of the brain caused by the John Cunningham virus. The virus damages the nerves through demyelination and can become fatal if left untreated.
- Affects patients that are immunocompromised
- Ataxia , weakness, visual changes , disturbed speech
- Multifocal non-enhancing lesions
What are some complications of meningitis?
- Sensorineural hearing loss
- Seizures
- focal neurological deficit
- Waterhouse- Friderichsen syndrome - adrenal insufficiency 2dary to adrenal haemorrhage
What are the potential risk factors for asystole?
- Complete heart block with broad complex QRS
- Recent asystole
- Mobitz type II AV block
- ventricular pause > 3 seconds
What is the most common inherited condition causing thrombophilia?
Factor V leiden
What is the INR target if on warfarin and VTE risk? ANd with recurrent VTE?
venous thromboembolism: target INR = 2.5, if recurrent 3.5
What is the INR target if on warfarin and has AF?
2.5
What are the fundamental INR action thresholds?
INR >5 = Vit K in some form or the other
Bleeding - IVI Vit K
Bleeding > 8 - stop warfarin + add Vit K
< 2 cover is required until patient is > 2 for 24hrs
What atypical pneumonia is associated with erythma multiforme?
Mycoplasma pneumoniae
When is warfarin stopped for surgery? and when is it restarted?
Usually stopped 5 days before planned surgery
Once the person’s international normalized ration (INR) is less than 1.5 surgery can go ahead.
Warfarin is usually resumed at the normal dose on the evening of surgery or the next day if haemostasis is adequate.
What are some causes of hypervolaemic hyponatraemia?
Renal failure
Heart failure
Liver failure
Nephrotic syndrome
What are some causes of euvolaemic hyponatraemia?
- Syndrome of inappropriate ADH release (SIADH)
- Hypothyroidism
What are the C450 inducers?
Reduce the concentration of drugs metabolised by the cytochrome P450
CRAPS out the drug
Carbamezapine Rifampicin Barbiturates Phenytoin St Johns Wort
What are some of the cytochrome P450 inducers?
Reduce the concentration of the drugs metabolised by the CP450 system
CRAPs out the drug
Carbamezapine Rifampicin bArbiturates Phenytoin St Johns Wort
What are some of the CP450 inhibitors?
Increase the concentration of drugs metabolised by the CP450 system
Some certain silly compounds annoyingly inhibit enzyme , Grrrrrrrr
Sodium valproate Ciprofloxacin Sulphonamide Cimetidine/ Omeprazole Antifungals, amiodarone Isoniazid Erythromycin/ clarithromycin Grapefruit juice
What are some drugs that interact with CP450 inhibitors or inducers?
Warfarin COCP Theophylline Corticosteroids Tricyclics Pethidine Statins
What medications can induce cerebellar syndrome effects?
Phenytoin and Carbamezepine
what are the conditions required for diagnosis of graft vs host disorder?
Billingham’s criteria:
- transplanted tissue contains immunologically functioning cells
- the recipient and donor are immunologically different
- recipient is immunocompromised
what are the risk factors causing graft vs host disorder in patients recieving allogenic bone marrow transplant?
- poorly matched donor and recipient
- type of conditioning used prior to transplantation
- gender disparity between donor and recipient
- graft source - bone marrow/peripheral blood source higher risk than umbilical cord blood
what is the definition of acute Graft vs host disorder and what are the classical symptoms?
Is classically defined as onset is classically within 100 days of transplantation*
Symptoms:
- Painful maculopapular rash (often neck, palms and soles), which may progress to erythroderma or a toxic epidermal necrolysis-like syndrome
- Jaundice
- Watery or bloody diarrhoea
- Persistent nausea and vomiting
- Can also present as a culture-negative fever
what are the typical features of myxoedema coma?
It is a complication of longstanding untreated hypothyroidism precipitated by illness, stress and drugs.
confusion hypothermia non-pitting periorbital and leg oedema reduced respiratory drive pericardial effusions anaemia seizures
what are the common bacteiral organisms causing infective exacerbation of asthma?
- haemophilus influenzae
- streptococcus pneumoniae
- moraxella catarrhalis
what is the triad seen in pharyngeal pouch?
- dysphagia
- aspiration pneumonia
- halitosis
what is the monitoring required for statins?
- liver impairment - 3 mths and then at 12 mths
2. myopathy
what causes pulsus paradoxus?
severe asthma
cardiac tamponade
what is the cause of the 3rd heart sound and aetiology?
Caused by diastolic filling of the ventricle
heard in LV failure (dilated cardiomyopathy), constrictive pericarditis and mitral regurg
what are the symptoms of unstable patient with tachycardia?
- shock - hypotension
- syncope
- myocardial ischaemia
- HF
what are the features of boerhaaves syndrome?
- spontaneous rupture of the oesophagus
- sudden history of severe chest pain - complicates vomiting
Triad of - vomiting, thoracic pain, subcutaneous emphysema. - Diagnosis - CT contrast swallow
what is the tx for boerhaave syndrome?
thoracotomy and lavage, if less than 12 hours after onset then primary repair is usually feasible, surgery delayed beyond 12 hours is best managed by insertion of a T tube to create a controlled fistula between oesophagus and skin.
