January Flashcards
8-4 weeks
Secondary prevention following TIA
75mg Clopidogrel
What medications should a patient take prior to PCI?
First, a loading dose of aspirin 300mg should be given for the STEMI
For those having primary PCI, NICE recommend adding prasugrel if the patient is not already taking an oral anticoagulant.
Nail changes seen in iron deficiency anaemia?
Kolionychia (spoon shaped nails)
Uraemia with what symptoms in AKI is an indication for dialysis?
Uraemia + encephalopathy or pericarditis is an indication for dialysis
Signs of anaemia + positive coombs test (direct antiglobulin test) indicates what?
Autoimmune haemolytic anaemia
Autoimmune haemolytic anaemia tx
Corticosteroids 1st line
- reduces the number of circulating antibodies.
C peptide levels in Type 1 vs Type 2 diabetes
Type 1 = C peptide low / undetectable due to deficiency in insulin
Type 2 = C peptide raised
Brown-green nipple discharge is most commonly associated with…
Duct ectasia
What is a small and medium vessel vasculitis that is strongly associated with smoking.
Features
extremity ischaemia
intermittent claudication
ischaemic ulcers
superficial thrombophlebitis
Raynaud’s phenomenon
Buerger’s disease (also known as thromboangiitis obliterans)
When can you watch and wait with a kidney stone?
Watchful waiting is incorrect. NICE guidelines suggest that renal stones with dimensions of 5mm or less should initially be managed using a watchful waiting approach, making sure that the patient remains well-hydrated, has an appropriate prescription of analgesia and is safety-netted for the signs and symptoms of infection.
Kidney stone 8mmx5mm treatment?
Shockwave lithotripsy and tamsulosin.
Kidney stone size 21mm tx?
Percutaneous nephrolithotomy involves a small incision in the back and the insertion of a needle into the kidney using fluoroscopy or ultrasound. The urinary tract is then dilated and the stone is fragmented using lasers or lithotripsy devices. This approach is used for renal stones larger than 20 mm, including staghorn stones, as it is the most invasive of the options and should be reserved for cases when minimally invasive approaches would not be enough.
Kidney stone size 14mm tx?
Ureteroscopy is a minimally invasive procedure which involves a ureteroscope being passed through the urethra and bladder to reach the stone in the ureter or kidney. Stones can then be fragmented with lasers or removed intact. This approach is indicated by NICE guidelines for renal and ureteric stones between 10 and 20 mm in size.
Hepatitis E most common method of transmission
Hepatitis E is spread by the faecal-oral route and is most commonly spread by undercooked pork
Angina management
(1st and 2nd line)
- Verapamil + GTN
- Beta blockers + GTN
- Isosorbide mononitrate + GTN
Chest drain indications for pneumothoax
Haemodynamic compromise (suggesting a tension pneumothorax)
Significant hypoxia
Bilateral pneumothorax
Underlying lung disease
≥ 50 years of age with significant smoking history
Haemothorax
Treatment of vestibular neuronitis
Prochlorperazine may be useful in the acute phase of vestibular neuronitis, but should be stopped after a few days as it delays recovery by interfering with central compensatory mechanisms
Most common causes of small bowel obstruction
Adhesions (any previous surgery)
Hernia
Infective endocarditis in IVDU typically affects what valve?
Tricuspid valve
What muscle relaxant is the first choice for rapid sequence induction for intubation
Suxamethonium is the muscle relaxant of choice for rapid sequence induction for intubation.
What antibodies are seen in primary biliary cholangitis?
- Anti-mitochondrial antibodies (AMA) M2 subtypeare present in 98% of patients and are highly specific
- Smooth muscle antibodies in 30% of patients
- Raised serum IgM
Management of primary biliary cholangitis:
(3 medical treatments and 1 surgical)
- First-line:Ursodeoxycholic acid
- slows disease progression and improves symptoms
- Pruritus:Cholestyramine
- Fat-soluble vitamin supplementation
- Liver transplantation
- e.g. if bilirubin > 100 (PBC is a major indication)
- Recurrence in graft can occur but is not usually a problem
Chlamydia treatment if pregnant?
Azithromycin, erythromycin or amoxicillin
Retro-orbital headache, fever, rash, bone break pain and muscle ache, thrombocytopenia in a returning traveller - treatment?
Dengue fever
- fluid resus and blood transfusion - no antivirals are available.
Read pathophysiology of subclavian steal syndrome
- You have stenosis of the proximal subclavian artery. This can occur due to any reason you get blockage e.g. hyperlipidaemia. It can also occur following CABG as this there can be stenosis at site of internal mammary artery removal for grafting.
- You use your arm. There is insufficient blood flow from the subclavian artery -> ouch/ ischaemic sx.
- A branch of the subclavian artery is the vertebral artery.
- To compensate for the lack of blood flow to the distal subclavian a., there is retrograde blood flow from the vertebral artery. I.e. it is stolen from there.
- The vertebral artery supplies the cerebellum and post circulation. As there is less blood flow there you get the symptoms of a POCS/ vertebrobasilar insufficiency = dizziness, vertigo, nausea, double vision.
In short: vertebral artery compensates for lack of blood supply from the subclavian. Don’t get enough blood to the cerebellum now -> dizziness.
What length break in between courses of topical corticosteroids in patients with psoriasis should you aim for?
4 week break in between courses of topical corticosteroids in patients with psoriasis.
What chemotherapy agents can cause cardiomyopathy and lead to HF?
Anthracyclines like doxorubicin
Replace magnesium before correcting hypokalaemia. Hypomagnesemia prevents potassium absorption
Replace magnesium before correcting hypokalaemia. Hypomagnesemia prevents potassium absorption
Most common cause of viral meningitis:
The most common causes of viral meningitis in adults with no other past medical history a
re enteroviruses, of which Coxsackie B virus is amongst the most common.
JAK2 mutation =
Polycythaemia vera - commence long term aspirin
Hypercalcemia on ECG =
Short QT
Pregnant women with blood pressure ≥ ?/? mmHg are likely to be admitted and observed
≥ 160/110 mmHg
Pathophysiology of secondary hyperparathyroidism:
Parathyroid gland hyperplasia occurs as a result of low calcium, almost always in a setting of chronic renal failure.
Hypertension with hypokalaemia and mild alkalosis =
Hyperaldosteronism
- Bilateral idiopathic adrenal hyperplasia is the most common cause of PRIMARY hyperaldosteronism
Management of peripheral arterial disease
All patients with peripheral arterial disease should take clopidogrel and atorvastatin
What diabetes medications cause weight gain?
Sulfonylurea’s like gliclazide cause weight gain.
HIV patients with a CD4 count lower than 200/mm3 should what?
Co-trimoxazole
All patients with a CD4 count lower than 200/mm3 should receive prophylaxis against Pneumocystis jiroveci pneumonia.
Biochemical profile seen in osteomalacia
Low serum calcium, low serum phosphate, raised ALP and raised PTH
Sickle cell on FBC findings:
- why?
Sickle cell disease causes a normocytic anaemia with raised reticulocyte count – due to haemolysis
Approach to a patient taking warfarin before surgery:
In general, warfarin is usually stopped 5 days before planned surgery, and once the person’s international normalized ration (INR) is less than 1.5 surgery can go ahead.
ACE inhibitors cause what electrolyte abnormality?
ACE inhibitor causes hyperkalaemia
Giardiasis tx?
Metronidazole
Poorly controlled angina, already on a BB add what?
If angina is not controlled with a beta-blocker, a longer-acting dihydropyridine calcium channel blocker should be added.
Add amlodipine rather than verapamil/diltiazem due to risk of 3rd degree heart block.
Men of any age with a Hb below 110g/L should be managed how?
Men of any age with a Hb below 110g/L should be referred for upper and lower GI endoscopy as a 2ww
Pyridoxine =
A form of vitamin B6 which is prescribed alongside isoniazid to reduce the risk of peripheral neuropathy.
When to transfuse female patient?
Hb under 70 or under 80 with ischaemic heart disease.
Which medication is known to exacerbate plaque psoriasis?
Beta blockers
When to give antibiotics for acute otitis media in children?
NICE advise that antibiotics may be beneficial in certain situations including bilateral infection in children under 2, otorrhoea, perforated tympanic membrane and symptoms not improving after 3 days.
Adult asthma diagnostic test:
Adults with suspected asthma should have both a FeNO test and spirometry with reversibility.
What investigation is needed for a patient presenting with amaurosis fugax?
Carotid doppler
Von Willebrand’s disease is what…?
Von Willebrand’s disease is a bleeding disorder caused by a deficiency or dysfunction of von Willebrand factor, which aids in the adhesion of platelets to the damaged subendothelium.
Most common inherited thromobphillia?
Activated protein C resistance (Factor V Leiden) is the most common inherited thrombophilia.
Rash seen in Scarlet fever
Fine punctate erythema (‘pinhead’) which generally appears first on the torso and spares the palms and soles.
Flushed appearance with circumoral pallor. The rash is often more obvious in the flexures.
Sandpaper texture
Desquamination occurs later in the course of the illness, particularly around the fingers and toes
Scarlet fever give
Pen V 10 days
Rectal tumour treatment
Anterior resection is the most commonly performed operation for rectal tumours, except in lower rectal tumours.
Prophylaxis for tumour lysis syndrome?
Allopurinol
Heparin reversal agent:
protamine sulphate
PICA lesion - contralateral or ipsilateral?
- Sensory loss
- Horners
PICA lesion - cerebellar signs, contralateral sensory loss & ipsilateral Horner’s
Aortic dissection tx type a vs b:
Aortic dissection
type A - ascending aorta - control BP (IV labetalol) + surgery
type B - descending aorta - control BP(IV labetalol)
What bloods are needed 3 months after starting a statin?
A lipid profile and liver function tests should be performed 3 months after starting a statin.
ST elevation and acute pulmonary oedema in a young patient with a recent flu-like illness
Myocarditis
Diagnosis criteria for gestational diabetes
fasting glucose is >= 5.6 mmol/L
2-hour glucose is >= 7.8 mmol/L
How should an unexplained breast lump be managed in a woman under 30?
A woman < 30 years of age presenting with an unexplained breast lump with or without pain does not meet 2WW criteria but can be considered for a non-urgent referral.
Syringomyelia pathophysiology
Syringomyelia classically presents with cape-like loss of pain and temperature sensation due to compression of the spinothalamic tract fibres decussating in the anterior white commissure of the spine
Alcohol withdrawal time periods:
Symptoms: 6-12 hours
Seizures: 36 hours
Delirium tremens: 72 hours
Delirium tremens is the most severe form of alcohol withdrawal and occur due to autonomic dysfunction from excitation of the CNS. Vital sign abnormalities also occur. This can present with visual hallucinations, tachycardia, hypertension, hyperthermia, agitation, and diaphoresis. These symptoms can last up to seven days after alcohol withdrawal and sometimes can progress even longer than this.
Delirium tremens is the most severe form of alcohol withdrawal and occur due to autonomic dysfunction from excitation of the CNS. Vital sign abnormalities also occur. This can present with visual hallucinations, tachycardia, hypertension, hyperthermia, agitation, and diaphoresis. These symptoms can last up to seven days after alcohol withdrawal and sometimes can progress even longer than this.
First line medication for ADHD
- Drug therapy should be seen as a last resort and is only available to those aged 5 years or more. Patients with mild/moderate symptoms can usually benefit from their parents attending education and training programmes.
Methylphenidate
Keratitis most common cause in a contact lens wearer
Pseudomonas infection should be suspected in contact lens associated keratitis.
Tramadol can interact with SSRI’s to cause serotonin syndrome.
Tramadol can interact with SSRI’s to cause serotonin syndrome.
Genital wart treatment:
Multiple, non-keratinised warts:
Solitary, keratinised warts:
Genital wart treatment:
Multiple, non-keratinised warts: topical podophyllum
Solitary, keratinised warts: cryotherapy
What medication should a patient take long term following a STEMI?
BRATS!
Beta blocker
Ramipril (ACE-i)
Aspirin
Ticagrelor
Statin
SLE antibodies:
Sensitive test =
Specific test =
SLE antibodies:
Sensitive test = ANA
Specific test = Anti-dsDNA
Metformin + what medication is best for weight loss in T2DM?
DPP-4 inhibitors (gliptins)
Acute heart failure not responding to treatment with intravenous furosemide, oxygen, and nitrates; consider what?
CPAP
A congenital obstruction caused by either complete absence or significant narrowing of the duodenum and would have presented with bilious vomiting and signs of intestinal obstruction shortly after birth.
Duodenal atresia
What hormonal therapies are offered to woman with ER+ breast cancer and when should they be used?
Tamoxifen is used in ER +ve women who are pre- or perimenopausal.
Aromatase inhibitors (letrozole) are used in those who are post-menopausal.
Reason: Aromatase inhibitors are crucial in the treatment of post-menopausal women because they inhibit the peripheral conversion of androgens to oestrogens, which is the predominant source of oestrogen in this population.
Howell-Jolly bodies =
splenectomy
A sudden but short-lived change in senses (which may be taste, smell, tactile, or visual) during which the patient remains fully conscious.
Focal aware seizure
Benign rolandic seizures
This is a form of childhood epilepsy characterised by partial seizures, which tend to occur during sleep. The seizures usually consist of hemifacial paraesthesias, oropharyngeal manifestations (e.g. strange noises) and hypersalivation. Occasionally these seizures can progress to generalised tonic-clonic seizures. Most children with benign rolandic epilepsy have a family history of the condition and are usually seizure-free during the day.
Auer rods on blood film =
AML
Anterior uveitis tx
Steroid + cycloplegic (mydriatic) drops
D-dimer when?
Suspected PE with a Wells PE score ≤4 - D-dimer is investigation of choice
Spastic cerebral palsy = UMN or LMN??
UMN
Polymyalgia rheumatica summary:
Presentation
Inv
Tx
Muscle STIFFNESS + lethargy
Raised ESR!
Prednisolone
Upper zone fibrosis:
CHARTS
Coal workers pneumoconiosis
Histiocytosis
Ank Spon/Allergic extrinsic alveolitis
Radiation
TB
Silicosis
Lower zone fibrosis:
ACID
Asbestos
Connective tissue disorders (eg. SLE)
Idiopathic pulmonary fibrosis
Drugs (Bleomycin, MTX, Amiodarone, Nitrofurantoin, Cyclophosphamide)
A boy with learning difficulties is noted to be extremely friendly and extroverted. He has short for his age and has supravalvular aortic stenosis…
William’s syndrome
A young child with recurrent episodes of macroscopic haematuria, typically associated with a recent respiratory tract infection and mild proteinuria =
IgA nephropathy
Diagnostic test for cushings syndrome!!!!!?
- think of kiera’s tips re syndrome v disease
The low-dose (overnight) dexamethasone suppression test is the best test to diagnosis Cushing’s syndrome
Flu like illness → brief remission→ followed by jaundice and haematemesis
Yellow fever
The Hba1c target for patients on a drug which may cause hypoglycaemia (eg sulfonylurea) is 53 mmol/mol
The Hba1c target for patients on a drug which may cause hypoglycaemia (eg sulfonylurea) is 53 mmol/mol
Azathioprine - check what before treatment?
Thiopurine methyltransferase deficiency (TPMT)
Refractory hypertension and reduced eGFR after starting ACE inhibitors…
Think renal artery stenosis.
Renin and ACE levels will both be high.
Miller Fisher syndrome presents with what symptoms?
Miller Fisher syndrome - areflexia, ataxia, ophthalmoplegia.
Treatment of Boerhaave’s syndrome:
Treatment is with 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.
Delays beyond 24 hours are associated with a very high mortality rate.
Complications of Boerhaave’s syndrome:
Severe sepsis occurs secondary to mediastinitis
Metatarsal stress fractures most commonly occur where?
The most common site of metatarsal stress fractures is the 2nd metatarsal shaft
Immunocompromised patients with toxoplasmosis are treated with what?
Pyrimethamine plus sulphadiazine
- if not immunocompromised no treatment is needed!!
What is used to diagnose liver cirrhosis?
Transient Elastography; brand name ‘Fibroscan’
Uses a 50-MHz wave is passed into the liver from a small transducer on the end of an ultrasound probe
measures the ‘stiffness’ of the liver which is a proxy for fibrosis.
Typical tx for acute prostatitis:
14-day course of a quinolone
Example of a quinolone
Ciprofloxacin, delafloxacin, levofloxacin, moxifloxacin, and ofloxacin.
Ciprofloxacin is contraindicated in what deficiency?
Ciprofloxacin is contraindicated in G6PD deficiency
Keloid scarring tx
Intra-lesional steroids may be a useful treatment for keloid scarring
Beta blocker OD is managed how?
If bradycardic then atropine
-> in resistant cases glucagon may be used
Ankylosing spondylitis - x-ray findings:
Subchondral erosions, sclerosis and squaring of lumbar vertebrae.
Most common organism found in central line infections
Staphylococcus epidermidis
COPD first line
A SABA or SAMA is the first-line pharmacological treatment of COPD
Note: Ipratropium is a SAMA ughhhhh!!
First line investigation for stable angina?
Contrast-enhanced CT coronary angiogram
Why does nephrotic syndrome result in a hypercoaguable state?
Nephrotic syndrome is associated with a hypercoagulable state due to loss of antithrombin III via the kidneys.
Most common cause of post-menopausal bleeding:
Vaginal atrophy
(still need to rule out endometrial cancer)
Dihydropyridine CCB =
Amlodipine
An ECG shows tall R-waves in leads V1 and V2…
Lateral / Posterior MI
Which test is the best test to diagnosis Cushing’s syndrome?
The LOW-dose (overnight) dexamethasone suppression.
Cushings syndrome = LOW dose dex supp
Duodenal atresia diagnosis and tx?
Abdo-xray (shows double bubble sign)
Treat with Duodenoduodenostomy.
Nephrogenic diabetes insipidus tx
Thiazide diuretic
Speech fluent, but repetition poor. Comprehension is relatively intact
Conduction dysphasia
MoA orlistat
Orlistat works by inhibiting gastric and pancreatic lipase to reduce the digestion of fat.
How are haptoglobin levels affected in haemolysis?
Haptoglobin binds to free haemoglobin therefore levels decrease as there is more free haemoglobin to bind to due to the haemolysis.
Jaundice following abdominal pain and pruritus during pregnancy think…
Acute fatty liver of pregnancy
Macrolide =
Azithromycin, clarithromycin etc
Leptospirosis tx
High-dose benzylpenicillin or doxycycline
What is the Blatchford score used for?
In an acute upper GI bleed, the Blatchford score can identify low risk patients who may be discharged
Inv for pyloric stenosis
Abdo ultrasound
SIADH management
correction must be done slowly to avoid precipitating central pontine myelinolysis
fluid restriction
demeclocycline: reduces the responsiveness of the collecting tubule cells to ADH
ADH (vasopressin) receptor antagonists have been developed
Polycythaemia rubra vera - around 5-15% progress to what?
Myelofibrosis or AML
Management of bed bugs:
Offer topical hydrocortisone, and wash bedding and clothing at a high temperature.
Bradycardia fails to resolve after 6 boluses of atropine then what?
transCUTANEOUS pacing
- generally unwell, lethargy, nausea & vomiting, anorexia, confusion, yellow-green vision
- arrhythmias (e.g.AV block,bradycardia)
- gynaecomastia
Digoxin toxicity!
Absolute risk reduction =
Absolute risk reduction = (Control event rate) - (Experimental event rate)
UC affects where most commonly in the bowel?
Ulcerative colitis - the rectum is the most common site affected.
Caecal volvulus: management?
Right hemicolectomy
Caecal volvulus: management is usually operative.
Why is vitreous haemorrhage worse in the morning?
Worse in the morning as the blood pools on the back of the macula as they lie down.
Ann arbor and Reed sternberg =
HODGKINS lymphoma
Reddening and thickening of nipple and areola → think…
Paget’s disease of the breast
What neurocutaneous syndrome is associated with bilateral vestibular schwannomas?
Neurofibromatosis type 2 is associated with bilateral vestibular schwannomas.
TYPE 2! (two schwannomas = type two)
Bone pain, tenderness and proximal myopathy (→ waddling gait) → ?
Osteomalacia
Not osteopenia and osteoporosis are normally asymptomatic, both have risk of fractures.
Cholesterol targets when starting statins
In the primary prevention of CVD using statins aim for a reduction in non-HDL cholesterol of > 40%
INITIAL scaphoid fracture management?
In the emergency department, suspected scaphoid fractures should be managed with immobilisation using a Futuro splint or standard below-elbow backslab before specialist review.
NNT =
1 / Absolute risk reduction
How long should a patient with C dif isolate for?
Patients suffering froInm C. difficile need isolation for at least 48 hours
Intussusception tx
Pneumatic reduction under fluoroscopic guidance.
Reduction using fluoroscopy with air is the usual first line management. Ileo-colic intussceceptions are generally most reliably reduced using this method, long ileo-ileal intussceceptions usually result in surgery.
Necrotising enterocolitis tx
Initially medical management but may need laparotomy if pt deteriorates.
Erysipelas is localised skin infection caused by what?
Note: Erysipelas has sharp well defined borders which differentiates it from cellulitis.
Streptococcus pyogenes
Fluclox
Premenstrual syndrome tx summary:
Mild
Moderate
Severe
mild symptoms can be managed with lifestyle advice
apart from the usual advice on sleep, exercise, smoking and alcohol, specific advice includes regular, frequent (2–3 hourly), small, balanced meals rich in complex carbohydrates
moderate symptoms may benefit from a new-generation combined oral contraceptive pill (COCP)
examples include Yasmin® (drospirenone 3 mg and ethinylestradiol 0.030 mg)
severe symptoms may benefit from a selective serotonin reuptake inhibitor (SSRI)
this may be taken continuously or just during the luteal phase (for example days 15–28 of the menstrual cycle, depending on its length)
Widened QRS or arrhythmia in tricyclic overdose - give what?
IV bicarbonate
Stress incontinence medical management?
Duloxetine
Oxybutinin is used for urge…
First line for a broad complex tachycardia with no adverse features?
IV amiodarone is the first-line treatment for regular broad complex tachycardias without adverse features.
Local anesthetic toxicity can be treated with what?
IV 20% lipid emulsion
A fracture to the shaft of the humerus can damage what nerve?
Radial nerve
Impetigo 1st line tx
Hydrogen peroxide cream 1%
Note: School exclusion until lesions are crusted over or 48hrs after abx tx.
A severe flare of ulcerative colitis should be treated how?
In hospital with IV corticosteroids
Tension pneumothorax tx =
Needle decompression
Lymphogranuloma venereum is caused by Chlamydia trachomatis and is characterised by unilateral tender lymphadenopathy. There may be some ulcers in lymphogranuloma venereum.
Tx?
Doxycycline
Heinz bodies =
G6PD
Heinz bodies represents damage to haemoglobin and is associated with Glucose-6-phosphate dehydrogenase (G6PD) deficiency and alpha-thalassaemia.
Granulomatosis with polyangiitis antibody?
cANCA
Haemolytic picture on bloods and direct antiglobulin test is positive think…
tx?
Autoimmune haemolytic anaemia
Steroids (+/- rituximab) are generally used first-line in the management of patients with warm autoimmune haemolytic anaemia.
Pulsus paradoxus think…
Cardiac tamponade
Pulsus paradoxus, also known as paradoxical pulse, is a phenomenon where the patient’s blood pressure decreases by more than 10 mmHg during inspiration. This condition is most commonly associated with cardiac tamponade, a medical emergency where fluid accumulates in the pericardial space, leading to impaired ventricular filling and subsequently reduced cardiac output.
Treatment of myxoedema coma:
If myxedema coma is suspected, IV corticosteroids (hydrocortisone) should be given alongside IV thyroid replacement until coexisting adrenal insufficiency has been excluded.
ACS secondary to cocaine give what?
IV lorazepam
Patients with MI secondary to cocaine use should be given IV benzodiazepines as part of acute (ACS) treatment (still give MONA).
Grave’s antibodies…
TSH receptor stimulating antibodies
Organophosphate poisoning give
atropine
Neuro + liver =
- tx?
Wilson’s - do copper studies
- Penicillamine (chelates copper) has been the traditional first-line treatment
VEAL CHOP for understanding accelerations and decelerations on a CTG:
Variable
Early
Accelerations
Late
Variable decelerations –> Cord compression
Early decelerations –> Head compression
Accelerations –> Okay!
Late decelerations –> Placental Insufficiency
