January Flashcards
What score do we use to assess need for anticoagulant medication?
CHADVASC HASBLED CHADVASC gives risk of stroke HASBLED risk of bleeding If risk of bleeding higher do not start anticoagulant
What’s the carina?
Bifurcation into right and left bronchus
Side effects of prolonged steroid use
Cushingoid Bones - osteoporosis Skin - thinning and bruising Weight gain Glucose - diabetes Hypertension Psychosis
Atrial fibrillation increases the risk of what condition
Stroke
Causes of loss of consciousness
Arrhythmias Head injury Hypercapnia Hypoglycaemia Hypotension Stroke
Symptoms of Hypoglycaemia
Anxious Tired Hunger Sweating Headache Nausea Coma
Which vessel is damaged if patient has following symptoms - Contralateral hemiplegia, hemisensory loss, homonymous hemianopia, aphasia?
Middle Cerebral artery
Which vessel is damaged if patient displays following symptoms - Contralateral weakness and sensory loss in the leg more than in the arm.
Urinary incontinence, confusion and behavioural disturbances are common.?
Anterior cerebral artery
Which vessel is damaged if patient displays following symptoms - Contralateral homonymous hemianopia, agnosia?
Posterior cerebral artery
What symptoms are caused by a lacunar stroke?
Pure motor
Pure sensory
Ataxia
Dysarthria clumsy hand syndrome
What investigations required for stroke?
Non-contrast CT head MRI head Carotid doppler ECHO ECG
TPA is given under 4.5 hours when which condition has been excluded in stroke?
Haemorrhagic stroke
Risk factors for stroke?
Hypertension Diabetes Smoking Lipids Alcohol excess
What is the term given when someone is unable to recognise and interpret visual information?
Visual agnosia
What is the term given when someone is unable to recognise objects, smells, shapes and sounds?
Sensory agnosia
What term is given to the denial of hemiplegia?
Anosagnosia
What term is given to the inability to recognise your own and others faces?
Prosopagnosia
Signs and symptoms of subarachnoid haemorrhage?
Thunderclap headache Loss of consciousness Photophobia Phonophobia Neck stiffness - nuchal rigidity
3 causes of aneurysmal subarachnoid haemorrhage
Trauma
Ehler Danlos
Polycystic kidney disease
Investigations for SAH?
CT head
Spinal tap - if CT head negative
Cause of SAH
Rupture of berry aneurysm
Rupture of arteriovenous malformation
Head injury
Where do intracranial aneurysms usually occur?
In circle of willis where arteries connect
40% - at junction of anterior cerebral and anterior communicating
Complications of subarachnoid haemorrhage
Cardiogenic shock Vasospasm Hydrocephalus Rebleeding Seizure Infection
How are SAH graded?
World Federation of Neurological Societies (WFNS) scale which uses GCS and motor deficits to grade the severity of the sub arachnoid haemorrhage
What is included in the WFNS scale to grade severity of SAH?
GCS
Motor deficits
3 points of HHS
Hypovolaemia
Hyperglycaemia
Hyperosmolality
How is SAH treated?
Treatment of aneurysm Coiling of aneurysm Craniotomy and clipping of aneurysm Nimodipine - for vasospasm HHH therapy - used to prevent or treat cerebral vasospasm after SAH Hypervolaemia Haemodilution Hypertension
What is meckel’s diverticulum?
Congenital diverticulum of small intestine
What type of cells are found in meckel’s diverticulum?
Ectopic ileal, gastric or pancreatic mucosa
Where does meckel’s diverticulum occur?
2 feet (60cm) from ileocaecal valve
What percentage of the population have meckel’s diverticulum?
2%
What is meckel’s diverticulum a remnant of?
omphalomesenteric duct (vitellomesenteric duct) - vitelline duct: joins yolk sac to midgut in foetus
Presenting symptoms of meckel’s diverticulum?
Abdominal pain; mimics appendicitis
Rectal bleeding
Intestinal obstruction
How does intestinal obstruction occur in meckel’s diverticulum?
Secondary to volvulus, omphalomesenteric band and intussusception
What is the most common cause of painless massive GI bleeding in children between ages 1 and 2?
Meckel’s diverticulum
When does the attachment between the vitellointestinal duct and yolk sac disappear?
6 weeks
Management of meckel’s diverticulum
Surgery - wedge excision or formal small bowel resection and anastomosis
Which plexuses fail to develop in Hirschspung’s disease?
Auerbach and Meissner parasympathetic
Risk factors for hirschsprung’s disease
Male
Down’s Syndrome
Family history
A defect in the anterior abdominal wall leading to protruding bowel is known as
Gastroschisis
Hypertrophy of the pyloric muscle leads to
Pyloric stenosis
Telescoping of the ileocolic junction occurs in which disease
Intussusception
Symptoms of intussusception
Bilious vomiting
Red currant jelly like stool
Treatment for intussusception
Air enema
What is Grey Turner’s sign?
Retroperitoneal haemorrhage leading to blue discolouration of the flanks.
Name the organs which are retroperitoneal
S: suprarenal (adrenal) gland
A: aorta/IVC
D: duodenum (second and third part)
P: pancreas (except tail)
U: ureters
C: colon (ascending and descending)
K: kidneys
E: oesophagus
R: rectum
Which part of the pancreas is intraperitoneal?
Tail
Barrett’s oesophagus increases the risk of what disease?
Oesophageal adenocarcinoma
Which type of cell present in a histological sample taken from the lower oesophagus is diagnostic of barrett’s?
Goblet cell
Risk factors for barrett’s
Male
GORD
Smoker
Centra obesity
Management for barrett’s oesophagus
Endoscopy for surveillance and biopsies every 3-5 years
Proton pump inhibitors
Endoscopic intervention used to treat Barrett’s oesophagus?
endoscopic mucosal resection
radiofrequency ablation
Which monoclonal antibody targets Toxin b of C difficile?
Bezlotoxumab
Which type of organism is Clostridium difficile?
Gram poositive bacillus
Which syndrome is caused by exotoxin released by C difficile?
Pseudomembranous colitis
How does c difficile infection tend to occur?
Normal gut flora suppressed by antibiotics
Which antibiotic is associated in causing c difficile?
Clindamycin
Which drugs other than clindamycin are associated with c diff?
Second and third gen cephalosporins
PPIs
Signs and symptoms of c difficile
Diarrhoea
Abdominal pain
Raised WCC
Toxic megacolon if severe
How is c difficile diagnosed?
Presenting signs and symptoms with history
Detection of CD toxin in the stool
First line treatment for c difficile
Metronidazole
Second line treatment for c difficile
Vancomycin
Life threatening c difficile is treated with which drug combination?
Oral vancomycin and IV metronidazole
Complications of diverticular disease
Diverticular stricture leading to obstruction Colovesical fistula Colovaginal fistula Haemorrhage Peritonitis Perforation and abscess
Risk factors for formation of diverticulum
Age Low dietary fibre intake Smoking Obesity Family history NSAIDS
Features of diverticular disease
Intermittent lower abdominal pain, colicky, relieved by defecation
Change in bowel habit
Nausea
Flatulence
Features of acute diverticulitis
Sharp left iliac fossa pain Worse on movement Decreased appetite Pyrexia Nausea
General causes of lower abdominal pain
Diverticular disease Bowel cancer Inflammatory bowel disease Gynaecological Renal stones Mesenteric ischaemia
Investigations for Diverticular disease
Bloods
CT abdopelvis
Barium enema
How does gastroschisis differ from exomphalos?
Both abdominal wall defects leading to protusion of contents
Contents held in amniotic sac in exomphalos
Exomphalos also associated with cardiac (cardiomegaly) and kidney (cysts) conditions
Exomphalos occurs at base of insertion of umbilical cord
Gastroschisis occurs lateral to umbilical cord
When do abdominal contents normally protrude in development?
Six weeks
Return by the twelth week
Foetal anomaly scan showing exomphalos and enlarged liver is indicative of which condition?
Beckwith-wiedemann syndrome
Features of Beckwith-wiedemann syndrome?
Overgrowth symptoms - large for gestational age, macrosomia, macroglossia, organomegaly and abdominal wall defects (exomphalos, umbilical hernia).
Blood sugar issues - neonatal hypoglycaemia, hyperinsulinism
Increased risk of childhood cancers - Wilm’s tumour, hepatoblastoma
What is Behcet’s disease?
Inflammatory disorder causing genital sores, uveitis and arthritis
Can’t pee, can’t see, can’t climb a tree
What is Dandy-walker syndrome?
Failure of growth or abscence of central part of cerebellum
Which mutation is a risk factor for a desmoid tumour?
APC
In which group of patients do desmoid tumours most commonly occur?
Women in the rectus abdominis after childbirth
How are desmoid tumours treated?
Surgical resection
Which 2 structures are most likely to be penetrated in peptic ulcer disease?
Posterior medial wall of second part of the duodenum
Into the gastroduodenal artery
What is a complication of peptic ulcer disease?
GI Bleed leading to Shock
How does a patient present with shock?
Low blood pressure
Sweating
Collapse
What is the most common cause of peptic ulcer disease?
Bleeding
Most common presenting symptoms of peptic ulcer disease?
Haematemesis
Melaena
Hypotension
Tachycardia
Management of peptic ulcer disease
ABCDE approach PPIs via IV Endoscopic intervention FAILURE OF FIRST LINE urgent interventional angiography with transarterial embolization or surgery
What is the method of inheritance of Gilbert’s syndrome?
Autosomal recessive
Which deficiency is present in Gilbert’s syndrome?
UDP glucoronosyltransferase
What is the prevalence of Gilbert’s syndrome>
1-2%
What are the features of Gilbert’s syndrome?
Unconjugated Hyperbilirubinaemia
Jaundice
What does unconjugated hyperbilirubinaemia indicate?
Bilirubin not present in the urine
When might someone experience jaundice if they have Gilbert’s syndrome?
In illness
Exercise
Fasting
What is the treatment for Gilbert’s?
No management
What type of epithelium lines the oesophagus?
Stratified squamous epithelium
Define metaplasia
Reversible change of differentiated cells to another ccell type
What type of metaplasia can smoking cause and what is the name given to this?
Ciliated columnar to simple squamous - Schistosomiasis
What is the acute treatment of variceal haemorrhage?
ABC
Clotting - FFP, Vitamin K
Vasoactive reagents - terlipressin, octreotide
Endoscopic variceal band ligation
Endoscopic sclerotherapy
If both methods fail - TIPP - Transjugular Intrahepatic Portosystemic Shunt
Which drug should be given to a patient with cirrhosis in acute variceal bleeding to reduce mortality?
Antibiotics - quinolones
What is the prophylactic treatment of variceal bleeding?
Endoscopic band ligation - particularly to patient with cirrhosis
Propanolol
What kind of drug is propanolol and why is it used in the prophylaxis of variceal bleeds?
Non-cardioselective B blocker
Causes splanchnic vasoconstriction - reduces portal flow
Which drug can cause oligospermia in men?
Sulfasalzine
What are the indications for sulfasalazine?
Crohns
Ulcerative colitis
Rheumatoid arthritis
Which vein is commonly harvested for CABG?
Great saphenous vein
Which nerve is prone to damage when harvesting vessel for CABG?
Saphenous nerve
What is carcinoid syndrome?
Occurs when metastases present in the liver - release serotonin
Also can occur in lung carcinoid
Features of a carcinoid tumour
Flushing Diarrhoea Bronchospasm Hypotension Right vavular stenosis ACTH and GHRH secretion Pellagra - inflamed skin, diarrhea, dementia, and sores in the mouth
ACTH and GHRH secretion as seen in carcinoid syndrome can result in what condition?
Cushing’s syndrome
investigations for carcinoid syndrome?
Urinary 5 HIAA
Plasma chromogranin A
Management of carcinoid syndrome
somatostatin analogues e.g. octreotide
diarrhoea: cyproheptadine may help
Which type of drug is metoclopramide and what is its action?
Antiemetic - D2 receptor antagonist
Metoclopramide functions both at the chemoreceptor trigger zone and on 5-HT receptors in the GI tract
Indications of metoclopramide
Nausea
Migraine
GORD
Adverse effects of metoclopramide
extrapyramidal effects: oculogyric crisis. This is particularly a problem in children and young adults
hyperprolactinaemia
tardive dyskinesia
parkinsonism
Symptoms of small bowel obstruction
Vomiting, severe abdominal pain and abdominal distension
Sign on Abdominal X ray in cholecystoenteric fistula
Air in the gallbladder and biliary tree on AXR is most likely due to cholecystoenteric fistula
Pneumobilia
What needs to be checked before prescribing a biologic - eg infliximab for Crohns?
Interferon gamma release assay - TB
What is the most common site affected in ischaemic colitis?
The splenic flexure is a watershed area for arterial supply from the superior and inferior mesenteric artery, and is the location most susceptible to ischaemic colitis.
Sigmoid - 2nd most affected
What is the typical presentation of acute mesenteric ischaemia?
Severe, sudden onset, constant abdominal pain
Diarrhoea
Out of keeping with physical examination findings
What condition is a risk factor for acute mesenteric ischaemia?
Atrial fibrillation
Which other conditions can result in raised troponin?
Pulmonary embolism Myocarditis Arrhythmia Heart failure Sepsis Renal failure Aortic dissection
Mechanism of methotrexate
Folic acid antagonist - deprives cells of functional folic acid
What monitoring is required with methotrexate?
Lowers the blood count
Remedy with fullinic acid????
