Key concepts Flashcards
Beck’s Triad
Found in Cardiac Tamponade
Fall in BP
Rise in JVP
Muffled heart sounds
Eating Disorders
- Atypical (most common)
- Binge Eating
- Bulimia
- Anorexia (least common; 10% mortality; 20% suicide risk)
Diagnosis:person’s history, suggestive clinical features, and supported, where possible, by corroboration from a relative or friend
Management:
- clear agreement between primary and secondary care about responsibility for monitoring
- Monitoring ongoing level of risk to the person’s mental and physical health and managing complications —
- Placing an alert in the person’s prescribing record
- ECG monitoring to people with an eating disorder who are taking medication that can compromise cardiac functioning for example drugs that may cause electrolyte imbalance, bradycardia, hypokalaemia, or a prolonged QT interval.
- Adults - 1st line CBT-ED, Maudsley Anorexia Nervosa Treatment (MANTRA); Children - 1st line Familt therapy, 2nd line CBT
- Giving advice on contraceptive use and pregnancy to women (LARC - implants and IUS recommended - not Depot) Ensuring the person and their family/carers have access to information and support.
Referral criteria for Anorexia: -
- BMI <13
- CVS instability,
- hypothermia
- metabolic and electrolyte imbalance
- oncurrent infection, overall ill health or abnormal blood tests.
- reduced muscle power
- risk of refeeding syndrome.
- lack of support at home.
- acute mental health risk — risk of suicide attempt/ DSH
Pemberton Sign
Signs of Superior Vena Cava Obstruction e.g in lung cancer, thyroid goitre
Neck + facial erythema and oedema
More pronounced on elevation of the arms over the head
Erythema Nodosum
Auto-immune T III reaction
Behcet,
Sarcoid,
IBD,
Streptococcal infect,
TB,
OCP,
Other drugs
Quadrantanopia
Lesion is on the opposite Parietal or Temporal site
PITS
Parietal - Inferior
Temporal - Superior
Visual field om opposite side is affected
Polymyalgia Rheumatica (PMR)
- > 50 years-old
- at least 2 weeks of bilateral shoulder and/or pelvic girdle pain
and
- stiffness lasting for at least 45 minutes after waking or periods of rest
Fibromyalgia
11 tender points in the body - 9/11 points should be positive
Ischemic stroke
- Aspirin 300 mg daily for 2 weeks
then,
- clopidogrel 75 mg daily long-term (life-long if Stroke with AF - give Warfarin)
Neuropathic Pain Mx
Amitriptyline, Duloxetine, Gabapentin or Pregabalin
Switch drugs - don’t add
Tramadol - rescue therapy for exacerbations
Topical Capsaicin- FRUIT Extract for localised neuropathic pain
Ovarian mass/ lump
Most common
Benign - Follicular cyst
Malignant - Serous Adenocarcinoma
Types:
Germ cell tumours
- Yolk Sac tumours (endodermal sinus tumour)- S_A_C Schiller Duval bodies, raised AFP, children
- Dysgerminomas: DysGERMANoma - German flag (Raised LDH and HCG)
- Teratoma - TERROR toma - monster - all kinds of tissues
Sex cord stromal tumour
- Fibroma (Meig’s Syn)
- Sertoli Leydig tumour: Virilisation due yo raised Androgens, Reinke Crystals (LeDIG for Crystals!)
- Granulosa Theca Call Tumour = Raised Estrogen, Call-Exner bodies (Gran Exner)
Others
- Brenner tumour (Bladder like)
- Krukenberg: metastasises from gut to ovary
Vomiting in neonate
Duodenal atresia - within few hours of birth (double bubble sign)
Meconium ileus - 24 - 48 hrs after birth
Necrotising enterocolitis - after 2 weeks, premature
Screening programmes in NHS -1
- Antenatal - diabetes (preconception, 28 weeks, anaemia at 16 weeks incl Hbinopathy, infection (HIV, Hep B and syphilis), FASP (10 -20 weeks; scan +/- blood tests), diabetic eye screen of T1DM and T2DM
- Neonatal: NIPE (72 hrs; eye, heart, hips, testes); heel prick/ blood spot (5 - 8 days; 9 disease - SCD, CF, CHT, PKU, MCAACD, MSUD, IVA1, GA1, HCU); Hearing (6-8 weeks; OAER/ AABR)
- Chlamydia - opportunistic; men and women <25 years, urine or swabs for females
- Cervical - cervical smear, 25-49 yrs women 3 yearly then 50-64 yrs 5 yearly
Screening programmes in NHS -2
- Breast - Mammogram; 47-73 yrs women (50 - 70 yrs); 3 yearly
- Bowel - FOB, 2 yrly; men and women 60 - 74 yrs
- Aortic Aneurysm - Ultrasound for men at 65 years
- Diabetes Eye screening - annual all T1 and T2 DM
- No screening for Prostate/ Ovarian Ca
Respiratory infections and common pathogens
Common cold - rhinovirus
Flu - influenza virus
Epiglottis - Haemophilus influenza B (HiB)
Bronchiolitis - Respiratory syncytial virus
Croup - parainfluenza virus
Bonchiectasis exarcebations - Hib
Pneumonia
- post flu: staphylococcus aureus
- community-acquired pneumonia: mycoplasma
- atypical pneumonia - Mycoplasma (flu-like, precedes dry cough & complications - haemolytic anaemia erythema multiforme); Legionella (A/C spread, lymphopaenia, hyponatraemia, and deranged LFT); Pneumocystis jiroveci in HIV+ (few chest signs - hilar interstitial infiltration and exertional dyspnoea). Mycobaterium TB - Cough, night sweats and weight loss, Klebsiella - apical and cavitating, associated with Alcohol misuse
Antipsychotic Drugs - Typical (old)
- Haloperidol
- Chlorpromazine
Side Effects:
Extra- Pyramidal e.g. Parkinsonisim, Tardive dyskinesia
Acute dystonia e.g. oculogyric crisis
Thromboembolism
Hyperprolactinaemia
Antipsychotic - Atypical (New drugs)
Quetiapine, Risperidone, Olanzapine, Clozapine
Side Effects: • Weight gain • Agranulocytosis • Hyperprolactinaemia • Stroke & thrombolembolism in elderly, amisulpride, aripiprazole
Clozapine causes:
agranulocytosis (1%), neutropaenia (3%), reduced seizure threshold - can induce seizures in up to 3% of patients, constipation, myocarditis: a baseline ECG should be taken before starting treatment, hypersalivation
School exclusions
- Measles: 4 days
- Mumps & Rubella: 5 days
- Chicken Pox: Till all the lesions have crusted
- Scarlet fever: 24 hrs after abx
- Whooping cough: 48 hrs after abx
- Impetigo: 48 hrs after starting abx or after crusting
- Diarrhoea: 48 hrs after recovery
- Hand foot and mouth, head lice: No exclusion
Ecstasy poisoning
Ecstasy aka MDMA, aka 3,4-Methylenedioxymethamphetamine
c/f: • Hyperthermia • Agitation, anxiety, confusion, ataxia • tachycardia, hypertension • hyponatremia • rhabdomyolysis
Supportive
Dantrolene for hyperthermia
Key features of atypical pneumonia
Mycoplasma A - dry cough, flu, auto-haemolytic anaemia, erythema multiforme
Klebsiella - Alcoholism, red-currant jelly sputum, cavitating in upper lobe
Legionella - AC, travel hx, lymphopenia, low sodium, abnormal LFT
Pneumocystis jiroveci - HIV +
Chlamydia psittaci - Birds, parrots
Tuberculosis (TB) - weight loss, fever, night sweat, cough with sputum
Treatment of atypical pneumonia
Mycoplasma - erythromycin
Klebsiella - erythromycin
Legionella - erythromycin
Pneumocystis jiroveci - co-tromoxazole
Chlamydia psittaci - erythromycin
TB - RIPE for 4/12, then RI for 2/12
Angina
breathlessness on exertion
Causes: Ishaemia, valvular ds (AS), HTN, HOCM
Types: Stable or Unstable
Referral to Specialist: if no relief on BB + CCB, worsening symps, unstable angina
Mx:
- Quit smoking,
- Cardioprotective diet,
- physical activity within limitation
- healthy weight
- alcohol use within limits
- Anti-anginal medication: sublingual GTN for rapid relief or before activity that triggers, beta blocker or calcium channel blocker - singly first, them switch to other, then combine, long acting nitrates - isosorbide, nicorandil, ivabradine, ranolazine - third drug while awaiting specialist review and cardiac revascularisation
- secondary protection = aspirin 75 mg, ACE inhibitor, statin, control of HTN +/- DM
Contraindications to COC use
4 point scale
UKMEC 1: no restriction
UKMEC 2: benefits outweigh the risks
UKMEC 3: risks outweigh benefits
UKMEC 4: unacceptable health risk
Relative contraindications to COC (UKMEC3)
> 35 years and smoking <15 cigarettes/day
BMI > 35 kg/m^2*
family hx of VTE disease in first degree relatives < 45 years
controlled hypertension
immobility e.g. wheel chair use
carrier of known gene mutations of breast cancer (e.g. BRCA1/BRCA2)
current gallbladder disease
Absolute contraindications to COC use (UKMEC4)
> 35 years and smoking <>5 cigarettes/day
Liver ds - cirrhosis, malignancy
migraine with aura
history of thromboembolic disease or thrombogenic mutation
history of stroke or ischaemic heart disease
breast feeding < 6 weeks post-partum
uncontrolled hypertension
current breast cancer
major surgery with prolonged immobilisation
Aspirin use in pregnancy
- Mother age above 40 years & first pregnancy
- FHx of eclampsia
- BMI above 35
- 10 yrs age between pregnancies
Types of Hypersensitivity reactions
A - Allergen, Atopy, Asthma, Allergic rhinitis, Anaphylaxis - IgE, basophils & mast cells - Rapid (<30’) - TYPE I
C - Cytotoxic - Complement mediated (csmooth deposition) activated by IgG/ IgM - GoodPasture’s, Myasthenia, AHA, Graves’, Intravascular reaction, Blood transfusion reaction - TYPE 2
I - Immunecomplex mediated, Ag and IgG & IgM form complexes (lumpi + bumpi) deposits, Tissue Damage RA, Erythema nodosum - Post streptococcal GN, SLE - TYPE 3
D - Delayed Cytotoxic - cell mediated, CD8 + killer cells - Lymphocyte, T-cells; 48-72 hrs later - Diabetes, dermatitis, Tuberculin test (Mantoux’s), contact dermatitis, graft - TYPE 4
Medical conditions notifiable to DVLA
Group 1 - car and motorcycles
Group 2 - lorries, heavy vehicles, buses
- diabetes taking insulin
- syncope (fainting) and sudden dizziness, Meniere’s disease - till symptoms in control
- heart conditions (including AF and pacemakers eg implanted defibrillator
- sleep apnoea
- epilepsy
- strokes & TIA
- glaucoma
hypertension: drive unless treatment causes unacceptable side effects, no need to notify DVLA - if Group 2 driver disqualified from driving if resting SBP consistently >180 mmHg or DBP > 100 mm Hg
angioplasty (elective) - 1 week off driving
CABG - 4 weeks off driving
acute coronary syndrome- 4 weeks off driving - 1 week if successfully treated by angioplasty
angina - driving must cease if symptoms occur at rest/at the wheel
pacemaker insertion - 1 week off driving
implantable cardioverter-defibrillator (ICD) - if implanted for sustained ventricular arrhythmia - stop driving for 6 months; if implanted prophylactically then cease driving for 1 month. Having an ICD results in a permanent bar for Group 2 drivers
successful catheter ablation for an arrhythmia - 2 days off driving
aortic aneurysm of 6cm or more - notify DVLA. Licensing will be permitted subject to annual review; an aortic diameter of 6.5 cm or more disqualifies patients from driving
heart transplant: do not drive for 6 weeks, no need to notify DVLA
1st seizure: 6 mth no driving, with established epilepsy till fit free for 12 months
Multiple TIA’s - 3 mth no driving
Stroke: 1/12 no driving
Craniotomy: 1 yaer of driving
Pituitary tumour - 6 mth off driving
Narcolepsy/ cataplexy: stop driivng on diagnosis
Drug Causes of Pernicious Anaemia
Auto-immune
Severe Vit B12 deficiency
PPI
H2 receptor antagonist
Metformin
Colchicine
Nitrous Oxide
Immunisation for those born before 2020
2 mth: 6 in 1, rotavirus, PCV, Men B
3 mth: 6 in 1, rotavirus
4 mth: 6 in 1, PCV, Men B
12 - 15 mth: MMR, Hib/MenC, Men B, PCV
3 - 4 yrs: pre-school 4 in 1 (DTP, polio), MMR
2 - 11 yrs: annual flu (LAIV - fluenz tetra; live)
12 - 13 yrs: HPV x 2 dose 6-24 mth apart
14 yrs: pre-university (DT, polio), Men ACWY
Pertussis: Pregnancy 28 - 32 weeks
Immunisation for those born after 2020
2 mth: 6 in 1, rotavirus, Men B
3 mth: 6 in 1, rotavirus, PCV
4 mth: 6 in 1, PCV, Men B
12 - 15 mth: MMR, Hib/MenC, Men B, PCV
3 - 4 yrs: pre-school 4 in 1 (DTP, polio), MMR
2 - 11 yrs: annual flu (LAIV - fluenz tetra; live)
12 - 13 yrs: HPV x 2 dose 6-24 mth apart
14 yrs: pre-university (DT, polio), Men ACWY
Pertussis: Pregnancy 28 - 32 weeks
Benzylpenicillin Dose in suspected Meningitis
< 1 year - 300 mg im/iv
1 - 10 years - 600 mg im/iv
>10 years - 1200 mg im/iv
Febrile convulsions in Children
Lasts 3 - 6 mins; tonic-clonic
May be simple (recovers in 10’, no recurrence in 24 hrs) or complex (lasts > 15’, recurs in <24 hrs, focal s/s)
d/d: epilepsy, hypoglycaemia, brain injury, apnoea, rigors, syncope, meningitis, encephalitis
referral criteria: < 18 mths old; first seizure, diagnostic uncertainty, complex seizures, parental anxiety, recently taken abx
Febrile convulsions
Treatment
- Midazolam buccal/ rectal diazepam
Diagnosing Diabetes
- Fasting glucose >7.0 mmol/ l
- Random or After oral 75 gm glucose > 11.1 mmol/ l
- done once in symptomatic patient and x 2 in asymptomatic
- HbA1C > 48 mmol/l
Impaired Fasting Glucose: FBS 6.1 - 7 mmol/ l
Impaired Glucose Tolerance: FBS < 7.0 mmol/l and OGTT 2-hour > 7.8 and above
Pre-diabetes: HbA1 C 42 - 47 mmol/ l
Diabetes: 48 mmol/ l
Blood Sugar Control targets
On metformin alone 48 mmol/ l
On insulin or combined drug producung hypoglycaemia 53 mmol/l
2 WW - Referral Criteria
https://www.nice.org.uk/guidance/ng12/resources/suspected-cancer-recognition-and-referral-pdf-1837268071621
- Suspected Oral Ca: Unexplained oral ulceration >3weeks; Lump on lip or in mouth, ?erythroplakia (red or red+white patch), Erythroleukoplakia; Persistent unexplained neck lump
- Suspected Laryngeal Ca: >=45 years PLUS Persistent unexplained hoarseness/ Unexplained neck lump
- Suspected ENT Ca: unilateral symptoms or unilatetal nasal polyp
- Suspected Lung Ca: chest X-ray findings that suggest lung cancer OR =>40years AND unexplained haemoptysis
URGENT CXR criteria (=>40 yrs over AND =>2 or more of unexplained symptoms, or if they have ever smoked and have 1 or more of the unexplained symptoms: cough, fatigue, SOB, chest pain, weight loss, appetite loss, finger clubbing
- Suspected Breast Ca: Aged =>30 years AND Unexplained breast/ axillary lump +/- pain; Aged =>50 years AND Unilateral discharge, retraction, other concerning changes like skin changes
- Suspected Oesophageal Ca: Dysphagia in >= 55 yrs PLUS weight loss AND upper abdominal mass, pain +/- reflux
- Suspected Stomach Ca: Dysphagia AND Aged >=55 with weight loss and upper abdo pain, reflux, dyspepsia
- Suspected Pancreatic Ca: Aged >=40 + jaundice OR Aged >=60 with weight loss and diarrhoea, back pain, abdo pain, nausea, vomiting, constipation, new diabetes
2 WW - Referral Criteria
- Suspected Colorectal Ca: Aged >=40 PLUS Unexplained weight loss + abdo pain; Aged <50 AND Rectal bleeding, abdo pain, change in bowel habit, weight loss, IDA; Aged >=50 PLUS Unexplained rectal bleeding; Aged >=60 PLUS Iron deficiency anaemia/ Changed in bowel habit, Any age AND FOBT +ve or Rectal/abdominal mass
- Suspected Anal Ca: Unexplained anal mass or Unexplained anal ulceration
Suspected Ovarian Ca: Ascites, Pelvic or abdo mass, USS suggestive ovarian cancer and raised Ca 125
Suspected Endometrial Ca: Aged >=55 with PMB or increased ET
Suspected Cervical Ca: On examination, appearance of cervix consistent with cervical cancer
Suspected Vulval Ca: Unexplained vulval lump, ulceration or bleeding
Suspected Vaginal Ca: Unexplained palpable mass in entrance to vagina
Suspected Prostate Ca: Feels malignant on DRE; PSA over age-specific range
Suspected Bladder Ca: >=45 AND Unexplained visible haematuria without UTI or after successful treatment of UTI or >=60 AND Unexplained non-visible haematuria AND dysuria with raised serum WCC
Suspected Renal Ca: Aged >=45 + unexplained visible haematuria without UTI or after successful treatment of UTI
Suspected Testicular Ca: Non-painful enlargement/change in shape or texture of testis
Suspected Penile Ca: Penile mass/ulcer with STI excluded or STI treated
Suspected Melanoma: Major features scoring 2 points each with change in size, irregular shape, irregular colour. Minor features of the lesions (scoring 1 point each): largest diameter 7 mm or more, inflammation, oozing, change in sensation.
Tests in Upper Limb
Hoffman’s sign - sign of UMN dysfunction due to degenratice cervical myopathy.
(Hoffman)-Tinel’s sign (wrist): paraesthesia on tapping at wrist in medial nerve distribution in carpal tunnel syndrome:
Phalen’s sign: Forced dorsiflexion of wrists in carpal tunnel syndrome
Finkelstein’s test: De Quervain’s tenosynovitis (gamer’s wrist or berry thumb) - pulls the thumb of the patient in ulnar deviation and longitudinal traction - pain over lateral styloid process.
Mill’s test: Lateral epicondilytis (tennis elbow)
Forced extension of the wrist with a supinated and extended forearm: Medial epicondilytis (Golfer’s elbow)
Tinel test (ankle) tapping in front and behind medial malleolus to check for compression/ damagetp ant tibial and post tibial nerve respectively.