Last week key info Flashcards
1
Q
In a haemorrhagic stroke what happens in response to high intracranial pressure
A
Cushing’s triad
2
Q
Name Cushing’s triad, and when it is seen
A
In haemorrhagic stroke causing raised intracranial pressure
Bradycardia
Hypertension
Irregular respiration
3
Q
What is the treatment for raised intracranial pressure (haemorrhagic stoke - Cushing’s triad)
A
Mannitol - osmotic diuretic
4
Q
Name the stroke that occurs in the basal ganglia
A
Intracerebral
5
Q
Where does an intracerebral stroke occur
A
Basal ganglia
6
Q
What is the main risk factor for an intracerebral stroke
A
Hypertension
7
Q
What is seen on a non-contrast CT head of a intracerebral stroke
A
Hyper density (fresh red blood)
Midline shift if large
8
Q
What is the general management of haemorrhagic strokes except one
A
ABCDE management
Supportive management
Burr-Hole craniotomy
9
Q
What stroke has a different management than other strokes
A
Subarachnoid
10
Q
Summarise a intracerebral stroke
Occurs
Main risk factor
Seen on Non-contrast CT head
A
Occurs - basal ganglia
Main rf = hypertension
Hyper density (fresh blood)
Midline shift if large
11
Q
What are the main risk factors of a subarachnoid stroke
A
Berry aneurysms - anterior communicating artery
PKD
12
Q
Which stroke would berry aneurysms/PDK be a risk factor
A
Subarachnoid
13
Q
What artery do berry aneurysms affect
A
Anterior communicating
14
Q
What stroke is described as a thunderclap headache
A
Subarachnoid
15
Q
Describe the investigations of a subarachnoid
A
Non-contrast CT head - after 48 hours - star sign (cistern and ventricles), hyperdense
Lumbar puncture (12 hours after) - bilirubin to breakdown - xanthochromia
16
Q
In a subarachnoid haemorrhage how long do you wait before doing a CT head
A
48 hours
Star sign
17
Q
Which type of stroke has a star sign
A
Subarachnoid
18
Q
What is seen on a lumbar puncture of subarachnoid haemorrhage
A
Xanthochromia
19
Q
Describe the treatment of a subarachnoid haemorrhage
A
Nimodipine (CCB) - prevents vasospasm
Surgery (coiling)
20
Q
Define a subdural stroke
A
Dura mater and arachnoid mater
21
Q
What type of stroke is caused by rupture of the bridging veins
A
Subdural
22
Q
What are the 3 reasons there are rupture of the bridging veins and what stroke is it seen in
A
Subdural
Brain atrophy elderly
Alcohol abuse (brain walls thinner)
Shaken baby
23
Q
Describe the CT scan of a subdural stroke
A
Hypodense (old blood)
Crescent shaped (concave)
Bleeding occurs across suture lines
Midline shift
24
Q
What stroke shows concave (crescent shaped) CT
A
Subdural
25
Summarise a subdural stroke
Cause
CT head
Rupture of the bridging veins - elderly, shaken baby, alcohol abuse
Hypodense, concave (crescent shaped), crosses suture lines
26
Summarise a extradural stroke
Where
Symptoms
CT head
Middle meningeal artery - skull fracture low impact
Lucid interval
Hyperdense (fresh)
Lemon shaped (convex)
Not cross suture lines
Midline shift
27
What type of stroke causes a lemon shaped (convex)
Extradural
28
What type of stroke causes a lucid interval
Extradural
29
Define Bamford classification - total anterior circulation stroke (TACS)
ALL 3
Unilateral weakness
Homonymous hemianopia
Dysphasia, visuospatial disorder
30
Define Bamford classification - partial anterior circulation stroke (PACS)
2 OF (same category as TACS)
Unilateral weakness
Homonymous hemianopia
Dysphasia, visuospatial disorder
31
Define Bamford Classification - lacunar stroke
ONE of
Pure sensory
Pure motor
Sensori-motor
Ataxic
No loss of higher
Small vessel disease
32
Define Bamford Classification - Posterior circulation syndrome (POCS)
One of
Cranial nerve palsy
Bilateral motor/sensory deficit
Gaze (conjugate eye movement)
Cerebellar dysfunction e.g. vertigo
Isolated hemianopia or cortical blindness
33
What are the 2 tools of strokes
FAST - community
ROSIER - hospital
34
What stroke do you not want to lower BP and why
Ischemic
Do not want to decrease perfusion to the brain
35
Describe the management of ischaemic stroke
< 4.5 hours = thrombolysis with alteplase
< 24 hours = medical thrombectomy
36
Describe the rules on driving after a TIA/stroke
No driving 1 month following a stroke/TIA no need to inform DVLA
37
Name 2 investigations and why in TIA strokes
MRI head - within 24 hrs
Carotid doppler - determine of suitable for carotid endarterectomy if > 70%
38
What % occlusion makes a patient suitable for a carotid endarterectomy
> 70%
39
Describe the management of a review in a TIA
1 or more TIA = urgent seen
Suspected TIA < 7 days = within 24 hours
Suspected TIA > 7 days = within 7 days
40
Describe the medical management of TIA
Immediate 300mg aspirin
Already on aspirin - wait for review
If on anticoagulant = CT head - check for bleeding
41
Describe features of Guillain-Barre Syndrome
Symmetrical + ascending muscle weakness
42
Name the key cause of Guillain-Barre Syndrome
Autoimmune to campylobacter jejuni (gastroenteritis)
43
What antibody is associated with Guillain-Barre Syndrome
Anti-GM1
44
Describe the 2 investigations of Guillain-Barre Syndrome
Brighton criteria
Lumbar puncture
45
What is seen on a lumbar puncture of Guillain-Barre syndrome
Increased protein
Normal WCC + glucose
46
What is the management of Guillain Barre syndrome
IV IG or plasma exchange
47
Describe Miller Fisher Syndrome
Variant of GBS
Triad
- ophthalmoplegia
- ataxia
- areflexia
48
What is a key complication of Gulilain-Barre syndrome and how do you measure it
Resp failure
Monitor FVC
49
What type of hypersensitivity reaction is multiple sclerosis
4
50
Name the 3 key symptoms of multiple sclerosis
Optic neuritis
Uthoff's phenomenon
Lhermitte's sign
51
Define Uhthoff's phenomena
Symptoms worse after heat e.g. shower
52
What condition may a patient complain that the symptoms are worse after heat e.g. a hot shower
Multiple sclerosis
Uhthoff's phenomenon
53
Define Lhermitte's sign
Electric shock sensation down the spine when flexing the neck
54
What criteria is used in multiple sclerosis
McDonald's criteria
55
Describe McDonalds criteria
> 24 hours apart
Disseminated in time > 1 month apart
Disseminated by space - MRI scan (visualise lesion)
56
Describe the treatment of acute relapse of multiple sclerosis
Corticosteroids e.g. methylprednisolone
57
Describe the long term management of multiple sclerosis
Natalizumab, interferon-beta, fingolimod
58
Define sensitivity
Ability of a test to correctly identify people with the disease
59
Define specificity
Ability of a test to correctly identify people without the disease
60
What condition causes 'worse with activity (fatigability) improves with rest
Myasthenia Gravis
61
Define myasthenia gravis
Worse with activity. Improves with rest
AchR antibodies - bind to post synaptic receptors of the neuromuscular junction = block and prevent acetylcholine binding
62
What is myasthenia gravis associated with
Thymomas
63
What is the GS investigation in myasthenia gravis
AchR (acetylcholine receptor antibodies)
64
What is the 1st line management of myasthenia gravis
Pyridostigmine
Long acting acetylcholinesterase inhibitor
65
Name a complication of myasthenia gravis and describe it and why it occurs
Myasthenic crisis
Illness can cause acute worsening of symptoms
Resp failure - measure ABG, FVC
Treatment - IV IG + plasmapheresis
66
Define lambert Eaton syndrome
Autoimmune affects neuromuscular junction
Muscle contractions get stronger with use
67
Describe the pathophysiology of lambert eaton syndrome
Antibodies against voltage-gated calcium channels in presynaptic membrane of neuromuscular junction
Less acetylcholine release into the synapse
68
What is lambert eaton syndrome associated with
Small cell lung cancer
69
What is the GS investigation for lambert eaton syndrome and what would be seen
EMG
Incremental response to repetitive electrical stimulation
70
What does motor neurone disease not affect
The eyes
71
What is the diagnosis of MND
Diagnosis of exclusion
72
What is the treatment of MND
Riluzole - glutamate antagonist
+ non-invasive ventilation
73
Describe the presentation of Parkinson's disease
Male 70 + TRAP BF
Tremor - resting tremor
Rigidity - cogwheel rigidity
Akinesia - lack of movement
Postural instability
Bradykinesia - slow and small movements
Festination's - shuffling gait
74
What is the mnemonic used to remember the symptoms of Parkinson's
TRAP BF
Tremor - resting tremor
Rigidity - cogwheel rigidity
Akinesia - lack of movement
Postural instability
Bradykinesia - slow and small movements
Festination's - shuffling gait
75
What does TRAP BF stand for
Tremor - resting tremor
Rigidity - cogwheel rigidity
Akinesia - lack of movement
Postural instability
Bradykinesia - slow and small movements
Festination's - shuffling gait
Symptoms of Parkinson's
76
Name the treatment for Parkinson's
Levodopa +peripheral decarboxylate inhibitor (carbidopa) = co-carbidopa
77
Name the symptoms of Parkinson's plus syndrome
Multiple system atrophy
Progressive supranuclear palsy
Dementia Lewy Body
Corticobasal degeneration
78
Describe the cause of Huntington's Disease
Degeneration of the nerve cells in the brain
Autosomal dominant - mutation in Huntington (HTT) gene on chromosome 4
79
Describe why anticipation occurs
Earlier + more severely due to unstable triplet repeat
80
Name the symptoms of Huntington's Disease
Chorea
Dysarthria
Dysphagia
Personality changes - irritable, outburst, impulsiveness
81
Name 3 medications which can help with chorea
Dopamine depleting agent - tetrabenazine
Benzodiazepines - diazepam
Anti-psychotics - olanzapine, risperidone
82
How is a AKI confirmed
One of
Rise in serum creatinine > 28 micromol/L within 48 hours
>= 50% rise in serum creatinine in 7 days
Urine output < -0.5ml/kg/hour for more than 6 hours
83
Describe how an AKI is diagnosed off urine criteria
Urine output < 0.5ml/kg/hour
Stage 1 > 6 hours
Stage 2 > 12 hours
Stage 3 > 24 hours or 12 hour anuria
84
Describe how an AKI is diagnosed off creatinine criteria
Stage 1 - Rise in creatinine > 28 micromol/L in 48 hours
OR
Rise in serum creatinine in last 7 days by
Stage 1 - 50-99%
Stage 2 - 100-199%
Stage 3 - > 200% / creatinine > 354 micromol/L with one other criteria
85
What is the main cause of an intrinsic AKI
Acute tubular necrosis
86
Name 7 nephrotoxic drugs
Aminoglyside antibiotics e.g. gentamycin
ACE-i
ARB
Bisphosphonates
NSAIDs
Loop diuretics
Lithium
87
Name 2 drugs which are renally excreted and should be stopped where possible in an AKI
Metformin
Opiates
88
What are the functions of the kidney
A WET BED
Acid-base balance
Water removal
Erythropoiesis
Toxin removal
Blood pressure control
Electrolyte balance
Vitamin D activation
89
What is the mnemonic for remembering kidney functions
A WET BED
90
Define eGFR
Total amount of fluid filtered through all functioning kidney nephrons within a set unit of time
Based of age, sex etc
91
Describe the diagnosis of CKD
One of
eGFR < 60ml/min/1.73^2 > 3 months
Urine ACR (albumin: creatinine ratio) > 3 mg/mmol
Presence of kidney damage markers
92
What does A score indicate
Proteinuria
93
Describe the main symptoms seen in nephritic syndrome
HOPS (2XHs)
Haematuria
Hypertension
Proteinuria
Oliguria
94
Describe the main symptoms seen in nephrotic syndrome
HOP
Hypoalbuminemia
Oedema
Proteinuria > 3g/24 hour - measure protein: creatinine ratio
95
What is the general management of nephritic syndrome
Will see increased CRP and ESR
BP control - ACEi/ARBs
Corticosteroids - inflammation
96
What is the general management of nephrotic syndrome
Fluid restriction
Loop diuretics - furosemide
ACEi/ARB
Treat cause
97
Name the conditions which are nephritic
IgA nephropathy
Goodpasture's
Post-strep
Henoch Schoenlein purpura
SLE
98
IgA nephritic or nephrotic
Nephritic
99
Goodpasture's nephritic or nephrotic
Nephritic
100
Post-strep nephritic or nephrotic
Nephritic
101
Henoch Schoenlein purpura nephritic or nephrotic
Nephritic
102
SLE nephritic or nephrotic
Nephritic
103
IgA nephropathy
Definition
Symptoms
Investigation
Treatment
Deposition into mesangium
Asymptomatic - microscopic haematuria
Diagnosis = biopsy
General management. > 6 months and persistent proteinuria = fish oil + steroids
104
Goodpasture's
Definition
Symptoms
Investigation
Treatment
Autoantibodies to type IV collagen in glomerular + alveolar membranes
SOB, oliguria < 400mL a day
Anti-GBM + biopsy
Plasma exchange, steroids
105
What is the antibody present in Goodpasture's
Anti-GBM
106
Henoch Schoenlein purpura
Definition
Symptoms
Investigation
Treatment
Small vessel vasculitis - effect kidney + joint due to IgA deposition
Purpuric rash on legs, joint pain
Clinical + confirm with biopsy
Corticosteroids, BP
107
SLE
Definition
Symptoms
Investigation
Treatment
Multisystem disorder
Rash, arthralgia, kidney failure
Anti-nuclear (ds-DNA)
Immunosuppression
108
What antibody is seen in SLE
Anti-nuclear (ds-DNA)
109
Name conditions which are secondary to nephrotic syndrome
DDANI
Diabetes
Drugs
Autoimmune
Neoplasia
Infection
110
Name 2 complications of nephrotic syndrome
Hyperlipidaemia = high cholesterol to compensate for albumin = statins
VTE = Increased clotting factors = heparin
111
Name the nephrotic syndromes
Minimal change disease
Focal segmental glomerulonephritis
Membranous nephropathy
112
Minimal change disease
Definition
Investigation
Treatment
Idiopathic nephrotic syndrome
Biopsy - electron microscopy = appearance normal,, function abnormal
Prednisolone
113
Focal segmental glomerulonephritis
Definition
Causes
Investigation
Treatment
Most common cause
Causes scaring in the kidneys filtering units.
Caused by idiopathic or secondary - HIV, malaria, heroin, lithium
Biopsy - microscopy = scaring of the glomeruli
Steroids, ACEi/ARBs
114
Membranous nephropathy
Definition
Investigation
Treatment
Immunoglobulin mediated
Renal biopsy - thickened basement membrane
Antiphospholipid A2 receptor antibody (80% patients)
Steroids - prednisolone, ACEi/ARBs, cyclophosphamide
115
What antibody is linked to membranous nephropathy
Antiphospholipid A2 receptor antibody
116
In BPH what cells does it affect
Stromal and epithelial cells of the prostate
117
What is the DRE of BPH
Enlarged, smooth, symmetrical
118
What are the 2 factors influencing BPH
Static = increase in tissue = narrowing of urethral lumen
Dynamic = increase smooth muscle tone mediated by alpha-adrenergic receptors
119
Name 3 treatments for BPH
Tamsulosin - alpha blocker (alpha 1 receptor antagonist)
Finasteride - 5-alpha reductase inhibitor
Surgery - transurethral resection of prostate (TURP)
120
Describe the mechanism of action of tamsulosin
BPH
Alpha blocker - alpha 1 receptor antagonist
Relaxes smooth muscle - relieve symptoms
121
Describe mechanism of action of finasteride
BPH
5-alpha reductase inhibitor
Slowly reduces the size of the prostate
122
What type of cancer is prostate cancer
Adenocarcinoma
123
Name the investigations of prostate cancer
Transrectal biopsy of prostate
DRE - asymmetrical, irregular, firm prostate
124
Describe the management of prostate cancer
GnRH agonist e.g. leuprolide
Androgen receptor blocker - bicalutamide
Radiotherapy
Prostatectomy
125
What type of cancer is bladder cancer
Transitional cell carcinoma
Aromatic dyes
126
Name the symptom of bladder cancer
Painless haematuria
127
Name the investigation for bladder cancer
Cystoscopy + biopsy
128
Name the management of bladder cancer
TURBT- trans urethral removal of baldder tumour (+/-) intravesical chemo for non-muscle invasive
129
What type of cancer is testicular
Germ cells in the testes
Seminomas
Non-seminomas (younger)
130
Describe the symptom of testicular cancer
Lump - dull ache, pain or heaviness
131
Describe the investigation of testicular cancer
Histology after orchidectomy
AFP = non-seminoma
132
What is the GS management of testicular cancer
Orchidectomy +/- chemotherapy
Would result in infertility
133
Testicular torsion - Summarise
Define
Symptoms
Risk factors
Investigations
Management
Acute onset of severe unilateral pain - triggered by activity
Prehn's sign - absence of cremaster reflex
Ball clapper deformity
Medical emergency. US = spiral appearance to spermatic cord or blood vessels
Surgical
134
Describe Prehn's sign
Absence of cremaster reflex
Positive = testicular torsion
135
What sign is used in testicular torsion
Prehn's sign
136
Describe the management of testicular torsion
Nil by mouth
Analgesia
Surgical exploration
- orchiopexy
- orchiectomy
137
Epididymal cyst - summarise
Define
Symptoms
Risk factors
Investigations
Management
Asymptomatic/lump - soft, round lump at top of testes (head of epididymis)
Middle aged men
US Scrotal
Removal if painful
Surgery - avoided in young men - infertility
138
Hydrocele - summarise
Define
Symptoms
Risk factors
Investigations
Management
Collection of fluid within tunica vaginalis
Painless, soft, swelling lump - water filled balloon
Common - premature, injury, connective tissue disorder
Testicle palpable with hydrocele, transilluminated
Large/symptomatic = surgery - aspiration, sclerotherapy
Idiopathic = conservative
139
What are the potential causes of hydrocele
Idiopathic or secondary to - testicular cancer, Epididymo-orchitis, inguinal hernia
140
What scrotal disease may present was a painless, soft swelling like a water balloon
Hydrocele
141
What scrotal disease may present as unilateral pain with a positive Prehn's sign
Testicular torsion
142
What scrotal disease may present as a soft, round lump at the top of the testes
Epididymal cyst
143
What scrotal disease may present as a throbbing, dragging, worse on standing, disappears when lying down
Varicocele
144
Varicocele - summarise
Define
Symptoms
Risk factors
Investigations
Management
Dilated pampiniform plexus = increased resistance + incomplete valves in testicular vein
Throbbing, dragging. Worse on standing, better when laying down. Bag of worms
Tall/low BMI
Doppler ultrasound (diagnosis is usually clinical)
Conservative unless very painful - surgery
145
Left sided varicocele may by indicative of what condition
Renal cell carcinoma
146
Describe testicular appendage torsion
Remnant of Mullerian duct
Blue dot sign
Boys 7-12
147
Describe the difference between testicular torsion and appendage torsion
Testicular torsion = twisting of spermatic cord cutting off blood flow to testicle. Medical emergency
Appendage torsion = affects extra appendage of the testicle (not testicle itself). Pain = less severe. Resolves on own
148
What scoring system is used in prostate cancer
Gleason's grading score
How differentiated the cells are from 'normal', the amount of cell atypia
149
How do you remember the typical pathogens of a UTI
KEEPS
Klebsiella
E.coli (most common)
Enterococcus species
Proteus species/pseudomonas
Staphylococcus aureus/staph. saprophyticus
150
What does KEEPS stand for
Typical bacteria causing UTI
Klebsiella
E.coli (most common)
Enterococcus species
Proteus species/pseudomonas
Staphylococcus aureus/staph. saprophyticus
151
Why are women more susceptible to cystitis
Shorter urethra than men
Closer proximity of urethral opening to anus
152
What age group may be non-specific for symptoms of UTI - what may the symptoms be
Fever
New urinary incontinence
New or worsening delirium
153
What is the GS investigation for UTI
MSU/CU microscopy, culture and sensitivity testing
154
Describe antibiotics given for a UTI in pregnancy
NO 1st trimester - Trimethoprim - inhibits folate
NO 3rd trimester - Nitrofurantoin - risk of neonatal haemolysis
155
When can trimethoprim NOT be given for a UTI in pregnancy and why
NOT in 1st trimester
Inhibits folate
156
When can Nitrofurantoin NOT be given for a UTI in pregnancy and why
NOT in 3rd trimester
Risk of neonatal haemolysis
157
What is the triad of symptoms in pyelonephritis
Unilateral flank pain
N&V
Fever
158
How is the diagnosis of pyelonephritis made
Loin pain +/- fever + positive urine culture
159
What is urethritis caused by
STI - gonococcal/ non-gonococcal
Post traumatic
160
Describe the symptoms of urethritis
Dysuria
Urethral discharge = main
Pruritis
161
Define urethritis
Inflammation/infection of urethra
162
What is used to test for gonorrhoea or chlamydia
NAAT - nucleic acid amplification test
163
Define Epididymo- orchitis
Inflammation or infection in epididymis + testicles on one side
164
What are the causes of Epididymo - orchitis
E.coli
Chlamydia
Gonorrhoea
Mumps
165
What are the symptoms of Epididymo - orchitis
Testicular pain
Urethral discharge
Dragging/heavy sensation
166
What is an extra test that may be done for epididymo - orchitis
Salvia mumps - serum antibodies
IgM = acute
IgG = previous
167
Define prostatitis
Inflammation or infection of prostate with evidence of recent or ongoing infection
Common cause = e. coli
168
Name the management of prostatitis
Acute - 2-4 weeks oral antibiotics
Chronic = alpha blockers e.g. tamsulosin
169
Define nephrolithiasis
Stones in the collecting ducts - deposited anywhere renal pelvis to ureter
170
What is the most common renal stone and name the other causes
Calcium oxalate
Others
Calcium phosphate
Uric acid
Struvite
Cysteine
171
What is a key symptom of renal colic
Colicky loin to groin pain in peristaltic waves
172
Describe the management of renal stones
< 5mm = pass spontaneously
> 5mm
Extracorpeal shock wave lithotripsy (ESWL) - break smaller fragments using shock waves
Percutaneous nephrolithotomy (PCNL) - percutaneous access, use nephoscope to remove stones
173
What are the two forms of PKD
Autosomal dominant = more common
- PKD1 - 16 (85%)
- PKD2 - 4 (15%)
Autosomal recessive
- PKHD1 - 6
- Severe
- Often picked up on antenatal scans
- End stage renal failure before adulthood
174
How is diagnosis of PKD made
Renal ultrasound + genetic testing
175
What is th prognostic factor for PKD
Fasting lipid profile
176
What is the management of autosomal dominant PKD
Tolvaptan
Vasopressin receptor antagonist - can slow development of cysts + progression to renal failure
177
What bacteria causes chlamydia
Chlamydia trichromatic bacteria
178
Name the 1st line treatment for chlamydia
Doxycycline for 7 days oral
CI pregnancy/breastfeeding
179
Name the 2nd line treatment for chlamydia
Azithromycin oral for 3 days
180
What causes gonorrhoea
Neisseria gonorrhoea
-ve diplococci
181
What is the treatment for susceptibility known gonorrhoea
1x ciprofloxacin 500mg oral
182
What is the treatment for susceptibility unknown gonorrhoea
Ceftriaxone 1g IM
183
What STI causes reactive arthiritis
Chlamydia
Gonorrhoea causes septic arthritis
184
What are the stages of syphilis
Primary - ulcer
Secondary - symmetrical, non-itchy, maculopapular rash
Tertiary - neurological, cardiovascular, Guthmata syphilis
185
What is the test for syphilis
Dark field microscopy + PCR
186
What is the treatment for syphilis
1x IM penicillin
3 weeks (1x a week) if late
187
Name 2 crystal arthropathy's
Pseudogout
Gout
188
What crystals are seen in gout
Monosodium urate crystals
189
What crystals are seen in pseudogout
Calcium pyrophosphate dihydrate crystals
190
What is an xray finding in pseudogout
Chondrocalcinosis - white line hovering in the space in the middle of the joint space
191
Describe the treatment of pseudogout/gout in an acute attack
1st line - NSAIDs e.g. naproxen + PPI
2nd line - colchicine - run before walk - severe diarrhoea suggests toxicity
3rd line - steroids
192
Describe the prophylaxis of gout/pseudogout
Xanthine oxidase inhibitors - lower uric acid levels. 2-3 weeks after attack
1. Allopurinol
2. Febuxostat
+ lifestyle changes
193
What can happen in the prophylaxis of gout/pseudogout
Paradoxical affect
Can trigger gout flare - offer colchicine or NSAIDs to cover
194
Define the diagnosis of osteoarthritis
Diagnosis + no investigation if > 45, pain associated with activity + no morning stiffness (< 30 minutes)
'Wear and tear'
Worse at the end of the day
195
Name 3 features that may be seen on the hand in osteoarthritis
Heberden's nodes = DIP (Hebrides = far away)
Bouchard's nodes = PIP
CMC joint = squaring of CMC joints
196
Name 4 general signs of osteoarthritis
Bulky, bone enlargement of the joint
Restricted range of movement
Crepitus on movement
Effusions (fluid) around the joint
197
Describe the x-ray signs of osteoarthritis
LOSS
Loss of joint space
Osteophytes (bone spurs)
Subchondral cysts (Increase density of bone along joint line)
Subarticular sclerosis (fluid-filled holes in bone)
198
Describe the key hand changes in rheumatoid arthiritis
Symmetrical polyarthritis - can spare DIP
Boutonniere
Swann-neck deformity
Z-thumb deformity
Ulnar deviation of fingers
Rheumatoid nodules
199
Describe the x-ray of rheumatoid arthritis
Periarticular osteopenia
Bony erosions
Soft tissue swelling
Joint destruction + deformity (in advanced disease)
200
What can be done in rheumatoid arthiritis to detect synovitis and help in acute flares to guide treatment
Ultrasound scan
201
Summarise the treatment of rheumatoid arthritis
1. DMARDS - methotrexate, sulfalazine, leflunomide
2. 2 of above
3. Methotrexate + biologic - e.g. infliximab (TNF-a inhibitor)
4. Methotrexate + rituximab (B-cell direct)
202
Describe 2 tests which can monitor the success of treatment in rheumatoid arthiritis
C-reactive protein
DAS28
203
Describe Felty's syndrome as a complication of rheumatoid arthiritis
Triad of
Rheumatoid arthiritis
Neutropenia
Splenomegaly
Do an abdominal ultrasound
204
Describe fibromyalgia - what points does it affect
Characterised by widespread pain + tender points
At
Occiput - connect brain to spine
Low cervical regions
Trapezius
Second rib
Greater trochanter
Gluteal region
Often co-occurs with many rheumatology diseases
205
Describe the diagnosis of fibromyalgia
31 point questionnaire - widespread pain index
> 3 months
Not have a condition which could explain the pain
206
Describe the treatment of fibromyalgia
1st line - physical therapy, graded exercise therapy
Severe pain - duloxetine, pregabalin, amitriptyline
Pain related depression - CBT, antidepressants
207
What are the antibodies for rheumatoid arthritis
Anti cyclic citrullinated peptide (anti-CCP)
208
What are the antibodies for vasculitis
c-ANCA - Granulomatosis with polyangiitis
p-ANCA - Eosinophilic granulomatosis with polyangiitis
209
Name the antibodies for SLE
Main= ds-DNA
ANA
Anti-smith
210
Name the antibody for scleroderma
Anti-centromere
211
Name the antibody for antiphospholipid syndrome
Anticardiolipin
212
Name the antibodies for Sjogren's
Anti-Ro
Anti-La
213
What would be seen in a joint aspiration of septic arthritis
Yellow, cloudy, WCC > 50,000
214
Describe the treatment of septic arthiritis
IV antibiotics 2 weeks + 4 weeks oral
1st = flucloxacillin
MRSA = vancomycin
Neisseria = ceftriaxone
Surgery = laparoscopic washout or surgical debridement
215
Name 2 complications of septic arthritis
Osteomyelitis
Permanent joint destruction
216
Describe the difference between osteomyelitis and septic arthiritis
Osteomyelitis - inflammation of bone and bone marrow
Septic arthiritis = inflammation of the joint (is not inside the bone)
217
What is the common cause of osteomyelitis
S. aureus
Salmonella infection is associated with sickle cell disease
218
Describe the management of osteomyelitis
6 week IV antibiotics (12 week if chronic) - flucloxacillin
Surgical debridement of bone
May require prosthetic joint revision
219
Describe polymyalgia rheumatica
Bilateral shoulder +/- pelvic girdle pain
Stiffness over 45 minutes after walking
Low grade fever
Decrease weight
220
Describe the diagnosis of polymyalgia rheumatica
ESR/CRP = increased
Diagnosis of exclusion
221
Name a complication of polymyalgia rheumatica
Giant cell arteritis
Long term steroid use
222
Define Giant cell arteritis
Inflammation in the walls of large size arteries
Sore when brushing hair
223
What is a key risk factor of giant cell arteritis
History of polymyalgia rheumatica
224
What is seen on a USS temporal artery of giant cell arteritis
Halo sign + stenosis of temporal artery
225
Describe the treatment of giant cell arteritis
Steroids
No visual symptoms = oral prednisolone
Visual symptoms = methylprednisolone
226
Describe the features of long term steroid use
Don't STOP
Don't - steroid dependence - occurs after 3 weeks. Risk of adrenal crisis. Wean down
S - Sick day rules - steroid doses need to be increased if unwell e.g. surgery, infection, mental stress
T - Treatment card - steroid treatment card alert
O - Osteoporosis prevention. Bisphosphonates + calcium/vitamin D score. Calculate FRAX score. DEXA scan
P - PPI required. Risk of reflex, ulcers, bleeding. Give omeprazole
227
What is the mnemonic for long term steroid use
Don't STOP
228
Name the 2 key features of long term steroid use
Use PPIs
Risk of osteoporosis
229
Define osteoporosis
Decrease in trabecular mass/density + disruption of bone architecture
230
Define FRAX tool
Predicts risk of major osteoporotic fracture and hip fracture
231
What are the two sections of the DEXA scan
Dual energy x-ray absorptiometry
Z-score = their age
T-score = healthy a young adult
232
Define Z-score
Number of standard deviations patient's bone density falls below the mean for their age
Think z = later in alphabet = older
233
Define T-score
Number of standard deviations patient's bone density falls below the mean for a health young adult
234
Classify the T-scores at hip
Normal > -1
Osteopenia = -1 to -2.5
Osteoporosis = < -2.5
Severe osteoporosis = < -2.5 + fracture
235
Describe the treatment for osteoporosis
1st line = bisphosphonates (alendronic acid or zoledronic acid)
2nd line
Denosumab = 6 months sub cut - blocks osteoclasts
Raloxifene = oestrogen stimulator
Teriparatide = increases osteoblast activity, PTH analogue
236
What are the 4 spondyloarthropathy
Ankylosing spondylitis
Reactive arthiritis
Psoriatic arthritis
Enteropathic arthiritis
237
What antibodies are linked to ankylosing spondylitis
HLA B27 serotype positive
238
What is the features of ankylosing spondylitis
Young man + back pain + stiffness worse at night
239
Describe what the features of HLA B27 serotype causes
Attacks entheses - causes inflammation, bone erosion + syndesmophyte formation - body growth inside a ligament
240
What test is used for ankylosing spondylitis
Schober's test
Marks L5 - 2nd line 10cam above 1st line
Touch toes and see difference
241
What is the mnemonic for spondyloarthropathy
SPINEACHE
Sausage digit
Psoriasis
Inflammatory back pain
NSAID good response
Enthesitis
Arthritis
Chron's/colitis/high CRP
HLA B27
Eye - Uveitis
242
What is the medical treatment of ankylosing spondylitis
Medical
1st line - NSAIDs
2nd line - anti-TNF biologics
3rd line - IL-7 biologics
NO DMARDS
243
Describe the x-ray findings of ankylosing spondylitis
'Bamboo findings'
Squaring of vertebral
Ossification
Subchondral
244
Define SPINEACHE
For spondyloarthropathy
Sausage digit
Psoriasis
Inflammatory back pain
NSAID good response
Enthesitis
Arthritis
Chron's/colitis/high CRP
HLA B27
Eye - Uveitis
245
Define psoriatic arthiritis and a key presentation
Autoimmune joint disease due to activation of CD8+ T cells
Dactylitis = inflammation of a digit that causes pain and swelling
246
Name the appearance of psoriatic arthiritis on xray
Periostitis
Ankylosis
Osteolysis
Pencil cup appearance - telescoping appearance of digits (most severe form)
247
Describe the treatment of psoriatic arthiritis
NSAID, physio, intra-articular injections
DMARDS
- 1st = methotrexate
- 2nd = sulfalazine
TNF a-inhibitor
- Etanercept/ustekinumab
248
Describe reactive arthiritis
Monoarthritis
Due dysregulated immune response to an infective trigger = joint inflammation.
Not an active infection (not infective)
249
Name the causes of reactive arthiritis
Gastroenteritis - shigella or salmonella
STI - chlamydia
250
What STI causes reactive arthiritis
Chlamydia
251
How do you remember the symptoms of reactive arthiritis
Can't pee, can't see, can't climb a tree
Urethritis, conjunctivitis, arthiritis
252
Summarise enteric arthiritis
Circulating immune complexes are deposited in the joint - causing inflammation
Associated with IBD - will be in remission with remission of IBD
1 in 5 get
Most common = limb joints and spine
253
Describe systemic lupus erythematous
Inflammatory autoimmune connective tissue disorder
Anti-nuclear antibodies (ANA) - attack cell body
Type III hypersensitivity reaction
254
Describe some key symptoms of systemic lupus erythematous
Proteinuria = throthy urine
Red rash on face - butterfly malar rash, photosensitive
Mouth ulcers
Raynaud's phenomenon
255
If you are carrier of what puts you at a risk factor of systemic lupus erythematous
HLLA-DR2/3
256
Describe the management of systemic lupus erythematous
Limit inflammation - methotrexate/hydrocholoroquine
NSAIDs
More severe disease = steroids
257
What are 3 complications of systemic lupus erythematous that could result in mortality
End stage renal disease
Atherosclerosis - cardiovascular disease
Steroid use - immunosuppression = infection
258
Define Sjogren's syndrome
Autoimmune destruction + fibrosis of the epithelial exocrine glands especially lacrimal and salivary glands
259
What is Sjogren's syndrome linked to and what are its antibodies
Can be isolated or linked to SLE or rheumatoid arthiritis
ANA - SLE
Anti-Ro and Anti-La
260
What condition is anti-Ro linked to
Sjogren's syndrome
261
What condition is anti-La linked to
Sjogren's syndrome
262
What conditions is ANA (anti-nuclear antibodies) linked to
SLE
Can be present in Sjogren's, scleroderma, dermatomyositis
263
Define anti-phospholipid syndrome
Increase risk of blood clots due to immune system creating antibodies to make blood more likely to clot = hyper-coagulable state
Autoimmune or idiopathic
264
What are the antibodies linked to anti-phospholipid syndrome
Main = anticardiolipin antibodies
Other
- Lupus anticoagulant
- Anti-beta-2 glycoprotein 1 antibodies
265
What condition is anticardiolipin antibodies seen in
Anti-phospholipid syndrome
266
How is antiphospholipid syndrome diagnosed
History of thrombosis (e.g. MI, stroke) or pregnancy complications + present antibodies
Other symptoms = thrombocytopenia
267
Describe the treatment of antiphospholipid syndrome
Long term = warfarin
Pregnant = LMWH + aspirin
268
What can be used to treat Raynaud's phenomenon
CCB = nifedipine
269
Define scleroderma
Fibroblast activation = hardened + sclerotic skin
Can be limited systemic sclerosis or diffuse systemic sclerosis
270
Name the symptoms of limited systemic sclerosis
CREST
Calcinosis
Raynaud's phenomenon
E - Oesophageal dysfunction
Sclerodactyly - tightening of skin on fingers
Telangiectasis - dilation of capillaries causing red marks on fingers
Diffuse = them +
- Beaked nose
- Interstitial lung disease
- Renal crisis
- Pulmonary hypertension
271
What antibodies are present in limited systemic sclerosis (scleroderma)
Anti-centromere
272
What are anti-centromere present in
Limited systemic sclerosis (scleroderma)
273
What are anti-scl70 present in
Diffuse systemic sclerosis (scleroderma)
274
What is the mnemonic to remember the symptoms of scleroderma
CREST
275
What does CREST stand for
Symptoms of scleroderma
Calcinosis
Raynaud's phenomenon
E - Oesophageal dysfunction
Sclerodactyly - tightening of skin on fingers
Telangiectasis - dilation of capillaries causing red marks on fingers
276
What is the mnemonic to remember the x-ray changes in rheumatoid arthiritis
LESS
Loss of joint space
Erosions
Soft tissue swelling
Soft bones - osteopenia
277
What does LESS stand for
X ray changes of rheumatoid arthiritis
Loss of joint space
Erosions
Soft tissue swelling
Soft bones - osteopenia
278
Describe Ehlers Danlos
Mutation in collagen - COL5A1 or COL5A2
Hypermobile - main subtype
279
Describe Marfan's
Mutation in EBN1 gene - chromosome 15
Less fibrin 1 = reduced functional microfibrils
280
Name 2 connective tissue disorders
Ehlers Danlos
Marfan's
281
What is the inheritance pattern of the connective tissue disorders
Autosomal dominant
282
Name some of the features of Ehlers's Danlos
Recurrent dislocation/hypermobile
Aortic dissection
AAA
Subarachnoid haemorrhage
283
Name some features of Marfan's
Tall stature, long arms, long body, spider fingers
284
If some was hypermobile or had an aortic dissection what connective tissue disorder do they have
Ehlers's Danlos
285
If someone was tall stature with long arms and legs what connective tissue disorder would they have
Marfan's
286
Describe the diagnosis of Ehlers's Danlos
Clinical diagnosis
287
Describe the diagnosis of Marfan's
>2 features
Lens dislocation
Flat feet (pes plantus)
Dural ectasia
Skeletal fractures
Inward growing of breast bone (pectus deformity)
288
Describe granulomatosis with polyangiitis
Small/medium vessel vasculitis (multisystem)
B cells produce cANCA against neutrophils which bind to proteinase 3 in the neutrophil
Neutrophil release oxygen free radicals
= Indirect damage to endothelial cells + inflammation
289
What is the antibody of granulomatosis with polyangiitis
cANCA - antineutrophil cytoplasmic antibodies
290
What is antineutrophil cytoplasmic antibodies present in (cANCA)
Granulomatosis with polyangiitis
291
What is the full name of cANCA
Antineutrophil cytoplasmic antibodies
292
Name a key presentation in granulomatosis with polyangiitis
Saddle nose deformity
293
Describe the management of granulomatosis with polyangiitis
Short term = steroids + cyclophosphamide
Maintanace = methotrexate + azathioprine
Severe renal disease = plasma exchange
294
Describe dermatomyositis
Complement mediated attack of the muscle capillaries and endothelium of arterioles.
Inflammation and atrophy leads to necrosis
Genetic + environment
295
Name the signs of dermatomyositis
Shawl sign
Heliotrope rash
Gottron's papules
296
Define shawl sign
Red rash over shoulders, arms and upper back and v shape chest
297
Define heliotrope rash
Darky red rash on hands and face
298
Define Gottron's papules
Red/purple hardened/eroded areas of the skin on upper surface of the finger joints, elbows or knees
299
Describe the diagnosis of dermatomyositis
At least 1 dermatological condition and one of at least 4 of the extra category
300
What is the treatment of dermatomyositis
1. exercise, physio, steroids - avoid sun
2. Immunosuppressants - methotrexate and azathioprine
301
Describe the mechanism of action of azathioprine
Immunosuppressant
Incorporates itself into replicating DNA and RNA to interrupt the replication process
302
What antibodies are present in dermatomyositis
ANA
Anti-Jo1 and anti Mi2
303
What condition is Anti-Jo1 and anti Mi2 seen in
Dermatomyositis
304
Define Osteomalacia
Defective bone mineralisation = soft bones as a result of insufficient vitamin D
305
Describe the pathophysiology of Osteomalacia
Vitamin D = essential for calcium and phosphate absorption
Low = low serum calcium + phosphate
Low calcium = increased PTH - reabsorbs calcium from bones
306
Where are you likely to see Osteomalacia pathological fractures
Top of femurs
307
What is the investigation for Osteomalacia
Serum 25-dihydoxyvitamin D
< 25 nmol/L = deficiency
25 - 50 nmol/L = insufficiency
308
What is the treatment of Osteomalacia
Cholecalciferol (vitamin D3)
Recheck calcium levels 1 month after loading regime
309
Define polyarteritis nodosa
Medium sized vessels - arteries
310
What is polyarteritis nodosa associated with
Hep B (Also C and HIV)
311
Name the key symptoms of polyarteritis nodosa
Cutaneous/subcutaneous nodules - hallmark
Unilateral orchitis
Livedo reticulitis - mottled, purplish, lace like rash
312
Name the investigations of polyarteritis nodosa
HBsAg
Biopsy - transmural fibrinoid necrosis
313
What is the serological marker for hepatitis B
HBsAg
314
What is the treatment of polyarteritis nodosa if there is not hepatitis B
Corticosteroids + cyclophosphamide
315
What is the treatment of polyarteritis nodosa if there is hepatitis B
Antiviral agent, plasma exchange + corticosteroids
316
Define Paget's disease of bone
Excessive bone turnover (formation and reabsorption) due to excessive osteoblast and osteoclast activity
317
Describe the x-ray of Paget's disease of bone
Bone enlargement + deformity
Well defined osteolytic lesions - osteoporosis circumscription
Cotton wool appearance - poorly defined areas of sclerosis and lysis
V-shaped defects in long bone
318
Describe the management
Biphosphates + calcium + vitamin D
NSAIDs - bone pain
Surgery - bone deformities
319
Name 2 complications of Paget's disease
Osteosarcoma
Spinal stenosis + cord compression = neurological symptoms
320
How do you remember the roles of bone cells
Osteoblasts = bone builders
Osteoclasts = bone bulldozers
Osteocytes = bone remodellers
321
What mnemonic can be used to remember the risk factors of osteoporosis
SHATTERED
Steroid use
Hyperthyroidism, hyperparathyroidism, hypercalcaemia
Alcohol + tobacco use
Thin (BMI < 18.5)
Testosterone (low) - women
Early menopause - oestrogen protective
Renal or liver failure
Erosive/inflammatory bone disease e.g. myeloma or RA
Dietary low calcium/malabsorption or DM1
322
What tool is used to assess back pain and summarise it
STarT back screening tool
9 questions for function and pain
Helps guide intensity of initial treatment
323
Describe vertebral disc degeneration
Osteoarthritis of the spine, which includes spontaneous degeneration of either disc or facet joints
324
Name 5 causes of acute liver failure
Viral (A/B/EBV)
Drugs
Alcohol (acute overdose)
Vascular
Obstruction
325
Name 4 causes of chronic liver failure
Alcohol (long term)
Viral (B/C)
Autoimmune
Metabolic
326
Name 5 signs of chronic liver failure
Dupuytren's contractures - deformity in flexion of fingers
Clubbing
Xanthelasma - yellow deposition of cholesterol under skin
Spider naevi
Hepatomegaly
327
What would be seen on blood tests of liver failure
Increased ALT, AST, PT
328
In liver failure what should be done with ascites
Peritoneal tap with microscopy + culture
329
What is the medical management of encephalopathy due to liver failure
Lactulose
330
What is the medical management of ascites
Diuretics
331
What is the medical management of bleeding due to liver failure
Vitamin K
332
Name possible causes of prehepatic jaundice
Due to increased production of bilirubin
Intravascular haemolysis
- TTP
- HUS
Extravascular
- Sickle cell disease
- Malaria
- Autoimmune haemolytic anaemia
- G6PD deficiency
333
What form of jaundice does decreased clearance of bilirubin cause
Intrahepatic or post hepatic
334
Name conditions which can cause intrahepatic jaundice
Decreased clearance of bilirubin
Gilbert syndrome
Hepatitis
Heart failure
Cirrhosis
Primary biliary cirrhosis
Lymphoma
TB
335
Name conditions which can cause post hepatic jaundice
Decreased clearance of bilirubin
Cholangiocarcinoma
Pancreatic cancer
Chronic pancreatitis
Parasitic infections
336
Summarise pathophysiology of jaundice
Unconjugated bilirubin (not soluble) transported to liver by albumin
Conjugated in liver by adding glucuronic acid by glucuronyl transferase (water soluble)
80% - oxidised create stercobilin = excreted by faeces
20% - transported to liver for bile production
337
What is the key blood finding in alcoholic liver disease
AST: ALT > 2
Other findings
- Increased - bilirubin, PT, GGT
- Decreased albumin
Macrocytic anaemia
338
What would be seen on an FBC of alcoholic liver disease
Macrocytic anaemia
339
Name the symptoms of Wernicke-Korsakoff syndrome
Nystagmus, ataxia, encephalopathy
Due to B1 deficiency and alcohol withdrawal
Treatment = IV thiamine
340
What marker on a liver function test will be raised in chronic liver damage but not acute liver damage
Albumin
Enzyme made by the liver and has a long half life
341
What do AST/ALT on a liver function test represent
Enzymes made in the liver - released when there is injury to hepatocytes.
342
What is the definition of binge drinking
6 or more units for women and 8 or more or men in a single session
343
What are the two questionnaires that can be used to assess for harmful alcohol use
CAGE
- cut down? annoyed? guilty? eye opener?
AUDIT questionnaire
- 10 questions, > 8 = harmful use
344
What two questionnaires can be used to assess fibrosis in liver disease
NAFLD
Fibrosis 4
345
What treatment can be used in non-alcoholic fatty liver disease and what does it improve
Vitamin E
Improves histological steatosis/fibrotic appearance
346
What imaging techniques can be used in liver cirrhosis
Transient elastography = used to assess stiffness
Ultrasound
- Nodularity on surface of liver
- Corkscrew appearance
- Enlarged portal vein
- Splenomegaly
Liver biopsy
347
What two scoring systems can be used in liver cirrhosis
MELD score
Child-Pugh score
348
Describe the MELD score
Every 6 months in patients with compensated liver cirrhosis
349
Describe child-Pugh score
Assess severity of cirrhosis and prognosis
Score 1-5
ABCDE
Ascites
Bilirubin
Clotting - INR
Dilation (ascites)
Encephalopathy
350
When is a liver transplant considered
When there are features of decompensated liver disease
A - ascites
H - hepatic encephalopathy
O - Oesophageal varices bleeding
Y - yellow (jaundice)
351
Name complications of liver cirrhosis
Portal hypertension
Malnutrition
Oesophageal varices
Hepatocellular carcinoma
352
In hepatitis what does IgM mean
Acute infection
353
In hepatitis what does IgG mean
Chronic infection or immunity after infection
354
If someone has been travelling and exhibits hepatitis symptoms what hepatitis is it likely to be
A
HAV IgM ab = active
Anti HAV IgG ab = post infection/vaccination
Self limiting
355
If there is an anti- before one of the hepatitis serology what does that mean
If with a none anti marker as well = chronic infection active
If without another marker or with another anti = chronic inactive, vaccinated or immune
Vaccinated only has one anti, immune has 2 antis
356
If someone has a hepatitis D infection what other condition must they have
Hepatitis B
357
If a person shows hepatitis symptoms and has recently eaten uncooked pork what hepatitis will they have
E
Self limiting
358
What is a complication of hepatitis B and C
Hepatocellular carcinoma
359
What condition is this
Positive
HcRNA positive
Active infection of hepatitis C
360
What condition is this
Positive
Anti Hc ab
HcRNA
Active infection (chronic/acute) hepatitis C
361
What condition is this
HcRNA negative
Anti Hc Ab positive
Resolved infection of hepatitis C
362
What condition is this
Positive
HBsAg
HBeAg
IgM
Acute infection hepatitis B
363
What condition is this
Positive
HBsAg
HBeAg
IgG
Active chronic infection hepatitis B
364
What condition is this
Positive
HBsAg
Anti-HBe
Chronic inactive hepatitis B
365
How can you tell chronic infections of hepatitis B apart based on HBV DNA
Active = high
Inactive = low
366
What condition is this
Positive
Anti-HBS
Anti-HBe
IgG
Immunity from a hepatitis B infection
367
What condition is this
Positive
Anti-HBS
Immunity from a hepatitis B vaccination
368
What hepatitis can you get from dialysis
Hepatitis B
369
What deposits are seen in autoimmune hepatitis
IgG
370
Describe the two types of autoimmune hepatitis
Type 1 - affects women around menopause
Type 2 - children/young girls, rapid onset
371
What antibodies are seen in type 1 autoimmune hepatitis
ANA
anti-actin
anti-SLA/LP
372
What antibodies are seen in type 2 autoimmune hepatitis
Anti-LKM1
Anti-LC1
373
What is the treatment for autoimmune hepatitis
Prednisolone + azathioprine
374
If the pain is triggered after a fatty meal what condition would it be
Biliary colic
375
What are the symptoms of cholecystitis and define it
Inflammation of the gallbladder
Referred pain to r. shoulder (phrenic nerve) + ve murphy sign
376
Define murphy sign
Pressure in RUQ, inspiration halts due to pain
377
What are the symptoms of ascending cholangitis and define it
Inflammation of bile duct
Charcot triad
Reynold pentad
378
Name Charcot triad
RUQ pain, fever, jaundice
379
Name Reynold pentad
Charcot triad + altered mental state + hypotension
380
In biliary tract disease what are the investigations
1st line = AUSS
GS = MRCP
381
What is the treatment of biliary colic
Laparoscopic cholecystectomy within 72 hours
382
What is the treatment of cholecystitis
Laparoscopic cholecystectomy within 1 week
+ Iv fluids, antibiotics, analgesia
383
What is the treatment of ascending cholangitis
ERCP - bile duct clearance
Once stable = cholecystectomy
+ Iv fluids, antibiotics, analgesia
384
Describe the differences between primary biliary cholangitis and primary sclerosing cholangitis
Primary biliary cholangitis
- intralobular bile ducts
- female, smoking
Primary sclerosing cholangitis
- intralobular and extralobular
- Male, UC
385
What are the antibodies of primary biliary cholangitis
AMA
386
What would be seen on a liver biopsy of primary biliary cholangitis
Inflamed bile ducts with intraepithelial lymphocytes, epithelioid granuloma and fibrosis
387
What are the antibodies and GS investigation for primary biliary cholangitis
pANCA
MRCP
388
What is 1st line management in primary biliary cholangitis
Ursodeoxycholic acid
389
How do you remember the causes for acute pancreatitis
I GET SMASHED
Idiopathic
Gallstones - acute
Ethanol - chronic
Trauma
Steroid use
Mumps
Autoimmune
Scorpion stings
Hypercalcaemia/hypertriglyceridemia
ERCP
Drugs/medications
390
What are the two signs seen in acute pancreatitis
Grey turner's
Cullen's sign
391
Describe grey turner's sign
Flank bleeding
(acute pancreatitis)
392
Describe cullens sign
Periumbilical bleeding
(acute pancreatitis)
393
Name the key investigation for acute pancreatitis
Increased lipase and amylase
394
Name the scoring systems for acute pancreatitis
Glasgow and Ranson's score
APPACHE II score - within 24 hours
395
What is the diagnostic investigation for chronic pancreatitis
Abdo USS + CT
396
What are gallstones made from
Cholesterol
397
Define ascites and a medical treatment
Pathological accumulation of fluid in peritoneal cavity
Abdominal dissention and shifting dullness
Spirolactone
398
Why is oesophageal varices a complication of portal hypertension
Shunting of blood to gastroesophageal vein
399
Define oesophageal varices
Dilated submucosal distal oespheageal vein connecting portal and systemic circulations
Presents as haematemesis
400
What is GS investigation for oesophageal varices
Upper GI OGD (oesophageal-gastro duodenoscopy)
401
Name what can be given in bleeding management of oesophageal varices
IV terlipressin
Variceal band ligation
TIPPS - trans jugular intrahepatic portosystemic shunt = diverts pressure to other veins to lower the pressure
402
In spontaneous bacterial peritonitis shows a gram positive organism what is it
Staph aureus
403
In spontaneous bacterial peritonitis shows a gram negative organism what is it
E.coli
Klebsiella
404
A 30 year old male non-smoker presents with COPD symptoms what is the cause
Alpha 1 antitrypsin deficiency
405
Name 3 metabolic disease and there inheritance pattern
Haemochromatosis
Wilsons disease
Alpha-1 antitrypsin
Autosomal recessive
406
Summarise haemochromatosis
Excess uptake of iron
Tris
- bronze skin
- hepatomegaly
- T2DM
407
Summarise Wilsons disease
Copper accumulates in the liver and spills out into the blood
Fleischer ring - green brown ring around cornea
408
What does alpha 1 antitrypsin deficiency result in
Neutrophil elastase increase
Affects the lungs and liver
No treatment
409
Describe the pathophysiology of a paracetamol overdose
5% is metabolised in the liver by cytochrome P450 enzymes
Form toxic metabolite N-acetyl-p-benzoquinone imine (NAPQ1)
Binds to glutathione (finite amount) become non toxic and excreted in urine
Excess NAPQ1 binds to hepatocytes in the liver causing mitochondrial injury
410
Describe the treatment of paracetamol overdose
< 8 hours from digestion
Wait 4 hours from last injection + take bloods
If over threshold start acetylcysteine treatment
411
Summarise pancreatic cancer
Type
Key symptoms
GS/monitoring
Treatment
Adenocarcinoma of head
Courvoisier's sign - palpable gallbladder + jaundice
GS = CT pancreas
Monitor CA19-9
Whipple procedure - pancreaticoduodenectomy
412
Describe Courvoisier's sign and when is it seen
Palpable gallbladder + jaundice
Pancreatic cancer (and cholangiocarcinoma)
413
Summarise hepatocellular carcinoma
Type
Key symptoms
GS/monitoring
Treatment
Liver cirrhosis - arises from parenchyma + metastases
Liver symptoms + non specific
1st line = AUSS
GS = CT abdomen
Tumour marker - serum-alpha fetoprotein
Poor prognosis
Resection
414
Summarise cholangiocarcinoma
Type
Key symptoms
GS/monitoring
Treatment
Adenomas - arises from biliary tree
Signs of cholestasis + Courvoisier sign
1st line - abdominal CT/US
GS = ERCP
Tumour marker = CA19-9
Increased bilirubin/ALP
Surgical resection
ERCP - used to plant stent in blocked duct = relieves symptoms
415
Describe Gilberts syndrome
Liver ability to metabolise bilirubin in affected
Autosomal recessive inheritance of UGT1A1 gene
416
Name the symptom of gilberts syndrome
Painless jaundice - especially at times of stress
417
Name 2 treatments in hepatic encephalopathy
1st line = lactulose
Other - rifaximin - decrease number of ammonia producing intestinal bacteria
418
Describe the pathophysiology of Wernicke-Korsakoff syndrome and the treatment
Alcohol prevents the absorption of thiamine (B1) by blocking thiamine pyrophosphate synthesise = thiamine deficiency
Treatment = IV thiamine
419
What are the symptoms of Wernicke encephalopathy
Ataxia, confusion, ophthalmalgia
420
What are the symptoms of Korsakoff syndrome
Wernicke's encephalopathy + short term memory loss + hallucinations
421
How do you remember the features of IBS
ABC
Abdominal pain
Bloating
Change in bowel habits
422
Describe the diagnosis of IBS
Clinical diagnosis
Recurrent abdominal pain - 1 day per week for 3 months. Plus 2 or more of the following
Related to defecation
Change in frequency
Change in stool form
423
What type of reaction is coeliac disease
Type 4
424
What markers are associated with coeliac disease
HLA DQ2
HLA DQ8
IgA deficiency
Anti-transglutaminase antibodies (anti-TTG)
425
What is anti-TTG associated with and give its full name
Coeliac disease
Anti-transglutaminase antibodies
426
What is the GS investigation for coeliac disease
Endoscopy + duodenal biopsy
427
What would be seen on a biopsy of coeliac disease
Complete villous atrophy
Crypt hyperplasia
Intraepithelial lymphocytes
428
What is the 1st line investigation in coeliac disease
IgA anti-TTG increased
Total serum IgA
429
Describe the pathophysiology of coeliac disease
Gluten (glandin) binds to IgA = taken up by macrophages = activates CD 4+ T helped cells = release proinflammatory cytokines = autoantibodies destroy epithelial cells of villi (enterocytes)
430
Describe a key differential diagnosis of coeliac disease
Topical sprue
Presents the same + associated with travel
Incomplete (key) villous atrophy
Tetracycline 6 months + leave affected area
431
What is the GS investigation for gastritis
Gastritis = inflammation of stomach lining
= Endoscopy
432
What type of bacteria is h. pylori
Gram negative spiral
Breath test
433
Describe the treatment for h. pylori
CAP
Clarithromycin, amoxicillin + PPI (omeprazole)
Allergy to penicillin = metronidazole
434
What antibiotic is given instead of amoxicillin in the treatment for h. pylori for someone with a penicillin allergy
Metronidazole
435
What is given in gastritis caused by autoimmune
IM vitamin B12
436
How do NSAIDs cause gastritis
Affect prostaglandin synthesis = less mucus secretion
437
What part of the stomach does autoimmune gastritis affect
Fundus
438
What is a key symptom of a h. pylori infection
Stomach pain especially when empty
439
Describe the investigation of GORD
No red flags = clinical diagnosis
Red flag =
1st line - OGD - oesophagogastroduodenoscopy
2nd line - if nothing seen - 24hr gastric monitoring pH or oesophageal manometry
440
Describe the medical management of GORD
1st line - PPI
2nd line - H2 receptor antagonist
Surgical - laparoscopic Nissen's fundoplication - fundus wrapped around the lower oesophageal to minimic sphincter
441
What is the change seen in Barrett's oesophageal and its investigation
Metaplastic - stratified squamous to simple columnar
OGD + biopsy - In z-line, 1cm above gastro-oesophageal sphincter
442
Define the diverticular diseases - how are they different from each other
Diverticular - broad term for outpouching of colonic mucosa
Diverticulosis - asymptomatic outpouching
Diverticular disease - symptomatic outpouching
Diverticulitis - inflammation (infection) of diverticula
443
Name the symptoms and treatment of diverticular disease
LLQ pain, constipation, haemochirazia
Surgery + bulk forming laxatives
444
Name the symptoms of diverticulosis
Triad - pyrexia, LLQ guarding, rebound tenderness
Antibiotics (co-amoxiclav)
445
What is the GS investigation for diverticular disease
Contrast CT abdomen and pelvis
446
Where is diverticular disease most common and what due to
Sigmoid colon
Increased colonic pressure or decreased wall strength
447
What is seen on an x-ray (1st line investigation) in small bowel and large bowel obstruction
3/6/9 rule
> 3cm = small bowel. Coil spring appearance
> 6cm = large bowel.
> 9cm = caecum
Coffee bean appearance
448
A coil spring appearance on a x-ray abdomen would be what
Small bowel obstruction
449
A coffee bean appearance on a x-ray abdomen would be what
Large bowel obstruction
450
Describe the management of a small and large bowel obstruction
Drip and suck
Drip - IV cannula + nil by mouth
Suck - nasogastric tube - decompress the stomach contents
451
Describe the management of pseudo bowel obstruction
IV neostigmine - stimulate motility
452
Gastric ulcer - what artery is affected
Left gastric artery
(usually get gastric ulcers on the lesser curvature)
453
Duodenal artery - what artery is affected
Gastroduodenal artery
more common
454
What is the GS investigation for peptic ulcers
Endoscopy
455
What is the GS investigation in anyone suspected of a GI bleed
Endoscopy
Variceal bleed - within 24 hours
456
Describe the difference between Mallory-Weiss tear and oesophageal varices
MWT - lower oesophageal mucosa due to vomiting e.g. alcohol or bulimia
Oesophageal varices - dilation of oesophageal vein. Liver cirrhosis, chronic alcoholism
457
What is the treatment of variceal bleeding
IV terlipressin
Endoscopic band ligation
Prevent further bleeding
Propanol, nitrates
Repeat endoscopic banding
458
What is the most common cause of appendicitis
Fecalith = stone made up of faeces
459
What signs can be seen in appendicitis
Rovsing's sign
Psoas sign
Obturator sign
460
Define Rovsing's sign
Palpitation of the left iliac fossa = pain in right iliac fossa
461
Define Psoas sign
Extension of the right hip in lateral position = right iliac fossa pain
462
What is seen in appendicitis
Murphy's triad
N&V
Low grade fever
R. iliac fossa pain
462
Define obturator sign
Internal rotation of the flexed right thigh = pain
463
Name Murphy's triad
N&V
Right iliac fossa pain
Low grade fever
464
What scoring system is used in appendicitis
Alvarado score
5-6 = CT/ultrasound
> 7 = predictive
464
What is the difference between gastroenteritis and gastritis
Gastritis = irritation
Gastro-enteritis = infection
465
What is the first line test for gastroenteritis
Faecal stool culture + sensitivities
466
What are 2 causative agents of gastroenteritis
Norovirus - adults abdominal pain 1-3 days. Care homes.
Rotavirus - severe abdominal pain in children 1 week
467
What two areas are more likely to get ischemic colitis
Sphenic flexure
Recto sigmoidal junction
468
Why may odynophagia be seen in oesophageal cancer
Voice hoarseness
Due to mass pressing on the recurrent laryngeal nerve
469
What are the two types of oesophageal cancer and where are they seen
Squamous cell
- developing world
- smoking
- upper 2/3
Adenocarcinoma
- developed world
- GORD
- lower 1/3
470
What is the 1st line investigation for oesophageal cancer and gastric cancer
OGD (upper endoscopy) + biopsy
471
What are the two types of gastric cancer
Type 1 (80%)
- intestinal
- antrum
- lesser curvature
- male
Type 2 (20%)
- diffuse
- cardia
- female
472
What may be seen on a biopsy in type 2 gastric cancer
Signet ring cells
473
Define Krukenberg tumour
Ovarian metastases
474
What are the 2 genetic links for bowel cancer
Autosomal familial adenomatosis polyposis (PAP mutation) = polyp formation
Lynch syndrome/HPCC = DNA mismatch repair
475
What classification is used to grade bowel cancer and what tumour marker can see how well treatment is going
Duke's classification
CEA tumour marker
476
What two signs can be seen in gastric cancer
Sister Mary Joseph sign
Troisier's sign
477
Describe sister mary joseph sign
Gastric cancer
Enlarged belly button nodes
478
Describe troisiers sign
Gastric cancer
Enlarged Virchows triad
479
Under 3 year old has diarrhoea what is it most likely to be
Rotavirus
480
Adult who has recently been in hospital/restaurant/cruise ship has diarrhoea what is it most likely to be
Norovirus
481
Someone how has come back from travelling has diarrhoea what is it most likely to be
Travellers diarrhoea - e. coli
482
Someone has bloody diarrhoea which is caused by a bacteria, what is it
Shigella
483
Someone has diarrhoea after recently attending a BBQ what is it
Campylobacter
484
Someone has signs of neurological problems after diarrhoea what is the most likely causative agent
Guillain-Barre - Campylobacter
485
Someone has oily diarrhoea which floats what do they have
Coeliac
Steatorrhea
486
What is the most common parasitic cause of diarrhoea and what is its treatment
Giardia lamblia
Metronidazole
487
What is the most common cause of diarrhoea
Virus
488
What is the treatment for clostridium difficile infection
Stop 'c' antibiotics
Metronidazole or vancomycin
489
Diarrhoea which needs antibiotic treatment what do you give
Travellers bacteria/campylobacter = self limiting
Salmonella/shigella = broad spectrum antibiotics e.g. ciprofloxacin, ceftriaxone
490
What are the investigations for diarrhoea
Stool culture - bacteria, parasites
PCR - viruses, c. diff or campylobacter
491
What is the mnemonic to remember red flag alarm symptoms
ALARMS
Anaemia - iron deficiency
Loss of weight - unintentional
Anorexia - loss of appetite
Recent onset of worsening symptoms
Melaena/haematemesis
Swallowing issues
492
Define Meckel's diverticulum
Failure of vitelline duct to obliterate during 5th week of fetal development
493
What is the imaging choice and diagnostic imaging of Meckel's diverticulum
Technetium-99m pertechnetate scan (Meckel's scan)
Diagnosis - contrast CT abdo + pelvis
494
What is a complication of a c. diff infection
Pseudomembranous colitis
Severe inflammation of the lining of the large intestine
495
What is the GS investigation of pseudomembranous colitis and what is seen
Colonoscopy + biopsy
Owl's eye inclusion bodies
496
What condition would you see owl's eye inclusion bodies
Pseudomembranous colitis
497
What is the treatment of pseudomembranous colitis
C. diff - vancomycin
Unknown - vancomycin + fidaxomicin
498
What condition would show beak like narrowing on barium swallow
Achalasia
Oesophageal motility disorder
499
What is GS investigation for achalasia
Oesophageal manometry
500
Which IBD causes RLQ pain
Chrons disease
501
What is the mnemonic to remember chrons disease
NESTS
No blood or mucus
Entire GI tract affected from mouth to anus
Skip lesions on endoscopy
Transmural inflammation and terminal ileum most affects
Smoking is a risk factor (do not set nests on fire)
502
Define NESTS
Chrons disease
No blood or mucus
Entire GI tract affected from mouth to anus
Skip lesions on endoscopy
Transmural inflammation and terminal ileum most affects
Smoking is a risk factor (do not set nests on fire)
503
Name 4 signs which would be seen in chrons disease
Transmural inflammation + non-ceasing granulomas
Cobblestone appearance
String-sign = strictures
Fissures - cracks in lining
504
What is the 1st line medication to maintain remission in chrons disease
Azathioprine
Antagonist of pure metabolism = inhibition of DNA, RNA and protein synthesis
505
What antibodies/mutations are associated with chrons disease
NOD2/CARD15 frame shift mutation
ASCA antibodies
506
What is the mnemonic to remember ulcerative colitis
CLOSEUP
Continuous inflammation
Limited to rectum and colon
Only superficial mucosa affected
Smoking may be protective
Excrete blood and mucus
Use aminosalicylate
Primary sclerosing cholangitis (70%)
507
Define CLOSEUP
Ulcerative colitis
Continuous inflammation
Limited to rectum and colon
Only superficial mucosa affected
Smoking may be protective
Excrete blood and mucus
Use aminosalicylate
Primary sclerosing cholangitis (70%)
508
Which IBD has LLQ pain
UC
509
What antibodies/gene are associated with UC
HLA-B27
p-ANCA antibodies
510
What would be seen on an xray of UC
Lead pipe
511
What scoring systems are used in UC
True love and witts severity scoring
Escalation = travis criteria
512
Name two risk/complications of UC
Increase risk of colorectal cancer
Toxic megacolon
513
What is the mnemonic to remember IBD extra manifestations
A PIE SAC
Ankylosing spondylitis
Pyoderma gangrenosum
Iritis (anterior uveitis)
Sclerosing cholangitis
Aphthous ulcers/ amyloidosis
Clubbing
514
Define A PIE SAC
Extra IBD manifestations
Ankylosing spondylitis
Pyoderma gangrenosum
Iritis (anterior uveitis)
Sclerosing cholangitis
Aphthous ulcers/ amyloidosis
Clubbing
515
Summarise Cushing's syndrome
Definition
Symptoms
Cause
Test
Management
Excess cortisol
Moon face
Purple striae
Buffalo hump
Usually by pituitary adenoma (other excess steroids)
Dexamethasone suppression test (low)
High test = excess cortisol
Trans-sphenoidal surgery
516
Summarise Acromegaly
Definition
Symptoms
Cause
Test
Management
Excess secretion of growth hormone (GnRH)
Prognathism
Bitemporal hemianopia
Pituitary adenoma
1st line - insulin like growth factor-1
GS - oral glucose tolerance test
Trans-sphenoidal surgery
517
Prolactinoma
Definition
Symptoms
Cause
Test
Management
Increased prolactin
Benign lactotroph adenoma (pituitary adenoma)
Male vs female (low libido, infertility etc).
Serum prolactin (elevated) + pituitary MRI
Dopamine agonist - oral cabergoline + bromocriptine
518
Carcinoid tumour/syndromes
Definition
Symptoms
Cause
Test
Management
Serotonin + other vasoactive particles into systemic circulation
Flushing, diarrhoea, palpitations
50+ MEN-1 female
Carcinoid tumour (from GI tract)
Urinary-5-hydroxin-choleacaetic acid test (elevated)
Only cure = surgery
Somatostatin analogues e.g. octreotide
519
Conn's
Definition
Symptoms
Cause
Test
Management
Too much aldosterone
Often asymptomatic
By adrenal glands - adrenal adenoma (syndrome)
Selective venous sampling
Serum renin = low
Aldosterone antagonist
520
Adrenal insufficiency
Definition
Symptoms
Cause
Test
Management
Adrenal glands do not produce enough steroid hormones - cortisol and aldosterone
Hyper-pigmentation
Primary = autoimmune (Addison's)
Secondary = loss/damage to pituitary
Short Synacthen test (failure to double)
Hydrocortisone = cortisol
Fludrocortisone = aldosterone
521
What is Na+ and K+ in adrenal insufficiency (Addison's)
Na+ = low
K+ = high
Cortisol = Low
ACTH = high
Secondary - ACTH - low
522
Summarise SIADH
Definition
Symptoms
Cause
Test
Management
Inappropriate secretion of ADH
Symptoms due to hyponatraemia e.g. seizures
Small cell lung cancer, medications (SSRI), surgery
Diagnosis of exclusion
Acute - treat underlying cause + fluid restriction
Chronic - vasopressin receptor antagonist
Complication = central pontine myelinolysis deficiency
523
Summarise arginine vasopressin deficiency
Definition
Symptoms
Cause
Test
Management
Lack of ADH - not produced by hypothalamus
Polyuria (> 3L of urine)
Damage/dysfunction to hypothalamus or pituitary
Water deprivation/desmopressin test
Low after water, high osmolality after desmopressin
Desmopressin
524
Summarise arginine vasopressin resistance
Definition
Symptoms
Cause
Test
Management
Lack of response by collecting ducts
Genetic, medication e.g. lithium, kidney conditions e.g. PKD
Water deprivation/desmopressin test
Low after water, low osmolality after desmopressin
High dose desmopressin
525
Summarise hyperparathyroidism
Definition
Symptoms
Cause
Test
Management
Excess secretion of PTH by parathyroid gland
Hyper/hypocalcaemia
Primary/secondary/tertiary
PTH, calcium and phosphate levels
1. surgical removal
2. vitamin D/transplant
Calaminetic
526
Describe primary hyperparathyroidism
Due to parathyroid adenoma
High PTH
High calcium
Low phosphate
527
Describe secondary hyperparathyroidism
Insufficient vitamin D/chronic renal failure
High PTH
Low calcium
Normal phosphate
528
Describe tertiary hyperparathyroidism
Prolonged CKD - does not respond to negative feedback
High PTH
High calcium
High phosphate
529
Summarise hypoparathyroidism
Definition
Symptoms
Cause
Test
Management
Reduced PTH production
Hypocalcaemia - Chvostek's sign, Trousseaus sign
Primary = autoimmune
Secondary = surgical removal or low magnesium
Bone profile - low calcium, phosphate, PTH
ECG - prolonged QT segment
IV calcium
530
What is needed for PTH production
Magnesium
531
Name two signs of low calcium
Chvostek's sign
Trousseau's sign
532
Define Chvostek's sign
Facial nerve induces spasm
533
Define Trousseau's sign
BP cuff causes wrist flexion and fingers to pull together
534
Summarise pheochromocytoma
Definition
Symptoms
Cause
Test
Management
Excessive, unregulated amounts of catecholamines (adrenaline)
Fluctuate depending on when tumour is secreting
Tumour of chromaffin cells - adrenal glands
MEN-1
Plasma metanephrines 24-hour urine catecholamines
Surgically remove tumour - control symptoms first alpha blockers then beta blockers
535
Describe metformin
Drug class
Mechanism of action
Side effect
Extra
Biguanide
Increased peripheral sensitivity to insulin + prevents gluconeogenesis from the liver (creating glucose from lipids)
GI upset
Risk of acute metabolic acidosis (lactic acidosis)
536
Name an example of an SGLT-2 inhibitor
Dapagliflozin
- end flozin
537
What type of medication is dapagliflozin
SGLT-2 inhibitor
538
Describe dapagliflozin
Class of medication
Mechanism of action
Side effects
Extra
SGLT-2 inhibitor
Prevents reuptake of glucose by the tubules = increase glucose urinary excretion
UTI
Weight loss
1st line if Q-risk = more than 10%
539
What is Qrisk(3) a measure of
Risk of having a heart attack or stroke in the next 10 years
540
Name a DPP-4 inhibitor
Linagliptin
541
What type of medication is linagliptin
DPP-4 inhibitor
End -liptin
542
Describe linagliptin
Class of drug
Mechanism of action
Side effects
Extra
DPP-4 inhibitor
Inhibits DPP-4 enzyme = increase insulin secretion by beta cells
Upper resp infections, GI upset, skin rashes
543
Name a sulfonylurea
Gliclazide
544
What type of medication is gliclazide
Sulfonylurea
545
Describe gliclazide
Class of drug
Mechanism of action
Side effects
Extra
Sulfonylurea
Stimulate release of insulin from beta cells
GI upset
Weight gain
546
Describe pioglitazone
Class of drug
Mechanism of action
Side effects
Extras
Pioglitazone
Alters transcription of genes influencing carbohydrate and lipid metabolism
Eyes - yellowing of the eyes
Weight gain
547
Why are beta blockers contraindicated in diabetes
Can hide hypoglycaemia
548
What are the key genetics in type 1 diabetes
HLA-DR3-DQ2
HA-DR4-DQ8
549
What can be used to measure the rate of b cell destruction
serum c-peptide
Type 1 diabetes = absent
550
What are the antibodies in type 1 diabetes
Anti-GAD (antibodies to glutamic acid decarboxylase)
Islet cell antibodies (ICA)
Insulin antibodies (IAA)
Insulinoma-associaed-2 antibodies (IA-2A)
551
What does a DKA cause
Metabolic acidosis
552
Describe 4 features of an ECG of DKA
Tall peaking T waves
Widened QRS complex
ST elevation
Prolonged ST interval
553
Describe the pathophysiology of DKA
Lack of insulin = uncontrolled lipolysis = breakdown of fasts = increased fatty acids converted into ketones = metabolic acidosis (pH < 7.3)
554
What is the treatment for DKA
FIG PICK
Fluid - 3L over 1st 3 hours (risk of cerebral oedema)
Insulin - sliding scale
G - glucose (dextrose + insulin)
Potassium
Infection
Chart fluid balance
Ketone monitoring
555
What is the marker for hypoglycaemia
< 3.9 mmol/L
556
Define the markers of hyperosmolar hyperglycaemic state
Hyperglycaemia > 30 mmol
Serum osmolality > 320 osmole/kg
No ketonuria
557
What is the treatment of hyperosmolar hyperglycaemic state
1. Fluid replacement
2. LWMH - due to increase risk of thrombolytic events = blood viscosity
3. Restore electrolytes
558
Describe the difference between Graves vs. De Quervain's
Both hyperthyroidism
Graves
- Painless goitre
- Treatment (block and treat)
- autoimmune
De Quervain's
- Painful goitre + pyrexia
- self-limiting
- viral infections
559
What is the name for T4
Thyroxine
560
What is the name for T3
Triiodothyronine
561
Describe the role of T3 and T4 and there names
Thyroxine (T4) is converted into triiodothyronine (T3) in the thyroid
TSH is produced by the anterior pituitary
562
What antibody is present in Grave's disease
Hyperthyroidism
TSH receptor antibody (anti-TSHR)
563
What antibody is present in Hashimoto thyroiditis
Hypothyroidism
Anti-thyroid peroxidase antibodies (anti-TPO)
564
What is the treatment for Grave's disease
Hyperthyroidism
Block and treat
Carbimazole + levothyroxine
565
What is produced in the posterior pituitary
Oxytocin
Antidiuretic hormone
566
What is produced in the anterior pituitary
Growth hormone
Prolactin
TSH
FSH/LH
567
Name a symptom and the treatment of thyroid cancer
Palpable thyroid nodule
Thyroidectomy + radioactive iodine
568
What are the symptoms of hypercalcaemia and what is seen on an ECG
Renal stones
Painful bones
Abdominal groans
Psychiatric moans
ECG = short QT
Cancer or hyperparathyroidism
569
What are the symptoms of hypocalcaemia and what is seen on an ECG
CATS go Numb
Convulsions
Arrythmia
Tetany
Spasms/stridor
Numbness in fingers
ECG = prolonged QT interval
570
What is a potential life threatening complication of hypocalcaemia
Low QT syndrome
Decreased HR and contractility
571
Describe ECG of hyperkalaemia
Tented T waves
Small p waves
Wide QRS complex
Ventricular fibrillation
Sine wave
572
Describe the management of hyperkalaemia
ECG changes - IV calcium gluconate/chloride - stabilise cardiac membranes
No ECG changes - insulin, dextrose, salbutamol
573
Name the ECG changes in hypokalaemia and 2 causes
Small or inverted T waves
Prominent U waves
Long PR interval
Deep ST segments
Bulimia (vomiting), diarrhoea
574
How do you calculate serum osmolality
2Na + Glu + Urea (all in mmol/L)
575
Auer rods
Acute myeloid leukaemia
576
Describe acute myeloid leukaemia
Proliferation of myeloblasts
Diagnosis > (or equal to) 20% myeloblasts in bone marrow
Blood film = Auer rods
577
Philadelphia chromosome
Chronic myeloid leukaemia
translocation 9:22
FISH PCR
578
Describe chronic myeloid leukaemia
Overproduction of myeloid cells
Philadelphia chromosome
Tyrosine kinase inhibitor - imatinib
579
Cancer seen in children
Acute lymphoid leukaemia
580
Describe acute lymphoid leukaemia
Rapid proliferation of lymphoblasts
Children
Diagnosis = > 20% lymphoblasts on bone marrow biopsy
581
Smudge cells
Chronic lymphoid leukaemia
582
Describe chronic lymphoid leukaemia
Failure of apoptosis
Smudge cells on blood
Complication ritcher formation
583
Describe Ritcher transformation
CLL transforms into non-Hodgkin's lymphoma
584
Reed-Stenberg cells
Hodgkin's lymphoma
585
Describe Non-Hodgkin's lymphoma
Failure of cell apoptosis
Aims to control - remission - incurable
Features - skin rashes, mycosis, fungicides (patches)
586
Describe Hodgkin's lymphoma
Failure of cell apoptosis
Reed-Stenberg cells - CD15+, CD30+
Features - skin picking
Most curable - immunosuppression
587
Abnormal proliferation of single Ig - mainly IgG
Multiple myeloma
588
Describe multiple myeloma
Abnormal proliferation of single Ig - mainly IgG
CRABBI
Calcium increase
Renal failure
Anaemia
Bone lytic lesions
Bleeding
Infections
Rouleaux formation
< 65 stem cell treatment
589
Rouleaux transformation
Multiple myeloma
590
Describe polycythaemia vera
Increased concentration of erythrocytes
Primary = abnormality of bone marrow
Secondary = disease outside bone marrow = overstimulation of bone marrow
Itching after warm water
Red cell mass > 25%
Venesection (removal of blood from body) = aspirin
591
Describe thrombolytic thrombocytopenia purpura (TTP)
ADAM 13 deficiency cannot break down clumps of VWF
Smear = schistocytes
Plasma exchange + ADAM13 replacement
592
Describe immune thrombocytopenia purpura (IPT)
Autoimmune destruction of IgG
Steroids + IV IG
593
Monoclonal band seen on serum and urine electrophoresis
Myeloma
594
Pain in the neck when drinking
Hodgkin's lymphoma
595
What's the combs test for
Autoimmune haemolytic anaemia
IgM antibodies are associated
596
Heinz bodies
G6PD haemolytic anaemia
597
What is the inheritance of von Willebrand's disease and what symptoms are seen
Autosomal dominant
Muscutaneous bleeding
Treat with desmopressin
Tranexamic acid - can reduce active bleeding
598
What is the inheritance pattern of haemophilia A/B and symptoms seen
X-linked recessive
A = 8
B = 9
Soft tissue bleeding - into muscles, joints, haematoma formation
599
Describe the symptoms of cardiac tamponade
Bucks Triad
Raised JVP
Muffled heart sounds
Low blood pressure
