Learning Objectives Flashcards
1
Q
What is the pathogenesis of T1D AND T2D?
A
T1D - autoimmune beta islet cell destruction in pancreas, causes insulin deficiency T2D - acquired insulin resistance due to beta cell fatigue, presents later in life due to poor health
2
Q
How is diabetes control assessed?
A
Regular FBG HbA1c - glycosylated haemoglobin 3 monthly (should be under 7% < 53)
3
Q
What lifestyle factors can be used for diabetes management?
A
Healthy diet (reduced sat fats, low GI CHO) Exercise Smoking cessation RBG monitoring
4
Q
What are the oral hypoglycaemics available for diabetes treatment?
A
Metformin (biguanides): First line treatment, inhibits hepatic glucose production and increases insulin sensitivity, does not cause severe hypoglycaemia, contraindications: renal impairment –> perpetuates lactic acidosis, SE: nausea, diarrhoea (avoid this by using slow release drug) Sulphonylureas: Stimulate beta cell insulin release, may cause weight gain, risk of hypoglycaemia (use with care in drivers, pilots etc.) Add if HbA1C is above target on maximum metformin tolerated, Gliclazide is drug of choice Alpha-Glucosidase Inhibitors: Acarbose, blocks starch digesting enzymes, no weight gain or hypoglycaemia, SE: flatulence, must be used with food Thiazolidinedione’s: Reverse insulin resistance, no hypoglycaemia, SE: weight gain, fluid retention, CCF, fractures, bladder cancer DPP4 Inhibitors: Advantage in overweight patients, no hypoglycaemia or weight gain, prolong GLP-1 action, increase insulin secretion, decrease glucagon secretion, inhibits in retina breakdown, SE: nausea, hypersensitivity (rare) GLP-1 Analogues: Advantage in overweight patients, no hypoglycaemia, slow gastric emptying, improve glucose sensing, weight loss, requires injection, SE: nausea, vomiting, pancreatitis SGLT2 Inhibitors: Promote glycosuria to lower blood glucose, mild weight loss, SE: candida infections
5
Q
What is the investigation for palpitations or syncope?
A
12 lead ECG Blood glucose U&E
6
Q
What is the pattern of AF on ECG?
A
No P waves Irregularly irregular rhythm
7
Q
What is the pattern of supra ventricular tachycardia on ECG?
A
Wide QRS complexes, retrograde P waves
8
Q
What is the pattern of VT on ECG?
A
Wide QRS (greater than 120msec)
9
Q
What is the management for AF?
A
Cardioversion Catheter Ablation (ablate part of heart that is out of rhythm) Beta Blockers Calcium Channel Blockers Digoxin Anti-arhythmics Anticoagulation - warfarin, heparin
10
Q
What is the score to determine stroke risk in AF patients?
A
C - chronic heart failure H - hypertension A - age >75 D - diabetes S - stroke V - vascular disease A - age >55 S - sex (female)
11
Q
What is the management for SVT?
A
Adenosine (induce AV block to allow SA node to take over rhythm control) IV Verapamil
12
Q
What is the management for VT?
A
Cardioversion Amiodarone (if hemodynamically stable)
13
Q
What is a stroke?
A
Ischaemic infarct of the brain, lasting over 24 hours, brain damage
14
Q
What is a TIA?
A
Brief neurological episode, usually lasting under 24 hours with no permanent brain damage
15
Q
What is ischaemic penumbra?
A
Area surrounding the infarcted brain that is also affected by relative ischaemia (but not yet permanently damaged)
16
Q
What are the types of hemorrhagic stroke?
A
Deep: hypertensive rupture of deep penetrating arteries, putamen, thalamus, brainstem, cerebellum Lobar: superficial, secondary to amyloid angiopathy, tumour, aneurysm
17
Q
What are the types of iscahemic stroke?
A
Large artery thromboembolism (>50% stenosis) Cardiogenic embolism (AF, LV thrombus) Small vessel infarct
18
Q
What are the major causes of SAH?
A
Berry aneurysm rupture AVM
19
Q
How is a stroke diagnosed?
A
CT (ischaemic vs. haemorrhagic - may not see clot in first few hours but will see haemorrhage)
20
Q
What is acute stroke management?
A
Thrombolysis - tPA (ateplase) - under 4.5 hours Anticoagulation Clot Retrieval Mannitol - relieve ICP
21
Q
What is stroke secondary prevention?
A
NOAC (dabigatrain, rivaroxaban, apixaban) Warfarin Aspirin Clopidogrel Antihypertensives Statins
22
Q
What are the common risk factors for stroke?
A
Age Gender (female) Family History HTN Diabetes Smoking AF Hyperlipidaemia Alcohol TIA/Migraines OCP/HRT OSA Sedentary/obesity
23
Q
What are the common signs of stroke?
A
F - facial weakness A - arm weakness S - speech difficulty T - time
24
Q
What happens if a patient develops a rash 24 hours into penicillin admin?
A
Change to cephalosporin - ceftriaxone
25
What is the side effect of ciprofloxacin?
Achilles tendon swelling and tearing
26
What is the treatment for C.diif?
Metronidazole or vancomycin
27
What is the treatment for klebsiella UTI and bacteriuria?
Gentamicin
28
What is the treatment for MRSA?
Vancomycin
29
What is the likely pathology: Recent haemoptysis, bright red blood mixed with cream coloured sputum, occasional night sweats, 4kg weight loss (1 month)?
TB - mycobacterium tuberculosis
30
What is the initial management of TB?
Isolation, bronchoscopy and washings, organism culture
31
What is the epidemiology of IHD?
3% of all Australians, accounts for 17% of all deaths
32
What are the risk factors for IHD?
Male Increasing Age Family History Hyperlipidaemia Hypertension Diabetes Obesity Smoking Poor diet and exercise CKD
33
What is the common presentation of IHD?
Chest Pain SOB Nausea Diaphoresis Palpitations Lethargy
34
What is AMI?
Acute myocardial infarct - diagnosed by at least 2 of: - ST segment changes, Q waves or inverted T waves - CK, troponin rise - MI Symptoms
35
What is acute coronary syndrome?
Caused by coronary thrombosis in association with ruptured atherosclerotic plaque - leads to narrowing or occlusion of coronary artery
36
What is the in hospital management of IHD?
PCI - cath lab, under 60 mins Fibrinolysis - early presentation Oxygen Morphine Nitrates Aspirin Heparin/clexane
37
What are the common complications of AMI and their management?
Angina, reinfarction, infarct extension - Revascularisation Heart failure, cardiogenic shock, mitral valve dysfunction, aneurysm, cardiac rupture - Surgical intervention Arrhythmic: atrial or ventricular, SA/AV node dysfunction - Anti-arrhythmic, pacemaker, implantable defibrillator Embolic: CNS, peripheral - Anticoagulants, antiplatelet (clopidogrel) Inflammatory: pericarditis (sharp inspiration pain) - Anti-inflammatory Pulmonary oedema (treat with diuretic - look for weight change in patient - and oxygen)
38
What is the post hospital management of AMI?
Medication - Aspirin - Beta Blocker - ACEi - Statin - GTN - Antiplatelet Additional - Antacid - Exercise - Vitamin B1 - Diuretic - Smoking cessation - Healthy diet - Weight loss - Alcohol reduction - Stress reduction - Regular cardiac monitoring
39
What are the typical insulin regimens for diabetes?
Basal bolus - rapid acting dose with meals (bolus - nova rapid, apidra) and long acting insulin once or twice a day for maintenance (deter, glargine)
40
What is the venous anatomy of the lower limb?
External iliac - common femoral - deep femoral - femoral - popliteal - anterior tibial and peroneal - posterior tibial - plantar metatarsal Great saphenous and small saphenous and dorsal venous arch
41
What are primary and secondary varicose veins?
Primary - rope like, present in superficial and perforating veins Secondary - deep vein incompetence due to recanalization of past DVT OR venous obstruction OR genetics
42
What are the complications of varicose veins?
Pain (relieved by elevation) Swelling (indurated hard) Thrombophlebitits Bleeding Ulcers Varicose Eczema Lipodermatosclerosis (inflammation of subcutansou fat, champagne bottle leg) Atrophie Blanche (white depressed scars)
43
What is the treatment for varicose veins?
Leg elevation, movement, ulcer care, compression stockings, sclerotherapy (inject into vein to shut it down), open surgery (vein stipping), EVLT (laser therapy), radio frequency ablation
44
What are the features of arterial ulcers?
Painful Claudication CV risk factors Punched out edges Ulcer base poorly developed, grey Little bleeding Foot cool Nail thickened
45
What are the features of venous ulcers?
Venous insuffiency - varicose, thrombophlebitis, DVT, surgery Large irregular edge Shallow Common over medial malleolus Moist Stasis dermatitis (darkened surrounding skin)
46
What are the features of neuropathic ulcers?
Painless Diabetes or peripheral neuropathy Deep Pressure points and calluses Neuropathy signs - loss of sensation Distorted foot architecture (charcouts - fractures leading to loss of foot arches, hyperextended MTP, hyper flexed IP)
47
What is the management of venous ulceration in the lower limbs?
Bed rest Elevation IV antibiotics Dressings Debridement Split skin graft Revascularisation Compression stockings
48
What structures can cause chest pain?
Heart (pericardium, myocardium) Pleura Aorta Oesophagus MSK Skin Abdominal Organs
49
What are the ECG changes in AMI?
ST elevation or depression Q waves Inverted T waves U waves (old infarct)
50
What is the typical presentation with pleuritic pain?
Worse with inspiration and coughing, sharp stabbing pain
51
What is the presentation of aortic dissection?
Tearing pain radiating to the back, BP different in each arm
52
What is the presentation of reflux?
Burning pain in the central chest, usually worse after meals and when lying down
53
What are the features of a migraine?
- Women - Genetic - Slow spread of reduced activity - Aura, scintillatinf scotoma, monochromatic vision pattern, semi or quadrantonopia - Usually starts in occipital lobe - Buildng pain, pulsating, throbbing, unilateral behind eye - Aggravating - stress, exercise, menstruation, OCP, fatigue - N&V, photophobia, vertigo, irritable, trigeminal pain, allodynia in scalp
54
What are the features of a tension headache?
Bilateral, band wrapping around head, may also involve neck and shoulders Worse with stress Usually relieved by analgesia
55
What is a chronic headache?
Present most days of the week for most of those days May be caused by medication overuse (opioids, triptans)
56
What is evident on a LP looking for SAH?
Xanthochromia - yellow spinal fluid 12+ hours after bleed
57
What are some possible symptoms of raised ICP?
Pappiloedema 6th nerve palsy Nausea Headache (morning) Better with standing
58
What are the diagnostic criteria of acute kidney injury?
Increased creatinine 150-200% Reduced urine output \< 500mL in \> 6 hours
59
How do you differentiate AKI from CKD?
AKI has acutely elevated serum creatinine and chronic kidney disease has creatinine elevation over time. 24 hour urine study for creatinine would demonstrate level of renal function.
60
What are the aetiologies of AKI?
Pre-renal: ATN, hypovolemia, haemorrhage, sepsis, hepatorenal syndrome (REDUCED PERFUSION) Intra-renal: ATN, glomerulonephritis, interstitial nephritis, thrombus Post-renal: fibrosis, tumour, stricture, BPH, renal calculi, pyelonephritis (OBSTRUCTION)
61
What is the treatment for AKI?
Fluid Overload - diuretics (frusemide), renal replacement therapy Avoidance of nephrotoxic agents
62
What is the pathophysiology of AKI?
Impaired renal perfusion leads to increased sodium and water retention. ATN is most common cause and causes microvascular endothelial injury and tubular ischaemia in proximal tubule. Hypoxaemia causes released of ROS and cell death.
63
What are the common antibiotic resistant organisms and their treatment?
MRSA - vancomycin VRE - linezolin Clostridium Difficile - metronidazole
64
What are the presenting features of meningitis and encephalitis?
Fever Neck Stiffness N&V Rash Headache Neurological Symptoms
65
What are the investigations for CNS infections?
LP (with no increased ICP) CT CRP (often takes 24 hours to raise so normal level may not be true)
66
What are the CSF findings of meningitis?
Bacterial - cloudy, elevated protein, low glucose, increased pressure Viral - clear, normal/high protein, normal glucose, normal pressure TB - increased pressure, clear, low glucose, high protein Cryptococcal - increased pressure, clear, low glucose, high protein
67
What are the common organisms that cause meningitis?
Neonates: group b strep, E.coli, listeria Infants & Kids: strep pneumoniae (GPC), Neisseria meningitidis (GNC), H. influenzae B (GNR) Adolescents: Neisseria meningitidis, strep pneumoniae Adults: strep pneumoniae (more likely with no rash and recurrent otitis media), Neisseria meningitidis Older Adults: listeria (GPR)
68
What is the treatment for meningitis?
Dexamethasone - anti-inflammatory (at the same time or before antibiotics is ideal) Ceftriaxone - strep pneumoniae, Neisseria Benzylpenicillin - listeria Vancomycin - beta lactam resistant strep pneumoniae
69
What are the common causes of encephalitis?
HSV-1 Listeria
70
What is the most common cause of spinal abscess and what are the risk factors?
Staph aureus Risk Factors - IVDU - Endocarditis - Sepsis - Bacteraemia - Immunosuppression - DM
71
What are some common causes of brain abscess?
Sinusitus Lung abscess Strep Staph aureus
72
What are the signs and symptoms of hyperglycaemia?
Dehydration Coma/LOC Headache Trouble concentrating Blurred vision Fatigue Urinary frequency
73
What are the signs and symptoms of hypoglycaemia?
Unconscious Confused Palpitations Fatigue Sweating Anxiety Hunger Shaky Pale Tingling Irritability
74
What are the signs and symptoms of diabetic foot?
Pale Cold Poor capillary refill Pedal pulses not palpable Ulcers Gangrenous
75
What drug can cause hyperglycaemia?
Corticosteroids
76
What is the treatment for DKA?
Resuscitation Rehydration - saline then dextrose Correct potassium imbalance Insulin (once potassium level is known)
77
What is the treatment for hyperglycaemic hyperosmolar state?
Glucose \> 25-30 Treat with fluids - 2L hypotonic saline over 1-2 hours, monitor urine, insulin, potassium, low molecular weight heparin
78
What are some causes of acute agitation?
Infection Dehydration Drugs Trauma Waiting
79
What are means of sedation?
Benzos - diazepam, midazolam (risk of respiratory depression) - Avoid in dementia due to paradoxical reaction Neuroleptics: olanzapine (increases QT interval, dystonic reaction including laryngospasm) Combination - lower combined doses may decrease agitation occurrence
80
What is the presentation of AAA?
Collapse Sudden onset back pain Pulsatile mass in lower abdomen Hypovolemia - dehydration, pallor, fatigue, LOC, SOB
81
What is the investigation for AAA and lower limb ischaemia?
Ultrasound
82
What is the conservative management for lower limb ischaemia?
Lifestyle modifications - reduce cholesterol, stop smoking, increase exercise, healthy diet, reduce alcohol, control blood pressure and diabetes Surgical - stenting, endarterectomy, bypass
83
What is the management for AAA?
Aortic surgery - give prophylactic antibiotics for GN organisms
84
What is hypertension?
BP \> 140/90 on 2 or more occasions
85
What are the secondary causes of HTN?
Renal disease, renal artery stenosis, adrenal tumours (secreting aldosterone, cortisol, catecholamine's - phaeochromocytoma), sleep apnoea, pregnancy, Cushing's, hyperaldosteronism
86
What is absolute cardiovascular risk?
Sex Age SBP Smoking Cholesterol Diabetes ECG LVH
87
What is the management of HTN?
Lifestyle - lose weight, improve fitness, avoid salt, moderate alcohol, stop smoking Medication - ACEi - \< 55, dry cough, renoprotective - ARBs - \< 55 - Calcium Channel blockers - \> 55, black, avoid non vascular selective (verapamil) in heart failure - Diuretics- thiazide first - Beta blockers - used if ACEi not tolerated, weight gain and insulin resistance, reduced exercise capacity, NOT IN ASTHMA
88
What are the approaches to resistant HTN?
Most common cause is poor medication compliance Add spironolactone (potassium sparing diuretic), beta blocker, centrally acting agent (methyldopa, clonidine, moxonidine), alpha-blocker, vasodilator
89
What does this image show?
Free gas under diaphragm
90
What does this image show?
Lobar consolidation
91
What does this image show?
Pneumocystis jirovecci - butterfly pattern
92
What does this image show?
Subdural haemorrhage
93
What does this image show?
Extradural haemorrhage
94
What does this image show?
Subarachnoid haemorrhage
95
What does this image show?
Pneumothorax
96
What does this image show?
Heart failure - with kersey B lines and pleural effusion
97
What disease processes can produce diffuse lung disease?
98
What are the red flags in joint disease?
IVDU
Previous cancer
Fatigue, weight loss, night sweats
Pain not relieved by rest or standard analgesia
Steroid use
\< 20, \> 50
99
What are the features of osteoarthritis?
Cartilage damage - non uniform loss and osteophyte growth
Causes - obesity, age, heavy joint use, female
Features - worse with movement, asymmetrical, deep ache, reduced ROM, crepitus, bouchard nodes (PIP), heberdens nodes (DIP), reduced quads mass, tender joints
Diagnosis clinical, can do x-ray and see loss of joint space and osteophytes
Treatment - NSAIDs, cortisone injection, joint replacement
100
What are the features of rheumatoid arthritis?
Autoimmune destruction of synovium - destruction of cartilage and bone - symmetrical - hands and feet first
Features - pain worse in the morning, pain better with movement, nodules, warm swollen joints, symmetrical, dry eyes and mouth (Sjrogens), fatigue, fever, weight loss
Investigations - rhuematoid factor, CRP, ESR, FBE, ANA, CCP
Treatment - NSAIDs, corticosteroids, methotrexate
101
What are the features of gout?
Aggravating Factors - dehydration, thiazide diuretics, alcohol, diet high in purines, obesity, aspirin, male, HTN, age
Features - intense peripheral joint pain, systemic symptoms, inflammation, rubour
Investigation - negative birefringence of monosodium urate crystals on tophous aspirate, urate levels not the best measure as they are altered by other processes in the body
Treatment - allopurinol, corticosteroids, NSAIDs, colchicine
102
What are the metabolic changes that occur during surgery or acute medical illness?
Surgery is a stressful event - causes elevation of catecholamines, growth hormone, glucagon, cortisol and ACTH, and depression of insulin and insulin resistance
Raised blood glucose levels, protein and fat breakdown, increase FFA and ketone production
103
What is the rationale for achieving glycameic control in perioperative period?
Hyperglycaemia increases the risk of infection and reduces healing capacity and induces osmotic diuresis which impacts hydration and electrolye balance
Hypoglycaemia may cause coma induction
104
What is the perioperative management of diabetic patients?
Assess for metabolic disturbance, microvascular and macrovascular complications and neuropathy
HbA1c level to assess control over last 3 months
105
What is the post op management for diabetics?
Monitor BSL
HbA1c
Record hypoglycaemic episodes and when they occur
Checking feet and seeing podiatrist
Seeing optometrist yearly
CV health screening
106
What are the most common causes of bowel obstructions?
Large - volvulus, malignancy
Small - hernia, adhesion
107
What are the features of biliary colic pain?
RUQ - referred to back and b/w scapula
Intermittent
Nausea
After fatty meal
108
What are the features of acute cholecystitis pain?
RUQ sharp pain with nausea, vomiting and anorexia
Fever
Tachycardia
Murphys sign (inspiratory pain on palpation)
Possible gallstone ileus causing absent bowel sounds
109
What are the features of acute pancreatitis pain?
Central - radiating to the back
Nausea and vomiting
IGETSMASHED (causes)
Grey Turners sign or Cullens Sign - due to retroperitoneal haemorrhage
Elevated lipase
110
What are the pain features of choledocolithiasis?
RUQ
Obstructive jaundice
Stone in the bile duct
Fever and tachycardia
111
What are the features of peptic ulcer pain?
Epigastrium (central)
Relieved by PPIs
May experience haematemesis and melena if ruptured ulcer
112
What are the features of intestinal ischaemia pain?
Pain out of proportion to clinical findings
Generalised pain
May have history of AF or coagulopathy
113
What are the features of IBD pain?
Chron's and Ulcerative Cholitis
Central recurrent pain worse with oral intake and associated with other GI sumptoms
Associated with primary sclerosing cholangitis (anal beads on ERCP), iritis/uveitis, akylosing spondylitis
114
What are the presenting features of a ruptured AAA?
Central sudden tearing pain radiating to the back
Pale, hypotension, unwell
115
What are the presenting features of acute appendicitis?
Tenderness at Mcburnies point
Psoas sign - pain when flexing right hip
Rovsings sign - right sided tenderness when palpating left side
Pale, ketotic breath (due to anorexia, N&V)
116
What are the presenting features of diverticulitis?
LIF
Altered bowel habit and rectal bleeding
More common \>50
May also get volvulus due to outpouching - sigmoid (coffee bean), caecal (kidney bean)
117
What are the presenting features of ectopic pregnancy?
IF pain
Sudden onset
Amenorrhea
Shock symptoms
118
What are the presenting features of ovarian cyst?
Iliac fossa pain
Altered menstrual pattern
119
What are the presenting features of salpingitis?
Iliac fossa pain
PID history
120
What are the presenting features of testicular lesion?
Scrotal pain
Nausea
121
What is intersusception of small bowel?
Ileocaecal, seen in children (3-18m) - due to peyer patch inflammation, infection causes hypertrophy (polyp like) - bowel obstruction and eventually ischaemia (treat with gas enema)
122
What is required for diagnosis of metabolic syndrome?
Abdominal obesity + 2 or more of:
* Elevated TG ( \> 1.7mmol/L)
* Low HDL ( \< 0.9mmol/L - male, \< 1.3mmol/L - female)
* Hypertension ( \> 130/85mmHg)
* Hyperglycaemia (FPG \>5.6mmol/L or T2DM or IGT)
* Pre-diabetes
* IFG: 5.6-7
* IGT 2 hour: 7-11.1
* HbA1c: 39-47
* Waist Circumference
* European \> 94cm male, \> 80cm female
* Asia \> 90cm male, \> 80cm female
123
What are some steps to reduce cardiometabolic risk?
* Diet - reduce salt
* Exercise (30 mins per day)
* Smoking cessation
* Reduce alcohol consumption (more alcohol free days)
* Weight loss
* Address dyslipidaemia Targets
* LDL \< 2mmol/L
* HDL \> 1mmol/L
* Triglycerides \< 1.5mmol/L
* Non-HDL Total Cholesterol \< 2.5mmol/L
* Treat HTN (statin, ACEi, aspirin, fibrates)
* Diabetes control
124
What is dyspnoea?
Subjective sensation of breathing discomfort
125
What are some mechanisms of dyspnoea?
Drive for ventilation
* Exercise
* Metabolic acidosis (clear CO2)
* Hypoxia
* Anxiety
Load/increased WOB
* Resistive load (consolidation, mass)
* Elastic load (asthma)
Reduced strength of respiratory muscles
126
What are the common features on examination of eczema?
Patchy scaly lesions worse on flexor areas - thin skin
Skin looks aged
Asthma, hayfever
Lichenification - normal skin lines exaggerated due to constant rubbing and scratching
127
What is the treatment for eczema?
Avoid soap, regular sorbolene, warm (not hot) showers, topical steroids (mild for face), systemic antibiotics, wet dressings, phototherapy, short term oral prednisolone, long standing (methotrexate, cyclosporin)
128
What are some complications of eczema?
Bacterial Superinfection - skin lacks antibaterial peptides, staph aureus infection, golden crust
Eczema Herpeticum - secondary infection with HSV, sudden worsening of eczema, corneal scarring
Contact Dermatitis - response due to an allergen
129
What are the common presenting features of psoriasis?
Extensor surfaces
Scaly
Age 20-50
Nail - onycholysis (yellow nail lifts off bed), psoriatic change - pitting of nail
Arthritic pain
130
What is the treatment for psoriasis?
Topical: steroids, tars (breaks down scale), calcipotriol, dithranol, keratoltics, emollients (sorbolene)
Phototherapy: UVB treatment
Systemic: oral acitretin, methotrexate, cyclosporin A, biologic treatment
131
What medications may cause acne?
Medication - topical corticosteroids, lithium, anabolic steroids, OCP
132
What are the features of rosacea?
More common in women and middle aged, occurs due to sun damage
Redness and facial flushing, papules and pustules
Long term - telangiectasia, rhinophyma
133
What are the features of a scabies infection?
Starts between digits on hands and feet, itch worse at night, spread to genital areas, usually spares face and head in adults
134
What are some signs of major depression?
Worse in the morning
Early morning waking
Agitation
Weight loss (not dieting or exercising)
Excessive guilt
Fatigue - loss of energy
Insomnia or hypersomnia nearly every day
135
What is the diagnosis of depression?
Low moos impairing ability to function leading to substantial stress, ongoing for at least 2 weeks on most days
136
What are some tests to outline severity of diabetic complications?
ECG - MI, LBBB
HbA1c
Urinalysis - protein, glucose, blood, creatinine
Neurovascular Exam - peripheral pulses and sensation
137
What are the microvascular complications of diabetes?
Retinopathy
* Non-proliferative: normal, no symptoms, microaneurysms, macular oedema
* Pre-proliferative: changes starting
* Proliferative: vitreous haemorrhage from neovascularisation can be prevented by laser treatment, new vessels, increased growth of blood vessels increases vitreous haemorrhage risk and blood vessels grow over retina impairing vision
* Can give anti-VEGF drugs, but often don't work beyond 18 months
* See cotton wool spots, flame haemorrhages and dot-blot haemorrhages
* Cataracts and glaucoma more common in diabetes patients
Nephropathy
* World leading cause of end stage kidney disease is diabetes - persistent eGFR \< 60m/min/1.73 OR increased albuminuria (albuminuria in 2 out of 3 tests)
* Enough nephropathy for proteinuria - ACEi is renoprotective
* Albuminuria
* 2.5mg/mmol males
* 3.5 mg/mmol females
138
What are the macrovascular diabetic complications?
CVD - silent MI (impaired pain response in diabetics)
PVD - medial surface 1st MT head, lateral surface 5th MT, secondary infections (staph aurea, strep)
Cerebrovascular Disease - stroke, TIA, multi infarct dementia
139
What are the neuropahic diabetic complications?
Peripheral - neuropathy (glove and stocking), amputation required
Autonomic - gastroporesis (slowed gastric emptying - vagal nerve damage), postural hypotension, erectile dysfunction
140
What are some treatment/management options for diabetic complications?
Eyes - optometrist visits, laser treatment, glucose control, smoking cessation, anti-VEGF
Kidneys - BP control (130/90), glucose control (7%/53mmol), early detection and treatment of UTIs, avoid nephrotoxic agents (contrast, gentamicin), glucose lowering agent (SGLT2i)
Nerves - glucose control, antidepressants/antiepileptics for neuropathic pain (pregabalin, amytriptyline, venlafaxine, tramadol), prevent ulcers with regular foot checking and podiatry visits
Heart - BP management (ACEi, ARBs), lifestyle modification, statins (atorvastatin), fenofibrate (lower HDL levels)
141
What are the red flags in dermatology?
Skin pain
Blisters or pustules - esp. if widespread
“Punched out” lesions - may be malignancy
Mucosal involvement - usually implies more generalised skin disease
Rapid change in any presentation
Purpura - meningococcal ecchymosis, serious vascular bleeding disorfer
Confluent erythema
Facial swelling, tongue swelling, hoarse voice, difficulty swallowing or breathing
Urticaria
Purpura
Blistering
Skin pain
Mucosal involvement
Change in size, shape, colour of a lesion
142
What are the types of tinea?
Corporis - polycyclic, scaly rash, AKA ringworm
Pedis - interdigital and sides of feet
Unguium (onychomycosis) - nails
Cruris - genitals, jock itch, also look at feet and nails
Capitis - scarring on the scalp, bald spots
143
What are the features of HSV?
Chickenpox in kids
Reactivation as shingles (dormant in DRG) - vesicular rash in dermatomal pattern
Can cause chronic neuropathic pain
144
What are school sores and how are they treated?
Staph aures infection
Flucloxacillin or cephalexin
145
What causes cellulitis?
Group A strep (strep pyogenes) and staph aureus
146
What is the treatment for tinea?
Cortisone gets rid of redness and itch, but promotes growth
Skin: imidazole, terbinafine - bd topical treatment for 3-4 weeks
Extensive skin infections respond to oral griseofulvin for 4 weeks or terbinafine, itraconazole or fluconazole
147
What are the features of paracetamol?
Acetaminophen
Acts in the CNS to inhibit peripheral prostaglandin receptors - for analgesia and antipyrexia
Causes hepatic necrosis in overdoes (need to give N-acetyl-cysteine)
148
What are the features of NSAIDs?
Inhibit COX to prevent prostaglandin formation
Adverse effects - anti-platelet, kidney damage, peptic ulcers (reduced gastric mucous secretion), bronchospasm (PGD2 blocked - bronchospasm)
149
What are the features of opiods?
Block opiod receptors for analgesia
Side Effects - nausea and vomiting, respiratory depression, euphoria, urinary retention, bradycardia, miosis
150
What factors reduce fracture healing?
Diabetes
Smoking
Poor nutrition
151
What is primary fracture management?
Biers block - IV regional anaesthesia
Numb limb with tourniquet to manipulate fracture
Wash with saline
Intramuscular analgesia
Dress with sterile gauze
IV antibiotics
Tetanus prophylaxis
152
What ions are in the extracellular and intracellular volumes?
Extra - sodium, chloride
Intra - potassium, organic anions
153
What happens if plasma sodium is low?
ICV is high
154
How can you tell if body sodium is high?
Signs of fluid retention - raised JVP, peripheral oedema, pulmonary oedema, weight gain
155
What would make ECV low?
Vomiting and diarrhoea - fluid loss
156
How does saline change ECV and ICV?
Only increase in ECV - as sodium is retained and water collects in ECV
157
How does water change ECV and ICV?
Increases both due to distrubution
158
What are the signs and symptoms of an intracranial mass/raised ICP?
Headache
Papilloedema
Nausea and vomiting
Visual disturbances
Neurological deficit
Behavioural changes
Confusion/hallucinations
6th cranial nerve palsy - eyes turned in
Seizures
159
What are the investigations for a person with suspected intracranial mass?
FBE
U&E
CT
CXR
MRI
160
What are the features of a glioma?
Tumour starting in brain parenchuma (astrocytoma, oligocytoma)
Glioblastoma multiforme (astrocytoma) - rapid aggressive tumour (chronic spastic paraparesis)
Headaches, visioon loss, pain, numbness
161
What are the features of a meningioma?
Benign brain tumour - common in middle aged women
Compressive rather than infiltrative - may be asymptomatic due to lack of damage to brain tissue
Causes raised ICP - seizures, papilloedema, diplopia, facial twiting, neurological deficit, incontinence, weakness
Slow growing
CSF protein elevated
162
What are the features of brain metastases?
More common than primary brain tumour
From lung, breast, melanoma, GIT, kidney
Present with rasied ICP deficit/seizures
163
What are the features and treatment of pituitary adenoma?
Bitemporal hemianopia
May secrete hormones leading to cushings, acromegaly, prolactinoma etc
Micro \<10mm, macro \>10mm
Treat with surgical resection (likely recur due to delicate surgery) - treat hormone imbalances
164
What are the features and treatment of an acoustic neuroma?
Schwann cell origin - cause unilateral hearing loss, headaches, bells palsy
Diagnose via MRI
Treatment - surgical resection, radiation, observation
\>4cm can cause hydrocephalous
165
What is the treatment for a glioma?
Steroids - dexamethasone and mannitol
Resection
Adjuvant Therapy - temozolomide
166
What is the treatment for meningioma?
Resection
Radiotherapy
167
What is the treatment for brain metastases?
Steroids - dexamethasone
Resection (unlikely)
Primary tumour diagnosis and adjuvant therapy
168
What distinguishes between diastolic and systolic heart failure?
Reduced EF: less than 40% --\> heart failure due to systolic dysfunction of LV
Heart failure with preserved EF (50-75%), diastolic failure
169
What are the signs and symptoms of heart failure?
SOB - worse with exercise and lying down (orthopnea), PND
Fatigue
Peripheral and sarcal oedema
Hypotension (low CO) - reduced muscle perfusion and strength
Chest pain - angina on exertion
Left
* Pulmonary oedema
* Tachypnoea
* Increased WOB
* Crackles
* Cyanosis
* Displaced apex beat
* Orthopnea
* Low exercise tolerance
* Fatigue
* Confusion
* Dizzy
* SOB
Right
* Elevated JVP
* Peripheral oedema
* Hepatomegaly
* Ascites
* Parasternal heave
* Sacral oedema
* Nocturia
* Jaundice
* Coagulopathy
170
What are the common underlying conditions of heart failure?
Coronary artery disease
MI
HTN
AF
Valvular heart disease
Rheumatic fever
Excess alcohol use
Infection
Cardiomyopathy
Congenital heart disease
Endocarditis
Myocarditis
Diabetes
Alcohol, cytotoxicity - cardiomyopathy
Lung disease: COPD, asthma, cystic fibrosis, pulmonary fibrosis
Cor pulmonale
Coxsackie causing pericarditis
PE
171
What is needed for heart failure diagnosis?
Framingham Criteria --\> 2 major criteria or 1 major criteria and 2 minor criteria Major criteria include the following:
* Paroxysmal nocturnal dyspnoea
* Weight loss of 4.5 kg in 5 days in response to treatment
* Neck vein distention
* Rales
* Acute pulmonary oedema
* Hepatojugular reflux
* S 3 gallop
* Central venous pressure greater than 16 cm water
* Circulation time of 25 seconds
* Radiographic cardiomegaly
* Pulmonary oedema, visceral congestion, or cardiomegaly at autopsy
Minor criteria are as follows:
* Nocturnal cough
* Dyspnoea on ordinary exertion
* A decrease in vital capacity by one third the maximal value recorded
* Pleural effusion
* Tachycardia (rate of 120 bpm)
* Bilateral ankle oedema
Based on history of symptoms
BNP investigation better for long term heart failure patients
Confirmed by echocardiography
Note: blood tests, ECG and CXR may be useful in determining the underlying cause
CXR Changes (erect PA film)
* Pleural effusion
* Heart enlargement
* Kerley B lines - horizontal lymphatic lines, base of lungs
* Pulmonary vessel enlargement
* Per-hilar shadowing
172
What is the treatment for heart failure?
Lifestyle modifications - smoking, exercise, diet
Medications - ACEi, ARB, beta blocker, vasodilator, diuretics, nitrates, digoxin, anticoagulants
Interventions - pacemaker, implanted defib, VAD, heart transplant
173
What are the presenting symptoms and signs of PHTN?
Symptoms
* SOB
* Syncope - don't rouse quickly, reset circulation
* Lassitude (weariness)
* Ankle swelling
* Abdominal distension
* Cough
* Pleuritic chest pain
* Haemoptysis
Signs
* Right ventricular heave
* Loud P2
* 4th heart sound
* Prominent V wave in JVP
* Elevated JVP
* Tricuspid regurgitation
* Ascites
* Pulsatile liver
174
What are the presenting symptoms and signs of PE?
SOB (unexplained)
Hypotension
Inspiratory pleuritic pain
Collapse
Widened Aa gradient
Pulmonary HTN
DVT
Tachypnoea
Pleural rub/effusion
Cough
Haemoptysis
Fever
175
What are the risk factors for PE?
Stasis - flight, hospital inpatient, obesity, surgery
Hypercoaguability - cancer, infection, protein C deficiency, thrombophilia, factor V leiden, dehydration, OCP/HRT
Vessel Injury - cannula, trauma, varicose veins, age, DVT
176
What are the investigations for a PE and the findings?
CXR - usually normal OR pulmonary oedema, raised hemidiaphragm, atelectasis
D-Dimer - not specific, good for diagnosing negatives (positive is not indicative of pathology)
ECG - T wave inversion, sinus tachycardia
Troponin - elevated in large PE
VQ Scan - can rule out PE
CTPA
ABG - oxygen low, CO2 low, hyperventilation, metabolic acidosis
177
What are common causes of PHTN?
Increased LA pressure
* Mitral stenosis, LVF, diastolic dysfunction
Increased pulmonary blood flow
* Left to right shunts, high flow states, excess central volume
Increased pulmonary vascular resistance
* Vasoconstriction, obstruction, obliteration
178
What is the treatment for PE?
Resp and haemodynamic suppoty
Thrombolytic therapy
Anticoagulation - heparin, warfarin, NOAC
179
What is the treatment for PHTN?
Oxygen
Diuretics
Blood thinners
Treat underlying disease
180
What are the red flags for a skin lesion?
Change in size, shape, colour
Itch, pain bleeding
Asymmetry
Border irregularity
Colour variability
Diameter \>5mm
Evolution and elevation (changes)
New lesion or ugly duckling
181
What are the investigations for a skin lesion?
Punch biopsy - may miss most important part of lesion
Shave biopsy - sample, may get false negative
Excisional biopsy - can see margins
182
What is the treatment for SCC, BCC and melanoma?
SCC - excision, radiotherapy (high risk lesion)
BCC - cryotherapy, excision, MOHS, curettage, topical chemotherapy (imiquomid)
Melanoma - surgical excision, adjuvant therapy
183
What is this lesion and what are it's features?
Basal Cell Carcinoma
67% of NMSC, common, slow growing, pearly nodule with central ulceratio, telangiectasia, usually found on head and neck, rarely metastasise
184
What is this lesion and what are it's features?
Squamous Cell Carcinoma
33% of NMSC, aggressive, scaly bleeding lesion, can progress to cancerous lesion
Can arise from actinic keratosis --\> SCC in situ (bowens - ulcerated legs) --\> SCC
Most common on hands, forearms, head and neck
Smoking is a risk factor for SCC on mouth
Rapidly growing in immunosuppressed patients (can lead to death)
185
What is this lesion and what are the features?
Melanoma
5% of skin lesions, less common and more lethal
Can metastasise
Arises from melanocytes
Risk factors - +5 dysplastic naevi, \>100 naevi, previous melanoma, hx blistering sunburn, immunosuppression, red hair, fair skin, blue eyes
More common in legs in women and trunk and head in males
NEVER USE CRYOTHERAPY OR SHAVE BIOPSY ON PIGMENTED LESION
186
What is this lesion and it's features?
Seborrheic Keratoses
Can progress to SCC (through bowens disease)
Warty stuck on appearance, common in elderly, may grow over time
187
What joints are commonly affected by osteoarthritis?
Knee
Shoulder
Hands and feet
Hip
188
What are some risk factors for osteoarthtitis?
Overweight
Overuse
Injury
Genetics
189
What imaging evidence is there of osteoarthritis?
X-ray: scotty dog (overlapping lumbar vertebrae, narrowed joint space, sclerosis)
MRI: nerve impingement, disc pathology
190
What is the management of osteoarthritis?
Pharmacological
* Muscle relaxants
* NSAIDs - better for early OA when its still inflammatory
* Paracetamol - first line
Non-pharmacological
* Stay active
* Heat wrap
* Spinal manipulation
* Surgery - joint replacement (not permanent solution)
* Physio
* Spinal manipulation
* Rest
191
What are the types of respiratory failure and their features?
Hypoxemic - Type I
* PaO2 lower than 60mmHg (\< 90% oxygen saturation) with normal or low CO2 level
* Most common
* V/Q mismatch - Shunting - Widening of Aa gradient (normally less than 15mmHg)
* Can be associated with most acute lung diseases - Oedema, Pneumothorax, PE, ARDS, Obesity, Pneumonia, Pulmonary haemorrhage
Hypercapnic - Type II
* PaCO2 greater than 50mmHg
* Decreased alveolar ventilation - CO2 build up
* Over time pH will become acidic, and levels of bicarbonate will increase in compensation for respiratory acidosis
* Common causes - Drug overdose, Neuromuscular disease, Chest wall abnormalities, COPD, Asthma, Myasthenia gravis
192
What is the triad for normal pressure hydrocephalus?
Dementia
Urinary Incontinence
Ataxia
193
What is the acute management for delirium?
Treat underlying cause
Keep patients with same medical team in well-lit room
Minimise sensory deficits
Can use sedatives but avoid these if possible as they can prolong delirium
194
What is the treatment for allergic disease?
Avoid allergens
Allergen specific immunotherapy
Non-specific Treatments
* Antihistamines
* Corticosteroids
* Adrenaline
* Leukotriene antagonists
* Anti-IgE antibodies (omalizumab
Action plan
195
What is the treatment for insect venom allergy?
Immunotherapy
196
What is the treatment for food allergy?
Avoidance and adrenaline
197
How does paracetamol dosing become toxic and how is this treated?
Too much paracetamol saturates glutathione pathway (CYP2E1) so there is toxic NAPQI build up which leads to widespread hepatocyte necrosis
N-acetyl-Cysteine - re-establish glutathione to metabolise NAPQI (continue until ALT starts dropping)
198
What is the treatment for organophosphate poisoning?
Atropine
199
What is the treatment for opiod overdose and what is the presentation?
Naloxone
Pupil constriction, respiratory depression
200
What are some causes of delirium?
CNS - stroke, abscess, tumour, subdural haematoma
Drugs - withdrawal, steroids, antipsychotics, benzos, digoxin, alcohol, opioids
Endocrine - hyperparathyroidism, hypo/hyperthyroidism
Infection - UTI, burns, encephalitis, meningitis, sepsis, pneumonia, hypothermia
Metabolic - acid base disturbance, hepatic encephalopathy, uraemia, hypo/hyperglycaemia, electrolyte disturbance, thiamine/vitamin B12 deficiency
Other - post-op stress, mental disorder, sleep deprivation, surgery, anaesthetics, dehydration, organ failure, hypoxia
Environment - insomnia, new environment, catheter, restraint, no sensory aids, immobility, pain
201
What are the risk factors and symptoms of OSA?
Risk Factors - age, obesity, male, alcohol, sedatives, nasal obstruction
Symptoms - heavy breathing, snoring, excessive daytime sleepiness, apnoea
202
What are the features of central sleep apnoea?
Reduced respiratory drive - problem with rhythm of breathing (cardiac failure, high altitude, CNS disorder, idiopathic)
203
What are the causes of sleep hypoventilation?
Reduced drive, neuromsucular disease, chest wall deformity, obesity, increased ventilation requirements
204
What are the features of insomnia?
Trouble getting to sleep or maintaining sleep - daytime symptoms of functional impairment
Primarily due to anxiety and hyperarousal
Treat with benzos (temazepam), relaxation, sleep hygiene
205
What are the features of restless leg syndrome?
Desire to move extremities - often associated with paraesthesia or dysesthesia - improved with movement
Treatment - opiods, benzos, pregabalin, dopamine agonists, iron replacement
206
What are the types of primary sleep disorder and their features?
Narcolepsy - disorder of sleep regulation, REM occurs during waking time, deficient in orexin, sleep attacks (+/- paralysis or cataplexy)
Idiopathic Hypersomnia - prolonged unrefreshing naps, trouble waking, treat with stimulants
207
What is the presentation, cause, risk factors, investigation and management for cellulitis?
Presentation - erythema, tender, chills and fever, unilateral, vesicles
Causes - group A strep (pyogenes), staph aureus
Investigation - swab, CRP, FBE, US (doppler - rule out DVT)
Risk Factors - trauma, IVDU, ulcers, wounds, derm infection (tinea), peripheral oedema, lymp stasis
Management - flucloxacillin, cephalexin, clindamycin
208
What is the presentation, cause, risk factors, investigation and management for chronic lymphedema?
Presentation - bilateral chronic swelling and erythema
Risk Factors - trauma, cancer, obesity, inflammatory disorder, chronic venous insufficiency
Management - exercise, compression, massage, meticulous skin care
209
What is the presentation, cause, risk factors, investigation and management for Necrotising Fasciitis?
Presentation - pain, swelling, fever, blisters, tight skin, infection
Risks - surgery, ulcers, DM, PVD, immunocompression
Causes - strep pyogenes, clostridium, vibrio, MRSA
Management - antibiotics, surgery, debridement
210
What is the presentation, cause, risk factors, investigation and management for osteomyelitis?
Presentation - pain, fever
Causes - direct, haematogenous
Risks - prosthesis, trauma, bite, penetrating wound, vascular insufficiency
Investigations - bone sample
Management - analgesia, IV Abx
211
What is the presentation, cause, risk factors, investigation and management for septic arthritis?
Presentation - pain, swelling, fever
Risks - trauma, RA, prosthesis, skin infection, IVDU
Investigation - joint aspirate, blood cultures
Management - joint washout, IV Abx, fluclox, cephazolin
212
What are the major causes of acute and chronic travellers diarrhoea?
Acute - E.coli, cholera, shigella, salmonella, campylobacter, entamoeba histolytica
Chronic - giardia
213
What is the management for travellers diarrhoea?
Rehydration
Antidiarrhoeal - loperamide
Empiric Abx - azithromycin, quinolone, ciprofloxacin
214
What are the important features of malaria?
P vivax may cause late relapse due to liver residement
P falciparum commonest cause of death, should be considered in all travellers returning from endemic areas
Symptoms - fever, chills, pain, faituge, malaise, nausea, vomiting, diarrhoea, cough
Diagnosis via thick and thin blood smear
Treat with chlorowuine then primaquine for vivax and artemetherlumafantrine for falciparum
215
What are the important features of enteric fever?
Salmonella and paratyphi
Non-specific febrile illness
Can cause bowel perforation and GI bleeds
Diagnosis with FBE (normal WCC with left shift), LFT (abnormal), blood (gram negative bacilli)
Treatment: ceftriaxone, azithromycin
216
What are the important features of dengue fever?
Flaviviruses from mosquitoes
Undifferentiated fever
Early neutropenia with subsequent lymphocytosis
Low platelets and elevated transaminases = severe disease
Management - supportive
217
What is this pathology and what are the main features?
CHRONIC MYELOID LUEKAEMIA
Signs & Symptoms - mass, hepatosplenomegaly, fatigue, loss of appetitie, weight loss, night sweats
Investigations - leukocytosis, hypercellular blasts in bone marrow, philadelphia chromosome (9:22) - BCR-ABL
Management - imatinib (tyrosine kinase inhibitor)
218
What is this pathology and what are the main features?
CHRONIC LYMPHOCYTIC LEUKAEMIA
Signs & Symptoms - fatigue, weight loss, appetitie loss, lymphadenopathy, splenomegaly
Investigations - lymphocytopenia, smear cells, B cells expressing CD5
Management - chemoimmunotherapy
219
What is this pathology and what are the main features?
ACUTE MYELOID LEUKAEMIA
Signs & Symptoms - bruising, bleeding (DIC, thrombocytopenia), fatigue
Investigations - low haemoglobin, pancytopenia, high INR, blasts nad promyelocytes with auer rods and faggot cells
Management - platelet transfusion, trans retinoic acid, arsenic and idarubicin
220
What is this pathology and what are the main features?
ACUTE LYMPHOCYTIC LEUKAEMIA
Signs & Symptoms - kids, dizzy, SOB, weight loss, fatigue, flushing
Investigations - low Hb, high urate, LDH, calcium, phosphate, potassium, CXR (wide mediastinum, lymphadenopathy)
Management - chemotherapy
