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M+M Flashcards

1
Q

Name three things to ask about in a suspected Bell’s palsy history?

A
  • Is the forehead involved? If you can’t raise eyebrows it’s LMN (Bell’s) if you can its UMN (Stoke/TIA)
  • Diabetes (increased risk)
  • Limbs affected (rule out CVS)
  • Other symptoms (migraine, partial seizure)
  • History of nerve problems (rule out MS)
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2
Q

How do you manage Bells palsy (2)

A

1 - Prednisolone for 10 days
2- Supportive (eye drops, tape eyes shut at night)

Should resolve fully in 6-12 months, may get worse initially

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3
Q

Patient presents with an isolated foot drop and frequent stumbling. The is some numbness on the upper side of the foot. What is the expected diagnosis (and what nerve is involved)?

A

Common perineal nerve (foot drop)

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4
Q

Patient presents with an isolated foot drop and frequent stumbling. The is some numbness on the upper side of the foot. What are the two main differentials and how would you distinguish?

A

1- Foot drop
2- L5 root compression

Distinguish as (2) will also see a loss of ankle reflex and possible back pain

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5
Q

How would you manage an isolated common perioneal nerve palsy?
How long would it take to resolve?

A

Conservative (splinting, avoid kneeling, leg crossing and squatting)

Should resolve in 2-3 months

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6
Q

Patient presents after a fracture of the humerus with a wrist drop, which nerve is involved and how should it be managed?

A

Radial nerve

Splint and see function return in 4 months

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7
Q

Name 5 questions for red flags that must be asked in any back pain history?

A

1- Saddle anaestheisa, changes in urine/ bowel symptoms/ LL neuro symptoms - CES
2- Point tendereness - #
3- Night pain, weight loss, night sweats - Cancer
4- Fever or recent infection - STI
5- Problems with prostate - metastatic
6- Sudden onset (AAA)

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8
Q

What 5 things should be `counselled on for a case of mechanical back pain?

A

1- Don’t avoid exercise and activity - stay active
2- Avoid rest
3- Posture
4- Adaptations at home and work
5- Short course low dose NSAIDS
6- Physio
7- 80% of people have an episode of low back pain at some point in their lives, 90% recover within 4 months

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9
Q

What is the management of an acute episode of sciatica?

A 
Most cases resolve in 6 weeks 
1- Oral NSAIDS + physio 
2- IM NSAIDS 
3- Opioids 
4- Manual therapy
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10
Q

A patient presents with Mania, you suspect Bipolar disease but suggest (3) other differentials?

A

Substance induced mood disorder
Psychosis
Personality disorder
ADHD

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11
Q

What is the definition of rapid cycling bipolar?

A

4 or more cycles of depression and mania within a year, with no asymptomatic episodes

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12
Q

What is your management of bipolar disorder?

A

1- Educate about triggers, self help groups etc.
Drugs:
- Lithium (GOLD standard)

If acutely manic episode:
Quetiapine or Olanzapine

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13
Q

How do you diagnose delirium?

A

Delirium must be diagnosed using either the CAM (Confusion assessment method) or 4AT tests

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14
Q

What are the CAM criteria for delirium?

A

To be delirum must be:
1- Acute onset with fluctuating course
2- Show inattention (count back from 20 to 1)
3- Have EITHER (disorganized thinking) or (changed level of consciousness)

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15
Q

What are the 4 questions and score of the 4AT test?

A

1- Alertness (Abnormal = 4)
2- AMT4 (Age, DOB, year and where. 2+ mistakes = 2)
3- Attention (Months backward). 7+=0, 7-=1, untestable=2)
4- Acute and fluctuating course (Y=4)

Any score over 4 shows possible delirium, then use CAM

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16
Q

A patient has suspected delirium, but what are 3 other DDx’s?

A 
Dementia
Depression
Bipolar
Psychosis 
Stroke
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17
Q

What investigations should be done if someone has a diagnosis of delirium? (3)

A

Hx and Obs
Urine dip
ECG
CXR

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18
Q

Name 5 management steps for a patient with delirium.

A 
Good communication
Clock
Familiar objects 
Avoid over/understimulation 
Side room
Control lighting and temperature 
Maintain mobility 
TREAT UNDERLYING CAUSE
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19
Q

If a patient has delirium, how does their prognosis change?

A

Worse if hypoactive compared to hyperactive

2-3x increase in mortality

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20
Q

What are the key components of a dementia history? (5)

A 
Onset duration 
Past strokes/ other neurological signs - Vascular 
HTN/ smoking - Vascular
Flucuation - Lewy body 
Hallucinations - Lewy body
Personality changes - Frontotemporal
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21
Q

What treatment can be used for Alzheimer’s dementia? (3)

A

1- Supportive (OT, support groups, charities)
2- Donepezil, rivastigmine or galantamine (ACh inhibitors)
3- Memantine

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22
Q

What is the mean survival from diagnosis for someone with Alzheimer’s dementia?

A

7 years

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23
Q

What medicines are used to treat vasular dementia?

A

None

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24
Q

What medicines can be used for Lewy Body Dementia?

A

Rivastigmine

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25
Q

Name three tools which could be used to measure cognitive function in a suspected dementia? (3)

A

ACE III (20-25 mins)
MoCA (10-15mins)
MMSE (15mins)

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26
Q

What are the DSM 5 criteria for depression?

A

Last month more days than not:
1- Down depressed or hopeless
2- Not enjoying normal activities and not getting pleasure
3- Three of SAGCLASS

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27
Q

Name 4 things which must be screened for in a depression history?

A 
Mania
Psychosis 
Suicide risk
Risk to others 
Substance misuse
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28
Q

What investigations should be done for depression? (3)

A

Rule out hypothyroid
PHQ-9
FBC - Anemia etc.

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29
Q

What management should be offer for mild to moderate depression? (3)

A

Watchful waiting - see again in two weeks
Low intensity CBT
Relaxation therapy

(only offer meds if depression persists or other comorbid problems)

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30
Q

What is the first line management of depression in adults? (3)

A

Supportive
SSRI (Sertraline/ citalopram)
CBT
Review in 2 weeks

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31
Q

Name 5 side effects of SSRI’s

A 
GI upset/ nausea (resolves in 1-2 weeks)
Increased anxiety (resolves in 1-2 weeks)
Dry mouth
Drowsiness 
Low sex drive
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32
Q

Which two common drugs should you try not to use with SSRI’s?

A

Triptans (migraine)

Aspirin (due to ulcer risk)

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33
Q

What is the second line medication for adults with depression?

A

Venlafaxine

CI uncontrolled hypertension

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34
Q

Name 3 symptoms of SSRI withdrawal syndrome

A 
Increased mood changes
Restlessness
Sleeping difficulty
GI (pain, cramping)
D+V
Paraesthesia, sweating, unsteadiness
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35
Q

What is the average length of a depressive episode?

A

6-8 months
(80% will have another episode in their lifetime)
(20% will become chronic)

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36
Q

What are the 5 ear symptoms you should always ask about in an ear history?

A 
Ache (otalgia)
Discharge (Otorrhoea)
Hearing loss
Tinnitus 
Dizziness
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37
Q

What are the 5 nose symptoms you should always ask about in an nosehistory?

A 
Obstruction
Running nose (rhinorrhoea)
Loss of smell
Nose bleeds (epistaxis) 
Facial pain
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38
Q

What are the 5 throat symptoms you should always ask about in a throat history?

A 
Sore throat
Difficulty swallowing (dysphagia)
Pain on swallow (odynophagia)
Hoarse voice (dysphonia)
Regurgitation
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39
Q

Name 4 differentials for a conductive hearing loss

A

Wax/ foreign body
Infection
Trauma + perforation of tympanic membrane
Otoscleroisis

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40
Q

Name 4 differentials for a blocked nose

A

Septal deviation
Acute rhinosinusitis
Chronic rhinosinusitis
Chronic rhinosinusitis with polyps

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41
Q

Where is the most common site in the nose to bleed from?

A

Kiessllbach’s plexus in little’s area

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42
Q

What is first line management of epistaxis?

A

Nasal oinment (Naspetin or Bactoban)

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43
Q

Name two broad categories of seizures

A

Generalised

Partial

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44
Q

Name three possible triggers for seizures?

A

Most idiopathic but sleep deprivation, alcohol, dehydration and not eating

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45
Q

Name two differentials for a seizure

A

Syncope
Non-epileptic attack disorder
Migraine

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46
Q

What investigations should be done following a first seizure?

A

Bloods (FBC, U+E) - looking for infection or metabolic disturbance
ECG
MRI (non urgent) to look for cause, only urgent if neurological signs

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47
Q

What is the first line management for an adult with generalised tonic-clonic seizures?

A

Valproate or lamotrigine (often better tolerated with less SE)

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48
Q

What is the first line management for partial (focal) seizures?

A

Carbamazepine or lamotrigine

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49
Q

What side effects should you council for antiepiletics?

A

Drowsiness and slowed cognition
Dizziness
RASH - Stephen Johnson Syndrome

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50
Q

Management of acute epilepsy is… (4)

A

ABCDE
Look for reversiable cause (bloods, glucose etc.)
IV Lorazepam or buccal midazolam
IV Phenytoin

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51
Q

In addition to a thorough before, during and after, what else should you ask about in a falls history?

A

Eyesight
Any problems with heart
Drugs
Any problems with blood pressure

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52
Q

What assessment tool can be used to calculate falls risk?

A

Tinetti Assessment Tool

(0-28) anything below 19 is a high risk

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53
Q

What tool can be used to calculate 10 year fracture risk?

A

FRAX

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54
Q

What investigations should be performed following a fall? (5)

A 
FBC (anaemia, infection)
Neuro exam (peripheral neuropathy)
ECG
Lying and standing blood pressure 
Tinetti assessment tool 
FRAX assessment tool
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55
Q

Name 5 symptoms of fibromyalgia

A 
Pain
Unrefreshing sleep
Tired
Some morning stiffness
Paraesthesia 
Felling of swollen joints 
Headaches 
Anxiety and depression
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56
Q

What 5 tests would you do to investigate a suspected fibromyalgia?

A

TFT- Rule out thyroid
ANA - Rule out lupus
FBC/ Iron studies - Anaemia can cause some symptoms
Vit D - Low can cause muscle pain and tiredness
Magnesium - low levels can lead to muscle cramps

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57
Q

What scoring tool could be used to assess fibromyalgia?

What is the cut off score for fibromyalgia?

A

Widespread pain score (0-19)

More than 7 with symptoms for 3 months and no cause = fibromyalgia

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58
Q

Name the first three lines of management for fibromyalgia?

A

1- Education and exercise (only one with evidence)
2- CBT
3- Paracetamol, weak opioids (not NSAIDS)

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59
Q

Name 5 features of compartment syndrome?

A 
Pain (worse on stretching)
Pallor 
Pulselessness 
Paralysis 
Parathesia
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60
Q

How should you manage compartment syndrome?

A

Measure pressure (if 30-40mmHg greater than systemic > Open fasiciotomy)

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61
Q

Which artery (and it’s root artery) is most likely to be affected causing loss of blood supply to the femoral head in a #NOF?

A

Medial circumflex artery

From deep femoral

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62
Q

What are the diagnosis criteria for GAD?

A

Excessive anxiety and worry
More days than not
Over a wide range of activities and events
Lasting over 6 months

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63
Q

Name 7 symptoms of anxiety

A 
Restlessness, irritability 
Difficulty concentrating 
Easily fatigued 
Sleep disturbance 
Palpitations
Fast HR
Sweating, trembling
Dry mouth
SOB 
Nausea
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64
Q

Name 5 possible differentials for someone presenting with anxiety?

A 
GAD
Panic disorder (trigger)
PTSD
Phobia
Social phobia 
Depression
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65
Q

What investigations should be done when suspecting GAD (4)

A 
PHQ-9
FBC (anaemia)
TFT (thyroid)
Cortisol 
B12 
Folic acid
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66
Q

Name the first two (non-pharma) management steps for GAD

A

1- Educate (avoid caffeine, alcohol, illicit drugs, stimulants). Try breathing exercises and exercise
2- Low intensity psychological support, support or self help groups,

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67
Q

Name the post education/ support group management steps for GAD (2)

A

1) CBT

2) SSRI (Sertraline, escitalopram)

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68
Q

How would you explain GBS to a patient?

A

Guillian Barre

An autoimmune disorder which attacks your nerves, and that causes this progressive neuropathy

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69
Q

What disease makes up 95% of Guillian Barre Syndrome cases?

A

AIDP (Acute inflammatory demyelinating polyradiculoneuropathy)

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70
Q

With a history of possible GBS, what key history questions should you ask? (3)

A

75% have preceding infection
More common if malignancy or post-partum
SOCRATES

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71
Q

A patient presents with possible GBS, what are your differentials? (3)

A 
Encephalitis 
Transverse myelitis (UMN)
Boutulism (descending) 
Stroke
Myasthenia gravis
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72
Q

What is the single best investigation for GBS?

A

Nerve conduction studies

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73
Q

What three maininvestigations could be done for GBS?

A

Nerve conduction
Lumbar puncture (raised protein)
Antibodies to peripheral nerves
SPIROMETRY (most important determinant for need to admit to ICU)

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74
Q

What is management of GBS?

A

IVIG or plasma exchange

  • Spirometry and consider ITU support
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75
Q

What is the prognosis of a patient with GBS?

A

80% walk unaided and fully recover in 6 months

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76
Q

Name 7 differentials for a headache?

A 
Tension-type headache
Migraine
Cluster headache
Meningitis 
SAH
Trigeminal neuralgia
Temporal arteritis   
Raised ICP
Sinusitis
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77
Q

Name 4 common features of a tension type headache? (including negatives)

A 
Bilateral
Feeling like pressing or tightening 
No nausea, no aggravation by physical activity, light or noise 
Often late in the day
Aggravated by stress
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78
Q

What investigations would you do for a tension headache (and all headaches)? (2)

A

Optic fundi

Blood pressure

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79
Q

What management for a tension type headache?

A

Simple analgesics, avoid triggers

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80
Q

What is the classic presentation of a migraine? (6)

A

Unilateral
Pulsating/ throbbing headache in trigeminal nerve
Nausea is common
Lasts between 4-72 hours
Photophobia
Aura (normally visual) - last 5 mins to one hour.

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81
Q

What investigations should be done for a patient with migraine? (1)

A

Neurological exam

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82
Q

What percentage of migraines involve aura?

A

33%

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83
Q

What is the diagnosis criteria for migraine without aura?

A

Need 5 attacks with three of classic symptoms

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84
Q

What is the diagnosis criteria for migraine with aura?

A

Can diagnose with one episode if no other pathology suspected

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85
Q

Name 7 potential triggers for migraine?

A

Stress, louid noise, bright light, travel, cheese, chocolate, alcohol, missed meals, dehydration, lack of sleep, oral contraceptives

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86
Q

What is first/ second line treatment for an episode of migraine?

A

1st: Soluble paracetamol
2nd: Triptain (sumatriptan)

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87
Q

Name two drugs/ classes of drugs which can’t be taken with Sumitriptan?

A

Citalopram

COCP

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88
Q

Name two non-drug CI for sumitriptan

A

CHD
Uncontrolled HTN
Risk factors for CHD

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89
Q

Name the first and second line preventative measures for migraine and the criteria to use them

A

AVOID TRIGGERS

2) Propanolol - only if QoL affected or <2 episodes per month

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90
Q

Name the classic presentation features of cluster headache

A

Short painful attacks
30mins-3hrs
Around one eye
Occur a few times a day fpr months then remission period
Often begins with severe pain which wakes them up
Symptoms like red eye and ptosis

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91
Q

What is the acute management of a cluster headache? (2)

A

100% oxygen for 15 mins upto 5x per day

Sumitriptan subcut

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92
Q

What is the preventative management of cluster headache?

A

Verapamil

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93
Q

Name 4 red flags in a headache history to screen for meningitis

A 
Neck stiffness
Fever
Non-blanching rash 
Seizures 
Photophobia and vomitting also for migraine
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94
Q

What is your first investigations (3) to order in suspected meningitis?

A

LP, blood cultures, throat swab

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95
Q

Name your first two management steps for meningitis

A

ABCDE

Broad spectrum AB’s (treat as bacterial until proven otherwise)

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96
Q

What is your first investigation for suspected SAH?

A

CT head

Neurosurgical consult

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97
Q

Name 5 possible features of trigeminal neuraliga

A

Pain in face
Electric shock sensation
Lasts a few seconds to ew mins
Exacerbated by touch or , cold or eating

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98
Q

What is the first line management of trigeminal neuralgia and how long do you treat for?

A

Carbamazepine (withdrawn one month after remission)

Surgical options available down the line but not curative

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99
Q

What patients classically experience temporal arteritis?

A

Over 50

Presenting with headache, scalp pain, transient visual symptoms

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100
Q

What investigations should be performed in suspected temporal arteritis? (2)

A

ESR (<50mm/hr)

Temporal artery biopsy

101
Q

What is the management of temporal arteritis?

A

Prednisolone 40mg

If visual symptoms admit and give IV

102
Q

What classic features are associated with a headache due to raised ICP?

A

Transient visual obscuration
Worse in morning
Vomitting
Worse on coughing, straining or bending forward

103
Q

What investigations should be done for suspected raised ICP? (2)

A

CT head

Fundoscopy

104
Q

How should raised ICP be managed? (1)

A

IV mannitol

105
Q

A patient presents with headache, reporting seeing halo’s around lights with pain in their eyebrow. You notice a red eye and a fixed dilated pupil, it has come on over a day. MLD?

A

Acute closed angle glaucoma

106
Q

Name 5 common symptoms of acute angle closure glaucoma

A 
Ocular pain
N/V
Halo's around lights 
Blurred vision 
Red eye (conjunctival injection)
107
Q

What’s your first investigation for acute closed angle glaucoma?

A

Check IOP (should be under 21mm/Hg)

108
Q

How should you manage acute closed angle glaucoma? (4)

A

Topical Beta Blockers, steroids and pilocarpine

IV Acetazolamide

109
Q

Name 4 common features of sinusitis?

A

Facial pain
Exacerbated by leaning forward or coughing
Rhinorrhoea
Nasal congestion
Pain on percussion of frontal or temporal sinus

110
Q

What is the management of sinusitis? (4)

A

Warm face packs, analgesia, saline nasal drops, antibiotics if bacterial

111
Q

Name 5 key questions which should be asked in any lupus history?

A 
Rashes (especially in sun)
Tiredness
Weight loss
Joint pain 
Cold hands changing colour 
Ulcers in the mouth 
Muscle pains or aches
112
Q

What is the most sensitive autoantibody for Lupus?

A

ANA

Negative almost excludes SLE

113
Q

What is the most specific autoantibody for Lupus?

A

Anti-Sm

followed by Anti-dsDNA

114
Q

Name 2 diseases commonly associated with Lupus

A

Anti-phospholipid syndrome
Thyroiditis
All other autoimmune conditions

115
Q

Name 2 lifestyle suggestions for patients with lupus

A

Stay out of sun

Encourage regular exercise

116
Q

What is the first line treatment for Lupus (pharmacological) and how long does it take to work?

A

Hydroxychloroquine

6-12 weeks

117
Q

What is second line Lupus treatment?

A

Add induction therapy

Mycophenolate, cyclophosphamide, azathioprine

118
Q

What does section 2 of the MHA allow?

A

Detained in hospital for 28 days for assessment and treatment if needed

119
Q

Who can detain under MHA section 2?

A

GP can refer then two doctors (one specialist) must approve within 14 days

120
Q

What does MHA section 3 allow?

A

Detained in hospital for 6 months for treatment

121
Q

What does MHA section 4 allow?

A

Detained for emergency assessment for up to 72 hours

122
Q

Who can approve MHA section 4?

A

Needs only one doctor (has to have seen in last 24 hours)

123
Q

Can you treat under MHA section 4 and 5?

124
Q

What does MHA section 5 allow?

A

Stopped from leaving hospital if needed

125
Q

What two subsections MHA section 5 are there and who do they apply to?

A

5(2) - doctors

5(4) - nurse (mental health nurse)

126
Q

What does an MHA section 135 allow?

A

Warrant to gain access to premises to remove patient to safety

127
Q

What does an MHA section 136 allow?

A

Removal of a person from a public place for there/ other’s safety

128
Q

Name 6 symptoms of alcohol withdrawal

A 
Shaking
Sweating 
Headache
Confusion
Tremor 
Hallucinations 
Agitation 
Ataxia
129
Q

What investigations should be done when querying alcohol issues?

A

Blood alcohol
Gamma GT
Urine drug screen

130
Q

How do you manage alcohol intoxication? (2)

A

Chlordiazepoxide for 5 days

Thiamine to prevent Wernicke’s

131
Q

What 4 factors should always be asked about in an opthalmic SHx?

A

OCDS

Occupation, carer?, driving, smoking/ alcohol

132
Q

Name 3 risk factors for angle closure glaucoma?

A

Female
Hyperopia
Asian

133
Q

Name 5 presenting symptoms of acute angle closure glaucoma?

A 
Blurred vision
Halo's around lights 
Painful 
Red eye
Headache
Nausea and vomiting
134
Q

How do you diagnose acute angle glaucoma (2)?

A 
Goldmann tonometry (<21mmHg)
Gonioscopy (examination of anterior chamber angle)
135
Q

Name 4 treatments for acute angle closure glaucoma?

A

Peripheral iridotomy
Drops:
-Carbonic anhydrase inhibitors, beta blockers, alpha agonists

136
Q

Name 4 risk factors for central retinal artery occlusion

A 
HTN
DM
CHD
PVD
Smoking
137
Q

How does a patient with central retinal artery occlusion present (1)

A

Sudden painless loss of vision

138
Q

What is seen in central retinal artery occlusion on fundoscopy?

A

Cherry red spot

139
Q

How does retinal detachment present? (3)

A

Sudden loss/ deterioration of vision
May be floaters
Can be peripheral or central
Described as a curtain coming down

140
Q

How should retinal detachment be treated? (1)

A

Urgent surgery

141
Q

Name 3 risk factors for retinal detachment?

A

Myopia
Trauma
DM
AMD

142
Q

How does orbital cellulitis present? (4)

A 
Red swollen eye
Painful 
Reduced vision 
Opthalmoplegia 
Systemic features like fever
143
Q

What investigations should be done for orbital cellulitis (4)

A

CT or MRI of sinus and orbits
Conjunctival cultures
Blood cultures
FBC

144
Q

Name 3 possible treatments for orbital cellulitis?

A

IV AB’s
Nasal decongestants
Surgical drainage of absess and pressure relief

145
Q

Name 3 presenting features of conjunctivitis?

A

Red eye
Itchy
Watery or purulent discharge

146
Q

What is the most common viral pathogen which causes conjunctivitis?

A

Adenovirus

147
Q

What is the most common bacterial pathogen which causes conjunctivitis?

A

Strep. pneumoniae

148
Q

What is first line Tx for suspected viral conjunctivitis? (3)

A

Artificial tears
Topical steroids
Topical antiviral

149
Q

Which agent is first line tx for bacterial conjunctivitis? (1)

A

Topical chloramphenicol

150
Q

What are the DVLA minimum driving sight requirements? (1)

A

6/12 with both eyes open

151
Q

A patient with dry AMD presents with sudden onset of blurred vision, what is most likely diagnosis?

152
Q

Name three fundoscopic features of dry AMD

A

Drusen
Geographic atrophy
Macular pigmentary changes

153
Q

What is the classical presentation of dry AMD? (1)

A

Progressive loss of central vision

154
Q

What investigations are routinely needed for CTS?

A

None

Electroneurograhy is gold standard but not routinely needed

155
Q

How long should it take CTS to resolve?

156
Q

Name three management steps for CTS?

A

Splint/ simple analgesia (but not NSAIDS)

2nd: Corticosteroid injections
3rd: Surgery (refer if not change in 3 mths)

157
Q

Which genetic mutation is associated with ankylosing spondylitis?

158
Q

Name three presenting features of ankylosing spondylitis (including age)?

A

Back pain which improves with exercise
Pain which wakes patient in early morning
Stiffness
Presents before age 30

159
Q

Name two common associations with ank spond?

A

Peripheral enthesitis - Achillies tendonitis, plantar fascitis
Peripheral arthritis - Hip/ shoulder

Both affect around 1/3 of patients

160
Q

Name three tests or investigations for ank spond?

A

Schobers test
Sacroilitis on x-ray < diagnostic
Bamboo spine on x-ray < late sign

161
Q

How should ank spond be managed? (4)

A

Physio and exercise
NSAIDS
Steroid injections
Biologics and surgery if severe

162
Q

What is the classical presentation of polymyalgia rheumatica?

A

Bilateral pain and morning stiffness of neck, shoulder and pelvic girdle
Only occurs in those age over 50

163
Q

What investigations should be done for PMR? (1)

A

ESR (>40mm/hr)

Note PMR is very similar to vasculitis

164
Q

What disease is commonly associated with PMR?

A

Giant cell/ temporal artertis

165
Q

What is the treatment for PMR (1)?

A

Steroids for 3 weeks then reducing over one year

166
Q

In a patient with PMR what three symptoms would you ask about to screen for GCA?

A

Headache, visual disturbance, jaw claudication

167
Q

How would you describe GCA to a patient?

A

Autoimmune, inflammation of the blood vessels

168
Q

What is the classical presentation of GCA? (4)

A

Temporal headache, scalp tenderness, transient visual symptoms and unexplained facial pain
Usually in over 50

169
Q

What investigations should be done for GCA? (2)

A

ESR (<50mm/hr)

Temporal artery biopsy if unsure

170
Q

How should GCA be managed? (3 points to note)

A

High dose steroids (pred)
If visual symptoms admit for IV steroid (methylpred)
Aspirin and PPI should also be given

171
Q

Name some presenting features of Granulomatosis with Polyangitis (Wegners)? (3)

A 
ENT+Lungs+Kidneys
Ulcers, sores, crusting of nose
Rhinorrhoea 
Haemoptysis
Haematuria
Fever
Cough 
Chest pain, joint pain, abdo pain
172
Q

How do you diagnose Granulomatosis with Polyangitis (Wegners)? (3)

A 
c-ANCA (80% sensitive) 
ESR raised
U+E plus urinalysis
CT chest 
FBC (anaemia)
173
Q

How should you manage Granulomatosis with Polyangitis (Wegners)?

A

High dose steroid

Can escalate do cyclophosphamide etc if needed

174
Q

What is the difference between Eosinophillic Granulomatosis with polyangitis (Churg-Strauss) and Granulomatosis with Polyangitis (Wegners)?

A

Presence of eosinophils (asthma is the defining symptom)

Eosinophillic has much more diffuse symptoms which can affect almost the whole body (diffuse vasculitis)

175
Q

How do you investigate Eosinophillic Granulomatosis with polyangitis (Churg-Strauss)?

A

Urine dip (glomerulonephritis)
CXR (lung cavities)
p-ANCA (present in 40%)

176
Q

What is pagets disease of the bone? How common is it? Where does it most commonly affect?

A

Uncontrolled bone turnover
Present in 5% of population but only 5% of these will have symptoms
Most commonly affects pelvis, lumbar spine, femur

177
Q

What investigations should you do for Paget’s disease of the bone? (2)

A

Isolated raised ALP is indicative
Xray- Osteolysis and excessive formation
Look out for blade of grass lesion and cotton wool pattern in skull

178
Q

How should you manage Paget’s disease of bone? (2)

A

Give patient bisphosphonates and ensure adequate calcium/ Vit D

179
Q

How do you exacerbate lateral epicondylitis (tennis elbow)?

A

Extend wrist and supinate

Tennis is throw up wrists and Turn over

180
Q

How do you exacerbate medial epicondylitis (golfers elbow)?

A

Flex wrist and pronate

Golfers is floppy wrists GO out

181
Q

How should tennis/ golfers elbow be managed? How long will it take to resolve? (4)

A

Supportive - APRICE (Takes anything from a few weeks to a year)
Analgesia - NSAIDS
Protection- Avoid activities which may cause harm
Rest
Ice (for pain)
Compression - Not relevant
Elevation- Not relevant

182
Q

How does adhesive capsulitis (frozen shoulder) present?

A

Reduced shoulder movements both actively and passively, can be bilateral in up to 20%

183
Q

How long does an episode of adhesive capsulitis normally take to resolve?

A

6 months to 2 years

184
Q

How should you treat adhesive capsulitis? (4)

A

NSAIDS
Physio
Oral steroids
IM Steroids

185
Q

What is a classic history of an ACL tear? (4)

A 
Twisting force to bent knee
Pain
Sensation of knee buckling and popping 
Very rapid swelling
Can't continue activity
186
Q

What is a classic history of a PCL injury? (3)

A

Hyperextension injury
Pain
Rapid swelling
Can continue activity

187
Q

What is a classic history of an MCL/ LCL injury? (3)

A

Blow to lateral aspect of knee
Pain
Less likely to have swelling

188
Q

What is a classic history of a meniscal injury?

A

Twisting MOI
Pain in joint line with stiffness
May have buckling, locking or catching

189
Q

Following an ACL injury what are the treatment options? (2)

A

Wait for swelling to go down
Do physio
Surgery not for around 3 weeks (although not everyone will have surgery)

190
Q

How long does a first episode of sciatica last?

A

Normally around 6 weeks

191
Q

What management steps are there for sciatica?

A

NSAIDS
Physio
Steroid injections

192
Q

What are the most common hip problems in 0-3 year olds (2)

A

Developmental dysplasia of the hip

Haematological malignancy

193
Q

What are the most common hip problems in 4-10 year olds (2)

A

Transient synovitis

Perthe’s disease

194
Q

What are the most common hip problems in 11-16 year olds (2)

A

Slipped upper femoral epiphysis

Osteosarcoma

195
Q

Name 5 risk factors for osteoporosis?

A 
Age
Female
Low body mass
Steroid therapy
Smoking
Immobility 
FHx
196
Q

Name 3 conditions associated with osteoporosis?

A 
Early menopause
Inflammatory arthritis
Hyperthyroidism 
IBD
COPD 
Chronic liver disease
197
Q

Who should have a FRAX risk assessment (3)

A

Women over 65
Men over 75
Those with risk factors

198
Q

What should be done about a low risk FRAX score?

A

Lifestyle advice only

Activity, strengthening and increase Ca and VitD intake

199
Q

What should be done about a medium risk FRAX score?

A

Do DEXA scan to establish BMD then recalculate FRAX

200
Q

What should be done about a highrisk FRAX score?

A

Start treatment

Bisphosphonates plus Ca and Vit D

201
Q

What is first line treatment in osteoporosis?

A

Bisphosphonates plus Ca and Vit D

202
Q

What is second line treatment for osteoporosis in postmenopausal women?

A

Raloxifene or Denosumab

203
Q

Name 7 features of Parkinsonism?

A 
Gait changes (shuffling, festinating (can't stop))
Stooped posture 
Bradykinesia
Rigidity 
Resting tremor (fine and pill rolling)
Hypophonia (quiet voice) 
Poverty of expression 
Micrographia 
Unilateral onset
204
Q

What are the classical features of a benign essential tremor? (4)

A

Familial (70%)
Improves with alcohol
Bilateral
Action tremor (rare at rest)

205
Q

What is the tx for benign essential tremor?

A

Propanolol

206
Q

What investigations should be done for someone with potential PD? (1)

A

None routinely
Neurological exam
Refer to movement disorder team

207
Q

How would you manage a patient with parkinson’s disease newly diagnosed? (4)

A

Refer to movement disorder team
Patient should inform DVLA
Consider if OT assessments etc are required
1st Line:
- If QoL affected: Levodopa (with co-benaldopa)
- If QoL not affected/ young etc: Rasagiline (MAO-B inhibitor)

208
Q

What prognosis for PD should be counselled to a patient?

A

Very variable (some little disability after 20 years, some may be severely disabled after 10 years)

209
Q

Name 5 differentials for a tremor?

A

Parkinsonism < rest tremor
Benign essential < action, FHx, relieved by alcohol
Hyperthyroid < Always present, too hot, tachycardia and other thyroid symptoms
Drug induced < Action (Salbutamol, alcohol)
Cerebellar (ataxic) < Intention tremor with other cerebellar signs

210
Q

Name one feature which would make you consider a diagnosis of drug induced PD as opposed to IPD?

A

Bilateral symptoms

Temporal onset correlating

211
Q

Name 3 RF’s for schizophrenia?

A 
FHx
Low birth weight
Social isolation 
Abnormal family interactions
Abuse 
Cannabis use
212
Q

Name four first rank symptoms of schizophrenia?

A

Delusions (grandiose or persecutory)
Hallucinations (auditory most common)
Thought disorder (insertion, removal, broadcasting)
Lack of insight

213
Q

Name 5 differentials for someone presenting with a schizophrenic type picture?

A
  • Schizophrenia
  • Substance induced psychosis
  • Schizoaffective disorder (mood disorder with schizophrenia but criteria not fully met)
  • Depression with psychosis (depression occurs first)
  • Bipolar with psychosis (mood syx first)
  • Organic psychosis (tumor etc)
214
Q

What investigations should be done for a patient presenting with schizophrenia like symptoms? (3)

A

Drug and alcohol screen
Urine dip
Serological tests for syphilis

215
Q

What is the criteria needed to diagnose schizophrenia?

A

Two positive symptoms, not attributable to any other cause for most of the time for one month or more

216
Q

How should a patient with newly diagnosed schizophrenia be managed? (5)

A

Refer to psychiatry for support
Assess social circumstances and family relationships
Formally assess and document capacity
Consider whether admission is needed under MHA (S2 or 3)
1st Line: Atypical anti-psychotics (Olanzapine, quetiapine)

217
Q

How long should a patient with schizophrenia be treated with antipyschotics?

A

1-2 years after event

Close supervision for withdrawal

218
Q

What is prognosis for a patient with schizophrenia?

A

80% will recover from first episode but most relapse

1 in 20 will go on to commit suicide

219
Q

What is the definition of a TIA?

A

An acute focal disturbance of cerebral function lasting less than 24 hours

220
Q

What percentage of strokes are caused by infarction?

A

85%
(10% inter-cerebral haemorrhage)
(5% subarchnoid haemorrhage)

221
Q

Name 5 modifiable risk factors for stroke which any patient with stroke/ TIA should be counselled on?

A 
HTN
Smoking
High cholesterol 
Obesity (loose weight) 
Alcohol
222
Q

Name 3 stroke mimics

A
  • Hypoglycemia - Whipples triad (BM<2.8, Syx’s and resolution after glucose back to normal)
  • Tumour
  • Migraine
  • Temporal arteritis
  • Todd’s palsy (post seizure)
223
Q

Name 5 investigations which should be done in a suspected stroke?

A 
CT head to rule out haemorrhage (needs to be immediately if considering for thrombolysis)
ECG!!! - AF
Carotid doppler
FBC - platelets 
Blood glucose - stroke mimic
Lipids 
INR 
BP - reversible cause
224
Q

What scoring system can be used to assess severity of a stroke?

A

NIHSS

National institute of health stroke scale

225
Q

What system can be used to classify stroke?

A

Oxford Stroke Classification (Bamford)

Has three symptoms, strokes classified according to how much affected

226
Q

What is the affected artery and Bamford criteria seen in a TACI? (3)

A

Total anterior infarct (15%):

  • Middle (face/ arms) and anterior cerebral (leg) arteries
  • All three Bamford criteria
  • Worst prognosis
227
Q

What is the affected artery and Bamford criteria seen in a PACI? (3)

A

Partial anterior infarct (25%)

  • Most common
  • Division of the middle cerebral artery
  • 2/3 Bamford
  • 1/3 die/ 1/3 disabled and 1/3 survive
228
Q

What is the affected artery and Bamford criteria seen in a lacunar infarct?

A

Lacunar (25%)

  • Arteries around internal capsule, thalamus, basal ganglia
  • One of Bamford criteria
229
Q

What is the affected artery and Bamford criteria seen in a posterior infarct?

A

Posterior infarct (25%)

  • Vertebrobasillar arteries
  • Either cerebellar issue, LOC or isolated homonymous hemianopia
230
Q

How should you manage an acute stroke? (5A’s)

A

The 5A’s of immediate stroke management:

  • ABCDE
  • Assess eligibility for thrombolysis (4.5hrs, clear onset)
  • Aspirin 300mg OD for 14 days
  • Assess for cause (ECG, glucose etc.)
  • Actively encourage early rehab (goal setting etc)

Carotid doppler

231
Q

How should you manage an acute TIA? (4)

A

Start 300mg Aspirin
ABCD2 Score (0-7)
- If score if over 4 then assess in 24hrs to look for cause (carotid doppler, ECG etc.)
- If score is 3 or below then review in one week same as above

Carotid doppler

232
Q

What is the long term management of a stroke or TIA? (5)

A
  • Rehab
  • Review and counsel on lifestyle factors
  • Start on Statin
  • Treat any risk factors such as HTN
    If due to AF/ PAF:
  • CHADSVASC to decide if starting LT anticoag
    If not due to AF/PAF:
  • Start on clopidogrel 14 days post event
233
Q

How long after a stroke or TIA are you unable to drive , do the DVLA need informing?

A 
1 month (or 1yr if group 2)
Normal drivers do not need to inform DVLA
234
Q

You are about to take an Alcohol history, name the 8 key areas which should be discussed?

A 
Thoughts (Do you feel you have a problem) 
Who/ what/ where/ when/ why?
Screening - CAGE
Dependence (Withdrawal, tolerance, priority, craving)
RISK - Mood and suicide 
Other psych history 
Social history (OCDS) 
Thoughts of quitting
235
Q

How should metastatic spinal cord compression be treated?

A

ABCDE
Immediate MRI and surgical referral
Dextamethasone
Nursed flat with log rolling to protect spine

236
Q

Name 3 differences you would see in RA and not OA on an examination?

A 
Boggy joint swellings (as opposed to hard)
Symmetrical involvement (OA is uni)
Extra-articular manifestations (OA doesn't)
MCP and PIP (vs. DIP and Wrist in OA)
237
Q

What are the components of an ABCD2 score?

A 
Age > 60 = 1 
Blood pressure > 140/90 = 1
Clinical features: 
- Unilateral weakness = 2
- Speech disturbance only = 1 
Duration of symptoms:
- > 60 mins = 2
- 10-59 mins = 1
- <10mins =0
Diabetes = 1
238
Q

How do you investigate and monitor severity of RA?

A

DAS Score (0-28)

239
Q

What is a major cause of morbidity with lupus and so needs to be regularly monitored for?

A 
Lupus nephritis 
(Do do regular urine dip)
240
Q

Talk through radiograph interpretation (8

A

Plain radiograph of L/R XXX… Patient details
View and additional views- lateral view also
State the view, exposure, adequacy
Fractures - describe (open/ closed, simple/ comminuted, transverse etc.)

241
Q

Comprehensive geriatric assessment

A 
Physical health
Functional capacity 
Polypharmacy 
Social function
Financial status 
Cognitive (MMSE) and Falls (Tinetti) 
Screen for low mood and other mental health
242
Q

What is a classic presentation of labrynthitis? (4)

A
  • Room spinning (exacerbated by movement but not triggered by movement)
  • Hearing loss/ tinnitus
  • URTI infections commonly preceed or are concurrent

Rule out stroke, mengitis etc, ear pain is not present

243
Q

What examination findings would be seen in viral labrynthitis? (3)

A

Abnormal head impulse test
Nystagmus
Fall to affected side when walking

244
Q

What is the main distinction between BPPV and viral labyrinthitis? (1)

A

BPPV is trigger by positional changes

245
Q

Management of viral labyrinthitis?

A

Self limiting - normally resolves in days to a few weeks
During acute episode - Lie down still
Prochlorperazine can be given for vertigo, nausea and vomiting

246
Q

How should Myasthenia Gravis be managed?

A

1- Avoid tiredness/ stress etc for exertion
2- Pyridostigmine (encourages movement, lasts a few hours so multiple doses needed)
3- Add steroids
4- Add immunosuppresant

247
Q

Name the 5 A’s of things affected by Dementia?

A 
Amnesia
Agnosia 
Aphasia 
Ataxia 
ADL's
248
Q

What should be asked about in an eating disorder history using the SCOFF acronym?

A 
Sick (laxatives, smoking, exercise)
Control foods (ask diet) 
One stone (weight loss)
Fat (perceptions)
Food dominate (most important thing in life)
249
Q

Name 5 features of charcot marie tooth?

A

Group of inherited peripheral neuropathies (AD)
Progressive weakness, muscle wasting and sensory loss
Inverted champagne bottle and pes cavus
Tx- Physio and surgery for deformities

OSCE (6 decks)

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