Make a Medic - Medicine & Surgery Flashcards
What is PRES? Where does it affect? Common causes?
Posterior Reversible Encephalopathy Syndrome (PRES) is a constellation of symptoms that results in oedema of the posterior occipital and parietal lobes.
Manifestations include headache, changes in vision, confusion and seizures.
It can be caused by severe hypertension, and it should resolve once the blood pressure is under control.
Initial management of acute HF
Sitting the patient upright, administering high flow oxygen and offloading the fluid with IV diuretics (usually furosemide 40-80 mg)
Management of Furosemide resistant HF. How may this present on an ABG?
Non-invasive ventilation. T1RF
What type of NIV is useful for each type of respiratory failure? Why?
T1RF - CPAP - CPAP is to splint open collapsed airways, thereby recruiting more alveoli for oxygenation. It is appropriate for type I respiratory failure when poor oxygenation is the main issue.
T2RF - BiPAP - BiPAP is useful for both oxygenation of the blood and removing carbon dioxide, so it is a useful treatment for type II respiratory failure.
Where are venous ulcers typically found?
gaiter region of the leg
Characteristics of venous ulcers
shallow, relatively painless with irregular boundaries and a wet sloughy appearance
Characteristics of arterial ulcers
clearly defined borders, are extremely tender and the pain worsens with elevation of the leg (this reduces blood flow to the ischaemic tissue by removing the beneficial effect of gravity).
Characteristics of neuropathic ulcers
painless and will tend to arise at pressure points across the foot (e.g. balls of the foot).
What is preferred method of VTE prophylaxis in hospital? When is this contraindicated? What should be used instead?
VTE prophylaxis in hospital is usually given as a low-molecular weight heparin (e.g. tinzaparin), however, it is contraindicated in renal impairment (eGFR < 30 mL/min) as it is primarily renally excreted. Patients with renal impairment should, therefore, be started on IV unfractionated heparin instead.
Scoring system for severitty of an upper GI bleed
Glasgow-Blatchford scale
Scoring system post-endoscopy to determine how likely a patient is to have another bleed
Rockall score
How does gliclazide lead to increased insulin secretion?
They act on SUR1 receptors, which are associated with the KATP channel, and lead to its closure. They increased intracellular K+.
1st line treatment for MODY
Sulphonylurea
Immediate management of addisonian crisis
IV hydrocortisone and IV fluids
Criteria for diagnosis of Adrenal insufficiency following synACTH administration
Individuals with adrenal insufficiency will not demonstrate a sufficient rise in cortisol (< 420 nmol/L).
How can ACTH level be used to guide whether it is priamry or secondary adrenal failure?
If the ACTH level is low, then the adrenal insufficiency is due to secondary adrenal failure.
Causes of secondary adrenal failure include hypopituitarism and exogenous glucocorticoid administration.
4 types of MND
There are four main types of motor neurone disease depending on the types of motor neurones affected:
amyotrophic lateral sclerosis (upper and lower motor neurones)
primary lateral sclerosis (upper motor neurones only)
progressive bulbar palsy (cranial nerves IX, X and XII)
progressive muscular atrophy (lower motor neurones only).
Triad of Wernicke’s
confusion, ophthalmoplegia and ataxia.
Treatment of Wernicke’s
Pabrinex is a medication that contains thiamine and should be given to all alcoholic patients, irrespective of whether they have presented with signs of Wernicke’s encephalopathy.
Treatment of beta blocker OD
Atropine (if patient is bradycardic)
Treatment of benzo OD
Flumazenil
Treatment of malignant hyperthermia following suxamethomium
IV dantrolene
Treatment of cyanide poisoning
Hydroxocobalamin
Treatment of paraccetemol OD
NAC
What is used to look for CF during the heel prick test?
Immunereactive trypsinogen
What is a Hartmann’s procedure? When is it used? What stoma are they left with?
A Hartmann’s procedure is an emergency procedure that is used to manage acute presentations caused by diseases of the sigmoid colon (e.g. diverticular complication or bowel obstruction). As the conditions are usually suboptimal for an anastomosis to heal, patients are left with an end colostomy and a rectal stump which can be reversed at a later stage.
What is a left hemicolectomy used for? What does it involve removal of?
A left hemicolectomy can be used for descending colon cancers and utilises a colocolic anastomosis. This involves removal of the inferior mesenteric artery.
What type of cancer is an abdomino-perineal resection used for? What does it involve the removal of?
For rectal cancer that is less than 5 cm from the anal verge, an abdomino-perineal resection is used. This involves the removal of the anus and results in a permanent end colostomy situated in the left iliac fossa.
What type of cancer is an anterior resection used fro? What type of stoma is used? Why?
An anterior resection is the operation of choice for any rectal tumours that are more than 5 cm from the anal verge. The operation leaves the anus intact, an anastomoses the distal end of the colon to the remaining portion of rectum, thereby preserving continence. Due to the poor blood supply of the rectum, a temporary defunctioning loop ileostomy is created to protect the distal bowel and allow time to heal. This can be reversed electively at a later stage.
NOTE: an anterior resection involves the removal of the inferior mesenteric artery up to its origin at the aorta. This is significant in oncological surgery as the lymphatic drainage of the tumour follows the arterial supply and is a crucial route of metastasis.
What type of cancer is a right hemicolectromy used for? What type of stoma is formed?
A right hemicolectomy is the operation of choice for caecal or ascending colon cancers. The cancer is resected, and the bowel loops re-joined using an ileocolic anastomosis; this is commonly a side-to-side stapled anastomosis. This procedure involves the removal of the relevant branches of the superior mesenteric artery (right colic, ileocolic and right branch of the middle colic).
Which procedure involves removal of SMA?
Right hemicolectomy
Which procedure involves removal of IMA?
Left hemicolectomy + Anterior resection
Clinical features of osmotic demyelination syndrome. When do they present?
Spastic quadriparesis, pseudobulbar palsy and reduced GCS. They tend to manifest about 3-5 days after overcorrection of sodium.
When should a lap chole be done in acute cholehycstitis?
within 1 week of diagnosis
When should a lap chole be done in biliary colic?
6-12 weeks after Sx onset
Mackler’s triad for boerhaave syndrome
vomiting, chest pain and subcutaneous emphysema
CXR findng of boerhaave
pneumomediastinum
Definitive imaging for diagnosis of boerhaave syndrome
CT scan of the chest, abdomen and pelvis with oral and IV contrast - Leakage of oral contrast from the oesophagus into the mediastinum confirms the diagnosis
Most common sources of gram negative sepsis
urinary tract and the biliary system.
What does the presence of a new-onset left sided varicocele in an older man (over the age of 40 years) suggest?
It could be the presenting symptom of an underlying renal cell carcinoma that is compressing the venous drainage of the left testicle into the left renal vein.
1st line treatment for BPH
Tamsulosin (alpha blocker)
Criteria for tonsillectomy
≥7 episodes of tonsillitis in the past 12 months
● ≥5 episodes of tonsillitis per year for 2 years
● ≥3 episodes of tonsillitis per year for 3 years
● ≥2 peritonsillar abscesses at any point in the patient’s life (≥1 in children)
Treatment of thyroglossla cyst
Thyroglossal cysts are managed by surgical excision, typically with a Sistrunk procedure, which involves complete removal of the cyst and part of the hyoid bone
Dual antiplatelet therapy post STEMI
aspirin 75 mg OD AND clopidogrel 75 mg OD OR ticagrelor 90 mg BD for 1 year. Aspirin 75 mg OD will continue as a single antiplatelet agent lifelong.
How does infective endocarditis affect the spleen? How might this present?
The vegetations in bacterial endocarditis can give rise to septic emboli which can get lodged in the renal glomeruli and cause microscopic haematuria. They can also lead to splenic infarcts and splenomegaly.
Equivalent dose of 40mg furosemide for bumetanide
1mg PO
What does a low BP and high HR indicate? How should you manage this?
As this patient’s blood pressure is stable and their heart rate is high, it is likely that the rise in heart rate is attempting to compensate for their hypovolaemia. Given that hypovolaemia is the key issue that is driving this tachycardia, a fluid bolus will help replenish the intravascular volume and, hence, balance the equation such that the heart rate will come down.
What agents should avoided in those with severe aortic stenosis? Why?
Vasodilatory agents should be avoided, such as isosorbide mononitrate.
This is because, by causing vasodilation, these agents reduce the preload of the heart and can therefore further reduce cardiac output in a patient whose left ventricular outflow is already compromised. This could lead to a dangerous fall in blood pressure and a reduction in myocardial perfusion.
Most common cause of aortic stenosis in a younger patient
bicuspid aortic valve
Most pathognomic ECG finding for pericarditis
PR depression
Pericarditis following STEMI
Dressler syndrome
Medical management of encephalopathy
Lactulose
Classification for oesophagael or gastroesophagael pathology
Paris and Prague classification
LP finding of GBS
Albuminocytologic dissociation is a CSF analysis result that is often associated with GBS
Tumour marker for medullary thyroid cancer
Calcitonin (produced by parafollicular C cells)
1st line treatment for prolactinoma
Why is it used?
The first-line treatment option for prolactinoma is a dopamine agonist such as bromocriptine or cabergoline. It is used because dopamine has a negative effect on the production of prolactin by the anterior pituitary gland.
How do subdural haemorrhages present on CT
On a CT head scan, subdural haemorrhages will have a crescentic appearance. If acute, the bleed will appear white or bright grey, whereas if it is chronic (older than around one week) it will appear dark grey.
How do extradural haemorrhages present on CT?
It has a lentiform (Concave) appearance on CT head scans as it is bound by the dura
MOA of co-careldopa
L-DOPA and DOPA decarboxylase inhibitor
Preventative medications for migraines
propranolol, topiramate and amitriptyline.
Generic management of acute asthma attack. What can be considered if ineffective?
high-flow oxygen, back-to-back salbutamol nebulisers, 6-hourly ipratropium bromide nebulisers and steroids (usually oral prednisolone or IV hydrocortisone)
If these measures are ineffective, adjuncts to treatment include IV magnesium and IV aminophylline.
fibrotic lung condition associated with prolonged exposure to inorganic dusts (e.g. coal dusts). Ix?
Pneumoconiosis. HRCT shows Fibrosis and honeycombing
What might be seen on a blood gas if sample is delayed?
Raised PaCO2
How to determine whether an inguinal hernia is indriect or direct?
To determine whether the hernia is direct or indirect, the hernia should be reduced, a finger should be placed over the deep inguinal ring (just above the midpoint of the inguinal ligament) and the patient should be asked to cough (increase intra-abdominal pressure). If the hernia reappears, it suggests the hernia is direct (passing through a weak point in the posterior wall of the inguinal canal). If it does not reappear, it is suggestive of an indirect inguinal hernia. The majority of inguinal hernias will be indirect.
What is subacromial impingement syndrome? How does it present?
Inflammation of the rotator cuff tendons as they pass through the subacromial space. It classically presents with progressive pain which is exacerbated by abduction, notably between 60° - 120° (known as a painful arc).
1st line management of adhesive capsulitis, if not successful try?
Physio, then intra articular steroid injections
Initial Ix for intermittent caludication
ABPI
What is intermittent claudication? What is it caused by?
ntermittent claudication (pain in the calves that occurs when walking and is relieved by rest). Claudication affecting the calf is caused by stenosis of the superficial femoral artery.
Fontaine classifcation for intermittent claudication
Stage A: Asymptomatic.
Stage B1: Mild intermittent claudication.
Stage B2: Moderate to severe intermittent claudication.
Stage C: Ischemic rest pain.
Stage D: Ulceration or gangrene (tissue loss).
NB: n Fontaine B1, patients can walk over 200 metres before experiencing symptoms of intermittent claudication. In Fontaine B2, patients experience symptoms when walking less than 200 metres.
HHV-3`
Shingles (Varicella Zoster)
HHV-4
EBV
HHV-5
CMV
HHV-8
Kaposi
What is PFO a common association in?
patients who have a stroke under the age of 50 years
Best Ix for prostate cancer
Multiparametric MRI scan
Why do persistent varicoceles warrant further Ix?
they could be the first presentation of an underlying intra-abdominal neoplasm (e.g. renal cell carcinoma that is impinging on the renal vein)
When may surgical excision for fibroadenomas be offered?
Surgical excision may be offered for fibroadenomas that are over 3 cm in diameter.
What is the best investigation for confirming a diagnosis of bacterial tonsillitis.
a throat swab for culture
What echocardiogram findings are highly suggestive of takotsubo?
apical ballooning
What is takotsubo characterised by? What is seen on their ECG?
sudden dysfunction of the ventricular myocardium in response to stress
Evidence of myocardial ischaemia on their ECG and blood tests
What is bifascicular block? What does it manifest as?
Bifascicular block is a combination of a right bundle branch block with a left bundle hemiblock (remember, the left bundle divides into the anterior and posterior hemi bundles).
This manifests as a right bundle branch block (triphasic QRS complexes (RSR’ pattern) in V1-2 and wide, slurred S waves in V6 and the limb leads) with axis deviation on the ECG
MARROW ON ECG
What is trifascicular block?
a combination of bifascicular block with 1st degree heart block (prolonged PR interval)
How does pain differ between peripheral vascular disease and spinal stenosis?
The pain in peripheral vascular disease tends to be crampy, compared to pain from spinal stenosis which tends to be dull and aching.
1st line treatment for mild PAD
treatment of RFs, smoking cessation, supervised exercise programme
In middle-aged men presenting with sudden-onset abdominal pain, what should always be considered as a potential diagnosis, especially when there is evidence of haemodynamic compromise?
AAA
What blood tests suggest a possible diagnosis of hypercalcaemia of malignancy?
hypercalcaemia with a suppressed PTH axis
Maximum rate of correction of sodium in first 24 hours
8-10mmol/L per day
Difference between presentation of botulism and GBS
GBS ascends, botulism descends
What does C denote in staging of Barrets? How does this affect treatment?
length of oesophagus
If <3 with gastric, repeat OGD and if same discharge
if <3 with gastric, repeat OGD and if intestinal now repeat OGD every 3-5 years
if <3 with intestinal repeat every 3-5 years
if >3 repeat every 2-3 years
What lobes does herpes simplex typically affecgt?
Temporal lobes
Management of an infective exacerbation of COPD
consists of four main components: oxygen, nebulisers (salbutamol and ipratropium bromide), steroids and antibiotics.
The steroid that is most commonly used for IECOPD is 30 mg Prednisolone OD for 5-7 days. Doxycycline and co-amoxiclav are the antibiotics of choice for IECOPD.
Which lung cancer is most likely to cause a cavitating lesion?
Squamous CC
1st line investigation for choleycstitis
US abdo
Following by CT CAP
What does Hartmann’s procedure involve?
resecting the sigmoid colon with formation of an end colostomy and a closed rectal stump
What is a high output stoma? How is it managed?
A high output stoma is generally defined as having a stoma output of 1.5-2 L or greater and results from the inability of the small bowel to reabsorb fluid and electrolytes efficiently
The management involves administering IV fluids and using loperamide or codeine to increase bowel transit time. Oral fluids should be restricted
Hypoechoic lesion on liver?
Think abscess
How is urobilinogen affected in cholangitis
low
Post surgical fever timeframe
1-2 days post op: respiratory or part of physiological inflammatory response to surgery
3-5 days post-op: respiratory or urinary tract
5-7 days: surgical site infection, venous thromboembolism, anastomotic leak
Mx of Dupuytren’s
Non-operative: hand exercises, needle aponeurotomy
· Operative: fasciectomy +/- skin grafting
How do boutonniere deformity and swan neck deformity differ?
Boutonniere deformity is characterised by flexion at the proximal interphalangeal (PIP) joint and extension at the distal interphalangeal (DIP) joint.
Swan neck deformity is characterised by hyperextension of the PIP joint and flexion of the DIP joint.
What to do if high suspicion of scaphoid fracture that is not detected on initial X-ray?
should be treated as if they have a scaphoid fracture (splint) and reassessed at 10-14 days with a repeat X-ray
Treatment of choice for ESBLs
Meropenem
When should a varicocele reduce? What happens if it doesn’t?
when lying down, if not red flag and urgent referral to urology
How to differ between epididymal cysts and hydroceles?
Both transilluminate but hydrocele cannot be felt separately from the testis
gold standard investigation for diagnosing deep vein thrombosis
USS Doppler
1st line surgical management for varicose veins
Endothermal radiofrequency ablation
Criteria for elective surgical repair for AAA patients
Symptomatic
Larger than 4 cm and grown by more than 1 cm in the last year
Larger than 5.5 cm
What is the most common arrest rhythm seen in patients who have had a myocardial infarction
Polymorphic ventricular tachycardia descending into ventricular fibrillation (VF)
Initial Ix for Wilson’s
Serum caeruloplasmin is a useful initial investigation as low levels would be suggestive of Wilson’s disease.
gold standard imaging modality for PSC.
A magnetic resonance cholangiopancreatography (MRCP) is a specialised MRI scan that provides high resolution images of the biliary tree
1st line pharmacological Mx of IIH
acetazolamide - this is a carbonic anhydrase inhibitor that has a diuretic effect
What is Lhermitte’s sign? When is it seen?
Lhermitte’s sign refers to paraesthesia that is felt in the upper limbs and trunk, often down the spine, when a patient flexes their neck. It occurs because of disruption to neuronal signalling pathways and is most commonly associated with multiple sclerosis (MS).
Gold standard imaging modality in MS
MRI brain
An elderly patient presenting with gradual, painless loss of vision is the classical presentation of
Cataract
Worse vision in bright light, and loss of red reflex
cataract
How is LMWH monitored
APTT or Factor Xa assay
How is unfractionated heparin monitored
APTT ratio
What does appendicitis need for diagnosis?
Can be diagnosed on clinical suspicion alone
Most appropriate Ix if persistent fever following appendicectomy
CT abdo
pain after a twisting movement and a positive McMurray’s test
Meniscal tear
Signs of aciute limb ischaemia
6 P’s: Pain, Pallor, Pulseless, Perishingly cold, Paraesthesia and Paralysis
What are the late signs of acute limb ischaemia? What do they suggest? Mx?
paraesthesia and paralysis - suggest irreversible damage and non-viability of affected limb. The only surgical treatment indicated in such patients is amputation.
ABG pattern in aspirin OD
Respiratory alkalosis –> metabolic acidosis
What medication to use if BP resistent to fluid resus in septic shock?
Vasopressors e.g. metaraminol
most common cause of neutropenic sepsis
Gram-positive organisms such as Staphylococcus aureus and Staphylococcus epidermidis
Tumour lysis syndrome diagnostic criteria
● Uric acid ≥476 micromol/L or 25% increase from baseline
● Potassium ≥6.0 mmol/L or 25% increase from baseline
● Phosphate ≥1.45 mmol/L or 25% increase from baseline
● Calcium ≤1.75 mmol/L or 25% decrease from baseline.
1st line Mx for large renal calculus (>20mm)
Percutaneous nephrolithotomy
1st line Mx for small renal calculus (<20mm)
Extracorporeal shockwave lithotripsy
What does leakage of CSF of the catheter in subdural suggest?
Catheter is in subarachnoid space, HIGH RISK OF CARDIAC ARREST
5 main types of MI
Type 1: Caused by ischaemia due to a sudden coronary artery occlusion (e.g. thrombus)
Type 2: Caused by ischaemia due to increased oxygen demand or decreased supply without any acute coronary event.
Type 3: Referred to cases of sudden death in patients with preceding features suggestive of a myocardial infarction but without available biomarkers.
Type 4: Associated with percutaneous coronary intervention or stent thrombosis.
Type 5: Associated with cardiac surgery (e.g. CABG).
What is PPI use ASx with an increassed risk of>
Fractures, C diff, hyponatraemia, gastric cancer
extensive mucosal ulceration across their oesophagus, stomach and duodenum?
Think GastrinOMA - zollinger ellison syndrome
Barrets transition
Keratinising squamous - non ciliating columnar
Refractory ascites Mx
Transjugular Intrahepatic Portosystemic Shunt (TIPS)
Following paracentesis to treat ascites, appropriate Mx?
Human albumin solution
What can Paget’s disease present with?
can present with bone pain, and warmth due to increased metabolic activity. Although it is often asymptomatic
1st line treatment for symptomatic paget’s disease of the bone
bisphosphonates e.g. zoledronic acid
SIADH results
concentrated urine, where urine osmolality is over 100 mOsmol/kg and urinary sodium is over 20 mEq/L due to excess ADH causing increased water retention.
Lateralising shoulder girl pain associated with upper limb neurological symptoms should raise suspicion of
brachial plexus injury
If Horner’s syndrome present, what Ix?
CXR
Important hearing finding in Bell’s
Hyperacusis in affected side ear
What does monophonic (single tone) wheeze indicate?
Bronchial obstruction. Can be an underlying sign of malignancy, especially if asx with poorly resolving pneumonia
What is excessive stoma output classified as? How can it be treated
over 1 L in 24 hours for 3 or more consecutive days. The management of excessive stoma output, in the first instance, involves the administration of an antidiarrhoeal agent (e.g. loperdamide) and a proton pump inhibitor (e.g. omeprazole) which decreases stomach acid generation.
What is an important Ix in acute pancreatitis?
ABG - shows paCO2 (important for severity assessment)
right upper quadrant discomfort with an obstructive picture on his LFTs, following TPN
cholestasis
Segond fracture is an avulsion fracture of the proximal lateral tibia and is pathognomonic of
ACL tear
What is Foucher’s sign?
Baker’s cysts feel firm when the knee is held in full extension, and softer when flexed
What are Baker’s cysts? What do they occur secondary to?
sac of synovial fluid which can form in the popliteal fossa secondary to damage to the joint
What is the most appropriate initial investigation to confirm AAA? WHat is gold standard?
US abdo, then CT angio is gold standard
Sx of SLE mnemonic
‘SOAP BRAIN MD’ – Serositis, Oral ulcers, Arthritis, Photosensitivity, Blood (low counts of all parameters), Renal (proteinuria), ANA positive, Immune system (anti-dsDNA), Neurological features (seizures), Malar rash and Discoid rash
Initial Ix for pyelonephritis
US KUB
Antidote for sevofluorone toxicity
Dantrolene (prevents malignant hyperthermia)
Heart failure with preserved ejection fraction is defined as?
heart failure with a left ventricular ejection fraction of more than 50%
Classes of antiarrythmic drugs
Class I antiarrhythmics work by blocking the voltage-gated sodium channel (e.g. flecainide, propafenone and lidocaine).
Class II antiarrhythmics are beta-blockers (e.g. bisoprolol, metoprolol).
Class III antiarrhythmics are potassium channel blockers (e.g. amiodarone, sotalol). It is worth noting that amiodarone also has some effect on sodium channels, beta-adrenergic receptors and calcium channels.
Class IV antiarrhythmics are calcium channel blockers (e.g. verapamil, diltiazem).
severe abdominal pain, rectal bleeding and diarrhoea
Think ischaemic colitis, a condition in which sudden reduced blood flow via the inferior mesenteric artery results in bowel ischaemia
Useful invesitgation in ischaemic colitis
VBG
SE of ondansetron
Constipation
Most commonly affected site in ischaemic colitis
Transverse colon
first-line treatment option for tumour-related hypercalcaemia
Bisphosphonates
Haematological tumours, as well as granulomatous disease (TB, sarcoidosis), are able to cause hypercalcaemia via?
increased calcitriol production. Activity of ectopic 25(OH)D-1-hydroxylase expressed by macrophages or tumour cells leads to the formation of excessive amounts of 1,25(OH)₂D (i.e. active vitamin D).
What should be performed before starting steroid therapy in bell’s?
Otoscopy to check for the presence of a vesicular rash in the outer ear that would be suggestive of Ramsay-Hunt syndrome
How does LEMS differ from MG?
LEMS differs from myasthenia gravis in that the weakness improves with repetitive use
Grading system for internal haemorrhoids
Grade I: does not prolapse
Grade II: spontaneously reduces
Grade III: can be reduced manually
Grade IV: irreducible
Describe the Trendelenburg test
xamines the strength of hip abductors when standing on one leg. When standing on one leg, the hip abductors on the same side contract to stabilise the pelvis and maintain neutral tilt. If the hip abductors are weak, the pelvis is not stabilised and thus tilts toward the side of the raised leg: the sound side sags. If the pelvis tilts toward the right, this indicates weakness in left hip abductors, due to superior gluteal nerve injury or wasting of the gluteus medius/minimus
What condition predisposes to atypical presentations?
Elderly and Diabetes
Which LNs does transitional cell carcinoma of the kidney metastasise too?
Para-aortic
Where do most nosebleeds arise from?
Little’s area
Mx of PVD
Mild: Supervised Exercise programme and modification of RFs
Moderate or severe (ABPI<0.8): Vascular surgery referral
NB: Medical maangement is usually a single antiplatelet agent
Normal threshold for blood transfusion? Exception?
Under most circumstances, the threshold for blood transfusion is 70 g/L, however, in the context of ACS the threshold rises to 80 g/L
widespread concave ST elevation that is usually seen in leads V2-5 with no flu like Sx
Think Benign early repolarisation if there is no flu like Sx and pleuritic chest pain to think pericarditis
ABx that c auses long QT syndrome
Clarithromycin
What may constrictive pericarditis present with signs of?
Heart failure
If a patient with gstro-oesophageal reflux disease has failed to respond adequately to a trial of a PPI, they should begin a trial of?
Histamine antagonist - e.g.nizatidine
abdominal pain, shock and normal abdominal examination findings
Acute mesenteric ischaemia
Initial screening test for cushing
late night salivary cortisol sample
patients with suspected metastatic spinal cord compression initial Mx
High dose dex
Essential Ix post stroke/TIA
ambulatory ECG monitoring, a carotid artery Doppler scan and an echocardiogram.
What is pneumoconiosis? Give an example
Pneumoconiosis is an umbrella term used to describe interstitial lung disease that occurs secondary to the inhalation of inorganic allergens (e.g. coal dust, asbestos, silica). Asbestosis is a form of pneumoconiosis that specifically occurs following exposure to asbestos
IPF Mx
Pirfenidone - antifibrotic
Abx asx with IPF
Nitrofurantoin
gold standard investigation for acute diverticulitis
Contrast CT abdomen and pelvis
first-line imaging modality for patients with suspected gallstone disease
US abdo
gold standard investigation for ascending cholangitis
ERCP
four main indications for haemodialysis in the context of acute kidney injury
intractable hyperkalaemia, treatment-resistant fluid overload (pulmonary oedema), acidosis and uraemic symptoms (nausea, pruritus, malaise, encephalopathy).
What is gangrene?
tissue necrosis usually resulting from an inadequate blood supply
Whhat is wet gangrene?
When necrosed tissue becomes infected, usually has a foul smell due to anaerohes
Treatment of gangrene
Urgent debridement and IV ABx
Difference between acute and subacute bacterial endocarditis
Bacterial endocarditis can be described as either acute or subacute. Acute bacterial endocarditis is when previously normal heart valves become damaged by very virulent organisms such as Staphylococcus aureus. Subacute bacterial endocarditis occurs in patients with pre-existing valvular damage (e.g. due to rheumatic heart disease). The abnormal valves provide ground on which less virulent bacteria, such as Streptococcus viridans, can form vegetations.
Which artery affected in ischaemic colitis
IMA
Mx of IBS
Pain: Mebeverine hydrochloride is an anticholinergic that has antispasmodic effects on the gastrointestinal tracts.
Constipation: Ispaghula husk is a bulk-forming laxative that is used to treat symptoms of constipation associated with IBS
Diarrhoea: Loperamide
What is a convenient test for monitoring patients with NAFLD who are at risk of developing liver fibrosis
Enhanced liver fibrosis (ELF)
Gold-standard investigation for the diagnosis of chronic pancreatitis
CT pancreas
Damage to wernicke’s
Receptive aphasia, fluent non-sensical speech
Damage to Broca’s
Productive aphasia, non-comprehensible speech
What can be used to reduce the viscosity of sputum?
Carbocisteine
Criteria for long term oxygen therapy
It should be offered to all COPD patients who have stopped smoking and have a resting PaO2 on air of less than 7.3 kPa. It should also be offered to patients with a PaO2 of 7.3-8 kPa if they also have one of either secondary polycythaemia, peripheral oedema or pulmonary hypertension.
What other condition can long term oxygen therapy be considered for besides copd
IPF, same criteria
Ix for perianal abscess
MRI
Mx of perianal abscess
Treatment is usually surgical, with incision and drainage being first line, usually under local anaesthetic. The wound can then either be packed or left open, in which case it will heal in around 3-4 weeks;
Abx may be used adjunct
Ottawa ankle rules
inability to weight bear immediately after the injury and in A&E, along with tenderness at the lateral malleolus (or posterior edge of fibula) and medial malleolus (or posterior edge of tibia).
Best Ix for varicose veins
Duplex US scan
Surgical Mx for dupuytrens
Fasciectomy
Describe Schober’s test
Schober’s test is a clinical test that is used to help identify patients with ankylosing spondylitis. A mark is made on the skin overlying the L5 spinous process and a second mark is made around 10 cm above the first. The patient is then asked to bend over and touch their toes. If the distance between the lines increases by less than 5 cm, it is considered a positive result (and, hence, suggestive of a significantly reduced range of spinal motion). You would expect to see a positive result in ankylosing spondylitis.
first-line management for ankylosing spondylitis is
NSAIDs
Wasting of thenar eminence
Carpal tunnel syndrome
What should app patients who are due to undergo PCI be started on?
IV unfractionated heparin
Bifid p waves aka? seen in?
P mitrale, seen in mitral stenosis - sign of left atrial enlargement
Beck’s triad of cardiac tamponade. Mx?
low blood pressure, muffled heart sounds and raised JVP. Pericardiocentesis
Leriche syndrome triad
buttock claudication, erectile dysfunction and absent or weak femoral pulses.
Where does Leriche syndrome affect?
narrowing of the distal aorta and the proximal common iliac arteries (aortic bifurcation)
Mx of SVT in asthma
Verapamil
Common complication of TIPS procedure
Hepatic encephalopathy
What blood test marker can help distinguish upper and lower GI bleeds
Urea
heart failure secondary to severe hypertension. Mx?
In this circumstance, IV nitrates (e.g. sodium nitroprusside) are the first-line option to reduce blood pressure
What anticoagulant should patient with an NSTEMI be started on
Fondaparinux
first-line treatment option for generalised tonic-clonic seizures, myoclonic seizures and tonic or atonic seizures
Sodium valproate
Most common cause of COPD exacerbation
H.Influenzae
What is a good option for patients who have high oxygen requirements and are unable to tolerate NIV?
High flow nasal oxygen therapy
HER2 positive medication
Trastuzumab (herceptin)
Indications for bariatric surgery
The indications for bariatric surgery on the NHS are a BMI of over 40 kg/m2 or a BMI between 35 and 40 kg/m2 and a significant comorbidity like hypertension or type 2 diabetes, when all other weight loss methods have failed (lifestyle and medical)
Ix for carpal tunnel syndrome
EMG
Important signs in carpal tunnel syndrome
The reproduction of symptoms when tapping the flexor retinaculum is describing Tinel’s sign which, alongside Phalen’s sign, is classically associated with carpal tunnel syndrome
Pts are at risk of what with nephrotic syndrome
VTE
What is congestive hepatopathy? How can it present?
term used to describe liver dysfunction that occurs in patients with congestive heart failure
Can present with jaundice and enlarged liver on abdo exam. Mx is by treating HF
Features of chronic venous insufficiency that may be seen adjunct to venous ulcers
varicose veins, lipodermatosclerosis (fibrosis of subcutaneous fat), atrophie blanche and haemosiderin deposition.
How to differentiate NSTEMI and unstable angina
Raised troponin
facial flushing, diarrhoea, palpitations and shortness of breath due to bronchospasm. Dx? Mx?
Carcinoid syndrome, It may be managed surgically by excising the tumour or medically with somatostatin analogues (e.g. octreotide).
CSF of a patient with tuberculous meningitis is likely to show a
raised protein concentration, high lymphocyte count and low glucose concentration.
Typically has a long prodrome of constitutional upset
What can recurrent gallstones lead to?
Gallstone ileus and therefore SBO due to the formation of a fistua
Mx of gallstone induced SBO
Enterotomy - incision and removal of gallstone from small bowel
distal radius fracture with dorsal displacement of the distal fracture component
Colles fracture
What abx to be used in women with UTI with renal impairment
Trimethoprim
What Mx contraindicated in aortic stenosis
GTN
persistent headache, breast pain and amenorrhoea?
Potential prolactinoma
What CXR finding is an absolute contraindication to NIV?
Pneumothorax
Which respiratory failure to use BiPAP and CPAP for
CPAP - T1
BiPAP - T2
COPD Mx
Offer SABA or SAMA to use as needed.
If the patient is limited by symptoms or has frequent exacerbations and:
Has no asthmatic symptoms:
Offer LABA + LAMA
Has asthmatic features or features of steroid responsiveness:
Offer LABA + ICS
Consider LABA + LAMA + ICS
Mainstay of treatment for acute mesenteric ischemia
Emergency theatre
Ix for bowel obstruction
CT CAP
Mx of perforated peptic ulcer
Initially NBM and NG tube
then laparotomy
Necrotising fasciitis occurring in the genital, perineal or perianal regions is also known a
Fournier’s gangrene
For this reason, patients with significant anaemia secondary to their CKD are often prescribed what?
EPO injections
Test used for sjogrens
Schirmers
1st line Ix for acute angle closure glaucoma
Slit lamp gonioscopy
Gold standard Ix for open angle glaucoma
Goldman tonometry
Mx pathway of non-obstructive renal stones
Non-Obstructive Renal Stones
· < 10 mm: Analgesia, reassurance, watch and wait
o If persistent stone/symptoms: offer shock wave lithotripsy
· 10-20 mmc: Ureteroscopy or shock wave lithotripsy
o If treatment failure, can consider percutaneous nephrolithotomy
· > 20 mm: Percutaneous nephrolithotomy
Mx pathway of non-obstructive ureteric stones
Non-Obstructive Ureteric Stone
· < 10 mm: Analgesia, alpha blockers (e.g. tamsulosin, alfuzosin)
· > 10 mm: Ureteroscopy or shock wave lithotripsy
o Treatment failure: percutaneous nephrolithotomy
Surgical options for BPH
If the prostate is smaller than 30 g, transurethral incision of the prostate may be considered. However, if the prostate volume is 30-80 g, then a trans-urethreal resection of the prostate (TURP) is indicated.
Trialled if dual medical therapy has failed
Examples of definitive airways
endotracheal tubes (nasotracheal/orotracheal), tracheotomy and cricothyrotomy
Dual antiplatelet therapy following MI with low bleeding risk
Aspirin and Ticagrelor
Dual antiplatelet therapy following Mi with high bleeding risk
Aspirin and Clopidogrel
early diastolic decrescendo murmur
Aortic regurg
pan-systolic murmur, loudest at the axilla on chest auscultation.
Mitral regurg
ejection-systolic (whooshing sound) murmur, loudest at the carotids on chest auscultation.
Aortic stenosis
mid-diastolic murmur, with an early opening snap on chest auscultation.
Mitral stenosis
pan-systolic murmur, loudest at the lower left sternal edge.
Tricuspid regurg
In patients with ischaemic symptoms, ST depression in leads V1-V4 should raise the suspicion of a>
Posterior MI - affects posterior descending artery
ECG manifestations of hypokalaemia
flattened T waves, U waves, prolonged PR interval and a long QT interval.
Bifid p waves on ECG
Mitral stenosis
bile acid sequestrant that is used in the treatment of cholestatic pruritus.
Cholestyramine
Management of severe flarew of UC
IV steroids
Type 1 hepatorenal syndrome
Type 1 HRS is characterised by a rapid, progressive impairment in renal function in a patient with advanced liver disease in the absence of another identifiable cause of the renal impairment.
Type 2 hepatorenal syndrome
more stable and less progressive impairment in renal function in a patient with advanced liver disease in the absence of another identifiable cause of the renal impairment
Mx of hepatorenal syndrome
human albumin solution and terlipressin
1st line Mx in a patient with hypogonadotrophic hypogonadism
Testosterone gel daily
1st line 1x for neck lump that has normal blood tests
US
RET oncogene
MEN 2A/B
Mx of status epilepticus
The first-step in the management of status epilepticus is the administration of IV lorazepam 4 mg. If IV access is unavailable, rectal diazepam or buccal midazolam are suitable alternatives. If the seizure has not resolved after another 10 mins, a second dose of lorazepam 4 mg should be given. If this also fails to terminate the seizure, a phenytoin infusion should be started. If this, too, is ineffective, an anaesthetic should initiate general anaesthesia.
What examination should be performed in a patient with suspected cauda equina?
a digital rectal examination in patients with suspected cauda equina to check for saddle anaesthesia and reduced anal tone. It should be investigated urgently with a whole spine MRI scan.
NF 1 Presentation
Cafe-au-lait spots (hyperpigmented patches), axillary/groin freckles, phaeochromocytomas and cutaneous neurofibromas
NF 2 presentation
bilateral vestibular schwannomas, meningiomas and ependyomas.
What is Cor Pulmonale? What can cause it?
Cor pulmonale is a term used to describe right-sided heart failure that occurs secondary to underlying respiratory disease. Widespread lung disease (e.g. interstitial lung disease) causes vasoconstriction of the pulmonary blood vessels resulting in an increase in pulmonary artery pressure and, hence, right ventricular pressures. This leads to right heart failure which manifests with peripheral oedema.
Common SE of salbutamol
Tachycardia and increased lactate
Mx of large breast cyst causing discomfort
FNA
Mx of intraductal papilloma
Wide local excision
Presentation of intraductal papilloma
lump behind the nipple with blood-stained nipple discharge
NOT MALIGNANT but need to undergo triple assessment before diagnosis
forearm and lateral elbow pain due to overuse.
Lateral epicondylitis or ‘Tennis elbow’
forearm and medial elbow pain due to overuse of the flexor muscles of the forearm.
Medial epicondylitis or ‘Golfer’s elbow’
evere pain that is out of proportion with the appearance of the affected limb. The pain is exacerbated by passive movement
Compartment syndrome
Ix for compartment syndrome
Clinical diagnosis
Can use compartmental needle manometry to aid Mx
urgent fasciotomy in those with an absolute pressure > 40 mm Hg or a difference of < 30 mm Hg between the compartment and diastolic blood pressure.
Bilateral symptoms of blurred vision, glare and washed-out colour vision
Cataracts
first-line treatment for open angle glaucoma
Topical latanoprost
Ix for hydrocele
Urgent US
old-standard investigation for a suspected urinary tract calculus
Non contrast CT KUB
SE of susxamethonium
Malignant hyperthermia - give dantrolene
Apnoea - propofol and ventilate
Monitor cholinesterase
What Ix should all patients with ACS undergo prior to discharge?
Echocardiogram - assess ventricular function and determine whether they have developed a degree of heart failure
Important Ix after pacemaker insertion
CXR to check for pneumothorax and correct positioning
What type of vitamin D should be supplements in chronic CKD
Alfacalcidol (has already been activated)
pANCA AKA
Anti-myeloperoxidase (anti-MPO)
symmetrical, bilateral ground-glass opacities and traction bronchiectasis
Non-specific interstitial pneumonia (NSIP) is a pattern of interstitial lung disease
What are both serum markers of right heart strain in the context of an acute PE
Raised troponin and BNP, requires thrombolysis
grading of haemorrhoids and Mx
● Grade I: Do not protrude/prolapse outside the anal canal but may bleed
● Grade II: Protrude/prolapse with defecation but reduce spontaneously
● Grade III: Protrude/prolapse with defecation. Do not reduce spontaneously but can be reduced manually
● Grade IV: Permanent protrusion/prolapse which cannot be reduced manually
2/3 - rubber band ligation is first line
4 - surgical haemorrhoidectomy
Mx of rectal prolapse
REctopexy
Best Ix for toxic megacolon
CT CAP
most common cause of TIAs
carotid artery atherosclerosis
deranged U&E in the context of acute urinary retention which is highly suggestive of
hydronephrosis and a post-renal AKI. In this case, an ultrasound should be performed to check for hydronephrosis. If this remains untreated, it can lead to chronic kidney damage.
1st line mx of prolactinoma
Cabergoline, then TSS
Main complication of chest drain removal? How can this risk be reducved?
main complication with chest drain removal is the risk of causing a pneumothorax if air were to leak into the pleural space. This risk can be reduced by asking the patient to perform the valsalva manoeuvre - this raises the intrathoracic pressure and reduces the risk of air from the atmosphere entering the pleural space during removal of the chest drain.
Yellow nail syndrome triad
pleural effusion, lymphoedema and yellow nails
Migratory consolidation on CXR with flu-like illness
Cryptogenic organising pneumonia
Triple assessment scan
US scan if <35
Mammogram if >35
What type of additional Ix van be done for haemorrhoids if DRE is inconclusive
Proctoscopy
1st line Ix for females with ?appendicitis
US abdo
Mx of warfarin in patients undergoing major surgical procedures
Due to the long half-life of warfarin, patients undergoing major surgical procedures must stop warfarin at least 5 days before surgery to reduce the risk of major bleeding in the perioperative period. Surgical patients with active cancer are also, however, at high risk of developing thromboembolic disease so should receive an alternative form of anticoagulation (usually low-molecular weight heparin).
Important Ix in mx of diverticulitis
CT CAP
Differentials for sudden loss of vision
Central Retinal Vein Occlusion:
Retinal haemorrhages
Widespread through all quadrants
Branch Retinal Vein Occlusion:
Retinal haemorrhage confined to one quadrant
Central Retinal Artery Occlusion:
Cherry red spot (dark spot on pale retina)
Vitreous Haemorrhage:
Dark spots in visual field
Red hue in vision
Associated with floaters without pain
Retinal Detachment:
Associated with flashing lights and floaters
Most common cause of nephrotic syndrome seen in adults? What condition is it often associated with?
FSGS, HIV
Alternative to haemodialysis in criticaill ill patients
Haemofiltration, less likely to cause haemodynamic instability
Initial and best Ix for SBO
Initial - abdo x ray
Best - CT CAP with contrast
slurred upstroke (delta wave) of the QRS complex, the broad QRS complex and short PR interval
WPW
Quincke’s sign
Nail bed pulsation
De Musset’s sign
Head bobbing
What bacteria is asx with colorectal cancer
Strep bovis
Alternative to PEG feeding in patietns who have HF or can’t tolerate endoscopy
Radiologicaloly inserted gastrostomy (RIG)
What varices can cirrhosis result in?
oesophageal varices, rectal varices, caput medusae and splenomegaly.
Causes of SAAG less than 11
The causes of a SAAG that is less than 11 g/L are usually exudative (e.g. infection, pancreatitis, peritoneal metastases)
Causes of SAAF greater than 11
causes of a SAAG greater than 11 g/L are generally transudative (e.g. cirrhosis, heart failure).
NOTE: Nephrotic syndrome is an exception to this rule because it gives rise to a low SAAG due to the loss of albumin in the urine (thereby resulting in a low serum albumin concentration).
What are patients with frequent comiting or poor oral intake at risk of?
Starvation ketosis
Managed wth IC fluids and antiemetics
How big increments should you increase levothyroxine dose in
25 micrograms
XRay findings of vit d deficiency
Looser’s zones - transverse lucencies with sclerotic borders that traverse part of the way through a bone and is perpendicular to the cortex. The pubic rami are commonly affected and they are sometimes referred to as ‘pseudofractures’.
1st line treatment of Parkinson’s
Co-careldopa is a combination of levodopa and a DOPA-decarboxylase inhibitor (carbidopa). It is often used as the first-line treatment in Parkinson’s disease.
Mx of patients with an infective exacerbation of COPD
oxygen, nebulisers (salbutamol and ipratropium bromide), antibiotics (e.g. doxycycline) and steroids (usually prednisolone)
Useful marker of chronic CO2 retainers
Bicarbonate
Bulk forming laxative example
Ispaghula husk
hest X-ray reveals a gastric air bubble above the diaphragm
Hiatus hernia
Managed with nissen fundoplication
restriction of both active and passive movement, especially in flexion and external rotation.
Adhesive capsulitis
What can stanford type A dissection lead to?
Cardiac tamponade
Mx of SBO
Non-surgical treatments preferred, except when lactate is high - then emergencfy surgery
Gastrografin is preferred non-surgical management
What additional heart sound is heard in diastolic cardiomyopathy? What often causes it
S3, chronic alcohol excess
What medication should be avoided in acute heart failure but is used in the management of chronic heart failure
Beta blocker
echocardiogram findings in mitral regurg
dilated left atrium
Chronic mestenteric ischaemia is caused by narrowing of which artery
Superior mestenteric artery
NOTE: Inferior mesenteric artery leads to ischaemic colitis
Anatomy of adrenal gland
Adrenal cortex:
Zona Glomerulosa (outermost) → Aldosterone
Zona Fasciculata (middle) → Cortisol
Zona Reticularis (innermost) → Androgens
The adrenal medulla produces catecholamines such as adrenaline and noradrenaline.
cardinal symptoms of Parkinson’s disease are
bradykinesia, rigidity, tremor and postural instability
Unique cause of viral meningitis. Presents with low CSF glucose
Mumps
Mx of perforated peptic ulcer
Laparaqtomy
Describe the trendelenberg test
The Trendelenberg test assesses the strength of gluteus medius and minimus – the abductors of the thigh. When standing on one leg, the abductors of the weight-bearing leg contract to keep the pelvis level. If the abductors are weak or there is a nerve injury then the pelvis will slump towards the weight-bearing side when the patient stands on one leg. The abductors are supplied by the superior gluteal nerve, hence this patient must have a lesion of the left superior gluteal nerve
Indications for carotid endartectomy in patients with recent TIA
symptomatic patients (i.e. TIA affecting the hemisphere supplied by the stenosed carotid artery) with 50-99% stenosis of the common or internal carotid artery on ultrasound should be admitted for further imaging and urgent consideration for carotid endarterectomy
Indications for rapid sequence induction
The main indications for RSI are:
Insufficient fasting (e.g. in emergencies)
Inability to protect own airway before administration of anaesthesia (e.g. intracranial injury)
Abdominal pathology (e.g. obstruction or GORD)
Delayed gastric emptying (e.g. opioids)
Pregnancy
Mx of bowel obstruction due to complicated malignancy with widespread mets
Defunctioning colostomy
What can be done to manage hypercapnic patients>
Increase minute ventilation. This can be achieved by either increasing the respiratory rate or the tidal volume.
Minute Ventilation = Tidal Volume x Respiratory Rate
