Med Flashcards
polycythemia
increase in the number of red blood cells
Co-trimoxazole
is a combination of trimethoprim and sulfamethoxazole and is in a class of medications called sulfonamides
Loss of kidney function leads to
reduced excretion of phosphate and low production of activated vitamin D. Calcium then falls which leads to secondary hyperparathyroidism, which maintains calcium but at the expense of raised phosphate.
Dressler’s syndrome
is pericarditis that occurs two to six weeks after, commonly, anterior myocardial infarction or heart surgery.
It thought to be due to an autoimmune response to myocardial antigens.
Pericarditis 4 clinical criteria
The diagnosis is confirmed in the presence of at least 2 of the 4 clinical criteria: typical chest pain, pericardial friction rub, widespread ST elevation, and pericardial effusion
Absolute contraindications to the use of the oral contraceptive pill include:
Cancer of the breast and genitalia End stage liver disease Previous or present history of thromboembolism Cardiac abnormalities Congenital hyperlipidaemia, and Undiagnosed abnormal uterine bleeding
pericarditis The key findings on history
constant, pleuritic central chest pain that is worse in the recumbent position and radiates to one or both trapezius ridges
Almost all patients report relief of pain with sitting up or leaning forward
Asplenic patients should receive
Pneumovax immunisation and it should be repeated every 5 years
Which medication is commonly associated with new onset of diabetes after transplantation (NODAT)
tacrolimus
QT prolongation also seen with
Hypocalcaemia
Hypokalaemia
Type 1a antiarrhythmic drugs.
The mnemonic for remembering the symptoms of hypercalcaemia is
stones, bones, groans, thrones and psychiatric overtones. Breaking this down we get:
Stones (renal)
Bones (bone pain)
Groans (abdominal pain, nausea and vomiting)
Thrones (polyuria)
Psychiatric overtones (confusion and cognitive dysfunction, depression, anxiety, insomnia, coma)
Amiloride
Epithelial Na Channel antagonists
K+ sparing diuretic
Goodpasture’s syndrome
is an autoimmune condition in which antibodies (anti-GBM) are produced against type 4 collagen in the lungs and glomeruli. It tends to cause a more nephritic state in the kidneys, and can also present with haemoptysis secondary to pulmonary haemorrhage.
IgA nephropathy
is also likely to present more towards the nephritic end of the spectrum, particularly with macroscopic haematuria in a young person following an upper respiratory tract infection. The renal biopsy in this disease (although not always necessary) would show mesangial proliferation and matrix accumulation.
heart failure: first line drugs
ACE-inhibitor and a beta-blocker
heart failure: second line drugs
aldosterone antagonist
heart failure: third line drugs
should be initiated by a specialist. Options include ivabradine, sacubitril-valsartan, hydralazine in combination with nitrate, digoxin and cardiac resynchronisation therapy
new diagnosis of cirrhosis
doing an upper endoscopy to check for varices
For people in whom no oesophageal varices have been detected, offer surveillance using upper gastrointestinal endoscopy every 3 years.
liver ultrasound every 6 months (+/- alpha-feto protein) to check for hepatocellular cancer
Calculate the Model for End‑Stage Liver Disease (MELD) score every 6 months for people with compensated cirrhosis.
Consider using a MELD score of 12 or more as an indicator that the person is at high risk of complications of cirrhosis.
Moderate asthma
PEFR 50-75% best or predicted
Speech normal
RR < 25 / min
Pulse < 110 bpm
severe asthma
PEFR 33 - 50% best or predicted
Can’t complete sentences
RR > 25/min
Pulse > 110 bpm
life threatening asthma
PEFR < 33% best or predicted Oxygen sats < 92% 'Normal' pC02 (4.6-6.0 kPa) Silent chest, cyanosis or feeble respiratory effort Bradycardia, dysrhythmia or hypotension Exhaustion, confusion or coma
Near-fatal asthma
a raised pC02 and/or requiring mechanical ventilation with raised inflation pressures.
Acute respiratory distress syndrome is a complication of
acute pancreatitis
Causes of Hyperlactataemia
Type A - Reduced Tissue Oxygen Delivery
Ex. Ischaemia, severe asthma, shock, HF (hypoperfusion)
Type B1 - Underlying Disease
Ex liver failure, cancer, endogenous b2 stimulation ex phaechromocytoma
Pyruvate dehydrogenase deficiency ex sepsis, thiamine deficiency
Type B2 - Drugs & Toxins
Metformin (biguanides)
Exogenous b stimulation
Linezolid, cyanide
Type B3 - Inborn Errors of Metabolism
Ex Enzyme deficiencies - e.g. pyruvate dehydrogenase deficiency
Indications for a temporary pacemaker
symptomatic/haemodynamically unstable bradycardia, not responding to atropine
post-ANTERIOR MI: type 2 or complete heart block*
trifascicular block prior to surgery
*post-INFERIOR MI complete heart block is common and can be managed conservatively if asymptomatic and haemodynamically stable
The most common organism causing infective exacerbations of COPD is
Haemophilus influenzae
infective exacerbations of COPD treatment
oral antibiotics first-line: amoxicillin or clarithromycin or doxycycline.
Phaeochromocytoma typically present symptomatically with a triad of
sweating, headaches, and palpitations
Rheumatic fever is caused by
group A Streptococcus species (GAS)
mitral stenosis features
mid-late diastolic murmur (best heard in expiration) loud S1, opening snap low volume pulse malar flush atrial fibrillation the normal cross sectional area of the mitral valve is 4-6 sq cm. A 'tight' mitral stenosis implies a cross sectional area of < 1 sq cm Chest x-ray left atrial enlargement may be seen
QRISK2
10-year cardiovascular risk) score.
Statins should be given to patients with a 10-year cardiovascular risk >= 10%
Bifascicular block
combination of RBBB with left anterior or posterior hemiblock
e.g. RBBB with left axis deviation
Trifascicular block
features of bifascicular block as above + 1st-degree heart block
Wolf-Parkinson-White syndrome ECG
short PR interval, a delta wave and QRS prolongation.
second degree heart block Mobitz type 1 ECG
increasing PR intervals until there is a P wave without a QRS complex.
second degree heart block Mobitz type 2 ECG
there is P wave to QRS ratio of 2:1 or 3:1.
Brugada syndrome
ST segment elevation in leads V1 to V3.
Brugada syndrome is a rare but serious condition that affects the way electrical signals pass through the heart.
It can cause the heart to beat dangerously fast. These unusually fast heartbeats – known as an arrhythmia – can sometimes be life threatening.
Autoimmune hepatitis
Anti-nuclear antibodies (ANA) and/or anti-smooth muscle antibodies (SMA)
Features
may present with signs of chronic liver disease
acute hepatitis: fever, jaundice etc (only 25% present in this way)
amenorrhoea (common)
ANA/SMA/LKM1 antibodies, raised IgG levels
liver biopsy: inflammation extending beyond limiting plate ‘piecemeal necrosis’, bridging necrosis
Management
steroids, other immunosuppressants e.g. azathioprine
liver transplantation
INR 5.0-8.0
No bleeding
Withhold 1 or 2 doses of warfarin
Reduce subsequent maintenance dose
INR 5.0-8.0
Minor bleeding
Stop warfarin
Give intravenous vitamin K 1-3mg
Restart when INR < 5.0
INR > 8.0
No bleeding
Stop warfarin
Give vitamin K 1-5mg by mouth, using the intravenous preparation orally
Repeat dose of vitamin K if INR still too high after 24 hours
Restart when INR < 5.0
INR > 8.0
Minor bleeding
Stop warfarin
Give intravenous vitamin K 1-3mg
Repeat dose of vitamin K if INR still too high after 24 hours
Restart warfarin when INR < 5.0
Major bleeding
Stop warfarin
Give intravenous vitamin K 5mg
Prothrombin complex concentrate - if not available then FFP*
Primary biliary cholangitis - the M rule
IgM
anti-Mitochondrial antibodies, M2 subtype
Middle aged females
Aplastic anaemia
is a rare, potentially life-threatening failure of haemopoiesis
Sideroblastic anaemia
are a group of blood disorders in which the body has enough iron but is unable to use it to make hemoglobin, which carries oxygen in the blood. As a result, iron accumulates in the mitochondria of red blood cells, giving a ringed appearance to the nucleus (ringed sideroblast)
Sideroblastic anaemia usually causes a microcytic anaemia with raised serum iron levels..
Ferritin is
an acute phase reactant and therefore raised in states of chronic inflammation,
reactive thrombocytosis
platelets are raised due to presence of inflammation
Charcot’s cholangitis triad
fever, jaundice and right upper quadrant pain
CHA2DS2-VASc score
management of atrial fibrillation
suggested anticoagulation strategy based on the score:
0 No treatment
1 Males: Consider anticoagulation
Females: No treatment (this is because their score of 1 is only reached due to their gender)
2 or more Offer anticoagulation
CHA2DS2-VASc score what each letter mean
C Congestive heart failure 1 H Hypertension (or treated hypertension) 1 A2 Age >= 75 years 2 Age 65-74 years 1 D Diabetes 1 S2 Prior Stroke or TIA 2 V Vascular disease (including ischaemic heart disease and peripheral arterial disease) 1 S Sex (female)
indication for anticoagulation.
valvular heart disease, in combination with AF
HASBLED scoring system.
consider whether warfarinisation is in the best interests of the patient
There are no formal rules on how we act on the HAS-BLED score although a score of >= 3 indicates a ‘high risk’ of bleeding, defined as intracranial haemorrhage, hospitalisation, haemoglobin decrease >2 g/L, and/or transfusion.
HASBLED scoring system.
H Hypertension, uncontrolled, systolic BP > 160 mmHg 1
A Abnormal renal function (dialysis or creatinine > 200)
Or
Abnormal liver function (cirrhosis, bilirubin > 2 times normal, ALT/AST/ALP > 3 times normal 1 for any renal abnormalities
1 for any liver abnormalities
S Stroke, history of 1
B Bleeding, history of bleeding or tendency to bleed 1
L Labile INRs (unstable/high INRs, time in therapeutic range < 60%) 1
E Elderly (> 65 years) 1
D Drugs Predisposing to Bleeding (Antiplatelet agents, NSAIDs)
Or
Alcohol Use (>8 drinks/week) 1 for drugs
1 for alcoho
widened mediastinum on x-ray is sign of
aortic dissection
prescribing an angiotensin converting enzyme (ACE) inhibitor to all patients with chronic kidney disease (CKD) who have
raised albumin:creatinine ratio
urinary ACR or 70mg/mmol or more
Lipid-lowering therapy with a statin is also recommended for all patients with CKD for the primary or secondary prevention of cardiovascular disease.
management of hyperkalaemia is as follows:
f K+ > 6.5 mmol/l or if there are ECG changes:
Administer calcium gluconate 10% 10-20ml by slow IV injection titrated to ECG response
Give 10 U Actrapid in 50 ml of 50% glucose over 10-15 minutes
Consider use of nebulised salbutamol
Consider correcting acidosis with sodium bicarbonate infusion
Cerebral oedema - can occur if
sodium levels rapidly decrease, as seen in rapid diabetic ketoacidosis correction.
rapid correction of hyponatraemia can lead to
Central pontine demyelination
The hyponatraemia should be corrected at a rate of 6 to 12mmol/L in the first 24. With rapid correction fluids shifts can cause damage to myelin.
Causes of hyperkalaemia:
acute kidney injury drugs*: potassium sparing diuretics, ACE inhibitors, angiotensin 2 receptor blockers, spironolactone, ciclosporin, heparin** metabolic acidosis Addison's disease rhabdomyolysis massive blood transfusion
A common endocrine complication of small cell lung cancer is
SIADH
The syndrome of inappropriate ADH secretion (SIADH) is characterised by hyponatraemia secondary to the dilutional effects of excessive water retention.
Causes of predominantly hypercholesterolaemia
nephrotic syndrome
cholestasis
hypothyroidism
The initial management of hypercalcaemia
is rehydration with normal saline, typically 3-4 litres/day. Following rehydration bisphosphonates may be used. They typically take 2-3 days to work with maximal effect being seen at 7 days
Warfarin mechanism of action
is an oral anticoagulant which inhibits epoxide reductase preventing the reduction of vitamin K to its active hydroquinone form, which in turn acts as a cofactor in the carboxylation of clotting factor II, VII, IX and X (mnemonic = 1972) and protein C
warfarin indications
ndications
venous thromboembolism: target INR = 2.5, if recurrent 3.5
atrial fibrillation, target INR = 2.5
mechanical heart valves, target INR depends on the valve type and location. Mitral valves generally require a higher INR than aortic valves.
Factors that may potentiate warfarin
liver disease
P450 enzyme inhibitors, e.g.: amiodarone, ciprofloxacin
cranberry juice
drugs which displace warfarin from plasma albumin, e.g. NSAIDs
inhibit platelet function: NSAIDs
warfarin
haemorrhage
teratogenic, although can be used in breastfeeding mothers
skin necrosis: when warfarin is first started biosynthesis of protein C is reduced. This results in a temporary procoagulant state after initially starting warfarin, normally avoided by concurrent heparin administration. Thrombosis may occur in venules leading to skin necrosis
purple toes
Any of the following features in a person aged 0-24 years should prompt a very urgent full blood count (within 48 hours) to investigate for leukaemia:
Pallor Persistent fatigue Unexplained fever Unexplained persistent infections Generalised lymphadenopathy Persistent or unexplained bone pain Unexplained bruising Unexplained bleeding
first-line antibiotic in the treatment of syphilis is:
intramuscular benzathine penicillin
, some common factors indicating severe pancreatitis include:
age > 55 years hypocalcaemia hyperglycaemia hypoxia neutrophilia elevated LDH and AST
Note that the actual amylase level is not of prognostic value.
Hepatocellular carcinoma Diagnosis
CT/ MRI (usually both) are the imaging modalities of choice
a-fetoprotein is elevated in almost all cases
Biopsy should be avoided as it seeds tumours cells through a resection plane.
In cases of diagnostic doubt serial CT and αFP measurements are the preferred strategy.
main risk factor for Cholangiocarcinoma
Primary sclerosing cholangitis
Mitral stenosis
mid-late diastolic murmur heard loudest in expiration.
Mitral valve prolapse
mid-systolic murmur heard loudest in expiration.
Tricuspid stenosis
mid/late diastolic murmur heard loudest in inspiration.
Aortic stenosis
ejection systolic murmur heard loudest in expiration.
Pulmonary stenosis
It is an ejection systolic murmur, heard loudest in inspiration. It is associated with dyspnoea.
breast Fibroadenoma
Common in women under the age of 30 years
Often described as ‘breast mice’ due as they are discrete, non-tender, highly mobile lumps
Fibroadenosis (fibrocystic disease, benign mammary dysplasia)
Most common in middle-aged women
‘Lumpy’ breasts which may be painful. Symptoms may worsen prior to menstruation
Breast cancer
Characteristically a hard, irregular lump. There may be associated nipple inversion or skin tethering
Paget’s disease of the breast - intraductal carcinoma associated with a reddening and thickening (may resemble eczematous changes) of the nipple/areola
Mammary duct ectasia
Dilatation of the large breast ducts
Most common around the menopause
May present with a tender lump around the areola +/- a green nipple discharge
If ruptures may cause local inflammation, sometimes referred to as ‘plasma cell mastitis’
Duct papilloma
Local areas of epithelial proliferation in large mammary ducts
Hyperplastic lesions rather than malignant or premalignant
May present with blood stained discharge
Fat necrosis
More common in obese women with large breasts
May follow trivial or unnoticed trauma
Initial inflammatory response, the lesion is typical firm and round but may develop into a hard, irregular breast lump
Rare and may mimic breast cancer so further investigation is always warranted
Breast abscess
More common in lactating women
Red, hot tender swelling
4 indications for haemodylasis
1- refractory hyperkalaemia
2- uraemia
3- fluid overload causing pulmonary oedema
4-metabolic acidosis
Light’s criteria
exudates have a protein level of >30 g/L, transudates have a protein level of <30 g/L
if the protein level is between 25-35 g/L, Light’s criteria should be applied. An exudate is likely if at least one of the following criteria are met:
pleural fluid protein divided by serum protein >0.5
pleural fluid LDH divided by serum LDH >0.6
pleural fluid LDH more than two-thirds the upper limits of normal serum LDH
Spontaneous bacterial peritonitis: most common organism found on ascitic fluid culture is
are gram-negative enteric bacteria. E coli is by far the most common followed by Klebsiella.
Spontaneous bacterial peritonitis (SBP) diagnosis
paracentesis: neutrophil count > 250 cells/ul
Spontaneous bacterial peritonitis (SBP) management
intravenous cefotaxime is usually given
Antibiotic prophylaxis should be given to patients with ascites if:
patients who have had an episode of SBP
patients with fluid protein <15 g/l and either Child-Pugh score of at least 9 or hepatorenal syndrome
NICE recommend: ‘Offer prophylactic oral ciprofloxacin or norfloxacin for people with cirrhosis and ascites with an ascitic protein of 15 g/litre or less until the ascites has resolved’
Allergic bronchopulmonary aspergillosis
results from an allergy to Aspergillus spores. In the exam questions often give a history of bronchiectasis and eosinophilia.
Allergic bronchopulmonary aspergillosis features
bronchoconstriction: wheeze, cough, dyspnoea. Patients may have a previous label of asthma
bronchiectasis (proximal)
Allergic bronchopulmonary aspergillosis Investigations
eosinophilia
flitting CXR changes
positive radioallergosorbent (RAST) test to Aspergillus
positive IgG precipitins (not as positive as in aspergilloma)
raised IgE
Allergic bronchopulmonary aspergillosis management
oral glucocorticoids
itraconazole is sometimes introduced as a second-line agent
ACE-inhibitors should be avoided in patients with
in hypertrophic obstructive cardiomyopathy (HOCM) with left ventricular outflow tract (LVOT) obstruction. ACE inhibitors can reduce afterload which may worsen the LVOT gradient.
Hypertrophic obstructive cardiomyopathy (HOCM) is an autosomal dominant disorder of muscle tissue caused by defects in the genes encoding contractile proteins
HOCM management
Amiodarone Beta-blockers or verapamil for symptoms Cardioverter defibrillator Dual chamber pacemaker Endocarditis prophylaxis*
HOCM drugs to avoid
nitrates
ACE-inhibitors
inotropes
Adenosine is contraindicated in
asthmatics, use Ca channel blocker instead
Defects in humeral immunity, makes you susceptible to:
‘Encapsulated organisms’
- Streptococcus pneumoniae
- Haemophilus influenzae
- Neisseria meningitis
Breast screening ages
women aged 50 to 70
Women over 70 can self-refer.
breast cancer screening every 3 years.
Cervical cancer screening age
Cervical screening is offered to women aged 25 to 64 to check the health of cells in the cervix. It is offered every 3 years for those aged 26 to 49, and every 5 years from the ages of 50 to 64.
Colorectal cancer screening age
Everyone aged 60 to 74 is offered a bowel cancer screening home test kit every 2 years.
If you’re 75 or over, you can ask for a kit every 2 years by phoning the free bowel cancer screening helpline
HLA for Ankylosing spondylitis, Reactive arthritis, colitic arthritis, psoriatic
arthritis:
HLA-B27
HLA for Coeliac disease
DQ2 & DQ8
HLA for type 1 diabetes
DQ8 & DQ2
HLA for MS
DQ6
HLA for rheumatoid arthritis
DR4
HLA for Cw6
HLA-Cw6
Truelove and Witts score
Severity Index for Ulcerative Colitis
Child- Pugh T Score – Child A
score less than 7
10 year life expectancy is 70%
Child- Pugh T Score – Child B
score 7-9
5 year life expectancy is 50%
Child- Pugh T Score — Child C
score more than 9
1 year life expectancy is 50%
crohns first line drug to induce remission
glucocorticoids
crohns first line drug to maintain remission
stopping smoking is a priority
azathioprine or mercaptopurine is used first-line to maintain remission
Anal fissures are
longitudinal or elliptical tears of the squamous lining of the distal anal canal. If present for less than 6 weeks they are defined as acute, and chronic if present for more than 6 weeks.
Adult patients outside of ICU with suspected infection are identified as being at heightened risk of mortality if they have quickSOFA (qSOFA) score meeting
> = 2 of the following criteria:
respiratory rate of 22/min or greater,
altered mentation, or
systolic blood pressure of 100mmHg or less
Contraindications to thrombolysis
active internal bleeding recent haemorrhage, trauma or surgery (including dental extraction) coagulation and bleeding disorders intracranial neoplasm stroke < 3 months aortic dissection recent head injury severe hypertension
American Society of Anaesthesiologists (ASA) classification
assessment tool to stratify risk for patients undergoing surgery.
ASA I
A normal healthy patient
Healthy, non-smoking, no or minimal alcohol use
ASA II
A patient with mild systemic disease
Mild diseases only without substantive functional limitations. Examples include (but not limited to): current smoker, social alcohol drinker, pregnancy, obesity (BMI 30 - 40), well-controlled Diabetes Mellitus/Hypertension, mild lung disease
ASA III
A patient with severe systemic disease
Substantive functional limitations; One or more moderate to severe diseases. Examples include (but not limited to): poorly controlled Diabetes Mellitus/Hypertension, COPD, morbid obesity (BMI > 40), active hepatitis, alcohol dependence or abuse, implanted pacemaker, moderate reduction of ejection fraction, End-Stage Renal Disease (ESRD) undergoing regularly scheduled dialysis, history (>3 months) of Myocardial infarction, Cerebrovascular accidents
ASA IV
A patient with severe systemic disease that is a constant threat to life
Examples include (but not limited to): recent (< 3 months) of Myocardial infarction, Cerebrovascular accidents, ongoing cardiac ischaemia or severe valve dysfunction, severe reduction of ejection fraction, sepsis, DIC, ARD or ESRD not undergoing regularly scheduled dialysis
ASA V
A moribund patient who is not expected to survive without the operation
Examples include (but not limited to): ruptured abdominal/thoracic aneurysm, massive trauma, intra-cranial bleed with mass effect, ischaemic bowel in the face of significant cardiac pathology or multiple organ/system dysfunction
ASA VI
A declared brain-dead patient whose organs are being removed for donor purposes
Subclavian steal syndrome
characteristically presents with posterior circulation symptoms, such as dizziness and vertigo, during exertion of an arm. There is subclavian artery steno-occlusive disease proximal to the origin of the vertebral artery and is associated with flow reversal in the vertebral artery. Management involves percutaneous transluminal angioplasty or a stent
Blood films: typical pictures
Hyposplenism e.g. post-splenectomy, coeliac disease (occurs in around 30% of coeliac patients)
target cells Howell-Jolly bodies Pappenheimer bodies siderotic granules acanthocytes
Blood films: typical pictures
Iron-deficiency anaemia
target cells
‘pencil’ poikilocytes
if combined with B12/folate deficiency a ‘dimorphic’ film occurs with mixed microcytic and macrocytic cells
Blood films: typical pictures
Myelofibrosis
‘tear-drop’ poikilocytes
Blood films: typical pictures
Intravascular haemolysis
schistocytes
Blood films: typical pictures
Megaloblastic anaemia
hypersegmented neutrophils
Heinz bodies
are large inclusion bodies within the RBCs composed of denatured haemoglobin, and are associated with glucose-6-phosphate dehydrogenase (G6PD) deficiency.
GCS score eyes
eyes don’t open - 1
eyes open to pain -2
eyes open to speech- 3
eyes open spontaneously-4
GCS score verbal
No verbal response -1 inappropriate sounds- 2 inappropriate words- 3 confused -4 oriented- 5
GCS score motor
no response- 1 extension- 2 abnormal flexion- 3 normal flexion-4 localises pain -5 obeys command-6
Ankle:brachial pressure index (ABPI) >1.3
High- usually calcified blood vessel (incompressible)
ABPI 0.92-1.3
NORMAL
ABPI 0.5-0.9
intermittent claudication
lifestyle, medical then surgery
ABPI < 0.5
severe arterial disease: rest pain, ulceration, gangrene
—> urgent referral to vascular surgeon
normal urine output
0.5ml/kg/h
Wilson’s disease investigation
Low ceruloplasmin & high urinary copper
definite diagnosis is obtained by liver biopsy
Abdominal aortic aneursym <3 cm
Normal - No further action
Abdominal aortic aneursym 3-4.4 cm
Rescan every 12 months
Abdominal aortic aneursym 4.4-5.4 cm
Rescan every 3 months
Abdominal aortic aneursym >= 5.5 cm
Refer within 2 weeks to vascular surgery for probable intervention
Only found in 1 per 1,000 screened patients
Stage 1 hypertension
clinic blood pressure ranging from 140/90 mmHg to 159/99 mmHg and subsequent ambulatory or home blood pressure monitoring average ranging from 135/85 mmHg to 149/94 mmHg
Stage 2 hypertension
clinic blood pressure ranging from 160/100 mmHg to 179/119 mmHg and subsequent ambulatory or home blood pressure monitoring average 150/95 mmHg or higher
Stage 3 hypertension
This is defined as a clinic systolic blood pressure 180mm Hg or higher or clinic diastolic blood pressure 120 mmHg or higher.
Accelerated or malignant hypertension is defined as
a blood pressure of 180/120 mmHg or greater, in combination with signs of papilloedema or retinal haemorrhages on fundoscopy.
Gallstone ileus
This describes small bowel obstruction secondary to an impacted gallstone. It may develop if a fistula forms between a gangrenous gallbladder and the duodenum.
Abdominal pain, distension and vomiting are seen.
Cholangiocarcinoma
Persistent biliary colic symptoms, associated with anorexia, jaundice and weight loss. A palpable mass in the right upper quadrant (Courvoisier sign), periumbilical lymphadenopathy (Sister Mary Joseph nodes) and left supraclavicular adenopathy (Virchow node) may be seen
In patients who are not currently bleeding or about to undergo a procedure, platelet transfusion should be performed if platelets fall below
0 x 109/L, however, there are certain conditions in which the use of platelet transfusion is associated with increased risk of death. One of these is thrombotic thrombocytopenic purpura, which should be treated with corticosteroids or other immunomodulatory medications
clinically significant bleeding (World Health organisation bleeding grade 2- e.g. haematemesis, melaena, prolonged epistaxis) - Offer platelet transfusions to patients with a platelet count of
platelet count of <30 x 10 9
for patients with severe bleeding (World Health organisation bleeding grades 3&4), or bleeding at critical sites, such as the CNS.
Platelet thresholds for transfusion are higher
maximum < 100 x 10 9
Platelet transfusion for thrombocytopenia before surgery/ an invasive procedure. Aim for plt levels of:
> 50×109/L for most patients
50-75×109/L if high risk of bleeding
100×109/L if surgery at critical site
For example, do not perform platelet transfusion for any of the following conditions:
Chronic bone marrow failure
Autoimmune thrombocytopenia
Heparin-induced thrombocytopenia, or
Thrombotic thrombocytopenic purpura.
Hypercalcaemia: causes
Two conditions account for 90% of cases of hypercalcaemia:
- Primary hyperparathyroidism: commonest cause in non-hospitalised patients
- Malignancy: the commonest cause in hospitalised patients. This may be due to number of processes, including; bone metastases, myeloma, PTHrP from squamous cell lung cancer
Other causes include sarcoidosis* vitamin D intoxication acromegaly thyrotoxicosis Milk-alkali syndrome drugs: thiazides, calcium containing antacids dehydration Addison's disease Paget's disease of the bone**
The Glasgow score is used to identify cases of severe pancreatitis.
There is a useful mnemonic that can be used to remember the criteria.
P - PaO2 (< 7.9 kPa).
A - age (>55).
N - neutrophils (white cell count > 15x 109/L).
C - calcium (calcium < 2 mmol/L).
R - renal function (urea > 16 mmol/L).
E - enzymes (lactate dehydrogenase > 600 IU/L).
A - albumin (albumin < 32 g/L).
S - sugar (blood glucose > 10 mmol/L).
3 points and above suggests a high risk for severe pancreatitis.
Discuss (1)
Improve
some common factors indicating severe pancreatitis include:
age > 55 years hypocalcaemia hyperglycaemia hypoxia neutrophilia elevated LDH and AST
If a patient with ulcerative colitis has had a severe relapse or >=2 exacerbations in the past year they should be given
either oral azathioprine or oral mercaptopurine to maintain remission
Inguinal hernia in infants treatment
= Urgent surgery
Grading of hepatic encephalopathy
Grade I: Irritability
Grade II: Confusion, inappropriate behaviour
Grade III: Incoherent, restless
Grade IV: Coma
Small cell Lung cancer: paraneoplastic features
ADH
ACTH - not typical, hypertension, hyperglycaemia, hypokalaemia, alkalosis and muscle weakness are more common than buffalo hump etc
Lambert-Eaton syndrome
Squamous cell Lung cancer: paraneoplastic features
parathyroid hormone-related protein (PTH-rp) secretion causing hypercalcaemia
clubbing
hypertrophic pulmonary osteoarthropathy (HPOA)
hyperthyroidism due to ectopic TSH
Adenocarcinoma Lung cancer: paraneoplastic features
gynaecomastia
hypertrophic pulmonary osteoarthropathy (HPOA)
Statins must be temporarily held when prescribing a
macrolides (e.g. erythromycin, clarithromycin)
statin contraindications
macrolides (e.g. erythromycin, clarithromycin) are an important interaction. Statins should be stopped until patients complete the course
pregnancy
Risk factors for Peptic ulcer disease
Helicobacter pylori is associated with the majority of peptic ulcers:
95% of duodenal ulcers
75% of gastric ulcers
drugs:
NSAIDs
SSRIs
corticosteroids
bisphosphonates
Zollinger-Ellison syndrome: rare cause characterised by excessive levels of gastrin, usually from a gastrin secreting tumour
the role of alcohol and smoking is not clear
Haemophilus influenzae pneumonia is a common cause of pneumonia in patients with
COPD.
Klebsiella pneumoniae pneumonia is typically associated with
alcoholics and diabetics. It causes classic red-currant jelly sputum.
Legionella pneumophila pneumonia is classically secondary to
to infected air conditioning units.
it is always worth asking about recent travel. It commonly causes hyponatraemia and lymphopenia.
Preceding influenza predisposes to ….. pneumonia
Staphylococcus aureus pneumonia
Ascending cholangitis is a bacterial infection (typically
E. coli
Most common organism found in central line infections
Staphylococcus epidermidis
Haemophilus influenzae B can cause
periorbital cellulitis, acute epiglottitis, and acute exacerbations of COPD.
Staphylococcus aureus causes
skin infections (e.g. cellulitis), abscesses, osteomyelitis, toxic shock syndrome.
Streptococcus agalactiae may lead to
neonatal meningitis and septicaemia.
Streptococcus pyogenes is the organism responsible for
heumatic fever, erysipelas, impetigo, cellulitis, type 2 necrotizing fasciitis and pharyngitis/tonsillitis.
Inguinal hernia
Above and medial to pubic tubercle
Strangulation is rare
Femoral hernia
Below and lateral to the pubic tubercle
More common in women, particularly multiparous ones
High risk of obstruction and strangulation
Surgical repair is required
Spigelian hernia
Also known as lateral ventral hernia
Rare and seen in older patients
A hernia through the spigelian fascia (the aponeurotic layer between the rectus abdominis muscle medially and the semilunar line laterally)
Richter hernia
A rare type of hernia where only the antimesenteric border of the bowel herniates through the fascial defect
Richter’s hernia can present with strangulation without symptoms of obstruction
Venous thromoboembolism - length of warfarin treatment
provoked (e.g. recent surgery): 3 months
unprovoked: 6 months
The most common causes of viral meningitis in adults are
enteroviruses (Coxsackie B )
Ventricular tachycardia contraindicated drug
verapamil
Mitral valve prolapse complications: mitral regurgitation
Associations congenital heart disease: PDA, ASD cardiomyopathy Turner's syndrome Marfan's syndrome, Fragile X osteogenesis imperfecta pseudoxanthoma elasticum Wolff-Parkinson White syndrome long-QT syndrome Ehlers-Danlos Syndrome polycystic kidney disease
An increase in serum creatinine up to ….. from baseline is acceptable when initiating ACE inhibitor treatment
30%
Marfan’s syndrome is
an autosomal dominant connective tissue disorder.
defect in protein fibrillin-1.
The main ECG abnormality seen with hypercalcaemia is
shortening of the QT interval
Alternating QRS amplitude
in pericardial effusion
‘Downsloping ST depression with biphasic T waves
myocardial ischaemia or digoxin toxicity.
Small P waves and QRS widening
hyperkalaemia (along with tall-tented T waves).
U waves, PR interval elongation, and ST depression
hypokalaemia
In life-threatening Clostridium difficile infection treatment is with
ORAL vancomycin and IV metronidazole
False aneurysms (pseudoaneurysm)
involve a collection of blood in outer layer only adventitia) which communicates with the lumen; can happen after trauma
True aneurysms
abnormal dilatations that involve all layers of arterial wall
Drugs to avoid in renal failure
antibiotics: tetracycline, nitrofurantoin
NSAIDs
lithium
metformin
Zollinger–Ellison syndrome
is a disease in which tumors cause the stomach to produce too much acid, resulting in peptic ulcers. Symptoms include abdominal pain and diarrhea. The syndrome is caused by a gastrinoma, a neuroendocrine tumor that secretes a hormone called gastrin
frothy pink sputum may come from
pulmonary edema
pancytopenia
is a condition that occurs when a person has low counts for all three types of blood cells: red blood cells, white blood cells, and platelets
Which antihypertensive agent is most appropriate as initial therapy in pheochromocytoma?
Alpha blockade using phenoxybenzamine is used in treatment of secondary hypertension in pheochromocytoma. Patients should always be well alpha blocked before commencing any beta blockade.
QRISK®3 algorithm calculates a person’s risk of developing a
heart attack or stroke over the next 10 years
risk factors
Chronic kidney disease, which now includes stage 3 CKD
Migraine
Corticosteroids
Systemic lupus erythematosus (SLE)
atypical antipsychotics
severe mental illness
erectile dysfunction
a measure of systolic blood pressure variability
Thiazide diuretics like bendroflumethiazide are known to cause
hypercalcaemia
An important side effect of PPIs to be aware of is the potential to increase the risk of
Clostridium difficile pseudomembranous colitis.
Management of an acute anal fissure (< 1 week)
soften stool
dietary advice: high-fibre diet with high fluid intake
bulk-forming laxatives are first-line - if not tolerated then lactulose should be tried
lubricants such as petroleum jelly may be tried before defecation
topical anaesthetics
analgesia
Management of a chronic anal fissure
the above techniques should be continued
topical glyceryl trinitrate (GTN) is first-line treatment for a chronic anal fissure
if topical GTN is not effective after 8 weeks then secondary care referral should be considered for surgery (sphincterotomy) or botulinum toxin
Causes of false-negative Mantoux test
immunosuppression (miliary TB, AIDS, steroid therapy) sarcoidosis lymphoma extremes of age fever hypoalbuminaemia, anaemia
In the 2013 guidelines NICE recommend the following requirements for maintenance fluids:
25-30 ml/kg/day of water and
approximately 1 mmol/kg/day of potassium, sodium and chloride and
approximately 50-100 g/day of glucose to limit starvation ketosis
