Medicine 11 Flashcards by Akash Srinivasan

List some causes of bloody diarrhoea.

Vascular: ischaemic colitis
Infective: shigella, salmonella, E. coli, C. difficile
Inflammatory bowel disease
Neoplastic: colorectal cancer, polyps

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List the different types of laxative with examples.

Bulking: fybogel, methylcellulose
Osmotic: movicol, lactulose 
Stimulant: senna, bisacodyl, docusate sodium, sodium picosulphate, co-danthramer
Softeners: liquid paraffin
Enemas: phosphate (osmotic) 
Suppositories: glycerol (stimulant)

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Outline the management options for achalasia.

Medical: CCBs, nitrates
Interventional: endoscopic balloon dilatation, botulinum toxin injection
Surgical: Heller cardiomyotomy

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Outline the management of new-onset dyspepsia.

OGD if > 55 years and red flags (anorexia, weight loss, anaemia, recent onset, melaena, dysphagia)
Conservative measures for 4 weeks
- stop drugs (NSAIDs, CCB)
- lose weight, stop smoking, reduce alcohol
- OTC antacids and alginates
Test H. pylori if no improvement (breath or serology)
- positive –> eradication
- negative –> PPI for 4 weeks, consider OGD if no improvement

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Describe the eradication therapy used to treat H. pylori.

Lansoprazole 30 mg BD + amoxicillin 1 g BD + clarithromycin 500 mg BD

Lansoprazole 30 mg BD + amoxicillin 1 g BD + metronidazole 400 mg BD

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Outline the management of peptic ulcer disease.

CONSERVATIVE: lose weight, stop smoking, reduce alcohol, stop NSAIDs/steroids
MEDICAL: OTC antacids, H. pylori eradication, PPI/H2RA
SURGERY: vagotomy, antrectomy, subtotal gastrectomy

NOTE: antrum contains most gastrin-producing cells (types of operation: BIlroth 1 and 2)

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List some causes of cirrhosis.

Alcoholic liver disease 
Viral hepatitis 
NASH
Genetic: Wilson's, HH, a1AT 
Autoimmune: PSC, PBC, AIH 
Drugs: methotrexate, amiodarone, nitrofurantoin 
Neoplasia: HCC, metastases 
Vascular: Budd-Chiari, right heart failure, constrictive pericarditis

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Outline the management of cirrhosis.

Alcohol abstinence
Cholestyramine for pruritus
Screening (HCC and varices)
Treat cause (interferon for HCV, ursodeoxycholic acid for PBC or penicillamine for Wilson’s disease)

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List some causes of portal hypertension.

Pre-hepatic: portal vein thrombosis
Hepatic: CIRRHOSIS, schistosomiasis, sarcoidosis
Post-hepatic: Budd-Chiari, RHF, constrictive pericarditis

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List some precipitants for decompensation of chronic liver failure.

Haemorrhage (e.g. varices) 
Electrolyte abnormality (e.g. hypokalaemia)
Alcohol
HCC 
Infection (SBP, pneumonia, UTI)
Constipation (MOST COMMON cause)
Hypoglycaemia 
Drugs (e.g. sedatives, anaesthetics)

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Which infections should patients be screened for before starting dialysis?

Hep B
Hep C
HIV

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What is a key distinction between bullous pemphigoid and pemphigus vulgaris?

Pemphigus = oral involvement 
Pemphigoid = NO oral involvement

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Define the following terms used to describe skin lesions.
Macule 
Nodule 
Papule 
Plaque
Vesicle

Macule - change in skin colour without change in elevation (called a patch if > 1 cm)
Nodule - raised lesion with a rounded surface > 1 cm
Papule - solid raised lesion < 1 cm in diameter
Plaque - elevated plateau of skin > 1 cm
Vesicle - fluid-filled lesion < 1 cm

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Describe the criteria by which left ventricular hypertrophy by voltage criteria?

Sokolow-Lyon Criteria: Add the S wave in V1 plus the R wave in V5 or V6. If the sum is > 35 mm, then LVH is present

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List some complciations of peptic ulcer disease.

Bleeding (haematemesis/melaenia)
Iron deficiency anaemia
Perforation and peritonitis
Malignancy

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Which red flag symptoms would warrant an OGD in patients with suspected peptic ulcer disease?

Anaemia
Weight loss
Dysphagia

NOTE: if no red flags and < 55 years, investigate with H. pylori breath test, stool antigen test and bloods (FBC)

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List some surgical management options for urinary tract calculi.

Extracorporeal shockwave lithotripsy (small stone < 20 mm)
JJ stent (hydronephrosis)
Ureteroscopy and laster/fragmentation (proximal stone)
Percutaneous nephrolithotomy/ureterolithotom (large stone > 20 mm)

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Which medications are used to treat hepatitis C?

Pegylated interferon
Ribavirin
Boceprevir (protease inhibitor)
Sofosbuvir (NS5B inhibitor)

NOTE: all patients should be investigated to identify their HCV genotype

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What treatment options are used for diabetic retinopathy with maculopathy and proliferative diabetic retinopathy?

With maculopathy - intravitreal anti-VEGF injections
Proliferative - panretinal photocoagulation

NOTE: you can’t use photocoagulation on the macula because it will impair vision

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How is post-operative atelectasis treated?

Salbutamol nebulisers
Chest physiotherapy

NOTE: incentive spirometers are used to prevent atelectasis

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Outline the treatment options for plaque psoriasis.

Avoid precipitants (alcohol, smoking, stress)
Emollients
Steroids - FIRST LINE
Vitamin D analogues (calcipotrol) - FIRST LINE
Coal tar
Dithranol
Phototherapy (PUVA)
Systemic (ciclosporin, methotrexate, retinoids and biologics (infliximab, etanercep))

NOTE: for PUVA, psoralens are either applied or given orally and then a UV lamp is shone over the affected skin

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Outline the steps in the pharmacological management of COPD.

STEP 1: SABA

STEP 2 (steroid responsive): LABA + ICS
STEP 3 (steroid responsive): LABA + ICS + LAMA

STEP 2 (steroid non-responsive): LABA + LAMA 
Use combo inhalers where possible

NOTE: conservative management includes stopping smoking, annual influenza and one-off pneumococcus vaccine, pulmonary rehab

Which causes of interstitial lung disease may respond to steroid treatment?

Sarcoidosis
Connective tissue diseases (e.g. rheumatoid arthritis)
Extrinsic allergic alveolitis

List some advantages and disadvantages of peritoneal dialysis.

PROS: simple to perform, can be done at home, less haemodynamic instability (good if cardiovascular disease)
CONS: body image, peritonitis, weight gain, exit site infection

List some pros and cons of Tesio lines.

PROS: well concealed (unliked fistula), can be used straight away CONS: increased infections risk, lower flow rates, adverse events on insertion (pneumothorax, line infection, retraction)

Outline the aspects of managing chronic kidney disease.

General: correct reversible causes, stop nephrotoxic drugs, phosphate restriction Hypertension: ACE inhibitor Oedema: frusemide Bone disease: phosphate binders, calcichew, vitamin D analogues Anaemia: EPO

Outline the criteria for diagnosing DKA.

Glucose > 11 Ketones > 3 pH < 7.3 Bicarbonate < 15

Which infection is associated with tonsillar squamous cell carcinoma?

HPV

How should a patient on oral morphine with inadequate pain control have their dose changed?

Divide total daily dose by 2 (give you BD dose of oral morphine) 1/6 of the BD dose is the breakthrough dose E.g. inadequate control with 30 mg BD + 10 mg PRN (used 3 times) = 90 mg per day --> 45 mg BD + 15 mg PRN

Which investigation can be used to explore the extent of skin involvement in vitiligo

Woods lamp inspection Areas of hyper and hypopigmentation will fluoresce (e.g. vitiligo, pityriasis versicolor, tinea capitis)

Which medication is usually used first-line for patients with SLE primarily affecting the skin and joints?

Hydroxychloroquine

How does urine sodium help you assess fluid status?

< 20 mmol/L = hypovolemia | > 40 mmol/L = SIADH

Define cranial nerve.

Nerves that emerge directly from the brain (not the spinal cord)

Which cranial nerve supplies a contralateral innervation as opposed to an ipsilateral innervation?

Trochlear - it crosses the midline before innervating the contralateral superior oblique NOTE: all cranial nerves are considered peripheral nerves

List some the components of a falls screen.

``` Bloods (FBC, U&E, CRP) Glucose ECG Urinalysis Lying-standing BP ```

Describe the mechanisms responsible for the following types of transfusion reaction: Febrile non-haemolytic Haemolytic Allergic Transfusion-related acute lung injury Transfusion-associated circulation overload

Febrile non-haemolytic: host antibodies against donor leucocyte antigens/pre-formed cytokines within donor plasma Haemolytic: host antibodies against donor RBC antigens Allergic: allergic reaction to plasma proteins Transfusion-related acute lung injury: activation of donated leucocytes in the lungs Transfusion-associated circulation overload: rapid volume expansion

Which nerves innervate the lower limbs?

Femoral (L2-4) Obturator (L2-4) Sciatic (L3-S3)

Under which conditions in DKA do you avoid giving K+ supplementation with the fluids?

Anuria | K+ > 5.5 mmol/L

List some risk factors for falls in the elderly.

``` Muscle weakness Gait abnormalities Visual impairment Postural hypotension Arthritis Cognitive impairment Drugs (e.g. antihypertensives, sedative, anti-arrhythmics) ```

What are the main features of Yellow Nail Syndrome?

Yellow nails Lymphoedema Pleural effusion Bronchiectasis

What are the main features of anterior cord syndrome?

Motor paralysis at the level of the lesion Loss of pain/temp at and below the level of the lesion Normal fine touch/proprioception (dorsal columns are fine) Autonomic dysfunction (hypotension) Areflexia Flaccid anal sphincter Urinary retention NOTE: caused by anterior spinal artery infarction

List some differentials for Marfan syndrome.

Ehlers-Danlos syndrome Pseudoxanthoma elasticum Homocystinuria

What are the main aspects of managing non-alcoholic fatty liver disease?

``` Weight loss (aim for 10% over 6 months) Good diabetes control Good cholesterol control Hepatitis immunisations Alcohol abstinence ```

List some different types of long and short-acting insulin.

LONG: glargine (lantus), detemir (levemir), degludec (tresiba) Short: actrapid, lispro (humolog), aspart (novolog), glulisine

What is pulsus paradoxus?

> 10 mm Hg drop in systolic blood pressure with inspiration Associated with pericarditis and pericardial effusion Interpreted as a sign of impending circulatory collapse due to tamponade

In which circumstance would a DPPIV inhibitor be considered a better second-line agent than a sulphonylurea?

Overweight patients - sulphonylureas cause weight gain

State the origin of each cranial nerve.

``` Cerebrum: I and II Midbrain: IV Midbrain-Pontine Junction: III Pons - V Pontine-Medulla Junction: VI, VII, VIII Medulla: IX, X, XI, XII ```

Outline the steps in the management of asthma.

``` STEP 1: SABA STEP 2: SABA + ICS STEP 3: SABA + ICS + LTRA STEP 4: SABA + ICS + LABA STEP 5: Switch ICS/LABA to MART (continue SABA +/- LTRA) STEP 6: Increase to moderate-dose ICS ```

Damage to which part of the brain causes apraxia?

Posterior parietal lobe

What are the main features of digoxin toxicity?

``` Nausea Diarrhoea Confusion Bradycardia Hyperkalaemia ``` WARNING: AKI can lead to digoxin toxicity

List some causes of bulbar palsy.

``` Brainstem stroke Brainstem tumours Syringomyelia MND Neurosyphylis Poliomyelitis GBS ``` NOTE: investigation include MRI, serology and CSF analysis

Which nerves pass through the cavernous sinus?

``` III IV V (1 and 2) VI Internal carotid artery ```

List some examples of seronegative spondyloarthitides.

Ankylosing spondylitis Psoriatic arthritis Enteropathic arthritis Reactive arthritis