Medicine 11 Flashcards
List some causes of bloody diarrhoea.
Vascular: ischaemic colitis
Infective: shigella, salmonella, E. coli, C. difficile
Inflammatory bowel disease
Neoplastic: colorectal cancer, polyps
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)
Outline the management options for achalasia.
Medical: CCBs, nitrates
Interventional: endoscopic balloon dilatation, botulinum toxin injection
Surgical: Heller cardiomyotomy
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
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
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)
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
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)
List some causes of portal hypertension.
Pre-hepatic: portal vein thrombosis
Hepatic: CIRRHOSIS, schistosomiasis, sarcoidosis
Post-hepatic: Budd-Chiari, RHF, constrictive pericarditis
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)
Which infections should patients be screened for before starting dialysis?
Hep B
Hep C
HIV
What is a key distinction between bullous pemphigoid and pemphigus vulgaris?
Pemphigus = oral involvement Pemphigoid = NO oral involvement
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
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
List some complciations of peptic ulcer disease.
Bleeding (haematemesis/melaenia)
Iron deficiency anaemia
Perforation and peritonitis
Malignancy
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)
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)
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
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
How is post-operative atelectasis treated?
Salbutamol nebulisers
Chest physiotherapy
NOTE: incentive spirometers are used to prevent atelectasis
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
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
