Medicine Flashcards

1
Q

Describe the laboratory features of haemochromatosis

A

Low TIBC, high ferritin, high transferrin saturation

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2
Q

Describe Peutz-Jeghers syndrome

A

AD condition

Clinical features
> Hamartomatous polyps in GI tract (causing intussusception)
> can lead to SBO

> Pigmented freckles on the lips, face, palms and soles

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3
Q

Describe the management of BPH

A

First-line: tamsulosin (alpha 1 antagonist)
> adverse effects: dizziness, postural hypotension

Second-line: finasteride (5 alpha reductase inhibitor) - takes 6 months to see results
> adverse effects: ED, reduced libido, gynaecomastia

anti-muscarinics such as tolterodine or darifenacin may be tried

Transurethral resection of the prostate (TURP) if medical management fails

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4
Q

Describe balanitis xerotica obliterans

A

Causes multiple itchy hyperkeratotic lesions on foreskin and glans

features
- dysuria
- reduction in sensation of glans
- can cause phimosis due to scarring

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5
Q

Describe the clinical features associated with Hodgkin’s lymphoma

A

Bimodal age distribution: peaks around 20-25 and 80 years

Usually B cell origin
> nodular sclerosing is the most common type
> lymphocyte depleted is the most aggressive
> lymphocyte predominant has best prognosis

Associated with history of glandular fever (EBV infection)

Presentation
> Asymmetrical painless lymphadenopathy (usually single rubbery lymph node in cervical, axillary or inguinal region) - may become painful after alcohol ingestion

> B symptoms: weight loss, sweating, fever, pruritis and general lethargy

Diagnosis
> excisional node biopsy: Reed-Sternberg cells (large malignant B cells).
> staging: PET-CT

Spread - Ann Arbor system
I = one node region involved
II = 2+ ipsilateral regions
III = bilateral node involvement
IV = extranodal disease
> Suffix “A” (B symptoms absent) or “B” (B symptoms present).

Management
> Early stage disease: radiotherapy alone
> Advanced: radiotherapy + chemotherapy

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6
Q

Describe the clinical features associated with Klinefelter’s syndrome

A

Karyotype 47XXY

Primary hypogonadism in patients with male external genitalia

Examination
> tall stature, low-volume testes, sparse pubic hair, and gynecomastia

Hypergonadotrophic hypogonadism
> High FSH and LH
> Low testosterone

Semen analysis - azoospermia
> infertility

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7
Q

Describe the mechanism of action of DPP-4 inhibitors such as sitagliptin

A

Reduce peripheral breakdown of incretins e.g. GLP-1

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8
Q

Describe allergic bronchopulmonary aspergillosis and its management

A

Due to allergy to Aspergillus spores

clinical features
- asthma
- bronchiectasis

investigations
- eosinophilia
- raised IgE
- sputum microscopy - eosinophils and fungal hyphae
- CXR - proximal bronchiectasis, consolidation

Treatment
- Oral prednisolone
- Oral itraconazole (second-line)

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9
Q

Describe Heberden’s nodes, Bouchard’s nodes and Oslers nodes

A

Bouchard’s: PIP joints, osteoarthritis

Heberden’s: DIP joints, osteoarthritis

Oslers nodes: tender purple/red raised lesions with pale centre, shows immune complex deposition. Causes: infective endocarditis, SLE, gonorrhoea, typhoid, haemolytic anaemia.

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10
Q

Describe Chronic Myeloid Leukaemia (CML)

A

BCR-ABL - t(9:22) - Philadelphia chromosome

Presentation 60-70 years of age

clinical features
- anaemia
- weight loss
- sweating
- splenomegaly

investigations
- bloods: increase in granulocytes, thrombocytosis

May undergo blast transformation - AML in 80%, ALL in 20%

Management
> Tyrosine kinase inhibitor (TKI) - imatinib
> Hydroxyurea
> Interferon-alpha
> Allogeneic bone transplant

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11
Q

Describe small bowel bacterial overgrowth syndrome (SBBOS)

A

Features
> chronic diarrhoea
> bloating, flatulence
> abdominal pain

Diagnosis
> hydrogen breath test
> small bowel aspiration and culture

Management
> correction of underlying disorder
> antibiotic therapy
» rifaximin
» Co-amoxiclav / metronidazole

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12
Q

Which enzyme must be checked before starting azathioprine or mercaptopurine therapy?

A

TPMT: thiopurine methyltransferase

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13
Q

Describe the clinical features of superior vena cava obstruction

A

Causes
- External pressure (e.g. malignancy, usually lung)
- Thrombus
- Direct tumour invasion

Clinical features
> facial flushing / swelling
> pain worsened leaning forward
> distended neck veins / bulging facial veins
> blurred vision
> papilloedema on fundoscopy
> Pemberton sign: bilateral arm elevation causes facial plethora

Treatment
- Sitting the patient up
- Oxygen
- Stat dose of dexamethasone
- Definitive management: SVC stenting, radiotherapy and chemotherapy

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14
Q

Describe the features of organophosphate insecticide poisoning

A

Salivation
Lacrimation
Urination
Defecation/diarrhoea
cardiovascular: hypotension, bradycardia
also: small pupils, muscle fasciculation

Management - atropine

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15
Q

Describe features associated with different gastroenteritis-causing bacteria

A

Staphylococcus aureus: severe vomiting after a short incubation period (30 minutes - 8 hours)
> Symptoms usually resolve within two days

Escherichia coli: incubation period of 3-4 days. Causes diarrhoea that usually becomes bloody, lasting up to a week. Common amongst travellers.

Giardia: watery diarrhoea at least 5 days after infection.

Salmonella: diarrhoea and fever; symptoms usually occur between 6 hours - 6 days

Shigella: fever and (sometimes bloody) diarrhoea begin1-2 days after infection

Cholera: profuse, watery diarrhoea
> Severe dehydration resulting in weight loss

Campylobacter: flu-like prodrome followed by crampy abdominal pains, fever and diarrhoea which may be bloody
> Complications include Guillain-Barre syndrome

Bacillus cereus: vomiting within 6 hours, stereotypically due to rice.

Amoebiasis: gradual onset bloody diarrhoea, abdominal pain and tenderness which may last for several weeks

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16
Q

Describe the differences between pneumonia caused by different bacteria

A

Community acquired pneumonia (CAP) :

> Streptococcus pneumoniae (80% of cases) - associated with cold sores

> Haemophilus influenzae

> Staphylococcus aureus: commonly after influenza infection

> atypical pneumonia
> Mycoplasma pneumoniae: dry cough, erythema multiforme, reticulo-nodular shadowing on CXR, RBC agglutination (haemolytic anaemia)
> can cause immune-mediated neurological disease
> serology is diagnostic

> viruses

Klebsiella pneumoniae: alcoholics, cavitating upper lobe pneumonia, red currant jelly sputum, empyema

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17
Q

Describe the diagnosis and management of IBS

A

Clinical diagnosis - diarrhoea/constipation, mucus in stool, abdominal discomfort relieved by defaecation, normal blood tests.

First-line - according to predominant symptom

> pain: antispasmodic agents

> constipation: laxatives but avoid lactulose
> if not responding to conventional laxatives try linaclotide

> diarrhoea: loperamide is first-line

Second-line pharmacological treatment
> low-dose tricyclic antidepressants (e.g. amitriptyline)
> sertraline

Psychological interventions - CBT, hypnotherapy

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18
Q

List and describe transfusion reactions as well as their management

A

acute haemolytic
> fever, abdo/lumbar pain, tachycardia, hypotension, tachypnoea
> caused by ABO incompatible blood
- management: stop transfusion, check patient identity/name, send blood for direct Coombs test, repeat typing and cross-matching. Supportive care (fluid resuscitation)

non-haemolytic febrile reaction
> fever and chills but no systemic upset
- management: slow/stop transfusion; paracetamol; monitor

minor allergic reaction
> pruritus, urticaria
- management: temporarily stop transfusion, give antihistamine, monitor

allergic/anaphylaxis
> hypotension, dyspnoea, wheezing, angioedema
- management: stop transfusion, IM adrenaline, oxygen, fluids

infective

transfusion-related acute lung injury (TRALI): hypoxia, pulmonary infiltrates, fever, hypotension, normal/unchanged JVP
- normal pulmonary capillary wedge pressure (PCWP systolic 7mmHg, diastolic 10mmHg)
- management: stop transfusion. O2, IV fluids & consider escalation of care

transfusion-associated circulatory overload (TACO): pulmonary oedema, hypertension, raised JVP, afebrile, S3 present
- raised PCWP
- management: slow/stop transfusion, consider IV diuretics and O2

other: hyperkalaemia, iron overload, clotting

First step is stopping transfusion

IgA deficiency increases risk of anaphylactic transfusion reactions

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19
Q

Describe autosomal dominant polycystic kidney disease (ADPKD)

A

Two disease loci have been identified, PKD1 and PKD2, which code for polycystin-1 and polycystin-2 respectively

Screening - renal USS

Clinical features
- Extensive cysts, enlarged kidneys
- Haematuria, abdominal pain, recurrent UTIs, renal failure

  • extra-renal manifestations
    > mitral regurgitation, mitral valve prolapse
    > cerebral berry aneurysms
    > hepatic, splenic, pancreatic, ovarian and prostatic cysts
    > colonic diverticula

Management
- tolvaptan (vasopressin receptor 2 antagonist)

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20
Q

Describe Q fever

A

Caused by Coxiella burnetti, a rickettsia

Features: farmer, fever, transaminitis

also atypical pneumonia and culture-negative infective endocarditis

contact with sheep, cattle

management - doxycycline

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21
Q

Describe sideroblastic anaemia

A

feature
- Hypochromic microcytic anaemia
- High ferritin iron and transferrin saturation
- Basophilic stippling of red blood cells

Congenital cause: delta-aminolevulinate synthase-2 deficiency

Acquired causes
myelodysplasia
alcohol
lead
anti-TB medications

symptoms of anaemia + hepatosplenomegaly

Management - supportive, treat underlying cause, pyridoxine may help

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22
Q

Describe an Addisonian crisis

A

Lab features: hyponatraemia, hyperkalaemia, hypoglycaemia

clinical features
- circulatory shock with severe hypotension
- unexplained pyrexia
- nausea and vomiting
- abdominal pain
- diarrhoea
- muscle cramps

Can be precipitated by
- sepsis or surgery causing exacerbation of chronic insufficiency
- adrenal haemorrhage e.g. Waterhouse-Friderichsen syndrome (fulminant meningococcaemia)
- steroid withdrawal

Management
- hydrocortisone 100mg IM or IV, no fludrocortisone required as high steroids exert mild mineralocorticoid effect
- 1 litre saline over 30-60 mins or with dextrose if hypoglycaemic

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23
Q

Describe the indications for LTOT in COPD patients

A

COPD - LTOT if pO2 of 7.3 - 8 kPa AND one of the following:
- secondary polycythaemia
- peripheral oedema
- pulmonary hypertension

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24
Q

Describe seborrhoeic dermatitis

A

clinical features
- erythematous, greasy, pruritic lesions
- affect the scalp, glabella, nasolabial folds, posterior auricular skin, and anterior chest

> due to over-proliferation of the Malassezia furfur fungus

> complications: otitis externa, blepharitis

> linked to Parkinson’s disease and HIV

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25
What is the Jarisch-Herxheimer reaction?
Fever, rash, chills and headache occurs following antibiotic administration for syphilis Management - antipyretics and supportive treatment
26
Describe haemochromatosis, its treatment and how to monitor treatment
AR iron absorption and metabolism disorder caused by HFE gene mutation Common features - Liver failure - type 2 diabetes - arthritis 2nd and 3rd MCP joints - bronze, greying of the skin - erectile dysfunction - hypogonadotrophic hypogonadism Diagnosis: - raised ferritin and transferrin saturation levels - reduced total iron binding capacity - molecular genetic testing for C282Y and H63D mutations complications: hepatocellular carcinoma Management: venesection > monitoring: ferritin and transferrin saturation
27
Describe a restrictive spirometry pattern
Reduced FVC Increased FEV1/FVC ratio reduced transfer factor for carbon monoxide (TLCO), reflecting impaired gas exchange caused by pulmonary fibrosis
28
Describe diabetic foot disease
occurs secondary to two main factors: neuropathy: resulting in loss of protective sensation, Charcot's arthropathy, dry skin peripheral arterial disease Presentations - neuropathy: loss of sensation - ischaemia: absent foot pulses, reduced ankle-brachial pressure index (ABPI), intermittent claudication complications: calluses, ulceration, Charcot's arthropathy, cellulitis, osteomyelitis, gangrene screening on at least an annual basis - ischaemia: palpating dorsalis pedis and posterial tibial artery pulse - neuropathy: a 10 g monofilament is used on various parts of the sole of the foot All patients who are moderate or high risk (I.e. any problems other than simple calluses) should be followed up regularly by the local diabetic foot centre
29
Describe the management of an acute exacerbation of COPD
4L via 28% Venturi aiming for 88-92% Salbutamol and ipratropium bromide nebuliser Oral prednisolone / IV hydrocortisone Antibiotics: doxycycline, clarithromycin or amoxicillin IF purulent sputum / clinical signs of pneumonia e.g. focal consolidation > if poor response, IV theophylline if unsuccessful start NIV (BiPAP) - pH 7.25-7.35 despite best medical treatment for 1h - if pH <7.25 consider invasive ventilation Contraindications to non-invasive ventilation include an inability to protect the airway, impaired consciousness, life-threatening acidosis and aspiration risk
30
Describe the treatment for chronic plaque psoriasis
First-line > regular emollients: reduce scale loss and reduce pruritus > topical potent steroid + vitamin D analogue e.g. topical betamethasone and calcipotriol > aim for 4 week break in between courses of topical steroids > Coal tar shampoo - scalp > dithranol > facial psoriasis: calcineurin inhibitors e.g. tacrolimus Phototherapy: narrowband ultraviolet B light Systemic therapy: oral methotrexate, ciclosporin, systemic retinoids (acitretin), apremilast, biologics (adalimumab, infliximab, ustekinumab)
31
Describe the management of hypercalcaemia
- rehydration with normal saline, 3-4 litres/day - Following rehydration bisphosphonates may be used. (take 2-3 days to work, maximal effect 7 days) > use IV bisphosphonate if Ca >3 Other options include: calcitonin - quicker effect than bisphosphonates steroids in sarcoidosis Loop diuretics e.g. furosemide can sometimes be used
32
Describe the clinical features of pancreatic cancer
painless jaundice and a palpable mass in the right upper quadrant (RUQ) Steatorrhoea due to loss of exocrine function weight loss
33
Describe secondary hyperparathyroidism
Decreasing kidney function results in kidneys not being able to convert enough vitamin D to its active form Kidneys are also not able to adequately excrete phosphate - HYPERPHOSPHATAEMIA Due to this. insoluble calcium phosphate forms, removing calcium from the circulation, which results in HYPOCALCAEMIA The parathyroid glands detect this and secrete parathyroid hormone to try and raise serum calcium levels. Treatment - addressing the underlying cause of hypocalcaemia
34
List causes of AKI
Prerenal (renal hypoperfusion) > urinary sodium <20 mmol/L > raised urea:creatinine ratio > good response to fluid challenge - hypovolaemia secondary to diarrhoea/vomiting - shock e.g. sepsis or blood loss - renal artery stenosis - heart failure Renal (intrinsic disease in the kidney) - toxins (drugs, contrast etc) - immune-mediated glomuleronephritis. - acute tubular necrosis (ATN) > urinary sodium >40 mmol/L > normal urea:creatinine ratio > poor response to fluid challenge - acute interstitial nephritis (AIN), respectively rhabdomyolysis (CK<10,000) - tumour lysis syndrome - haemolytic uraemic syndrome Postrenal - obstruction - unilateral ureteric stone - bilateral hydronephrosis secondary to acute urinary retention caused by benign prostatic hyperplasia - gynaecological malignancy - urethral strictures - retroperitoneal fibrosis
35
Describe the features associated with obstructive sleep apnoea
Predisposing factors - obesity - macroglossia: acromegaly, hypothyroidism, amyloidosis - large tonsils - Marfan's syndrome clinical features - daytime somnolence - compensated respiratory acidosis - hypertension - partners report excessive snoring or periods of apnoea Assessment of sleepiness - Epworth Sleepiness Scale - Multiple Sleep Latency Test (MSLT) Diagnostic tests - sleep studies (polysomnography) Management - weight loss - CPAP is first line for moderate or severe OSA - intra-oral devices (e.g. mandibular advancement) may be used if CPAP is not tolerated or for patients with mild OSA - DVLA should be informed if OSA is causing excessive daytime sleepiness
36
Describe haemophilia
Haemophilia is an X-linked recessive disorder of coagulation. Haemophilia A - deficiency of factor VIII Haemophilia B (Christmas disease) - lack of factor IX Features haemoarthroses haematomas prolonged bleeding after surgery or trauma Blood tests - prolonged APTT - bleeding time, thrombin time, prothrombin time normal
37
Which medications can cause drug-induced thrombocytopaenia?
Drug-induced thrombocytopenia (probable immune-mediated) quinine abciximab NSAIDs diuretics: furosemide antibiotics: penicillins, sulphonamides, rifampicin anticonvulsants: carbamazepine, valproate heparin: HIT is a prothrombotic condition
38
Describe the management of PE
PE is 'likely' (more than 4 points) > CTPA > interim therapeutic anticoagulation if delay in scanning (DOAC e.g. apixaban / rivaroxaban) > CTPA is positive - PE is diagnosed (offer/continue DOAC) > CTPA is negative - proximal leg vein ultrasound scan if DVT is suspected PE is 'unlikely' (4 points or less) > arranged a D-dimer test > if positive arrange CTPA (If there is a delay in getting the CTPA then give interim DOAC) > if negative then PE is unlikely - stop anticoagulation and repeat proximal leg vein ultrasound in 6-8 days In severe renal impairment (<15/min): unfractionated heparin, direct thrombin inhibitor e.g. argatroban second-line - provoked VTE: anticoagulation for 3 months - unprovoked VTE: anticoagulation 6 months > cancer patients with VTE: 6 months if PE with haemodynamic instability - thrombolysis consider IVC filter for patients with recurrent PE despite adequate anticoagulation V/Q scan if renal impairment
38
Describe the mechanism of action of Loop diuretics
inhibits the Na-K-Cl cotransporter in the thick ascending limb of the loop of Henle
39
Describe the causes of Cushing's syndrome
Exogenous causes of Cushing's syndrome (e.g. glucocorticoid therapy) are far more common than endogenous ones. ACTH dependent causes > Cushing's disease (80%): pituitary tumour secreting ACTH producing adrenal hyperplasia > ectopic ACTH production (5-10%): e.g. small cell lung cancer is the most common causes ACTH independent causes > iatrogenic: steroids > adrenal adenoma (5-10%) > adrenal carcinoma (rare) > Carney complex: syndrome including cardiac myxoma > micronodular adrenal dysplasia (very rare) Pseudo-Cushing's - mimics Cushing's > often due to alcohol excess or severe depression > causes false positive dexamethasone suppression test or 24 hr urinary free cortisol > insulin stress test may be used to differentiate
40
describe the management of T2DM
Metformin first-line (+lifestyle advice) > target HbA1C of 48 mmol/mol > If this is not met, titrate up metformin (1 week interval between titration) > contraindicated in eGFR <30 > a second drug should only be added if HbA1C rises to 58 mmol/mol > SGLT2i should be used in addition to metformin in patients with CVD, high-risk CVD or chronic heart failure (but metformin should be started and titrated up first) > if metformin is contraindicated + patient has CVD risk/chronic heart failure: SGLT2 monotherapy OR sulfonylurea e.g. gliclazide > HbA1C target on sulfonylurea is 53 > best second-line intensification in non-obese patients OR pioglitazone OR DPP-4 inhibitor e.g. sitagliptin OR GLP1- agonist e.g. semaglutide > failure of triple combination of drugs: switching one to GLP-1 > or if BMI >35 Consider insulin
41
Describe G6PD deficiency and contraindicated medications
commonest red blood cell enzyme defect, X-linked recessive inheritance > more common in people from the Mediterranean and Africa factors which can precipitate a crisis - infections - broad (fava) beans - drugs: anti-malarials e.g. primaquine, ciprofloxacin, sulph-group drugs: sulphonamides, sulphasalazine, sulfonylureas, co-trimoxazole Features - neonatal jaundice - intravascular haemolysis - gallstones - splenomegaly blood film: Heinz bodies, bite and blister cells Diagnosis - G6PD enzyme assay levels should be checked at time of presentation and around 3 months after an acute episode of hemolysis
42
Describe autoimmune hepatitis
most commonly seen in young females Associated with > Anti-nuclear antibodies (ANA) > anti-smooth muscle antibodies (SMA) > raised IgG levels > biopsy: inflammation extending beyond limiting plate, "piecemeal necrosis", bridging necrosis Features > chronic liver disease > acute hepatitis: fever, jaundice etc > amenorrhoea (common) Management steroids other immunosuppressants e.g. azathioprine liver transplantation
43
Describe De Quervain's thyroiditis and its management
subacute (De Quervain's) thyroiditis clinical features - following a viral illness - raised ESR/CRP - tender goitre - initial hyperthyroid phase, then euthyroid then hypothyroid - usually self-limiting investigations > thyroid scintigraphy: globally reduced uptake of iodine-131 management - simple analgesia e.g. ibuprofen, naproxen - if severe: steroids
44
List antibiotic choices for the following conditions Resp > Exacerbations of chronic bronchitis > Uncomplicated CAP > pneumonia secondary to influenza > Atypical pneumonia > HAP
Resp > Exacerbations of chronic bronchitis: amoxicillin / doxycycline / clarithromycin > Uncomplicated CAP: amoxicillin > pneumonia secondary to influenza: flucloxacillin >> associated with cavitating lesions > Atypical pneumonia: clarithromycin > HAP: >> within 5 days of admission: co-amoxiclav / cefuroxime >> more than 5 days after admission: piperacillin/tazobactam OR ceftazidime OR ciprofloxacin
45
List antibiotic choices for the following conditions Urinary > Lower UTI > Acute pyelonephritis > Acute prostatitis
Lower UTI - trimethoprim / nitrofurantoin Acute pyelonephritis - gentamicin / ciprofloxacin Acute prostatitis: quinolone or trimethoprim
46
List antibiotic choices for the following conditions Skin > Cellulitis > Impetigo > Erysipelas > Animal / human bite > Mastitis
Cellulitis - flucloxacillin Impetigo: topical hydrogen peroxide, oral flucloxacillin / erythromycin if widespread Erysipelas: flucloxacillin > raised well-defined border, most common cause is Strep pyogenes Animal / human bites: co-amoxiclav Mastitis: flucloxacillin
47
List antibiotic choices for the following conditions ENT > Throat infections > Sinusitis > Otitis media > Otitis externa > periapical / periodontal abscess > gingivitis:
Throat infections - phenoxymethylpenicillin Sinusitis - phenoxymethylpenicillin Otitis media - amoxicillin Otitis externa - flucloxacillin Periapical / periodontal abscess: amoxicillin Gingivitis: metronidazole
48
List antibiotic choices for the following conditions GI > C. diff > Campylobacter > Salmonella (non-typhoid) > Shigellosis
C. diff: oral vancomycin (first episode), oral fidaxomicin if second episode Campylobacter: clarithromycin Salmonella (non-typhoid): ciprofloxacin Shigellosis: ciprofloxacin
49
describe the management of subclinical hypothyroidism
TSH is > 10mU/L & T4 level is normal: consider offering levothyroxine if the TSH level is > 10 mU/L on 2 separate occasions 3 months apart and positive anti-TPO antibodies TSH is between 5.5 - 10mU/L and T4 is normal if < 65 years consider offering a 6-month trial of levothyroxine if: the TSH level is 5.5 - 10mU/L on 2 separate occasions 3 months apart,and there are symptoms of hypothyroidism in older people - 'watch and wait' asymptomatic - observe and repeat thyroid function in 6 months
50
Describe the diagnosis of Cushing's syndrome
Cushing's disease > cortisol & ACTH suppressed by high dose dexamethasone suppression testing Non-ACTH-dependent e.g. adrenal adenoma > cortisol not suppressed by high dose dexamethasone suppression testing > ACTH suppressed by high dose dexamethasone suppression testing Ectopic ACTH e.g. Small cell lung cancer > cortisol and ACTH not suppressed by high dose dexamethasone suppression testing
51
List side-effects of steroids
endocrine: impaired glucose regulation, increased appetite/weight gain, hirsutism, hyperlipidaemia Cushing's syndrome: moon face, buffalo hump, striae musculoskeletal: osteoporosis, proximal myopathy, avascular necrosis of the femoral head (crescent sign on X-ray) immunosuppression: increased susceptibility to severe infection, reactivation of tuberculosis psychiatric: insomnia, mania, depression, psychosis gastrointestinal: peptic ulceration, acute pancreatitis ophthalmic: glaucoma, cataracts dermatological: acne suppression of growth in children intracranial hypertension neutrophilia
52
Describe the causes and diagnosis of urinary retention, acceptable post-void volumes and complications
causes - BPH - Urethral obstructions e.g. strictures, calculi, constipation, masses - Medications e.g. anticholinergics, TCAs, antihistamines, opioids - UTI - post-op or post-partum diagnosis >300mL on bladder scan > inability to pass urine > palpable distended urinary bladder > lower abdominal tenderness manage via catheterisation and treatment of underlying cause acceptable post-void volumes <50ml if <65 years old <100ml if >65 years old chronic urinary retention if >500ml in bladder after catheterisation post-catheterisation urinary volume of >800ml in bladder suggests acute on chronic retention complications - post-obstructive diuresis
53
Describe the features, diagnosis and management of syphilis
STI caused by the spirochaete Treponema pallidum Primary syphilis > chancre - painless ulcer at the site of sexual contact > local non-tender lymphadenopathy Secondary syphilis > systemic symptoms: fevers, lymphadenopathy > rash on trunk, palms and soles > buccal 'snail track' ulcers > condylomata lata (painless, warty lesions on the genitalia ) Tertiary syphilis > gummas (granulomatous lesions of the skin and bones) > ascending aortic aneurysms > general paralysis > insane tabes dorsalis > Argyll-Robertson pupil Congenital syphilis > blunted upper incisor teeth (Hutchinson's teeth), 'mulberry' molars > rhagades (linear scars at the angle of the mouth) > keratitis > saber shins > saddle nose > deafness diagnosis: NAAT testing management: single IM dose benzathine benzylpenicillin
54
Describe the management of prostate cancer
Localised prostate cancer (T1/T2) > conservative: watchful waiting > radical prostatectomy > radiotherapy: external beam and brachytherapy Localised advanced prostate cancer (T3/T4) - hormonal therapy > GnRH agonists e.g. goserelin (zoladex) >> give with cyproterone acetate - radical prostatectomy - radiotherapy - external beam and brachytherapy Metastatic prostate cancer disease - hormonal therapy - GnRH agonists: e.g. Goserelin (Zoladex) - bicalutamide: non-steroidal anti-androgen - abiraterone: androgen synthesis inhibitor bilateral orchidectomy Chemotherapy with docetaxel
55
Describe the classification of acute asthma
Moderate - PEFR 50-75% of best - speech normal - RR <25 - Pulse <110 Severe - PEFR 33-50% of best - can't complete sentences - RR >25 - Pulse >110 Life-threatening - PEFR <33% - O2 sats <92% (perform an ABG) - Silent chest, cyanosis or feeble respiratory effort - Bradycardia, dysrhythmia or hypotension - Exhaustion, confusion or coma - Normal PCO2 Respiratory acidosis indicates near fatal asthma
56
describe the treatment of IBS
Constipation - ispaghula husk is first-line - lactulose not recommended - linaclotide if other drugs are unsuccessful
57
Which PPI should be prescribed with clopidogrel?
Lansoprazole Omeprazole & esomeprazole decrease the efficacy of clopidogrel
58
Describe bronchiectasis
Permanent dilatation of the airways secondary to chronic infection or inflammation Management - chest physiotherapy e.g. inspiratory muscle training, postural drainage is first-line - antibiotics for exacerbations + long-term rotating antibiotics in severe cases - bronchodilators - immunisations - surgery if localised disease Haemophilus influenzae is the most common organism causing infection in bronchiectasis
59
Describe morphea
Localised scleroderma. single or multiple hard plaques on the skin, initially erythematous or violaceous then yellowish or ivory
60
List clinical features of lichen planus and describe its management
clinical features - purple, pruritic, papular, polygonal rash - flexor surfaces - Wickham's striae "white lines" over surface - oral involvement common - Can occur at site of previous skin injury - Koebner's phenomenon drug causes - gold - thiazides - quinine management - potent topical steroids e.g. clobetasone butyrate - benzydamine mouthwash for oral lichen planus - extensive lichen planus may require oral steroids or immunosuppression
61
Describe hepatitis A and its management
benign self-limiting disease transmission via faecal-oral spread (including anal-oral sex) > men who have sex with men should be offered immunisation - risk factors: > consuming undercooked meat / unclean water in developing countries features - flu-like prodrome - RUQ abdo pain - tender hepatomegaly - jaundice - deranged LFTs Treated supportively, no increased risk of hepatocellular carcinoma
62
List side-effects of quinolone therapy
- Tendinopathy - lower seizure threshold
63
List some QTc prolonging medications
- Macrolide antibiotics e.g. erythromycin – risk of Torsades de Pointes - Specific SSRIs e.g. citalopram/escitalopram - Tricyclic antidepressants - Antipsychotics e.g. chlorpromazine - Antiemetics - Quinines - Antiarrhythmics
64
Describe eczema herpeticum and its treatment
Severe primary infection of the skin caused by HSV1 or 2, uncommonly coxsackie virus More commonly seen in children with atopic eczema Presentation - rapidly progressing painful rash - monomorphic punched out erosions (circular, depressed, ulcerated lesions) Management - Hospital admission - IV aciclovir
65
Describe the different types of hypersensitivity reactions giving examples
Type 1 hypersensitivity: antigen reacts with IgE bound to mast cells e.g. anaphylaxis, asthma > can repeat adrenaline every 5 minutes in anaphylaxis Type 2: IgG/IgM binds to antigen on cell surface e.g. autoimmune haemolytic anaemia Type 3: immune-complex mediated e.g. lupus Type 4; delayed hypersensitivity. E.g. allergic contact dermatitis, TB, MS, GBS Type 5: autoantibodies e.g. Graves' disease, myasthenia gravis
66
Describe Kaposi's sarcoma
Caused by HHV-8, usually underlying HIV infection Features - Raised purple lesions (papules/plaques) on skin or mucosa e.g. GI/ respiratory tract - respiratory involvement: massive haemoptysis and pleural effusion - children: generalised lymphadenopathy suggestive of lymphoma treatment: radiotherapy + resection
67
Which factors exacerbate psoriasis?
- trauma - alcohol, smoking, stress - discontinuing steroids - initiating NSAIDs (including aspirin) - lithium - antimalarials - beta-blockers - ramipril - infliximab streptococcal infections precipitate guttate psoriasis
68
Name the most common viral infection in solid organ transplant patients and its management
Cytomegalovirus Features - arthralgia - jaundice - lymphadenopathy - hepatomegaly Treatment - ganciclovir
69
Describe disseminated intravascular coagulation (DIC)
Widespread clotting leading to bleeding Causes - Sepsis - Trauma - obstetric complications e.g. HELLP syndrome - malignancy Diagnosis -Low platelet count, low fibrinogen - Prolonged PT & APTT - raised fibrin degradation products - schistocytes due to microangiopathic haemolytic anaemia management - treat underlying cause - give fresh frozen plasma (FFC)
70
Describe the mechanism of action of thiazide diuretics and common adverse effects
inhibition of sodium reabsorption at the DCT by blocking the Na/Cl symporter Common adverse effects - dehydration - postural hypotension - hypokalaemia - hyponatraemia - hypercalcaemia and hypocalciuria
71
Describe acne rosacea and its treatment
Rosacea features in nose, cheeks and forehead Flushing, erythema and telangiectasia Papules and pustules Treatment - Sunscreen - Erythema/flushing: topical brimonidine - mild/moderate papules/pustules: topical ivermectin - moderate/severe papules or pustules: topical ivermectin + oral doxycycline (first-line) - laser therapy for prominent telangiectasia
72
List causes of decompensation of liver disease
- Infection (SBP) - GI bleeding - Alcoholic hepatitis - Constipation - Dehydration - Acute portal vein thrombosis - Hepatocellular carcinoma - Drugs (alcohol, opiates, NSAIDs) - Ischaemic liver injury (sepsis, hypotension)
73
Describe hepatic encephalopathy and its management
features - confusion, altered GCS - asterixis - constructional apraxia (inability to draw 5 pointed star) - triphasic slow waves on EEG - raised ammonia level precipitating factors - infection e.g. SBP - GI bleed - TIPS procedure - Constipation - Drugs: sedatives, diuretics - Hypokalaemia - Renal failure - Increased dietary protein stages - I: irritability - II: confusion, inappropriate behaviour - III: incoherent, restless - IV: coma Management - treat trigger - lactulose is first-line - secondary proophylaxis: lactulose, rifaximin
74
describe the diagnosis and management of spontaneous bacterial peritonitis (SBP)
ascitic tap: WCC > 500 OR neutrophils >250 most commonly due to E. coli management - IV co- trimoxazole or IV tazocin - IV albumin on day 1 and day 3 to reduce risk of renal dysfunction prophylaxis: PO ciprofloxacin
75
Why give enoxaparin during an IBD flare?
VTE prophylaxis
76
when should you perform an ascitic tap?
in all patients with clinical ascites within <6h admission
77
List signs of opioid toxicity
- Delirium - Vivid dreams / nightmares - Persistent sedation - Myoclonus - Peripheral shadows / hallucinations - Hyperalgesia
78
List typical palliative medications on a syringe driver aka continuous subcutaneous infusion (CSCI)
- Morphine - Midazolam - Levomepromazine - Hyoscine butylbromide
79
Describe the guidelines on management of hypertension
Stage 1: ambulatory BP >= 135/85 or clinic BP >=140/90 > start antihypertensives if less than 80 and cardiovascular risk Stage 2: (>= 150/95 ambulatory B[ or 160/100 clinic BP) start hypertensives regardless of age Patients <40 - referral to exclude secondary causes Lifestyle advice > low salt diet ideally 3g/day > reduce caffeine, alcohol, weight > stop smoking > improve diet and exercise Choice of antihypertensives - If <55 or T2DM: > 1st line ACEi / ARB > 2nd line ACEi/ARB + CCB or ACEi/ARB + thiazide-like diuretic e.g. indapamide > 3rd line: ACEi/ARB + CCB + thiazide-like diuretic > 4th line add beta blocker if K >4.5, spironolactone if K<=4.5 - If >55 and no T2DM or Black African or African-Caribbean ethnicity > 1st line CCB > 2nd line ACEi/ARB (preferably ARB in black African/African-Caribbean) + CCB or CCB + thiazide-like diuretic > 3rd line: ACEi/ARB + CCB + thiazide-like diuretic > 4th line add beta blocker if K >4.5, spironolactone if K<=4.5 ACEi/ARB contraindicated in renovascular disease
80
List blood pressure targets
Age <80y: clinic BP <140/90 mmHg, ABPM <135/85 mmHg Age >80y: <150/90 mmHg clinic BP or <145/86 ABPM T1DM: <135/85 mmHg T2DM: same as everyone else T2DM with nephropathy: <130/80 mmHg
81
Describe features of hypocalcaemia
- Perioral numbness / tingling (paraesthesia) - Muscle twitching, cramping and spasms - Carpopedal spasm - Tetany - if chronic: depression, cataracts Trousseau's sign: carpal spasm if brachial artery occluded by inflating blood pressure cuff: wrist flexion and fingers drawn together Chvostek's sign: tapping over parotid causes facial muscles to twitch can be caused by end-stage renal failure
82
What is the maximum rate of potassium infusion?
40 mmol/L over 4h
83
List cancers that commonly metastasise to bone
- Breast - Prostate - Kidneys - Lung - Multiple myeloma - Lymphoma - thyroid cancer
84
Describe the guidelines for prescribing pain medication in palliative care
advanced and progressive disease: regular oral modified-release (MR) or oral immediate-release morphine (depending on patient preference), with oral immediate-release morphine for breakthrough pain if no comorbidities use 20-30mg of MR a day with 5mg morphine for breakthrough pain. When increasing the dose of opioids the next dose should be increased by 30-50%. Selected points > breakthrough dose of morphine: one-sixth daily dose of morphine > converting oral to parenteral morphine: half the dose > oxycodone is preferred in mild-moderate renal impairment > alfentanil, fentanyl and buprenorphine are preferred in severe renal impairment metastatic bone pain may respond to strong opioids, bisphosphonates or radiotherapy. also denosumab
85
Describe renal tubular acidosis
All types are associated with hyperchloraemic metabolic acidosis (normal anion gap). Type 1 (distal): inability to generate acid urine (secrete H+) in distal tubule > causes hypokalaemia > complications: nephrocalcinosis, renal stones causes: idiopathic, rheumatoid arthritis, SLE, Sjogren's, amphotericin B toxicity, analgesic nephropathy Type 2 (proximal): decreased HCO3- reabsorption in proximal tubule > causes hypokalaemia > complications: osteomalacia causes: idiopathic, Fanconi syndrome, Wilson's disease, cystinosis, outdated tetracyclines, carbonic anhydrase inhibitors (acetazolamide, topiramate) Type 3 (mixed): extremely rare caused by carbonic anhydrase II deficiency results in hypokalaemia Type 4 (hyperkalaemic): > reduction in aldosterone leads in turn to a reduction in proximal tubular ammonium excretion > causes hyperkalaemia : causes hypoaldosteronism, diabetes
86
Describe findings on a full blood count in alcoholic liver disease
Macrocytic anaemia and thrombocytopaenia high ferritin high GGT
87
Describe the features and management of alpha-1 antitrypsin deficiency
Features lungs: panacinar emphysema (lower lobes) liver: cirrhosis and hepatocellular carcinoma in adults, cholestasis in children Management: no smoking supportive: bronchodilators, physiotherapy intravenous alpha1-antitrypsin protein concentrates surgery: lung volume reduction surgery, lung transplantation
88
Describe membranous glomerulonephritis
Presents with nephrotic syndrome or proteinuria (most common cause in adults) investigations > 24h urinary protein excretion >3g >Renal biopsy: >> electron microscopy: thickened basement membrane with 'spike and dome' appearance Causes > idiopathic: anti-phospholipase A2 antibodies > infections: hepatitis B, malaria, syphilis > malignancy: prostate, lung (spiculated mass), lymphoma, leukaemia > drugs: gold, penicillamine, NSAIDs autoimmune diseases: SLE, thyroiditis, rheumatoid Management > ACEi / ARB > corticosteroid + another agent e.g. cyclophosphamide > consider anticoagulation for high-risk patients >> increased risk of thrombus due to loss of antithrombin III via kidneys
89
Describe the management of variceal haemorrhage
both terlipressin and prophylactic antibiotics should be given before endoscopy in patients with suspected variceal haemorrhage endoscopy: endoscopic variceal band ligation Sengstaken-Blakemore tube if uncontrolled haemorrhage Transjugular Intrahepatic Portosystemic Shunt (TIPSS) if above measures fail > connects the hepatic vein to the portal vein > exacerbation of hepatic encephalopathy is a common complication
90
Describe the management of acne vulgaris
mild to moderate acne: > 12-week course of topical combination therapy (first-line): - topical adapalene with topical benzoyl peroxide - topical tretinoin with topical clindamycin moderate to severe acne: > a 12-week course of a fixed combination of topical adapalene with topical benzoyl peroxide + either oral lymecycline or oral doxycycline Topical and oral antibiotics should not be used in combination Gram-negative folliculitis may occur as a complication of long-term antibiotic use - high-dose oral trimethoprim is effective if this occurs COCP are an alternative to oral antibiotics in women > levonorgestrel first-line > co-cyprindiol (Dianette) second-line oral isotretinoin: only under specialist supervision
91
Name inducers and inhibitors of warfarin (P450 ENZYME)
Inducers: CRAP GPs (decrease in INR) - carbamazepine - rifampicin - alcohol (chronic) - phenytoin - griseofulvin - phenobarbitone - sulphonylureas Inhibitors: SICKFACES.COM (increase in INR) - sodium valproate - isoniazid - cimetidine - ketoconazole - fluconazole - alcohol (acute) and grapefruit juice - chloramphenicol - erythromycin - sulphonamides - ciprofloxacin - omeprazole - metronidazole
92
Describe the management of DKA
Glucose: >11 OR Known diabetes Acidosis: pH <7.3 or Bicarb <15 Ketones: >3 mmol/l or ++ on urine dip. Management 1. Fluid replacement - 1L IV 0.9% NaCl over one hour 2. Insulin therapy > fixed rate IV insulin initially at 8 units/h OR 0.1 units/kg/h within 30 minutes of admission or diagnosis. When the patient’s blood glucose drops below 14 the rate is reduced to 3 units/hour. aiming to keep blood glucose between 9-14 mmol/L continue patient's long acting insulin but stop short acting 3. IV Glucose therapy > IV 10% dextrose is not used until blood glucose has fallen to <14 > continue until patient eating and drinking 4. Electrolyte replacement > Potassium (KCl) can be added to 0.9% NaCl if K levels are <5 mmol/L 5. Treatment of underlying triggers if ketonaemia / acidosis is not improving after 24h review by senior endocrinologist
93
How would you manage a patient with high ketones who wasn't acidotic?
Give 20% of their total daily dose of insulin as fast acting bolus VRII if fasting
94
List criteria for discontinuing the DKA pathway
In order to safely discontinue the DKA pathway the patient must be: 1. Eating and drinking 2. Bicarbonate >15 and pH >7.3 3. Ketones <0.6 4. Restarted on normal insulin regime Discontinue IV insulin and IV fluids 30 mins after SC fast acting insulin Long acting insulin should be continued while on DKA pathway > if above criteria are met and the patient is eating and drinking, switch to subcutaneous insulin > review by diabetes specialist nurse prior to discharge
95
Describe the management of anaemia in chronic kidney disease
Determine and optimise iron status before starting erythropoiesis-stimulating agents i.e. correct iron deficiency ESAs: erythropoietin, darbepoietin Oral iron if not on ESA or haemodialysis Switch to IV iron if target Hb levels (100-120) are not reached within 3 months patients on ESAs or haemodialysis generally require IV iron
96
Describe the criteria for HHS and its management
Laboratory glucose >30 mmol/L H+ <50 mmol/L Bicarb >15 mmol/L Capillary ketones <3mmol/L Serum osmolality >320 mosmol/kg Management - IV 0.9% sodium chloride > switch to 0.45% nacl if osmolality not declining (<3mOsm/kg/hour) despite adequate positive fluid balance - rate of fall of plasma sodium should not exceed 10 mmol/L in 24 hours. - fall in blood glucose should be no more than 5 mmol/L/hour (so that serum osmolality doesn’t fall too quickly) - Low dose IV insulin should only be commenced EITHER once the blood glucose level plateaus with IV fluids alone OR immediately if there is significant ketosis (blood ketones > 1.5 or urine ketones greater than ‘+’ “
97
List causes of HHS
Intercurrent or coexisting illness - Infection - MI, stroke/TIA Drug-induced - Metformin - Diuretics - alcohol, cocaine Diabetes-related - first presentation - poor glycaemic control
98
Describe the complications of chronic lymphocytic leukaemia (CLL)
Richter transformation: into high-grade non-Hodgkin's lymphoma > lymph node swelling > fever without infection > night sweats > nausea > abdominal pain Other complications - warm autoimmune haemolytic anaemia (Coombs +ve) - anaemia - hypogammaglobulinaemia investigations - lymphocytosis - anaemia: due to bone marrow replacement or AIHA - blood film: smear/smudge cells - immunophenotyping: key investigation
99
Describe primary hyperaldosteronism and its management
aka Conn's syndrome Most commonly caused by bilateral idiopathic adrenal hyperplasia > also adrenal adenoma, unilateral hyperplasia, familial hyperaldosteronism and adrenal carcinoma Features > hypernatraemia and hypokalaemia e.g. muscle weakness > hypertension > metabolic alkalosis Investigations: > plasma renin:aldosterone ratio is first-line: should show high aldosterone and low renin > high resolution CT abdomen and adrenal venous sampling Management > adrenal adenoma: surgery (laparoscopic adrenalectomy) > bilateral adrenocortical hyperplasia: aldosterone antagonist e.g. spironolactone
100
List tumour markers for the following cancers: - hepatocellular - testicular - pancreatic - colon - breast - ovarian - prostate
- hepatocellular: AFP - Testicular: bHCG, LDH, AFP - Pancreatic: CA19-9 (also cholangiocarcinoma) - Colon: CEA - Breast: CA 15-3 - Ovarian: CA-125 - Prostate: PSA
101
Describe the following causes of nipple discharge - galactorrhoea - hyperprolactinaemia - mammary duct ectasia - carcinoma - intraductal papilloma
- galactorrhoea: response to emotional events, drugs like histamine receptor antagonists - hyperprolactinaemia: prolactinomas are the commonest type of pituitary tumour, drugs like metoclopramide, haloperidol, domperidone... - mammary duct ectasia: menopausal women, smokers, thick green discharge - carcinoma: often blood-stained, may be underlying mass or axillary lymphadenopathy - intraductal papilloma: blood-stained discharge, can be painful, usually no palpable lump
102
Describe the presentation and diagnosis of T1DM
Presentation - Weight loss - Fatigue - Polyuria / nocturia / polydipsia - Osmotic diuresis / dehydration - Muscle wasting - DKA - Other autoimmune diseases Diagnosis - Random blood glucose >11.1 OR fasting blood glucose >7.0 - HbA1C >48 - low C-peptide (insulin production) - Autoantibodies > Anti-GAD65 > Islet cell antibodies (ICA) > Insulin autoantibodies (IAA) > IA-2A > Anti-ZnT8
103
List complications of diabetes mellitus
- nephropathy > enlarged kidneys on USS (early stages) > mesangial expansion > biopsy: fibrosis, Kimmelstiel-Wilson nodules > annual review with early morning albumin:creatinine ratio (ACR) - retinopathy - neuropathy > autonomic: gastroparesis, postural hypotension - acute: DKA, HHS - cardiovascular disease - associated endocrine diseases: thyroid disease, coeliac disease, addison's - diabetic foot disease: peripheral neuropathy + PVD
104
Describe Clostridium difficile and its management
Clostridioides difficile - Gram positive rod Risk factors - 4Cs: clindamycin, coamoxiclav, cephalosporins, ciprofloxacin - proton pump inhibitor Features - diarrhoea - abdominal pain - raised white blood cell count (WCC) Complications - pseudomembranous colitis - toxic megacolon Diagnosis - C. difficile toxin (CDT) in the stool - C. difficile antigen shows colonisation / exposure to bacteria, not current infection Management - First episode: oral vancomycin for 10 days (first-line) > second-line: oral fidaxomicin > third-line therapy: oral vancomycin +/- IV metronidazole Recurrent episode > within 12 weeks of symptom resolution: oral fidaxomicin > after 12 weeks of symptom resolution: oral vancomycin OR fidaxomicin Life-threatening: > indications: failure of oral vancomycin, hypotension, ileus, toxic megacolon > oral vancomycin AND IV metronidazole > faecal microbiota transplant: 2 or more previous episodes bezlotoxumab is a monoclonal antibody which targets C difficile toxin B
105
Describe factor V Leiden
Factor V Leiden (activated protein C resistance) is the most common inherited thrombophilia Mis-sense mutation resulting in activated factor V (clotting factor) being inactivated 10 times more slowly by activated protein C than normal results in prothrombotic state > more likely to experience VTE
106
Describe the management of a high INR in a patient on warfarin
Major bleeding - stop warfarin - IV Vitamin K 5mg - Prothrombin complex concentrate or FFP if unavailable INR >8 and minor bleeding - stop warfarin - IV vitamin K 1-3mg, repeat IV Vitamin K if INR too high after 24h - repeat warfarin when INR <5 INR >8, no bleeding - stop warfarin - vitamin K 1-5mg by mouth INR 5-8, minor bleeding - stop warfarin - IV vitamin K 1-3mg INR 5-8 no bleeding - withhold 1-2 doses of warfarin and monitor INR - reduce maintenace dose
107
Describe trypanosomiasis
2 main forms of protozoal disease > African trypanosomiasis (sleeping sickness) > American trypanosomiasis (Chagas' disease). spread by the tsetse fly Clinical features of African trypanosomiasis: > Trypanosoma chancre - painless subcutaneous nodule at site of infection > intermittent fever > enlargement of posterior cervical lymph nodes > later: central nervous system involvement e.g. somnolence, headaches, mood changes, meningoencephalitis Management > early disease: IV pentamidine or suramin > later disease or central nervous system involvement: IV melarsoprol American trypanosomiasis, > acute infection is asymptomatic but the following can be seen - chagoma (an erythematous nodule at site of infection) - periorbital oedema > Chronic Chagas' - myocarditis may lead to dilated cardiomyopathy (with apical atrophy) and arrhythmias > gastrointestinal features includes megaoesophagus and megacolon causing dysphagia and constipation Management - acute phase: benznidazole or nifurtimox - chronic disease management involves treating the complications e.g., heart failure
108
List triggers for DKA
- Infection - Alcohol - MI - First presentation of diabetes - Missed / insufficient insulin doses
109
Describe the presentation of DKA (as well as severe DKA)
- Polydipsia, polyuria - Acetone breath - Kussmaul breathing - Abdominal pain - Nausea and vomiting - Tachycardia, hypotension - confusion, drowsiness - Dehydration, dry mucous membranes - Ketonuria, glycosuria Severe DKA - Severe acidosis (pH <7.1, H+ >80, HCO3 <5) - reduced GCS - Cerebral oedema - Hypokalaemia (K <3.5)
110
List complications of DKA
- VTE - Arrhythmias - Cerebral oedema - ARDS - AKI - hypophosphataemia
111
Which electrolyte imbalances occur after prolonged vomiting?
Hypochloraemia, hypokalaemia
112
Describe Kallman syndrome
failure of GnRH secreting neurons to migrate to hypothalamus Lack of GnRH leads to hypogonadotrophic hypogonadism > failure to start puberty > anosmia > hypogonadism, cryptorchidism > low LH/FSH levels, low testosterone > cleft lip and palate seen in some patients management - testosterone supplementation - gonadotrophin supplementation
113
Describe the clinical features of acromegaly, investigations and management
clinical features - prominent forehead (frontal bossing) - large nose, large hands, large feet - arthritis - large tongue (macroglossia) - protruding jaw (prognathism) investigations - serum IGF-1 levels first-line - oral glucose tolerance test and serial growth hormone measurements if IGF-1 is raised to confirm - pituitary MRI complications - hypertension - diabetes - cardiomyopathy - colorectal cancer management - transsphenoidal surgery to remove pituitary adenoma - - medical options > pegvisomant: GH receptor antagonist > octreotide: somatostatin analogue > bromocriptine: dopamine agonist
114
Describe the lab values associated with the following bone disorders - osteoporosis - osteomalacia - primary hyperparathyroidism (osteitis fibrosa cystica) - secondary hyperparathyroidism (CKD) - Paget's disease - Osteopetrosis
osteoporosis: all normal osteomalacia - low calcium, low phosphate, high ALP, high PTH primary hyperparathyroidism - high calcium, low phosphate, high ALP, high PTH > parathyroidectomy is definitive management > nephrolithiasis secondary to hyperparathyroidism is an indication for parathyroidectomy CKD - low calcium, high phosphate, high ALP, high PTH Paget's - all normal except increased ALP - X-ray shows mixed sclerotic and lytic lesions - treat with risedronate Osteopetrosis - all normal
115
Describe a Marjolin's ulcer
SCC developing at site of chronic inflammation e.g. burns or osteomyelitis after 10-20 years
116
Describe features of chronic venous insufficiency on examination
brown pigmentation (haemosiderin), lipodermatosclerosis, venous eczema,venous ulcers
117
Describe Alport's syndrome
X-linked dominant inheritance due to a defect type IV collagen resulting in an abnormal glomerular-basement membrane (GBM) clinical features: > microscopic haematuria > progressive renal failure > bilateral sensorineural deafness > lenticonus: protrusion of the lens surface into the anterior chamber > retinitis pigmentosa > renal biopsy: splitting of lamina densa seen on electron microscopy Diagnosis - molecular genetic testing - renal biopsy - electron microscopy: longitudinal splitting of the lamina densa of the glomerular basement membrane, resulting in a 'basket-weave' appearance
118
Describe the symptoms of infection with Giardia lamblia
caused by protozoan parasite Giardia lamblia endemic areas include india incubation period 1-2 weeks Giardia causes fat malabsorption so greasy stool can occur (floating in water) resistant to chlorination so can be transferred in swimming pools features - water diarrhoea - abdominal cramping - bloating - flatulence - apyrexia and non-tender abdomen
119
Describe the management of tuberculosis and the associated side-effects
- Isoniazid > peripheral neuropathy (prevent with pyridoxine aka vitamin B6) > hepatitis > agranulocytosis - Rifampicin > hepatitis, orange secretions - Ethambutol > optic neuritis - Pyrazinamide > hyperuricaemia causing gout > arthralgia, myalgia > hepatitis
120
Describe the use of bisphosphonates and adverse effects associated
Bisphosphonates inhibit osteoclasts by reducing recruitment and promoting apoptosis Clinical uses - prevention and treatment of osteoporosis - hypercalcaemia - Paget's disease - pain from bone metastases Adverse effects - oesophageal reactions: oesophagitis, oesophageal ulcers (especially alendronate) - osteonecrosis of the jaw - atypical stress fractures of the proximal femoral shaft in patients taking alendronate - acute phase response: fever, myalgia and arthralgia may occur following administration - hypocalcaemia: due to reduced calcium efflux from bone. Usually clinically unimportant > Hypocalcemia/vitamin D deficiency should be corrected before giving bisphosphonates
121
What is the transfer factor value in asthma?
Raised
122
What airway is contraindicated in non-fasted patients?
Laryngeal mask if patient is not fasted, there is a risk of aspiration of gastric contents during induction of anaesthesia. A laryngeal mask is, therefore, contraindicated as this cannot protect the trachea and bronchial tree from aspirate.
123
List medications and conditions that can cause gingival hyperplasia
Gingival hyperplasia: phenytoin, ciclosporin, calcium channel blockers e.g. amlodipine and AML
124
Describe the management of coeliac disease
gluten-free diet Immunisation > Patients with coeliac disease often have a degree of functional hyposplenism > offer pneumococcal vaccine, as well as Haemophilus type B, meningococcus type C
125
Describe Plummer-Vinson syndrome
Triad of: dysphagia (secondary to oesophageal webs) glossitis iron-deficiency anaemia Treatment includes iron supplementation and dilation of the webs
126
Describe silicosis
Silicosis is a fibrosing lung disease caused by the inhalation of fine particles of crystalline silicon dioxide (silica). It is a risk factor for developing tuberculosis (silica is toxic to macrophages). Occupations at risk of silicosis mining slate works foundries potteries Features upper zone fibrosing lung disease 'egg-shell' calcification of the hilar lymph nodes
127
Describe asbestosis
Pneumoconiosis occupations at risk are classically firefighters, dockyard workers, and construction workers rather than miners. crocidolite (blue) asbestos is the most dangerous form Radiological findings > pleural plaques (benign) > lower lobe fibrosis > pleural thickening complications - lung cancer (most common) - mesothelioma > diagnosis on histology following thoracoscopic biopsy
128
Describe factors which indicate severe acute pancreatitis
age > 55 years hypocalcaemia hyperglycaemia hypoxia neutrophilia elevated LDH and AST serum amylase is diagnostic but NOT prognostic
129
List causes of acanthosis nigricans
type 2 diabetes mellitus gastric adenocarcinoma obesity polycystic ovarian syndrome acromegaly Cushing's disease hypothyroidism familial Prader-Willi syndrome drugs combined oral contraceptive pill nicotinic acid insulin resistance → hyperinsulinemia → stimulation of keratinocytes and dermal fibroblast proliferation via interaction with insulin-like growth factor receptor-1 (IGFR1)
130
Describe gastric MALT lymphoma and its management
associated with H. pylori infection in 95% of cases good prognosis if low grade then 80% respond to H. pylori eradication
131
Describe adverse effects of vancomycin
nephrotoxicity ototoxicity thrombophlebitis red man syndrome; occurs on rapid infusion of vancomycin >> if this occurs stop vancomycin infusion and re-start at slower rate
132
List indications for CT head within 1 hour in head injury
GCS < 13 on initial assessment GCS < 15 at 2 hours post-injury suspected open or depressed skull fracture any sign of basal skull fracture (haemotympanum, 'panda' eyes, cerebrospinal fluid leakage from the ear or nose, Battle's sign). post-traumatic seizure. focal neurological deficit. more than 1 episode of vomiting
133
Describe adverse effects associated with azathioprine
thiopurine methyltransferase (TPMT) test may be needed to identify individuals prone to azathioprine toxicity adverse effects: bone marrow depression nausea/vomiting pancreatitis increased risk of non-melanoma skin cancer A significant interaction may occur with allopurinol and hence lower doses of azathioprine should be used. Azathioprine is generally considered safe to use in pregnancy.
134
describe basal cell carcinoma and its management
Features sun-exposed sites, especially the head and neck initially a pearly, flesh-coloured papule with telangiectasia may later ulcerate leaving a central 'crater' Management options: surgical removal curettage cryotherapy topical cream: imiquimod, fluorouracil radiotherapy
135
Describe the diagnosis and clinical features of tuberculosis (TB)
Clinical features - weight loss - haemoptysis - fever - productive cough - fatigue - erythema nodosum - CXR: bilateral hilar lymphadenopathy, upper lobe cavitation Diagnosis - Mantoux test: latent TB - nucleic acid amplification test (NAAT) - Interferon gamma release assay - Acid-fast bacilli staining (Ziehl-Neelsen stain) - sputum culture: determine drug sensitivities - gold standardli - all patients should receive HIV test False negative tests may be caused by: miliary TB sarcoidosis HIV lymphoma very young age (e.g. < 6 months)
136
list causes of erythema nodosum
infection: streptococci, tuberculosis, brucellosis sarcoidosis inflammatory bowel disease Behcet's malignancy/lymphoma drugs: penicillins, sulphonamides, combined oral contraceptive pill pregnancy
137
List causes of a normal anion gap metabolic acidosis (hyperchloraemic) and a raised anion gap metabolic acidosis
normal anion gap: 10-14 mmol/L Causes of a normal anion gap or hyperchloraemic metabolic acidosis > gastrointestinal bicarbonate loss: diarrhoea (w/ hypokalaemia), ureterosigmoidostomy, fistula > renal tubular acidosis > drugs: e.g. acetazolamide > ammonium chloride injection > Addison's disease > large volumes of 0.9% NaCl Causes of a raised anion gap metabolic acidosis > lactate: shock, hypoxia > ketones: diabetic ketoacidosis, alcohol > urate: renal failure > acid poisoning: salicylates, methanol > 5-oxoproline: chronic paracetamol use
138
List symptoms of hypoglycaemia
Autonomic - Trembling - Sweating - Anxiety - Palpitations - Hunger - Nausea - Tingling Neuroglycopaenic - Confusion - Weakness - Drowsiness - Visual change - Difficulty speaking - Headache - Dizziness - Tiredness impaired hypoglycaemia awareness occurs due to neuropathy of parts of the autonomous nervous system
139
Describe the management of hypoglycaemia
Mild: conscious, orientated and able to swallow - 15-20g of quick-acting carbohydrate e.g. > 4-5 glucotabs > 150-200ml pure fruit juice >> repeat up to 3 times Moderate: conscious and able to swallow but confused, disorientated or aggressive - capable and cooperative: treat as mild - uncooperative but able to swallow > 2 tubes 40% glucose gel >> repeat up to 3 times Severe: unconscious, fitting, very aggressive or NBM - IV glucose over 15 mins > 100ml 20% dextrose OR 200ml 10% dextrose - if no IV access: 1mg IM glucagon repeat blood glucose measurement in 10-15 minutes; if ineffective after 3 times treat as severe
139
Describe acute interstitial nephritis
Causes - drugs: the most common cause, particularly > antibiotics: penicillin, rifampicin > NSAIDs > allopurinol > furosemide - systemic disease: SLE, sarcoidosis, and Sjögren's syndrome - infection: Hanta virus , staphylococci histology: marked interstitial oedema and interstitial infiltrate in the connective tissue between renal tubules Features > raised urinary WCC and eosinophils > fever, rash, arthralgia > eosinophilia > mild renal impairment > hypertension Investigations: sterile pyuria, white cell casts
139
Describe Lyme disease and its management
Lyme disease is caused by the spirochaete Borrelia burgdorferi and is spread by ticks. Early features (within 30 days) > erythema migrans - 'bulls-eye' rash > systemic features >> headache >> lethargy >> fever >> arthralgia - Later features: > cardiovascular: heart block, peri/myocarditis > neurological: facial nerve palsy, radicular pain, meningitis Investigation > enzyme-linked immunosorbent assay (ELISA) antibodies to Borrelia burgdorferi > immunoblot test Management - doxycycline if early disease - ceftriaxone if disseminated disease - Jarisch-Herxheimer reaction is sometimes seen after initiating therapy: fever, rash, tachycardia after first dose of antibiotic (more commonly seen in syphilis, another spirochaetal disease)
139
list causes of metabolic alkalosis
Metabolic alkalosis may be caused by a loss of hydrogen ions or a gain of bicarbonate Causes > vomiting / aspiration > diuretics > liquorice, carbenoxolone > hypokalaemia > primary hyperaldosteronism > Cushing's syndrome > Bartter's syndrome
139
Describe the diagnosis of diabetes mellitus
If the patient is symptomatic: > fasting glucose greater than or equal to 7 mmol/L > random glucose greater than or equal to 11 mmol/L (or after 75g oral glucose tolerance test) > If the patient is asymptomatic the above criteria apply but must be demonstrated on two separate occasions. HbA1c: greater than or equal to 48 mmol/mol > not recommended in diagnosis of T1DM > in patients without symptoms, the test must be repeated to confirm the diagnosis > 42-47 mmol/mol - prediabetes (discuss diet & exercise) > misleading HbA1c results can be caused by increased red cell turnover (see below) higher than expected HbA1C (increased RBC life span): > splenectomy > IDA > Vitamin B12/folate deficiency lower than expected HbA1C (reduced RBC life span): > sickle cell anaemia > G6PD deficiency > hereditary spherocytosis > haemodialysis
139
Describe the ebola virus and its management
Ebola spreads through human-to-human transmission via direct contact (through broken skin or mucous membranes) with the blood, secretions, organs or other bodily fluids of infected people Incubation period: 2 to 21 days > patients are not infectious until they develop symptoms Clinical features > fever > fatigue > muscle pain > headache > sore throat > followed by vomiting, diarrhoea, rash, symptoms of impaired kidney and liver function > internal and external bleeding
139
Describe beta thalassaemia
AR condition caused by mutation in chromosome 11 leading to defective beta globin chains most commonly seen in mediterranean, african and southeast asian populations split into 3 types - thalassaemia minor > aka beta thalassaemia trait > one abnormal and one normal gene > mild microcytic anaemia, microcytosis is disproportionate to the anaemia > HbA2 raised (>3.5%) > absent HbA, raised HbF > monitor, no active treatment - thalassaemia intermedia > two abnormal copies of gene > more significant anaemia > may require occasional blood transfusions - thalassaemia major > no functioning beta globin genes (homozygous for deletion genes) > severe microcytic anaemia and failure to thrive in early childhood > splenomegaly and bone abnormalities > manage with regular transfusions, iron chelation (desferrioxamine) and splenectomy > bone marrow transplant can be curative
140
Describe falciparum malaria and its treatment
commonest, and most severe, type of malaria. fever on alternating days, think malaria Feature of severe malaria > schizonts, trophozoites on a blood film > parasitaemia > 2% > hypoglycaemia > acidosis > temperature > 39 °C > severe anaemia Complications > cerebral malaria: seizures, coma > acute renal failure: blackwater fever, secondary to intravascular haemolysis, mechanism unknown > acute respiratory distress syndrome (ARDS) > disseminated intravascular coagulation (DIC) Management > artemisinin-based combination therapies (ACTs) as first-line therapy >> artemether plus lumefantrine >> artesunate plus amodiaquine >> malarone (atovaquone/proguanil) >> quinine sulphate tablets >> OR chloroquine if low resistance > primaquine >> used in non-falciparum malaria to destroy liver hypnozoites and prevent relapse Severe falciparum malaria > intravenous artesunate > if parasite count > 10% consider exchange transfusion > shock may indicate coexistent bacterial septicaemia - malaria rarely causes haemodynamic collapse
141
List risk factors for hepatotoxicity in paracetamol overdose
- patients taking liver enzyme-inducing drugs > rifampicin, phenytoin, carbamazepine, chronic alcohol excess, St John's Wort > malnourished patients (e.g. anorexia nervosa) or patients who have not eaten for a few days acute alcohol intake, as opposed to chronic alcohol excess, is not associated with an increased risk of developing hepatotoxicity and may actually be protective
142
Describe the appearance of the following on blood films - hyposplenism - IDA - myelofibrosis - intravascular haemolysis - megaloblastic anaemia
Hyposplenism e.g. post-splenectomy, coeliac disease target cells Howell-Jolly bodies Pappenheimer bodies siderotic granules acanthocytes Iron-deficiency anaemia target cells 'pencil' poikilocytes if combined with B12/folate deficiency a 'dimorphic' film occurs with mixed microcytic and macrocytic cells low transferrin, low ferritin, high TIBC Myelofibrosis 'tear-drop' poikilocytes Intravascular haemolysis schistocytes Megaloblastic anaemia hypersegmented neutrophils
143
List causes of gynaecomastia (physiological and drug side-effects)
Causes of gynaecomastia - physiological: normal in puberty - syndromes with androgen deficiency: Kallman's, Klinefelter's - testicular failure: e.g. mumps - liver disease - testicular cancer e.g. teratoma secreting hCG - ectopic tumour secretion - adenocarcinoma of the lung - hyperthyroidism - haemodialysis Drug causes of gynaecomastia - spironolactone (most common drug cause) - ketoconazole - cimetidine - digoxin - cannabis - finasteride - GnRH agonists e.g. goserelin, buserelin oestrogens, anabolic steroids
144
Describe the SCAM and ABCD approach to describing a skin lesion as well as the common morphology and pattern of rashes
Size (with measuring tape), shape Colour Associated secondary change Margins, morphology Morphology of rashes > erythematous > maculopapular > vesiculobullous > petechial / purpuric Pattern of rashes > discrete / confluent > demarcated / indistinct > linear > target > annular > discoid Pigmented skin lesion Asymmetry Borders (irregular) Colour (2 or more) Diameter >6mm, distribution
145
List conditions that cause all-over redness (erythroderma)
psoriasis eczema pityriasis rubra pilaris cutaneous adverse drug reaction e.g. vancomycin causing red man syndrome cutaneous lymphoma
146
Describe pityriasis rubra pilaris
rare, cutaneous, inflammatory papulosquamous disorder - classically characterized by follicular, hyperkeratotic papules - waxy, yellow palmoplantar keratoderma - erythroderma with islands of sparing
147
Describe the clinical features of psoriasis
Nail changes: pitting, onycholysis, leukonychia, subungal hyperkeratosis, oil spot sign, Beau's lines (transverse ridging) Types of psoriasis: - Plaque psoriasis > well-demarcated raised salmon pink plaques with silvery white scales on extensor surfaces (also scalp) - Guttate psoriasis: tear-drop shape > often triggered by streptococcal throat infection, lesions on the trunk - Pustular psoriasis: sterile pus-filled pustules, not infectious - Palmoplantar psoriasis: can cause painful fissures in palms / soles - Erythrodermic psoriasis: serious, involves heat, fever, systemic upset - Inverse psoriasis (flexural): can affect submammary, axillary and anogenital folds Association with psoriatic arthritis (often before skin changes)
148
Describe features of Stevens Johnsons syndrome & Toxic Epidermal Necrolysis
Common drug causes: > penicillin > sulphonamides > NSAIDs > allopurinol > carbamazepine, lamotrigine, phenytoin > COCP infectious causes - HSV, Mycoplasma pneumoniae, CMV, HIV occurs days up to 2 months after initiation of medication Skin features of TEN/SJS include: > Diffuse erythema > Maculopapular rash with target lesions > Skin detachment, erosions and flaccid blisters (vesicles/bullae) > mucosal involvement > fever, arthralgia FBC - neutropaenia, leukopaenia, anaemia U&Es - AKI due to fluid loss from skin LFTs - transaminitis, hepatitis SJS if <10% skin involvement TEN if >30% Severity scoring system - SCORTEN Nikolsky sign - blisters and erosions appearing when the skin is rubbed gently Management - Identify and stop culprit drug - Fluid balance +/- catheterisation - Temperature and glycaemic control - Barrier nursing - Skin care: regular skin care with greasy emollients, anti-shear sheets and non-adherent dressings. - Mouth and eye care - Analgesia - Identification and treatment of infection - Regular skin swabs
149
Describe erythema multiforme major and staphylococcal scalded skin syndrome
- erythema multiforme major > infectious trigger e.g. EBV, HSV, mycoplasma > target lesions on extremities + mucosal involvement > Nicolsky sign negative staphylococcal scalded skin syndrome > usually in children, mucous membranes spared > Nicolsky sign may be positive
150
Describe pemphigus vulgaris and bullous pemphigoid
Pemphigus vulgaris > Autoimmune intra-epidermal blistering condition > presents with mucosal ulceration over weeks – months > Skin involvement - flaccid blisters Bullous pemphigoid > Autoimmune subepidermal blistering condition > intact bullae on erythematous base > no mucosal involvement > usually in older patients. > managements: oral steroids
151
Describe hereditary spherocytosis and its management
Basics - AD defect of red blood cell cytoskeleton - red blood cell survival reduced as destroyed by the spleen Presentation > failure to thrive > jaundice, gallstones > splenomegaly > aplastic crisis precipitated by parvovirus infection > degree of haemolysis variable > MCHC elevated Diagnosis - spherocytes on blood film - raised mean corpuscular haemoglobin concentration [MCHC] - increase in reticulocytes - EMA ( electrophoresis analysis of erythrocyte membranes) binding test and the cryohaemolysis test for atypical presentations Management acute haemolytic crisis: > treatment is generally supportive > transfusion if necessary longer term treatment: > folate replacement > splenectomy
152
List side-effects and contraindications of beta-blockers
Side-effects - bronchospasm - cold peripheries - fatigue - sleep disturbances, including nightmares - erectile dysfunction Contraindications - uncontrolled heart failure - asthma - sick sinus syndrome - concurrent verapamil use: may precipitate severe bradycardia
153
Describe dengue fever and its management
viral infection that can progress to viral haemorrhagic fever dengue virus is a RNA virus of the genus Flavivirus transmitted by the Aedes aegypti mosquito incubation period of 7 days Clinical features - fever - headache (often retro-orbital) - myalgia, bone pain and arthralgia ('break-bone fever') - pleuritic pain - facial flushing (dengue) - maculopapular rash - haemorrhagic manifestations e.g. positive tourniquet test, petechiae, purpura/ecchymosis, epistaxis - 'warning signs' include: > abdominal pain, hepatomegaly, persistent vomiting, clinical fluid accumulation (ascites, pleural effusion) Severe dengue (dengue haemorrhagic fever) a form of disseminated intravascular coagulation (DIC) resulting in thrombocytopenia, spontaneous bleeding, can go on to develop dengue shock syndrome (DSS) Investigations > leukopenia, thrombocytopenia, raised aminotransferases > diagnostic tests: serology, nucleic acid amplification tests for viral RNA > NS1 antigen test Treatment > entirely symptomatic e.g. fluid resuscitation, blood transfusion etc > no antivirals are currently available
154
Describe squamous cell carcinoma and its management
Risk factors - exposure to sunlight or psoralen UVA therapy - actinic keratoses and Bowen's disease (SCC in situ) - immunosuppression e.g. following renal transplant, HIV - smoking - genetic conditions: xeroderma pigmentosum, oculocutaneous albinism features - sun-exposed sites - rapidly expanding painless, ulcerate nodules - cauliflower-like appearance and areas of bleeding - non-healing painless ulcer associated with chronic scar treatment - surgical excision with 4mm margins if lesion <20mm diameter - surgical excision with 6mm margins if lesion >20mm > Mohs micrographic surgery in high-risk patients and cosmetically important sites
155
Describe epididymo-orchitis and its management
causes - sexually active young adults > chlamydia trachomatis > neisseria gonorrhoeae - older adults with low-risk sexual history > E. coli (more common) > Enterococcus faecalis Features - unilateral testicular pain and swelling - pain eased by elevating testicle - cremasteric reflex present - urethral discharge - rule out testicular torsion Investigations - STI screen (high risk sexual history) - MSU (low risk sexual history) - microscopy and culture Management - STI likely: IM ceftriaxone 500mg single dose + doxycycline 100mg BD for 10-14 days - Enteric organisms likely: oral quinolone
156
Describe UTI treatment guidelines
Non-pregnant women - trimethoprim or nitrofurantoin 3 days - send urine culture of aged >65, haematuria Pregnant women > symptomatic: nitrofurantoin (avoid near term) >> second-line: amoxicillin or cefalexin - avoid trimethoprim - teratogenic > asymptomatic bacteriuria: 7 dayas of nitrofurantoin / amoxicillin / cefalexin Men > nitrofurantoin or trimethoprim for 7 days Catheter-related > do not treat asymptomatic bacteria - symptomatic: 7 day course of antibiotics, change catheter Acute pyelonephritis: broad-spectrum cephalosporin or quinolone for 10-14 days do not use urine dipsticks in women >65, men and catheterised patients
157
Describe erythrasma and its management
Generally asymptomatic, flat, slightly scaly, pink or brown rash found in the groin / axillae Caused by overgrowth of diphtheroid Corynebacterium minutissimum Examination with Wood's light reveals a coral-red fluorescence Treatment - Topical miconazole or antibacteriall - Oral erythromycin for extensive infection
158
Describe phaeochromocytoma and its management
Rare catecholamine secreting tumour > associated with MEN type II, neurofibromatosis and Von Hippel-Lindau syndrome Features (episodic) - hypertension, may be sustained - headaches - palpitations - sweating - anxiety Tests - 24h urinary collection of metanephrines Management - first-line: phenoxybenzamine (alpha-blocker) BEFORE beta-blocker e.g. propranolol/labetalol - surgery
159
Describe schistosomiasis and its treatment
parasitic flatworm infections 3 main species - S. mansoni, S. japonicum, S. haematobium Clinical features - swimmers' itch - acute schistosomiasis syndrome (Katayama fever) > fever > urticaria/angioedema > arthralgia / myalgia > cough > diarrhoea > eosinophilia Chronic infections - schistosoma haematobium: deposition of egg clusters in bladder leading to frequency, haematuria and bladder calcification - schistosoma mansoni/japonicum: hepatomegaly, splenomegaly Investigation - serum schistosome antibodies (Asymptomatic) - urine/stool microscopy looking for eggs (symptomatic) Management - single dose oral praziquantel complication: squamous cell carcinoma of the bladder
160
Describe the management of acute asthma and criteria for discharge
1. oxygen if saturations <94% 2. bronchodilation with salbutamol nebulisers 3. ipratropium bromide nebulisers 4. IV hydrocortisone or oral prednisolone 40-50mg PO for at least 5 days 5. magnesium sulfate IV 6. IV aminophylline / IV salbutamol Criteria for discharge - stable on discharge medication for 12-24h - inhaler techique checked and recorded - PEF >75% of best or predicted
161
Describe the following testicular lumps - epididymal cysts - varicocoele - testicular cancer - inguinal hernia
- epididymal cyst > single or multiple painless cysts > may contain clear fluid (spermatocoele) > usually occur over 40 years of age > lie above and behind the testis > can "get above it" on examination > associated conditions: PKD, CF, VHL - varicocoele > varicosities of the pampiniform plexus > may be presenting feature of RCC > affected testis may be smaller, bag of worms appearance - testicular cancer > discrete testicular nodule (may have associated hydrocoele) > hard, fixed, does not transilluminate - inguinal hernia > inguinoscrotal swelling > cough impulse may be present, may be reducible > cannnot "get above it" on examination
162
Describe iliopsoas abscesses
causes > haematogenous spread of bacteria (primary), usually staph aureus secondary - Crohn's - diverticulitis, CRC - UTI, GU cancers - vertebral osteomyelitis - femoral catheter, lithotripsy - endocarditis - IVDU Clinical features - back/flank pain - fever - limp - weight loss investigations: clinical examinatino + CT abdomen management - antibiotics - percutaneous drainage - surgery if failure of percutaneous drainage
163
Describe Non-Hodgkin's lymphoma
B or T cell malignancy associated with t(14;18) translocation increased risk with increasing age, 1/2 of cases >75 symptoms - painless lymphadenopathy (non-tender, rubbery. asymmetrical) - B symptoms - fever, weight loss, night sweats important subtypes - MALT lymphoma - Burkitt lymphoma (associated with EBV, C-myc gene translocation) - diffuse large B cell lymphoma Biopsy - some subtypes have classic appearance e.g. Burkitt's lymphoma - starry sky appearance. > CT CAP Staging - Ann Arbor classification Management - dependent on subtype - radiotherapy, chemotherapy - rituximab + CHOP (R-CHOP) for a variety of types of NHL Complications - bone marrow infiltration: anaemia, neutropaenia, thrombocytopaenia - SVC obstruction - metastasis - spinal cord compression
164
Describe coal workers' pneumoconiosis
aka black lung disease causes upper zone fibrosis 2 types - simple pneumoconiosis > often asymptomatic > increases risk of lung diseases e.g. COPD > may lead to progressive massive fibrosis (PMF) - progressive massive fibrosis > round fibrotic masses in upper lobes > symptoms: breathlessness on exertion, cough, black sputum PFTs show mixed obstructive/restrictive picture Investigations > CXR: upper zone fibrosis > Spirometry: reduced FEV1, reduced FVC management - avoid exposure to coal dust and other respiratory irritants e.g. smoking - manage symptoms of chronic bronchitis
165
List causes of upper lobe fibrosis
CHARTS - Coal workers' pneumoconiosis - Histiocytosis / hypersensitivity pneumonitis - Ankylosing spondylitis, allergic bronchopulmonary aspergillosis - Radiation - Tuberculosis - Silicosis, sarcoidosis
166
Describe tetanus and its management
Caused by tetanospasmin exotoxin released from Clostridium tetani. tetanus spores are present in soil and may be introduced into the body from a wound. may be seen in IVDU using unclean needles features - prodrome fever, lethargy, headache - trismus (lockjaw) - risus sardonicus: facial spasms - opisthotonus: arched back, hyperextended neck - spasms e.g. dysphagia management - supportive therapy including ventilatory support and muscle relaxants - IM human tetanus immunoglobulin for high-risk wounds - antibiotic treatment with metronidazole
167
Describe thyroid eye disease
occurs in patients with Graves' disease features - exophthalmos - conjunctival oedema - optic disc swelling - ophthalmoplegia - sore dry eyes which can lead to exposure keratopathy management - topical lubricants - steroids - radiotherapy - surgery urgent review by ophthalmologist if changes in vision with thyroid eye disease contraindications - radioiodine treatment
167
describe hypomagnesaemia and its symptoms
causes of low magnesium - drugs e.g. diuretics, PPIs - total parenteral nutrition (TPN) - diarrhoea - alcohol - hypokalaemia - hypercalcaemia - metabolic disorders e.g. Gitleman's, Bartter's features may be similar to hypocalcaemia - paraesthesia - tetany - seizures - arrhythmias - ECG features similar to hypocalcaemia - exacerbates digoxin toxicity management <0.4mmol/L or tetany, arrhythmias or seizures: - IV magnesium replacement e.g. 40 mmol magnesium sulphate over 24h >0.4 mmol/L: oral magnesium salts (10-20 mmol orally per day in divided doses). side-effects may include diarrhoea
168
Describe the management of proteinuric CKD and its complications
management of proteinuric CKD - ACEi or ARB: first-line in hypertension + CKD if ACR > 30mg/mmo > if >70mg/mmol then start ACEi regardless of BP - SGLT2i: all regardless of diabetes mineral bone disease - reduce phosphate and PTH levels > reduce dietary intake > phosphate binders e.g. calcichew, sevelamer > give alendronate if osteoporosis - vitamin D supplementation: calcitriol - erythropoietic stimulating agent: anaemia + renal insufficiency (if iron levels normal)
169
Describe acne vulgaris and its management
Features - closed and open comedones - papules - pustules - seborrhoea - nodules medications which exacerbate acne - steroids - lithium - ciclosporin - progesterone only contraceptives associated conditions: PCOS Management - topical: benzoyl peroxide, topical antibiotics, adapalene (topical retinoid) - systemic: oral antibiotics e.g. lymecycline / doxycycline / erythromycin / clindamycin - isotretinoin (Roaccutane) - COCP in some patients
170
List side-effects of isotretinoin
highly concentrated vitamin A - dry mucous membranes, can cause nosebleeds - headache - deranged LFTs (avoid alcohol due to risk of transaminitis) - highly teratogenic, patients must be on pregnancy prevention programme - low mood - photosensitivity: caution patients to avoid direct sunlight
171
List examples of a mild steroid, intermediate, potent and very potent
mild steroid - hydrocortisone intermediate steroid - eumovate (clobetasone butyrate) potent steroid - betamethasone valerate (betnovate) very potent steroid - dermovate (clobetasol propionate)
172
Describe Nelson's syndrome
rapid enlargement of a pituitary corticotroph adenoma that occurs after bilateral adrenalectomy for Cushing's syndrome removal of both adrenal glands eliminates cortisol production which ceases to exert its negative feedback on ACTH, allowing unchecked growth of adenoma Adenoma causes mass effect on brain and increased melanocyte stimulating hormone leading to hyperpigmentation therefore, following bilateral adrenalectomy monitor ACTH levels and perform pituitary MRI every 3-6 months.
173
Describe the treatment of pituitary adenomas
Medical therapy - prolactinoma: dopamine agonists e.g. cabergoline, bromocriptine - acromegaly / GH secreting adenomas > somatostatin analogues: octreotide, lanreotide > GH receptor antagonists: pegvisomant - ACTH-secreting adenomas > cortisol synthesis inhibitors: ketoconazole, metyrapone > neuromodulators; pasireotide Transsphenoidal surgery Radiotherapy: recurrent or residual tumours
174
Describe the causes and presentation of pleural effusion
Transudate (<30g/L protein) - heart failure - hypoalbuminaemia > liver failure > nephrotic syndrome > malabsorption - hypothyroidism - Meig's syndrome: transudative pleural effusion and ascites in the presence of a benign ovarian tumour (usually fibroma) Exudate (>30g/L protein) - infection: pneumonia, TB, subphrenic abscess > turbid effusion with pH <7.2, low glucose, high LDH - PE - malignancy; lung cancer, mesothelioma, metastases - connective tissue disease: RA, SLE - pancreatitis - Dressler's syndrome - yellow nail syndrome Presentation - dyspnoea, pleuritic chest pain - non-productive cough - signs: dull percussion, reduced breath sounds, reduced chest expansion
175
Describe refeeding syndrome
metabolic abnormalities associated with feeding a person after a period of starvation Lab features - hypophosphataemia (can lead to heart and respiratory failure, neurological complications, haemolysis, rhabdomyolysis) - hypokalaemia patients are high risk if they have a low BMI, little nutritional intake >10 days, unintentional weight loss if a patient hasn't eaten for >5 days, aim to re-feed at no more than 50% of requirements for 2 days - hypomagnesaemia features - abnormal fluid balance - arrhythmia
176
Describe pulmonary function test results for obstructive and restrictive lung pathology using examples
Obstructive FEV1 - significantly reduced FVC - reduced/ normal FEV1/FVC - reduced (<0.7) e.g. COPD, asthma Restrictive FEV1 - reduced FVC - significantly reduced FEV1/FVC - normal or increased e.g. pulmonary fibrosis, asbestosis
177
Describe seborrhoeic keratosis
benign epidermal skin lesions seen in older people features - large variation in colour from flesh to light brown to black - keratotic plugs may be seen on surface Management - removal of patient wishes - curettage, cryosurgery, shave biopsy
178
Describe sarcomas and their treatment
Classification - bone sarcoma > osteosarcoma > chondrosarcoma > Ewing's sarcoma - soft tissue sarcoma > liposarcoma > rhabdomyosarcoma > leiomyosasrcoma > synovial sarcoma > fibrosarcoma > angiosarcoma presentation - pain - swelling or palpable mass - impaired function - pathological fracture - systemic symptoms: fatigue, weight loss, fever investigations > imaging: X-rays, CT, MRI, PET scan > biopsy: FNA, core needle biopsy, incisional biopsy Management - surgery - radiation - chemotherapy - targeted therapy e.g. TKIs - immunotherapy: immune checkpoint inhibitors
179
Describe enteric fever (typhoid/paratyphoid)
caused by salmonella typhi and paratyphi Symptoms - fever - headache - arthralgia - relative bradycardia - abdominal pain, distension - diarrhoea or constipation - splenomegaly - rose spots: erythematous maculopapular lesions often on torso - complications > osteomyelitis > GI bleed/perforation > meningitis > cholecystitis > chronic carriage management - ciprofloxacin
180
Describe the clinical features and diagnosis of shingles
shingles (herpes zoster infection) is an acute, unilateral, painful blistering rash caused by reactivation of the varicella zoster virus following primary infection with VZV (chickenpox) the virus lies dormant in the dorsal root or cranial nerve ganglia risk factors - increasing age - immunosuppression features - prodromal period: severe burning pain over affected dermatome 2-3 days - fever, headache, lethargy - rash: initially erythematous macular rash over the affected dermatome and quickly becomes vesicular diagnosis is clinical
181
Describe Ehlers-Danlos syndrome
clinical features - translucent looking skin and hypermobility of small joints - sigmoid colon perforation at young age of unknown cause - aortic dissection
182
Describe renal cell cancer and its management
Most common is adenocarcinoma > most common histological subtype is clear cell carcinoma > also papillary and chromophobe Features - classical triad: haematuria, loin pain and abdominal mass - pyrexia of unknown origin - endocrine effects > may secrete erythropoietin leading to polycythaemia > PTHrP (hypercalcaemia), renin > ACTH - paraneoplastic hepatic dysfunction syndrome - varicocoele - Stauffer syndrome: cholestasis / hepatosplenomegaly - transitional cell carcinoma: textile, plastic and rubber industry management - if confined disease: partial or total nephrectomy depending on tumour size e.g. T1, partial nephrectomy - alpha-interferon and IL-2 to reduce tumour size - receptor tyrosine kinase inhibitors e.g. sorafenib, sunitinib
183
Describe post-thrombotic syndrome
Complications following venous outflow obstruction and venous insufficiency result in chronic venous hypertension. Clinical features: - painful, heavy calves - pruritus - swelling - varicose veins - venous ulceration management - compression stockings, leg elevation
184
Describe different thyroid nodules and appropriate investigations
Benign - thyroid adenoma > Simple – iodine deficiency > Toxic – Grave's / solitary nodule / multinodular goitre: patchy uptake on thyroid scintigraphy - Thyroiditis – Hashimoto's, Riedel's, De Quervain's - Amyloid / Bacterial infection (TB, syphilis) - Thyroglossal duct cyst - Thyroglossal fistula - Ectopic/lingual thyroid Malignant - papillary carcinoma > excellent prognosis despite tendency to spread to cervical lymph nodes early - follicular carcinoma - medullary carcinoma > serum calcitonin to assess recurrence - anaplastic carcinoma - lymphoma > thyroglobulin antibodies to detect recurrence investigation - ultrasonography (first-line) - TFTs
185
Describe primary biliary cholangitis and its management
chronic liver disorder typically seen in middle aged females clinical features - asymptomatic e.g. raised ALP on routine LFTs - fatigue, pruritus - cholestatic jaundice - hyperpigmentation (especially over pressure points) - RUQ pain - xanthelasma, xanthomata Investigations - raised IgM - Positive antimitochondrial M2 antibody - smooth muscle antibody present in some patients - imaging > required before diagnosis to exclude extrahepatic biliary obstruction (RUQ ultrasound or magnetic resonance cholangiopancreatography (MRCP)) Management - first-line: ursodeoxycholic acid - pruritus: cholestyramine - fat-soluble vitamin supplementation - liver transplantation Complications - cirrhosis > portal hypertension > ascites, variceal haemorrhage - osteomalacia, osteoporosis - increased risk of hepatocellular carcinoma
186
Describe hyperhidrosis and its management
excessive sweat production management - topical aluminium chloride (first-line) > side-effect: irritation - iontophoresis - botulinum toxin - surgery: endoscopic transthoracic sympathectomy > risk of compensatory sweating
187
Describe a major side effect of hydroxychloroquine therapy
Severe and permanent retinopathy clinical features > reduced colour differentiation > reduced central visual acuity > floaters Bull's eye maculopathy > appearance on ophthalmoscopy: red spot on the macula surrounded by a ring of retinal epithelial pigment loss
188
Describe rabies and the management of possible exposure
viral disease caused by an RNA rhabdovirus that causes an acute encephalitis tranmission: dog bites, bat, raccoon and skunk bites features > prodrome: headache, fever, agitation > hydrophobia > hypersalivation > Negri bodies: cytoplasmic inclusion bodies found in infected neurons management - vaccination - if bitten and previously vaccinated: 2 further vaccines - if bitten and not vaccinated: human rabies immunoglobulin + full course vaccination
189
describe the management of COPD
- smoking cessation - annual influenza vaccination + one-off pneumococcal vaccination - pulmonary rehabilitation Bronchodilators - SABA or SAMA first-line - Second line > steroid-responsive: >> add LABA + ICS >> if still unresponsive: LABA/LAMA/ICS >> if no benefit after 3 months with ICS, switch to LABA/LAMA > non-steroid-responsive: >> LABA + LAMA >> if taking a SAMA, discontinue and switch to SABA Consider oral theophylline oral prophylactic antibiotic therapy + home supply of prednisolone > azithromycin mucolytics e.g. carbocysteine - if >=2 exacerbations on triple therapy and FEV1 <50%: > PDE-4 inhibitors e.g. roflumilast
190
Describe herpes simplex virus and its management
Features - gingivostomatitis - cold sores - painful genital ulceration management - gingivostomatitis > oral aciclovir, chlorhexidine mouthwash - cold sores > topical aciclovir - painful genital ulceration > oral aciclovir pregnancy > delivery by caesarean section and oral aciclovir 400mg TDS until delivery if first presentation
191
describe erectile dysfunction and its management
persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance organic cause > gradual onset > lack of tumescence > normal libido psychogenic cause > sudden onset > reduced libido > good quality spontaneous or self-stimulated erections risk factors for organic cause: obesity, diabetes, smoking, hypertension, alcohol, SSRIs, beta-blockers investigations - free testosterone: first-line > if low, measure FSH, LH and prolactin - 10-year cardiovascular risk - nocturnal penile tumescence test Management - lifestyle: weight loss, regular exercise, smoking cessation - counselling if psychological factors - PDE-5 inhibitors e.g. sildenafil > can cause blue vision - vacuum erection devices - intracavernosal injections - young men who have always had difficulty achieving erection - urology referral
192
describe diabetic neuropathy and its treatment
peripheral neuropathy > glove and stocking sensory loss > painful neuropathy treatment - first-line: amitriptyline, duloxetine, gabapentin, pregabalin - tramadol (rescue therapy) - topical capsaicin for localised neuropathic pain GI autonomic neuropathy - gastroparesis > erratic blood glucose control, bloating, vomiting - management: metoclopramide, domperidone or erythromycin (prokinetic) - chronic diarrhoea (at night) - GORD
193
What electrolyte and acid-base disturbance is associated with Cushing's syndrome?
Hypokalaemic metabolic alkalosis
194
Describe the prescription of morphine in palliative care
divide oral dose by two when converting from oral to subcutaneous morphine divide by 10 when converting from codeine to morphine starting treatment: if no comorbidities use 20-30mg of MR a day with 5mg morphine for breakthrough pain > 1/6 of daily dose for breakthrough laxatives should be prescribed with strong opioids > nausea is often transient but if it persists patient should be offered antiemetic drowsiness is usually transient - if not, adjust dose oxycodone is prescribed in preference to morphine in mild-moderate renal impairment > if renal impairment is more severe, alfentanil, buprenorphine and fentanyl are preferred when increasing the dose of opioids the next dose should be increased by 30-50% metastatic bone pain: strong opioids, bisphosphonates, radiotherapy, denosumab
195
Describe hidradenitis suppurativa
chronic, painful, inflammatory skin disorder characterised by nodules, pustules, sinus tracts and scars in intertriginous areas axilla is the most common site nodules may rupture releasing purulent, malodorous discharge coalescence of nodules can result in plaques, sinus tracts and rope-like scarring diagnoses is clinical management - good hygiene and loose-fitting clothing - smoking cessation - weight loss in obese - topical (clindamycin) or oral (lymecycline, clindamycin) antibiotics - lumps that persist may be excised surgically complications - sinus tracts, fistulas - comedones - scarring - contractures - lymphatic obstruction
196
Describe idiopathic pulmonary fibrosis
typically seen in patients aged 50-70 years and is twice as common in men features - progressive exertional dyspnoea - bibasal fine end-inspiratory crepitations on auscultation - dry cough - clubbing diagnosis - spirometry - restrictive - impaired gas exchange: reduced transfer factor (TLCO) - imaging: HR-CT > bilateral interstitial shadowing; ground glass progressing to honeycombing management > pulmonary rehabilitation > pirfenidone - antifibrotic > supplementary oxygen > lung transplant
197
Describe Kartagener's syndrome
aka primary ciliary dyskinesia pathogenesis - dynein arm defect results in immotile cilia features - dextrocardia or complete situs inversus - bronchiectasis - recurrent sinusitis - subfertility
198
describe thyroid storm
rare but life-threatening complications of thyrotoxicosis precipitating event: surgery, trauma, infection, acute iodine load e.g. CT contrast clinical features - fever >38.5 - tachycardia - confusion and agitation - nausea and vomiting - hypertension - heart failure - abnormal liver function; jaundice management - symptomatic treatment: paracetamol - beta-blockers e.g. IV propranolol - hydrocortisone / dexamethasone - anti-thyroid drugs (thionamides): propylthiouracil, methimazole - Lugol's iodine
199
describe diabetes sick day rules
do not stop insulin due to risk of DKA continue normal insulin regime but ensure they are checking their blood sugars frequently (1-2 hourly) normal blood sugar checks in diabetics are at least 4 times a day, including before each meal and before bed blood glucose targets - waking: 5-7 mmol/l - before meals and other times of day: 4-7 mmol/l
199
describe medial epicondylitis
aka golfer's elbow features - pain and tenderness localised to the medial epicondyle - pain is aggravated by wrist flexion and pronation - symptoms accompanied by numbness/tingling in 4th and 5th finger due to nerve involvement
199
describe diabetes insipidus and its management
- cranial DI: decreased secretion of ADH - nephrogenic DI: insensitivity to ADH Causes of cranial DI - idiopathic - post head injury - pituitary surgery - craniopharyngioma - infiltrative: histiocytosis X, sarcoidosis - haemochromatosis Causes of nephrogenic DI - genetic - hypercalcaemia, hypokalaemia - lithium - demeclocycline - tubulo-interstitial disease: obstruction, sickle cell, pyelonephritis features: polyuria, polydipsia investigation - high plasma osmolality, low urine osmolality - water deprivation test management - nephrogenic: thiazides e.g. chlorothiazide, low salt/protein diet - cranial: desmopressin (vasopressin V2 receptor agonist)
200
Describe hepatorenal syndrome
functional kidney impairment due to advanced liver disease clinical features - ascites - low urine output - significant increase in serum creatinine Management - terlipressin - volume expansion with 20% albumin - transjugular intrahepatic portosystemic shunt - liver transplant > type 1 HRS >> Rapidly progressive >> doubling of serum creatinine or halving of creatinine clearance > type 2 HRS >> slowly progressive >> poor prognosis
200
Describe the classification in epilepsy
- focal seizures > start in a specific area on one side of the brain > level of awareness can vary >> focal aware >> focal impaired awareness > other features >> motor e.g. Jacksonian march, automatism >> non-motor e.g. deja vu, jamais vu >> aura - generalised seizures > involves networks on both sides of the brain > all patients lose consciousness immediately > specific types >> tonic-clonic (grand mal) >> tonic >> clonic >> typical absence (petit mal) >> atonic - unknown onset - focal to bilateral seizure > starts on one side of the brain in a specific area before spreading to both lobes
200
Describe vitiligo
aka alopecia areata autoimmune condition which results in the loss of melanocytes and consequent depigmentation of skin clinical features > well-demarcated patches of depigmented skin > peripheries tend to be most affected > trauma may precipitate new lesions (Koebner phenomenon) management - sunblock for affected areas - camouflage makeup - topical steroids - topical tacrolimus, phototherapy
200
Describe drugs which cause the following changes in the liver - hepatocellular - cholestatic
- hepatocellular > paracetamol > sodium valproate, phenytoin > MAOIs > halothane > anti-TB meds > statins > alcohol > amiodarone > methyldopa > nitrofurantoin - cholestasis > COCP > abx: flucloxacillin, co-amoxiclav, erythromycin > anabolic steroids, testosterone > phenothiazines: chlorpromazine, prochlorperazine > sulphonylureas > fibrates > nifedipine
201
What medication can be given for the prevention of calcium stones?
potassium citrate
201
Describe pseudohyponatraemia and its causes
to diagnose pseudohyponatraemia > Calculate osmolarity = 2*Na + urea + blood glucose > calculate osmolar gap = measured serum osmolality - calculated osmolality. > normal osmolar gap <10 mmol/l. this rules out pseudohyponatraemia. causes of pseudohyponatraemia - hyperlipidaemia - taking blood from a drip arm
202
Describe hyponatraemia and its causes
exclude pseudohyponatraemia and determine fluid status clinically - hypovolaemic > urine sodium <20 >> vomiting >> diarrhoea >> 3rd space losses > cerebral salt wasting syndrome > urine sodium >20 >> diuretics >> Addison's - euvolaemic > urine osmolality > 100 mOsm/kg >> SIADH >> Hypothyroidism >> ACTH deficiency > urine osmolality <100 mOsm/kg >> Primary polydipsia >> Beer potomania - hypervolaemic > urine sodium <20 >> heart failure >> cirrhosis >> nephrotic syndrome >> hypoalbuminaemia > urine sodium >20 >> renal failure
203
Describe multiple myeloma and its diagnosis
haematological malignancy characterised by plasma cell proliferation Features - 70 year olds - CRABBI: > Calcium (hypercalcaemia) > Renal >> monoclonal production of immunoglobulins results in light chain deposition within the renal tubules >> amyloidosis, nephrocalcinosis, nephrolithiasis > Anaemia > Bones bone marrow infiltration by plasma cells creates lytic bone lesions > back pain, pathological fractures > Infection Investigations - Bloods > FBC: anaemia > peripheral blood film: rouleaux formation > urea and electrolytes: renal failure > bone profile: hypercalcaemia - Protein electrophoresis > Bence-Jones proteins - Bone marrow aspiration: plasma cells raised (plasmacytoma) Imaging > whole-body MRI > X-rays: 'rain-drop skull'
204
Describe Addison's disease and its management
features - lethargy, weakness, anorexia - nausea and vomiting - weight loss - salt craving - hyperpigmentation - vitiligo - loss of pubic hair in women - hypotension - hypoglycaemia - hyponatraemia and hyperkalaemia - crisis: collapse, shock, pyrexia management > hydrocortisone 20-30mg daily >> split dose with majority given in first half of day e.g. 20mg 8am and 10mg 5pm > fludrocortisone Give patients a hydrocortisone injection kit for adrenal crises intercurrent illness: double glucocorticoid dose
205
Describe athlete's foot and its treatment
tinea pedis usually caused by fungi in the genus Trichophyton features - scaling - flaking - itching between toes management - first-line: topical imidazole, undecenoate - second-line: oral terbinafine
206
Describe the management of the following overdoses - heparin - ethylene glycol (anti-freeze) - methanol - benzodiazepines - beta-blockers - digoxin - iron - lead - carbon monoxide - cyanide - methotrexate
- heparin: protamine sulphate - ethylene glycol (anti-freeze): fomepizole, ethanol - methanol: fomepizole, ethanol - benzodiazepines: flumazenil - beta-blockers: atropine if bradycardic, glucagon if resistant - digoxin: digoxin-specific antibody fragments (digibind) - iron: desferrioxamine - lead: dimercaprol, calcium edetate - carbon monoxide: 100% O2, hyperbaric oxygen - cyanide: hydroxycobalamin - methotrexate: folinic acid
207
Describe primary sclerosing cholangitis and its management
inflammation and fibrosis of intra and extrahepatic bile ducts associated with UC Features - cholestasis: jaundice, pruritus, raised bilirubin and ALP - RUQ pain - fatigue - hepatosplenomegaly Investigations - US: bile duct dilatation - MRCP/ERCP: beaded appearance of multiple biliary structures - p-ANCA may be positive - liver biopsy: fibrous, obliterative cholangitis with appearance of onion skin complications: cholangiocarcinoma, colon cancer management - ERCP for dominant strictures +/- stenting - liver transplant in advanced disease
208
describe cushing's triad for increased ICP
- bradycardia - irregular breathing - hypertension with wide pulse pressure
209
describe malignant otitis externa
found in immunocompromised individuals, mostly diabetics most commonly caused by Pseudomonas aeruginosa can progress to temporal bone osteomyelitis features - severe, unrelenting, deep-seated otalgia - temporal headaches - purulent otorrhoea - possibly dysphagia, hoarseness, facial nerve dysfunction diagnosis - CT scan management - ciprofloxacin, ENT referral
210
deficiency of what vitamin causes angular cheilitis
riboflavin - vitamin B2
211
Describe myocarditis and its treatment
causes - viral: coxsackie, HIV - bacteria: diphtheria, clostridia - spirochetes: Lyme disease - protozoa: Chagas disease, toxoplasmosis - autoimmune - drugs: doxorubicin presentation - usually young with acute history - chest pain - dyspnoea - arrhythmias Troponin - raised ECG - ST elevation, T wave inversion Management - treatment of underlying cause - supportive treatment complications - heart failure - arrhythmia - dilated cardiomyopathy
212
describe spinal stenosis
features - back pain - neuropathic pain - sitting is better than standing - symptoms mimic claudication > patients find it easier to walk uphill than downhill diagnosis - MRI treatment - laminectomy
213
describe diagnostic testing for asthma in adults
1. Blood eosinophils or FeNO (>=50 ppb is positive) 2. Bronchodilator reversibility with spirometry >> FEV1/FVC < 0.7 >> Reversibility of >=200ml or 12% or more 3. Peak expiratory flow variability is 20% or more 4. Bronchial challenge test: bronchial hyperresponsiveness occupational asthma: serial peak flow measurements at work and at home > most common cause is isocyanates
214
describe myelofibrosis
myeloproliferative disorder caused by hyperplasia of abnormal megakaryocytes haematopoiesis develops in the liver and spleen features - elderly person presenting with anaemia or fatigue - massive splenomegaly - hypermetabolic symptoms: weight loss, night sweats lab findings - anaemia - high WBC and platelet count - tear drop poikilocytes on blood film - unobtainable bone marrow biopsy - dry tap - so trephine biopsy needed - high urate and LDH due to increased cell turnover
215
what is lanugo hair?
fine layer of soft unpigmented hair that covers the body aside from palmar and plantar surfaces caused by malnutrition can be found in newborn babies, chronic malnutrition or anorexia nervosa
216
describe carcinoid syndrome
signs and symptoms caused by a tumour arising from neuroendocrine cells releasing serotonin, bradykinin and histamine features - flushing - diarrhoea - wheeze due to bronchospasm - hypotension - right heart valvular stenosis: tricuspid insufficiency, pulmonary stenosis - Cushing's syndrome if ACTH is secreted - pellagra rarely investigation - urinary 5-hydroxyindoleacetic acid (5-HIAA) > collected as 24h urine sample in bottle with acid to maintain pH <3 - niacin (vitamin B3) deficiency - plasma chromogranin A test management - somatostatin analogues e.g. octreotide - diarrhoea: cyproheptadine
217
describe alcohol withdrawal
6-12h: symptoms like tremor, sweating, tachycardia, anxiety 36h: seizures 48-72h: delirium tremens, confusion, hallucinations management - long-acting benzodiazepines e.g. chlordiazepoxide, diazepam (lorazepam in hepatic failure) - carbamazepine also effective - IV Pabrinex
218
describe fragile X syndrome
X-linked dominant trinucleotide repeat disorder - learning difficulties - large low set ears, long thin face, high arched palate - mitral valve prolapse - pes planus - autism - memory problems - speech disorders - macroorchidism - hypotonia features in females range from normal to mild diagnosis - antenatally by chorionic villus sampling or amniocentesis - analysis of the number of CGG repeats using restriction endonuclease digestion and Southern blot sampling
219
describe tumour lysis syndrome
characteristics - hyperuricaemia - hyperkalaemia - hyperphosphataemia - hypocalcaemia - increased serum creatinine - seizure - cardiac arrhythmia or sudden death can occur within 3 days before or 7 days after chemotherapy complications management - give IV fluids, allopurinol or rasburicase prior to chemotherapy to reduce the risk of developing tumour lysis syndrome
220
describe driving guidelines for epilepsy
all patients must not drive and must inform the DVLA - first unprovoked / isolated seizure: 6 months off if no relevant structural abnormalities on brain imaging and no definite epileptiform activity on EEG > if these conditions are not met it is increased to 12 months - established epilepsy or those with multiple unprovoked seizures > may qualify for driving licence if free from seizures for 12 months
221
describe takayasu's arteritis
large vessel vasculitis typically causing occlusion of the aorta leading to absent limb pulses features - systemic features e.g. malaise, headache - unequal blood pressure in upper limbs - carotid bruit and tenderness - aortic regurgitation - intermittent upper and lower limb claudication - absent or weak peripheral pulses - young females, Asian people associations - renal artery stenosis investigations - magnetic resonance angiography or CT angiography management: steroids
222
describe antiphospholipid syndrome
features - venous and arterial thrombosis - recurrent foetal loss - thrombocytopaenia - livedo reticularis - pre-eclampsia - pulmonary hypertension can occur as a primary disorder or secondary to SLE , lymphoproliferative disorders, phenothiazines lab investigations - paradoxical rise in APTT - low platelets - antibodies > anticardiolipin antibodies > anti-beta2 glycoprotein I antibodies > lupus anticoagulant - thrombocytopaenia management - primary thromboprophylaxis with low-dose aspirin - secondary thromboprophylaxis > lifelong warfarin with target INR 2-3
223
name the most likely electrolyte abnormality in a patient taking a thiazide diuretic
hyponatraemia
224
list causes of a false negative mantoux test
- immunosuppression > miliary TB, AIDS, steroid therapy - sarcoidosis - lymphoma - extremes of age - fever - hypoalbuminaemia, anaemia
225
describe hepatitis B serology interpretation
HBsAg - acute or chronic disease Anti-HbS - immunity (exposure or immunisation) > negative in chronic disease Anti-HbC - previous or current infection > negative in immunisation HbeAg - marker of replication and infectivity microscopy: chronic hepatitis B infection leads to ground glass hepatocytes
226
describe hyperosmolar hyperglycaemic state (HHS)
typically presents in the elderly with T2DM Precipitating factors: intercurrent illness, dementia, sedative drugs clinical features - insidious onset - clinical signs of dehydration - polyuria, polydipsia - lethargy - nausea and vomiting - altered level of consciousness, focal neurological deficits - haematological: hyperviscosity > can result in MI, stroke, peripheral arterial thrombosis diagnostic criteria - hypovolaemia - marked hyperglycaemia (>30 mmol/L) - significantly raised serum osmolarity (>320 mosmol/kg) > calculated by 2* Na + glucose + urea - no significant hyperketonaemia (<3 mmol/L) - no significant acidosis (HCO3 >15, pH >7.3) management - IV 0.9% NaCl given at 0.5-1L/h - monitor potassium - insulin if necessary - VTE prophylaxis
227
describe haemolytic anaemia
intravascular causes - mismatched blood transfusion - G6PD deficiency - red cell fragmentation: heart valves, TTP, DIC, HUS - paroxysmal nocturnal haemoglobinuria - cold autoimmune haemolytic anaemia extravascular causes - haemoglobinopathies: sickle cell, thalassaemia - hereditary spherocytosis - haemolytic disease of the newborn - warm autoimmune haemolytic anaemia lab - low haptoglobin (binds to free haemoglobin)
228
which medication increases the risk of azathioprine toxicity?
allopurinol
229
describe myelodysplastic syndrome
group of disorders characterised by dysfunctional blood cell production in the bone marrow risk of progression to acute myeloid leukaemia > associated with Auer rods causes pancytopaenia risk factors - previous radiation and chemotherapy features - fatigue - shortness of breath - weakness - pallor - splenomegaly - easy bruising/bleeding - petechiae treatment - supportive care e.g. blood transfusions, growth factors - disease modifying therapy e.g. hypomethylating agents, lenalidomide - immunosuppressive therapy - haematopoietic stem cell transplant
230
describe acute management of seizures
- check airway and apply oxygen - place patient in recovery position - if seizure is prolonged give benzodiazepines adult: 10-20mg (max 30mg) > rectal diazepam after 5 minutes > repeated once after 10-15 mins if necessary midazolam oromucosal solution may also be used > adult 10mg
231
what is the management of antiphospholipid syndrome in pregnancy?
aspirin + LMWH
232
describe von willebrand disease (VWD)
most common genetic bleeding disorder (AD) features - mucocutaneous bleeding after mild injury e.g. nose bleeds, bruising - menorrhagia in women - haemarthroses and muscle haematomas are rare Lab features - prolonged bleeding time - normal platelet count - prolonged APTT management - tranexamic acid for mild bleeding - desmopressin - factor VIII concentrate
233
describe cryptosporidium diarrhoea
intracellular protozoa most commonly Cryptosporidium parvum or Cryptosporidium hominis most common cause of diarrhoea in patients with HIV features - watery diarrhoea - abdominal cramps - fever - if severe immunocompromise: sclerosing cholangitis, pancreatitis modified Ziehl-Neelsen stain of stool may reveal the characteristic red cysts of cryptosporidium management - supportive therapy if immunocompetent - immunocompromised patients: nitazoxanide or rifaximin
234
describe renal artery stenosis
secondary hyperaldosteronism - renin levels are high > higher than in primary hyperaldosteronism - aldosterone levels are high > mostly due to atherosclerosis but can be due to fibromuscular dysplasia features > often presents in younger patients with refractory hypertension > flash pulmonary oedema > ACE inhibitors can worsen stenosis resulting in drop in eGFR
235
describe urethral strictures
causes - idiopathic - iatrogenic e.g. traumatic placement of indwelling urinary catheters - sexually transmitted infections e.g. gonorrhoea - penile fractures - hypospadias - lichen sclerosus features - decreased urinary stream - incomplete bladder emptying - spraying of urine stream, dysuria investigations - uroflowmetry - ultrasound postvoid residual measurement management - dilation - endoscopic urethrotomy
236
describe the staging of severity of COPD
FEV1 >80%: stage 1 - mild FEV1 50-79%: stage 2 - moderate FEV1 30-49%: stage 3 - severe FEV1 <30%: stage 4 - very severe
237
describe familial hypercholesterolaemia
AD disorder caused by mutation in LDL receptor gene Clinical diagnosis are based on the Simon Broome criteria: - adults total cholesterol (TC) > 7.5 mmol/l and LDL-C > 4.9 mmol/l - children TC > 6.7 mmol/l and LDL-C > 4.0 mmol/l, plus: - tendon xanthoma or DNA-based evidence of FH - family history of myocardial infarction below age 50 years Management - high-dose statins - first-line - screening for first-degree relatives
238
describe theophylline toxicity
features - vomiting - agitation - dilated pupils - tachycardia - hyperglycaemia - hypokalaemia management - measure acute levels - activated charcoal - supportive management > antiemetics > IV fluids > correct hypokalaemia > benzodiazepines for seizures > IV beta-blockers for SVTs definitive treatment - haemodialysis
239
describe alcoholic hepatitis and its management
lab features of alcoholic liver disease - elevated gamma GT - ratio of AST:ALT is normally >2, a ratio of >3 is strongly suggestive of acute alcoholic hepatitis management - glucocorticoids e.g. prednisolone during acute episodes - pentoxyphylline can be used
240
how long should patients wait before flying if they have a full plaster cast
should not fly if flight is >2h duration until 48h after cast applied unless bivalved
241
describe the treatment of fungal nail infections
aka onychomycosis causative organisms - dermatophytes: 90% of cases > mainly Trichophyton rubrum - yeasts: 5-10% of cases > e.g. Candida - non-dermatophyte moulds features - unsightly nails - thickened, rough, opaque nails investigations - nail clippings / scrapings management - do not need to treat if asymptomatic / unbothered by appearance - if dermatophyte or candida infection > limited involvement (<50% nail affected, <=2 nails): topical treatment with amorolfine 5% nail lacquer, 9-12 months > more extensive involvement due to dermatophyte (Trichophytion rubrum) infection: oral terbinafine 3-6 months > more extensive involvement due to Candida infection: oral itraconazole
242
list causes of hypoadrenalism
Primary - tuberculosis - metastases - meningococcal septicaemia (Waterhouse-Friedrichsen syndrome) - HIV - antiphospholipid syndrome Secondary - pituitary disorders e.g. tumours, irradiation, infiltrationa exogenous glucocorticoid therapy
243
describe the management of hyponatraemia
if suspecting a hypovolaemic cause > 0.9% NaCl > if serum sodium rises this supports hypovolaemic hyponatraemia > if serum sodium falls an alternative diagnosis such as SIADH is more likely euvolaemic cause > fluid restrict to 500-1000ml / day > consider medications > demeclocycline > vaptans hypervolaemic cause > fluid restrict 500-1000ml/day > consider loop diuretics acute hyponatraemia (<120 mmol/L) with severe symptoms > hypertonic 3% saline may be used
244
list associated nerve lesions for the following operations - posterior triangle lymph node biopsy - Lloyd Davies stirrups - thyroidectomy - anterior resection of the rectum - axillary node clearance - inguinal hernia surgery - varicose vein surgery - posterior approach to the hip - carotid endarterectomy
- posterior triangle lymph node biopsy: accessory nerve - Lloyd Davies stirrups; common peroneal nerve - thyroidectomy: laryngeal nerve - anterior resection of the rectum: hypogastric autonomic nerves - axillary node clearance: long thoracic nerve, thoracodorsal nerve, intercostobrachial nerve - inguinal hernia surgery; ilioinguinal nerve - varicose vein surgery: sural and saphenous nerves - posterior approach to the hip: sciatic nerve - carotid endarterectomy: hypoglossal nerve
245
differentiate between arterial and venous ulcers
venous ulcers - oedema - brown pigmentation - lipodermatosclerosis - eczema - location above the ankle - painless - management: 4 layer compression banding after exclusion of arterial disease or surgery arterial ulcers - occur on the toes and heel - typically have a deep, punched out appearance - painful - there may be areas of gangrene - cold with no palpable pulses - low ABPI measurements
246
describe toxoplasmosis
caused by Toxoplasma gondii, an obligate intracellular protozoan animal reservoir: cats, rats immunocompetent patients - asymptomatic self-limiting infection - symptomatic: clinical features mimic infectious mononucleosis - rare: meningoencephalitis, myocarditis investigations: serology HIV/immunocompromised - cerebral toxoplasmosis in 50% > constitutional symptoms, drowsiness, headache - chorioretinitis - CT: single or multiple ring-enhancing lesions, mass effect may be seen > thallium SPECT negative management: pyrimethamine plus sulphadiazine for at least 6 weeks (if immunosuppressed, immunocompetent individuals require no treatment)
247
what is the most sensitive and specific lab finding for diagnosis of liver cirrhosis in those with chronic liver disease?
thrombocytopaenia
248
describe malignant hyperthermia and its treatment
AD disorder presenting as hypermetabolic crisis with > increased end-tidal CO2 > tachycardia > muscle rigidity > rhabdomyolysis > hyperthermia > arrhythmia commonly associated with volatile inhalational anaesthetic agents e.g. sevoflurane and the muscle relaxant succinylcholine (suxamethonium) > suxamethonium can cause hyperkalaemia > suxamethonium can also increase IOP, contraindicated in penetrating eye injury / acute glaucoma management - IV dantrolene
249
describe thyroid problems which may arise during pregnancy
Untreated thyrotoxicosis increases the risk of fetal loss, maternal heart failure and premature labour Graves' disease is the most common cause of thyrotoxicosis in pregnancy > activation of TSH receptor by HCG may occur - transient gestational hyperthyroidism > HCG levels will fall in the second and third trimester Management > propylthiouracil 1st trimester > carbimazole for remainder of pregnancy Hypothyroidism > maternal free thyroxine levels should be kept in the upper third of the normal reference range to avoid fetal hypothyroidism > women require an increased dose of thyroxine during pregnancy by up to 50% as early as 4-6 weeks of pregnancy
250
describe acute intermittent porphyria
rare AD condition caused by a defect in porphobilinogen deaminase, (enzyme involved in biosynthesis of haem), usually presents in 20-40 year olds > results in toxic accumulation of delta aminolaevulinic acid and porphobilinogen features > abdominal symptoms >> abdominal pain, vomiting > neuropsychiatric symptoms >> depression > neurological: motor neuropathy > hypertension, tachycardia Diagnosis > urine turns deep red on standing > raised urinary porphobilinogen (elevated between attacks and to a greater extent during acute attacks) > assay of red cells for porphobilinogen deaminase > raised serum levels of delta aminolaevulinic acid and porphobilinogen Management > avoiding triggers > acute attacks >> IV haematin/haem arginate >> IV glucose should be used if haematin/haem arginate is not immediately available
251
describe scabies and its management
Scabies is caused by the mite Sarcoptes scabiei and is spread by prolonged skin contact > affects children and young adults Features > widespread intense pruritus worsening at night > linear silver burrows on the side of fingers, interdigital webs and flexor aspects of the wrist > in infants, the face and scalp may also be affected Management > permethrin 5% is first-line > malathion 0.5% is second-line pruritus persists for up to 4-6 weeks post eradication Patient guidance > avoid close physical contact with others until treatment is complete > all household and close physical contacts should be treated at the same time, even if asymptomatic > launder, iron or tumble dry clothing, bedding, towels, etc., on the first day of treatment to kill off mites. > patient treated twice, applications one week apart Crusted (Norwegian) scabies > immunocompromise e.g. HIV > management with ivermectin and isolation
252
describe polycythaemia rubra vera
myeloproliferative disorder caused by clonal proliferation of a marrow stem cell leading to an increase in red cell volume, overproduction of neutrophils and platelets peak incidence in the sixth decade features > hyperviscosity > pruritus (particularly after warm bath) > splenomegaly > positive JAK2 mutation > gout > ruddy complexion > peptic ulcer disease Management - aspirin first-line: reduces the risk of thrombotic events - venesection - chemotherapy - hydroxyurea - slight increased risk of secondary leukaemia - phosphorus-32 therapy 5-15% progress to myelofibrosis or AML
253
describe sagittal sinus thrombosis
may occur in females or males with thrombophilic tendencies Risk factors - dehydration - malignancy - oral contraceptive pill (OCP) - thrombocytosis - congenital coagulopathies: antiphospholipid syndrome, factor V Leiden deficiency, protein C and S deficiency and antithrombin III deficiency features - sudden severe headache radiating across top of head investigations - Fundoscopy: papilloedema - CT head with contrast - positive delta sign
254
describe non-alcoholic fatty liver disease (NAFLD)
largely caused by obesity spectrum of disease ranging from - steatosis - steatohepatitis - fibrosis and liver cirrhosis features - usually asymptomatic - hepatomegaly - ALT > AST - increased echogenicity on ultrasound investigations - enhanced liver fibrosis (ELF) test to check for advanced fibrosis > hyaluronic acid + procollagen III + tissue inhibitor of metalloproteinase 1 - calculate FIB4 score or NAFLD fibrosis score - liver biopsy to stage disease management - weight loss - monitoring - ? gastric banding and insulin-sensitising drugs e.g. metformin
255
describe osteogenesis imperfecta
AD type I collagen disorder characterised by - multiple fractures in childhood - dental caries - deafness (otosclerosis) - blue sclera investigations - adjusted calcium, phosphate, PTH and ALP - normal
256
describe intestinal angina
aka chronic mesenteric ischaemia characteristics - triad of severe colicky post-prandial abdominal pain, weight loss and abdominal bruit most common cause is atherosclerotic disease in arteries supplying GI tract
257
describe Bartter syndrome
AR disorder which causes renal tubular disease characterised by hypokalaemia, hypochloraemia renal stones and metabolic alkalosis are commonly seen in this condition
258
describe the mechanism of action of the following drugs - domperidone - prochlorperazine - ondansetron - metoclopramide
- domperidone: dopamine receptor antagonist - ondansetron: 5HT3 antagonist > first-line for chemotherapy induced nausea and vomiting - prochlorperazine: phenothiazine - metoclopramide: dopamine receptor antagonist
259
what is the mechanism of action of bupropion?
norepinephrine and dopamine reuptake inhibitor, nicotinic antagonist
260
describe acute bacterial prostatitis
typically caused by gram negative bacteria entering prostate via urethra risk factors - recent UTI - urogenital instrumentation - intermittent bladder catheterisation - recent prostate biopsy features - pain may be referred to perineum, penis, rectum or back - obstructive voiding symptoms - fever and rigors - digital rectal examination: tender, boggy prostate gland management - 14 day course of quinolone - consider STI screening
261
Describe keloid scars and their treatment
keloid scars are tumour-like lesions that arise from the connective tissue of a scar and extend beyond the dimensions of the original wound most common in black men treatment - intra-lesional steroids e.g. triamcinolone in early stages - excision
262
state liver transplantation criteria in paracetamol overdose
pH <7.3 more than 24h after ingestion
263
describe latent tuberculosis
negative sputum culture, normal CXR positive interferon gamma release assay, positive mantoux test cannot pass the disease onto others treatment - 3 months of isoniazid (with pyridoxine) and rifampicin - 6 months of isoniazid (with pyridoxine)
264
describe tetanus vaccination
uncertain tetanus vaccination history > booster vaccine + immunoglobulin, unless wound is very minor and <6h old, in which case just booster patient has had a full course (5 doses) of tetanus vaccines with the last dose <10 years ago > no intervention needed patient has had a full course of tetanus vaccines with the last dose >10 years ago > tetanus prone wound: booster > high risk wound: booster + tetanus immunoglobulin
265
describe quinine toxicity (cinchonism)
ECG changes > sinus tachycardia > QRS widening > prolongation of PR and QTc intervals features - similar to aspirin overdose - hypotension - metabolic acidosis - hypoglycaemia - tinnitus - flushing - visual disturbances (delayed blindness) - flash pulmonary oedema may occur check salicylate levels to exclude aspirin overdose management - supportive: fluids, inotropes, bicarbonate
266
describe the features and diagnosis of infectious mononucleosis
aka glandular fever causes - EBV, aka human herpesvirus 4 (90%) - cytomegalovirus - HHV-6 clinical features - sore throat, lymphadenopathy, pyrexia - palatal petechiae - splenomegaly (avoid contact sports for 4 weeks after) - hepatitis - maculopapular pruritic rash in patients who take ampicillin/amoxicillin during illness transmission - salivary exchange e.g. kissing investigations > FBC - lymphocytosis with at least 10% atypical activated lymphocytes - haemolytic anaemia secondary to cold agglutinins (IgM) - thrombocytopaenia > Heterophile antibody test (Monospot test) management - supportive > symptoms resolve after 2-4 weeks complications - post-viral chronic fatigue syndrome - splenic rupture (especially if contact sports) - Guillain-Barre syndrome - meningitis / encephalitis - severe upper airway obstruction
267
describe the management of DVT depending on its likelihood investigation
if DVT is likely (2 points or more): arrange proximal leg vein ultrasound scan within 4h > positive scan: start treatment with DOAC or LMWH if eGFR<15 > negative scan: D dimer test if DVT is unlikely (1 point or less): perform D dimer test > positive D dimer: arrange proximal leg vein ultrasound >> negative proximal leg vein ultrasound scan and positive D dimer: stop anticoagulation and repeat scan in 1 week > negative D dimer and negative proximal leg vein ultrasound scan: consider alternative diagnosis
268
which blood-thinning medication should be avoided if patients are allergic to sulfasalazine?
aspirin
269
which medication is used to reverse - dabigatran - apixaban / rivaroxaban - warfarin
- dabigatran: idarucizumab - apixaban / rivaroxaban: andexanet alfa - warfarin: vitamin K (phytomenadione)
270
describe acute tubular necrosis
most common cause of AKI 2 main causes - ischaemia > shock > sepsis - nephrotoxins > aminoglycosides > myoglobin secondary to rhabdomyolysis > radiocontrast agents > lead features > raised urea, creatinine, potassium > Granular muddy brown casts in urine
271
describe the mechanism of action of orlistat
pancreatic lipase inhibitor
272
what is the most likely cardiac sequela of thyrotoxicosis?
high output cardiac failure atrial fibrillation
273
what patient factors are required to calculate Z score?
age, gender, ethnicity
274
what is the waterlow score used to identify?
patients at risk of pressure sores
275
describe amoebiasis
entamoeba histolytica (amoeboid protozoan) may cause - dysentery: profuse, bloody diarrhoea - liver abscesses: anchovy sauce appearance - colonic abscesses - inflammatory masses in colon long incubation period stool microscopy - trophozoites treatment - oral metronidazole - a luminal agent e.g. diloxanide furoate
276
how would you calculate % of body surface covered by burns in a patient
Wallace's Rule of Nine: Each of the following is 9% of the body when calculating surface area % if a burn: Head + neck each arm each anterior part of leg each posterior part of leg anterior chest posterior chest anterior abdomen posterior abdomen
277
describe solitary rectal ulcer syndrome
features > chronic constipation and straining > passing small amounts of blood > examination: indurated area proximal to anal verge investigations - biopsy - exclude malignancy - endoscopy - defecating proctogram - ano-rectal manometry studies
278
describe the management of sickle cell crisis
classes - painful or vaso-occlusive crises - acute chest syndrome > dyspnoea, chest pain, cough, hypoxia and new pulmonary infiltrates on chest x-ray - anaemic: aplastic or sequestration - infection management: - painful crisis: IV fluids + oxygen + opiates > consider antibiotics if evidence of infection > hydroxyurea as prophylaxis due to increase in HbF levels acute chest syndrome: > IV fluids + oxygen + opiates + antibiotics + transfusion - aplastic crisis: infection with parvovirus > blood transfusion if Hb is low > exchange transfusion if: acute chest syndrome, stroke, multiorgan failure, splenic sequestration crisis
279
describe the following conditions Idiopathic thrombocytopaenic purpura (ITP) Thrombotoic thrombocytopaenic purpura (TTP) Haemolytic uraemic syndrome (HUS) Henoch Schonlein Purpura (HSP) Haemorrhagic Haemolytic Telangiectasis (HHT)
idiopathic thrombocytopaenic purpura (ITP) - Isolated thrombocytopaenia in a relatively well person Thrombotoic thrombocytopaenic purpura (TTP) - Thrombocytopaenia in a very unwell person Haemolytic uraemic syndrome (HUS) - Thrombocytopaenia, schistocytes, renal failure, post-dysentery Henoch Schonlein Purpura (HSP) - Abdo pain, joint pain, haematuria, purpura. Kids. Haemorrhagic Haemolytic Telangiectasis (HHT) - Epistaxis, GI bleeds, telangiectasia.
280
which medications should be held in C diff inspection?
agents which slow peristalsis e.g. opioids, loperamide > can predispose to toxic megacolon by slowing clearance of C diff toxin
281
describe vitamin C deficiency (scurvy)
Vitamin C (ascorbic acid) - citrus fruits - tomatoes - potatoes - Brussel sprouts - cauliflower, broccoli, cabbage and spinach associated with severe malnutrition as well as drug and alcohol abuse, and those living in poverty with limited access to fruits and vegetables. features - Follicular hyperkeratosis and perifollicular haemorrhage - Ecchymosis, easy bruising - Poor wound healing - Gingivitis with bleeding and receding gums - Sjogren's syndrome - Arthralgia - Oedema - weakness, malaise, anorexia and depression
282
which medication shouldn't be given in VT?
Verapamil
283
describe infection with clostridium botulinum
gram positive anaerobic bacillus produces botulinum toxin, a neurotoxin which irreversibly blocks the release of acetylcholine neurotoxin often affects bulbar muscles and autonomic nervous system features - patient usually fully conscious with no sensory disturbance - descending flaccid paralysis - diplopia - ataxia - bulbar palsy risk factor: IVDU, home canning Treatment - botulism antitoxin and supportive care - antitoxin is only effective if given early - once toxin has bound its actions cannot be reversed
284
what test can confirm an acute haemolytic transfusion reaction?
Direct Coombs test
285
state transfusion threshold for the following conditions
patients without ACS: Hb 70 g/L patients with ACS: Hb 80 g/L
286
List side-effects associated with the following antibiotics - amoxicillin - co-amoxiclav - flucloxacillin - erythromycin - ciprofloxacin - metronidazole - doxycycline - trimethoprim
- amoxicillin: rash with infectious mononucleosis - co-amoxiclav: cholestasis - flucloxacillin: cholestasis (several weeks after use) - erythromycin: GI upset, QTc prolongation - ciprofloxacin: lower seizure threshold, tendonitis - metronidazole: reaction following alcohol ingestion - doxycycline: photosensitivity - trimethoprim: rashes (photosensitivity), pruritus, suppression of haemotopoiesis
287
Describe autoimmune haemolytic anaemia
features - macrocytic anaemia - reticulocytosis - low haptoglobin - raised LDH and bilirubin - positive direct antiglobulin test (Coombs' test) - spherocytes 2 types > warm AIHA - most common, IgG mediated - causes: > idiopathic > autoimmune e.g. SLE > neoplasia: lymphoma, CLL > drugs e.g. methyldopa - management: treat underlying disorder, steroids +/- rituximab > cold AIHA - IgM mediated, worse in cold - symptoms of Raynaud's and acrocyanosis - causes: > neoplasia e.g. lymphoma > infections e.g. mycoplasma, EBV - treat underlying cause, respond less well to steroids
288
describe driving rules for insulin-dependent diabetics
check BM before driving and every 2 hours whilst driving regardless of whether they have eaten or not
289
describe the management of a ruptured AAA
haemodynamically unstable - immediate vascular review with a view to emergency surgical repair - palliative if patient is frail with multiple comorbidities haemodynamically stable - CT angiogram - assess suitability of repair
290
how would you manage an immunosuppressed patient who has been exposed to varicella zoster virus (chickenpox)?
- send a blood test for varicella antibodies - give varicella zoster immunoglobulin immediately (antibody testing should not delay post-exposure prophylaxis past 7 days after initial contact)
291
describe myxoedema coma and its management
features - confusion - bradycardia - hypothermia - profoundly hypothyroid Management - IV thyroid replacement (T3 + T4) - IV hydrocortisone (until coexisting adrenal insufficiency has been excluded) - IV fluids - Electrolyte imbalance correction - Sometimes rewarming
292
Describe Legionella pneumophila
Cause of atypical pneumonia classically spread by air conditioning systems clinical features > dry cough > fever > relative bradycardia > confusion > lymphopaenia > deranged LFTs > hyponatraemia > pleural effusion > bilateral mid-lower zone consolidation investigations > urinary Legionella antigen treatment - clarithromycin
293
describe the following surgical incisions - midline incision - paramedian incision - Battle - Kocher's - Lanz - Gridiron - Gable - Pfannenstiel's - McEvedy's - Rutherford Morrison
- midline > structures divided: linea alba, transversalis fascia, extraperitoneal fat, peritoneum - paramedian > parallel to midline > structures divided: anterior rectus sheath, rectus (retracted), posterior rectus sheath, transversalis fascia, extraperitoneal fat, peritoneum - Gable (rooftop): good access to upper abdomen e.g. pancreatectomy - battle > similar location to paramedian but rectus displaced medially (seldom used) - Kocher's > incision under right subcostal margin: open cholecystectomy - Lanz > incision in RIF: appendicectomy - Gridiron > oblique incision over McBurney's point (appendicectomy) but less cosmetically acceptable than Lanz - Pfannenstiel's: transverse suprapubic, C-section - McEvedy's: groin incision e.g. emergency repair strangulated femoral hernia - Rutherford Morrison: extraperitoneal approach to left or right lower quadrants: renal transplantation
294
describe alcoholic ketoacidosis
presents with similar features to DKA but BM might be normal or low
295
describe the management of burns
assess airway and consider early intubation if deep burns to face or neck, blisters/oedema of oropharynx, stridor conservative management - superficial burns and mixed superficial burns that will heal in 2 weeks - complex burns: excision and skin grafting IV fluids if >15% burn area > Parkland formula says volume of fluid = TBSA % x weight (kg) x 4 > half of the fluid is administered within first 8h no evidence for antimicrobial prophylaxis or topical antibiotics transfer burns involving hand, perineum and face to burns unit escharotomies - indicated in circumferential full thickness burns to torso or limbs - can improve ventilation or relieve compartment syndrome/oedema
296
list features of urethral injury after trauma
pelvic fractures may cause laceration of the urethra features - urinary retention - blood at urethral meatus - high riding prostate on DRE
297
describe acute liver failure
triad of jaundice, encephalopathy and coagulopathy most accurate marker for assessing liver function acutely - prothrombin time
298
describe multiple endocrine neoplasia
AD condition MEN I - 3 Ps > parathyroid (hyperparathyroidism) > pituitary e.g. prolactinoma > pancreas e.g. insulinoma, gastrinoma also adrenal and thyroid, MEN1 gene MEN IIa - 2 Ps: hyperparathyroidism, phaeochromocytoma - medullary thyroid cancer > originates from parafollicular cells, produces calcitonin - RET oncogene MEN IIb - medullary thyroid cancer - 1 P: phaeochromocytoma - marfanoid body habitus - neuromas - RET oncogene
299
describe periorificial dermatitis
condition seen in women 20-45 topical and inhaled steroids are involved in the development of this condition features - clustered erythematous papules, papulovesicles and papulopustules - most commonly in perioral region but also perinasal and periocular region management - steroids may worsen symptoms - treat with topical or oral antibiotics e.g. doxycycline
300
describe carbon monoxide poisoning
features - headache - nausea and vomiting - vertigo - confusion - subjective weakness - severe toxicity: pink mucosa and skin, hyperpyrexia, arrhythmias, extrapyramidal features, coma, death investigations - pulse oximetry not reliable - do VBG or ABG Management - 100% O2 via non-rebreather mask - hyperbaric oxygen in severe cases e.g. CO >25%
301
describe step down of asthma treatment
aim for reduction of 25-50% in ICS dose keep LABA the same
302
describe serum ascites albumin gradient (SAAG)
SAAG >11 indicates portal hypertension - liver disorders are the most common cause e.g. cirrhosis, acute liver failure management: - paracentesis if tense ascites - reduce dietary sodium - aldosterone antagonist e.g. spironolactone - prophylactic antibiotics against SBP: ciprofloxacin, norfloxacin - TIPS in some patients - cardiac causes: right heart failure, constrictive pericarditis - other causes: budd chiari syndrome, myxoedema SAAG <11 - hypoalbuminaemia e.g. nephrotic syndrome, severe malnutrition - malignancy e.g. peritoneal carcinomatosis - other causes e.g. pancreatitis, bowel obstruction, biliary ascites
303
What benign haematological finding is common in people of black African and Afro-Caribbean ethnicity
benign ethnic neutropaenia
304
describe water deprivation testing
cranial DI > urine osmolality after fluid deprivation: low > urine osmolality after desmopressin: high healthy individual / primary polydipsia > urine osmolality after fluid deprivation: high > urine osmolality after fluid deprivation: high nephrogenic DI > urine osmolality after fluid deprivation: low > urine osmolality after desmopressin: low
305
what route of administration is most appropriate for the delivery of total parenteral nutrition
central line as it is strongly phlebitic
306
describe cataplexy
sudden and transient episode of muscle weakness > can result in fall/collapse triggers > strong emotions e.g. laughter, anger, surprise often associated with narcolepsy (excessive daytime sleepiness and fragmented nighttime sleep)
307
describe dermatitis herpetiformis
intensely pruritic chronic autoimmune skin condition caused by formation of IgA antibodies features - papules and vesicles - affects extensor surfaces such as elbows, knees and buttocks associated with gluten sensitivity and coeliac disease
308
when co-prescribing spironolactone and ramipril which electrolyte abnormality can occur?
potassium-sparing diuretics may interact with K+ supplemented or ACEi to cause dangerous hyperkalaemia
309
describe a dermatofibroma
aka histiocytoma fibrous solitary slow-growing papules caused by abnormal growth of dermal dendritic histiocyte cells features - raised - brown in colour - may be itchy - rarely painful - dimple sign: applying lateral pressure produces central depression can occur anywhere but most commonly arms and legs often precipitated by injury such as insect bite or thorn prick
310
list EBV associated conditions
- oral hairy leukoplakia > white patches on lateral borders of tongue > painless / mild discomfort > cannot be removed with light pressure - Burkitt's lymphoma - Hodgkin's lymphoma - nasopharyngeal carcinoma - HIV-associated CNS lymphomas
311
Describe temporal arteritis
aka giant cell arteritis inflammatory disease of large blood vessels commonly in patients >50 with symptoms such as - temporal headache - scalp tenderness - jaw claudication - lethargy - visual disturbances e.g. sudden visual loss fundoscopy - optic disc appears pale and oedematous due to anterior optic ischaemic neuropathy > secondary to inflammation of posterior ciliary arteries
312
which medication can be used for the prophylaxis of calcium renal stones?
chlorthalidone > thiazide-like diuretic which increases tubular calcium reabsorption, lowering its concentration in the urine
312
list complications of coeliac disease
- anaemia: iron, folate or B12 deficiency > mixed anaemia may lead to normocytic anaemia: low/normal ferritin, wide distribution of red blood cell volume - hyposplenism - osteoporosis, osteomalacia - lactose intolerance - enteropathy-associated T cell lymphoma of small intestine - subfertility - rare: oesophageal cancer, other malignancies
313
describe the management of motion sickness
hyoscine is most effective cyclizine is second most effective promethazine is third most effective
314
describe anti-glomerular basement membrane disease aka Goodpasture's syndrome
rare small vessel vasculitis associated with - pulmonary haemorrhage - rapidly progressive glomerulonephritis > rapid onset AKI >nephritis: proteinuria + haematuria caused by anti-GBM antibodies against type IV collagen associated with HLA DR2 investigations: > renal biopsy: linear IgG deposits along basement membrane > raised TLCO secondary to pulmonary haemorrhage Management - plasma exchange: plasmapheresis - steroids - cyclophosphamide
315
describe tertiary hyperparathyroidism
features - extremely high PTH - moderately raised calcium occurs almost exclusively in patients with CKD ongoing hyperplasia of parathyroid glands leads to excess PTH causing > accelerated bone breakdown > bone pain > fractures > kidney stones
316
describe the management of splenic trauma
conservative - small subcapsular haematoma - minimal intra-abdominal blood - no hilar distribution laparotomy with conservation - increased amounts of intra-abdominal blood - moderate haemodynamic compromise - tears/lacerations affecting <50% resection - hilar injuries - major haemorrhage - major associated injuries
317
describe cryptococcosis
cryptococcus neoformans - encapsulated yeast usually in the lungs but can cause fungal meningitis/encephalitis in immunocompromised patients staining - India ink
318
describe the following anaesthetic agents - propofol - sodium thiopentone - etomidate - halothane - ketamine
- propofol > GABA receptor agonist > mild antiemetic properties > rapid onset of anaesthesia > pain on IV injection > moderate myocardial depression - sodium thiopentone > extremely rapid onset of action for RSI > marked myocardial depression > unsuitable for maintenance infusion > few analgesic effects - ketamine > NMDA receptor antagonist > moderate to strong analgesic properties > produces little myocardial depression > can lead to dissociate anaesthesia and induce nightmares - etomidate > favourable cardiac safety profile > no analgesic properties > can lead to adrenal suppression so not suitable for prolonged use > can cause post-op vomiting - halothane: hepatotoxic
318
describe neoplastic spinal cord compression
features - back pain > earliest and most common symptom > may be worse on lying down and coughing/straining - lower limb weakness - sensory changes: sensory loss and numbness - neurological signs depend on level of lesion investigation - urgent MRI whole spine management - high-dose oral dexamethasone - urgent oncological assessment for consideration of radiotherapy or surgery
318
describe discitis
infection of IVD space features - back pain - pyrexia, rigors - changing lower limb neurology causes - bacterial: most commonly staph aureus - viral - TB - aseptic diagnosis - MRI - CT-guided biopsy complications - sepsis - epidural abscess management - 6-8 weeks of IV Abx - assess for endocarditis with echocardiogram
319
describe the treatment of urticaria
aspirin is a common cause first-line: non-sedating oral antihistamine - loratadine - cetirizine sedating antihistamine e.g. chlorphenamine for nighttime use severe urticaria (>24h) > short course of oral prednisolone + oral loratadine
320
describe molluscum contagiosum
common skin infection caused by molluscum contagiosum virus (MCV), a DNA poxvirus. features - pinkish or pearly white papules with a central umbilication - lesions appear in clusters in areas anywhere on the body (except the palms and soles) - children: lesions on trunk and in flexures; anogenital lesions may also occur - adults: sexual contact may lead to lesions developing on the genitalia, pubis, thighs, and lower abdomen. Treatment - not usually recommended, self-resolves - If lesions are troublesome: simple trauma or cryotherapy treatment may be required if > problematic itching: emollient and mild topical corticosteroid (e.g. hydrocortisone 1%) > infections: topical antibiotic (e.g. fusidic acid 2%) Referral: > HIV-positive with extensive lesions > eyelid-margin or ocular lesions and associated red eye > Adults with anogenital lesions
321
describe the management of atelectasis
chest physiotherapy and deep breathing exercises
322
explain the interpretation of syphilis testing
Treponemal tests > T. pallidum enzyme immunoassay (TP-EIA) test - acute IgM antibody to syphilis > may be negative in reinfection > T-pallidum particle agglutination (TPPA) test (treponemal test) > often remains positive in patients who have been previously infected Non-treponemal tests: The rapid plasma reagin (RPR) test OR venereal disease research laboratory (VDRL) > useful to monitor disease activity and reinfection > A rise by 4-fold or more in a previously infected patient either indicates no treatment response or reinfection > false positives: SLE, TB, malaria, HIV, pregnancy, leprosy test results - positive non-treponemal + positive treponemal = active syphilis infection - positive non-treponemal test + negative treponemal test = false positive syphilis result - negative non-treponemal test + positive treponemal test: successfully treated syphilis
323
what is the treatment for local anaesthetic toxicity?
IV lipid emulsion
324
which group of drugs is associated with the presence of hyaline casts in urine?
loop diuretics
325
what is the most common cause of peritonitis in patients undergoing peritoneal dialysis?
staphylococcus epidermis (CoNS)
326
describe ischaemic colitis
acute transient compromise in blood flow to large bowel can lead to inflammation, ulceration and haemorrhage most commonly in splenic flexure investigations > thumbprinting on AXR due to mucosal oedema / haemorrhage management - supportive - surgery if generalised peritonitis, perforation or ongoing haemorrhage
327
what does the snowstorm sign on ultrasound of axillary lymph nodes indicate?
implant rupture
328
patients with type I DM and BMI >25 should be considered for what treatment in addition to insulin
metformin
329
describe streptococci and their associated infections
alpha haemolytic streptococci - streptococcus pneumoniae: pneumonia, meningitis, otitis media - streptococcus viridans beta haemolytic streptococci - only groups A, B & D are important in humans - group A > Streptococcus pyogenes: erysipelas, cellulitis, impetigo, type 2 necrotising fasciitis, pharyngitis / tonsillitis > immunological reactions can cause rheumatic fever or post-strep glomerulonephritis > erythrogenic toxins cause scarlet fever - group B > streptococcus agalactiae: neonatal meningitis, septicaemia - group D > enterococcus
330
describe conversion rates between different opioids
oral codeine to oral morphine: divide by 10 oral tramadol to oral morphine: divide by 10 oral morphine to oral oxycodone: divide by 2 oral morphine to oral diamorphine: divide by 3 oral morphine to SC morphine: divide by 2 oral morphine to SC diamorphine: divide by 2 oral oxycodone to SC diamorphine: divide by 1.5
331
describe thromboangiitis obliterans
aka buerger's disease small and medium vessel vasculitis strongly associated with smoking characterised by raynaud's phenomenon with extremity ischaemia > intermittent claudication > ischaemic ulcers also superficial thrombophlebitis
332
describe a keratoacanthoma
benign epithelial tumour features - said to look like a volcano or crater - initially a smooth dome-shaped papule - rapidly grows to become a crater centrally-filled with keratin spontaneous regression within 3 months is common, often resulting in a scar however, lesions should be removed urgently > difficult to exclude SCC > can prevent scarring
333
describe side-effects associated with the following chemotherapy drugs: - alkylating agents - cytotoxic antibiotics - anthracyclines - antimetabolites - act on microtubules - cisplatin
alkylating agents - cyclophosphamide: haemorrhagic cystitis, myelosuppression, transitional cell carcinoma cytotoxic antibiotics - bleomycin: lung fibrosis anthracyclines e.g. doxorubicin: cardiomyopathy antimetabolites - methotrexate: myelosuppression, mucositis, liver fibrosis, lung fibrosis - fluorouracil: myelosuppression, mucositis, dermatitis - cytarabine: myelosuppression, ataxia act on microtubules - vincristine, vinblastine: peripheral neuropathy, paralytic ileus, myelosuppression - docetaxel: neutropaenia cisplatin: ototoxicity, peripheral neuropathy, hypomagnesaemia
334
Describe the clinical features of prolactinoma
- headaches - amenorrhoea - visual field defects (bitemporal hemianopia)
335
describe yellow fever
caused by yellow fever virus, a member of Flaviviridae group, transmitted by Aedes mosquito clinical features - flu-like illness followed by brief remission > high fever, malaise, nausea, myalgia, headache, bradycardia - some patients recover completely - some patients progress > hepatitis with jaundice > haematemesis > fever > nausea and vomiting > AKI with oliguria > haemorrhage Councilman bodies may be seen in hepatocytes
336
what medications can a GP give in a patient with suspected meningitis while an ambulance arrives?
IM benzylpenicillin, IV ceftriaxone
337
describe the treatment of DVT depending on renal function
eGFR 15-50: DOAC eGFR <15: unfractionated heparin or dose-adjusted LMWH
338
describe the KDIGO criteria for AKI
Stage I - rise in serum creatinine 1.5-1.9x baseline - urine output <0.5ml/kg/h for 6h Stage II - rise in serum creatinine 2.0-2.9x baseline - urine output <0.5ml/kg/h for 12h Stage III - rise in serum creatinine >=3x baseline - urine output <0.3ml/kg/h for 24h
339
describe restless leg syndrome
syndrome of spontaneous, continuous lower limb movements that may be associated with paraesthesia Clinical features - uncontrollable urge to move legs (akathisia) > Symptoms initially at night but as condition progresses may occur during the day - worse at rest - paraesthesias e.g. 'crawling' or 'throbbing' sensations - periodic limb movements during sleep associations iron deficiency anaemia uraemia diabetes mellitus pregnancy Management simple measures: walking, stretching, massaging affected limbs dopamine agonists are first-line treatment (e.g. Pramipexole, ropinirole) benzodiazepines gabapentin
340
list clinical features of coeliac disease and its diagnosis
features - failure to thrive in young children - bloating - diarrhoea - fatigue - weight loss - mouth ulcers - dermatitis herpetiformis diagnosis - HLA DQ2/8 - anti-TTG antibodies (tissue transglutaminase) - anti-endomysial antibodies > Both are IgA antibodies so must test for total immunoglobulin A levels before interpretation > must eat gluten for 6 weeks before testing duodenal biopsy features - crypt hyperplasia - villous atrophy - lymphocytic infiltration associations: T1DM, thyroid disease, autoimmune hepatitis...
341
what is the most likely organism to be associated with gangrene?
clostridium perfringens
342
describe autoimmune hepatitis
most common in young females type I - ANA - anti smooth muscle antibody - adults and children type II - anti liver/kidney microsomal type 1 antibodies (LKM1) - children type III - soluble liver-kidney antigen - middle-aged adults features - acute hepatitis: fever, jaundice... - signs of chronic liver disease - amenorrhoea - raised IgG - liver biopsy: piecemeal necrosis, bridging necrosis management - steroids - other immunosuppressants e.g. azathioprine - liver transplantation
343
describe lead poisoning
features - abdominal pain - constipation - blue lines on gum margin - neuropsychiatric features - peripheral neuropathy (mainly motor) - fatigue blood film: basophilic stippling, clover leaf morphology bloods - lead levels >10 mcg/dl are significant - microcytic anaemia raised serum and urine levels of delta aminolaevulinic acid (difficult to differentiate from acute intermittent porphyria) urinary coproporphyrin also increased management - dimercaptosuccinic acid (DMSA) - D-penicillamine - EDTA - dimercaprol
344
describe bile acid malabsorption
causes - primary: excessive production of bile acid - secondary: underlying GI disorder causing malabsorption > cholecystectomy > coeliac disease > Crohn's > SIBO features - steatorrhoea - vitamin A,D,E,K malabsorption investigations - SeHCAT management - bile acid sequestration with cholestyramine
345
describe alpha thalassaemia
- autosomal recessive disorder more common in african and asian populations - due to defects in alpha globin genes causes a hypochromic microcytic anaemia with target cells > 1 defective gene: silent carrier > 2 defective genes: alpha thalassaemia minor > 3 defective genes: HbH disease > 4 defective genes: Hb Bart's hydrops fetalis - incompatible with life diagnosis - haemoglobin electrophoresis, genetic testing
346
describe DEXA scans
areas commonly scanned are femoral neck and lumbar spine DEXA scan involves two X-ray beams aimed at bones bone mineral density is calculated by subtracting X-ray absorbed by soft tissue from total X-ray absorbed, which gives the amount of X-ray absorbed by bones
347
describe staphylococcal toxic shock syndrome
severe systemic reaction to staphylococcal exotoxins features - fever - hypotension - diffuse erythematous rash - desquamation of rash, especially of the palms and soles - involvement of three or more organ systems: e.g. gastrointestinal (diarrhoea and vomiting), mucous membrane erythema, renal failure, hepatitis, thrombocytopenia, CNS involvement (e.g. confusion) Management - speculum examination: removal of infection focus (e.g. retained tampon) - IV fluids - IV antibiotics
348
describe an aspergilloma
- non-saphrophytic (non-invasive) - leads to colonisation of pre-existing cavities > TB, sarcoidosis, bullous emphysema, bronchiectasis lesion can impinge on a major vessel or airway leading to haemoptysis presents as a fungus ball CXR - partially filled cavity with crescent of air
349
describe the following conditions - Zoon's balanitis - circinate balanitis - erythroplasia of Queyrat
zoon's balanitis - benign idiopathic condition in uncircumcised men - may be secondary to lichen planus or erythroplasia of Queyrat - features: orange-red lesions with pinpoint redder spots on glans and adjacent areas of foreskin circinate balanitis - chronic balanitis in men with Reiter's syndrome / in isolation - features: well-demarcated erythematous plaque with ragged white border erythroplasia of queyrat - in-situ squamous cell carcinoma - features: single or multiple plaques with red, velvety appearance, often asymptomatic
350
describe melanosis coli
benign condition characterised by the presence of pigment-laden macrophages in the lamina propria of the colon most commonly associated with chronic laxative abuse particularly anthraquinone-containing laxatives such as cascara or senna
351
describe leptospirosis
caused by spirochaete Leptospira interrogans spread by contact with infected rat urine, more common in tropics/sewers features - flu-like illness, fever - conjunctival haemorrhage - hepatitis: jaundice, hepatomegaly - AKI - aseptic meningitis investigations - serology (antibodies may not be present until after 7 days) - PCR is less commonly used - culture: blood and CSF samples positive for 10 days, urine cultures become positive during second week management - high dose benzylpenicillin or doxycycline
352
describe lipomas and their investigation
benign masses made up of fat alone clinical diagnosis - lump is smooth, mobile and painless features suggestive of sarcomatous change (becoming a liposarcoma) - size >5cm - increasing size - pain - deep anatomical location management - reassurance and no need to review if <5cm - can be removed surgically if causing symptoms such as pain or affecting nearby structures - ultrasound if suspicious or >5cm
353
describe thoracic outlet syndrome
disorder involving compression of brachial plexus, subclavian artery or vein at the site of thoracic outlet
354
describe the following complications of sickle cell anaemia - aplastic crisis - sequestration crisis - vaso-occlusive crisis - acute chest syndrome - haemolytic crisis
- aplastic crisis > often triggered by parvovirus B19 infection > features: significant pancytopenia, most notably a severe drop in haemoglobin - acute chest syndrome > features: chest pain, cough, wheeze, dyspnoea and tachypnoea > Imaging: pulmonary infiltrates - haemolytic crisis > features: severe anaemia and jaundice due to sudden haemolysis - Sequestration crisis > features: abdominal pain, signs of haemodynamic compromise and hepatomegaly/splenomegaly > Pooling of blood in the spleen occurs, leading to severe anaemia and haemodynamic collapse. - Vaso-occlusive crisis > could affect different organs, but would present with acute pain due to microvascular occlusion > Other presentations: dactylitis, cerebral infarction, mesenteric ischaemia, avascular necrosis of the femoral head or priapism.
355
describe - latent autoimmune diabetes of adulthood (LADA) - maturity onset diabetes of the young (MODY)
- LADA > late onset type 1DM > progression of autoimmune -cell failure is slow > patients are younger than in T2DM without increased body habitus > do not require insulin early in stages of disease > diagnosis: autoantibody testing - MODY > early onset type 2 DM > inherited genetic disorder affecting insulin production > symptoms similar to T2DM e.g. asymptomatic hyperglycaemia but can progress to DKA
356
list dermatological manifestations of SLE
- alopecia - photosensitivity - butterfly rash - discoid lupus - livedo reticularis
357
describe paget's disease
increased uncontrolled bone turnover - disorder of osteoclasts, with excessive osteoclastic resorption followed by increased osteoblastic activity Predisposing factors: increasing age, male sex, northern latitude, family history Clinical features - bone pain (e.g. pelvis, lumbar spine, femur) - classical, untreated features: bowing of tibia, bossing of skull Investigations - bloods: isolated raised ALP - calcium and phosphate are typically normal but hypercalcaemia can occur - raised alkaline phosphatase (ALP) x-rays - osteolysis in early disease → mixed lytic/sclerotic lesions later - skull x-ray: thickened vault, osteoporosis circumscripta - bone scintigraphy: increased uptake is seen focally at the sites of active bone lesions Management (if symptomatic) - bisphosphonate (either oral risedronate or IV zoledronate) - calcitonin is less commonly used now Complications - deafness (cranial nerve entrapment) - bone sarcoma - fractures - high-output cardiac failure
358
describe arterial ulcers
- Occur distally: toes or dorsum of foot - associated with peripheral arterial disease > absent pulses, pallor and intermittent claudication - smaller and deeper than venous ulcers - well defined borders - “punched-out” appearance - pale colour due to poor blood supply, less likely to bleed - painful: worse at night (when lying horizontally) and on elevation management same as peripheral arterial disease, >urgent referral for surgical revascularisation. If the underlying arterial disease is effectively treated, the ulcer should heal rapidly. Debridement and compression are not used in arterial ulcers.
359
describe venous ulcers
clinical features - location: gaiter area (between the top of the foot and bottom of the calf muscle) - associated with chronic venous changes > hyperpigmentation, venous eczema and lipodermatosclerosis - after a minor injury to the leg - larger and more superficial than arterial ulcers - irregular, gently sloping border - more likely to bleed, less painful than arterial ulcers - pain relieved by elevation and worse on lowering the leg management - good wound care > cleaning the wound > debridement (removing dead tissue) > dressing the wound - compression bandaging - pentoxifylline (taken orally) - analgesia is used to manage pain (avoid NSAIDs as they can worsen the condition).
360
describe varicose veins and tests used for their assessment
Varicose veins: distended superficial veins >3mm in diameter, usually in legs due to incompetent valves in perforating veins, so blood flows from the deep veins back into superficial veins and overloads them presentation - asymptomatic - Heavy or dragging sensation in the legs - Aching - Itching - Burning - Oedema - Muscle cramps - Restless legs special tests - Tap test - Cough test - Trendelenburg’s test - Perthes test - Duplex venous ultrasound
361
describe management options for varicose veins and associated complications
conservative - Weight loss - Staying physically active - Keeping the leg elevated when possible to help drainage - Compression stockings (exclude arterial disease first with an ankle-brachial pressure index) Surgical options: - Endothermal ablation – inserting a catheter into the vein to apply radiofrequency ablation - Sclerotherapy – injecting the vein with an irritant foam that causes closure of the vein - Stripping – the veins are ligated and pulled out of the leg Complications - Prolonged and heavy bleeding after trauma - Superficial thrombophlebitis - DVT
362
describe neutropaenic sepsis and its management
neutropaenic sepsis - neutrophil count <0.5 x 10^9 /L (don't wait for FBC to start treatment) - OR temperature >38 most often associated with anti-cancer treatment but can be caused by - clozapine - hydroxycholorquine - methotrexate - carbimazole - infliximab - others most common cause: coagulase negative gram positive bacteria (CoNS) such as Staphylococcus epidermis treatment - piperacillin/tazobactam > if penicillin allergic: amikacin / vancomycin / ciprofloxacin - granulocyte colony stimulating factor (G-CSF) is sometimes given
363
describe overflow incontinence
due to chronic urinary retention features - dribbling - intermittent stream - straining - frequent voiding small amounts - feel sincomplete after emptying caused by blockage e.g. BPH or inefficient contraction e.g. spinal cord injury management - treat underlying cause - intermittent self-catheterisation - indwelling catheter only if recurrent UTIs or high pressure retention - devices: urosheaths - percutaneous sacral nerve stimulation (PTNS)
364
explain the difference between functional and passive urinary incontinence
Functional - know they need to go but physically can't get there e.g. reduced mobility Passive - physically can control bladder but cognitive impairment so don't go to toilet
365
list symptoms of hyponatraemia
- nausea and vomiting - headache - confusion - drowsiness, fatigue - restlessness, irritability - muscle weakness, cramps or spasms - severe: seizures, coma
366
list the Wells criteria
- clinical signs of DVT: 3 points - alternative diagnosis is less likely than PE: 3 points - heart rate >100 bpm: 1.5 points - immobilisation >3 days or surgery previous 4 weeks: 1.5 points - previous DVT/PE: 1.5 points - haemoptysis: 1 point - malignancy: 1 point
367
describe pityriasis versicolor
Pityriasis versicolor is a superficial fungal infection features - flaky rash - predominantly affects trunk - white, red and brown variants - can be pruritic management - ketoconazole shampoo - if ineffective, send scrapings to confirm diagnosis and start oral itraconazole.
367
describe pyoderma gangrenosum
rare non-infectious neutrophilic dermatosis clinical features - initially small painful red nodule/pustule - progresses to a deep necrotic ulcer with violaceous borders 50% idiopathic but can be associated with > IBD > Connective tissue disorders e.g. RA, SLE > Myeloproliferative disorders e.g. AML, lymphoma > granulomatosis with polyangiitis > primary biliary cirrhosis management - oral prednisolone first-line - other immunosuppressants if resistant
368
describe necrobiosis lipoidica diabeticorum
rare skin disorder commonly seen in people with diabetes usually presents on shins clinical features - shiny red-brown patches - develop into plaques with atrophic centres and raised borders - associated with telangiectasia
369
what is the treatment for adrenaline-induced ischaemia?
local infiltration of phentolamine > alpha-adrenoceptor antagonist
370
which vein is usually used for venous cutdown
long saphenous vein (anterior to medial malleolus)
371
list monitoring requirements for methotrexate
3 monthly FBC, U&Es, LFTs
372
When should diabetic patients get in contact with the DVLA?
More than one episode of severe hypoglycaemia - requiring assistance - in the past 12 months must inform DVLA and surrender their license
373
describe hepatocellular carcinoma and its management
features - jaundice - ascites - RUQ pain - splenomegaly - hepatomegaly screening: ultrasound +/- alpha fetoprotein management - early: resection - liver transplantation - radiofrequency ablation - metastatic HCC: sorafenib (multikinase inhibitor)
374
describe hepatitis E
RNA hepevirus spread by the faecal-oral route; incubation period: 3-8 weeks common in Central and South-East Asia, North and West Africa, and in Mexico similar disease to hepatitis A but significant mortality during pregnancy does not cause chronic disease or increased risk of HCC
375
describe a non-functioning pituitary adenoma
features - headaches - hypogonadism - hypothyroidism - mildly elevated prolactin (stalk compression effect)
376
describe hypophysitis
failure of anterior and posterior pituitary features - adrenal insufficiency - diabetes insipidus - hypogonadism - hypothyroidism
377
describe the classification of CKD
CKD 1 - eGFR >=90 AND symptoms CKD 2: eGFR 60-89 AND symptoms CKD 3a: eGFR 45-59 CKD 3b: eGFR 30-44 CKD 4: eGFR 15-29 CKD 5: eGFR <15
378
how long should you wait between courses of topical steroids
4 weeks
379
describe acute respiratory distress syndrome (ARDS)
Causes - infection: sepsis, pneumonia - massive blood transfusion, trauma - smoke inhalation - acute pancreatitis - cardio-pulmonary bypass Clinical features (acute onset and severe): - dyspnoea, tachypnoea - bilateral lung crackles - low oxygen saturations Investigations pulmonary oedema: bilateral infiltrates on chest x-ray non-cardiogenic (pulmonary artery wedge pressure to confirm) pO2/FiO2 < 40kPa Management - oxygenation/ventilation: hypoxaemia - general organ support - treatment of underlying cause e.g. antibiotics for sepsis
380
describe pseudocholinesterase deficiency
aka suxamethonium apnoea - rare abnormality in the production of plasma cholinesterases - leads to increased duration of action of muscle relaxants e.g. suxamethonium - results in respiratory arrest - patient requires mechanical ventilation while the circulating muscle relaxants degrade
381
describe the ORBIT scoring system for bleeding risk
- haemoglobin <130g/L for males, <120g/L for females: 2 points - age >74: 1 point - bleeding history (GI bleeds, haemorrhagic stroke): 2 points renal impairment (GFR<60): 1 point - treatment with antiplatelets: 1 point
382
how can the risk of contrast nephropathy be reduced?
volume expansion with 0.9% NaCl prior to scan
383
list the components of the CHA2DV2ASC scoring system
scoring system to assess need for anticoagulation in AF Congestive heart failure: 1 point Hypertension: 1 point Age >75: 2 points Diabetes: 1 point S: stroke, TIA, VTE: 2 points Vascular disease: 1 point Age 65-74: 1 point Sex category (female): 1 point need for anticoagulation - males >=1 points - females >=2 points if no anticoagulation required, perform echocardiogram to exclude valvular heart disease
384
differentiate between gastric and duodenal ulcers
gastric ulcer - worsened by eating - associated with weight loss duodenal ulcer - improved by eating - associated with weight gain - gastroduodenal artery most at risk
385
describe a hydrocoele and its management
clinical features > non-painful, soft, fluctuant swelling > contains clear fluid which transilluminates > may be presenting feature of testicular cancer in young men > can "get above it" on examination management - infants > common in newborn males due to patent processus vaginalis > usually resolve within first months of life > repaired if do not resolve by 1-2 years of age - adults > conservative approach > ultrasound to exclude malignancy
386
describe hookworms
e.g. ancylostoma braziliense, strongyloides stercoralis, toxocara canis clinical features - anaemia (visceral larva migrans) - eosinophilia - rash (cutaneous larva migrans) - abdo pain - diarrhoea - pneumonitis - can have liver involvement - pruritus hookworms aka nematodes are acquired from skin contact with contaminated soil or ingestion of eggs from soil contaminated by dog faeces endemic in areas e.g Asia, Africa, South America diagnosis - stool culture: ova management - thiabendazole, albendazole - ivermectin in chronic infection
387
describe Mycobacterium avium intracellulare
atypical mycobacteria seen in HIV when CD4 count is below 50 features - fever - sweats - abdominal pain - diarrhoea - hepatomegaly - deranged LFTs diagnosis - blood culture - bone marrow examination management - rifabutin - ethambutol - clarithromycin
388
name a common side-effect of indapamide
erectile dysfunction
389
describe high altitude cerebral oedema
features - headache - ataxia - papilloedema Management - descent - dexamethasone - prevention: acetazolamide
390
describe the management of high altitude pulmonary oedema
acute mountain sickness develops after 6-12 hours at >2500-3500m > features: nausea, headache, fatigue can progress to HACE and HAPE Management of HAPE - descent - nifedipine - dexamethasone - acetazolamide - phosphodiesterase type V inhibitors - oxygen if available
391
describe pellagra
vitamin B3 (niacin) deficiency 4 D's - diarrhoea - dermatitis (brown scaly rash on sun-exposed sites) > Casal's necklace if around the neck - dementia, depression - death causes - isoniazid (prevents dietary tryptophan conversion to vitamin B3) - alcoholics
392
describe the management and complications associated with shingles
management - advise patients they are infectious until lesions have crusted over, 5-7 days following onset - analgesia: paracetamol, NSAIDS, amitriptyline - oral steroids if severe refractory pain - antivirals within 72h for most patients > first-line: oral famciclovir or valacyclovir > second-line: oral aciclovir complications - post-herpetic neuralgia (most common complication, antivirals reduce risk) - herpes zoster ophthalmicus - herpes zoster oticus (Ramsay Hunt syndrome): may result in ear lesions and facial paralysis
393
describe pityriasis alba
features - dry rough skin cheeks (keratosis pilaris) - subtle hypopigmentation - more common in Asian skin - often atopic management - emollients - sunscreen
394
describe tinea capitis
more common in Black African populations organisms - trichophyton tonsurans, trichophyton violaceum features - diffuse scale - patchy alopecia - black dots (broken hairs) - pustules - post-auricular lymphadenopathy - boggy swelling (kerion) diagnosis: > scrape from affected site > rub with moist swab > sterile tooth brush management - ketoconazole shampoo / topical terbinafine if head shaved to prevent spread - oral griseofulvin / terbinafine / fluconazole
395
describe pityriasis rosea
self-limiting rash, viral origin > initial presentation: single pink or red "herald patch" > then smaller similar lesions develop along skin cleavage lines in christmas tree pattern on the trunk management: none, self-resolves
396
describe breast screening
mammogram every 3 years in women 50-70
397
describe allergy testing
skin prick test - most commonly used - food allergies, pollen radioallergosorbent test (RAST) - determines amount of IgE reacting to suspected/known allergens like IgE to egg protein - food allergies, inhaled allergens (e.g. pollen), wasp/bee venom skin patch testing - contact dermatitis
398
list side-effects of diabetic drugs
metformin - GI upset e.g. diarrhoea > improved with modified release preparations > risk of lactic acidosis during intercurrent illness / AKI > contraindicated in eGFR <30 sulfonylurea e.g. gliclazide - risk of hypoglycaemia - hyponatraemia - weight gain - avoid when breastfeeding - contraindicated in renal failure thiazolidinedione e.g. pioglitazone - contraindicated in heart failure, bladder cancer DPP-4 inhibitor e.g. sitagliptin GLP-1 agonists e.g. semaglutide > weight loss SGLT2 inhibitor e.g. dapagliflozin - risk of euglycaemic DKA - risk of recurrent thrush / UTI due to glycosuria - risk of leg ulcers and amputation
399
list indications for urgent haemodialysis
AEIOU - acidosis (pH <7.1) - electrolytes: refractory hyperkalaemia - ingestion or overdose - overload (refractory to diuretics) - uraemia (uraemic pericarditis / encephalopathy)
400
describe Lemierre's syndrome
infectious thrombophlebitis of internal jugular vein following anaerobic oropharyngeal infection usually secondary to bacterial pharyngitis caused by Fusobacterium necrophorum leading to peritonsillar abscess clinical features - bacterial sore throat - neck pain and stiffness - systemic involvement: fevers, rigors may cause thrombus formation with subsequent septic emboli going to lung, liver and other areas
401
describe an insulinoma
Whipple's triad - hypoglycaemia with fasting/exercise - reversal of symptoms with glucose - recorded low BMs at the time of symptoms C-peptide does not fall on exogenous insulin injection in patients with an insulinoma
402
describe fluid prescription in adults
fluid bolus: 500ml STAT (over 10-15 mins) > if still hypotensive after 2L resuscitation fluids, d/w senior/ICU maintenance fluids - 25-30 mls/kg/24h of water - 1mmol/kg/24h of sodium, potassium respectively - 50-100g glucose daily - types: > 0.9%NaCl (upper GI losses, DKA resuscitation) > Hartmanns, plasmalyte > 0.18%NaCl/4%glucose/KCl - underlying cardiac disease / frailty / renal disease: 20-25ml/kg/24h
403
describe CXR signs of pulmonary oedema
- mild LVF: > dilated upper lobe pulmonary veins - moderate LVF: > pleural effusion (may not be present if lying down) > perihilar interstitial oedema: increased opacification of hilar structures > Kerley B lines: interstitial oedema (peripheral, horizontal, 2-3cm, mid-lower zones) > peribronchial cuffing - severe LVF: > bats' wing alveolar oedema
404
describe psittacosis
infection caused by Chlamydia psittaci usually causing atypical pneumonia history of bird contact especially parrot owners features - respiratory: dyspnoea, dry cough, chest pain - flu-like symptom: headache, myalgia, fever - hepatosplenomegaly - failure to respond to penicillin-based antibiotics investigations - inflammatory markers, CXR - serology management - first-line: tetracyclines e.g. doxycycline - macrolides e.g. erythromycin
405
describe euthyroid sick syndrome
aka non-thyroidal illness syndrome (NTIS) commonly seen in critically ill patients labs - TSH normal/low - thyroxine low - T3 low
406
describe transfusion associated graft v host disease
delayed reaction occuring 2-6 weeks after transfusion clinical features - diarrhoea - liver damage - rash - pancytopaenia skin biopsy: abundant necrotic keratinocytes bone marrow biopsy: marked hypocellularity with macrophage infiltration management - no treatment - prevention: gamma-irradiated blood products
407
describe actinic keratosis
crusted lesions found on sun-exposed sites such as balding scalps management - fluorouracil cream - topical imiquimod - cryotherapy
408
describe the complications associated with rapid correction of sodium levels
hyponatraemia correction: osmotic demyelination syndrome aka central pontine myelinolysis hypernatraemia correction: cerebral oedema "from high to low, your brain will blow. from low to high, your pons will die"
409
describe central pontine myelinolysis
aka osmotic demyelination syndrome caused by rapid correction of hyponatraemia clinical features - brainstem damage - spastic quadriparesis - pseudobulbar palsy: dysarthria, dysphagia - emotional lability (pseudobulbar affect) - seizures, confusion, coma - locked in syndrome
410
describe Light's criteria for pleural effusions
protein ratio (pleural / serum): >0.5 LDH ratio (pleural / serum): >0.6 or >2/3 upper limit of normal
411
describe subclavian steal syndrome
caused by subclavian artery steno-occlusive disease proximal to the origin of the vertebral artery > leads to flow reversal in vertebral artery clinical features - dizziness and vertigo during exertion of an arm management - percutaneous transluminal angioplasty or a stent
412
describe Grave's disease
Autoimmune disease > autoantibodies >> TSH receptor stimulating antibodies (most common) >> anti-thyroid peroxidase antibodies Thyroid enlarged and increased vascularity (may be audible bruit) Usually young females Symptoms of hyperthyroidism and thyroid eye disease > Proptosis > Lid retraction and lid lag > Oedema > pretibial myxoedema > thyroid acropachy thyroid scintigraphy > diffuse, homogeneous, increased uptake of radioactive iodine
413
describe Hashimoto's thyroiditis
autoimmune disease leading to hypothyroidism > initial hyperthyroid phase, then euthyroid, then hypothyroid associated with anti-TPO antibodies initially goitre, then atrophy of thyroid gland management: levothyroxine associated with development of MALT lymphoma
414
List the clinical features of hypothyroidism
Symptoms > Tiredness > Weight gain > Anorexia > Cold intolerance > Depression > Poor libido > Dry brittle hair and dry coarse skin > Constipation > Menorrhagia Signs > Ataxia > Deafness > Hypertension > Bradycardia > Cold peripheries > Anaemia euvolaemic hyponatraemia
415
Describe the features of hyperthyroidism
Features - Palpitations - Tachycardia - Cardiac arrhythmias - Sweating - Tremor - Lethargy - Heat intolerance - Diarrhoea TFTs – low TSH, high T4 management - antithyroid drugs – carbimazole, prophylthiouracil - propranolol - radioactive iodine - surgery
416
Describe the features of primary hyperparathyroidism
Primary – disorder of parathyroid gland > High PTH, high calcium > Causes: adenoma, hyperplasia, cancer clinical features - fatigue, aches, low mood PTH may be normal
417
describe pearly penile papules
normal variants of glans 1-2mm in size distributed around corona of penis benign and do not require intervention
418
describe dialysis disequilibrium syndrome
rare but serious complication of haemodialysis causes cerebral oedema, usually in those who have recently started RRT diagnosis of exclusion
419
describe diabetic nephropathy screening
measure urinary albumin-creatinine ratio on a spot urine sample if results abnormal, repeat with a first-pass morning urine specimen
420
describe the management of obesity
management - conservative: diet, exercise - medical: orlistat, liraglutide - surgical orlistat: pancreatic lipase inhibitor - side-effects: flatulence, faecal urgency/incontinence - prescribe if BMI>28 with risk factors or BMI>30 liraglutide: GLP-1 agonist - prescribe if BMI at least 35 and prediabetic hyperglycaemia (HbA1c 42-47 mmol/mol) BMI >50 - first-line: bariatric surgery
421
what paraneoplastic syndrome is most associated with squamous cell lung cancer
parathyroid hormone related protein secretion
422
describe superficial thrombophlebitis
inflammation associated with thrombosis of one of the superficial veins, usually long saphenous vein usually non-infective but secondary bacterial infection may lead to septic thrombophlebitis management - NSAIDs > topical for limited/mild disease > oral if severee.g. naproxen - US if long saphenous to exclude DVT - compression stockings
423
describe the following testicular tumours - seminoma - non-seminomatous germ cell tumours
seminoma > commonest subtype > average age at diagnosis is 40 > AFP normal, HCG and LDH elevated in 10-20% non-seminomatous germ cell tumours > including teratomas, yolk sac tumours, choriocarcinomas... > younger age at presentation (20-30s) > AFP and HCG usually elevated
424
describe hepatitis C
no vaccine available diagnosis: > HCV antibodies > viral load (used in monitoring response to treatment) management - direct acting antivirals
425
describe extrinsic allergic alveolitis
aka hypersensitivity pneumonitis e.g. - bird fanciers' lung - farmers lung - malt workers' lung - mushroom workers' lung presentation - acute (4-8h after exposure) > dyspnoea > dry cough > fever - chronic (weeks-months after exposure) > lethargy > dyspnoea > productive cough > anorexia and weight loss investigations - imaging: upper/mid-zone fibrosis - bronchoalveolar lavage: lymphocytosis - serologic assays fpr IgG antibodies - blood: NO eosinophilia management - avoid precipitating factors - oral glucocorticoids
426
what is the most common cause of osteomyelitis
salmonella enteritidis
427
what is the most common organism found in central line infections
staphylococcus epidermis
428
what blood product is more associated with transfusion-related infection
platelet concentrate as they are stored at room temperature
429
describe focal segmental glomerulosclerosis
causes nephrotic syndrome causes - idiopathic - secondary - HIV - heroin - Alport's syndrome - sickle cell investigations - renal biopsy: focal and segmental sclerosis and hyalinosis on light microscopy management - steroids +/- immunosuppressants
430
describe melanoma
malignant tumour of melanocytes variants - superficial spreading - acral lentiginous - lentigo maligna - nodular
431
describe Waldenstrom's macroglobulinaemia
lymphoplasmacytoid malignancy characterised by secretion of monoclonal IgM paraprotein features - weight loss, lethargy - hyperviscosity syndrome e.g. visual disturbance - hepatosplenomegaly - lymphadenopathy - cryoglobulinaemia e.g. Raynaud's investigations - monoclonal IgM paraproteinaemia - bone marrow biopsy is diagnostic management - rituximab-based combination chemotherapy
432
describe progressive multifocal leukoencephalopathy
infection of oligodendrocytes by JC virus or BK virus leads to widespread demyelination features - subacute onset - behavioural changes - speech, motor or visual impairment CT: single or multiple non-enhancing lesions, no mass effect
433
describe the management of asthma in patients aged 12 and over
step 1 - low dose ICS + formoterol combination inhaler prn > anti-inflammatory reliever (AIR) - if highly symptomatic > start treatment with low-dose MART step 2 - low dose MART (maintenance and reliever therapy) > ICS + formoterol (LABA) regularly step 3 - moderate dose MART step 4 - check feNO and eosinophil count > if elevated referral to asthma specialist > if neither is raised consider leukotriene receptor antagonist (LTRA) or LAMA in addition to MART step 5 - specialist referral
434
describe zinc deficiency
Features - acrodermatitis: red, crusted lesions > acral distribution > peri-orificial > perianal - alopecia - short stature - hypogonadism - hepatosplenomegaly - geophagia (ingesting clay/soil) - cognitive impairment
435
describe diphtheria
bacterial infection caused by Corynebacterium diphtheriae travel from Eastern Europe/Russia/Asia clinical features - dyspnoea - dysphagia - grey pseudomembrane on posterior pharyngeal wall - fever - bulky cervical lymphadenopathy - "bull neck" - neuritis e.g. cranial nerves - heart block investigations: throat culture with tellurite agar or Loeffler's media management - IM penicillin - diphtheria antitoxin
436
describe the management of hiccups in palliative care
chlorpromazine, haloperidol or gabapentin dexamethasone if hepatic lesions
437
describe post-transplant complications
acute tubular necrosis of graft - first few weeks after transplant - more common in cadaver transplants vascular thrombosis - rare - presentation: abdominal pain, reduced urinary output, pyrexia acute graft failure - around 6 months post-transplant - investigations > urinalysis: pyuria, proteinuria > U&Es: rising creatinine - management: IV steroids, T cell depletion post-transplant urinary leak - common early post-op complications - high drain output and reduced urinary catheter output - low volume leaks may present later with abdominal tenderness and pyrexia
438
describe narcolepsy
associated with low levels of orexin (hypocretin), protein responsible for controlling appetite and sleep patterns features - onset in teenage years - hypersomnolence - cataplexy - sleep paralysis - vivid hallucinations on going to sleep or waking up - early onset REM sleep investigations: multiple sleep latency EEG management: daytime stimulants (modafinil) and nighttime sodium oxybate
439
describe malnutrition
unintentional weight loss >10% within the last 3-6 months
440
describe hydatid cysts
caused by tapeworm parasite Echinococcus granulosus outer fibrous capsule containing multiple small daughter cysts > cysts are allergens, precipitate a type 1 hypersensitivity reaction endemic in Mediterranean and Middle Eastern countries Clinical features - cysts in liver and lungs - asymptomatic or symptomatic if cysts > 5cm Complications: cyst bursting, infection and organ dysfunction Investigations - ultrasound first-line - CT abdomen gold standard - serology Management: surgery
441
describe pompholyx eczema
aka vesicular palmar eczema > can affect hands and feet sweating is a common precipitant > condition is associated with hot, humid environments clinical features - small blisters on palms and soles - pruritic, burning sensation - once blisters burst skin may become dry and crack management - cool compresses - emollients - topical steroids
442
list side-effects of amiodarone
- pulmonary fibrosis - hypothyroidism - corneal opacities - optic neuritis
443
describe budd chiari syndrome
aka hepatic vein thrombosis causes - polycythaemia rubra vera - thrombophilia - pregnancy - COCP classic triad - sudden onset severe abdominal pain - ascites: abdominal distension - tender hepatomegaly investigations - US with doppler flow studies
444
describe leprosy
granulomatous disease caused by Mycobacterium leprae features - patches of hypopigmented skin affecting buttocks, face, extensor surfaces of limbs - sensory loss - hair loss management: rifampicin, dapsone and clofazimine
445
describe primary CNS lymphoma
associated with EBV in HIV patients CT: single lesion, solid (homogeneous) enhancement - Thallium SPECT positive treatment - steroids - chemoradiotherapy
446
describe priapism
persistent penile erection >4 hours not associated with sexual stimulation 2 types: ischaemic and non-ischaemic Causes - idiopathic - sickle cell disease or other haemoglobinopathies - erectile dysfunction medication - other drugs - trauma clinical features - persistent erection - pain localised to the penis - rarely, non-painful erection or erection that is not fully rigid: suggestive of non-ischaemic priapism. Investigations: - cavernosal blood gas analysis: > ischaemic: pO2 and pH reduced, pCO2 increased - doppler or duplex ultrasonography - FBC, toxicology Management - ischaemic priapism: medical > >4 hours: aspiration of blood from cavernosa + injection of saline flush > intracavernosal injection of a vasoconstrictive agent e.g. phenylephrine > surgery - non-ischaemic priapism: not a medical emergency, observation first-line
447
state the investigation required for definitive diagnosis of sickle cell anaemia
Haemoglobin electrophoresis
448
describe Leriche syndrome
atherosclerosis of abdominal aorta and/or iliac arteries triad of features in men - claudication in buttocks / thighs - impotence - atrophy of leg musculature investigations: angiography management - correct underlying factors e.g. smoking - endovascular angioplasty and stent insertion