Medicine Flashcards

Question

Stable Angina - definition/pathophysiology

Answer 1

Caused by atherosclerosis affecting coronary arteries, narrowing lumen and reducing blood flow to myocardium During times of high demand, insufficient supply of blood to meet demand "Stable" when symptoms only come on with exertion and are always relieved by rest of glyceryl trinitrate

Answer 2

3 main features: Constricting pain expe4rienced in the chest +/- typical radiation to the arm/neck/jaw Precipitated by physical exertion Relieved by rest or GTN within 5m other features: dyspnoea, palpitations, syncope

Answer 3

bed: physical examination [cardiovascular], ECG blood: FBC, U&Es, LFTs, Lipid profile, TFTs, HbA1C and fasting glucose imaging: CTCA [CT coronary angiogram], invasive coronary angiography special: cardiac stress testing

Answer 4

Unstable Angina/ACS claudication

Answer 5

Medical management: immediate symptomatic relief [GTN spray], long-term symptomatic relief [bisoprolol, verapamil] secondary prevention of cvd - four A's - aspirin 75mg OD; atorvastatin 80mg OD; ACE inhibitor; Already on a b-blocker Surgical management: PCI or CABG

Answer 6

As a result of a thrombus from an atherosclerotic plaque blocking a coronary artery 3 types: Unstable angina, STEMI/N-STEMI

Answer 7

central, constricting, crushing chest pain radiates to the jaw/arms; nausea/vomiting; sweating/clamminess; a feeling of impending doom; sob; palpitations symptoms continue at rest for >15m silent MI is when a pt doesn't experience typical pain during ACS; pt w/ diabetes are at risk of silent MIs due to neuropathy

Answer 8

STEMI: ST-segment elevation; new left bundle branch block N-STEMI: ST depression, T wave inversion

Answer 9

I, aVL, V3-6: left coronary artery: anterolateral V1-4: Left anterior descending: anterior I, aVL, V5-6: circumflex artery: lateral II, III, aVF: right coronary artery: inferior

Answer 10

bed: ECG bloods: FBC, U&Es, LFT, lipid profile, glucose, troponins imaging: CXR, echocardiogram [once stable to assess functionality]

Answer 11

STEMI: ST elevation and new left bundle branch block N-STEMI: raised troponin with either normal ECG or other ECG changes [ST depression/ T wave inverison] Unstable angina: symptoms suggest ACS, normal troponin, normal ECG or other ECG changes [ST depression/T wave inversion]

Answer 12

CPAIN Call ambulance Perform ECG Aspirin 300mg Intravenous morphine if required [and antiemetic] Nitrate [GTN spray] ROMAN Reassure Oxygen if required Morphine Aspirin 300mg Nitrate [GTN spray]

Answer 13

STEMI within 12hrs Percutaneous coronary intervention PCI if available within 2hr of presenting [angiography and angioplasty with stenting] Thrombolysis if PCI is not available within 2hr [streptokinase, alteplase, tenecteplase]

Answer 14

Echocardiogram once stable to assess functional damage Cardiac rehabilitation Secondary prevention

Answer 15

Aspirin 75mg OD Another Antiplatelet clopidogrel for 12/12 Atorvastatin 80mg OD ACE inhibitor [Ramipril] Atenolol [or bisoprolol] Aldosterone antagonist for those with HF

Answer 16

DREAD Death Rupture of heart or papillary muscles oEdema [heart failure] Arrhythmia and Aneurysm Dressler's syndrome

Answer 17

often symptomatic can have a classic triad of symptoms: angina; dizziness; dyspnoea Thrill in the aortic area on palpation; slow rising pulse; narrow pulse pressure; exertional syncope Ejection-systolic, high-pitched murmur

Answer 18

idiopathic age-related calcification [most common cause] bicuspid aortic valve rheumatic heart disease

Answer 19

dyspnoea is the main presenting symptom [develops insidiously in chronic severe AR with LVF symptoms] Thrill in the aortic area on palpation; collapsing pulse; wide pulse pressure; heart failure and pulmonary oedema Early diastolic, soft murmur

Answer 20

idiopathic age-related weakness bicuspid aortic valve connective tissue disorders [Ehlers-Danlos syndrome; Marfan syndrome]

Answer 21

main presenting features are exertional dyspnoea and fatigue; can also have ankle swelling, palpitations, haemoptysis; chest pain Tapping apex beat, malar flush, atrial fibrillation Mid-diastolic, low-pitched 'rumbling' murmur

Answer 22

Rheumatic heart disease Infective endocarditis

Answer 23

Thrill in mitral area on palpation, signs of HF and pulmonary oedema, AF, palpitations, fatigue and reduced exercise tolerance, dyspnoea Pan-systolic, high-pitched 'whistling' murmur Murmur radiates to the left axilla Third heart sound may be heard

Answer 24

Idiopathic weakening of the valve with age ischaemic heart disease infective endocarditis rheumatic heart disease connective tissue disorders [Ehlers-Danlos, Marfan]

Answer 25

Thrill in tricuspid area on palpation, raised JVP, pulsatile liver, peripheral oedema, ascites Pan-systolic murmur with split second heart sound

Answer 26

Pressure due to LSHF or pulmonary hypertension Infective endocarditis Rheumatic heart disease Carcinoid syndrome Ebstein's anomaly Connective tissue disorders [Marfan syndrome]

Answer 27

Thrill in pulmonary area on palpation, raised JVP, peripheral oedema, ascites Ejection systolic murmur; widely split second heart sound

Answer 28

Usually congenital, may be associated with Noonan syndrome or Tetralogy of Fallot

Answer 29

Ischaemic heart disease; myocarditis/cardiomyopathy, hypertension, valvular heart disease, arrhythmias

Answer 30

Symptoms- breathlessness, cough [pink/white frothy sputum], orthopnoea, paroxysmal nocturnal dyspnoea, peripheral oedema, fatigue Signs, can include- tachycardia, tachypnoea, hypertension, murmurs on auscultation, 3rd heart sound, bilateral basal crackles, raised JVP, peripheral oedema

Answer 31

bed: obs, ECG blood: BNP, U&Es, FBC, LFTs, TFTs, lipid profile, glucose, iron studies imaging: CXR, echocardiogram

Answer 32

Class I: no limitation on activity Class II: comfortable at rest; symptomatic with ordinary activities Class III: comfortable at rest; symptomatic with any activity Class IV: symptomatic at rest

Answer 33

ACE inhibitor [Ramipril] / ARB [candesartan] can be used if ACEi not tolerated Beta blocker [Bisoprolol] Aldosterone antagonist [Spironolactone] Loop diuretics [Furosemide]

Answer 34

Life-threatening condition caused by compression of the heart from the accumulation of fluid, blood, clots, or gas within the pericardial space It prevents adequate filling and contraction of the heart

Answer 35

Any cause of pericardial effusion or haemorrhage into the pericardium can lead to cardiac tamponade Common: pericarditis, tuberculosis, iatrogenic [post-invasive cardiac procedure], trauma, malignancy Uncommon: connective tissue disease, radiation-induced, uraemia, post-MI, aortic dissection, bacterial infection

Answer 36

Acute cardiac tamponade presents as hypotension due to cardiogenic shock Symptoms- chest pain, dyspnoea, collapse, fatigue, peripheral oedema Signs- [Beck's triad: hypotension, elevated venous pressure and muffled heart sounds], tachycardia, pulsus paradoxus, pericardial rub, other features of shock [i.e. cool extremities, peripheral cyanosis, reduced urine output]

Answer 37

Diagnosed with urgent echocardiography bed: obs, ECG blood: ABG imaging: urgent echo, CXR, CT or MRI

Answer 38

Urgent needle pericardiocentesis - urgent drainage of the pericardial fluid may be done using anatomical landmarks, with echocardiography guidance or using fluoroscopy in a cardiac suite cardiac surgery may be an option to drain effusions in some situations

Answer 39

BP above 140/90 in clinical setting confirmed with ambulatory or home readings above 135/85

Answer 40

Essential HTN accounts for 90% - aka primary hypertension; developed on its own with no secondary cause Secondary causes: ROPED mnemonic Renal disease Obesity Pregnancy induced or Pre-eclampsia Endocrine Drugs [alcohol, steroids, NSAIDs, oestrogen]

Answer 41

Ischaemic heart disease Cerebrovascular accident Vascular disease Hypertensive retinopathy Hypertensive nephropathy Vascular dementia Left ventricular hypertrophy Heart failure

Answer 42

Typically asymptomatic however s/s may reflect underlying end organ damage Symptoms- palpitations, angina, headaches, blurred vision, new neurology [limb weakness, paraesthesia] Signs- new neurology [limb weakness, paraesthesia], retinopathy, cardiomegaly, arrhythmias, proteinuria

Answer 43

Keith-Wagener Barker grades Grade 1: generalised arteriolar narrowing [silver wiring] Grade 2: focal narrowing and arteriovenous nipping Grade 3: retinal haemorrhages, cotton wool spots Grade 4: papilloedema

Answer 44

bed: obs, bp, urinalysis, urinary protein creatinine ratio, ECG, direct ophthalmoscopy blood: FBC, U&Es, fasting glucose, cholesterol, HbA1c special: ambulatory bp monitoring, renal uss, endocrine tests [if indicated]

Answer 45

Stage 1: ABPM >135/85 or clinic bp 140/90 Stage 2: ABPM >150/95 or clinic bp >160/100 Stage 3: clinic bp >180/120

Answer 46

Lifestyle- stop smoking, reduce alcohol, improve diet, exercise, decrease caffeine Medical mx- T2DM or <55 start on ACEi/ARB, then add CCB or Thiazide like diuretic, then all 3 options if still not controlled >55 or Black/Caribbean origin start on CCB, then add Thiazide like diuretic or ACEi/ARB, then all 3 options if still not controlled 4th option: spironolactone or alpha/beta-blocker depending on K+

Answer 47

A BP >180/120 with signs of papilloedema and/or retinal haemorrhage severe condition resulting in neurological, renal and cardiac damage, requiring admission and immediate management Tx includes: IV Nitroprusside, labetalol and GTN infusions

Answer 48

may only be seen in patients with very high levels of lipids corneal arcus, tendon xanthoma, xanthelasma

Answer 49

Full lipid profile, HbA1c, assess for secondary causes of hyperlipidaemia, assess risk for anti-lipid therapy

Answer 50

Lifestyle modifications: dietary advice, physical activity, weight management, alcohol consumption, smoking cessation Statin [HMG-CoA reductase inhibitor] - atorvastatin 80mg OD, at night Fibrate - ezetimibe Bempedoic acid [ACL inhibitor] PCSK9 inhibitor - alirocumab

Answer 51

Refers to the narrowing of the arteries supplying the limbs and periphery, reducing blood supply. Usually affects lower limbs, resulting in claudication

Answer 52

Non-modifiable: older age, family history, male sex Modifiable: smoking, alcohol consumption, poor diet, low exercise/sedentary lifestyle, obesity, poor sleep, stress

Answer 53

diabetes htn ckd inflammatory conditions [rheumatoid arthritis, for example] atypical antipsychotic medications

Answer 54

Crampy pain that predictably occurs after walking a certain distance After stopping and resting, pain will ease

Answer 55

6P's Pain Pallor Pulseless Paralysis Paraesthesia Perishing cold typically causes burning pain. Worse at night when leg is raise, as gravity no longer helps pull blood into foot

Answer 56

signs of risk factors: tar staining, xanthomata signs of cvd: missing limbs/digits, midline sternotomy scar, inner calf scarring for saphenous vein harvesting, focal weakness suggestive of previous stroke weak peripheral pulses on palpation pallor, cyanosis, dependent rubor, muscle wasting, hair loss, ulcers, poor wound healing, gangrene reduced skin temperature, reduced sensation, prolonged capillary refill time, changes during Buerger's test

Answer 57

Caused by ischaemia secondary to inadequate blood supply smaller than venous deeper than venous well defined borders 'punched-out' ppearance occur peripherally [on toes] reduced bleeding painful

Answer 58

Caused by impaired drainage and pooling of blood in legs occur after minor injury to leg larger than arterial more superficial than arterial irregular, gently sloping borders affect the gaiter area [mid-calf to ankle] less painful than arterial occur with other signs of chronic venous insufficiency [haemosiderin staining, venous eczema]

Answer 59

ABPI Duplex ultrasound Angiography- CT or MR- using contrast to highlight arterial circulation

Answer 60

0.9-1.3 normal 0.6-0.9 mild peripheral arterial disease 0.3-0.6 moderate to severe peripheral disease 0.3 severe disease to critical ischaemia >1.3 can indicate calcification of arteries, this is more common in diabetic pts

Answer 61

Lifestyle changes Exercise training - structured, supervised program of regularly walking to the point of near-maximal claudication and pain, then resting and repeating Medical mx- atorvastatin 80mg OD; clopidogrel 75mg OD; Naftidrofuryl oxalate [5HT2 receptor antagonist; peripheral vasodilator] Surgical mx- endovascular angioplasty and stenting; endarterectomy; bypass surgery

Answer 62

Urgent referral to vascular team and analgesia for pain Urgent revascularisation: endovascular angioplasty and stenting; endarterectomy; bypass surgery; amputation if it is not possible to restore blood flow

Answer 63

Urgent referral to on-call vascular team for assessment options include: endovascular thrombolysis; endovascular thrombectomy; surgical thrombectomy; endarterectomy; bypass surgery; amputation if it is not possible to restore blood flow

Answer 64

MI, ACS, HF, other cardiac problems AF, AFlutter, other arrhythmias Acute cardiac problems

Answer 65

Hypertension Smoking High cholesterol Diabetes Inactivity/Sedentary lifestyle Overweight/obesity Family history of CVD Ethnicity [south asian or black african or african caribbean - ++risk of cvd] Increased age Male sex Poor diet Excessive alcohol consumption

Answer 66

Stop smoking Have a balanced diet Exercise regularly Maintain a healthy weight Cut down on alcohol Take medications prescribed to you by doctors Manage/control other chronic conditions

Answer 67

4 T's tired, thirsty, toilet [polyuria], thin [weight loss] vomiting, mild-moderate dehydration, BMI <25 some patients can present with DKA as their first s/s of DMTI

Answer 68

Destruction of beta-cells in the pancreas leads to the progressive reduction in insulin secretion Leads to impaired ability to maintain normal blood glucose levels and results in hyperglycaemia

Answer 69

Type II DM Diabetes insipidus Steroid therapy Psychogenic polydipsia MODY-DM

Answer 70

diagnosed when classical clinical features are found in the presence of a raised random blood glucose level Majority of patients will be children/adolescents, but don't discount in adults [LADA] Further investigations if required: *autoantibodies *investigations for pancreatic cancer

Answer 71

Life-long exogenous insulin to prevent acute complications [DKA] and long-term complications [CKD, IHD, retinopathy] Some oral hypoglycaemics can be used too

Answer 72

Basal-bolus: typically involves a rapid/short acting insulin before meals and a long acting insulin for basal requirements. This is the standard approach for patients newly diagnosed with TIDM one/two/three injections per day: uses both short and intermediate acting insulin continuous insulin infusion via a pump: uses short/rapid acting insulin. Used in patients who are experiencing troubling hypoglycaemic episodes with multiple daily injections

Answer 73

All patients with TIDM should be offered continuous blood glucose monitoring known as CGM. There are two types: real-time continuous CGM: automatically recorded BGs and shown on a handheld device intermittently scanned CGM: BG measured only when you scan a device over a sensor Patients don't have to use CGM, they can instead opt for a capillary blood glucose monitor

Answer 74

On waking- 5-7mmol/L Before meals- 4-7mmol/L Post meals: test 90m after food, 5-9mmol/L

Answer 75

Long-term control is monitored with HbA1c - should be assessed/repeated every 3-6months to assess glycaemic control Patients and clinicians should target a HbA1c <48mmol/L

Answer 76

regular diabetic assessment is essential for all patients to improve morbidity and mortality annual basis [or more frequently if required], pts should receive a diabetic review. includes assessment of injection site problems, retinopathy, nephropathy, diabetic foot problems, cardiovascular risk factors and thyroid disease retinopathy- annual screening nephropathy- renal function [eGFR] and albumin:creatinine ratio diabetic foot problems- full examination including footwear, monofilament assessment of neuropathy, vascular assessment +/- dopplers cardiovascular- primary/secondary prevention strategy with optimisation of bp, lipids, weight, smoking and others thyroid- tfts dental disease- advise regular oral health review

Answer 77

Use a special insulin prescribing chart MUST write Units, not U Specify the brand name and indicate the device the patient uses [vial, pen, pen cartridge, pump] Write pre-breakfast/lunch/dinner instead of times if insulin must be taken before meals Ensure you confirm with their prescription if unsure of the dose - never estimate

Answer 78

May be asymptomatic May have: lethargy, polyuria, polydipsia, weight loss, recurrent infections [thrush, balanitis]

Answer 79

major diagnostic tool is the measurement of glycated haemoglobin HbA1c Symptomatic and elevated HbA1c = diagnosis Asymptomatic and elevated HbA1c = repeat HbA1c, if that's elevated then a diagnosis can be made

Answer 80

1. lifestyle advice 2. antidiabetic drugs 3. insulin use in tiidm

Answer 81

dietary changes - healthy and balanced, plenty of fibre, low-index carbohydrate and controlling intake of high-fat foods; weight loss may be appropriate exercise and physical activity - can help lower blood glucose; at least 150 minutes of moderate intensity activity over a weekly period alcohol consumption - increases weight and may exacerbate or prolong hypoglycaemia induced by oral hypoglycaemic smoking cessation - should be available and offered to all patients

Answer 82

Metformin is one of most common medications in TIIDM - biguanide; lowers BG through inhibiting hepatic gluconeogenesis and increasing peripheral insulin sensitivity; first line unless contra-indicated [poorly tolerated, CKD, risk of lactic acidosis]

Answer 83

exs- Gliclazide, glipizide, glimepiride, tolbutamide moa- Stimulate the pancreas to produce more insulin c/i- porphyria; ketoacidosis; renal impairment; hepatic impairment s/e- abdo pain/n/v/d/c, hepatic impairment, weight gain, rash, pruritus, angioedema, erythema, hypoglycaemia, hyponatraemia, dizziness/tremor/drowsiness d/i- beta-blockers, other antidiabetic drugs, alcohol, steroids, some abx, phenytoin

Answer 84

exs- sitagliptin, saxagliptin, alogliptin moa- blocks DPP-4 enzyme; increases levels of incretins to inhibit glucagon release and increase insulin secretion c/i- ketoacidosis, hepatic impairment, heart failure, pancreatitis, elderly s/e- c/v/n/d, gord, gastritis, pancreatitis, headache, dizziness, tremor, back pain, arthralgia, increased risk of infections d/i- b-blocker, acei, digoxin, rifampicin, other antidiabetics, alcohol, steroids

Answer 85

exs- pioglitazone moa- activate ppar[gamma]; enhances tissue sensitivity to insulin and reduces hepatic gluconeogenesis c/i- HF, bladder cancer, hepatic impairment, elderly, insulin, rf for bone fracture, bladder cancer, hf s/e- ++fractures, ++infection, bladder cancer, hepatic impairment, numbness, visual impairment, weight gain, insomnia d/i- b-blockers, nsaids, other antidiabetic drugs

Answer 86

exs- empagliflozin, dapagliflozin moa- blocks sglt2 transporter in proximal convoluted tubule, stopping reabsorption of glucose c/i- dka, renal impairment, increasing age, active foot disease, hepatic impairment s/e- uti, urosepsis, vulvovaginitis, balanoposthitis, fournier's gangrene, constipation/nausea, thirst, dyslipidaemia, lower limb amputation, renal impairment d/i- thiazides and loops diuretics, insulin, digoxin, lithium

Answer 87

exs- exanatide, dulaglutide, semaglutide [administered as a sc injection] moa- activates GLP-1 receptor; increases insulin secretion and decreases glucagon secretion ; slows gastric emptying and decreases food intake c/i- ketoacidosis, pancreatitis, renal impairment, hepatic impairment, gi disease s/e- acute pancreatitis, n/v/d, gord, gallbladder disorders/cholecystitis/cholelithiasis, headache, drowsiness, dizziness, renal impairment, sinus tachy, skin reactions d/i- b-blockers, paracetamol, warfarin, other antidiabetic drugs

Answer 88

should be considered in patients with poor glycaemic control despite dual antidiabetic with metformin and another agent regimes include: 1. once/twice daily intermediate acting insulin 2. intermediate insulin along a short acting as separate injections or a premixed formula 3. once daily long acting insulin therapy 4. basal/bolus regimes

Answer 89

largely based on serial measurements of HbA1c mx with lifestyle: <48mmol/L mx with lifestyle and single antidiabetic agent: <48mmol/L mx with drug associated with hypoglycaemia: <53mmol/L mx with higher intensification regimes: <53mmol/L

Answer 90

Inability to utilise glucose leads to an accumulation of glucose within the blood As glucose can't be utilised, glycogen stores are broken down [glycogenolysis] and there's an increased formation of glucose from other substrates [gluconeogenesis] Lack of use of glucoes leads to the breakdown of fats [lipolysis] to increase fatty acids; these are used in ketogenesis Ketone bodies [acetone, beta-hydroxybutyrate and acetoacetate] are increased in the blood - leading to ketonaemia; they are weak acids, leads to significant acidosis and severe illness in increasing quantities

Answer 91

Symptoms- nausea, vomiting, polyuria, polydipsia, abdominal pain, leg cramps, headache Signs- abdominal tenderness, dehydration, hypotension, Kussmaul breathing, reduced consciousness, coma

Answer 92

Diagnosis is made on identification of biochemical triad of hyperglycaemia, acidaemia, ketonaemia/ketonuria Lab glucose: >11.0mmol/L VBG/ABG: <7.3 or bicarb <15mmol/L Ketone: cap. >=3mmol/L or urinary +++ or above

Answer 93

bed: ECG, urinalysis +/-MSU, beta hcg blood: FBC, U&Es, CRP, LFTs, cultures, troponin imaging: CXR

Answer 94

*restore circulating volume and tissue perfusion *clear serum/urinary ketones and halt ketogenesis *decrease serum glucose towards a normal level *correct electrolyte derangements *identify and treat underlying precipitant

Answer 95

One or more of the following *blood ketone >6mmol/L *bicarbonate level <5mmol/L *pH <7.0 *GCS <=12 *Systolic BP <90mmHg *Hypokalaemia on admission <3.5mmol/L

Answer 96

Fluid of choice is usually 0.9% NaCl 1L over 1hr, then 2Ls each over 2hrs, then 2Ls each over 4hrs

Answer 97

IV insulin regime reduces K+ so potassium should be monitored closely and potassium should be added to the fluids when necessary/indicated

Answer 98

patients are started on a fixed rate IV infusion 0.1units/kg/hour infusion is set up using 50units of short acting insulin with 50mls of 0.9% saline When blood glucose drops <14mmol/L, IV 10% dextrose should be administered at 125ml/hr continue with patients long-acting insulin

Answer 99

Each hour blood ketones and glucose should be checked VBG should be used at 1hr, 2hrs and then 2hrs thereafter K+ checked every 4hrs minimum within first 24hrs consider cardiac and saturation monitoring fluid input/output chart should be kept

Answer 100

blood ketones: fall by >=0.5mmol/L/hr bicarbonate: rise by >=3.0mmol/L/hr blood glucose: fall by >=3.0mmol/L/hr poatssium: maintain between 4-5.5mmol/L

Answer 101

Relative lack of insulin coupled with a rise in counter-regulatory hormones [cortisol, growth hormone, glucagon] that leads to a profound rise in glucose reduced glucose utilisation, increased gluconeogenesis and glycogenolysis leads to hyperglycaemia and osmotic diuresis [increased urination due to increased glucose in the urine] as water is lost, there is profound dehydration and reduced circulating volume - results in hyperosmolarity and hyperglycaemia

Answer 102

Usually insidious onset, with development of increased renal water loss and dehydration over days-weeks Symptoms- polydipsia, polyuria, nausea, vomiting, muscle cramps, weakness, altered mental status, seizures, coma Signs- dehydration, hypotension, decreased urine output, decreased conscious level, coma, focal neurology signs, features of a precipitating cause

Answer 103

based on identification of characteristic features: lab glucose: >30mmol/L serum osmolality: >320mOsm/kg [2NA + urea + glucose] ketones: urine 1+, trace, negative OR blood <3mmol/L

Answer 104

bed: ECG, urinalysis +/- MSU, beta hcg blood: FBC, U&Es, CRP, LFTs, blood cultures, troponin, amylase, CK imaging: CXR, CT head [if reduced GCS or focal neurology]

Answer 105

*normalise osmolality *normalise blood glucose *replace fluid and electrolytes *prevention of arterial/venous thrombosis *prevention of complications and foot ulceration

Answer 106

*osmolality >350mOsm/kg *sodium >160mmol/L *pH <7.1 *GCS <12 *systolic BP <90mmHg *serum creatinine >200μmol/L *macrovascular event [mi, cva] *severe electrolyte abnormalities [hyper/hypokalaemia]

Answer 107

0.9% normal saline; at least 1L should be given over an hour further fluids can be given, aiming for a positive fluid balance based on hourly measurement of urine output rapid correction of fluid deficit is not advisable as it can precipitate osmolar shifts leading to cerebral oedema - aim for 4L positive within the first 24hrs

Answer 108

should only be commenced if there's evidence of significant ketonaemia should be given as a fixed rate iv insulin infusion at 0.05units/kg/hr

Answer 109

sodium, potassium, phosphate and magnesium should be monitored regularly [4hrly min.] and replaced as necessary

Answer 110

should be on cardiac monitoring and assessed at regular intervals every hour- blood glucose, urea and electrolytes and lab/calculated osmolality should be completed for the first 6hr satisfactory fall in osmolality [3-8mOsm/kg/hr] and glucose [5mmol/L/hr] then bloods reduced to two hourly

Answer 111

often painless drainage/pus from the foot; unusual swelling; irritation; erythema; odour partial/complete gangrene can appear around the ulcer depending on severity - odours, discharge, pain and numbness can occur alongside

Answer 112

X-rays; MRI; bone scans non-surgical: shoe modification; wound care; total contact casting surgical: surgical debridement, abx, contact casting; ostectomy; partial calcanectomy; amputation better management of diabetes or glycaemic control

Answer 113

on viewing the retina: dot and blot haemorrhages, hard exudates, cotton wool spots intraretinal microvascular abnormalities, venous beading new vessels at the disc and elsewhere, fibrosis, traction retinal detachment exudates, oedema persistent damage to the retina leads to areas of ischaemia and release of angiogenetic factors [e.g. vascular endothelial growth factor]; this promotes new formation of vessels that are weak and friable and consequently leads to complications such as haemorrhage, fibrosis, and retinal detachment

Answer 114

Good glycaemic control and regular screening to assess early changes are key to preventing and managing disease photocoagulation is used to manage proliferative disease - aim is to burn holes within the ischaemic retina to prevent release of angiogenesis factors

Answer 115

Earliest sign is presence of microalbuminuria, is assessed with an albumin:creatinine ratio Microalbuminuria is a marker of systemic microvascular damage CKD in diabetes is evidence by a persistently low eGFR <60mmol/L and/or AC persistently >3mg/mmol/L

Answer 116

Patients should be treated with an ACE inhibitor or ARB, even in the presence of normotension TIIDM and CKD: consider SGLT2 inhibitor

Answer 117

Peripheral neuropathy occurs in leg secondary to loss of vibration, pain, temperature sensation - symmetrical polyneuropathy damage to a single cranial or peripheral nerve - mononeuropathy symmetrical pain, weakness, wasting of proximal muscles of the leg [as a result of disease affecting the lumbosacral plexus] - diabetic amyotrophy postural hypotension, gastroparesis, diarrhoea, bladder dysfunction, erectile dysfunction - autonomic neuropathy [requires MDC]

Answer 118

medications for nausea/vomiting, analgesia maintaining good glycaemic control, cholesterol monitoring, bp monitoring +/- tx cannot reverse disease, can only manage symptoms and prevent symptoms from getting worse

Answer 119

Polyuria; polydipsia; lethargy; thrush/other recurring bladder/skin infections; headaches; blurred vision; weight loss; nausea

Answer 120

Increased blood sugar in people with diabetes can be caused by stress, illness, eating too much, lack of exercise, dehydration, missing/taking an incorrect dose of medication, over-treating an episode of hypoglycaemia, taking steroids or other medications

Answer 121

bed: CBG, ECG, beta hcg, urine dip blood: fbc, u&es, lfts, tfts, VBG/ABG imaging: - special: -

Answer 122

Lifestyle: improve diet, drink plenty of fluids, exercise more often Medical: adjust insulin or other antidiabetic medications

Answer 123

feeling hungry, trembling/shakiness, sweating in more severe cases- confusion, difficulty concentrating very severe cases- loss of consciousness

Answer 124

bed: CBG blood: fbc, u&es, tfts, VBG/ABG imaging: - special: -

Answer 125

Lift juice, dextrose tablets, something high in sugar Glucogel Glucose infusion Glucagon IM injection then assess medications and insulin regime - ensure that it's not too much for the patient

Answer 126

overdose of diabetes medication exercise, food, alcohol fasting/malnutrition reactive hypoglycaemia - pancreas produces too much insulin after a large carbohydrate-based meal Addison's disease some medications- propranolol, malaria medication severe illness affecting liver, kidneys or thyroid

Answer 127

Symptoms- thirst, dehydration, lethargy, fever, n/v/d, confusion, abnormal speech Signs- dry mucous membranes, postural hypotension, tachycardia, hypotension, altered mental status, oliguria, polyuria

Answer 128

Diagnosis is made on lab sample of plasma sodium >145mmol/L Urine electrolytes and osmolality can help identify a cause bloods: FBC, U&Es, LFTs, bone profile, blood glucose, plasma omsolality, CRP/ESR, CK

Answer 129

Restoration of total body water and treating the underlying cause usually a combination of crystalloids are used to help restore water depletion while not overcorrecting the serum sodium vital to recheck sodium regularly and fluid balance assessed

Answer 130

Often asymptomatic, if symptoms present then typically vague and non-specific Headache, confusion, n/v, lethargy, irritability, seizures, LOC, coma s/s may also reflect the underlying cause [HF, pancreatitis]

Answer 131

urine: omsolality and sodium blood: U&Es, glucose, lipids, TFTs, LFTs, early morning cortisol

Answer 132

Should be managed in a HDU especially if neurological symptoms present mild/moderate neurological symptoms- treat underlying cause, medication review, non-essential fluids to be stopped moderate/severe neurological symptoms- rapid correction of serum sodium using hypertonic saline [1.8-3% saline]

Answer 133

mx is based on underlying cause hypovolaemic- iv fluid replacement with normal saline, medication review euvolaemic- fluid restriction as it is typically SIADH; demeclocycline [ADH inhibitor] or vaptan [vasopressin receptor antagonist] hypervolaemic- treat underlying cause, fluid and salt restriction and use diuretics

Answer 134

cerebral oedema osmotic demyelination syndrome

Answer 135

Frequently asymptomatic and difficult to diagnose without a lab sample Symptoms- fatigue, generalised weakness, chest pain, palpitations Signs- arrhythmias, reduced power, reduced reflexes, signs of the underlying cause

Answer 136

Lab sample of plasma potassium of >=5.5mmol/L; usually achieved by A/VBG other ix to consider: urinalysis, ECG, FBC, U&Es, bone profile, CRP, blood cultures, CK

Answer 137

peaked/tall tented T waves prolonged PR interval widening QRS interval small/absent P waves AV dissociation sine wave pattern asystole

Answer 138

Medical emergency - ABCDE assessment ECG, cardiac monitoring, stop any K-containing fluid or medication Protect myocardium- 30ml of 10% calcium gluconate over 10minutes Drive potassium intracellularly- insulin infusion 10units of short acting insulin alongside dextrose [50ml 50%] over 30minutes Eliminate potassium from the body- loop diuretics, potassium-binding resins, haemodialysis

Answer 139

Symptoms- fatigue, generalised weakness, muscle cramps and pain, palpitations, constipation Signs- arrhythmias, muscle paralysis and rhabdomyolysis

Answer 140

Diagnosis is based on plasma potassium <3.5mmol/L other ix to consider: ECG, urine osmolality and electrolytes, FBC, U&Es, bone profile, magnessium, A/VBG, CK

Answer 141

flat T waves ST depression U waves prolonged PR

Answer 142

mild to moderate - oral replacement route, SANDO-K for example severe or symptomatic - IV replacement, 40mmol of KCL in 1L of normal saline; if higher K required then should be done in HDU/ITU setting

Answer 143

Bones- fragility fractures, bone pain Stones- renal calculi Thrones- polyuria, constipation Abdominal groans- abdo pain, n/v, pancreatitis Psychic moans- mood disturbance, depression, fatigue, psychosis other features: myalgia, insomnia, dehydration, hypertension, cardiac arrhythmias

Answer 144

Confirm hypercalcaemia with a bone profile PTH levels - helps identify a cause other ix to consider: FBC, U&Es, LFT, CRP/ESR, TFTs, Vit D levels, malignancy screen, urine calcium levels, general imaging [CXR, CT chest abdo pelvis if malignancy suspected], parathyroid imaging

Answer 145

Mild and asymptomatic/mild symptoms- increase oral fluids and avoid precipitants Moderate- acute rise requires inpatient admission for IV fluids Severe- all patients require urgent admission to hospital and treatment; aggressive iv fluids and consideration of bisphosphonates, particularly if malignancy is suspected alternative therapies: corticorsteroids; surgery [1` hyperparathyroidism]; cinacalcet; dialysis

Answer 146

Symptoms- paraesthesia, muscle cramps, wheezing, voice changes, CNS disturbances, chest pain, palpitations Signs- Trousseau's sign; Chvostek's sign

Answer 147

Serum corrected calcium <2.2mmol/L for a diagnosis consider: bone profile, U&Es, Vit D, parathyroid hormone, magnesium, ECG [can cause prolonged QT interval and arrhythmias]

Answer 148

Acute severe [<1.9mmol/L] is medical emergency IV calcium gluconate 10-20ml of 10% calcium gluconate over 10min Follow up infusion of 100ml 10% in 1L of dextrose 5% or NaCl 0.9% Treat co-existing pathology- vit d or magnesium Calcium monitoring

Answer 149

results from a deficiency of, or resistance to, anti-diuretic hormone ADH usually acts on DCT and collecting duct to increase water reabsorption independent of sodium. Stimulates arginine vasopressin receptor 2 leading to insertion of aquaporin-2 channels onto membrane, allowing free entry of water ADH also causes vasoconstriction of arterioles

Answer 150

central - reduced release of ADH: *idiopathic *neurosurgery *trauma *familial/genetic DI *infection- TB, abscess, meningitis *tumours *infiltrative disease - sarcoidosis *other- post-radiotherapy, vascular nephrogenic - normal ADH but impaired response from kidneys: *arginine vasopressin receptor 2 mutation *aquaporin 2 mutation acquired - impair the ability to concentrate urine: *medications *electrolyte imbalances *renal disease

Answer 151

characteristic features are polyuria, polydipsia, nocturia polyuria can reach 10-15L/day may be signs of dehydration may be signs of underlying pathology

Answer 152

Water deprivation test can be used to diagnose blood: FBC, renal function, plasma glucose and osmolality, HbA1c, bone profile urine: 24hr urine collection, urine specific gravity, urine osmolality further testing may be indicated depending on the suspected underlying cause

Answer 153

Central may be treated with synthetic ADH [desmopressin] -risk of water retention and subsequent hyponatraemia -if underlying cause is identified, treat appropriately Nephrogenic is more complicated -orla hydration may be sufficient -diuretics may be used [Bendroflumethiazide] -Desmopressin may be used, supraphysiological levels may overcome the relative resistance to it

Answer 154

results from excess ADH secretion abnormal release leads to the kidney retaining more water, leading to an increase in total body water - subsequent dilutional hyponatraemia increase in TBW causes an increase in extracellular fluid that results in increased sodium excretion results in: hypotonic hyponatraemia, concentrated urine, euvolaemic state

Answer 155

CNS: stroke, subarachnoid haemorrhage, trauma, psychosis neoplasia: small cell lung cancer, other lung cancers, neuroblastoma infective: HIV, pneumonia drugs: carbamazepine, cyclophosphamide, SSRIs, MDMA hormonal: hypothyroidism, hypopituitarism surgery: trans sphenoidal pituitary surgery is a procedure with a high-risk of SIADH

Answer 156

Large proportion will be asymptomatic Symptoms- headache, confusion, lethargy, anorexia Signs- seizures, reduced GCS, coma, myoclonus, ataxia, hyporeflexia, asterixis features of underlying pathology may be present

Answer 157

blood: renal function, serum osmolality urine: urinary osmolality, urine sodium

Answer 158

Fluid restriction: typically 500ml-1000ml/24hrs Pharmacological: demeclocycline, though vaptans are typically used now Hyponatraemia: severe hyponatraemia requires intensive care due to risk of neurological damage as a result of cerebral oedema Long-term: many cases it is self-limiting or reversible; other times it may persist for longer and require fluid restriction and oral salt

Answer 159

Symptoms occur due to low calcium tingling/numbness in fingers, muscle cramps, wheezing, voice changes, CNS disturbances, chest pain, palpitations Trousseau's sign and Chvostek's sign

Answer 160

blood: calcium, thyroid functions, kidney function, LFTs, bone profile, vitamin D imaging: bone scan, kidney scan urine: 24hr urine collection

Answer 161

calcium medications and a vitamin d analogue

Answer 162

++PTH lead to increased kidney calcium reabsorption, increased intestinal absorption of calcium and increased osteoclast activity and ++ calcium absorption from bone all of these increase serum calcium so ++PTH leads to hypercalcaemia

Answer 163

Kidney stones Painful bones, fragility fractures Constipation, n/v fatigue, depression, psychosis

Answer 164

1`- uncontrolled PTH due to a tumour of the parathyroid glands 2`- low vit d or CKD reduces calcium reabsorption, so PTH is excreted, but calcium will remain low and PTH will be high 3`- when 2` continues for an extended period after the underlying cause has been treated; hyperplasia of PTglands as a result of increased PTH requirements, then when underlying cause has gone, there's still a high level of PTH

Answer 165

1`- remove the tumour surgically 2`- treat underlying vitamin D deficiency or CKD [transplant] 3`- surgically remove part of the parathyroid tissue to return the parathyroid hormone to an appropriate level

Answer 166

When adrenal glands don't produce enough steroid hormones, particularly cortisol and aldosterone Addison's disease is when adrenal glands have been damaged, reducing cortisol and aldosterone- primary adrenal insufficiency - commonly autoimmune

Answer 167

1`- autoimmune typically, Addison's disease 2`- inadequate ACTH and lack of stimulation of adrenal glands, subsequently low cortisol- as a result of loss or damage to pituitary gland- tumours, surgery, radiotherapy, trauma 3`- inadequate CRH from hypothalamus, usually from pt taking long-term oral steroids causing suppression of hypothalamus

Answer 168

Symptoms- fatigue, muscle weakness and cramps, dizziness and fainting, thirst and craving salt, weight loss, abdominal pain, depression, reduced libido Signs- bronze hyperpigmentation [particularly in creases, as a result of ACTH stimulating melanocytes to produce melanin], hypotension

Answer 169

U&Es [hyponatraemia, hyperkalaemia, hypoglycaemia, raised U+C, hypercalcaemia] early morning cortisol short Synacthen test ACTH levels in blood Autoantibodies CT/MRI of adrenal glands - not routinely required MRI of pituitary gland

Answer 170

aka ACTH stimulation test Provide a dose of synthetic ACTH, and cortisol is checked before, 30 and 60 min after the dose Would usually stimulate adrenal glands to produce cortisol, it should be at least double Failure to double indicates: primary adrenal insufficiency or very significant adrenal atrophy after prolonged ACTH absence in 21 adrenal insufficiency

Answer 171

Hydrocortisone [glucocorticoid] to replace cortisol Fludrocortisone [mineralocorticoid] to replace aldosterone if it is also insufficient Pts are given a steroid card, ID tag and emergency letter to alert emergency services that they depend on steroids Double doses are given during acute illness to match normal steroid response Pts and close contacts are taught to give IM hydrocortisone in an emergecny

Answer 172

Acute presentation of severe adrenal insufficiency may be the initial presentation of adrenal insufficiency or triggered by infection, trauma, other acute illness Don't wait to perform investigations to establish diagnosis before starting treatment

Answer 173

reduced consciousness hypotension hypoglycaemia hyponatraemia and hyperkalaemia

Answer 174

ABCDE approach IM or IV hydrocortisone [100mg initially, followed by an infusion or 6hrly doses until recovered] IV fluids correct hypoglycaemia [IV dextrose, for example] monitor electrolytes and fluid balance

Answer 175

Caused by prolonged exposure to an excess of glucocorticoids can be exogenous or endogenous [external or internal cortisol] defined based on whether the cortisol excess is ACTH dependent [cortisol excess is driven by PTH, from pituitary or ectopic sources] or independent [cortisol excess isn't related to ACTH, can be consumption of cortisol or adrenal lesions]

Answer 176

ACTH dependent: Cushing's Disease [pituitary adenoma]; ectopic ACTH producing tumour [bronchial carcinoma] ACTH independent: endogenous administration [prolonged glucocorticoid intake, results in suppression of crh and acth]; primary adrenal lesion [adenomas, carcinomas, hyperplasia]

Answer 177

Symptoms- tiredness, depression, weight gain, easy bruising, amenorrhoea, reduced libido, striae Signs- acne, moon face, facial plethora [excessive blood flow to the face], buffalo hump, hypertension, proximal muscle weakness, hyperpigmentation [in ACTH dependent causes]

Answer 178

24-hr urinary cortisol - levels 3-4x higher than normal are highly suggestive of Cushing's syndrome midnight cortisol - demonstrates loss of normal circadian pattern low-dose dexamethasone suppression - 1mg of dex given at 11pm, cortisol measured at 8am. cortisol should be reduced however it isn't in cushing's ACTH measured in plasma - suppressed ACTH indicates ACTH independent cause; raised suggests ACTH dependent cause then further investigate for causes of each cause of in/dependent

Answer 179

Exogenous Cushing's - withdraw glucocorticoid medications, but should not stop suddenly - this can cause Addisonian crisis Cushing's Disease - remove adenoma with transsphenoidal surgery [gold standard] Medical mx - medical therapy is used to bridge the gap between definitive mx or when surgery isn't possible; metyrapone can be used to reduce cortisol synthesis Pituitary irradtion - used in children/young people/surgical option hasn't worked; takes 6-12m to work Adrenalectomy - all other therapies have failed, last resort option, is to take both adrenal glands out [bilateral adrenalectomy]; but will have to take lifelong glucocorticoid and mineralocorticoid replacement

Answer 180

Exogenous Cushing's - withdraw glucocorticoid medications, but should not stop suddenly - this can cause Addisonian crisis Cushing's Disease - remove adenoma with transsphenoidal surgery [gold standard] Medical mx - medical therapy is used to bridge the gap between definitive mx or when surgery isn't possible; metyrapone can be used to reduce cortisol synthesis Pituitary irradiation - used in children/young people/surgical option hasn't worked; takes 6-12m to work Adrenalectomy - all other therapies have failed, last resort option, is to take both adrenal glands out [bilateral adrenalectomy]; but will have to take lifelong glucocorticoid and mineralocorticoid replacement

Answer 181

1` hyperthyroidism- thyroid pathology, produces too much thyroid hormone 2` hyperthyroidism- pathology of hypothalamus or pituitary gland; too much TSH stimulates T3 and T4 production Graves' disease- autoimmune condition where TSH receptor antibodies cause primary hyperthyroidism; TSH receptor antibodies stimulate TSH receptors on thyroid, causing hyperthyroidism Toxic multinodular goitre- nodules on thyroid are unregulated by the thyroid axis, continuously producing excessive thyroid hormones

Answer 182

GIST G- Graves' disease I- Inflammation [thyroiditis] S- Solitary toxic thyroid nodule T- Toxic multinodular goitre

Answer 183

anxiety and irritability, sweating and heat intolerance, tachycardia, weight loss, fatigue, insomnia, frequent loose stools, sexual dysfunction, brisk reflexes on examination Graves' disease specifically: *diffuse goitre without nodules *graves' eye disease [inc. exophthalmos] *pretibial myxoedema *thyroid acropachy [hand swelling and finger clubbing]

Answer 184

Thyrotoxic crisis presents- fever, tachycardia, delirium, v/d, abdo pain can be life-threatening and requires admission for monitoring treated the same as any other thyrotoxicosis, although may also require fluid resus, anti-arrhythmic meds, b-blockers

Answer 185

bed: ECG, CBG blood: FBC, U&Es, LFTs, TFTs, autoantibodies imaging: ultrasonography, thyroid uptake scan

Answer 186

Pharmacological- carbimazole or propylthiouracil [pancreatitis risk]; b-blocker or ccb may be prescribed to treat symptoms Radioactive iodine- uptake of radioactive idone caused destruction in the thyroid and reduces thyroid hormone release [c/i- pregnancy, falling pregnant, breastfeeding, fathering a child] Thyroidectomy- removal of thyroid gland is definitive if malignancy is suspected or medications aren't suitable

Answer 187

Insufficient T3 and T4 1`- thyroid behaves abnormally and doesn't produce enough T3/4; negative feedback is absent, resulting in ++TSH 2`- pituitary behaves abnormally and produces inadequate TSH, under stimulating thyroid gland and insufficient T3/4 is produced

Answer 188

Hashimoto's thyroiditis is most common cause of 1` hypothyroidism Autoimmune condition causing inflammation of thyroid gland Associated with anti-TPO antibodies and anti-Tg antibodies

Answer 189

most common cause in the developing world

Answer 190

treatments for hyperthyroidism can cause hypothyroidism *carbimazole *propylthiouracil *radioactive iodine *thyroid surgery lithium inhibits production of thyroid hormones and can cause goitre and hypothyroidism amiodarone can cause hypothyroidism and thyrotoxicosis

Answer 191

Often associated with a lack of other pituitary hormones [e.g. ACTH] can be caused be: *tumours *surgery *radiotherapy *Sheehan's syndrome *trauma

Answer 192

Symptoms- tiredness, lethargy, weight gain, cold intolerance, menstrual irregularities, reduced libido, goitre Signs- hair loss, dry skin, goitre, bradycardia, myxoedema, delayed relaxation phase of deep tendon reflexes

Answer 193

Thyroid profile - measure TSH and T3/4 +TSH; -T3/4: primary hypothyroidism -TSH; -T3/4: secondary hypothyroidism Autoantibodies: anti-TPO and anti-Tg Other blood: FBC, B12 and folate, serum lipids, HbA1c, coeliac serology Suspicious of malignancy? ultrasonography and urgent 2ww

Answer 194

Oral levothyroxine is main management option; synthetic T4 and metabolises to T3 in the body Dose is titrated based on TSH level, usually every 4wks if TSH is high, levothyroxine is too low so increase dose if TSH is low, levothyroxine is too high so reduce dose Liothyronine sodium is a synthetic T3 and is rarely used, only under specialist supervision, when levothyroxine is not tolerated

Answer 195

GORD, gastritis, PUD, perforated ulcer, perf AAA, hepatitis, cholecystitis, gallstones, IBD/IBS, gastroenteritis, diverticula disease, mesenteric ischaemia, colitis, bowel obstruction, testicular pathology, ovarian pathology, urinary retention, kidney stones, cancers, ectopic pregnancy, abnormal MI presentation, UTI

Answer 196

bed: ECG, beta-HCG, urine dip + MSU blood: FBC, U&Es, LFTs, CRP, CK, Troponins imaging: CT abdo pelvis with contrast, ultrasound of abdomen/urinary tract, erect CXR, abdominal XR stool: culture and sensitivity, faecal calprotectin, occult test surgery: exploratory laparotomy may be used; if testicular torsion is suspected surgery is required for diagnosis and treatment

Answer 197

ABCDE approach to guide management pain relief, IV fluids if needed pt NBM if surgery suspected other management options are dependent on what hx, ex, ix show

Answer 198

GORD, PUD, malignancy, Mallory-Weiss tears, Boerhaave syndrome, gastritis, oesophagitis

Answer 199

bed: insert IV cannulas [two grey 16G large bore] blood: FBC, U&Es, LFTs, CRP, ABG, crossmatch and G+S, coagulation screen imaging: endoscopy

Answer 200

ABCDE approach; emergency situation if hypovolaemic; fluid resuscitate. Administer 500ml bolus of 0.9% NaCl over <15m; then reassess for fluid overload. Blood loss is typically replaced with blood however. So pt will probably require blood products O- blood should be administered, reassess after each unit Platelets may be required, especially in pts with liver pathology FFP can be given if PT or APPT is 1.5x greater than normal Prothrombin complex is offered to pts on warfarin to reverse effects of warfarin Terlipressin causes vasoconstriction of splenic artery - good if suspecting varices Prophylactic antibiotic therapy to pts with suspected/confirmed variceal bleeding - Ciprofloxacin 1g OD for 7/7 Endoscopy performed on all unstable pts urgently; all other pts within 24hrs - allows diagnosis and management

Answer 201

GORD, PUD, malignancy, Mallory-Weiss tears, Boerhaave syndrome, gastritis, oesophagitis

Answer 202

Same as for haematemesis

Answer 203

Same as for haematemesis

Answer 204

diverticulosis, haemorrhoids, fissures, fistulas, ischaemic colitis, angiodysplasia, polyps, malignancy, IBD, infection

Answer 205

bedside: DRE, obs, BP, CBG, ECG, stool microscopy, culture and sensitivities, faecal calprotectin bloods: FBC, U&Es, LFTs, haematinics, clotting, A/VBG, G+S/CM imaging: erect CXR, CT abdo/pelvis with contrast, CT angiography special: flex sig, colonoscopy, UGI endoscopy, angiographic transarterial embolisation

Answer 206

ABCDE approach; acute patient Assess and resuscitate as necessary Then calculate shock index Stable? Unstable? Active bleed? Stable: endoscopy Unstable/Active: CT angiogram, treat with IR/endoscopy, surgery is an option

Answer 207

Yellow complexion occurs from elevated bilirubin Pre-hepatic [excessive breakdown of RBCs]: sickle cell disease, hereditary spherocytosis, autoimmune haemolytic anaemia, iatrogenic Hepatic and unconjugated: Gilbert's syndrome, hyperthyroidism, antibiotics, anti-retroviral drugs Hepatic and conjugated: hepatocellular injury [hepatitis, alcohol, fatty liver, hereditary haemochromatosis, medications], infiltrative disorders [sarcoidosis, amyloidosis, tuberculosis], malignancy Post-hepatic [biliary obstruction]: primary sclerosing cholangitis, stricturing of bile ducts, choledocholelithasis [gallstones], malignancy [i.e. head of pancreas tumour] parasitic infections, Mirizzi's syndrome

Answer 208

blood: FBC, U&Es, LFTs, coagulation, CRP, renal function, haemolysis screen imaging: USS, CT abdo/pelvis, MRI liver, MRCP/ERCP

Answer 209

treat underlying cause anti-histamines for pruritus ERCP - removing obstruction of biliary tree, placing stents, taking biopsy for malignancy

Answer 210

malignancy, IBD/IBS, gastroenteritis, diet, hyperthyroidism, medication side-effects may be normal for some patients

Answer 211

bed: DRE, faecal calprotectin, occult test, stool microscopy/sensitivity/cultures blood: FBC, U&Es, LFTs, TFTs, CRP

Answer 212

Fluids Antimotility medication- codeine phosphate, loperamide

Answer 213

medication side effects, pregnancy, post-operative, bowel obstruction, infection, gastroenteritis, motion sickness, migraine, pain, indigestion, stress, alcohol

Answer 214

bed: ECG, beta-HCG, CBG blood: FBC, U&Es, LFTs, TFTs, CRP imaging: AXR, CT abdo contrast, USS

Answer 215

anti-emetics fluids, especially if dehydrated electrolyte monitoring and replacement if indicated treatment for underlying pathology/disease

Answer 216

PUD, gastritis, oesophageal varices account for majority of cases oesophagus: oesophagitis, varices, malignancy, GORD, MWT stomach: PUD, MWT, gastric varices, gastritis, malignancy duodenum: PUD, diverticulum, aortoduodenal fistula, duodenitis other: swallowed blood, bleeding disorders, angiodysplasia

Answer 217

Symptoms- haematemesis, dizziness, syncope, weakness, abdominal pain, dyspepsia, heartburn, melaena, haematochezia, weight loss Signs- dehydration, pallor, confusion, tachycardia, hypotension, abdominal tenderness, melaena, haematochezia, stigmata or liver disease [spider naevi, ascites, hepatomegaly], telangiectasia

Answer 218

bed: obs, ECG, urine output, DRE blood: FBC, A/VBG, U&Es, LFTs, coagulation screen, G+S/CM imaging: CXR; upper GI endoscopy

Answer 219

Initially resuscitated with ABCDE approach Endoscopy Non-variceal bleeding: endoscopy [clips with adrenaline, or thermal coagulation with adrenaline] or medical [PPI] Variceal bleeding: endoscopy [band ligation or endoscopic sclerotherapy]; pharmacological [terlipressin IV, prophylactic abx therapy] Varices may re-bleed: in this case, Sengtaken-blakemore tube to tamponade bleeding; oesophageal stent; transjugular intrahepatic portosystemic shunt TIPS procedure

Answer 220

Cobblestone appearance, rosethorn ulcers, obstruction, hyperplasia, narrowing, skip lesions Symptoms- n/a, low grade fever, weight loss, abdo pain, diarrhoea, rectal bleeding, perianal disease Signs- pyrexia, dehydration, angular stomatitis, aphthous ulcers, pallor, tachycardia, hypotension, abdominal tenderness/mass/distension can have extra-intestinal manifestations - skin, eyes, joints, anaemia

Answer 221

bed: obs, ECG, urinalysis, stool microscopy/sensitivity/culture/parasites/c.diff toxin, faecal calprotectin blood: FBC, LTFs, U&Es, CRP, magnesium, haematinics, bone profile, clotting imaging: AXR, CT, MRI small bowel, Barium follow through, colonoscopy, upper gi endoscopy special: examination under anaesthesia

Answer 222

Induce remission and then maintain *diet management *corticosteroids [budesonide/prednisolone] *infliximab *methotrexate *azathioprine Surgical options are available

Answer 223

Continuous mucosal inflammation, inflammatory polyps, goblet cell depletion, crypt abscesses, inflammatory infiltrate in lamina propria Symptoms- weight loss, fatigue, abdominal pain, loose stools, rectal bleeding, tenesmus, urgency Signs- febrile, pale, dehydrated, abdominal tenderness, abdominal distension/mass, tachycardic, hypotensive

Answer 224

fever tachycardia hypotension dehydration altered mental status biochemical abnormalities abdominal distension and tenderness

Answer 225

bed: obs, ECG, urinalysis, urine MCS, C.diff toxin, faecal calprotectin blood: FBC, LFTs, U&Es, CRP, A/VBG, haematinics, magnesium, clotting, autoantibodies imaging: AXR endoscopy: colonoscopy is diagnostic investigation of choice

Answer 226

Induce and maintain remission *aminosalicylates and/or steroids *steroid enema *azathioprine *infliximab Surgical intervention- proctocolectomy, with ileal pouch anal anastamosis or end ileostomy

Answer 227

Symptoms- n/v, anorexia, malaise, abdominal pain, altered mental status, confusion, scars [?previous self harm] Signs- asterixis, bruising, jaundice, RUQ tenderness, oliguria/anuria, tachycardia, hypotension, coma

Answer 228

blood: FBC, U&Es, LFTs, bone profile, A/VBG, blood glucse, paracetamol levels, salicylates levels, coag screen special: Nomogram

Answer 229

Principle treatment is N-acetylcysteine [NAC] 21 hr regime: Over 1hr: 200ml 0.9% NaCl with 150mg/kg of NAC Over 4 hrs: 500ml 0.9% NaCl with 50mg/kg of NAC Over 16hrs: 1L 0.9% NaCl with 100mg/kg of NAC within 8hrs of ingestion- activated charcoal can be given stop tx when INR <=1.3 and ALT normal referral to psychiatry should be considered

Answer 230

A syndrome of acute liver dysfunction without underlying chronic liver disease -coagulopathy of hepatic origin -altered levels of consciousness due to hepatic encephalopathy

Answer 231

viruses [A, B, E] paracetamol non-paracetamol medications [statins, carbamazepine, ecstasy] toxin-induced Budd-Chiari syndrome pregnancy-related autoimmune hepatitis Wilson's disease

Answer 232

ischaemic hepatitis liver resection severe infection malignant infiltration heat stroke haemophagocytic syndromes

Answer 233

Characterised by jaundice, confusion, coagulopathy S/S- altered mental status, confusion, asterixis, jaundice, RUQ pain/tenderness, hepatomegaly, ascites, bruising, GI bleeding, hypotension, tachycardia, raised intracranial pressure

Answer 234

Early transfer to a transplant centre urgent blood tests: FBC, LFTs, U&Es, bone profile, blood glucose, arterial ammonia, ABG, coagulation, lactate dehydrogenase, lipase/amylase, blood cultures imaging: Doppler ultrasound, CT abdo/pelvis

Answer 235

Toxicology screen Paracetamol serum level Autoimmune markers [ANA, autoantibodies, immunoglobulins, ANCA] Viral screen [hep A through to E; CMV, EBV, HSV, VZV, Parvovirus]

Answer 236

CVS- fluid resus +/- inotropic agents Resp- intubation + ventilation may be needed; chest physio GI- nutrition [NG feed+/-TPN] gastric ulcer prophylaxis, pancreatitis risk assessment, manage GI bleeding if/when necessary Metabolic- hypoglycaemia [maintain 8-11mmol/L]; hyponatraemia [140-145mmol/L]; acidosis and lactate; hypophosphatemia [suggests liver regeneration, good prognostic sign, needs correction] Renal- AKI is common, monitor and treat when necessary Coagulopathy- use blood products if bleeding Sepsis- Early aggressive treatment of infection with broad spec abx Neurological- may require ventilation + intubation; at risk of raised ICP, monitor Liver- assessed and considered for urgent transplantation

Answer 237

Repeated insults to the liver, which can result in inflammation, fibrosis, and ultimately cirrhosis

Answer 238

alcohol viral [hep a-e] inherited [alpha-1-antitrypsin deficiency; wilson's disease; hereditary haemochromatosis] metabolic [non-alcohol fatty liver disease] autoimmune [autoimmune hepatitis] biliary [primary biliary cholangitis; primary sclerosing cholangitis] vascular [ischaemic hepatitis; Budd-Chiari syndrome; congestive hepatopathy] medication [drug-induced liver injury] cryptogenic [no known cause] other [many rare cases]

Answer 239

alcohol- alcohol history virus- sexual health history, food/diet history, travel history, iv drug use, tattoos inherited- past family history metabolic- diabetic, diet, exercise autoimmune- other autoimmune conditions biliary- IBD? medication- drug hx

Answer 240

Haemochromatosis- 'golden skin', endocrine abnormalities, thyroid problems, erectile dysfunction Alpha-1-antitrypsin- COPD, liver cirrhosis, emphysema Wilson's- psychiatric changes, eye changes Autoimmune- 'period problems', typically young women

Answer 241

stigmata of cld- caput medusa, splenomegaly, palmar erythema, dupuytren's contracture, leukonychia, gynaecomastia, spider naevi features of hepatic decompensation- encephalopathy, ascites, jaundice, GI bleeding, coagulopathy

Answer 242

Liver biopsy is considered gold-standard diagnostic method for identifying cirrhosis LFTs Transient elastography Imaging: USS, CT, MRI

Answer 243

Treat underlying pathology, prevent progression and manage complications hepatic encephalopathy- lactulose, long term abx [refaximin] ascites- spironolactone, furosemide, paracentesis gi bleeding- b-blockers if not bleeding; acute bleed needs ligation; after bleeding use surveillance and b-blockers spontaneous bacterial peritonitis- abx as per local guidelines, albumin solution, long term prophylactic abx hepatocellular carcinoma- high risk so 6monthly surveillance with uss +/- afp blood test transplant is potentially life-saving treatment

Answer 244

hepatitis, infection, cirrhosis, liver cancer, other liver diseases may also be a lack of blood flow to the liver medications or poisons

Answer 245

hepatitis, cirrhosis, mono, other lvier disease, heart problems, pancreatitis

Answer 246

high- blockage of bile ducts, cirrhosis, hepatitis, mono, bone disorders, heart failure, hodgkin lymphoma, infection low- zinc deficiency, malnutrition, pernicious anaemia, thyroid disease, Wilson's disease

Answer 247

high- hepatitis, cirrhosis, mono, other liver diseases, heart problems, pancreatitis

Answer 248

Gilbert's syndrome, gallstones, liver dysfunction, hpcc, hepatitis, bile duct inflammation, intrahepatic cholestasis of pregnancy, haemolytic anaemia

Answer 249

low- cirrhosis, hepatitis, fatty liver disease, kidney disease, malnutrition, infection, digestive diseases, burns, thyroid dysfunction high- dehydration, diarrhoea, medications

Answer 250

anaemia, kidney disease, liver disease, muscle injury, heart attack, pancreatitis, infections [meningitis, encephalitis, mono], some types of cancer [lymphoma, leukaemia]

Answer 251

high- type 1 autoimmune hepatitis low- type 2 autoimmune hepatitis none- symptoms aren't caused by autoimmune hepatitis

Answer 252

*manage alcohol withdrawal [benzodiazepines, alcohol team input] *alcohol cessation *hydration [cautious fluid resus, use of albumin to reduce risk of ascites, hyponatraemia, precipitating GI bleed] *nutrition [dietitian input, low threshold for NG feed and vit. supplementation] *aggressive treatment of infections [++risk of life-threatening infections due to immune dysfunction] *pharmacological therapy [corticosteroids can be used in severe alcoholic hepatitis] *transplantation [6/12 abstinent from alcohol prior to transplantation]

Answer 253

Treatment centres on dietary advice, exercise and managing co-morbidities [e.g .diabetes] *weight loss *control htn, diabetes, high cholesterol *liver transplantation [only curative treatment for end-stage liver disease]

Answer 254

A- usually resolves without treatment, supportive tx may help [analgesia] B- antiviral medications, screen for other diseases, liver transplantation, contact tracing and informing at-risk contacts C- antiviral treatment with direct-acting antivirals for 8-12/52 D- pegylated interferon alpha over at least 48/52 E- usually cleared within a month, no treatment aside from supportive treatment necessary

Answer 255

*venesection [weekly blood removal to decrease total iron] *monitoring serum ferritin *avoid alcohol *genetic counselling *monitoring and treatment of complications

Answer 256

high-dose steroids [prednisolone] immunosuppressants [azathioprine] - useful for inducing remission liver transplantation may be required in end-stage liver disease; autoimmune hepatitis can reoccur in the new liver

Answer 257

Hepatic encephalopathy Ascites Hyponatraemia GI bleeding Infections - SBP AKI Hepatocellular carcinoma Hepatorenal syndrome Hepatopulmonary syndrome Acute-on-chronic liver failure

Answer 258

confusion, forgetfulness, personality/mood changes, stale/sweet odour on breath, poor judgement, poor concentration, change in sleep patterns, worsening of handwriting or small hand movement asterixis, extreme anxiety, seizures, severe confusion, fatigue, severe personality changes, jumbled/slurred speech, slow movement

Answer 259

Lactulose - changes acidity of stools to help prevent growth of bacteria that produce ammonia in the bowel Rifaximin - abx used to stop growth of bacteria in the intestines; taken alongside lactulose nutritional support

Answer 260

fluid accumulation within peritoneal cavity swelling/distention fluid thrill and shifting dullness

Answer 261

low sodium diet aldosterone antagonists [spironolactone] paracentesis [ascetic tap or ascetic drain] prophylactic antibiotics [ciprofloxacin] transjugular intrahepatic portosystemic shunt [TIPS] considered in refractory ascites liver transplantation in refractory ascites

Answer 262

typically asymptomatic until they start bleeding bleeding from varices can cause patients to bleed out due to high blood flow

Answer 263

immediate senior help consider blood transfusion [activate major haemorrhage protocol] treat any coagulopathy vasopressin analogues [terlipressin] prophylactic broad-spectrum antibiotics urgent endoscopy with variceal band ligation consider intubation and intensive care Sengstaken-Blakemore tube to tamponade bleeding Transjugular intrahepatic portosystemic shunt [TIPS]

Answer 264

can be asymptomatic presenting features include: fever, abdominal pain, deranged bloods, ileus, hypotension organisms: Escherichia coli, Klebsiella pneumoniae

Answer 265

sample of ascitic fluid for culture before abx IV broad-spec abx according to local guidelines human albumin solution to help prevent aki and hepatorenal syndrome long-term prophylactic antibiotics

Answer 266

sample of ascitic fluid for culture before abx IV broad-spec abx according to local guidelines human albumin solution to help prevent aki and hepatorenal syndrome long-term prophylactic antibiotics

Answer 267

increased resistance to blood flow to the liver due to liver cirrhosis; back pressure on the portal system splenomegaly oesophageal varices, caput medusae

Answer 268

Non-selective b-blockers [propranolol] Watchful waiting - hope varices don't bleed

Answer 269

impaired kidney function reduced blood pressure

Answer 270

liver transplant - best option for pt

Answer 271

jaundice, weight loss, deranged LFTs, abdominal pain, anorexia, n/v, pruritus

Answer 272

resection of early disease can be curative liver transplant when isolated to liver can be curative kinase inhibitors to inhibit proliferation of cancer cells [sorafenib] chemo/radiotherapy don't tend to work; but can be used as palliative treatment or clinical trials

Answer 273

Body launches a large immune response to an infection that causes systemic inflammation and organ dysfunction

Answer 274

Arterial BP drops and results in organ hypo-perfusion, leading to increased anaerobic respiration *systolic bp <90 despite fluid resuscitation *hyperlactaemia [lactate >4mmol/L] aggressively treated with IV fluids, inotropes [noradrenaline], as well as sepsis treatment

Answer 275

resp- --Pa02, --FiO2, need for ventilation, tachypnoea cardio- --bp, need for inotropes renal- oliguria, anuria, AKI haematological- platelet count, coagulation liver- coagulation, bilirubin neurological- --GCS

Answer 276

very young/very old [<1 or >75] chronic conditions [COPD, diabetes] chemotherapy, immunosuppression, steroids surgery or recent trauma or burns pregnancy or peripartum indwelling medical devices [catheters, central lines]

Answer 277

features of specific infection warm, flushed skin [vasodilation due to inflammatory mediators] or cool, mottled skin [suggests shock] prolonged CRT febrile [>38`C] hypothermic [<36`C] tachycardic tachypnoea hypotension jaundice, ileus, bleeding, bruising, altered mental status, reduced consciousness, low urine output, anuric

Answer 278

SEPSIS 6 should be initiated within an hour of recognition of the signs +oxygen; +antibiotics; +IV fluids; -blood cultures; -urine output; -lactate FBC, U&Es, CRP, clotting screen, LFTs, ongoing obs CXR, urine MC&S, CT abdo/pelvis, lumbar puncture, blood film, joint aspiration - find source of infection

Answer 279

SEPSIS 6 should be initiated within an hour of recognition of the signs +oxygen; +antibiotics; +IV fluids; -blood cultures; -urine output; -lactate senior review - all pts with sepsis should be reviewed by a senior clinician and have ongoing monitoring any deterioration and should be reviewed by intensive care team

Answer 280

Symptoms- fever, malaise, cough [with purulent sputum], dyspnoea, pleuritic pain Signs- dull percussion, reduced breath sounds, bronchial breathing, coarse crepitations, increased vocal transmission, tachycardia, hypotension, confusion, cyanosis

Answer 281

bed: sputum culture, obs blood: FBC, U&Es, CRP, cultures imaging: CXR

Answer 282

CURB-65 helps to guide treatment 0-1: outpatient treatment 2: consider inpatient 3+: inpatient treatment antibiotics - amoxicillin 500mg TDS [PO] for 5/7 or co-amoxiclav 1.2g TDS [IV] and Clarithromycin 500mg BD [PO] for 5/7

Answer 283

Symptoms- fever, malaise, lethargy, anorexia, weight loss, abdominal pain, haematuria, cardiac symptoms [sob, chest pain, palpitations] Signs- cardiac murmur, features of heart failure, splinter haemorrhages, petechiae, Janeway lesions, Osler nodes, Roth spots, splenomegaly

Answer 284

IV drug use Chronic kidney disease Immunocompromised Hx of infective endocarditis Structural heart pathology: *valvular heart disease *congenital heart disease *hypertrophic cardiomyopathy *prosthetic heart valves *implantable cardiac devices

Answer 285

Staphylococcus aureus - IVDU Coagulase negative staphylococcus - prosthetic devices Viridans streptococci - poor dentition Candida albicans, Aspergillus - poor prognosis

Answer 286

bacteria enters bloodstream and deposit onto the endocardial surface of the heart once deposited, the organisms adhere and eventually lead to invasion and destruction of the valve leaflets key pathological process is formation of infected vegetations

Answer 287

Microbiology- at least 3x blood cultures 30m apart before systemic antibiotics Echocardiography- trans thoracic or oesophageal echo are imaging modalities of choice. Findings suggestive include: vegetation, abscess formation, pseudoaneurysm, valve perforation, new dehiscence of a prosthetic valve bed: urine dip, ECG blood: FBC, U&E, CRP/ESR, LFT, VBG imaging: echo, CXR

Answer 288

Streptococci- benzylpenicillin plus low grade gentamicin Enterococci- amoxicillin plus low grade gentamicin Staphlococci- flucloxacillin plus gentamicin

Answer 289

Echo [1x weekly] to assess vegetation size ECG [twice weekly] to detect conduction disturbances Bloods [twice weekly] ESR, CRP, FBC, U&Es Duration of abx will depend on clinical response; may require 6+wks of abx

Answer 290

valve dehiscence uncontrolled infection relapse after therapy threatened or systemic embolism fungal infections valve obstruction aortic root abscess mod-severe cardiac failure due to valve compromise

Answer 291

Bacterial meningitis is most commonly caused by Neisseria meningitidis and Streptococcus pneumoniae Neonates- group B strep is most common Can also be viral [HIV, VZV, enteroviruses, HSV] or fungal [Cryptococcus neoformans, candida]

Answer 292

Gram negative diplococci commensal organism in 5-11% of population Vaccinated against as part of the UK vaccination programme

Answer 293

Gram positive diplococci 5-10% asymptomatic carriers in adults; higher in children Offer vaccinations to children as part of the UK vaccination programme, also offered to patients with significant co-morbidities [diabetes] and adults >65

Answer 294

Typically acquired through droplets or secretions from the upper respiratory tract Causes meningeal inflammation via: a) invasion of bloodstream OR b) direct contiguous spread [as a result of ENT infections or trauma] Mild- infection confined to subarachnoid space Severe- brain parenchyma underneath pia mater can be affected

Answer 295

Symptoms- neck stiffness, photophobia, headache, fever, n/v, fatigue, confusion, irritable or unsettled behaviours, altered mental status Signs- tachycardia, hypotension, marked neck stiffness, photophobia, non-blanching rash, seizures, focal neurological deficits, reduced consciousness, coma Two classic signs- Kernig's sign: unable to extend knee when hip is flex to 90` Brudzinski's sign: spontaneous flexion of knees and hips on flexion of the neck due to pain

Answer 296

Diagnosis is typically made on clinical suspicion and treatment starts while further investigations are carried out Definitive diagnosis- isolation of a pathogen from CSF following a lumber puncture also can be diagnosed using blood cultures too

Answer 297

ABCDE approach if critically unwell bed: throat swab, nasopharyngeal swab for viral screen blood: FBC, U&Es, LFTs, bone profile, coagulation, CRP, blood cultures, VBG, meningococcal PCR imaging: CT head to look for any contraindications to lumber puncture

Answer 298

Bacterial - first line is ceftriaxone 2g BD; caution with pen.allergic dexamethasone can be given as an adjunct Viral - supportive treatment w/ rest, hydration, analgesia, antipyretic Meningitis is a notifiable disease - contact tracing, chemoprophylaxis

Answer 299

Inflammation of the brain parenchyma can be secondary to infection or secondary to other causes [cancer, autoimmunity]

Answer 300

Possible features- fever, headache, seizures, altered mental status, behavioural changes, brainstem dysfunction, memory problems, focal neurological deficits

Answer 301

bed: obs, urinalysis, ECG, sputum cultures blood: FBC, U&Es, bone profile, LFTs, CRP, blood cultures, coagulation imaging: CXR, CT head special: EEG to record electrical activity in the brain CSF analysis to potentially identify a cause Serological testing can be used to check for antibodies associated with paraneoplastic or autoimmune encephalitis

Answer 302

Aim to treat the underlying cause ?infection - antibiotics or antivirals ?paraneoplastic/autoimmune/post-infective - immunosuppression [i.e. steroids]

Answer 303

Acute transient diarrhoeal illness +/- vomiting due to an enteric infection Transmitted by a number of routes [faecal-oral; foodborne; airborne; environmental]

Answer 304

Viral - rotavirus; norovirus; adenovirus Bacteria causing watery diarrhoea - Clostridioides difficile; Clostridium perfringens; Entertoxigenic Escherichia coli Bacteria causing bloody diarrhoea - Non-typhoidal salmonellosis; Campylobacter spp.; Shigella spp.; Yersinia enterocolitica; Enterhaemorrhagic Escherichia coli Parasites - Cryptosporidium parvum; Entamoeba histolytica; Giardia spp.

Answer 305

Rare in adults due to long-lasting immunity Commonly causes watery diarrhoea with vomiting vomiting settles in 1-3d diarrhoea settles in 7d Oral vaccine against virus is now part of the childhood immunisation programme

Answer 306

Most common cause of gastroenteritis in UK; common in winter months Full recovery within 2 days typically

Answer 307

Most common bacterial cause [C. jejuni] Gram negative bacillus Acquired through ingesting undercooked poultry Watery or bloody diarrhoea 2-5 days after exposure Majority of cases are self-limiting within 1wk

Answer 308

commonly causes vomiting illness after reheating starchy food heat stable emetic toxin causes vomiting; heat labile diarrhoeal toxin causes diarrhoea

Answer 309

acquired through ingestion of contaminated food [i.e undercooked poultry] typically causes water diarrhoea but can be bloody, associated with abdo pain/fever/vomiting illness starts within 3d of exposure and resolves within a week caused by S. enteritidis and S. typhimurium

Answer 310

cause of bloody/mucoid diarrhoea associated with fever/abdo pain in young childrne [<5y] common in late summer spreads via direct human-to-human contact illness begins within 1-3d of exposure and resolves within a week

Answer 311

there are different types of E.coli: *enterohaemorrhagic E.coli [EHEC] *enterotixigenic E.coli [ETEC] *enteropathogenic E.coli [EPEC]

Answer 312

cause a bloody diarrhoeal illness/may also be asymptomatic E.coli 0157 is most common in children <5 begins within 3-4d of exposure and resolves within 10d transmitted through contaminated food; also seen from direct human-to-human contact and contact with infected animals can cause haemolytic uraemic syndrome in children

Answer 313

commonly associated with water diarrhoeal illness in travellers or resource limited countries

Answer 314

entamoeba histolytica - anaeorbic parasite majority of cases are asymptomatic if symptoms, usually subacute onset over weeks s/s range from mild diarrhoeal illness to severe dysentery

Answer 315

Giardi lambila is commonly implicated in Travellers' diarrhoea classically watery diarrhoea alongside abdo pain/anorexia/flatulence/bloating if left untreated may lead to malabsorption and weight loss

Answer 316

Characterised by acute onset of diarrhoea +/- vomiting Hx- food+drink, foreign travel, contacts, occupation, co-morbidities Symptoms- diarrhoea, n/v, fever, abdo pain, general malaise, bloating/cramping, weight loss Signs- features of dehydration, features of shock, abdominal tenderness

Answer 317

stool- MC&S, virology, C.diff toxin, OCP blood- FBC, U&Es, bone profile, CRP, VBG, blood cultures imaging- not routinely recommended in pts with gastroenteritis

Answer 318

mainly supportive treatment - good oral intake, rest, good basic hygiene consider hospital admission if: systemically unwell, persistent vomiting or high output diarrhoea, suspected sepsis, failure to respond to supportive treatment, major co-morbidities

Answer 319

cholera food poisoning infectious bloody diarrhoea HUS enteric fever [typhoid or paratyphoid]

Answer 320

bacillus cereus campylobacter spp. clostridium perfringens cryptosporidium spp. entamoeba histolytica giardia lambila salmonella spp. shigella spp.

Answer 321

inflammation of the gallbladder most commonly due to impacted gallstones

Answer 322

Symptoms- RUQ pain, epigastric pain, n/v, fever Signs- RUQ/epigastric tenderness +/- guarding, pyrexia, tachycardia, hypotension Murphy's sign- as pt breathes out, place hand below the right costal margin. as pt breathes, inflamed gallbladder moves inferiorly and hits the hand, causing patient to catch their breath.

Answer 323

bed: obs, urine dip, pregnancy test blood: FBC, U&Es, CRP, LFTs, amylase imaging: ultrasound, CT abdo w/contrast, MRCP special: ERCP

Answer 324

Medical: A-E if critically unwell; abx [augmentin +stat dose of gentamicin]; IV fluids; analgesia Percutaneous cholecystostomy - drain inside the gallbladder placed by IR Cholecystectomy - definitive management in simple cholecystitis

Answer 325

Infection of the biliary tree caused by bacterial infection secondary to biliary obstruction obstruction can be due to gallstones or biliary strictures [benign and malignant]

Answer 326

Charcot's triad - fever, jaundice, RUQ pain Symptoms- RUQ/epigastric pain; fever; malaise; n/v Signs- RUQ/epigastric tenderness; pyrexia; jaundice; hypotension; confusion

Answer 327

bed: obs, urine dip, pregnancy test blood: FBC, U&Es, CRP, LFTs, amylase imaging: ultrasound, CT abdo w/contrast, MRCP special: ERCP

Answer 328

Medical- A-E if unwell, IV abx [augmentin + stat dose of gentamicin]; IV fluids; analgesia Biliary drainage: ERCP or PTC [percutaneous transhepatic cholangiography]

Answer 329

Idiopathic Gallstones Ethanol Trauma Steroids Mumps Autoimmune Scorpion sting Hyperlipidaemia/Hypercalcaemia ERCP Drugs

Answer 330

Symptoms- abdo pain; n/v; anorexia; diarrhoea Signs- abdo tenderness; abdo distention; tachycardia; tachypnoea; pyrexia Cullen's sign- peri-umbilical bruising Grey-Turner's sign- flank bruising

Answer 331

bed: obs, ECG blood: FBC, U&Es, LFTs, CRP, amylase, lipase, glucose, lipids, bone profile, ABG imaging: ultrasound; CT; MRCP

Answer 332

Completed within first 48hrs, hleps to assess severity of acute pancreatitis P- PaO2 <8kPa A- Age >55 N- Neutrophils, WCC >15x10[9]0/L C- Calcium <2mmol/L R- Renal, urea >16mmol/L E- Enzymes, AST >200iu/L or LDH >600iu/L A- Albumin <32g/L S- sugar, glucose >10mmol/L >=3 is a sign of severe disease [should have HDU/ITU input]

Answer 333

General management consists of analgesia, appropriate fluids and nutritional support antibiotics not routinely indicated in acute pancreatitis

Answer 334

Pancreatic necrosis Pancreatic pseudocyst Pseudoaneurysm Venous thrombosis systemic: Acute respiratory distress syndrome Renal failure Shock

Answer 335

cystitis results from colonisation and ascending spread of microorganisms from the urethra to the bladder typically Escherichia coli uncommon in men

Answer 336

recent sexual intercourse diabetes history of UTIs spermicide use catheters

Answer 337

Symptoms- dysuria; frequency; urgency; incontinence; suprapubic pain; haematuria; n/v Signs- fever; rigors; flank pain; confusion; costovertebral angle tenderness

Answer 338

Definitive diagnosis of UTI is based on typical clinical features and positive lab evidence of pyuria +/- bacteriuria bed: urine dip, urine MC&S, obs, pregnancy test, STI screen blood: FBC, U&Es, CRP imaging: not routinely used but can use ultrasonography and CT

Answer 339

Appropriate antibiotic therapy according to local guidelines consider delaying if not unwell unwell/men/pregnant/diabetes/others - immediate treatment Nitrofurantoin 100mg BD for 3/7; 7/7 if pregnant/men/complications

Answer 340

pyelonephritis results from colonisation and ascending spread of microorganisms from the urethra to the bladder typically Escherichia coli uncommon in men

Answer 341

Symptoms- dysuria; frequency; urgency; incontinence; suprapubic pain; haematuria; n/v Signs- fever; rigors; flank pain; confusion; costovertebral angle tenderness

Answer 342

Definitive diagnosis of UTI is based on typical clinical features and positive lab evidence of pyuria +/- bacteriuria bed: urine dip, urine MC&S, obs, pregnancy test, STI screen blood: FBC, U&Es, CRP imaging: not routinely used but can use ultrasonography and CT

Answer 343

Abx according to local guidelines Co-amoxiclav 625mg TDS for 10/7 pregnant- cefalexin 500mg BD for 10/7

Answer 344

Acute bacterial infection of the skin Affects both dermis and subcutaneous tissue Occurs anywhere on the body; ranges from self-limiting to necrotising infection

Answer 345

Beta-haemolytic streptococcus Staphylococcus aureus ^^ commonly

Answer 346

Symptoms- pain, redness, swelling, malaise, fever Signs- tenderness on palpation, erythema, skin warmth, superficial bullae/blisters, abscess, lymphadenopathy

Answer 347

Diagnosis usually made clinically based on the classic appearance Lab investigations are often unnecessary bed: skin swabs, blood glucose blood: FBC, U&Es, LFTs, CRP, blood cultures, HbA1c imaging: ultrasound, X-ray

Answer 348

Mild cellulitis can be treated in community with oral antibiotics - penicillin or flucloxacillin or erythromycin Severe cellulitis/unwell pt/lymphoedema/complications may warrant hospital admission; IV abx [flucloxacillin, clindamycin, vancomycin]

Answer 349

rapidly progressive infection resulting in extensive tissue destruction

Answer 350

Can be confused with cellulitis Disproportionate pain compared with physical findings Skin changes: Stage I- erythema, tenderness, swelling, warmth Stage II- bullae formation, blistering, fluctuation of the ksin Stage III- haemorrhagic bullae, crepitus, tissue necrosis

Answer 351

Diagnosis is essentially clinical Gold standard is surgical exploration and tissue biopsy Fascial necrosis with loss of natural tissue planes is diagnositc If suspected, do not delay surgical exploration and debridement

Answer 352

Prompt resuscitation Antibiotics- Tazocin, meropenem, clindamycin Surgical debridement- early and aggressive surgical debridement is priority Supportive care Reconstruction- should only be considered when the infection is completely eradicated; can include skin grating, local/regional flaps/free tissue transfer

Answer 353

Defined as any type of skin, soft tissue or bone infection below the ankle in patients with diabetes

Answer 354

ulcer, pain, loss of protective sensation malaise, anorexia, foot erythema, oedema of foot/ankle/calf, absent pedal pulses, fluctuance

Answer 355

bed: swabs for culture, glucose blood: FBC, U&Es, CRP, HbA1c imaging: X-ray; MRI or CT special: ABPI; duplex ultrasound

Answer 356

Debridement Supportive treatment Antibiotics Diabetic review - better control to stop further progression Negative pressure wound therapy Skin grafts Surgery

Answer 357

Commonly a bacterial infection of one or more joints; typically Staphylococcus aureus Haematogenous spread is most common mechanism of infection; direct inoculation can occur through an animal bite, surgery, wounds or joint injection

Answer 358

Diabetes Advancing age Prosthesis Immunodeficiency/immunosuppression IV drug use

Answer 359

High index of suspicion for any patient presenting with acute atraumatic joint pain Symptoms- pain, swelling, fevers, inability to weight bear Signs- pain on active and passive movement, reduced ROM, erythema, warmth, joint effusion

Answer 360

bed: obs, glucose, urine dip, consider sexual health screen blood: FBCV, U&Es, CRP, LFTs, ESR, urate, blood cultures imaging: plain X-ray; ultrasound; CT/MRI special: joint aspiration [gold standard for diagnosing; should be send for WBC, gram stain, culture and crystal microscopy]; synovial tissue culture

Answer 361

Should be referred to and managed by orthopaedics Antibiotics- typically a long course of antibiotics 6wks with 2 weeks of IV therapy; refer to local guidelines [flucloxacillin 2g QDS] Joint drainage- joint should be aspirated to dryness; arthroscopic drainage and washout considered

Answer 362

Infection of the bone Most common cause- Staphylococcus aureus [Gram positive cocci] Haematogenous spread [rf: indwelling intravascular catheter, haemodialysis, endocarditis, IVDU] Non-haematogenous spread occurs due to skin ulcers, trauma, surgery, animal/insect bites

Answer 363

Symptoms- fever, pain, overlying redness, swelling, malaise Signs- erythema, swelling, evidence of previous surgery or trauma, tenderness, discharging sinus, ulcers/skin breaks

Answer 364

bed: obs, glucose, urine dip blood: FBC, U&Es, CRP, LFTs, ESR, HbA1c microbiology: urine MSU, blood cultures, wound swab, bone culture imaging: diagnosed on MRI usually; X-ray; CT

Answer 365

Antibiotics +/- surgical debridement is main focus of treatment

Answer 366

involves infection of the vertebra and infection of the vertebral disc Similar to osteomyelitis but also affects the disc Staphylococcus aureus

Answer 367

Symptoms- fever, pain, overlying redness, swelling, malaise Signs- erythema, swelling, evidence of previous surgery or trauma, tenderness, discharging sinus, ulcers/skin breaks

Answer 368

bed: obs, glucose, urine dip blood: FBC, U&Es, CRP, LFTs, ESR, HbA1c microbiology: urine MSU, blood cultures, wound swab, bone culture imaging: diagnosed on MRI usually; X-ray; CT

Answer 369

Referral to infectious disease specialist and a spinal surgeon Antibiotics Monitoring for neurological changes, sepsis, spinal instability, intraspinal empyema ^ indications for surgical treatment

Answer 370

febrile illness, diarrhoea +/- vomiting, jaundice, lymphadenopathy, hepatosplenomegaly, cough, sob, rash ^ any combination of symptoms

Answer 371

*geographic region of travel within last 12m *dates of travel and duration of stay *careful documentation of time of onset and nature of various symptoms/signs *type of accommodation [hotels vs more rural backpacker areas have different levels of exposure to certain things] *recreational activities and exposures [insects, animals, lakes and streams, canal water] *type of food/drink consumed *sexual history [condom use, sex with commercial sex worker, MSM] *past medical history and predisposition to infection

Answer 372

0-10d: dengue fever, rickettsia, viral [inc. mono], GI [bacterial/amoeba] 10-21d: malaria, typhoid, primary HIV >21d: malaria, chronic bacterial infection, TB, parasitic infections

Answer 373

pulse: brady can indicate typhoid skin: maculopapular rash can be indicative of dengue fever, mono, rubella, parvovirus B19, primary HIV skin: rose spots, pink macules 2-3mm in diameter on chest/abdomen indicates typhoid skin: black necrotic ulcer with erythematous margins - rickettsia [tick exposure] skin: petechiae, ecchymoses, or haemorrhagic lesions - dengue fever, meningococcaemia, viral haemorrhagic fever eye: conjunctival suffusion - leptospirosis spleen: splenomegaly - mono, malaria, typhoid fever neurological system: fever+altered mental status may represent meningo-encephalitis

Answer 374

bed: obs, urinalysis+/-culture blood: FBC, U&Es, LFTs, blood film, blood cultures [x2 with biohazard labels], serology for hep b/c/hiv/syphilis stool: culture +/- stool for ova, cysts and parasites [OCP]

Answer 375

Caused by parasite - plasmodium falciparum [can be f. vivax and p. ovale too]

Answer 376

Symptoms- fever +/- rigours and sweating, fatigue, malaise, headache, anorexia, n/v/d, myalgia, arthralgia, confusion, sore throat, cough Signs- pallor, splenomegaly, jaundice Signs of severe malaria: *cerebral malaria [seizures/low GCS] *AKI [oliguria/anuria] *metabolic acidosis *hypoglycaemia *respiratory distress [sob/hypoxia due to ARDS] *severe anaemia [<70g/L] [breathlessness, chest pain, dizziness, syncope, severe pallor] *spontaneous bruising or bleeding [suggestive of DIC] *thrombocytopenia *hypovolaemia and shock

Answer 377

Diagnosis is based on thick and thin slides [gold standard diagnostic tool for malaria] 3x in 36hrs rapid diagnostic test [detection of malarial antigens]; can be completed in 15-20m blood: FBC, U&Es, LFTs, bone profile, CRP, VBG, blood glucose imaging: CXR, CT head [if low GCS] cultures: septic screen

Answer 378

Riamet - 4 tablets OR Malarone - 4 tablets daily for 3d

Answer 379

caused by salmonella typhi faecal-oral route of transmission

Answer 380

Persistent fever Dull frontal headache Anorexia Apathetic-lethargic state Constipation Cough Diarrhoea Malaise Nausea Prostration- extreme physical weakness Chills; hepatomegaly; pneumonia; relative bradycardia; rigors; rose spots; splenomegaly

Answer 381

Pulse-temperature dissociation [high fever, low pulse] Hepatosplenomegaly Rose spots, but may disappear before presentation

Answer 382

bed: obs, stool MS&U+culture, urine culture blood: FBC, U&Es, LFTs, TFTs, CRP, blood cultures imaging: ?CT head for headache/altered mental status special: bone marrow culture, rose spot culture

Answer 383

Antibiotic therapy and supportive care IV ceftriaxone 2g OD, the nonce sensitivities known switch to an appropriate abx

Answer 384

Classical definition: Temperature >38` on multiple occasions Illness of >3wks duration No diagnosis despite >1wk inpatient investigation

Answer 385

hx- chronology of events/symptoms; pets/animal exposure; travel; occupation; medications; family history; vaccination history; sexual history o/e- lymph nodes; stigmata of endocarditis; evidence of weight loss; joint abnormalities; abdominal exam blood: FBC, U&Es, LFTs, bone profile, CRP, clotting, TFTs, multiple blood cultures, LDH, ferritin, B12, folate, ?immunoglobulins, ?autoimmune screen micro: HIV, hepB/C, syphilis, MSU, sputum cultures, ?malria films, ?atypical pneumonia screen, viral swabs, CMV/EBV serology imaging: CXR, CTthorax/abdo/pelvis, transthoracic echo, ?MRI, ?PET

Answer 386

Aim to find a diagnosis to treat instead of going in blind Don't use abx, steroids, antifungals without speaking to a senior Rheumatology, haematology are asked to see patients Stable patients can be managed as outpatients Prognosis does tend to be good, even without a diagnosis

Answer 387

infection: TB, abscess, infective endocarditis, brucellosis autoimmune/connective tissue: adult onset Still's disease, temporal arteritis, Wegner's granulomatosis Neoplastic: leukaemias, lymphomas, renal cell carcinoma Other: drugs, thromboembolism, hyperthyroidism, adrenal insufficiency

Answer 388

*age *chronic disease *malnutrition *immunosuppression drugs - for crohn's or rheumatoid arthritis - azathioprine/methotrexate/monoclonal antibodies/anti-tnf drugs *oral steroids *anti-rejection drugs for after a transplant *chemotherapy or radiotherapy for cancer *some types of cancer - particularly lymphomas, leukaemias, myelomas *splenectomy patients *HIV/AIDS *genetic conditions - SCID, DiGeorge's syndrome

Answer 389

*avoid eating food that would put you at risk of food poisoning *handle raw meat safely *good hygiene *avoid close contact with people with infections *ensure all routine vaccinations are up to date *extra vaccinations - i.e. annual flu-jab; COVID-19 vaccination; shingles vaccine *don't take live vaccines - ask your doctor if this is suitable for you *post-splenectomy patients tend to take prophylactic antibiotics

Answer 390

Comprehensive Geriatric Assessment multidimensional, interdisciplinary diagnostic process to determine all of the capabilities of a frail older person in order to develop a coordinated and integrated plan for treatment and long-term follow-up

Answer 391

*problem list - current and past *medication review *nutritional status *mental health - cognition, mood, anxiety, fears *functional capacity - ADLs, gait/balance, activity/exercise status, instrumental ADLs [cooking, cleaning, laundry, transport] *social circumstances - support from family/friends, social network from visitors/daytime activities, eligibility for being offered care resources *environment - home, facilities and safety at home, transport, accessibility to local resources

Answer 392

Frailty is a distinctive health state related to the ageing process in which multiple body systems gradually lose their in-built reserves This group of people are most at risk of adverse health outcomes

Answer 393

Tool to quickly and simply assess frailty Has been validated in adults over 65y Can help optimise quality of life outcomes for geriatric patients Score >=5 is a marker for completing a CGA

Answer 394

When 6 or more drugs are prescribed at any one time

Answer 395

Screening Tool of Older Persons' Prescriptions and Screening Tool to Alert to Right Treatment -criteria used as a tool for clinicians to review potentially inappropriate medications in older adults

Answer 396

Medications for clinicians to consider stopping or starting in >65 patients Some medications may not be useful for patient anymore, some medications may provide extra benefit for patient Lots of evidence based medicine

Answer 397

bed: obs [bp standing/lying], ECG, cranial nerve exam, nutritional status blood: FBC, U&Es, CRP, CK, blood cultures imaging: X-ray/s, CT head other investigations may be indicated depending on patient history and other investigation findings

Answer 398

bed: PR, medication review blood: imaging: AXR, CT abdo/pelvis

Answer 399

review of bladder and bowel diary abdominal examination urine dipstick and msu PR examination external genitalia review - particularly looking for atrophic vaginitis in females post micturition bladder scan

Answer 400

good history - witnessed/unwitnessed? how did fall happen? dizziness/light-headedness? LOC? cardiac symptoms? weak? happened before? medication history? normal mobilisation? o/e- CVS exam, ECG, neurological examination, MSK exam, functional assessment of mobility suspicion of a specific cause may warrant further investigations - CT head for example

Answer 401

Acute confused state, with sudden onset and fluctuating in course Develops over 1-2 days and is recognised by a change in consciousness - either hyper or hypoalert and inattention

Answer 402

*underlying medical problem *substance intoxication *substance withdrawal *combination of any of ^ Good to exclude these causes: *infection *electrolyte imbalances *hypoxia *drugs - inc. opiates *urinary retention *constipation *uncontrolled pain

Answer 403

A progressive decline in cognitive functioning usually occurring over several months Affects many areas of function including: retention of new information; managing complex tasks; language and word finding difficulty; orientation; recognition; ability to self care; reasoning

Answer 404

*Alzheimer's disease *Vascular dementia *Dementia with Lewy Body *Parkinson's disease with dementia *Frontotemporal dementia

Answer 405

Always assume somebody has capacity A person has capacity if they can do all of the following: *understand information relevant to the decision in question *retain that information *use the information to make their decision *communicate a decision

Answer 406

Patients who are likely to die within the next 12months Patients with advanced, progressive, incurable conditions Generally frail with co-existing conditions that mean they are expected to die within 12m Patients with existing conditions if they're at risk of dying from a sudden acute crisis in their condition Patients with life-threatening acute conditions caused by sudden catastrophic events

Answer 407

pain n/v dyspnoea agitation confusion constipation anorexia terminal secretions

Answer 408

Form used by medical professionals to communicate that a decision has been made to not attempt CPR

Answer 409

*patient's diagnosis, prognosis, and current situation *what outcomes the patient would value and fear *what treatments might help to achieve their desired outcomes *you must tell them if a clinical decision has been made that CPR is not appropriate and a DNAR has been added to their records *forms can be reviewed when necessary - if patient's wishes have changed or their health has improved/declined