Medicine Flashcards
What is the first-line treatment option for patients with newly-diagnosed rheumatoid arthritis?
DMARD Monotherapy (Methotrexate, Sulfasalazine or Leflunomide)
https://cks.nice.org.uk/topics/rheumatoid-arthritis/management/confirmed-ra/
Which autoantibody is most specific for rheumatoid arthritis?
Anti-CCP Antibody
What are the main clinical features of reactive arthritis?
Mono- or oligoarthritis
Urethritis
Uveitis
Other features include keratoderma blenorrhagicum and circinate balanitis
Which markers of disease activity are useful in a patient with a suspected flare of systemic lupus erythematosus?
C3 and C4 (usually low)
Anti-dsDNA Titre (usually high)
What is the main treatment used for Familial Mediterranean Fever?
Colchicine
https://patient.info/doctor/familial-mediterranean-fever#nav-4
What are the main features of limited cutaneous systemic sclerosis?
Calcinosis
Raynaud’s Phenomenon
Esophageal Dysmotility
Sclerodactyly
Telangiectasia
List some clinical features of pseudogout.
Acute-onset joint pain and swelling
X-ray will reveal chondrocalcinosis (calcification of the cartilage)
How does asthma tend to present?
Chronic cough (worst at night)
Shortness of breath (reduced exercise tolerance)
Wheezing
Screen for symptoms of other atopic diseases (e.g. eczema)
Resources:
OSMOSIS: https://www.osmosis.org/learn/Asthma
What is the first step in managing mild asthma?
PRN Salbutamol Inhaler
Which clinical features are associated with tuberculosis?
Productive cough
Haemoptysis
Shortness of breath
Fever
Weight loss
Night sweats
How may cystic fibrosis present in children who were not identified during routine neonatal screening?
Recurrent chest infections
Shortness of breath
Chronic cough
Failure to thrive
Chronic diarrhoea
Rectal prolapse
Nasal polyps
Which parameter is measured during the heel-prick test to determine whether a newborn is at risk of having cystic fibrosis?
Immunoreactive Trypsinogen
What is the most common type of lung cancer in smokers?
Squamous cell carcinoma
What is the gold-standard treatment option for patients with stage 1-2 non-small cell lung cancer?
Lobectomy
What is the most common bacterial cause of pneumonia?
Streptococcus pneumoniae
Outline the components of the CURB-65 score.
C – Confusion
U – Urea > 7mmol/L
R – Respiratory Rate >30
B – Systolic BP <90, Diastolic BP <60
65 – Age >65
Score 0 = Mild and home management with oral antibiotics should be considered.
Score 1-2 = Moderate, consider admission and PO/IV antibiotics.
Score >3 = Severe and requires admission and prompt IV antibiotics.
How should a mild CAP be treated?
Oral Amoxicillin 500 mg TDS
How should a primary spontaneous pneumothorax that is > 2 cm or associated with shortness of breath be treated?
Initially → Needle Aspiration
If fails → Chest Drain Insertion
Which paraneoplastic syndrome, associated with small cell lung cancer, presents with weakness due to damage to integral components of the neuromuscular junction?
Lambert-Eaton Syndrome
Characterised by the production of anti-voltage gated calcium channel antibodies
Results in muscle weakness that improves with repetition (in contrast to myasthenia gravis that fatigues with repetition)
Which ECG finding is seen most commonly in patients with pulmonary embolism?
Sinus tachycardia
What is the first-line anticoagulant in the management of a confirmed PE?
Apixaban or Rivaroxaban
Outline the interpretation of the CURB-65 score.
0-1 (mild) = oral antibiotics as outpatient
2 (moderate) = admit to hospital for antibiotics
3+ (severe) = admit to hospital and consider ITU admission if the patient is very unwell
What is the first pharmacological agent used in the management of an acute exacerbation of asthma?
Nebulised Salbutamol
What are the four aspects of treating an infective exacerbation of COPD?
Oxygen
Bronchodilators (e.g. salbutamol and ipratropium bromide)
Steroids (e.g. oral prednisolone)
Antibiotics (e.g. co-amoxiclav, doxycycline)
Define Light’s criteria for pleural effusions.
Used when the pleural fluid protein concentration is 25-35 g/L
It is considered exudative if:
- Effusion protein: serum protein ratio > 0.5
- Effusion LDH: serum LDH ratio > 0.6
- Effusion LDH level > two-thirds the upper limit of the laboratory’s reference range of serum LDH
Outline the management of a primary spontaneous pneumothorax.
< 2 cm and no SOB: discharge with outpatient review in 2-4 weeks
> 2 cm and/or SOB: aspirate with 16-18G cannula, if unsuccessful, insert chest drain
How is a tension pneumothorax managed?
Urgent needle decompression
Which tuberculosis treatment causes red secretions?
Rifampin
Describe the presenting features of sarcoidosis.
Dry cough
Shortness of breath
Painless, enlarged lymph nodes
Erythema nodosum
Weight loss
List some causes of tracheal deviation towards the side of the lesion.
Unilateral fibrosis
Lung collapse
Lobectomy or pneumonectomy
What is the best way of determining whether a blood gas sample is arterial or venous?
Compare the SaO2 on the blood gas to the patient’s non-invasive SaO2 at the time the sample was taken. It should match.
Which organism most commonly causes respiratory tract infections in adult patients with cystic fibrosis?
Pseudomonas aeruginosa
List some of the absolute contraindications for lung transplantation in cystic fibrosis patients.
Recent malignancy
Multi-organ dysfunction
Unstable medical condition (e.g. sepsis)
Uncorrectable bleeding disorder
Poorly controlled infection
Evidence of active tuberculosis
Obesity
Poor compliance
Unable to participate in rehabilitation programme
Which questionnaire is used to facilitate the diagnosis of obstructive sleep apnoea?
Epworth Sleepiness Score
What is the probability that two carriers of a cystic fibrosis allele will have a child affected by the condition?
25% (0.5 x 0.5 = 0.25)
What are the chest X-ray features commonly seen in congestive heart failure?
Alveolar shadowing
Kerley B lines
Cardiomegaly
Upper lobe Diversion
Effusions
How is oral thrush treated?
Nystatin
Alternative: Fluconazole
What is the first-line antibiotic in patients with suspected streptococcal pharyngitis?
Phenoxymethylpenicillin
If penicillin allergy: Clarithromycin
What classical CT scan finding is seen in invasive aspergillosis?
Halo Sign
Which criteria are commonly applied to stage acute kidney injury?
RIFLE Criteria
Outline the NICE guidelines advice about ultrasound KUB in patients with AKI.
When pyonephrosis (infected and obstructed kidney(s)) is suspected, offer immediate ultrasound of the urinary tract to be performed within 6 hours of assessment.
When patients have no identified cause of their AKI or are at risk of urinary tract obstruction, offer urgent ultrasound within 24 hours of assessment
List some risk factors for developing gout.
Male
Obese
CKD
Diabetes mellitus
Hypertension
Diuretics
Alcohol Excess
High Red Meat or Seafood Intake
Which lymph nodes does transitional cell carcinoma of the kidneys tend to drain to?
Para-aortic lymph nodes
How long after having a renal transplant does acute graft rejection tend to happen?
Within days to weeks
Caused by cell-mediated damage to the graft (usually lymphocytes)
List some clinical features associated with renal cell carcinoma.
Haematuria
Fever
Hypertension
Secondary polycythaemia
Describe the typical presenting features of post-streptococcal glomerulonephritis.
Haematuria
Hypertension
Deteriorating renal function
Usually arises 2-6 weeks after a streptococcal infection (e.g. throat or skin)
What form of screening should be offered to immediate family members of a person with autosomal dominant polycystic kidney disease?
Ultrasound KUB
Which long-term treatment option should be considered in patients with anaemia secondary to CKD?
Erythropoietin Injections
Which components of a diet do dieticians primarily focus on in a patient with CKD?
Potassium
Phosphate
Protein
What is the mechanism of action of tacrolimus?
Calcineurin Inhibitor
What is acute tubular necrosis?
Damage to the renal tubular epithelium caused by hypoperfusion or exposure to toxins
Damage to the tubules impairs the ability of the kidneys to concentrate urine and retain sodium appropriately. This can lead to hyponatraemia with low urine osmolality and raised urinary sodium concentrations.
Which imaging modality is used first in the investigation of Wilm’s tumours?
Abdominal Ultrasound
What is cardiorenal syndrome?
Complex condition in which impaired renal function develops in a patient with heart failure
The mechanism is complex but is thought to be related to elevated intra-abdominal pressures resulting from ascites and abdominal wall oedema. There are also several hormonal mediators that are associated with cardiorenal syndrome.
Why is an ultrasound scan of the urinary tract recommended in patients who are being investigated for secondary causes of hypertension?
To assess renal size as this can provide some useful information about the possibly underlying cause (e.g. in renal artery stenosis, one kidney will likely be bigger than the other, polycystic kidney appear large and bulky)
What is the mechanism of action of acetazolamide?
Carbonic anhydrase inhibitor
It increases urinary bicarbonate and sodium excretion, thereby causing a diuretic effect
Which organism most commonly causes lower urinary tract infections?
Escherichia coli
How does acute angle closure glaucoma classically present?
Headache
Reduced visual acuity
Conjunctival injection
Dilated pupil
What is the first-line investigation for a patient with a suspected angle closure glaucoma?
Slit-Lamp Gonioscopy
How do cataracts tend to present?
Gradual worsening of vision (usually bilateral)
Washed-out colour vision
Absent red reflex or straw-coloured lens on examination
Which surgical management option is often used to treat cataracts?
Phacoemulsification
What is the first-line medical treatment option for chronic angle closure glaucoma?
Topical Prostaglandin Analogues (e.g. latanoprost)
What is the most common cause of TIAs?
Carotid Atherosclerosis
Which investigation is required to confirm a diagnosis of cataracts?
Slit-Lamp Examination
How does episcleritis present?
Acute-onset redness of the eye associated with mild pain
May also cause photophobia and watering of the eye
What are the fundoscopic appearances of central retinal artery occlusion?
Pale retina
Cherry red spot in the macula
How do cataracts tend to present?
Painless and gradual loss of vision
Vision may be worse in bright light
Examination may reveal a loss of the red reflex in the affected eye(s)
Which blood or bone marrow film feature is highly specific for acute myeloid leukaemia?
Auer Rods
What is the first-line treatment option for acute promyelocytic leukaemia?
All-Trans-Retinoic Acid (ATRA)
Which chromosomal abnormality is associated with acute promyelocytic leukaemia?
t(15;17)
Which fusion gene is responsible for acute promyelocytic leukaemia?
PML-RARA (caused by t(15;17))
How does acute lymphoblastic leukaemia tend to manifest?
Features of bone marrow failure
Anaemia (shortness of breath, fatigue, pallor)
Thrombocytopaenia (easy bruising)
Low white cell counts (recurrent infections)
Outline the Ann Arbor staging system for Hodgkin lymphoma.
Stage I: Single lymph node region
Stage II: Two or more lymph node regions on the same side of the diaphragm
Stage III: Two or more lymph node regions on both sides of the diaphragm
Stage IV: Extranodal spread
‘b’ refers to the presence of B symptoms (fever, weight loss, night sweats)
What is the classical histological appearance of Burkitt’s lymphoma?
Starry Sky Appearance
What rare but classical examination finding is commonly associated with Hodgkin lymphoma?
Pain after alcohol consumption
Which point mutation causes sickle cell disease?
Point mutation on codon 6 of chromosome 11 which leads to the encoded amino acid changing from glutamine to valine
Which common infection can precipitate an aplastic crisis in patients with sickle cell disease?
Parvovirus B19
How does haemophilia tend to present?
Usually within the first 3 years of life
Deep bleeding into muscles and joints (haemarthrosis) with minimal trauma
How is haemophilia diagnosed?
Factor VIII and IX Assay
How does multiple myeloma present?
Features of hypercalcaemia (joint pain, constipation, psychiatric changes, polyuria, nausea and vomiting)
What bone marrow biopsy results would you expect to see in multiple myeloma?
Over 10% monoclonal plasma cells
What haemolysis screen results would you expect to see in autoimmune haemolytic anaemia?
Macrocytic Anaemia
High Unconjugated Bilirubin
Low Haptoglobin
High LDH
How does polycythaemia vera classically present?
Headaches
Facial Flushing
Pruritus after exposure to hot baths or showers
Which gene mutation is most closely associated with polycythaemia vera?
JAK2 V617F
What type of blood test results do you expect to see in beta thalassemia trait?
Mild microcytic anaemia that is usually asymptomatic
The microcytosis is often out of proportion with the degree of anaemia
Which features are considered by the Centor criteria?
Age
Fever
Tonsillar Exudate
Cervical Lymphadenopathy
Absence of Cough
Which investigation should patients with suspected colorectal cancer urgently undergo?
Colonoscopy
What is the best imaging modality of suspected prostate cancer?
Multiparametric MRI Scan
What differential should be considered in a post-menopausal woman with breast swelling and tenderness that fails to respond to antibiotic treatment?
Inflammatory Breast Cancer
What is a vestibular schwannoma?
Benign slow-growing primary brain tumour that usually presents with unilateral sensorineural hearing loss associated with dizziness and facial numbness. Larger tumours may cause headaches, ataxia, papilloedema and obstructive hydrocephalus, which can be life threatening.
How does cholangiocarcinoma present?
Painless jaundice
Abdominal discomfort/fullness
Change in stool appearance and frequency (looser and paler)
Constitutional upset (e.g. weight loss)
Which organisms are most commonly implicated in neutropenic sepsis?
Gram-positive organisms (e.g. S. aureus, S. epidermidis)
Which blood test parameters are important to check in a patient with suspected tumour lysis syndrome?
Potassium (High)
Phosphate (High)
Calcium (Low)
Uric Acid (High)
How does radial nerve palsy due to a defect at the axilla manifest?
Weakness of forearm, wrist and finger extension (resulting in wrist drop)
Sensory impairment over the lateral and posterior arm, posterior forearm and dorsal surface of the lateral three fingers h
How can a spinal cord lesion be distinguished from cauda equina syndrome?
Spinal cord lesions will likely cause a sensory level and cause upper motor neurone signs whereas cauda equina syndrome is characterised by lower motor neurone signs, perianal numbness and bladder and bowel dysfunction
Describe the clinical features of acute inflammatory demyelinating polyneuropathy.
Ascending symmetrical limb weakness and numbness
It can progress to involve the respiratory muscles resulting in respiratory failure
What CSF finding is often seen in Guillain-Barré syndrome?
High CSF Protein
Normal CSF White Cell Count
This is known as albuminocytologic dissociation
Which part of the brain does herpes simplex encephalitis tend to affect?
Temporal Lobes
Which preventative treatment should be offered to close contacts of a case of meningococcal meningitis?
Single dose of ciprofloxacin
Rifampicin is an alternative
What is the first-line pharmacological management option for idiopathic intracranial hypertension?
Acetazolamide
What is Lhermitte sign?
Paraesthesia that is felt in the upper limbs and trunk, often down the spine, when a patient flexes their neck. Commonly associated with multiple sclerosis
What is the gold-standard imaging modality for multiple sclerosis?
MRI Brain and Spinal Cord
What is Horner syndrome?
Triad of ptosis, miosis and anhidrosis that occurs as a result of disruption to the sympathetic chain supplying the head and neck.
List some causes of Horner syndrome.
Syringomyelia
Multiple Sclerosis
Thyroid Cancer
Apical (Pancoast) Lung Tumour
Carotid Artery Dissection
Cavernous Sinus Thrombosis
Outline the difference in aetiology between upper and lower motor neurone facial nerve palsies.
The fibres providing motor innervation to the forehead receives descending inputs from primary neurones arising in both cerebral hemispheres.
Therefore, if there is a defect in the right primary motor cortex resulting in left-sided facial weakness, the forehead will be spared because the lower motor neurones of the facial nerve will still receive descending inputs from the left primary motor cortex.
Aside from a neurological examination, which other examinations should be conducted in a patient with unilateral subacute facial weakness?
Otoscopy - look for evidence of Ramsay-Hunt Syndrome (it will feature a vesicular rash in the outer ear)
What are the main presenting features of Huntington’s disease?
Cognitive decline
Motor dysfunction (chorea, dystonia, dyskinesia)
Which genetic defect causes Huntington’s disease?
CAG Triplet Repeat
Which medications are recommended for the acute treatment of migraines?
Aspirin
Paracetamol
Ibuprofen
Sumatriptan
Describe the classical presentation of a subarachnoid haemorrhage.
Sudden-onset worst headache ever. Often starting occipitally and spreading. Associated with meningism and may present unconscious.
What dose of phenytoin is administered in status epilepticus?
20 mg/kg (maximum 2 g)
Cardiac Monitoring
What are the main symptoms of Parkinson’s disease?
Resting tremor (usually unilateral)
Rigidity
Bradykinesia
Gait instability (stooped and shuffling)
Hypomimic face
Low mood
Insomnia
How is Parkinson’s disease diagnosed?
Clinical diagnosis (sometimes a DaT scan may be used if there is any diagnostic uncertainty)
Which class of medications is useful in reducing the on-off motor fluctuations in patients with Parkinson’s disease that is treated with levodopa/carbidopa?
COMT Inhibitors (e.g. entacapone)
What are the main clinical features that are seen in neurofibromatosis type 1?
At least 2 or more of:
- 5 or more cafe-au-lait macules that are over 15 mm in diameter if post-pubertal (may be fewer in children under 5 years)
- 2 or more neurofibromas of any type or 1 plexiform neurofibroma
- Multiple freckles in the axillary or inguinal regions
- Optic nerve glioma
- 2 or more iris Lisch nodules on slit lamp examination
- Sphenoid wing dysplasia or congenital boeing or thinning of long bone cortex with or without pseudoarthrosis
- A first degree relative with NF1 by the above criteria
How does normal pressure hydrocephalus present?
Dementia
Urinary Incontinence
Gait Instability (broad-based)
What can be used to treat neuropathic pain associated with multiple sclerosis?
Gabapentin
Pregabalin
Duloxetine
Carbamazepine
A stroke involving which artery results in lateral medullary syndrome?
Posterior Inferior Cerebellar Artery
What are some key features of vascular dementia that help distinguish it from other forms of dementia?
Stepwise decline in cognitive function
Background of vascular risk factors (e.g. hypertension, diabetes mellitus)
How does a cluster headache tend to manifest?
Intense unilateral headaches that tend to occur at a specific time every day for a period of weeks or months
Associated with ipsilateral lacrimation, rhinorrhoea, nasal congestion and eyelid swelling.
What is the first-line medical treatment in the acute management of cluster headaches?
SC Sumatriptan
Which antibodies are associated with myasthenia gravis?
Nicotinic Acetylcholine Receptor Antibodies
What is the main priority in managing a patient with suspected meningitis?
IV Antibiotics
How should suspected giant cell arteritis be managed?
Check ESR
High-Dose Steroids (e.g. prednisolone)
Describe how tension headaches usually present.
Relatively mild pain in a band-like distribution across the front of the head . Often related to stress and usually responsive to simple analgesia (e.g. paracetamol)
Define spondylolysis.
A stress fracture of the pars interarticularis.
Describe the classical presenting symptoms of ankylosing spondylitis.
Chronic lower back pain (worse in the morning and improves with exercise or NSAIDs)
Reduced range of lumbar spinal movement
Extra-articular manifestations (aortic regurgitation, apical lung fibrosis, achilles tendinitis)
How is Schober’s test carried out?
Mark a point on the skin overlying the L5 spinous process.
Mark a second point about 10 cm superior to the first point.
Ask the patient to bend over and touch their toes
If the distance between the point increases by less than 5 cm, that is a positive result (reduced range of motion in the lumbar spine.
What is the first-line management option for ankylosing spondylitis?
NSAIDs
What are the main manifestations of carpal tunnel syndrome?
Pain (often worse at night and relieved by shaking the affected hand)
Impaired sensation in the median nerve distribution (palmar aspect of thumb, index finger and middle finger)
Weak grip and loss of dexterity
Wasting of the thenar eminence
Which investigation may be used in the investigation of a patient with suspected carpal tunnel syndrome?
Electromyography
How should severe carpal tunnel syndrome be managed?
Carpal Tunnel Release Surgery
What are the contents of the carpal tunnel?
Flexor Pollicis Longus
Flexor Digitorum Profundus (4 tendons)
Flexor Digitorum Superficialis (4 tendons)
How does giant cell arteritis manifest?
Unilateral headache
Scalp tenderness
Jaw claudication
Visual changes
Constitutional upset (e.g. fever, fatigue)
What definitive investigation is used in suspected giant cell arteritis?
Temporal Artery Biopsy
Which branch of the external carotid artery is implicated in giant cell arteritis?
Superficial Temporal Artery
Which clinical test is used for Sjogren syndrome?
Schirmer’s Test
Involves placing a strip of filter paper under the patient’s eyelid and monitoring the progress that the tears make through the paper. Progression of less than 10 mm after 5 mins is considered a positive result.
What are the main sources of Gram-negative sepsis?
Urinary tract
Biliary tree
What is human herpes virus 3?
Varicella Zoster Virus
How does non-alcoholic fatty liver disease usually present?
Incidental finding of deranged liver function test results in a patient without a background of excessive alcohol intake
Common associated features include obesity and type 2 diabetes mellitus
https://www.nice.org.uk/guidance/ng49/chapter/context#:~:text=The%20prevalence%20of%20NAFLD%20in,2%20diabetes%20or%20metabolic%20syndrome.
What is the gold standard imaging modality for primary sclerosing cholangitis?
MRCP
Which scoring system is used to determine the severity of an upper gastrointestinal score before endoscopy?
Glasgow-Blatchford Score
What is the first-line treatment option for hepatic encephalopathy?
Lactulose (aiming for 2 or more bowel movements per day)
Rifaximin may be used as an adjunct
Which classification system is used to classify the endoscopic findings of a patient with Barrett’s oesophagus?
Paris and Prague Classification
How should a patient with Barrett’s oesophagus with low grade dysplasia be managed?
Repeat endoscopy in 6 months
How does gastroenteritis caused by Campylobacter jejuni infection tend to present?
Diarrhoea (may be bloody)
Fever
Abdominal Cramps
Usually contracted by eating under-cooked poultry
How does gastro-oesophageal reflux disease tend to present?
Retrosternal chest discomfort that is usually worst after a large meal and when lying down
Describe the clinical features associated with Whipple’s disease.
Diarrhoea
Abdominal pain
Joint pain
Jejunal biopsy reveals vacuolated macrophages that appear purple with periodic acid-Schiff stain
Which stool test is useful in cases of suspected inflammatory bowel disease?
Faecal Calprotectin
Which blood test is important to conduct before starting a patient on azathioprine?
TPMT Level
Which investigation should be urgently performed in patients with suspected colorectal cancer?
Which investigation should be urgently performed in patients with suspected colorectal cancer?
Which medical treatment can reduce the risk of complication from oesophageal varices in patients with chronic liver disease?
Non-selective beta-blockers (e.g. carvedilol)
Describe the appearance of simple liver cysts on a contrast CT scan.
Thin-walled, round, homogenous lesions that demonstrate hypoattenuation
Which scoring system is used to assess whether treatment with steroids has been effective in a patient with alcoholic hepatitis?
Lille Score
What Maddrey’s score would warrant treatment with steroids?
Over 32
List some common causes of drug-induced liver injury.
Amiodarone
NSAIDs
Steroids
COCP
Erythromycin
Isoniazid
Statins
Tetracyclines
What is the first-line medical management option for ascites due to chronic liver failure?
Spironolactone
What essential medication will patients undergoing large-volume paracentesis need to reduce the risk of post-paracentesis circulatory dysfunction?
20% Humans Albumin Solution (HAS)
How is the serum ascites albumin gradient (SAAG) interpreted?
< 11 g/L = exudative (and nephrotic syndrome)
> 11 g/L = transudative
What non-invasive test is useful in the investigation of suspected chronic pancreatitis?
Faecal Elastase (low in chronic pancreatitis)
What investigation is most appropriate to confirm a diagnosis of ulcerative colitis?
Flexible Sigmoidoscopy and Biopsy
What endoscopic findings are classically associated with Crohn’s disease?
Longitudinal and circumferential fissures and ulcers separating islands of mucosa
How does hereditary haemochromatosis present?
Impaired liver function test results
Hepatomegaly
Type 2 diabetes mellitus
Hyperpigmentation of the skin
Loss of libido
Erectile dysfunction
Which investigation is most important for prognostication in a patient with hereditary haemochromatosis?
Liver Biopsy
What are the different stages of haemochromatosis?
Stage 1: C282Y homozygosity and increased transferrin saturation with a normal ferritin and no symptoms
Stage 2: C282Y homozygosity with increased transferrin and ferritin levels with no symptoms.
Stage 3: C282Y homozygosity with increased transferrin and ferritin levels with clinical symptoms affecting the quality of life (asthenia, impotence, arthropathy).
Stage 4: C282Y homozygosity with increased transferrin and ferritin levels with evidence of end-organ damage (e.g. cirrhosis, insulin-dependent diabetes mellitus).
Describe the barium swallow appearance that you would classically see in a patient with achalasia.
Bird’s beak appearance with dilated proximal oesophagus
How might coeliac disease present in adults?
Chronic diarrhoea
Pale stools
Weight loss
Consequences of vitamin and mineral malabsorption (e.g. anaemia)
How does Wilson’s disease tend to present?
Liver dysfunction
Neuropsychiatric symptoms (e.g. tremor, dystonia, dyskinesia, change in personality)
What is the first-line management option for Wilson’s disease?
Zinc and Dietary Modification
What liver function test results would you expect to see in viral hepatitis?
Very High ALT, Very High AST, High Bilirubin, Normal GGT, Normal ALP
What is the classical pattern of liver function test results that you would expect to see in alcoholic liver disease?
High ALT and AST (with an AST: ALT ratio of over 2)
High Bilirubin
Normal GGT and ALP
What patterns of liver function test results would you expect to see in a patient with primary biliary cholangitis?
High ALT, High AST, High Bilirubin, High GGT, High ALP
What hepatitis B serology results would you expect to see in a patient with acute hepatitis B infection?
HBsAg +, HBeAg +, HBsAb -, HBcAb IgM +
Which investigations are used in the diagnosis of achalasia?
Oesophageal Manometry
Also barium swallow and OGD (to check for other differentials)
How is vitamin B12 deficiency treated?
Hydroxocobalamin or Cyanocobalamin
What is the best investigation for confirming a diagnosis of autoimmune hepatitis?
Liver Biopsy
What ascitic fluid analysis results would you expect to see in a patient with spontaneous bacterial peritonitis?
Cloudy Appearance
High Protein
Low Glucose
High WCC (Predominantly Neutrophils)
How is alcohol withdrawal managed in hospital inpatients?
CIWA score and chlordiazepoxide
Which medications can be used to reduce cravings for alcohol
Acamprosate
Naltrexone
How is delirium tremens treated?
Benzodiazepines (e.g. lorazepam)
What electrolyte abnormalities would you expect to see in a patient with refeeding syndrome?
Hypophosphataemia
Hypokalaemia
Hypomagnesaemia
Hypercalcaemia
How do anal fissures tend to present?
Pain upon defecation
Small amount of blood on the toilet paper noted upon wiping
Often occurs on a background of constipation
What ascitic fluid finding is diagnostic of spontaneous bacterial peritonitis?
Polymorphonuclear cell count of >250 cells/mm3
What type of molecule is alpha-1 antitrypsin?
Neutrophil elastase inhibitor
Describe the mechanism of action of sulfonylureas.
Act on SUR1 receptors which close the ATP-dependent potassium channel on pancreatic beta cells.
This leads to an increase in intracellular potassium concentration, membrane depolarisation and, consequently, opening of the voltage-gated calcium channels. Influx of calcium triggers the exocytosis of insulin.
Outline the immediate management of an Addisonian crisis.
IV Hydrocortisone
IV Fluid Resuscitation
Which antithyroid medications are often used in the management of Graves disease?
Carbimazole
Propylthyiouracil
What are the presenting symptoms of acromegaly?
Change in appearance (coarse facies)
Large hands
Carpal tunnel syndrome
Visual field defect
Describe the clinical features of tertiary hyperparathyroidism.
Usually occurs in the context of vitamin D deficiency in CKD
After a prolonged period of secondary hyperparathyroidism, the parathyroid gland eventually becomes autonomous resulting in tertiary hyperparathyroidism.
Bloods will reveal a normal or raised PTH and a high serum calcium concentration.
For which type of thyroid cancer is calcitonin used as a tumour marker?
Medullary Thyroid Cancer
What is the first-line treatment option for prolactinoma?
Dopamine agonists (e.g. bromocriptine)
What TFT results would you expect to see in a patient with primary hypothyroidism?
High TSH
Low T4
Describe the presenting symptoms of phaeochromocytoma.
Hypertension
Episodic palpitations, sweating and anxiety
What blood test results would you expect to see in hypercalcaemia of malignancy?
High Calcium
Low PTH
What initial diagnostic test is used in the diagnosis of suspected hyperaldosteronism?
Plasma Renin: Aldosterone Ratio
How is a high-dose dexamethasone test interpreted?
It is done to distinguish Cushing disease from other causes of Cushing syndrome.
A reduction in serum cortisol of > 50% the morning after administration of dexamethasone is suggestive of Cushing disease
A reduction of < 50% is suggestive of ectopic ACTH secretion or a hypersecreting adrenal tumour.
What is the maximum rate of correction of serum sodium concentration in patients with hyponatraemia?
10 mmol/L over 24 hours
Why is it important to monitor urine output in patients receiving treatment for severe hyponatraemia?
Patients with hypovolaemic hyponatraemia will have a significant ADH response that reduces their urine output. As they become intravascularly replete with IV fluids, the stimulus for ADH secretion will diminish and the patient will start producing increasing volumes of urine. The relative loss of fluid in the urine is greater than the loss of sodium meaning that this diuresis can lead to a rapidly increasing serum sodium concentration. This, in turn, can lead to osmotic demyelination syndrome.
How long after overcorrection of hyponatraemia would you expect osmotic demyelination syndrome to manifest?
3-5 days
What are the criteria that are often quoted in the diagnosis of hyperosmolar hyperglycaemic state?
Marked Hyperglycaemia (> 30 mmol/L) without significant ketonaemia
Raised Serum Osmolality (> 320 mOsmol/kg)
Hypovolaemia
What is the best diagnostic test for suspected primary adrenal insufficiency?
Short synacthen test
What water deprivation test results would you expect to see in a patient with nephrogenic diabetes insipidus?
High Plasma Osmolality
Low Urine Osmolality (that does not become more concentrated with water deprivation or following the administration of desmopressin)
What is the strongest prognostic factor for the development of Graves’ eye disease?
Smoking
Which biochemical test results would you expect to see in a patient with Paget’s disease?
Normal Calcium, Normal Phosphate, Normal PTH, High ALP
What is the first-line treatment option for Paget’s disease of the bone?
Bisphosphonates
List some euvolaemic causes of hyponatraemia.
SIADH
Hypothyroidism
Adrenal Insufficiency
What is the main investigation that is used to diagnose familial hypocalciuric hypercalcaemia?
24-hour Urinary Calcium Collection
What is the first-line medical treatment option for hypercalcaemia of malignancy?
Bisphosphonates
By what mechanism does lymphoma cause hypercalcaemia?
Activity of ectopic 25(OH)D-1-hydroxylase expressed by macrophages or tumour cells leads to the formation of excessive amounts of 1,25(OH)₂D (i.e. active vitamin D)
How should a the long- and short-acting insulin doses of a patient with well-controlled type 1 diabetes mellitus be managed ahead of a short operation in which they are only expected to miss one meal?
Reduce long-acting insulin dose (usually to around 80%)
Omit short-acting insulin dose whilst fasting
List some signs and symptoms of Cushing syndrome.
Weight gain
Low mood
Thin skin
Easy bruising
Hypertension
Proximal myopathy
What screening test is sometimes used to rule out Cushing syndrome?
Late night salivary cortisol level
What 11 pm cortisol and low-dose dexamethasone suppression test results would you expect to see in a patient with Cushing syndrome?
High 11 pm Cortisol
High LDDST Cortisol
How is Cushing disease definitively treated?
Trans-sphenoidal Hypophysectomy
List some features that are specific to Graves disease (compared to other forms of hyperthyroidism).
Exophthalmos
Pretibial Myxoedema
Which autoantibody causes Graves’ disease?
TSH-Receptor Stimulating Antibody
What is a rare but important side-effect of carbimazole that patients should be counselled about?
Agranulocytosis (they should be advised to seek medical attention if they ever develop any symptoms of an infection)
What serum and urine osmolality results would you expect to see in SIADH?
Low Serum Osmolality, High Urine Osmolality, High Urine Sodium
What are the usual presenting features of polycystic ovarian syndrome?
Diagnosed using the Rotterdam criteria
Oligo- or anovulation (irregular periods)
Clinical or biochemical evidence of hyperandrogenism (e.g. acne, weight gain, raised serum androgen levels)
Presence of polycystic ovaries on ultrasound (> 12 follicles measuring 2-9 mm in diameter and/or an ovarian volume > 10 mL in at least one ovary)
Which criteria are used to make a diagnosis of polycystic ovarian syndrome?
The Rotterdam criteria states that 2 or more of the following must be fulfilled to make a diagnosis of PCOS:
- Oligo- or anovulation (irregular periods)
Clinical or biochemical evidence of hyperandrogenism (e.g. acne, weight gain, raised serum androgen levels)
- Presence of polycystic ovaries on ultrasound (> 12 follicles measuring 2-9 mm in diameter and/or an ovarian volume > 10 mL in at least one ovary)
Which contraceptive option is best for a patient with polycystic ovarian syndrome who would like to have predictable periods?
Cyclical Progestogens
Which type of cancer are people with polycystic ovarian syndrome at particularly increased risk of developing?
Endometrial Cancer
How does Conn syndrome present?
Hypertension in a young person
Hypokalaemia (may cause arrhythmias and muscle cramps)
What blood test abnormalities would you expect to see in a patient with primary hyperaldosteronism?
Hypokalaemia
High Aldosterone: Renin Ratio
What is the main medical treatment option for primary hyperaldosteronism?
Aldosterone antagonist (e.g. spironolactone)
What thyroid function test results would you expect to see in a patient with central hypothyroidism?
Low TSH
Low T3 and T4
What is the most common cause of hypothyroidism worldwide?
Iodine Deficiency
How does carcinoid syndrome manifest?
Facial flushing
Diarrhoea
Palpitations
Shortness of breath (due to bronchospasm)
How does prolactinoma manifest?
Secondary amenorrhoea
Headaches
Breast pain and tenderness
Lactation
Which metric is used to assess whether a child is obese?
BMI Centiles (above the 98th centile is considered obese)
List some drugs that reduce bone mineral density.
Steroids
PPIs
Heparin
Warfarin
How is osteoporosis defined based on the DEXA scan results?
Score of less than -2.5 is suggestive of osteoporosis
How does phaeochromocytoma manifest?
Episodes of anxiety, sweating, palpitations and tremor. During these episodes, the patient will likely be tachycardic and hypertensive.
List some features of hypogonadism in males.
Erectile dysfunction
Low libido
Reduced energy
Muscle weakness
How is idiopathic hypogonadotropic hypogonadism initially managed?
Testosterone Gel
What is the initial imaging modality that is used in the work-up of suspected thyroid cancer?
Ultrasound
Which gene mutation is associated with multiple endocrine neoplasia type 2?
RET Oncogene Mutation
What is starvation ketosis?
Depletion of carbohydrates within the body triggers the compensatory generation of ketones by the liver
It is associated with poor oral intake and dehydration
How would poor compliance with thyroid hormone replacement manifest in the thyroid function test results?
Low Free T4 and High TSH
NOTE: if the patient erratically takes their medications in the short-term before an appointment, the free T4 may be normal or high but the TSH will remain high
What TFT results would suggest under-treated hypothyroidism?
Low T4
High TSH
Which classical X-ray feature is associated with osteomalacia?
Looser’s zones (transverse lucencies with sclerotic borders that traverse part of the way through a bone and is perpendicular to the cortex)
What is the most common side-effect of oral bisphosphonates?
Dyspepsia due to oesophagitis/gastritis
What is the initial investigation of choice for patients with suspected primary hyperaldosteronism?
Serum Aldosterone: Renin Ratio
What electrolyte abnormalities are caused by hypoparathyroidism?
Hypocalcaemia
Hyperphosphataemia
Outline the anatomy of the adrenal gland and the hormones produced.
Zona Glomerulosa (outermost) → Aldosterone
Zona Fasciculata (middle) → Cortisol
Zona Reticularis (innermost) → Androgens
Adrenal Medulla → Catecholamines
How is osteoporosis initially managed?
Bisphosphonates with vitamin D and calcium supplementation
What visual field defect would be caused by a pituitary macroadenoma that invades the cavernous sinus?
Oculomotor nerve palsy
Abducens nerve palsy
Bitemporal hemianopia
Describe the clinical features of acromegaly.
Prognathism
Widening of the nose
Coarse facial features
Carpal tunnel syndrome
Skin/hair changes
Goitre (due to increased vascularity of the thyroid gland)
Insulin resistance (and, hence, type 2 diabetes mellitus)
What is the first-line management option for acromegaly?
Surgery (trans-sphenoidal hypophysectomy)
What urine and plasma osmolality would you expect to see in a patient with diabetes insipidus?
High Plasma Osmolality
Low Urine Osmolality
NOTE: if it is nephrogenic DI, the urine will fail to concentrate after administration of desmopressin
What is the best investigation for suspected diabetes insipidus?
Water Deprivation Test
What is the most important initial management step in the management of pituitary apoplexy with some evidence of haemodynamic instability?
Administer Steroids
What is the gold-standard investigation for diagnosing Cushing’s disease (i.e. ACTH secreting pituitary adenoma)?
Inferior Petrosal Sinus Sampling
What is the first-line management option for a non-functioning pituitary adenoma that is causing a mass effect (e.g. visual field defect)?
Trans-sphenoidal Hypophysectomy
How does Conn syndrome manifest?
Refractory hypertension
Hypokalaemia
After an aldosterone: renin ratio confirms a diagnosis of primary hyperaldosteronism, which investigation should be requested next?
CT Adrenal Glands
Which investigation is useful for pyrexia of unknown origin?
PET-CT Scan
What is the first-line investigation for diagnosing a DVT?
Duplex ultrasonography
What are some clinical features of life-threatening asthma?
PEFR < 33% of Predicted
SpO2 < 92%
Cyanosis
Hypotension
Exhaustion, confusion
Silent chest, poor respiratory effort
Tacy/brady/arrhythmias
What can cause a paradoxical embolism?
Patent foramen ovale
Atrial septal defect
Ventricular septal defect
Describe the classical features of vasovagal syncope.
Dizziness, nausea, sweating and visual disturbances followed by transient loss of consciousness that resolves.
What treatment is used for opioid toxicity?
Naloxone
What is the antidote used for paracetamol overdose?
N-Acetylcysteine
What blood gas result would you expect to see in a patient in the early stages of an aspirin overdose?
Respiratory Alkalosis
Occurs because aspirin stimulates the respiratory centre and causes an increase in minute ventilation
Which peripheral vasopressor is often used to support blood pressure in critically unwell patients?
Metaraminol (alpha-1 agonist)
What is the first-line management option for mild-to-moderate acne?
Topical adapalene with topical benzoyl peroxide
or
Topical tretinoin with topical clindamycin
or
Topical benzoyl peroxide with topical clindamycin
What would be the most appropriate next step in the management of a patient whose acne has worsened despite 12 weeks of topical therapy with adapalene and benzoyl peroxide?
Add in oral antibiotic (lymecycline or doxycycline)
Outline the monitoring requirements of isotretinoin.
Measure liver function and lipid profile before treatment and at 1 month after commencing treatment and then every 3 months thereafter.
List the main topical steroids in order of potency.
> Mildly Potent – hydrocortisone 0.1%, 0.5% and 1.0%.
Moderately Potent – betamethasone valerate 0.025% and clobetasone butyrate 0.05% (Eumovate)
Potent – betamethasone valerate 0.1% (Betnovate) and betamethasone dipropionate 0.05%.
Very Potent – clobetasol propionate 0.05% (Dermovate)
Describe the appearance of eczema herpeticum.
Predominantly affects the face and neck
Lesions spread over 7-10 days
Rash consists of monomorphic blisters that are filled with yellow fluid or blood and have a central umbilication
They have a tendency to weep or bleed and crust over
Secondary bacterial infection is common
Describe the options that can be used by patients with frequent relapses of eczema requiring steroid therapy.
Step Down Treatment (use the lowest potency steroid that controls the eczema indefinitely)
Intermittent Therapy (steroid is used on two consecutive days per week or every 3-4 days.
Describe the appearance of erythema multiforme.
Polymorphous, well demarcated, round, red macules
Become raised and form papules
The centre of the lesion darkens and becomes blistered or crusted (resulting in the target appearance)
Describe the classical presentation of guttate psoriasis.
Acute-onset, widespread raindrop-like rash after having a throat infection (streptococcal)
What is the first-line treatment option for chronic plaque psoriasis?
Potent topical steroid with a topical vitamin D preparation
How is molluscum contagiosum managed?
No treatment required as it is self-limiting
What are the most common drug causes of toxic epidermal necrolysis?
Allopurinol
Sulphonamides
Penicillins
Anticonvulsants
NSAIDs.
Briefly describe the advice that should be given to a patient that is starting treatment with topical steroids.
One finger tip unit is equivalent to an area about half the size of the flat of the hand.
Steroids should be applied 15 minutes after emollient
Describe the appearance of seborrhoeic keratosis.
Raised and flat papules that have a warty appearance and may vary in colour
They have a distinctive ‘stuck on’ appearance
Describe the appearance of progression of a keratoacanthoma.
Single, well demarcated nodule with a central hyperkeratotic plug
Grows rapidly within a few weeks, then remains stable for several weeks before regressing
How is a keratoacanthoma usually treated?
Surgical excision
Describe the different types of basal cell carcinoma.
Nodular BCC: the classic pearly lesion and the most common type as demonstrated in this case.
Superficial BCC: scaly, irregular plaque with a very thin rolled border.
Morphoeic BCC: waxy appearance resembling a scar.
Basosquamous carcinoma: mixed BCC and squamous cell carcinoma.
Describe the main types of malignant melanoma.
Superficial Spreading: As the name suggests, these spread outwards first. It is the most common type of melanoma.
Nodular: Proliferate downwards into the skin and can form a nodule at the surface.
Lentigo Maligna Melanoma: A discoloured patch that grows outwards over 5-20 years from the precursor, lentigo maligna.
Amelanotic: Non-melanin producing lesions often appearing as pink- or skin-coloured nodules. There may be a thin rim of melanin.
Acral Lentiginous: Rare type of melanoma that arises from the palms and soles.
What is Hutchinson’s sign of the thumb?
Pigmentation of the cuticle that extends to the nail fold
Associated with acral lentiginous melanoma
Describe the appearance of the rash in pityriasis rosea.
The appearance of multiple, small oval-shaped macules along lines of skin tension (Christmas tree distribution)
This is usually preceded by the appearance of a large macule or patch (Herald patch)
Describe the appearance of bullous pemphigoid.
Tense bullae that spare the mucosal membranes
What is allergic contact dermatitis?
Delayed type lV hypersensitivity reaction to an allergen, commonly adhesives, topical antibiotics, perfumes, nickel, clothing and rubber.
This occurs in two stages - the first is sensitisation in which allergens activate Langerhans cells that travel to lymph nodes and activate naïve T cells. Re-exposure then triggers elicitation in which sensitised T cells travel to the sites of the allergen and trigger an inflammatory reaction, occurring 1-2 days after exposure.
Outline the management of urticaria.
Oral non-sedating antihistamine (e.g. cetirizine)
A short course of oral prednisolone may be considered if symptoms are severe
Define papule.
Elevated skin lesion with an elevation of less than 1 cm
Describe the appearance of the rash in lichen planus.
Violaceous polygonal lesions usually found on the wrists and legs
Involvement of the oral mucosa is common, and may appear as lace-like white streaks (known as Wickham’s striae)
Outline the management of severe acne rosacea with prominent papules and pustules.
Topical Ivermectin with an Oral Antibiotic (e.g. doxycycline)
Which features of a cutaneous horn would be suggestive of malignancy?
Painful
Large size
Indurated, wide or erythematous base
What is an epidermoid cyst?
Arise from hair follicles due to obstruction of the pilosebaceous unit
Commonly found on the chest and shoulder
appear as skin-coloured papules or nodules with a central punctum that may express cheesy debris
What is hidradenitis suppurativa?
Chronic inflammatory skin condition affecting areas that are rich in sweat glands (e.g. groin, axilla)
It is characterised by the development of inflammatory lesions (papules, pustules, nodules and abscesses) and can be complicated by draining sinuses and scarring
What is onycholysis?
Separation of the nail from the underlying nail bed
May occur secondary to trauma, skin diseases (e.g. psoriasis), infections, systemic diseases (e.g. hypothyroidism) or medications (e.g. tetracyclines).
What is acute generalised exanthematous pustulosis?
Severe adverse cutaneous reaction that is characterised by rapid-onset erythema that is studded with tiny sterile pustules
These have a predilection towards skin folds and the rash often starts on the face before becoming widespread
The majority of cases are triggered by medications (in particular, beta-lactam antibiotics)
What is erythema multiforme?
A hypersensitivity reaction associated with particular infections, most commonly the Herpes Simplex Virus (HSV). It can also be associated with mycoplasma infection or, less commonly, certain medications or vaccines. It is characterised by target lesions which have 3 concentric colour regions; a dark red centre which may be blistered or crusted, a paler pink ring which is raised due to oedema, and a deep red outermost ring.
How is erythema multiforme diagnosed?
Clinical diagnosis
How is erythema multiforme associated with HSV infection managed?
Topical Emollient and Steroid with Oral Antihistamine
Which rash is strongly associated with inflammatory bowel disease?
Erythema Nodosum
What histological findings would you expect to see in erythema nodosum?
Inflammation of the septa between subcutaneous fat lobules, without vasculitis
What is the treatment of choice for patients with severe, symptomatic erythema nodosum?
Oral potassium iodide
What are pressure sores?
Localised injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or of pressure in combination with shear force.
They are typically found on the sacrum, heels of the feet, over the greater trochanters of the hips, and the shoulders.
Describe the appearance of chronic plaque psoriasis.
Symmetrical, well-demarcated, erythematous plaques covered by adherent silvery-white scale
It commonly appears on the scalp and extensor surfaces
Which tool is used to assess the severity and extent of psoriasis?
Psoriasis Area Severity Index (PASI)
What is the third-line management option for chronic plaque psoriasis after emollients and preparations containing steroids and vitamin D?
PUVA (Psoralen and UVA therapy)
Describe the appearance of molluscum contagiosum.
Pearly umbilicated papules
Which commonly used cardiac medications are contraindicated in severe aortic stenosis?
Vasodilators such as nitrates
What are the two main causes of an ejection systolic murmur heard loudest over the aortic area?
Aortic Stenosis (e.g. bicuspid aortic valve)
Aortic Sclerosis
What is Dressler syndrome?
Pericarditis that develops around 2-10 weeks after a myocardial infarction
Patients tend to present with pleuritic chest pain and may have a low-grade fever
What murmur is associated with tricuspid regurgitation?
Pansystolic murmur heard loudest at the lower left sternal edge during inspiration
What is Takotsubo cardiomyopathy?
Sudden dysfunction of the ventricular myocardium in response to stress
An echocardiogram classically reveals apical ballooning of the ventricles
What ECG features are associated with digoxin toxicity?
Sinus bradycardia
Down-sloping ST segment (‘reverse tick’ sign)
Supraventricular tachycardia
Atrioventricular block
Slow atrial fibrillation
Premature ventricular complexes
Define trifascicular block.
Commonly used definition: bifascicular block (right bundle branch block and left or right axis deviation) with a 1st degree heart block
True trifascicular block: 3rd degree heart block with right bundle branch block and left anterior or posterior fascicular block
Which investigation should be arranged in a patient who is noted to have high blood pressure during a GP appointment?
Ambulatory blood pressure monitoring
What is the most appropriate initial investigation to request in a patient with suspected peripheral artery disease?
Ankle Brachial Pressure Index (ABPI)
What is the mainstay of managing mild peripheral vascular disease in the community?
Aggressive risk factor modification (e.g. statin therapy, smoking cessation) and enrolment in a supervised exercise programme
Which investigation should be requested urgently in a patient with a suspected leaking abdominal aortic aneurysm?
CT Aortogram
How is viral pericarditis managed?
NSAIDs and Colchicine
Describe the ECG appearance of Third-Degree heart block.
Complete dissociation between the P waves and the QRS complexes.
Which medication should be administered as soon as possible once a non-shockable rhythm is identified in cardiac arrest?
IV Adrenaline 1 mg (1:1000)
What is the gold standard investigation for diagnosing deep vein thrombosis?
Doppler Ultrasound Scan
What is the first-line interventional option in a patient who has failed a trial of conservative management for symptomatic varicose veins?
Endothermal radiofrequency ablation
Outline the management of AAA based on the diameter.
3.0-4.4 cm: Annual Ultrasound
4.5-5.4 cm: 3-Monthly Ultrasound
> 5.5 cm: Referral for Consideration of Surgical Intervention
Which arrest rhythm is most commonly seen in someone who is having a myocardial infarction?
Polymorphic ventricular tachycardia descending into ventricular fibrillation.
Which medication should be administered as soon as possible once a non-shockable rhythm is identified in cardiac arrest?
IV Adrenaline 1 mg (1:1000)
What are the clinical and diagnostic features of myocardial infarction?
- Rise in serum troponin concentration
- Symptoms of ischaemia
- ECG changes indicative of new ischaemia (new ST-T changes or new left bundle branch block)
- ECG changes showing development of pathological Q waves
- Imaging evidence of new loss of viable myocardium or a new regional wall motion abnormality
- Identification of an intracoronary thrombus during angiography or autopsy.
What are the presenting symptoms of pericarditis?
Sharp chest pain that is worse on inspiration
Improved by leaning forward
Often preceded by a viral infection (e.g. upper respiratory tract infection or gastroenteritis)
Which combination of antiplatelets is recommended in patients who have had a myocardial infarction requiring stent insertion?
Aspirin and Ticagrelor (for 1 year, followed by aspirin alone for life).
Clopidogrel is an alternative to ticagrelor. Ticagrelor is associated with a lower rate of future adverse cardiac events, but it is also associated with a higher risk of bleeding.
What kind of murmur is caused by aortic regurgitation?
Early diastolic decrescendo murmur
What ECG features do you expect to see in a posterior wall myocardial infarction?
ST depression in V1-V4
If V4-6 are moved to the patient’s back (and, hence, renamed V7-9), ST elevation will be seen in these leads.
Q waves may also be seen in V7-9.
What is the first-line antihypertensive for a 60-year-old Caucasian patient with newly-diagnosed hypertension?
Calcium channel blocker
What are the ECG features of hypokalaemia?
Flattened T waves
U waves
Prolonged PR interval
Long QT interval
What are the first steps in the management of acute heart failure?
Sit Up
High-Flow Oxygen
IV Furosemide
+/- IV Morphine and Nitrates
Which factors favour the use of rhythm control instead of rate control for the management of atrial fibrillation?
There is a clear reversible cause for the AF (e.g. pneumonia, PE)
The patient has no underlying heart disease (e.g. valvular disease)
The patient has presented within 48 hours of the onset of symptoms
Which condition is associated with Roth spots?
Infective endocarditis
They are white-centred retinal haemorrhages
What are the clinical features of cardiac tamponade?
Beck’s Triad: Hypotension, Raised JVP and Muffled Heart Sounds
Aside from ECG, troponins and coronary angiograms, which other investigation should all patients with an acute coronary syndrome have performed before discharge?
Echocardiogram
Which type of medication that is commonly used in the context of ACS should be generally avoided in patients with severe aortic stenosis?
Nitrates (it can cause a sudden reduction in preload which can cause a sudden drop in coronary perfusion in patients with severe aortic stenosis)
Why should amiodarone be generally run through a central vein?
Achieves greater haemodilution and hence reduces the risk of phlebitis
Why is it important to carry out a chest X-ray after a pacemaker is inserted?
To check for a pneumothorax (from pleural damage caused by insertion) and to ensure the leads are in the correct position.
Which medical treatment option is most appropriate for the treatment of bigeminy?
Beta-blockers (e.g. bisoprolol)
What is the mechanism of action of tirofiban?
GPIIb/IIIa inhibitor (prevents platelet aggregation)
Which PPI is preferred in patients on clopidogrel?
Lansoprazole
NOTE: omeprazole interacts with clopidogrel and reduces its effectiveness
Why does metformin need to be withheld in a patient who is undergoing a percutaneous coronary intervention?
There is a risk of contrast-induced nephropathy in patients who are undergoing a coronary angiogram.
Metformin is associated with an increased risk of lactic acidosis in patients with renal impairment so it should be held for 48 hours before undergoing an elective angiogram.
In the context of acute coronary syndrome, what can cause non-sustained ventricular tachycardia?
Ischaemia
Reperfusion after PCI
Electrolyte imbalances (e.g. hypomagnesemia or hypokalaemia)
Underlying myocardial scar
Increased automaticity (ability of heart cells to spontaneously depolarise) in the myocardium adjacent to the infarcted area
Why does metformin need to be withheld in a patient who is undergoing a percutaneous coronary intervention?
There is a risk of contrast-induced nephropathy in patients who are undergoing a coronary angiogram.
Metformin is associated with an increased risk of lactic acidosis in patients with renal impairment so it should be held for 48 hours before undergoing an elective angiogram.
Which medication has a positive inotropic and negative chronotropic effect?
Digoxin (it is, therefore, useful in patients with fast AF and a background of heart failure)
What is the most common cause of mitral stenosis?
Rheumatic Heart Disease
Describe the ECG appearance of complete heart block.
Regular P waves and regular QRS complexes but shows no relationship between them (loss of connection between the atria and the ventricles)
In which leads would you expect to see ECG changes when the right coronary artery is occluded?
II, III and aVF
Describe the ECG appearance of Wolff-Parkinson-White syndrome.
Short PR interval, a broad QRS complex and a slurred upstroke of the QRS complex (delta wave)
What murmur is associated with aortic regurgitation?
Early diastolic murmur that is high-pitched and blowing in character, and usually heard best over the left sternal edge on expiration
What is the initial intervention of choice in a haemodynamically unstable patient with ventricular tachycardia?
DC Cardioversion
Which type of malignancy is Streptococcus bovis endocarditis associated with?
Colorectal Cancer
What is the risk of giving rate-limiting calcium channel blockers with beta-blockers?
Complete Heart Block
Which ECG features would you expect to see due to the left atrial hypertrophy that develops as a result of mitral stenosis?
Bifid P Waves
What is the most common cardiac complication in patients with hyperthyroidism?
Atrial Fibrillation
Which murmur would you expect to hear in a patient with heart failure secondary to dilated cardiomyopathy?
An S3 heart sound and a holosystolic murmur in the left fifth intercostal space at the midclavicular line
Why should beta-blockers be used with caution in patients with acute heart failure?
It can diminish the sympathetic drive to the heart and worsen cardiogenic shock.
List the indications for ICD insertion.
- If medical treatment of the underlying cause of VT/VF fails (e.g. electrolyte imbalances)
- Patients who have survived cardiac arrest due to VT/VF
- Idiopathic and prolonged VT/VF with either syncope, haemodynamic instability or a reduced ejection fraction < 35%
- Inherited conditions that increase risk of developing VT/VF such as long QT syndrome, hypertrophic cardiomyopathy and Nrugada syndrome.
- Patients who have developed heart failure with a reduced ejection fraction < 35% secondary to myocardial infarction
What are the main indications for pacemaker insertion?
Complete atrioventricular block or third degree heart block.
Mortbitz type II atrioventricular block. There is a risk of progressing to third degree heart block, and therefore a pacemaker is needed.
Persistent symptomatic bradycardia.
Medication resistant tachyarrhythmias (e.g. SVT, AF).
What echocardiogram findings do you expect to see in mitral regurgitation?
Dilated left atrium with poor ventricular ejection fraction
List some clinical features of infective endocarditis.
New Murmur
Fever
Janeway Lesions
Osler’s Nodes
Roth Spots on Retina
Microscopic Haematuria
Which investigation should be requested for a patient with symptoms suggestive of stable angina?
CT Coronary Angiogram
Why are regular VBGs important in the ongoing management of a patient who has undergone an embolectomy for acute limb ischaemia?
Reperfusion can lead to drainage of the potassium and acids released by damaged myocytes into the systemic circulation.
What is the most appropriate imaging modality to request in a patient with a suspected leaking abdominal aortic aneurysm?
CT Angiogram
Outline the frequency with which patients should have an ultrasound scan if a AAA is identified.
< 3 cm = No Follow-Up
3 - 4.4 cm = 1 Year
4.5-5.4 cm = 3 Months
> 5.5 cm = Refer to Vascular Surgery
What are the indications for surgical intervention in infective endocarditis?
Heart failure
Fistula formation
Perforation
Recurrent emboli despite antibiotic treatment
Abscess formation
Which ECG findings are associated with pericarditis?
PR Depression
Widespread, saddle-shaped ST elevation
What is the most accurate way of diagnosing pulmonary hypertension?
Right Heart Catheterisation
Which medication is usually prescribed in patients with a new diagnosis of peripheral vascular disease?
Antiplatelets (e.g. clopidogrel)
Outline the initial management of crescendo angina.
Dual antiplatelet therapy
Discuss with on-call cardiology registrar and/or nearest PCI centre
Which class of medications should be avoided in patients with Prinzmetal angina?
Beta blockers (can worsen vasospasm)
What is Prinzmetal angina?
Also known as variant angina
Form of angina that is caused by coronary artery vasospasm (unclear aetiology)
Patients complain of chest pain that can occur at rest and with exercise (ischaemic ECG changes may be noted during an episode)
Outline the initial management of STEMI.
Loading dose of dual antiplatelet therapy (aspirin 300 mg AND ticagrelor 180 mg OR clopidogrel 300 mg OR prasugrel 60 mg)
Urgent PCI within 120 mins
If PCI is not available within 120 mins, fibrinolysis should be considered
Outline the acute management of NSTEMI.
Loading dose of dual antiplatelet therapy (aspirin 300 mg AND ticagrelor 180 mg OR clopidogrel 300 mg OR prasugrel 60 mg)
Fondaparinux 2.5 mg SC OD
Risk stratify to determine when coronary angiogram should be performed
How is asymptomatic first degree heart block managed?
No intervention required
How is symptomatic third degree heart block treated?
If the patient is haemodynamically unstable, an isoprenaline infusion can be used in the short term or temporary pacing could be trialled.
If the patient is stable, they should be admitted to a cardiac monitor bed and arrangements should be made to have a permanent pacemaker fitted.
Outline the management of hypoplastic left heart syndrome.
Prostaglandin E1 infusion
Staged surgical management
What are the echocardiographic features that you may see in patients with a pulmonary embolism?
Right heart strain
Which intervention is considered in patients with critical aortic stenosis who are not suitable for surgical valve replacement?
Transcatheter Aortic Valve Implantation (TAVI)
What is often the first step in decompensated heart failure?
IV Furosemide
What should muffled heart sounds and hypotension soon after PCI raise suspicion of?
Haemopericardium causing cardiac tamponade
What are the ECG findings in bifascicular block?
Right bundle branch block and left or right axis deviation
How is Torsades de Pointes treated?
IV Magnesium Sulphate
Describe the ECG appearance of monomorphic ventricular tachycardia.
Broad and uniform QRS complexes with a regular rhythm throughout all leads
Which risk assessment tool is used for DVTs?
Wells’ Score
Describe the ECG changes seen in bifascicular block.
Left or Right Axis Deviation and Right Bundle Branch Block
What are the ECG features of hypokalaemia?
Widespread ST Depression
T wave inversion
Prominent U waves
Long QT interval
Describe the ECG changes seen in bifascicular block.
Left or Right Axis Deviation and Right Bundle Branch Block
What are the ECG features of hypokalaemia?
Widespread ST Depression
T wave inversion
Prominent U waves
Long QT interval
What murmur is associated with mitral regurgitation?
Pansystolic murmur heard at the left 5th ICS in the midclavicular line and radiates to the axilla
Describe the ECG features of AVNRT.
GAP DECK BACK
Regular narrow complex tachycardia with no p waves
Pseudo R waves
What is a normal cardiac axis?
-30° to 90°
How does aortic dissection classically present?
Sudden-onset, central, tearing chest pain that radiates to the back (between the shoulder blades)
What is Quincke’s sign?
Visible pulsation of the nail bed associated with aortic regurgitation.
Describe the appearance of 1st degree heart block on an ECG.
Fixed prolonged PR interval (over 200 ms)
Which autoantibody is most specific for SLE?
Anti-dsDNA antibody
