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
