Medicine Flashcards
1
Q
What are the causes of a raised PSA?
A
Prostate Cancer
BPH
Prostatitis
UTI
Urinary retention
Ejaculation
Vigorous exercise
2
Q
Which score is used for the prognosis of prostate cancer, and explain how to calculate it.
A
Gleason grading system.
Histological; 2 numbers added together. One for the most prevalent grade present, and another for the second most prevalent grade present. Add together.
E.g. 3+4 = 7.
<6 low risk
7 moderate risk
>7 high risk
3
Q
95% of prostate cancers are which type?
A
Adenocarcinoma
4
Q
Complications of radiotherapy in prostate cancer:
A
radiation proctitis and rectal malignancy
5
Q
VT / VF rhyme to remember ecg signs:
A
VT = very tidy
VF = very funny
6
Q
Which tachycardic rhythm is incompatible with cardiac output, therefore the patient would not be conscious?
A
Ventricular fibrillation
7
Q
Monomorphic VT is most commonly caused by:
A
Myocardial Infarction
7
Q
Torsades de Pointes is a subtype of:
A
polymorphic VT
7
Q
What precipitates torsades de pointes?
A
QTc prolongation
7
Q
Management of VT if adverse signs present:
A
Immediate cardioversion
7
Q
Adverse signs in VT:
A
Systolic BP <90
Chest pain
Heart failure
7
Q
Drugs that cause QTc prolongation:
A
Sotalol
Amiodarone
Fluoxetine
Tricyclic Antidepressants (amitriptyline)
Erythromycin
7
Q
Non-drug causes of QTc prolongation:
A
hypokalaemia
hypocalcaemia
hypomagnaesemia
MI
myocarditis
hypothermia
SAH
7
Q
Management step in VT if drug therapy fails:
A
Implantable Cardioverter-Defibrillator (ICD)
7
Q
Which drug should NOT be used in VT:
A
Verapamil
8
Q
Management of VT when adverse signs not present:
A
amiodarone
lidocaine (caution in LVSD)
procainamide
9
Q
Warfarin management during a major bleed:
A
Stop warfarin immediately
Give IV vitamin K 5mg
Give prothrombin complex concentrate
10
Q
What do you do when someone’s INR is >8 with minor bleeding (/no bleeding) and they’re on warfarin?
A
Stop warfarin
Give vitK orally
Repeat dose 24hrs later if still too high
Restart when INR<5
11
Q
Poor prognostic predictor in liver cirrhosis:
A
Ascites
12
Q
What drug is used to treat small bowel bacterial overgrowth? + what symptoms might the patient present with?
A
Rifaximin.
Abdo pain, belching, diarrhoea, bloating, flatulence
13
Q
Which drug is used to treat ongoing diarrhoea in Crohn’s patients post resection (normal CRP)?
A
Cholestyramine.
Patients are likely to have bile acid malabsorption as a result of resection, and cholestryramine is a bile acid sequestrant that can control diarrhoea.
14
Q
A patient is in VF. A shock is delivered and compressions are started up again. What drug should be given first?
A
IV Adrenaline 1mg
15
Q
IV Adrenaline has been administered to a patient in VF. What is the next line drug that should be administered?
A
IV amiodarone 300mg
16
Q
Which drug is used to treat SVT?
A
Adenosine, increasing in doses 6, 12, 18.
17
What drug is used to treat bradycardias?
Atropine
18
Adverse effects of metoclopramide:
diarrhoea
parkinsonism
tardice dyskinesia
hyperprolactinaemia
acute dystonia
19
Uses and mechanism of metoclopramide:
D2 receptor antagonist
- nausea
- GORD
- gastroparesis secondary to diabetic neuropathy (prokinetic action is useful)
- combined with analgesics for migraine treatment
20
Normally you give 3 months of a DOAC for a provoked DVT; what do you give to cancer patients?
6 months of a DOAC
21
Presentation of malaria:
Anaemia
Jaundice
Fever
Headache
Myalgia
(no constipation or abdo pain)
22
Classic presentation of Salmonella typhi infection:
Typhoid!
Fever, headache, arthralgia, blanching maculopapular rose spots. Splenomegaly.
23
First step in management with patients presenting within 8-24 hours of a paracetamol overdose:
Start acetylcysteine immediately if patient has taken over 150mg/kg.
24
NAC should be given following a paracetamol overdose if: (4)
1. The patient has ingested >150mg/kg and presents within 8-24 hours
2. Patient is jaundiced or have hepatic tenderness and their ALT is high.
3. There has been a staggered overdose and there is doubt about time of ingestion.
4. Plasma paracetamol conc is above single treatment line.
25
What is Beck's Triad comprised of and what does it indicate?
Hypotension
Raised JVP
Muffled heart sounds
= Cardiac Tamponade
26
Management of PBC:
1) Ursodeoxycholic Acid.
+ cholestyramine for pruritis
+ fat soluble vitamin supplementation
+ liver transplant (if Br >100). PBC is a major indication
*Note: AMA antibody indicates PBC
27
Associated diseases of PBC: (4)
1) Sjogren's syndrome
2) Rheumatoid Arthritis
3) Systemic Sclerosis
4) Thyroid disease
28
Complications of PBC:
Cirrhosis --> portal HTN --> oesophageal varices --> haemorrhage
Hepatocellular carcinoma risk increases x20
Osteomalacia and osteoporosis
29
Reed-Sternberg cells are diagnostic of:
Hodgkin's Lymphoma.
They are also referred to as 'mirror image' cells.
30
Risk factors for Hodgkin's lymphoma:
HIV
EBV
31
Presentation of Hodgkin's lymphoma:
Large rubbery painless lymphadenopathy
Neck > axilla > inguinal
Alcohol-induced lymph node pain is a characteristic of Hodgkin's
Systemic B symptoms
Mediastinal mass?
32
Investigation findings in Hodgkin's lymphoma:
Normocytic anaemia (may be multifactorial e.g. hypersplenism, bone marrow replacement, Coomb's +ve AIHA)
Eosinophilia caused by production of cytokines
LDH raised
Lymph node biopsy will show Reed-Sternberg cells ('owl eyes' / mirror cells)
33
Side effects of RIPE:
Rifampicin - orange secretions, hepatitis
Isoniazid - peripheral neuropathy *take pyridoxine*
Pyrazinamide - hyperuricaemia causing gout
Ethambutol - optic neuritis
34
CO2 levels during a near fatal asthma attack:
CO2 >6.0kPa indicates near fatal asthma.
As patient's respiratory rates will most likely be very high during an asthma attack, you would expect CO2 to be low as it gets blown off; the fact that CO2 is high, or even normal, indicated tiring and the beginning of hypoventilation.
35
What accounts for 50% of cerebral lesion in HIV, and how does it present?
TOXOPLASMOSIS
Constitutional symptoms, headache, confusion, drowsiness
36
How do you investigate and manage toxoplasmosis in HIV?
CT shows multiple ring enhancing lesions, mass effect may be seen.
Sulfadiazine and pyrimethamine
37
What is a common cerebral lesion in HIV, accounting for around 30%? + treatment
Primary CNS lymphoma.
Single lesions usually, solid enhancement, not ring.
Steroids, chemo inc methotrexate, +/- whole brain irradiation
38
Subacute onset, behavioural changes, speech, motor + visual impairment + widespread demyelination =
PML. Can be seen in HIV.
Caused by the JC virus.
Image with MRI, see high signal white matter demyelinating lesions.
39
How would renal artery stenosis typically present?
Older, male smokers
Atherosclerotic risk factors such as hypercholesterolaemia
Hypokalaemia, hypernatraemia
Renal bruit
40
3 symptoms of a pontine haemorrhage:
Reduced GCS
Pinpoint pupils
Paralysis
41
Which medical condition can give an over-estimate of blood sugar levels inc HbA1c, and why?
Splenectomy, due to increased lifespan of RBCs.
42
Drug Causes of SIADH:
Carbamazepine
SSRIs
Sulfonylureas
Tricyclics
43
Describe the symptoms of lithium toxicity, based on blood levels.
<1.5 symptoms not seen
1.5-2.5 = mild symptoms including nausea, fatigue and tremor
2.5-3.5 = confusion, ataxia, hypotonia, tachycardia
3.5 = hyperthermia, hypotension, seizure, coma
Lithium is associated with diabetes insipidus; hypernatraemia with a raised serum osmolality and decreased urine osmolality.
44
Stereotypical presentation of Paget's disease of the bone:
older male, bone pain, isolated raised ALP
lytic / sclerotic lesions on xray
45
COPD LTOT indications:
pO2 of 7.3-8kPa AND one of:
1. Secondary polycythaemia
2. Peripheral oedema
3. Pulmonary hypertension
46
PERC criteria to rule out a DVT (8):
1. Haemoptysis
2. Prev DVT/PE
3. HR >100
4. Unilateral leg swelling
5. Age >50
6. Recent trauma / surg in last 4 weeks
7. Hormone therapy e.g. HRT, OCP
8. Oxygen sats <94%
47
Classic signs of intracranical hypertension (3)
bilateral papilloedema, headache, diplopia
48
Treatment of pulmonary oedema refractory to diuresis in AKI:
haemodialysis
49
Most accurate marker for assessing acute liver function?
PT
Prothrombin has a shorter half life than albumin, therefore making it a more accurate measure of acute liver failure.
50
Causes of acute liver failure (4):
Paracetamol overdose
Alcohol
Viral hepatitis (a or b)
Acute fatty liver of pregnancy
51
Describe King's College Hospital criteria for liver transplant following paracetamol induced liver failure:
Arterial pH <7.3 24hrs post ingestion
OR all of:
1. PT >100s
2. creatinine >300
3. encephalopathy grade III or IV
52
Risk factors for developing hepatotoxicity post paracetamol overdose:
Drugs that induce liver enzymes:
Rifampicin, carbamazepine, phenytoin
Chronic alcohol excess
Malnutrition
53
Treatment of an Addisonian crisis:
100mg IV/IM hydrocortisone over 30-60 mins
+ 1L IV saline (+ dextrose if hypoglycaemic)
Continue hydrocortisone 6hrly until patient stabilised, then can switch to oral after 24 hours, and reduce down to maintenance dose at 3-4 days.
54
Causes of an Addisonian crisis:
sepsis and surgery can cause acute exacerbation of chronic Addison's disease
adrenal haemorrhage (Waterson-Friderichsen)
steroid withdrawal
55
Predisposition to acute confusion state (5) :
1. history of dementia
2. age >65
3. recent significant injury e.g. hip fracture
4. frailty / multimorbidity
5. polypharmacy
56
5 causes of nephrotic syndrome:
1. Minimal change disease
2. Membranous GN
3. diabetic nephropathy
4. FSGS
5. Amyloidosis
57
3 causes of nephritic syndrome (HTN+haematuria):
1. RPGN
2. IgA nephropathy
3. Alport's syndrome
58
Complications of nephrotic syndrome:
1. Hypercoagulable state due to loss to antithrombin III and plasminogen (DVT/PE/renal vein thrombosis)
2. Infections due to loss of Ig
3. Hyperlipidaemia
4. CKD
5. Hypocalcaemia as VitD and binding protein is lost
59
Cause of acute interstitial nephritis:
Drugs (NSAIDs, allopurinol, penicillin, rifampicin, furosemide)
60
Features of acute interstitial nephritis:
rash, fever, arthralgia
white cell casts in urine
hypertension
insterstitial oedema and infiltrates
eosinophilia
mild renal impairment
61
Blood and X ray results in Paget's disease of the bone:
Isolated raised ALP
Calcium and phosphate normal
?hypercalcaemia if prolonged immobilisation
Osteolysis in early disease --> lytic lesions later
Skull --> thickened vault, osteoporosis circumscripta
62
Indications for treatment of Paget's disease of the bone:
bone pain
long bone or skull deformity
fractures
periarticular Paget's
63
Complications of Paget's disease of the bone
Deafness (CN entrapment)
Sarcoma
Fractures
HO cardiac failure
64
Bones most commonly affected in Paget's?
Long bones of lower extremities, pelvis, skull, spine
65
Pathophysiology of Paget's disease
Excessive osteoclast activity followed by increased osteoblast action
66
What is the inheritance pattern of MODY/?
Autosomal dominant
67
What are the 2 genes involved in MODY and what are the differences between them?
HNF1A = MODY3 --> treat with sulfonylurea!!!
GCK = MODY2
MODY3 is more common (60%) than MODY2.
In HNF1a you get 1/3 of an insulin response than normal, and GCK is only a slight reduction.
68
Presentation of monogenic (MODY) diabetes:
Mild hypoglycaemia
Do not present with ketosis typically, unless extreme stress
Normal weight usually, + significant family history.
Don't present with the classic features of insulin resistance e.g. polyuria, polydipsia
69
MODY and pregnancy:
Be aware of patients with MODY mutations as they can have problems in pregnancy:
If both the mother and baby have the mutation, its fine.
If just the mother has the mutation, can cause macrosomia (big baby).
If just the baby has it, IUGR.
70
Causes of lung fibrosis, split into upper and lower:
CHARTS for upper:
Coalworker's lung
Histiocytosis, hypersensitivity pneumonitis
Ankylosing spondylitis
Radiation induced (6-12 months post)
TB
Silicosis, sarcoidosis
Lower:
Idiopathic
Amiodarone, bleomycin, MTX
Connective tissue diseases apart from ank spond
Asbestosis
71
Causes of granulomatous lung disease:
GPA
EGPA
TB
Sarcoid
72
Acute and insidious features of sarcoidosis:
Non caseating granulomas
Acute = bilateral hilar lymphadenopathy, erythema nodosum, swinging fever, polyarthralgia
Insidious = dyspnoea, non-productive cough, malaise, weight loss
73
Extra-pulmonary manifestations of sarcoidosis:
Skin = erythema nodosum, lupus pernio
Ocular = uveitis
Hypercalcaemia (macrophages inside the non-caseating granulomas convert vitamin into it's more active form)
74
Lofgren's syndrome
An acute form of sarcoidosis usually characterised by bilateral lymphadenopathy, erythema nodosum, fever and polyarthralgia. .
Good prognosis.
75
Blood tests in sarcoidosis:
Raised ACE
Hypercalcaemia
76
Factors associated with poor prognosis in sarcoidosis:
Insidious onset, sx for >6 months
Absence of erythema nodosum
Extra pulmonary signs e.g. lupus pernio, splenomegaly etc etc
CXR signs
Black African / afro-caribbean descent
77
TB granuloma lesion formation:
Macrophages migrate to regional lymph nodes, lymph node + lung lesion = Ghon complex.
Caseating necrosis occurs in the middle of the lesion.
Inflammatory response is mediated by type IV hypersensitivity.
78
5 Categories of pulmonary hypertension causes:
1. idiopathic or CTD (SLE)
2. Left heart failure e.g. MI / HTN
3. pulmonary vascular problem e.g. PE
4. Chronic lung disease e.g. COPD/fibrosis
5. Misc e.g. sarcoidosis
79
Process of pulmonary hypertension:
1. Increased pressure in the pulmonary arteries
2. Increased strain on right side of the heart
3. Back pressure into systemic venous system
80
Signs and symptoms of pulmonary HTN:
SOB!
+ syncope, raised JVP, peripheral oedema, hepatomegaly
81
What is cor pulmonale?
Enlargement and strain on the right side of the heart (RVhypertrophy, right atrial enlargement). May cause heart failure due to chronically increased pressure.
Caused by pulmonary hypertension, COPD i.e. chronic hypoxic pulmonary vasoconstriction.
Increased p wave amplitude, RBBB.
82
3 types of benign bone tumours:
osteochondroma
osteoma
giant cell tumour
83
3 types of malignant bone tumours:
osteosarcoma
chondrosarcoma
Ewing's sarcoma
84
Features of osteochondroma
Most common benign bone tumour
<20 yrs
Male
Cartilage capped bony projection on long bone surface
85
Features of osteoma
Associated with FAP
benign overgrowth of the bone, typically skull.
86
Features of giant cell tumour
Tumour of multinucleated giant cells in the fibrous stroma
Double bubble / soap bubble appearance on x-ray
Peak incidence = 20-40yrs
Epiphyses of long bones
87
Which malignant bone tumour presents with 'onion skin' on x-ray, and give some other features?
Ewing's sarcoma.
Kids / adolescents primarily affected.
Severe pain.
t(11:22) translocation.
small round blue cell
pelvis and long bones
88
What is the most common primary bone malignancy, and give features of it?
osteosarcoma
metaphysis of long bones before epiphyseal closure
Adolescents and kids
Ass/w Rb gene, therefore retinoblastoma
Radiotherapy and Paget's are risk factors
Femur>tibia>humerus
X-ray shows Codman's triangle from periosteal elevation and 'sunburst' pattern
89
3 features of a chondrosarcoma?
Cartilage tumour
Axial skeleton
Middle age onset
90
Most common causes of bone mets (most common first):
Prostate > breast > lung
91
Most common sites of bone mets:
Spine > pelvis > ribs > skull > long bones
92
Other signs of bony mets?
Hypercalcaemia
Raised ALP
Pathological fractures
93
Name 4 types of small vessel vasculitides:
1. EGPA
2. GPA
3. MPA
4. HSP
94
Name 2 types of vasculitis that affect medium vessels:
1. Kawasaki disease
2. Polyarteritis nodosa
95
2 large vessel vasculitides:
Takayasu
Giant cell arteritis / temporal arteritis
96
Features of HSP
Small vessel IgA complex deposition
Purpuric rash, buttocks, lower limbs
Children
IgA nephritis --> haematuria
Polyarthritis, abdo pain
97
Features of MPA
pANCA
Renal failure due to GN is classic
+ diffuse alveolar haemorrhage
98
Features of GPA
cANCA
Saddle shaped nose, epistaxis
Hearing loss
RPGN
Cough, wheeze, haemoptysis
99
Features of EGPA
pANCA
Late onset severe asthma in middle age (but can occur earlier)
Eosinophils present
Sinusitis + allergic rhinitis
100
Kawasaki disease features;
Young kids
High grade fever >5 days, refractory to antipyretics
Strawberry tongue
Desquamating palms and soles
Bilateral conjunctivitis
Cervical lymphadenopathy
Coronary artery aneurysms !
Treat with aspirin
101
Polyarteritis nodosa features;
Microaneurysms leading to renal failure, CVA, MI
Necrotising inflammation causing the microaneurysms
Mesenteric aneurysms = intestinal symptoms
*Associated with HBV!* (30%)
102
Takayasu's vasculitis features:
Most commonly affects the aorta - reference to 'absent limb pulses'.
MRA/CTA required for diagnosis.
Upper limb BP discrepancy.
Absent / weak limb pulses.
Carotid bruit / tenderness.
Upper and lower limb claudication on exertion.
Younger women + asian descent.
Systemic features like malaise / headache.
Aortic regurg in 20%
103
Classic signs and symptoms of idiopathic pulmonary fibrosis on examination:
finger clubbing
bi-basal fine end-inspiratory crackles
dry cough
exertional SOB
fatigue
normal or restrictive spirometry
104
Diagnosis of pulmonary fibrosis:
clinical features
High resolution CT with ground glass appearance
spirometry (normal or restrictive pattern, FEV1 and FVC reduced equally, with ratio >70%)
+ BAL
+ Biopsy
105
Drug causes of secondary pulmonary fibrosis:
Amiodarone
Methotrexate, sulfasalazine
Bleomycin
Nitrofurantoin
Cabergoline, bromocriptine
106
Other conditions that cause secondary pulmonary fibrosis:
RA, SLE, sarcoidosis (CTDs)
Hypersensitivity pneumonitis
Asbestos exposure
TB
alpha-1-antitrypsin deficiency
107
Spirometry results in pulmonary fibrosis:
normal or restrictive
FEV1/FVC reduced equally
ratio >70%
108
Features of idiopathic pulmonary fibrosis
Insidious onset, hx of dry cough >3 months.
onset >50 yrs
Poor prognosis, 2-5 yr life expectancy from diagnosis
109
Acute vs chronic features of hypersensitivity pneumonitis / EAA:
Acute (within 4-8 hours) = type III hypersensitivity, dry cough, dyspnoea, fever
Chronic (within weeks to months) = type IV hypersensitivity, productive cough, anorexia and weight loss, lethargy, dyspnoea
110
Features of EAA / hypersensitivity pneumonitis:
Lymphocytosis on BAL - raised lymphocytes is important.
Acute and chronic symptoms differ.
Sensitized to allergen in air, causes inflammation and lung damage.
E.g. birds, mushrooms, malt, farm
Eosinophils absent.
Upper / mid zone fibrosis.
111
Different types of pulmonary fibrosis:
Idiopathic
Drug induced
Secondary causes
Hypersensitivity / EAA
Cryptogenic Organising Pneumonia
Asbestosis
112
Features of cryptogenic organising pneumonia:
Focal area of the lung, often very similar to infective pneumonia.
Idiopathic or triggered
Lung biopsy is definitive
113
Discuss asbestos and malignancy:
Asbestos is oncogenic (and fibrogenic).
Can cause adenocarcinoma (lung) and mesothelioma (pleura).
Adenocarcinoma is actually more common.
Mesothelioma is cancer of the pleura - features include chest pain, pleural effusion and progressive SOB. Very poor prognosis. Cricodolite is the worst type of asbestos.
Can get compensation.
114
Features of asbestosis:
Can takes years after exposure to develop (15-30 yrs).
Pleural plaques are benign, don't need follow up.
Can cause mesothelioma and adenocarcinoma.
Lower zone fibrosis.
Restrictive picture.
Clubbing.
Dyspnoea, reduced exercise tolerance.
Bi-basal fine end-inspiratory crackles.
115
Describe the signet ring sign and tram tracks on lung CT:
Signet ring = dilated airway and pulmonary artery branch are seen together on CT - normally same size but airway is grossly dilated, looking like a signet ring.
Tram track = widened, non-tapering airways
116
Discuss causes of bronchiectasis:
Post infection e.g. TB, pertussis, pneumonia, measles
Cystic fibrosis
Bronchial obstruction e.g. mass, foreign object
Immune deficiency e.g. selective IgA, hypogammaglobulinaemia
Allergic bronchopulmonary aspergillosis
Yellow nail (bronchiectasis, yellow nails + lymphoedema)
Ciliary dyskinesia e.g. Kartagener's
117
What is bronchiectasis?
Permanent dilation of the bronchioles / airways due to chronic inflammation / infection.
118
Signs and symptoms of bronchiectasis:
Persistent, productive cough (large volume)
Dyspnoea
Haemoptysis
Crackles
Wheeze
Clubbing
119
Diagnosis of bronchiectasis:
Sputum culture to check for colonising infection (pseudomonas aeruginosa + haemophilus influenzae are the most common).
CXR signs include tram tracks and signet ring sign.
HRCT is gold standard, provides a definitive diagnosis.
120
Functions of peripheral nervous system (3):
sensory input to CNS
motor output to muscles
innervation of viscera
121
2 causes of swinging fever:
Malaria
Sarcoidosis
122
First line therapy for uncomplicated falciparum malaria:
artemether + lumefantrine
123
Complications of falciparum malaria:
DIC
pulmonary oedema
cerebral malaria
seizures
reduced consciousness
AKI
severe haemolytic anaemia
124
CPAP in heart failure mechanism:
Consider after medical therapy has not worked (furosemide, 15L high flow).
CPAP increases intrathoracic pressure
Reduces venous return to the heart
Reduces preload and reduces pulmonary venous pressure
125
Things that exacerbate psoriasis:
Beta blockers, NSAIDs, ACEi, anti-malarials, lithium, infliximab
Trauma
Alcohol
Withdrawal of steroids
126
Features of a CNIII palsy (3):
Down and out eye
Ptosis
mydriasis (dilation of the pupil)
127
Features and examples of type I hypersensitivity:
Antigen reacts with IgE bound to mast cells.
Anaphylaxis, atopy
128
Features and examples of type II hypersensitivity:
Cell bound: IgG or IgM binds to antigen on cell surface.
AIHA
ITP
Goodpasture's
Pernicious anaemia
Acute transfusion reactions
Rheumatic fever
Bullous pemphigoid
129
Features and examples of type III hypersensitivity:
Immune complex - free antigen and IgG/IgA combine.
SLE
Post-strep GN
Acute phase of extrinsic allergic alveolitis
130
Features and examples of type IV hypersensitivity:
Delayed - t-cell mediated.
TB
GvHD
Allergic contact dermatitis
Scabies
Chronic phase of EAA
MS
GB
131
Features and examples of type V hypersensitivity:
Antibodies recognise and bind to cell surface receptors. This stimulates or blocks ligand binding.
Grave's
Myasthenia Gravis
132
Clinical presentation of neuropathy, split into motor, sensory and autonomic:
MOTOR = weakness, muscle atrophy
SENSORY = large myelinated fibres = sensory ataxia, loss of vibration sense. Small = sharp nerve pain, temp loss etc.
AUTONOMIC = ED, postural hypotension, excessive sweating, GI disturbance
133
ABCDE causes of peripheral neuropathy:
Alcohol
B12 deficiency (SCDSC)
Cancer (myeloma), CKD
Diabetes and Drugs (isoniazid, cisplatin, amiodarone, leflunomide)
Every vasculitis
134
Features of Charcot Marie Tooth:
AD inheritance in most cases.
Presents <10 yrs mostly, but onset can be delayed until 40yrs.
Distal muscle weakness e.g. lower legs and hands.
High stepping gait due to foot drop because of weakness.
Muscle atrophy in calves.
Minimal sensory loss.
Reduced tendon reflexes and tone.
Pes cavus (high foot arch).
135
Features of Guillain Barre syndrome:
Post infection e.g. campylobacter is most common + EBV+CMV.
Anti-GM1 antibodies. Mimicry?
Presents within 4 weeks of infection, symptoms peak at 2-4 weeks, recovery months to years.
Ascending symmetrical weakness.
Reduced reflexes.
Some sensory loss, neuropathic pain.
Can affect CNs (diplopia, bilateral facial nerve palsy and oropharyngeal weakness) and autonomic system (urinary retention + diarrhoea).
Dx clinically + LP + nerve conduction studies. (Brighton score.)
136
What are you likely to see in a CSF analysis and nerve conduction studies of someone with GBS?
CSF - raised protein, normal glucose and wcc
Nerve conduction studies - decreased velocity of motor nerve conduction.
137
Most common cause of a polyneuropathy?
Length-dependent axonal neuropathy (multiple causes e.g. diabetes)
138
What is mononeuritis multiplex?
subsequent or simultaneous development of mononeuropathy in 2 or more nerves.
139
Commonly affected nerves in mononeuritis multiplex?
common peroneal, radial, axillary, median, sciatic
140
Causes of mononeuritis multiplex?
Similar to most causes of neuropathy;
Diabetes, vasculitis, SLE/RA/Sjogren's, lymphoma, sarcoidosis, HCV/HIV
141
Dog bite in Ecuador management:
Human rabies immunoglobulin + full course of vaccination
142
Causes of ascites (SAAG >11g/L):
>11 indicates portal hypertension:
Cirrhosis / alcoholic liver disease
Acute liver failure
Massive liver mets
Constrictive pericarditis
Right heart failure
Budd-Chiari syndrome
Veno-occlusive disease
143
Threshold for treating SBP?
wcc >500 or neut >250
144
Causes of ascites (SAAG <11g/L)
peritoneal mets
Hypoalbuminaemia - nephrotic syndrome / severe malnutrition
Pancreatitis
Bowel obstruction
Biliary ascites
Tuberculous ascites
145
What is Wolff-Parkinson White syndrome?
A pre-excitation syndrome where there is an accessory pathway that bypasses the AVN, leading to early depolarisation of the ventricles.
This manifests as a shortened PR interval on ECG.
(+ delta wave, widened QRS)
It's classes as 'AVRT' = AVN re-entry tachycardia, type of SVT.
146
What can Wolff-Parkinson White syndrome rapidly deteriorate into?
VF, as the accessory pathway does not slow conduction AF.
147
Causes of acute pericarditis:
Coxsackie virus
TB
Post MI
Radiotherapy
RA/SLE
Trauma
Malignancy
Hypothyroidism
148
Features of acute pericarditis:
Inflammation of the pericardial sac lasting 4-6 weeks.
Chest pain, can be pleuritic and relieved by sitting forwards.
SOB, flu like symptoms, non-productive cough.
Pericardial rub.
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Features of constrictive pericarditis:
Main cause is TB.
Kussmaul's sign +ve (JVP elevation / x+y)
SOB, right heart failure.
Calcifications on CXR.
150
Summary of HOCM:
AD condition - family history prevalent.
Leading cause of sudden cardiac death in the young.
Can be aSX, can have exertional SOB and syncope following exercise.
Mainly LVH --> decreased compliance --> decreased output.
Pansystolic murmur.
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Summary of dilated cardiomyopathy:
All 4 chambers dilated, but the LV more so than others. Mainly systolic dysfunction. Balloon appearance on CXR.
Classic symptoms of heart failure + mitral and tricuspid regurg.
Causes: MAJORITY IS IDIOPATHIC
Myocarditis e.g. coxsackie virus, diphtheria, Chaga’s disease
Infiltrative causes include haemochromatosis, sarcoidosis
Hypertension
Ischaemic heart disease
Alcohol and cocaine abuse
Doxorubicin
Acromegaly
Familial predisposition. Majority of defects are AD. Can be associated with a syndrome e.g. duchenne muscular dystrophy.
152
Characteristic features of PCOS (5):
1. multiple ovarian cysts
2. insulin resistance
3. hyperandrogenism
4. oligomenorrhoea
5. infertility
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Describe the multi-role effect of insulin in PCOS (3):
In PCOS you have reduced insulin sensitivity, so the pancreas has to make more insulin for it to have the correct effect. The increased insulin acts on the ovaries and adrenal glands to produce more androgens.
Insulin also suppresses production of SHBG from the liver, which usually binds to androgens and reduces their action.
Finally, insulin inhibits the development of follicles in the ovaries, seen as cysts on US, and also manifests as anovulation.
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Diagnostic criteria of PCOS:
2 of the 3 following criteria are met:
1. Signs of hyperandrogenism e.g. hirsutism, acne, male pattern balding.
2. Oligo/anovulation e.g.
3. Multiple cysts seen on US >12, 2-9mm, unilateral or bilateral OR volume >10cm3.
'String of pearls' sign.
155
5 types of thyroid cancer:
Please Feel My Amazing Lumps
Papillary
Follicular
Medullary
Anaplastic
(Lymphoma)
156
NICE malnutrition defintion:
BMI <18.5 OR
Unintentional weight loss >10% within last 3-6 months OR
BMI <20 with >5% weight loss in last 3-6 months
Nutrition support should be considered for anyone who falls into this category.
157
People who are at risk of malnutrition:
Eaten little / nothing in last 5 days and/or won't eat much in the next 5 days
OR
Poor absorptive capacity and/or high nutrient losses and/or increased nutritional needs from causes such as catabolism
158
Clinical presentation of refeeding syndrome:
1. Cardiac failure - cardiac muscle weakness due to hypophosphataemia
2. Respiratory failure - diaphragm muscle weakness
3. Neurological - impaired ATP metabolism in CNS leading to confusion, seizure and coma.
4. Haematological - impaired oxygen binding to rbcs, therefore tissue hypoxia. Also haemolysis.
5. Rhabdomyolysis - reduced ATP production, muscle cells waste.
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Pathophysiology of refeeding syndrome:
160
Important management points in managing malnourished patients at risk of refeeding syndrome:
Start slow, i.e. 50% of requirement and then work up.
Make sure fluid balance is okay and checked.
Give oral thiamine and b vitamins prior to and during refeeding, up to 10 days.
Give oral/enteral/IV electrolyte replacements e.g. phosphate, magnesium, potassium.
161
Criteria of people who are malnourished and are at risk of refeeding syndrome:
Any 1 of:
- BMI <16
- Lost >15% body mass in last 3-6 months
- Minimal or zero intake for 10 days prior
- Low potassium, magnesium, phosphate before feeding.
Any 2 of:
Definition criteria + alcohol or drug abuse inc. insulin, chemo, antacids or diuretics.
162
Drugs that impair wound healing:
NSAIDs
Steroids
Antineoplastics
immunosuppressive agents
163
Causes of NAGMA:
If you keep NAGging me I'll put you in a CAGE:
Chloride excess
Addison's / Acetazolamide
GI causes e.g. diarrhoea/vomiting/fistulae
Extra = RTA
164
Causes of HAGMA:
HAGs need Left Total Knee Replacements:
Lactate
Toxins e.g. salicylates, metformin
Ketones
Renal
165
Breakdown of MEN:
1 = parathyroid, pancreatic, pituitary
2a = medullary thyroid, phaeo, parathyroid
2b = medullary thyroid, phaeo, Marfanoid + mucosal neuroma
166
Features of papillary thyroid cancer:
RET/B-RAF oncogene
Empty nuclei, papillary projections on histology
Young women, 20-50, good prognosis
Lymph > haem spread
167
Features of follicular thyroid cancer:
Follicular adenoma = single solitary nodule. Can be hard to tell apart between papillary (capsulated?), but it gets into vascular system and spreads, causing bone mets due to infiltration direct from blood to bone marrow.
RAS oncogene (both adenoma and carcinoma)
168
Features of medullary thyroid cancer:
parafollicular c-cells, that also secrete calcitonin.
Ass/w MEN2a+b
169
Which type of thyroid cancer is rarely de novo and almost always has a history of thyroid neoplasm?
Anaplastic
170
Describe the timeline of subacute / De Quervain's thyroiditis:
Hyperthyroid 3-6 weeks, then euthyroid, then hypothyroid for weeks - months.
171
Drugs that can cause hypothyroidism:
carbimazole, PTU, amiodarone, lithium
172
What is Sheehan's syndrome?
secondary hypothyroidism cause by avascular necrosis of the pituitary gland following post-partum haemorrhage
173
Management of hypothyroidism:
Levothyroxine (synthetic t4)
Titrate based on TSH levels
174
Side effects of levothyroxine:
reduced bone mineral density
angina worsening
AF
175
Threshold for gestational diabetes diagnosis:
Fasting glucose = >/=5.6
2hr GTT = >/=7.8
176
Risk factors for gestational diabetes:
1. high BMI >30
2. previous gest diabetes
3. prev macrosomic baby
4. first degree relative with diabetes
5. black african / afro caribbean origin
177
When to consider a diagnosis and diagnostic guidelines for type 1 diabetes:
Classic symptoms:
Polydipsia, thirst, nocturia, polyuria, pruritis vulvae/balanitis, tiredness or lethargy, recurrent skin / urine infections.
T1 specific:
Recurrence of bedwetting in a previously dry child.
Failure to thrive in children
Unexplained weight loss
Random plasma glucose >11 = likely.
Medical emergency when first diagnosed, requiring immediate referral.
Diagnostic:
Fasting >=7
Random >=11 or after 75g OGTT
178
When to consider T2DM in a patient?
Classic symptoms:
Polydipsia, thirst, nocturia, polyuria, pruritis vulvae/balanitis, tiredness or lethargy, recurrent skin / urine infections.
T2 specific:
IHD / HTN / stroke history.
Obesity with a family history of diabetes, or arterial disease.
Evidence of foot disease
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Diagnostic criteria of T2DM:
Suspicion of T2DM - do a fasting glucose.
<6.1 = unlikely
6.1 -7.0 + sx = possible OR >7.0 + asymptomatic = possible
>7.0 + classic symptoms = diagnostic of T2DM.
If 'possible', do a HbA1c:
<41 = unlikely
41-47 = prediabetes
>48 = Dx of T2DM
180
When not to use HbA1c to diagnose diabetes:
1. Rapid onset e.g. T1, pancreatitis/surgery
2. Pregnancy
3. increased rbc lifespan e.g. splenectomy (HbA1c increased)
4. reduced rbc lifespan e.g. haemolytic anaemia, haemoglobinopathy e.g. sickle cell, splenomegaly, blood loss and antiretroviral drugs (hba1c decreased)
5. Haemodialysis - hba1c significantly reduced.
6. b12/iron deficiency, but minimal
In these situations, apart from pregnancy, use 2 measurement of >7mmol, or once with symptoms.
181
People have a diagnosis of metabolic syndrome when they have 3/5 of the following:
1. Large waist circumference
2. Low HDL levels
3. High LDL/triglycerides
4. Hyperglycaemia
5. High blood pressure
182
MALT lymphoma and associations:
MALT = b cell, non-hodgkins lymphoma.
Gastric MALT is most common.
Sjogren's syndrome + MALT of the salivary glands
Hashimoto's + MALT of the thyroid gland
183
What is the Amsterdam criteria and what is it used for?
Investigating HNPCC
1. at least 3 family members with colon cancer
2. cases span 2 generations
3. at least one case diagnosed before age 50
184
What are the risk factors for colorectal cancer (8)?
Age
Genetic (HNPCC, FAP)
Smoking
Alcohol
Sedentary lifestyle
High fat low fibre diet
Obesity
IBD esp UC
185
Red flags for colorectal cancer (6):
change in bowel habit
rectal bleeding
rectal or anal mass
unexplained weight loss
unexplained abdominal pain
anaemia
186
Genetic factors in colorectal cancer:
HNPCC - DNA MMR pathway, 80% will get cancer. MSH2, MLH1. Associated with endometrial cancer in women.
FAP - hundreds of polyps / adenomas that can turn cancerous. Start yearly screening from age 11. APC gene mutation.
Most people have a panproctocolectomy in their 20s + IPAA.
187
Types of resection in colorectal cancer and their indications (5):
Right hemicolectomy - lesion cecum to proximal transverse colon
Left hemicolectomy - lesion distal transverse colon to sigmoid
High anterior resection - sigmoid lesion
Anterior resection / low - rectum
Abdominoperianal resection - anal edge
188
Causes of bowel obstruction (7):
ADHESIONS
HERNIA
MALIGNANCY
+ strictures secondary to Crohn's
+ volvulus
+ diverticular disease
+ intussusception in kids
189
Complications of bowel obstruction (4):
hypovolaemic shock from third space losses
bowel ischaemia
bowel perforation
intrabdominal sepsis
190
Symptoms and management of bowel obstruction:
Green bilious vomiting
Distension
Diffuse abdo pain
Tinkling bowel sounds (early on)
Complete constipation and lack of flatulence
Drip and suck
- IVF
- NG with free drainage
- NBM
+ surgery if conservative management doesn't work
191
Indications for emergency surgery in bowel obstruction:
Evidence of perforation
Peritonitis
Closed-Loop obstruction
