medicine 2 Flashcards
commonest type of non-small cell lung cancer is
squamous
what type of cancer is small cell lung cancer
neurosecretory
signs and symptoms of lung cancer
Shortness of breath Cough Haemoptysis (coughing up blood) Finger clubbing Recurrent pneumonia Weight loss Lymphadenopathy – often supraclavicular nodes are the first to be found on examination
CXR findings of lung cancer include
Hilar enlargement
“Peripheral opacity” – a visible lesion in the lung field
Pleural effusion – usually unilateral in cancer
Collapse
Ix for lung cancer
CXR, CT contract enhanced, PET-CT, bronchoscopy with US and histological diagnosis
first line option for non-small cell lung cancer
surgery: lobectomy, segmentectomy and wedge resection
other options for lung cancer treatment
RT +Chemo
small cell lung cancer Tx
RT + chemo
palliative options for lung cancer
endobronchial debulking or stents
extra pulmonary manifestations of lung cancer
recurrent laryngeal palsy (hoarse voice), phrenic nerve palsy (SOB), SVC obstruction, horner’s syndrome
SVC obstruction presentation
facial swelling, difficulty breathing and distended veins in the neck and upper chest.
“Pemberton’s sign” is
SVC obstruction: raising the hands over the head causes facial congestion and cyanosis.
horner’s syndrome presentation
riad of partial ptosis, anhidrosis and miosis.
horner’s syndrome arises from obstruction too
sympathetic ganglion.
paraneoplastic presentations in small cell lung cancer
Syndrome of inappropriate ADH (SIADH)
Cushing’s syndrome
Limbic encephalitis.
Lambert-Eaton myasthenic syndrome.
Syndrome of inappropriate ADH (SIADH) presents with what biochemical abnormality
hyponatraemia
squamous cell carcinoma paraneoplastic syndrome
Hypercalcaemia
limbic encephalitis presentation
memory impairment, hallucinations, confusion and seizures.
limbic encephalitis is associated with
anti-Hu antibodies.
Lambert-Eaton Myasthenic Syndrome presents with
leads to weakness, particularly in the proximal muscles but can also affect intraocular muscles causing diplopia (double vision), levator muscles in the eyelid causing ptosis and pharyngeal muscles causing slurred speech and dysphagia
Lambert-Eaton Myasthenic Syndrome is the result of
antibodies produced by the immune system against small cell lung cancer cells. These antibodies also target and damage voltage-gated calcium channels sited on the presynaptic terminals in motor neurones
presentation of pneumonia
Shortness of breath
Cough productive of sputum
Fever
Haemoptysis (coughing up blood)
Pleuritic chest pain (sharp chest pain worse on inspiration)
Delirium (acute confusion associated with infection)
Sepsis
signs of pneumonia
Tachypnoea (raised respiratory rate) Tachycardia (raised heart rate) Hypoxia (low oxygen) Hypotension (shock) Fever Confusion
characteristic chest signs of pneumonia
bronchial breathing, focal course crackles and dullness to percussion
CURB 65 stands for
C – Confusion (new disorientation in person, place or time)
U – Urea > 7
R – Respiratory rate ≥ 30
B – Blood pressure < 90 systolic or ≤ 60 diastolic.
65 – Age ≥ 65
CURB score of what would indicate hospital admission
> 2
common causes of pneumonia include
Streptococcus pneumoniae (50%) Haemophilus influenzae (20%)
CF is associated with what other pneumonia bugs?
Pseudomonas aeruginosa
Staphylococcus aureus
Moraxella catarrhalis
atypical pneumonias are usually treated with
macrolides (e.g. clarithomycin), fluoroquinolones (e.g. levofloxacin) or tetracyclines (e.g. doxycycline).
legionella pneumophilia usually presents with what biochemical abnormality
hyponatraemia (low sodium)
mycoplasma pneumoniae presentation is with
erythema multiforme characterised by varying sized “target lesions” formed by pink rings with pale centres. It can also cause neurological symptoms
Chlamydophila pneumoniae. presentation
a school aged child with a mild to moderate chronic pneumonia and wheeze.
Coxiella burnetii AKA “Q fever”. presentation
exposure to animals and their bodily fluids. The MCQ patient is a farmer with a flu like illness.
Chlamydia psittaci. presentation
This is typically contracted from contact with infected birds.
Atypical pneumonias are
“Legions of psittaci MCQs”
M – mycoplasma pneumoniae
C – chlamydydophila pneumoniae
Qs – Q fever (coxiella burnetii)
what pneumonia commonly occurs in the immunocompromised
Pneumocystis jiroveci (PCP) pneumonia
presentation of pneumocystis jiroveci pneumonia is with
subtly with a dry cough without sputum, shortness of breath on exertion and night sweats.
Tx of pneumocystis jiroveci is
co-trimoxazole (trimethoprim/sulfamethoxazole)
patients with a low CD4 count receive what prophylaxis against PCP?
co-trimoxazole
in hospital the minimum Ix for pneumonia are
Chest xray
FBC (raised white cells)
U&Es (for urea)
CRP (raised in inflammation and infection)
in severe cases of pneumonia Ix
Sputum cultures
Blood cultures
Legionella and pneumococcal urinary antigens (send a urine sample for antigen testing)
mild pneumonia Tx
5 day course of oral antibiotics (amoxicillin or macrolide)
mod-severe pneumonia Tx
7-10 day course of dual antibiotics (amoxicillin and macrolide)
FEV1 refers too and reflects
forced expiratory volume in 1 second. if reduced then obstruction likely.
FVC refers too and reflects
forced vital capacity. if reduced then restriction likely.
obstructive lung disease diagnosis requires
FEV1 is less than 75% of FVC (FEV1:FVC ratio < 75%)
restrictive lung disease diagnosis requires
FEV1 and FVC are equally reduced and FEV1:FVC ratio > 75%
presentation of asthma
Episodic symptoms
Diurnal variability. Typically worse at night.
Dry cough with wheeze and shortness of breath
A history of other atopic conditions such as eczema, hayfever and food allergies
Family history
Bilateral widespread “polyphonic” wheeze
1st line Ix in asthma
Fractional exhaled nitric oxide
Spirometry with bronchodilator reversibility
further Ix in asthma includes
Peak flow variability measured by keeping a diary of peak flow measurements several times per day for 2 to 4 weeks
Direct bronchial challenge test with histamine or methacholine
ICS example
beclometasone
LABA example
salmeterol
LAMA example
tiotropium
LAMA mechanism
these block the acetylcholine receptors. Acetylecholine receptors are stimulated by the parasympathetic nervous system and cause contraction of the bronchial smooth muscles. Blocking these receptors leads to bronchodilation.
NICE guidelines for asthma Tx
- Add short-acting beta 2 agonist inhaler (e.g. salbutamol) as required for infrequent wheezy episodes.
- Add a regular low dose inhaled corticosteroid.
- Add an oral leukotriene receptor antagonist (i.e. montelukast).
- Add LABA inhaler (e.g. salmeterol). Continue the LABA only if the patient has a good response.
- Consider changing to a maintenance and reliever therapy (MART) regime.
- Increase the inhaled corticosteroid to a “moderate dose”.
- Consider increasing the inhaled corticosteroid dose to “high dose” or oral theophylline or an inhaled LAMA (e.g. tiotropium).
- Refer to a specialist.
additional managment for asthma includes
Each patient should have an individual asthma self-management programme
Yearly flu jab
Yearly asthma review
Advise exercise and avoid smoking
acute asthma presentation
Progressively worsening shortness of breath
Use of accessory muscles
Fast respiratory rate (tachypnoea)
Symmetrical expiratory wheeze on auscultation
The chest can sound “tight” on auscultation with reduced air entry
moderate acute asthma
PEFR 50 – 75% predicted
severe acute asthma
PEFR 33-50% predicted
Resp rate >25
Heart rate >110
Unable to complete sentences
life threatening asthma
PEFR <33% Sats <92% Becoming tired No wheeze. This occurs when the airways are so tight that there is no air entry at all. This is ominously described as a “silent chest”. Haemodynamic instability (i.e. shock)
moderate acute asthma Tx
Nebulised beta-2 agonists (i.e. salbutamol 5mg repeated as often as required)
Nebulised ipratropium bromide
Steroids. Oral prednisolone or IV hydrocortisone. These are continued for 5 days
Antibiotics if there is convincing evidence of bacterial infection
severe acute asthma Tx
Oxygen if required to maintain sats 94-98%
Aminophylline infusion
Consider IV salbutamol
life threatening asthma Tx
IV magnesium sulphate infusion
Admission to HDU / ICU
Intubation in worst cases – however this decision should be made early because it is very difficult to intubate with severe bronchoconstriction
ABG pattern in acute asthma
Initially patients will have a respiratory alkalosis as tachypnoea causes a drop in CO2. A normal pCO2 or hypoxia is a concerning sign as it means they are tiring and indicates life threatening asthma. A respiratory acidosis due to high CO2 is a very bad sign in asthma.
salbutamol has an effect on what ion?
serum potassium causing tachycardia
presentation of COPD
long term smoker presenting with chronic shortness of breath, cough, sputum production, wheeze and recurrent respiratory infections,
Dx of COPD
clinical presentation and spirometry (FEV1/FVC ratio <0.7)
Ix for COPD
CXR, BMI, sputum culture, ECG, ECHO, CT thorax, serum alpha 1-antitrypsin, transfer factor for carbon monoxide.
step 1 for long term managment
pneumococcal and annual flu vaccine, SABA or short acting anti muscarinic
Step 2 for long term management
LABA or LAMA, long term oxygen therapy
indications for LTOT in COPD
chronic hypoxia, polycythaemia, cyanosis or heart failure
ABG signs of acute exacerbation of COPD
Low pO2 indicates hypoxia and respiratory failure
Normal pCO2 with low pO2 indicates type 1 respiratory failure (only one is affected)
Raised pCO2 with low pO2 indicates type 2 respiratory failure (two are affected)
Ix in acute exacerbation of COPD
CXR, ECG, FBC, U+E’s, sputum culture and blood culture
what mask do you use to deliver specific percentages of oxygen
venturi masks
if retaining CO2 in COPD aims for sats of
88-92%
medical treatment of acute exacerbation of COPD in community
Prednisolone 30mg once daily for 7-14 days
Regular inhalers or home nebulisers
Antibiotics if there is evidence of infection
hospital Tx of acute exacerbation of COPD
Nebulised bronchodilators (e.g. salbutamol 5mg/4h and ipratropium 500mcg/6h)
Steroids (e.g. 200mg hydrocortisone or 30-40mg oral prednisolone)
Antibiotics if evidence of infection
Physiotherapy can help clear sputum
non invasive ventilation can be
BIPAP (bilevel positive airway pressure) or CPAP (continuous positive airway pressure)
BIPAP is typically used for
type 2 respiratory failure
CI to BIPAP is
untreated pneumothorax.
high resolution CT of interstitial lung disease will show what appearance
ground glass
idiopathic pulmonary fibrosis presentation
insidious onset of shortness of breath and dry cough over more than 3 months. It usually affects adults over 50 years old.
signs of idiopathic pulmonary fibrosis
bibasal fine inspiratory crackles and finger clubbing
Tx for idiopathic pulmonary fibrosis
Pirfenidone is an antifibrotic and anti-inflammatory
Nintedanib is a monoclonal antibody targeting tyrosine kinase
drug induced pulmonary fibrosis may be caused by
Amiodarone
Cyclophosphamide
Methotrexate
Nitrofurantoin
Hypersensitivity Pneumonitis is what type of hypersensitivity reaction
type III hypersensitivity reaction
hypersensitivity pneumonitis. bronchial lavage will reveal
raised lymphocytes and mast cells
Cryptogenic organising pneumonia aetiology
this can be idiopathic or triggered by infection, inflammatory disorders, medications, radiation or environmental toxins or allergens.
Cryptogenic organising pneumonia presentation
similar to infectious pneumonia with shortness of breath, cough, fever and lethargy. It also presents on similarly to pneumonia on a chest xray with a focal consolidation.
Cryptogenic organising pneumonia Tx
systemic steroids
exudative effusion is
a high protein count (>3g/dL)
transudative effusion is
protein count (<3g/dL).
exudative causes are related too
inflammation
exudative causes:
Lung cancer
Pneumonia
Rheumatoid arthritis
Tuberculosis
transudative causes are related too
fluid shifts
transudative causes:
Congestive cardiac failure
Hypoalbuminaemia
Hypothroidism
Meig’s syndrome
CXR signs of pleural effusion
Blunting of the costophrenic angle
Fluid in the lung fissures
Larger effusions will have a meniscus. This is a curving upwards where it meets the chest wall and mediastinum.
Tracheal and mediastinal deviation if it is a massive effusion
presentation of pleural effusion
Shortness of breath
Dullness to percussion over the effusion
Reduced breath sounds
Tracheal deviation away from the effusion if it is massive
Tx of pleural effusion
conservative, pleural aspiration or chest drain
pleural aspiration of empyema reveals
pus, acidic pH (pH < 7.2), low glucose and high LDH.
suspect empyema when
Suspect an empyema in a patient who has an improving pneumonia but new or ongoing fever.
pneumothorax If no SOB and there is a < 2cm rim of air on the chest xray then
no treatment required
pneumothorax If SOB and/or there is a > 2cm rim of air on the chest xray then
it will require aspiration and reassessment.
if aspiration of a pneumothorax fails twice, unstable patient or bilateral then
chest drain.
signs of a tension pneumothorax
Tracheal deviation away from side of pneumothorax
Reduced air entry to affected side.
Increased resonant to percussion on affected side.
Tachycardia.
Hypotension.
Mx of a tension pneumothorax
“Insert a large bore cannula into the second intercostal space in the midclavicular line.”
triangle of safety for a chest drain is
The 5th intercostal space (or the inferior nipple line)
The mid axillary line (or the lateral edge of the latissimus dorsi)
The anterior axillary line (or the lateral edge of the pectoris major)
the neurovascular bundle runs where in relation to the rib
just below
Risk factors for pulmonary embolism
Immobility Recent surgery Long haul flights Pregnancy Hormone therapy with oestrogen Malignancy Polycythaemia Systemic lupus erythematosus Thrombophilia
presentation of a pulmonary embolism is
Shortness of breath Cough with or without blood (haemoptysis) Pleuritic chest pain Hypoxia Tachycardia Raised respiratory rate Low grade fever Haemodynamic instability causing hypotension
high Wells score requires
a CT pulmonary angiogram
low wells score requires
perform a d-dimer and if positive perform a CTPA
alternative to a CTPA for PE Dx is
V/Q scan
PE ABG sign
respiratory alkalosis due to high RR
initial managment of PE is with
enoxaparin and dalteparin. -> LMWH
long term options for VTE are
warfarin, a NOAC or LMWH.
massive PE may require
thrombolysis
thrombolytic agents include
streptokinase, alteplase and tenecteplase.
pulmonary hypertension signs
SOB and Syncope Tachycardia Raised JVP Hepatomegaly Peripheral oedema.
ECG signs of pulmonary hypertension
Right ventricular hypertrophy seen as larger R waves on the right sided chest leads (V1-3) and S waves on the left sided chest leads (V4-6)
Right axis deviation
Right bundle branch block
CXR signs of pulmonary hypertension
Dilated pulmonary arteries
Right ventricular hypertrophy
other Ix for pulmonary hypertension
A raised NT-proBNF blood test result indicates right ventricular failure
Echo can be used to estimate pulmonary artery pressure
Tx for primary pulmonary hypertension is
IV prostanoids (e.g. epoprostenol) Endothelin receptor antagonists (e.g. macitentan) Phosphodiesterase-5 inhibitors (e.g. sildenafil)
20-40 year old black female presenting with a dry cough and shortness of breath. They may have nodules on their shins suggesting erythema nodosum. - what is the diagnosis?
sarcoidosis
sarcoidosis is an example of
granulomatous inflammatory condition
granulomas are
nodules of inflammation full of macrophages
lung symptoms of sarcoidosis
Mediastinal lymphadenopathy
Pulmonary fibrosis
Pulmonary nodules
systemic symptoms of sarcoidosis
Fever
Fatigue
Weight loss
liver symptoms of sarcoidosis
Liver nodules
Cirrhosis
Cholestasis
eye symptoms of sarcoidosis
Uveitis
Conjunctivitis
Optic neuritis
skin symptoms of sarcoidosis
Erythema nodosum (tender, red nodules on the shins caused by inflammation of the subcutaneous fat) Lupus pernio (raised, purple skin lesions commonly on cheeks and nose) Granulomas develop in scar tissue
Lofgren’s Syndrome, a special presentation of sarcoidosis is a triad of
Erythema nodosum
Bilateral hilar lymphadenopathy
Polyarthralgia (joint pain in multiple joints)
differentials for sarcoidosis are
Tuberculosis Lymphoma Hypersensitivity pneumonitis HIV Toxoplasmosis Histoplasmosis
blood tests for sarcoidosis will reveal
Raised serum ACE. This is often used as a screening test.
Hypercalcaemia (rasied calcium) is a key finding.
Raised serum soluble interleukin-2 receptor
Raised CRP
Raised immunoglobulins
CXR of sarcoidosis will reveal
hilar lymphadenopathy
CT of sarcoidosis will reveal
hilar lymphadenopathy and pulmonary nodules
MRI of sarcoidosis will reveal
CNS involvement
gold standard diagnosis for sarcoidosis is
histology of mediastinal lymph nodes
sarcoidosis histology will reveal
non-caseating granulomas with epithelioid cells.
tests for other organs in sarcoidosis include
U+E’s, urine dipstick, LFT, ophthalmology, ECG, ECHO, US
Tx for sarcoidosis is
no treatment, oral steroids , bisphosphonates
severe sarcoidosis may require
lung transplant from fibrosis or methotrexate and azathioprine.
features of obstructive sleep apnoea
Apnoea episodes during sleep (reported by partner) Snoring Morning headache Waking up unrefreshed from sleep Daytime sleepiness Concentration problems Reduced oxygen saturation during sleep
Tx for sleep apnoea
correct reversible factors, CPAP, and surgery
what is the stepwise progression of alcoholic liver disease?
alcohol related fatty liver->alcoholic hepatitis->cirrhosis
recommended daily alcohol intake
14 units per week
CAGE Q’s
C – CUT DOWN? Ever thought you should?
A – ANNOYED? Do you get annoyed at others commenting on your drinking?
G – GUILTY? Ever feel guilty about drinking?
E – EYE OPENER? Ever drink in the morning to help your hangover/nerves?
complications of alcohol
Alcoholic Liver Disease Cirrhosis and the complications of cirrhosis including hepatocellular carcinoma Alcohol Dependence and Withdrawal Wernicke-Korsakoff Syndrome (WKS) Pancreatitis Alcoholic Cardiomyopathy
signs of liver disease
Jaundice Hepatomegaly Spider Naevi Palmar Erythema Gynaecomastia Bruising – due to abnormal clotting Ascites Caput Medusae – engorged superficial epigastric veins Asterixis – “flapping tremor” in decompensated liver disease
bloods for liver disease
FBC raised MCV LFT - raised ALT and AST Raised GGT elevated bilirubin in cirrhosis clotting raised PT U+E's may be deranged in hepatorenal syndrome
Ix for liver disease
CT, MRI, US/fibroscan, endoscopy for varices, liver biopsy if considering steroid treatment
alcohol withdrawal natural history
6-12 hours: tremor, sweating, headache, craving and anxiety
12-24 hours: hallucinations
24-48 hours: seizures
24-72 hours: “delirium tremens”
alcohol stimulated what receptors and inhibits
stimulates GABA - relaxing
inhibits glutamate
alcohol withdrawal on the brain causes
under functioning GABA and over functioning glutamate = extremely excitable brain with access adrenergic function
presentation of delirium tremens
Acute confusion Severe agitation Delusions and hallucinations Tremor Tachycardia Hypertension Hyperthermia Ataxia (difficulties with coordinated movements) Arrhythmias
Tx for alcohol withdrawal
Chlordiazepoxide (“Librium”) is a benzodiazepine
and
IV high dose B vitamins (pabrinex)
Wernicke-Korsakoff Syndrome (WKS)Wernicke-Korsakoff Syndrome (WKS) is caused by
thiamine B1 deficiency
features of Wernicke’s encephalopathy
Confusion
Oculomotor disturbances (disturbances of eye movements)
Ataxia (difficulties with coordinated movements)
features of korsakoff’s syndrome
Memory impairment (retrograde and anterograde) Behavioural changes
four commonest causes of liver cirrhosis
Alcoholic liver disease
Non Alcoholic Fatty Liver Disease
Hepatitis B
Hepatitis C
signs of cirrhosis are
Jaundice – caused by raised bilirubin
Hepatomegaly – however the liver can shrink as it becomes more cirrhotic
Splenomegaly – due to portal hypertension
Spider Naevi – these are telangiectasia with a central arteriole and small vessels radiating away
Palmar Erythema – caused by hyperdynamic cirulation
Gynaecomastia and testicular atrophy in males due to endocrine dysfunction
Bruising – due to abnormal clotting
Ascites
Caput Medusae – distended paraumbilical veins due to portal hypertension
Asterixis – “flapping tremor” in decompensated liver disease
bloods for cirrhosis are
LFT albumin and PT hyponatraemia Urea and creatinine viral markers or autoantibodies alpha fetoprotein
first line ix for assessing fibrosis is
enhanced liver fibrosis blood test
US of a cirrhotic liver may show
Nodularity of the surface of the liver A “corkscrew” appearance to the arteries with increased flow as they compensate for reduced portal flow Enlarged portal vein with reduced flow Ascites Splenomegaly
severity of cirrhosis scoring is called
child-pugh
child pugh features that score one
bilirubin <34
albumin >35
INR <1.7
child pugh features that score two are
bilirubin 34-50 albumin 28-35 INR 17-23 Ascites mild encephalopathy mild
child pugh features that score three are
bilirubin >50 albumin <28 INR >2.3 ascites severe encephalopathy severe
what score system is used for compensated cirrhosis
MELD every 6 months
complications of cirrhosis include
Malnutrition
Portal Hypertension, Varices and Variceal Bleeding
Ascites and Spontaneous Bacterial Peritonitis (SBP)
Hepato-renal Syndrome
Hepatic Encephalopathy
Hepatocellular Carcinoma
Mx of cirrhosis is
Regular meals (every 2-3 hours) Low sodium (to minimise fluid retention) High protein and high calorie (particularly if underweight) Avoid alcohol
varices occur at
Gastro oesophageal junction
Ileocaecal junction
Rectum
Anterior abdominal wall via the umbilical vein (caput medusae)
Tx of stable varices include
Gastro oesophageal junction
Ileocaecal junction
Rectum
Anterior abdominal wall via the umbilical vein (caput medusae)
Resus for a bleeding oesophageal varices includes
Vasopressin analogues (i.e. terlipressin)
vit K + FFP
prophylactic broad spectrum antibiotics
ITU
urgent endoscopy with sclerosant injection or band ligation
Sengstaken-blakemore tube
Ascites effect on the RAAS system
The kidneys sense this lower pressure and release renin, which leads to increased aldosterone secretion (via the renin-angiotensin-aldosterone system) and reabsorption of fluid and sodium in the kidneys. Cirrhosis causes a transudative, meaning low protein content, ascites.
Mx of ascites includes
Low sodium diet
Anti-aldosterone diuretics (spironolactone)
Paracentesis (ascitic tap or ascitic drain)
Prophylactic antibiotics against spontaneous bacterial peritonitis (ciprofloxacin or norfloxacin) in patients with less than 15g/litre of protein in the ascitic fluid
Consider TIPS procedure in refractory ascites
Consider transplantation in refractory ascites
presentation of spontaneous bacterial peritonitis
Can be asymptomatic so have a low threshold for ascitic fluid culture
Fever
Abdominal pain
Deranged bloods (raised WBC, CRP, creatinine or metabolic acidosis)
Ileus
Hypotension
common causes of spontaneous bacterial peritonitis
Escherichia coli
Klebsiella pnuemoniae
Gram positive cocci (such as staphylococcus and enterococcus)
management of spontaneous bacterial peritonitis includes
Take an ascitic culture prior to giving antibiotics
Usually treated with an IV cephalosporin such as cefotaxime
Hepatorenal Syndrome refers too
hypotension in the kidney and activation of the renin-angiotensin system. This causes renal vasoconstriction, which combined with low circulation volume leads to starvation of blood to the kidney. fatal within a week.
Tx for hepatorenal syndrome
liver transplant
Hepatic Encephalopathy is caused by what toxin
ammonia
why does ammonia increase in cirrhosis
Firstly, the functional impairment of the liver cells prevents them metabolising the ammonia into harmless waste products. Secondly, collateral vessels between the portal and systemic circulation mean that the ammonia bypasses liver altogether and enters the systemic system directly.
Tx for hepatic encephalopathy
laxatives (lactulose) and antibiotics rifaximin, nutritional support
precipitating factors for hepatic encephalopathy
Constipation Electrolyte disturbance Infection GI bleed High protein diet Medications (particularly sedative medications)
RF for NAFLD
Obesity Poor diet and low activity levels Type 2 diabetes High cholesterol Middle age onwards Smoking High blood pressure
non-invasive liver screen includes
Ultrasound Liver
Hepatitis B and C serology
Autoantibodies (autoimmune hepatitis, primary biliary cirrhosis and primary sclerosing cholangitis)
Immunoglobulins (autoimmune hepatitis and primary biliary cirrhosis)
Caeruloplasmin (Wilsons disease)
Alpha 1 Anti-trypsin levels (alpha 1 anti-trypsin deficiency)
Ferritin and Transferrin Saturation (hereditary haemochromatosis)
Tx for liver fibrosis may include
vitamin E or pioglitazone.
hepatitis symptoms
Abdominal pain Fatigue Pruritis (itching) Muscle and joint aches Nausea and vomiting Jaundice Fever (viral hepatitis)
biochemical findings of hepatitis is
massively raised transaminases (ASt/ALT) proportionally less in ALP
hepatitis A type of virus and route
RNA: faecal-oral route
hepatitis B type of virus and route
DNA - blood.
natural history of hepatitis A
t presents with nausea, vomiting, anorexia and jaundice. It can cause cholestasis (slowing of bile flow through the biliary system) with dark urine and pale stools and moderate hepatomegaly. It resolves without treatment in around 1-3 months.
Mx of hepatitis A is
notify public health, analgesia and a vaccine is available
hepatitis B natural history
Most people fully recover from the infection within 2 months, however 10% go on to become chronic hepatitis B carriers. Due to DNA intergration
active infection marker for hep B
Surface antigen (HBsAg)
marker of viral replication and implies high infectivity for hepatitis B
E antigen (HBeAg)
implies past or current infection for hepatitis B
Core antibodies (HBcAb)
implies vaccination or past or current infection for hepatitis B
Surface antibody (HBsAb)
this is a direct count of the viral load for hepatitis B
Hepatitis B virus DNA (HBV DNA
hepatitis B screen consists of
HBcAb (for previous infection) and HBsAg (for active infection).
hepatitis C is what type of virus and route
RNA and blood
disease course in hepatitis C
1 in 4 fights off the virus and makes a full recovery
3 in 4 it becomes chronic
Complications: liver cirrhosis and associated complications and hepatocellular carcinoma
hepatitis D is what sort of virus
RNA but requires infection with hepatitis B
hepatitis E is what sort of virus and route?
RNA faecal oral route.
type 1 autoimmune hepatitis presents in
adults
type 1 autoimmune hepatitis antibodies
Anti-nuclear antibodies (ANA)
Anti-smooth muscle antibodies (anti-actin)
Anti-soluble liver antigen (anti-SLA/LP)
type 2 autoimmune hepatitis presents in
kids
Tx for autoimmune hepatitis is with
high dose steroids and immunosuppressants such as azathioprine.
Haemochromatosis pathology
iron storage disorder that results in excessive total body iron and deposition of iron in tissues.
gene responsible for haemochromatosis
human haemochromatosis protein (HFE) gene is located on chromosome 6
haemochromatosis genetic transmission is
autosomal recessive
symptoms of haemochromatosis
Chronic tiredness
Joint pain
Pigmentation (bronze / slate-grey discolouration)
Hair loss
Erectile dysfunction
Amenorrhoea
Cognitive symptoms (memory and mood disturbance)
main diagnostic method for haemochromatosis is
serum ferritin level
how to differentiate a high serum ferritin from iron overload and inflammation
transferrin saturation
liver biopsy with what stain for haemochromatosis
Perl’s stain
liver biopsy with Perl’s stain reveals
iron concentration in the parenchymal cells
Ix for hemochromatosis
CT or MRI
complications of haemochromatosis
cardiomyopathy, hepatocellular carcinoma, hypothyroidism, chrondocalcinosis/pseudogout
Mx of haemochromatosis is with
venesection, avoid alcohol and genetic counselling
Wilson’s disease is caused by excessive
copper
wilson’s disease is caused by a mutation in chromosome
13
the wilson’s disease protein is called
“ATP7B copper-binding protein”
Wilson’s disease inheritance is
autosomal recessive
features of wilson’s disease are
Hepatic problems (40%) Neurological problems (50%) Psychiatric problems (10%)
neuro symptoms of wilson’s disease include
dysarthria (speech difficulties) and dystonia (abnormal muscle tone). Copper deposition in the basal ganglia leads to Parkinsonism (tremor, bradykinesia and rigidity). Motor symptoms are often asymmetrical in Wilson disease.
slit lamp examination of wilson’s disease will reveal
Kayser-Fleischer rings in cornea
other possible features of wilson’s disease are
Haemolytic anaemia
Renal tubular damage leading to renal tubular acidosis
Osteopenia (loss of bone mineral density)
first line Ix wilson’s disease is through
serum caeruloplasmin. A low serum caeruloplasmin is suggestive of Wilson disease
gold standard diagnosis for wilsons disease is
liver biopsy
other diagnosis for wilson’s disease includes
24-hour urine copper assay
Wilson’s disease Mx is with
Penicillamine
Trientene
elastase is secreted by what cell?
neutrophils
Alpha-1-antitrypsin (A1AT) role is to
inhibit the neutrophil elastase
Alpha-1-antitrypsin (A1AT) exists on chromosome
14
inheritance of Alpha-1-antitrypsin (A1AT) deficiency is by
autosomal recessive
organs effected byAlpha-1-antitrypsin (A1AT) deficiency
Liver and lungs
Dx of Alpha-1-antitrypsin (A1AT) deficiency
serum alpha 1 antitrypsin, liver biopsy and acid-Schiff-positive staining globules, genetic testing, high resolution CT
Alpha-1-antitrypsin (A1AT) deficiency liver Mx
stop smoking, organ transplant
Primary biliary cirrhosis is a condition where the immune system attacks
small bile ducts within the liver. The first parts to be affected are the intralobar ducts, also known as the Canals of Hering. This causes obstruction.
what is usually excreted via the bile ducts
Bile acids, bilirubin and cholesterol
presentation of PBC
Fatigue Pruritus GI disturbance and abdominal pain Jaundice Pale stools Xanthoma and xanthelasma Signs of cirrhosis and failure (e.g. ascites, splenomegaly, spider naevi)
associations with PBC are
Middle aged women Other autoimmune diseases (e.g. thyroid, coeliac) Rheumatoid conditions (e.g. systemic sclerosis, Sjogrens and rheumatoid arthritis)
diagnosis of PBC is with
raised alk P, raised IGM and ESR and Anti-mitochondrial antibodies is the most specific to PBC and forms part of the diagnostic criteria
Anti-nuclear antibodies are present in about 35% of patients and liver biopsy
Tx of PBC is with
ursodeoxycholic acid and colestyramine, liver transplant
Primary sclerosing cholangitis is a condition where the
ntrahepatic or extrahepatic ducts become strictured and fibrotic. This causes an obstruction to the flow of bile out of the liver and into the intestines.
risk factors or PSC
Male
Aged 30-40
Ulcerative Colitis
Family History
presentation of PSC is
Jaundice Chronic right upper quadrant pain Pruritus Fatigue Hepatomegaly
LFT cholestatic picture is
deranged ALK P, potentially a rise in bilirubin. later deranged transaminases
gold standard for PSC is
magnetic resonance cholangiopancreatography.
Tx for PSC is
ERCP, ursodeoxycholic acid, and cholestyramine
commonest primary liver cancer is
hepatocellular carcinoma
other type of liver cancer is
cholangiocarcinoma
Risk factors for hepatocellular carcinoma is
Viral hepatitis (B and C)
Alcohol
Non alcoholic fatty liver disease
Other chronic liver disease
cholangiocarcinoma is associated with
primary sclerosing cholangitis
presentation of liver cancer is with
Weight loss Abdominal pain Anorexia Nausea and vomiting Jaundice Pruritus
cholangiocarcinoma presentation is with
Cholangiocarcinoma often presents with painless jaundice in a similar way to pancreatic cancer.
Ix for liver cancer is with
AFP, CA19-9 for cholangiocarcinoma, US, CT, MRI and ERCP
Tx for hepatocellular carcinoma
kinase inhibitors such as sorafenib, regorafenib and lenvatinib or liver transplant
Tx for cholangiocarcinoma is
early resection of palliation with ERCP
Haemangiomas are
common benign tumours of the liver
Focal nodular hyperplasia is associated with
COCP
orthotopic transplant refers too
dead patient transplant
types of transplant
orthotopic, split donation or living donor
surgery incision for transplant liver is
rooftop or mercedes benz
presentation for GORD is
Heartburn Acid regurgitation Retrosternal or epigastric pain Bloating Nocturnal cough Hoarse voice
red flags for GORD are
Dysphagia (difficulty swallowing) at any age gets a two week wait referral Aged over 55 (this is generally the cut off for urgent versus routine referrals) Weight loss Upper abdominal pain / reflux Treatment resistant dyspepsia Nausea and vomiting Low haemoglobin Raised platelet count
PPI examples are
Omeprazole
Lansoprazole
H2 receptor antagonist example is
ranitidine
surgery for GORD is
laparoscopic fundoplication
H.pylori is hat sort of bacteria?
gram negative aerobic bacteria
H.pylori produces what to neutralise stomach acid?
It also produces ammonia to neutralise the stomach acid. this damages the epithelial cells
tests for H. pylori
Urea breath test using radiolabelled carbon 13
Stool antigen test
Rapid urease test can be performed during endoscopy.
triple therapy consists of
proton pump inhibitor (e.g. omeprazole) plus 2 antibiotics (e.g. amoxicillin and clarithromycin) for 7 days.
barrett’s oesophagus is an example of
metaplasia
barett’s eosophagus may become
adenocarcinoma
Tx for barret’s is
PPI, or endoscopy with photodynamic therapy, laser therapy or cyrotherapy.
what type of GI ulcer is more common?
duodenal
presentation of an ulcer is through
Epigastric discomfort or pain
Nausea and vomiting
Dyspepsia
Bleeding causing haematemesis, “coffee ground” vomiting and melaena
Iron deficiency anaemia (due to constant bleeding)
eating effect on ulcers
worsens the pain of gastric ulcers and improves the pain of duodenal ulcers.
presentation of oesophageal bleed is
Haematemesis (vomiting blood)
“Coffee ground” vomit. This is caused by vomiting digested blood that looks like coffee grounds.
Melaena, which is tar like, black, greasy and offensive stools caused by digested blood
Haemodynamic instability
suspected upper GI bleed scoring is with
glasgow-blatchford score
glasgow blatchford score areas
Drop in Hb Rise in urea Blood pressure Heart rate Melaena Syncopy
why does urea rise in an upper GI bleed
lood in the GI tract gets broken down by the acid and digestive enzymes. One of the breakdown products is urea and this urea is then absorbed in the intestines.
what is the score system used for risk of recurrent rebleed in an upper GI bleed
Rockall score
management for an upper GI bleed
A – ABCDE approach to immediate resuscitation
B – Bloods
A – Access (ideally 2 large bore cannula)
T – Transfuse
E – Endoscopy (arrange urgent endoscopy within 24 hours)
D – Drugs (stop anticoagulants and NSAIDs)
bloods in an upper GI should be
Haemoglobin (FBC) Urea (U&Es) Coagulation (INR, FBC for platelets) Liver disease (LFTs) Crossmatch 2 units of blood
group and save is for
s where the lab simply checks the patients blood group and keeps a sample of their blood saved incase they need to match blood to it.
crossmatch is for
is where the lab actually finds blood, tests that it is compatible and keeps it ready in the fridge to be used if necessary.
Crohn’s Crows nest
N – No blood or mucus (less common)
E – Entire GI tract
S – “Skip lesions” on endoscopy
T – Terminal ileum most affected and Transmural (full thickness) inflammation
S – Smoking is a risk factor (don’t set the nest on fire)
UC Closeup
C – Continuous inflammation
L – Limited to colon and rectum
O – Only superficial mucosa affected
S – Smoking is protective
E – Excrete blood and mucus
U – Use aminosalicylates
P – Primary Sclerosing CholangitisC – Continuous inflammation
L – Limited to colon and rectum
O – Only superficial mucosa affected
S – Smoking is protective
E – Excrete blood and mucus
U – Use aminosalicylates
P – Primary Sclerosing Cholangitis
presentation of IBD
Diarrhoea
Abdominal pain
Passing blood
Weight loss
testing for IBD is with
routine bloods, thyroid, U+E’s, LFTm faecal calprotectin, endoscopy with biopsy, imaging for complications
Crohn’s first line
steroids
crohn’s second line
Azathioprine Mercaptopurine Methotrexate Infliximab Adalimumab
Crohn’s maintaining remission
Azathioprine
Mercaptopurine
surgery for crohn’s involves
distal ileum, strictures and fistulas
inducing remission for UC is with
First line: aminosalicylate (e.g. mesalazine oral or rectal)
maintaining remission with UC is
Aminosalicylate (e.g. mesalazine oral or rectal)
Azathioprine
Mercaptopurine
surgery for UC is with
(panproctocolectomy) leaving either a ileo-anal anastomosis or j pouch.
coeliac disease auto antibodies are
anti-tissue transglutaminase (anti-TTG) and anti-endomysial (anti-EMA).
coeliac disease particularly effects
the jejunum
presentation of coeliac is with
Failure to thrive in young children
Diarrhoea
Fatigue
Weight loss
Mouth ulcers
Anaemia secondary to iron, B12 or folate deficiency
Dermatitis herpetiformis (an itchy blistering skin rash typically on the abdomen)
genetic associations with coeliac disease is
HLA-DQ2 gene (90%)
biopsy in coeliac disease will show
Crypt hypertrophy”
“Villous atrophy”
first line for diarrhoea is
Loperamide for diarrhoea
Gram positive bacteria features
have a thick peptidoglycan cell wall that stains with crystal violet stain.
bacterial folic acid pathway
PABA is then converted to DHFA which is converted inside the cell to THFA then folic acid.
gram negative bacteria stain
counterstain (such as safranin) which binds to the cell membrane in bacteria that don’t have a cell wall (gram negative bacteria) turning them red/pink.
gram positive cocci
Staphylococcus
Streptococcus
Enterococcus
gram positive rods
Corney – Corneybacteria Mike’s – Mycobacteria List of – Listeria Basic – Bacillus Cars – Nocardia
gram positive anaerobes
C – Clostridium
L – Lactobacillus
A – Actinomyces
P – Propionibacterium
gram negative bacteria
Neisseria meningitis Neisseria gonorrhoea Haemophilia influenza E. coli Klebsiella Pseudomonas aeruginosa Moraxella catarrhalis
atypical bacteria
Legions – Legionella pneumophila Psittaci – Chlamydia psittaci M – Mycoplasma pneumoniae C – Chlamydydophila pneumoniae Qs – Q fever (coxiella burneti)
antibiotics options for MRSA
Doxycycline Clindamycin Vancomycin Teicoplanin Linezolid
ESBLs are resistant too
beta lactam antibiotics
ESBLs tend to be
e.coli or klebsiella
ESBLs are sensitive too
carbapenems such as meropenem or imipenem.
antibiotics that inhibit cell wall synthesis with a beta lactam ring
Penicillin
Carbapenems such as meropenem
Cephalosporins
antibiotics without a beta lactam ring but inhibit cell wall synthesis
Vancomycin
Teicoplanin
antibiotics that inhibit folic acid metabolism
Sulfamethoxazole blocks the conversion of PABA to DHFA
Trimethoprim blocks the conversion of DHFA to THFA
Co-trimoxazole is a combination of sulfamethoxazole and trimethoprim
metronidazole mechanism
reduction of metronidazole into its active form only occurs in anaerobic cells. When partially reduced metronidazole inhibits nucleic acid synthesis.
antibiotics inhibit protein synthesis by targeting ribosomes
Macrolides such as erythromycin, clarithromycin and azithromycin Clindamycin Tetracyclines such as doxycycline Gentamicin Chloramphenicol
streptococcus, listeria and enterococcus consider which antibiotic?
amoxicillin
staphylococcus, haemophilus and e. coli consider which antibiotic
co-amoxiclav
septic shock is defined as
Systolic blood pressure less than 90 despite fluid resuscitation
Hyperlactaemia (lactate > 4 mmol/L)
risk factors for sepsis
Very young or old patients (under 1 or over 75 years)
Chronic conditions such as COPD and diabetes
Chemotherapy, immunosuppressants or steroids
Surgery or recent trauma or burns
Pregnancy or peripartum
Indwelling medical devices such as catheters or central lines
neutropenic sepsis is defined as
1 x 10*9/L.
neutropenic sepsis treatment is with
tazocin
common cause of chest infection is
streptococcus pneumoniae
atypical bacterial chest infection Tx
Macrolides such as clarithromycin
Quinolones such as levofloxacin
Tetracyclines such as doxycycline
lower UTI presents with
Dysuria (pain, stinging or burning when passing urine)
Suprapubic pain or discomfort
Frequency
Urgency
Incontinence
Confusion is commonly the only symptom in older more frail patients
pyelonephritis presents with
Fever is a more prominent feature than lower urinary tract infections.
Loin, suprapubic or back pain. This may be bilateral or unilateral.
Looking and feeling generally unwell
Vomiting
Loss of appetite
Haematuria
Renal angle tenderness on examination
duration of simple lower UTI for women Tx
3 days
what is the classification system for cellulitis
Eron classification
what antibiotics is very effective against gram positive cocci?
flucloxacillin
bacterial tonsillitis is commonly caused by
Group A Streptococcus (GAS) infections, mainly streptococcus pyogenes.
the Centor criteria for tonsillitis is
Fever > 38ºC
Tonsillar exudates
Absence of cough
Tender anterior cervical lymph nodes (lymphadenopathy)
common causes of intraabdominal infections
Anaerobes (e.g. bacteroides and clostridium) E. coli Klebsiella Enterococcus Streptococcus
co-amoxiclav cover
good gram positive, gram negative and anaerobic cover.
quinolones cover
Ciprofloxacin and levofloxacin provide reasonable gram positive and gram negative cover and also cover atypical bacteria however they don’t cover anaerobes
gentamicin coverage
This provides very good gram negative cover with some gram positive cover particularly against staphylococcus.
vancomycin coverage
This provides very good gram positive cover including MRSA.
common regimes for intra-abdominal antibiotics
Co-amoxiclav alone
Amoxicillin plus gentamicin plus metronidazole
spontaneous bacterial peritonitis treatment first line
tazocin
septic arthritis presentation
Hot, red, swollen and painful joint
Stiffness and reduced range of motion
Systemic symptoms such as fever, lethargy and sepsis
commonest cause of septic arthritis is
Staphylococcus aureus
In a young patient presenting with a single acutely swollen joint always think of
gonococcus septic arthritis
differentials for septic arthritis
gout, pseudogout, reactive arthritis, haemarthrosis
first line antibiotics for septic arthritis
Flucloxacillin plus rifampicin is often first line
who are offered the Flu vaccine?
Aged 65 Young children Pregnant women Chronic health conditions such as asthma, COPD, heart failure and diabetes Healthcare workers and carers
presentation of the flu
Fever Coryzal symptoms Lethargy and fatigue Anorexia (loss of appetite) Muscle and joint aches Headache Dry cough Sore throat
Dx of flu
Viral nasal or throat swabs with PCR and send data to public health
two treatments for influenza
Oral oseltamivir 75mg twice daily for 5 days
Inhaled zanamivir 10mg twice daily for 5 days
campylobacter jejuni incubation period
2-5 days
antibiotics choices for campylobacter jejuni and shigella treatment
azithromycin or ciprofloxacin
patient develops symptoms soon after eating leftover fried rice that has been left at room temperature. It has a short incubation period after eating the rice and they then recover within 24 hours. What is the likely cause?
bacillus cereus
frequently affects children causing watery or bloody diarrhoea, abdominal pain, fever and lymphadenopathy after eating undercooked pork what is the likely cause?
Yersinia enterocolitica
example of antidiarrheal medication
loperamide
example of antiemetic medication
metoclopramide
post gastroenteritis complications
Lactose intolerance
Irritable bowel syndrome
Reactive arthritis
Guillain–Barré syndrome
Neisseria meningitidis is what type of bacteria?
gram negative diploccous
meningococcal septicaemia is the cause of what classic sign?
non-blanching rash
common causes of bacterial meningitis are
Neisseria meningitidis (meningococcus) and Streptococcus pneumoniae (pneumococcus).
what are the two special tests for meningitis
Kernig’s (hip flexed leg straighten) and Brudzinski’s test (chin flex to chest)
benzylpenicillin doses for community suspected meningitis
< 1 year – 300mg
1-9 years – 600mg
> 10 years and adults – 1200mg
what is the prophylactic treatment for meningitis complication
dexamethasone
post exposure prophylaxis for meningitis is guided by
public health
Post exposure prophylaxis for meningitis is with
ciprofloxacin
viral CSF infection
clear, mildly raised protein, glucose normal, lymphocytes
bacterial CSF
cloudy, increased protein, low glucose, neutrophils
what type of bacteria is mycobacterium tuberculosis
small rod shaped bacillus
what stain is required for the acid fastness tuberculosis bacteria
Zeihl-Neelsen stain. This turns TB bacteria bright red against a blue background.
TB infection and spread via
droplets and then via lymphatics and bloods
BCG vaccine
intradermal live attenuated
prior to BCG vaccine they are tested with
mantoux test - tuberculin protein.
presentation of TB
Lethargy Fever or night sweats Weight loss Cough with or without haemoptysis Lymphadenopathy Erythema nodosum Spinal pain in spinal TB (also known as Pott’s disease of the spine)
what are the two tests for immune response to TB
mantoux and interferon gamma release assay
what is the interferon gamma release assays used for in Tb?
diagnosis of latent TB
CXR presentation of primary TB
patchy consolidation, pleural effusions and hilar lymphadenopathy
CXR of reactivated TB
patchy or nodular consolidation with cavitation (gas filled spaces in the lungs) typically in the upper zones
CXR of disseminated miliary TB
millet seeds” uniformly distributed throughout the lung fields
cultures for Tb
sputum (3*), mycobacterium blood cultures and lymph node aspiration
latent Tb Tx
Isoniazid and rifampicin for 3 months
Isoniazid for 6 months
RIPE treatment for acute pulmonary TB
R – Rifampicin for 6 months
I – Isoniazid for 6 months
P – Pyrazinamide for 2 months
E – Ethambutol for 2 months
“they are started on R, I, P and E for TB, what should also be prescribed?”
pyridoxine.
why is pyridoxine prescribed for the Tb regime
isoniazid causes peripheral neuropathy and pyridoxine (vitamin B6) is usually co-prescribed prophylactically to help prevent this.
patients with active TB should be kept in what rooms in the hospital?
negative pressure
Side effects of rifampicin
can cause red/orange discolouration of secretions like urine and tears.
side effects of isoniazid
cause peripheral neuropathy. Pyridoxine (vitamin B6) is usually co-prescribed prophylactically
Side effects of pyrazinamide
hyperuricaemia (high uric acid levels) resulting in gout.
side effects of ethambutol
colour blindness and reduced visual acuity.
what is the specific antigen to test in the blood for HIV
p24 antigen
end stage HIV/AIDS is defined as
Under 200 cells/mm3
HIV and breast feeding
Breastfeeding is only considered where the viral load is undetectable however there may still be a risk of contracting HIV through breastfeeding.
malaria is an infectious disease caused by
the Plasmodium family of protozoan parasites.
most severe malaria is the
plasmodium falciparum
malaria is spread via
female anopheles mosquitoes
freshly injected sporozoites travel to which organ?
the liver
the sporozoites in the liver mature into
merozoites and then infect red blood cells
presentation of malaria
Fever, sweats and rigors Malaise Myalgia Headache Vomiting
signs of malaria
Pallor due to the anaemia
Hepatosplenomegaly
Jaundice as bilirubin is released during the rupture of red blood cells
Dx of malaria
blood film in an EDTA bottle . three samples over three days.
Treatments for malaria
Artesunate. This is the most effective treatment but is not licensed.
Quinine dihydrochloride
complications of falciparum
Cerebral malaria Seizures Reduced consciousness Acute kidney injury Pulmonary oedema Disseminated intravascular coagulopathy (DIC) Severe haemolytic anaemia Multi-organ failure and death
antimalarial options
proguanil and atovauone (malarone), mefloquine and doxycycline
