Medicine 5 Flashcards
What are the main risks of radioiodine treatment for hyperthyroidism?
May worsen thyroid eye disease
Patients become hypothyroid
What are the main risks of thyroidectomy?
Haematoma
Recurrent laryngeal nerve palsy
Hypothyroidism
Hypoparathyroidism
List some causes of macroglossia.
Acromegaly
Amyloidosis
Hypothyroidism
Down syndrome
List some causes of acanthosis nigricans.
Obesity and metabolic syndrome Diabetes mellitus Cushing syndrome Acromegaly Gastric cancer Pancreatic cancer
Which conditions are associated with acromegaly?
Carpal tunnel syndrome
Diabetes mellitus
Sleep apnoea
Cardiovascular disease
List some complications of Cushing syndrome.
Osteoporosis Hypertension Cardiovascular risk Diabetes mellitus Immunosuppression
List some side-effects of steroid use.
MSK: proximal myopathy, osteoporosis
ENDO: HPA suppression, obesity, diabetes
METABOLIC: hypokalaemia, hypertension, fluid retention
IMMUNE: increased susceptibility to infection
CNS: depression, psychosis
EYE: cataracts, glaucoma
What is hemiballismus and what causes it?
Involuntary flinging movements of the extremities, usually isolated to one side of the body
Caused by damage to subthalamic nucleus (e.g. infarct, MS)
What are the exacerbating and relieving factors for benign essential tremor?
Exacerbating: anxiety, caffeine
Relieving: alcohol, sleep
NOTE: it is autosomal dominant
Which investigations may be useful in acute rheumatic fever?
Raised ASO titre
Positive throat cultures for group A streptococcus
What CXR features may be seen in long-standing untreated mitral stenosis?
Left atrial enlargement Pulmonary haemosiderosis (iron deposition in the lungs due to haemolysis)
List some signs of aortic regurgitation.
Collapsing pulse (DDx: pregnancy, PDA, hyperthyroid) Wide pulse pressure Corrigan's sign (visible neck pulses) De Musset sign (head bobbing) Quincke's sign (nail bed pulsation) Dynamic apex Early diastolic murmur at left sternal edge Systolic flow murmur
What is R wave progression on ECG?
The R waves get bigger from V1 to V6 which is a feature of a normal ECG
Patients with a history of ischaemic heart disease will NOT have R wave progression
What are some differentials for bundle branch block?
Ventricular ectopic
Ventricular tachycardia
NOTE: You cannot interpret ST elevation in patients with BBB
What are the main complications of right coronary artery and left coronary artery infarcts?
RIGHT: Heart block - RCA supplies the SA node and AV node
LEFT: Heart failure - most important in maintaining blood pressure
Describe the rhythm seen in the three types of heart block.
1st Degree: regular rhythm, fixed prolonged PR interval
2nd Degree type 1: irregular, gradually increasing PR interval
2nd Degree type 2: irregular, fixed PR interval, missed beats
3rd Degree: regular bradycardia
List some complications of MI.
Arrhythmia (VF and death) Cardiac failure Embolism Aneurysm rupture Pericarditis (early in full thickness MI or Dressler syndrome)
What ECG feature would be seen in a patient with a ventricular aneurysm?
Persistent ST segment elevation in the left sided leads
List some ECG changes seen in PE.
May be normal
Sinus tachycardia
Right ventricular strain
S1Q3T3
List some signs of heart failure.
S3 heart sound (may be the first sign) Tachycardia Tachypnoea Wheeze (cardiac asthma) Bilateral crepitations Raised JVP Ankle/sacral oedema
What is the mainstay of treatment in cardiogenic shock?
Dobutamine or dopamine in ITU (this has a stimulant effect on the heart through beta-1 agonism)
What are the key differences between dilation and hypertrophy with regards to the position of the apex beat?
Dilation causes displacement (CXR diagnosis)
Hypertrophy does not cause displacement (ECG diagnosis)
List some causes of cardiac dilation and hypertrophy.
Dilation: ischaemia, heart failure, AR, MR, VSD/ASD
Hypertrophy: pressure overload (AS, hypertension, coarctation)
How is cardiac hypertrophy diagnosed by ECG?
Deep S waves and tall R waves in V5/6
List the main ECG changes seen in MI.
ST elevation within the first 4-12 hours (reversible)
Q waves after about 6 hours (irreversible)
T wave inversion as ST segments normalise
Non-Q wave infarct (NSTEMI) = subendocardial infarct
What is the first line investigation for stable angina?
Exercise ECG
Which treatment is often used in ICU for septic shock?
Noradrenaline (alpha and beta-1 stimulant) that causes peripheral vasoconstriction
List some respiratory causes of clubbing.
Bronchial carcinoma Cystic fibrosis Bronchiectasis Empyema Fibrosing alveolitis
List some signs of carbon dioxide retention.
Retention flap Bounding pulse Vasodilation (warm hands) Papilloedema Mental change Drowsiness (narcosis)
List some clinical features of acute severe asthma.
Not able to speak Peak flow < 150 L/min Cyanosis Tachycardia Paradox > 20 mm Hg Silent chest Normal CO2
NOTE: BP paradox is a phenomenon where the patient’s blood pressure rises by more than 20 mm Hg when the patient is blowing out (detected by pumping cuff to a level at which Korotkoff sounds can be heard during expiration but not inspiration)
What follow-up is important to arrange in patients with a pneumonia?
CXR in 4-6 weeks to check for underlying cause (e.g. tumour)
List some signs of obstructive airway disease.
Hyperexpansion Hyperresonant Barrel chest Tracheal tug Decreased expansion Expiratory wheeze
List some signs of chronic liver disease.
Spider naevi (> 5) Clubbing Palmar erythema Dupuytren's contracture Gynaecomastia Testicular atrophy
List some signs of portal hypertension.
Splenomegaly
Ascites
Caput medusae
Haematemesis
List some signs of liver cell failure (decompensation).
Jaundice Leukonychia (hypoalbuminaemia) Bruising (clotting/fibrinogen) Ascites Encephalopathy
How can inferior vena cava obstruction be distinguished from portal hypertension?
IVCO also causes ascites but the dilated veins on the abdomen only flow upwards
NOTE: IVCO is considerably more rare than portal hypertension
How can obstructive jaundice be clinically differentiated from other causes of jaundice?
Pruritus causing excoriation marks - due to bile salts accumulating in the skin
Other features of cholestasis include: pale stool (PR), dark urine (negative for urobilinogen), jaundice, xanthelasmata
How can an enlarged spleen be distinguished from an enlarged kidney?
Spleen has a notch
Cannot get above the spleen
Spleen is dull to percussion (whereas the kidney is resonant due to overlying bowel)
Kidney is ballotable
Spleen moves towards the RIF as it grows
Kidney moves downwards as it grows
How can you distinguish between cardiogenic, septic and hypovolaemic shock on clinical examination in an unconscious patient?
Feel their hands and check their JVP
Cardiogenic = high JVP + cold
Septic = low JVP + warm
Hypovolaemic = low JVP + cold
NOTE: anaphylaxis has a similar pathophysiology to sepsis
What is erythema ab igne and what causes it?
Brown pigmentary discoloration caused by chronic heat over skin
Usually seen in areas of chronic pain where patients have been applying hot water bottles (also seen on the shins of elderly who sit in front of coal fires)
IMPORTANT: check whether using hot water bottle on the area and why (e.g. back pain, knee pain)
What causes migratory necrolytic erythema?
Glucagonoma
Which electrolytes are driven into cells by insulin?
Potassium
Phosphate
In which circumstances are insulin sliding scales particularly useful?
T2DM patients being fasted for surgery (they are not ketotic so you need to titrate their insulin according to their blood glucose)
NOTE: its use in DKA is controversial, because the main purpose of insulin in DKA is to switch off ketones not to regulate glucose
Outline the use of bicarbonate in DKA.
This should NOT be given by F1s (it can only be given by specialists)
A small about of dilute (1.26%) bicarbonate may be used by specialists to raise pH to > 7 (because insulin doesn’t work at lower pHs)
NOTE: 8.4% bicarbonate is poisonous and will kill patients
What are the stages of diabetic retinopathy?
Background: blot haemorrhages, microaneurysms (dots), hard exudates
Pre-proliferative: soft exudates (cotton wool spots), venous beading
Proliferative: new vessels, vitreous haemorrhage, retinal detachment
Maculopathy: hard exudates near the macula, reduced acuity
NOTE: diabetics should have their eyes checked every year
What are the grades of hypertensive retinopathy?
NOTE: known as the Keith-Wagener classification
1: arteriolar narrowing and silver wiring
2: AV nipping
3: Flame haemorrhages and cotton wool spots
4: papilloedema
What is a major cause of retinal artery occlusion?
Giant cell arteritis
List some causes of central retinal vein occlusion.
Hypercoagulable states: cancer, multiple myeloma
What is retinitis pigmentosa?
Inherited condition that cases slowly worsening blindness and it is incurable
Causes tunnel vision
List some features of thyrotoxicosis.
Weight loss Increased appetite Breathlessness Palpitations Tachycardia Sweating Heat intolerance Diarrhoea Lid lag
GRAVES: pretibial myxoedema, exophthalmos
