Medicine 7 Flashcards by Akash Srinivasan

How is HRCT different from volumetric CT?

10-15 mm interspace (fewer slices)
Doesn't cover the whole chest 
No contrast so not very good for mediastinum/vasculature 
Used for ILD/emphysema/bronchiectasis 
Less radiation

NOTE: volumetric CT is used for cancer staging, lymph nodes and pleural space

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How is asthma defined on the basis of investigation results?

Variable airway obstruction (PEF > 20% variability, FEV1 > 12% or 200 mL improvement)
Airway hyper-responsiveness (PC20 - provocation test using either histmaine or metacholine)

NOTE: PC20 means the amount of histamine you need to give a patient to see a 20% drop in FEV1. FeNO is a surrogate marker for airway inflammation if high.

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List some complications of bronchiectasis.

Pulmonary hypertension
Cachexia
Lobar collapse 
Massive haemoptysis 
Type 2 respiratory failure 
Situs inversus (Kartagener's)

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Which investigations should be requested in a patient with bronchiectasis?

CXR 
HRCT (dilated thickened airways with evidence of mucus plugging - signet ring sign)
Sputum cultures 
Spirometry (obstructive)
Aspergillus markers 
Immunoglobulins 
CF genetic testing

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Outline the management of bronchiectasis.

Physiotherapy (mucus clearance, postural drainage)
Prompt treatment of infection with abx
Correct underlying causes 
Prophylactic antibiotics 
Bronchodilators 
Pulmonary rehabilitation 
Smoking cessation

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Which investigations would you request for a patient with suspected lung cancer?

CXR
Volumetric CT
Lung function (assess fitness for surgery)
PET-CT wit 18-FDG (to look for distant metastases)
Biopsy/bronchoscopy/endobronchial ultrasound

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List some complications of COPD.

Cor pulmonale
Secondary pneumothorax 
Polycythaemia 
Lung cancer 
Steroid therapy complications

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What are the cardinal signs of hyperinflation in COPD?

Reduced crico-sternal distance (normal = 3 fingers)
Loss of cardiac dullness
Displaced liver edge

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Which investigations should be requested in a patient with suspected COPD?

FBC (secondary polycythaemia)
CXR (is there anything else going on? Cancer? Infection?)
Lung function (fixed obstructive with no reversibility)
Blood gas
HRCT (to assess whether volume reduction surgery is feasible)
Echo to check for pulmonary hypertension
A1AT

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Which scoring system is used to assess how functionally impaired a COPD patient is?

mMRC
0 = only breathless with strenuous exercise
1 = short of breath when hurrying or walking slightly uphill
2 = walk slower than the average person of the same age due to breathlessness, have to stop for breaks
3 = stop for breath after walking 100 m or after a few mins
4 = too breathless to leave the house, breathless when dressing

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What is tested for when a pleural effusion is sampled?

Microscopy and culture 
TB 
Protein 
Glucose 
pH (< 7.2 in empyema)
LDH
Cytology

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Outline the management of a pleural effusion.

Drain (may include video-assisted thorascopic surgery, indwelling pleural catheter)
Treat underlying cause

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Which investigations should be requested in a patient with suspected interstitial lung disease?

CXR
HRCT (ground glass, honeycombing, traction bronchiectasis)
FBC (complement, autoimmune screen)
Lung function including transfer factor (TLCO)
BAL (cell differentials), transbronchial biopsy
Echocardiogram (pulmonary hypertension)
6 min walk
ABG

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Outline the management of interstitial lung disease.

Physiotherapy and pulmonary rehabilitation 
Ambulatory oxygen 
Anti-tussives 
Smoking cessation 
Pirfenidone/ninetadinib (IPF only)
Immunosuppressives/steroids (especially sarcoid or CTD-associated)
Transplant 
Palliative care

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Which investigations should be requested in the case of any cardiac valve lesion?

Bloods - exclude endocarditis if new (blood cultures, FBC, CRP, U&E)
Clotting - if anticoagulated
Echo - confirm diagnosis, check all valves, assess severity and ventricular function
ECG - for rhythm, LVH and ischaemia
CXR - for associated lung lesions
Other vascular risk factors (e.g. BP, lipids)

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Which investigations should be requested in a patient with signs of ischaemic heart disease?

Bloods - FBC, U&E, glucose, lipids
ECG 
CXR 
Echo - function and evidence of old MI 
Angiography
Dynamic testing (e.g. stress echo)
Assess rest of vasculature

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Which investigations should be requested in a patient with a suspected pleural effusion?

CXR - confirm diagnosis and look for cause
Bloods - FBC, clotting, U&E, LFT, CRP, TFT, blood cultures, sats
Urine - protein
US-guided aspiration
CT chest

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Which investigations should be requested in a patient with suspected liver disease?

Bloods - FBC, U&E, LFT, CRP, INR, clotting, AFP, hepatitis serology, autoantibodies
Ultrasound of the abdomen
Endoscopy for varices

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Which investigations should be requested in a patient with polycystic kidney disease?

Ultrasound to confirm the diagnosis
Bloods - FBC, U&E, eGFR, LFT, PTH, urine for protein
Blood pressure
ECG for LVH and possibly echo

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Which investigations should be requested in a patient with a transplanted kidney?

Bloods - FBC, U&E, eGFR, LFT, lipid profile, immunosuppressant levels
Urine for blood and protein
Ultrasound to confirm and check perfused
Examine for complications (vascular, infectious, cancer)

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Which investigations would you request in a patient with a suspected cerebrovascular accident?

Bloods - FBC, U&E, CRP, glucose, lipids, INR
ECG
Urgent CT head
Carotid doppler or echo

List some causes of peripheral neuropathy.

Diabetes mellitus 
Alcoholism
B12 deficiency 
Hypothyroidism
Autoimmune (RA, SLE, Sjogren)
Amyloidosis

Which investigations should be requested in a patient with peripheral neuropathy?

Bloods - FBC, U&E, glucose, LFT, TFT, B12 and folate, autoantibodies
CXR - especially if smoker
Nerve conduction studies
May need MRI if there are doubts about the location of the lesion

Which investigations should be requested in a patient with suspected rheumatoid arthritis?

Bloods - FBC, ESR, CRP, RF, anti-CCP, U&E, LFT 
Urine for protein 
X-ray hands and ultrasound joints
ECG 
CXR (lung involvement)

What are the components of a confusion screen?

B12/folate TFTs Glucose Bone Profile (Calcium)

Outline the NICE guidelines on maintenance fluids.

25-30 ml/kg/day of water 1 mmol/kg/day of potassium, sodium and chloride 50-100 g/day of glucose to limit starvation ketosis GENERAL RULE: 1 salty, 2 sweet

What are the diagnostic criteria for asthma?

FeNO of > 40 parts per billion Post-bronchodilator improvement in lung function of 200 mL Post-bronchodilator improvement in FEV1 of > 12% PEFR variability of > 20% FEV1/FVC ratio < 70%

What are the main differences between spasticity and rigidity?

Spasticity - Weakness present - More resistance in one direction than another - Clasp knife spasticity (more resistance in first part of movement) - Velocity-dependent (spasticity more noticeable with fast movements) Rigidity - Same resistance in all directions - Not velocity-dependent

What is the haemoglobin threshold that requires transfusion?

Non-ACS: < 70 g/L | ACS: < 80 g/L

What triad of features of characteristic of insulinoma?

Whipple's triad - symptoms and signs of hypoglycaemia - plasma glucose < 2.5 mmol/L - reversibility on administration of glucose

What are the main features of age-related macular degeneration?

Advanced age Gradual loss of vision Blurring of small words Straight lines appearing 'curvy' Fundoscopy: neovascularisation (wet), drusen (dry)

What are the indications for urgent referral of a patient with dyspepsia?

Dysphagia Upper abdominal mass (stomach cancer?) Patients > 55 yrs with weight loss AND upper abdominal pain OR reflux OR dyspepsia

How should patients with dyspepsia and no red flags be managed?

Review medications for possible cause Lifestyle advice Trial of full-dose PPI for 1 month OR test and treat approach for H. pylori (using C13 urea breath test/stool antigen/serology)

List some causes of unilateral foot drop.

Common peroneal nerve injury (MOST COMMON) L5 radiculopathy Sciatic nerve injury NOTE: main dorsiflexor of the foot is tibialis anterior

What counts as orthostatic hypotension?

Lying/standing blood pressure Drop by 20 mm Hg systolic Drop by 10 mm Hg diastolic Drop below 90 mm Hg systolic (even if drop is less than 20)

List some causes of sudden visual loss.

Ischaemic/vascular (e.g. central retinal vein/artery occlusion) Vitreous haemorrhage Retinal detachment Retinal migraine

What is the target HbA1c for patients with T2DM and when would you consider adding a second drug?

Target = 48 mmol/mol Consider adding 2nd agent = 58 mmol/mol Target when on more than one drug or on an agent that causes hypoglycaemia = 53 mmol/mol

What is the Hoffman reflex?

Quick forced flexion of the distal IP joint of the middle finger will cause flexion of the index finger and adduction of the thumb Associated with UMN diseases: degenerative cervical myelopathy, MS

What are the main features of degenerative cervical myelopathy?

Pain (neck and limbs) Loss of motor function (loss of dexterity) Numbness Loss of autonomic function (e.g. incontinence, impotence) Hoffman's sign NOTE: DCM results from cervical spondylosis

What signs of cardiovascular disease may you see on the face?

Malar flush (MS) Eyes - hyperlipidaemia (xanthelasma, corneal arcus), anaemia (conjunctival pallor) Mouth - central cyanosis, dry, dental caries, high arched palate

What could cause an impalpable apex beat?

COPD Obesity Pericardial effusion Dextrocardia

What signs of respiratory disease may you see on the face?

``` Flushed/plethoric - polycythaemia, SVCO, carbon dioxide retention Cushingoid Conjunctival pallor Horner syndrome Central cyanosis Oral candidiasis (steroid inhaler use) ```

Which signs of abdominal disease may you see on the face?

Eyes - conjunctival pallor, scleral icterus, Keiser-Fleischer rings Mouth - aphthous ulcers, glossitis, gum hypertrophy, fetor hepaticus, pigmented macules, telangiectasia

Define 'upper motor neurone lesion'.

The lesion is above the level of the anterior horn cell NOTE: LMN is a lesion of the anterior horn cell or distal to it

What are some clinical features of lesions that affect the brainstem (subcortical)?

``` Extraocular movement impairments Diplopia Dysphagia Dysarthria Nystagmus ``` NOTE: subcortical cerebellar damage can cause DANISH

What are some clinical features of cortical brain damage?

Dysphasia Visual/sensory inattention Neglect

What do you look for on inspection of a limb when doing a neurological examination?

``` Scars Wasting Involuntary movements Fasciculations Tremor ```

``` Which nerve roots are responsible for the following upper limb movements: Wrist extension Wrist flexion Finger flexion Finger abduction Thumb abduction ```

Wrist extension - C6 + C7 via radial nerve Wrist flexion - C6 + C7 via median nerve Finger flexion - C8 via median nerve Finger abduction - T1 via ulnar nerve Thumb abduction - C8 and T1 via median nerve

``` Which muscles and nerves are tested by the following movements of the lower limb: Hip flexion Hip extension Knee flexion Knee extension Ankle dorsiflexion Ankle plantarflexion Great toe extension ```

Hip flexion - iliopsoas - L1 + L2 Hip extension - gluteus maximus - L4 + L5 Knee extension - quadriceps - L3 + L4 Knee flexion - hamstrings - L5 + S1 Ankle dorsiflexion - anterior compartment - L4 + L5 Ankle plantarflexion - gastrocnemius and soleus - S1 + S2 Great toe extension - extensor hallucis longus - L5

List some causes of hepatomegaly.

``` Hepatitis Carcinoma (metastases) Congestive cardiac failure Autoimmune (PSC, PBC, AIH) Infiltrative (amyloid, myloproliferative) ```