Medicine 7 Flashcards
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
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.
List some complications of bronchiectasis.
Pulmonary hypertension Cachexia Lobar collapse Massive haemoptysis Type 2 respiratory failure Situs inversus (Kartagener's)
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
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
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
List some complications of COPD.
Cor pulmonale Secondary pneumothorax Polycythaemia Lung cancer Steroid therapy complications
What are the cardinal signs of hyperinflation in COPD?
Reduced crico-sternal distance (normal = 3 fingers)
Loss of cardiac dullness
Displaced liver edge
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
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
What is tested for when a pleural effusion is sampled?
Microscopy and culture TB Protein Glucose pH (< 7.2 in empyema) LDH Cytology
Outline the management of a pleural effusion.
Drain (may include video-assisted thorascopic surgery, indwelling pleural catheter)
Treat underlying cause
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
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
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)
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
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
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
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
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)
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)
