Medicine PACES Flashcards
List the cardiac causes of clubbing.
Infective endocarditis
Congenital cyanotic heart disease
Atrial myxoma
What causes the four heart sounds?
S1: mitral valve closure
S2: aortic valve closure
S3: rapid ventricular filling of dilated left ventricle
S4: atrial contraction against stiff ventricle
What murmur is caused by aortic stenosis?
Ejection systolic murmur loudest in the right 2nd ICS heart best when sitting forward and in end expiration
Radiates to the carotids
Soft S2 and presence of S4 indicates severity
How does aortic sclerosis differ from aortic stenosis on examination?
No radiation to the carotids
Normal pulse character
NOTE: HOCM is another differential for an ejection systolic murmur
List some causes of aortic stenosis.
Senile calcification
Bicuspid aortic valve (2% of population)
Rheumatic heart disease
What are the main symptoms of severe aortic stenosis?
Syncope
Angina
Dyspnoea (this carries worst prognosis)
List the echocardiogram features of severe aortic stenosis.
Pressure gradient > 40 mm Hg
Valve area < 1 cm^2
Jet velocity > 4 m/s
Outline the management of aortic stenosis.
General: MDT, optimise cardiovascular risk, monitor with regular follow-up/echos, treat angina (BB) and heart failure (ACEi + BB)
Surgical valve replacement
TAVI (effective in older/frail patients who are not fit for open repair)
Balloon valvuloplasty is an alternative to TAVI (NOTE: effect reduces after 1 year)
What are the benefits of TAVI compared to open repair?
Heart does not need to be stopped and heart-lung bypass is not necessary
Avoids large thoracotomy scar
Less strain on body (so better for frail patients)
NOTE: it is associated with a higher risk of stroke
What murmur is caused by mitral regurgitation?
Pansystolic murmur heard loudest at the apex in the left lateral position at end-expiration
Radiates to the axilla
What are some clinical signs of mitral regurgitation?
Displaced apex
Apical thrill
Quiet S1
Pansystolic murmur radiating to the axilla
S3 (rapid ventricular filling)
Look for valvulotomy scar
List some causes of mitral regurgitation.
LV dilatation (e.g. hypertension, connective tissue disorders)
Annular calcification
Rheumatic heart disease
Mitral valve prolapse
What are some echocardiogram features of severe mitral regurgitation?
Regurgitant volume > 60 mL
Systolic pulmonary flow reversal
Outline the management of mitral regurgitation.
General: MDT, risk factor modification
AF - rate control and anticoagulation
Reduce afterload (ACEi, BB, diuretics)
Valve replacement (if symptomatic)
What murmur is caused by aortic regurgitation?
High-pitched early diastolic murmur loudest at the lower left sternal edge when sitting forward in end-expiration
NOTE: can cause Austin-Flint murmur (rumbling mid-diastolic murmur due to regurgitant blood hitting the mitral valve)
List some causes of aortic regurgitation.
Bicuspid aortic valve
Rheumatic heart disease
Ankylosing spondylitis
Rheumatoid arthritis
Connective tissue disease (Marfan’s, Ehlers-Danlos)
Infective endocarditis
Type A aortic dissection
Outline the management of aortic regurgitation.
General: MDT, risk factor modification
Reduce afterload (ACEi, BB, diuretics)
Surgical valve replacement (if symptomatic or LV dysfunction)
What murmur does mitral stenosis cause?
Loud S1 (opening snap) and rumbling mid-diastolic murmur heard loudest at the apex in the left lateral position in end-expiration with the bell
Radiates to the axilla
What are some signs of mitral stenosis?
Malar flush (severe)
AF
Tapping apex beat (palpable first heart sound)
NON-displaced apex beat
Right ventricular heave
Blowing mid-diastolic murmur with presystolic accentuation (if not in AF)
NOTE: tends to be middle-aged women who had rheumatic fever in childhood
List some causes of mitral stenosis.
Rheumatic heart disease (MOST COMMON)
Senile degeneration
Endocarditis
Congenital
Outline the management of mitral stenosis.
Consider rheumatic fever prophylaxis (pen V)
AF rate control and anticoagulation
Surgical: percutaneous balloon valvuloplasty (FIRST LINE provided valve mobile and not calcified)
Alternative: valvotomy or replacement
NOTE a TOE to check for a left atrial mural thrombus should be performed before intervention
What is the Duckett-Jones criteria for rheumatic heart disease?
MAJOR
- joints (arthritis)
- carditis
- nodules subcutaneous
- erythema marginatum
- Sydenham’s chorea
MINOR
- Fever
- High ESR or CRP
- Arthalgia
- Prolonged PR interval
- Previous rheumatic fever
Rheumatic heart disease if 2 major or 1 major + 2 minor
Outline the management of rheumatic fever.
Bed rest
Ben pen 1.2 mg IM for 10 days
Analgesia for carditis/arthritis: aspirin/NSAIDs
Consider oral prednisolone if CCF
Consider diazepam for chorea
Outline the secondary prevention of rheumatic fever.
900 mg Benzathine benzylpenicillin every 3-4 weeks IM for 10 years
What is the difference between acute and subacute endocarditis?
Acute: normal valves –> caused by S. aureus and S. epidermidis –> RF: IVDU, skin wounds, immunosuppression
Subacute: abnormal valves –> caused by S. viridans, S. bovis, HACEK –> RF: prosthetic valves, damages valves
List some clinical features of infective endocarditis.
Petechiae (common)
Splenomegaly (common)
Clubbing
Splinter haemorrhages
Janeway lesions
Osler’s nodes
Fever
Roth spots
Haematuria
Which murmurs are most commonly associated with infective endocarditis?
Mitral regurgitation
Aortic regurgitation
Outline the Duke criteria for infective endocarditis.
MAJOR
- +ve blood culture (typical organism in 2 cultures or persistently positive cultures)
- endocardial involvement (positive echo (e.g. vegetation), new valvular regurgitation)
MINOR
- predisposition (cardiac lesion, IVDU)
- fever
- emboli (e.g. Janeway lesions)
- immune phenomena (e.g. Osler’s nodes)
- +ve blood culture not meeting major criteria
For diagnosis: 2 major OR 1 major + 3 minor OR 5 minor
Outline the management of infective endocarditis.
Acute Severe: flucloxacillin/vancomycin + gentamicin IV
Subacute: benzylpenicillin + gentamicin IV
What might you see on general inspection of a patient with a valve replacement?
Audible valve click
Bruising (anticoagulation)
Warfarin alert bracelet
Anaemia
Midline sternotomy (CABG, open valve replacement) +/- saphenous vein sampling
Neck scars from line insertion
Femoral/radial scars from angiography
Name three different types of prosthetic valve.
Starr-Edwards - 3 artificial sounds
Tilting disc (Bjork-Shiley) or bileaflet (St. Jude) - 1 artificial sound
Bioprosthetic - normal heart sounds
NOTE: bileaflet valves are most commonly used
How might mitral valve replacements sound different from aortic valve replacements?
Aortic: Lub-Click (systolic flow murmur)
Mitral: Click-Dub (diastolic flow murmur)
What might a lateral thoracotomy scar be due to?
Mitral valve replacement
Mitral valvotomy
Coarctation repair
Blalock-Taussig shunt
What might leave a subclavicular scar in cardiology?
Pacemaker
ICD
What is a scar in the antecubital fossa of a cardiology patient suggestive of?
Angoigraphy
Which cardiothoracic procedures may be done through a midline sternotomy?
CABG
Aortic valve replacement
Mitral valve replacement
Outline the factors considered when deciding on a type of valve replacement.
METAL: durable, needs lifelong warfarin, better for young patients or patients who are already on warfarin (e.g. for AF)
PORCINE: less durable (10 years), no need for warfarin, better for elderly/at risk of haemorrhage
NOTE: porcine also known as Carpentier-Edwards valves
List some complications of valve replacement.
Thromboembolus
Bleeding (due to warfarin)
Bioprosthetic dysfunction and LVF (usually within 10 years but can be treated percutaneously by valve in valve)
Haemolysis
Infective endocarditis (S. viridans, S. epidermidis)
Atrial fibrillation (particularly mitral valve replacement)
How can any murmur be made louder in a patient?
Make them exercise
List some causes of atrial fibrillation.
Ischaemic heart disease
Valvular pathology (mainly mitral)
Rheumatic heart disease
Thyrotoxicosis
Pneumonia
PE
Post-op
Electrolytes (e.g. hypokalaemia)
Alcohol
Which investigations are useful for identifying a cause of AF?
FBC (infection)
U&E (K+)
TFTs (hyperthyroid)
Troponin
D-dimer
CXR (pulmonary oedema, pneumonia, calcified mitral valve)
Echo (valve pathology, LV function)
NOTE: important differential is multiple ventricular ectopics
How can ventricular ectopics be clinically distinguished from AF?
Exercise the patient
AF: pulse remains irregularly irregular
VE: as heart rate increases, pulse becomes regular (closes the window for ventricular ectopics)
What is the difference between paroxysmal, persistent and permanent AF?
Paroxysmal: < 7 days and self-terminates
Persistent: > 7 days and requires cardioversion
Permanent: > 1 year or when no further attempts to rhythm control are made
What CHADS-Vasc score requires warfarinisation?
1 or more
How should a patient with acute AF presenting < 48 hours of onset be managed?
1st line: rhythm control (DC cardioversion or chemical cardioversion (flecainide or amiodarone))
Start LMWH
Rate control (BB, CCB, digoxin)
NOTE: rhythm control is first line in younger patients, first episode AF and when there is an obvious precipitant to the AF
Which medications should be used in the management of paroxysmal AF?
Prevention: bisoprolol or sotalol
Pill in the pocket: flecainide or amiodarone
How should patients presenting more than 48 hours after the onset of AF be managed?
3 weeks of warfarin (and rate control) before cardioversion
Can be done earlier if a TOE excludes a mural thrombus
List some contraindications of warfarin.
Bleeding tendency
Compliance issues (dosing/monitoring)
Risk of falls
Peptic ulcer disease
Pregnancy
List some complications of warfarin.
Bleeding
Osteoporosis
List some indications for permanent pacing.
Complete AV block
Mobitz type 2
Symptomatic bradycardia
Drug-resistant tachyarrhythmias
Biventricular pacing in chronic heart failure
What do the three letters in naming pacemakers mean?
1st: chamber paced (A, V, D)
2nd: chamber sensed (A, V, D)
3rd: response (inhibited, triggered, dual)
E.g. VVI: paces the ventricle but also senses intrinsic ventricular activity which would inhibit a pacing output
What are biventricular pacemakers used for?
Leads to both ventricles
Used for cardiac resynchronisation therapy in heart failure
NOTE: this aims to maximise the pumping action of the heart
List some complications of pacemakers.
Insertion:
- Bleeding
- Arrhythmia
Post-Insertion:
- Erosion
- Lead migration
- Pocket infection
- Malfunction
List some causes of heart failure.
LEFT: ischaemic heart disease, dilated cardiomyopathy, hypertension, mitral and aortic valve disease
RIGHT: LVF, cor pulmonale, tricuspid and pulmonary valve disease
Which main investigations are used in heart failure?
Blood test - BNP, FBC, U&E, glucose, urine
CXR - heart size, lung fields
ECG - rhythm, ischaemia, LVH
Echo - valves, ventricular function
Lipid and BP
Outline the management of chronic heart failure.
Risk factor modification
1st line: Beta-blocker + ACE inhibitor + loop diuretics (e.g. frusemide)
2nd line: add spironolactone
3rd line: consider digoxin
4th line: consider CRT
Final line: heart transplant
What cardiovascular signs should you check for in a patient with COPD?
Cor pulmonale
Raised JVP
Left parasternal heavy (RVH)
Tricuspid regurgitation
Ascites and pulsatile hepatomegaly
Peripheral oedema
What spirometry results would you expect to see in COPD?
Reduced FEV1
Low FEV1/FVC ratio (< 0.7)
Increased total lung capacity and residual volume
NOTE: bronchiectasis also gives an obstructive pattern
Which treatments can be offered to help people with COPD to stop smoking?
Specialist nurse and support programme
Nicotine replacement programme
Varenicline (partial nicotinic acetylcholine receptor agonist) and bupropion (noradrenaline-doparmine reuptake inhibitor)
List some causes of interstitial lung disease.
UPPER
- aspergillosis
- pneumoconiosis
- extrinsic allergic alveolitis
- TB
LOWER
- sarcoidosis
- toxins (amiodarone, nitrofurantoin, methotrexate, sulfasalazine, bleomycine)
- asbestosis
- idiopathic
- rheumatological (RA, SLE, systemic sclerosis)
What is the imaging modality of choice for interstitial lung disease?
High resolution CT
What spirometry results would you expect to see in a patient with pulmonary fibrosis?
FEV1: FVC ratio > 0.8
Low TLC
Low RV
Low FEV1 and FVC
What would you expect to hear on auscultation of the chest in a patient with bronchiectasis?
Coarse, wet crackles which may change once the patient coughs
May also hear a wheeze
Coughing may clear the wheeze if it is due to a mucus plug
ALSO: clubbing, copious sputum, features of cor pulmonale (raised JVP, loud P2)
List some causes of bronchiectasis.
ACQUIRED
Idiopathic (50%)
Post-infectious (pertussis, TB, measles)
Obstruction (tumour, foreign body)
Associated (RA, IBD, ABPA)
CONGENITAL
Cystic fibrosis
Kartagener’s syndrome
Young’s syndrome
Hypogammaglobulinaemia (CVIS, Bruton’s X-linked)
What are some causes of a transudative pleural effusion?
Congestive cardiac failure
Renal failure
Liver failure (hypoalbuminaemia)
Hypothyroidism
Meig syndrome
What are some causes of an exudative pleural effusion?
Infection (e.g. pneumonia)
Cancer
Inflammation (RA, SLE)
Infarction (e.g. PE)
Trauma
What are Light’s criteria for an exudative pleural effusion?
Effusion: serum protein ratio > 0.5
Effusion: serum LDH ratio > 0.6
Effusion LDH is 0.6 x ULN
Effusion protein < 25 g/L = transudate
Effusion protein > 35 g/L = exudate
Between
What are some complications of Pancoast tumours?
Horner’s syndrome
Recurrent laryngeal nerve palsy
Clawing of the hand and wasting of interossei (due to brachial plexus injury (T1))
List some indications for lobectomy or pneumonectomy.
Non-disseminated bronchial carcinoma (90%)
Bronchiectasis
COPD
TB
NOTE: they both have a relatively high mortality
What are the main types of lung cancer and which is most common?
Non-Small Cell Lung Cancer (80%)
- SCC (35%) - smoking, central, PTHrP
- Adenocarcinoma (25%) - peripheral, less associated with smoking
- Large cell
Small Cell Lung Cancer (20%)
- highly related to smoking, central, ADH/ACTH
Which dermatological conditions are associated with lung cancer?
Acanthosis nigricans
Trousseau syndrome (migratory thrombophlebitis)
Aside from imaging, what other important test needs to be done before a patient is surgically treated for lung cancer?
Pulmonary function tests to assess fitness for surgery
Pneumonectomy is contraindicated if FEV1 < 1.2 L
Which organisms most commonly cause community-acquired, hospital-acquired and aspiration pneumonia?
CAP: pneumococcus, mycoplasma, haemophilus (COPD), chlamydia pneumophila, viruses
HAP: pseudomonas, staph aureus, Gram negative enterobacteriaceae (Klebsiella)
Aspiration: anaerobes
What is a thoracoplasty?
Old treatment for TB which involved surgically removing a rib in order to collapse the part of the lung affected by TB
List the main side-effects of medical TB treatment.
Rifampicin: orange urine, enzyme induction (reduced COCP efficacy), hepatitis
Isoniazid: peripheral neuropathy
Pyrazinamide: hepatitis, arthralgia
Ethambutol: optic neuritis (loss of colour vision)
Describe the different X-ray features of primary TB.
Ghon Focus: primary subpleural lesion
Ghon Complex: hilar lymphadenopathy + lung lesion
Ranke Complex: fibrosis and calcification of Ghon complex
Which investigations are used to diagnose TB?
Latent TB: IGRA assay, tuberculin skin test
CXR
3 x sputum samples (one in morning) - microscopy (Ziehl-Neelsen) and culture on Lowenstein-Jensen
PCR (identify rifampicin resistance)
What are the components of a liver screen?
FBC and LFTs (alcohol, macrocytic anaemia)
Hepatitis serology
Lipids (NASH)
Autoantibodies (ASMA, AMA, pANCA, ANA)
Immunoglobulins (high IgG in autoimmune hepatitis; high IgM in PBC)
Caeruloplasmin, ferritin, A1AT
Cancer (AFP, CA19-9)
What should patients with chronic liver failure be screened for?
Hepatocellular carcinoma: US + AFP
Varices: OGD
What grading system is used for Cirrhosis and what factors does it take into account?
Child-Pugh Grading System
Albumin
Bilirubin
Clotting
Distension (ascites)
Encephalopathy
How can the complications of chronic liver disease be managed?
Ascites: daily wt, fluid and Na restrict, diuretics, tap
Coagulopathy: Vit K, FFP, platelets
Encephalopathy: avoid sedatives, lactulose, rifaximin
Sepsis / SBP: tazocin or cefotaxime
Hypoglycaemia: dextrose
Hepatorenal syndrome: IV albumin + terlipressin
How might hepatic encephalopathy manifest?
Asterixis
Ataxia
Confusion
Dysarthria
Constructional apraxia
Seizures
NOTE: plasma ammonia will be high
How should hepatic encephalopathy be treated?
Lactulose (reduces nitrogen-forming bowel bacteria)
Rifaximin (kills intestinal microflora)
Outline the treatment of spontaneous bacterial peritonitis.
Cefotaxime or tazocin (until sensitivities known)
Long-term ciprofloxacin and beta-blocker (propranolol)
NOTE: diagnosed if > 250 PMN/mm^3 in ascitic fluid. Usual organisms are E. coli, Klebsiella and Streptococci
Outline how SAAG is used to differentiate causes of ascites.
SAAG > 11 g/L
- Cirrhosis
- congestive cardiac failure
SAAG < 11 g/L
- neoplasia
- inflammation
- infection (e.g. TB peritonitis)
- nephrotic syndrome
NOTE: portal hypertension = pressure > 10 mm Hg
Outline the management of ascites.
GENERAL: alcohol abstinence, daily weight, fluid restrict (< 1.5 L), low sodium diet
DIURETICS: spironolactone, add frusemide if poor response
Therapeutic paracentesis with albumin infusion
Refractory ascites: TIPSS, transplant
Prophylactic ciprofloxacin for SBP prevention
List some signs of immunosuppressant use.
Cushingoid (steroids)
Skin tumours (e.g. actinic keratosis, SCC, BCC)
Gingival hypertrophy (ciclosporin)
Hypertension (ciclosporin, tacrolimus)
Fine tremor (tacrolimus)
What are the main indications for a liver transplant?
Cirrhosis
Acute liver failure (e.g. hepatitis A/B, paracetamol overdose)
Malignancy
Which stains should be used on a liver biopsy of a patient with cirrhosis?
Pearl’s stain (iron)
Rhodamine stain (copper)
PAS stain (A1AT)
Apple-green birefringence with Congo Red (amyloidosis)
Check for granulomata
List some differentials for splenomegaly.
Infection: EBV
Haematological: CLL, lymphoma, CML, myelofibrosis, splenic sequestration crisis
Infiltrative: amyloidosis, Gaucher’s disease
Other: malaria, leishmaniasis, portal hypertension, RA, SLE
List some causes of hyposplenism.
Splenectomy
Coeliac disease
Inflammatory bowel disease
Sickle cell disease
NOTE: hyposplenism is managed with immunisations (pneumovax, Hib, men C, annual flu) and daily antibiotics (Pan V or erythromycin)
List some complications of splenectomy.
Redistributive thrombocytosis (leads to VTE)
Gastric dilatation (transient ileus)
Left lower lobe atelectasis
Pancreatitis
Increased susceptibility to infection (encapsulated)
List some differentials for enlarged kidneys.
BILATERAL
- ADPKD
- bilateral RCC
- bilateral cysts (von Hippel Lindau)
- amyloidosis
UNILATERAL
- simple renal cyst
- renal cell carcinoma
- compensatory hypertrophy
What blood test results would you expect to see in a patient with renal failure?
Anaemia
Deranged U&E
Hypocalcaemia, high phosphate, high PTH (secondary hyper PTH)
Which gene most often causes polycystic kidney disease?
PKD1 gene on chromosome 16 (85%)
Remainder caused by PKD2 gene on chromosome 4
NOTE: patients with ADPKD should be screened for Berry Aneurysms with an MRA
List some causes of renal cysts.
Simple renal cysts (present in 1/3 over 60 yrs)
Dialysis-associated renal cysts (increased risk of RCC)
Tuberous sclerosis
Which paraneoplastic phenomenon can result from RCC?
EPO –> polycythaemia
PTHrP –> hypercalcaemia
Renin –> hypertension
ACTH –> Cushing’s syndrome
Amyloidosis
What are the most common indications for renal transplant?
Diabetic nephropathy
Glomerulonephritis
Polycystic kidney disease
Hypertensive nephropathy
Which assessments need to be carried out before renal transplantation?
Virology
Co-morbidities (anaesthetic fitness)
ABO
Anti-HLA antibodies
Haplotype (DR > B > A)
Pre-implantation cross-match
List some complications of renal transplantation.
Bleeding
Graft thrombosis or dysfunction
Infection secondary to immunosuppression (PCP, CMV)
Increased risk of other pathology (skin cancer, post-transplant lymphoproliferative disease, cardiovascular disease)
Recurrence of original disease
Urinary leaks
What are the three main types of graft rejection and how are they different?
Hyperacute: within minutes, ABO incompatibility, thrombosis and SIRS
Acute Rejection: < 6 months, cell-mediated, fever and graft pain, reduced urine output, increased creatinine, responsive to immunosuppression
Chronic Rejection: > 6 months, gradual increase in Cr and proteinuria, interstitial fibrosis and tubular atrophy, not responsive to immunosuppression
What are the main side effects of ciclosporin?
Nephrotoxic
Gingival hypertrophy
Hypertrichosis
Hepatic dysfunction
What are the main side effects of tacrolimus?
Nephrotoxic (less than ciclosporin)
Diabetogenic
Cardiomyopathy
Neurotoxic (peripheral neuropathy)
List some complications of dialysis.
Cardiovascular disease
Malnutrition
Infection (uraemic –> granulocyte dysfunction –> sepsis)
Amyloidosis (b2 microglobulin accumulation)
Renal cysts –> RCC
Issues with fluid balance (e.g. hypotension, pulmonary oedema)
Electrolyte imbalance
NOTE: specific complications of peritoneal dialysis include peritonitis, exit site infection, catheter malfunction, obesity (glucose in dialysate)
What is an AV fistula and how are they made?
Surgically created connection between an artery and a vein
- Radio-cephalic at wrist (Cimino-Brescia)
- Brachio-cephalic at elbow
What are the advantages and disadvantages of AV fistulas?
ADVANTAGES: high flow, low infection rate, low chance of stenosis
DISADVANTAGES: takes 6 weeks to arterialise, body image, must take care around area (e.g. shaving)
List some complications of AV fistulas.
Thrombosis and stenosis
Infection
Bleeding
Aneurysm
Steal syndrome (reduced pulses, pallor, necrosis)
List some causes of chronic renal failure.
Diabetes mellitus
Hypertension
Renal artery stenosis (mainly due to atherosclerosis)
Glomerulonephritis
Connective tissue disease (SLE, SS, RA)
Polycystic disease
Drugs
Pyelonephritis
Multiple myeloma
What are the components of a renal screen?
Fasting blood glucose/HbA1c
ESR
Immune: ANA, complement, anti-GBM, ANCA, viral serology
Serum protein electrophoresis
List some complications of chronic renal failure.
Cardiovascular disease
Renal osteodystrophy (osteomalacia, osteporosis)
Fluid overload
Hypertension
Electrolyte imbalance (hyperkalaemia, acidosis)
Anaemia
Restless legs
Sensory neuropathy
Describe the type of tremor seen in the early stage of Parkinson’s disease.
Asymmetrical resting tremor (5 Hz)
Exacerbated by counting backwards
Aside from inspecting and assessing tone in the arms, what else should be done when assessing a patient with Parkinson’s disease?
Check eye movements (nystagmus, vertical gaze palsy, saccades)
Glabellar tap
Gait
Write a sentence (micrographia)
Lying-standing BP (autonomic dysfunction)
What are the four main Parkinson’s plus syndromes?
Progressive supranuclear palsy
Multiple system atrophy
Dementia with Lewy bodies
Corticobasilar degeneration
Which type of scan is used to diagnose Parkinson’s disease?
DAT scan
Outline the management of Parkinson’s disease.
MDT, assess disability using UPDRS
Physiotherapy
L-DOPA + carbidopra/benserazide
Dopamine agonists (e.g. ropinirole, pramipexole)
MAO-B inhibitors (rasagiline)
COMT inhibitors (tolcapone)
Amantadine
Anti-muscarinics (e.g. procyclidine)
What are the main clinical features of Parkinson’s disease?
Resting tremor (4-7 Hz)
Rigidity (lead pipe)
Akinesia
Postural instability
Postural hypotension
Sleep disorders
Psychosis
Depression
Dementia
Shuffling gait
Synkinesis (increase in tone when distracted with another movement)
List some side-effects of L-DOPA.
Tardive dyskinesia
Acute dystonia
On-off phenomena
Psychosis
Dry mouth
Daytime sleepiness
What are the main features of multiple system atrophy
Autonomic dysfunction (postural hypotension)
Parkinsonism
Cerebellar ataxia
NOTE: Shy Drager syndrome is when the autonomic features predominate
What are the main features of progressive supranuclear palsy?
Vertical gaze palsy
Pseudobulbar palsy (speech and swallowing problems)
Postural instability
Parkinson’s disease (symmetrical, usually no tremor)
What are the main features of corticobasal degeneration?
Unilateral parkinsonism (especially rigidity)
Aphasia
Apraxia
Alien hand syndrome (can’t control one hand)
What are the main features of Lewy Body dementia?
Dementia
Visual hallucinations
Fluctuating consciousness
Parkinsonism
What are the main features of vascular parkinsonism?
Sudden-onset
Worse in legs than arms
Pyramidal signs
Prominent gait abnormality
List some differentials for a tremor.
Resting: parkinsonism
Intention: cerebellar
Postural (worse when arms outstretched): benign essential tremor, hyperthyroidism, alcohol withdrawal,
What are some key features of a benign essential tremor?
Autosomal dominant
Occurs with movement
Worse when anxious or with caffeine
Doesn’t occur during sleep
Better with alcohol
What are the main features of cerebellar pathology?
Dysdiadochokinesia
Ataxia
Nystagmus (and saccades)
Intention tremor (and dysmetria)
Staccato speech
Hypotonia
Other: ocular dysmetria, pendular reflexes (continues to swing after reflex), heel-shin ataxia, truncal ataxia (vermis lesion)
List some causes of cerebellar disease.
Demyelination
Alcohol abuse
Infarction
SOL (e.g. schwannoma)
Inherited (Wilson’s, Friedreich ataxia, ataxia telangiectasia, VHL)
Epilepsy medication (phenytoin)
Multiple system atrophy
NOTE: bilateral signs are likely to be due to more global pathology (e.g. alcohol as opposed to infarction)
What are the key features of a cerebellar vermis lesion?
Ataxic trunk and gait
Normal arms
What are the main differences between nystagmus caused by cerebellar pathology and vestibular pathology?
Cerebellar: fast phase towards lesion, maximal when looking towards lesion
Vestibular: fast phase away from lesion, maximal looking away from lesion
What is lateral medullary syndrome (Wallenberg syndrome) caused by?
Occlusion of PICA or vertebral artery
NOTE: it is the most common brainstem vascular syndrome
What are the main features of lateral medullary syndrome?
Ipsilateral anaesthesia or the face
Contralateral anaesthesia of the body (pain and temp)
Cerebellar signs: dysphagia, ataxia, nystagmus, vertigo
What are the features of cerebellopontine angle syndrome?
Unilateral hearing loss
Speech impediments
Disequilibrium (loss of balance)
Tremors
NOTE: this can also be accompanied by classical cerebellar signs, CN 6-8 palsies
Causes: vestibular schwannoma, meningioma, metastases, astrocytoma
What are the main features of von Hippel Lindau syndrome?
Renal cysts
Bilateral renal cell carcinoma
Haemangioblastoma (often cerebellar)
Phaeochromocytoma
Islet cell tumours
What is Friedreich ataxia caused by?
Autosomal recessive disorder of the mitochondria characterised by progressive degeneration of the dorsal columns, spinocerebellar tracts and corticospinal tracts
Onset in teenage years and associated with HOCM and dementia
What are the main features of Friedreich ataxia?
INSPECTION: Young adult, wheelchair, Pes cavus
MOTOR: Bilateral cerebellar signs (ataxia, dysarthria, nystagmus), Leg wasting, Areflexia but extensor plantars
SENSORY: Loss of vibration and proprioception
Other: high-arched palate, optic atrophy, retinitis pigmentosa, diabetes mellitus, HOCM
What are the main features of ataxia telangiectasia?
Progressive ataxia
Telangiectasia (conjunctivae, eyes, nose)
Propensity for infections
Lymphoproliferative disease
NOTE: it is an autosomal recessive disease with onset in childhood/early adulthood
What are the main upper motor neurone signs seen on examination?
Increased tone
Pyramidal distribution of weakness (LEG: extensors stronger than flexors; ARMS: flexors stronger than extensors)
Hyperreflexia
Extensor plantars
Weakness
Pronator drift
List some causes of bilateral lower limb spastic paraparesis.
Multiple sclerosis
Cord compression/trauma
Cerebral palsy
Aortic dissection
Syringomyelia
List some causes of mixed upper and lower motor neurone signs.
Motor neurone disease (ALS)
Friedreich ataxia
Subacute combined degeneration of the spinal cord (B12)
Describe the pattern of UMN/LMN signs in cord compression.
LMN at level of lesion
UMN below level of lesion
NOTE: there will also be a sensory level, deep pain/radicular pain and potentially sphincter disturbance
List some causes of cord compression.
Trauma (vertebral fracture)
Infection (epidural abscess, TB)
Malignancy
Disc prolapse
NOTE: MRI is the investigation of choice
What are the main features of cauda equina syndrome?
Back pain
Radicular pain down the legs
Bilateral flaccid, areflexic lower limb weakness
Saddle anaesthesia
Urinary/faecal incontinence/retention
Lax anal tone
What are the cardinal signs of syringomyelia?
Dissociated sensory loss (loss of pain/temperature, preserved light touch/vibration) usually affecting upper limbs and chest
Wasting/weakness of hands (may include claw hand)
Loss of upper limb reflexes
Charcot joints (shoulder and elbow)
NOTE: may be caused by blocked CSF circulation in Arnold-Chiari malformation or masses, spina bifida, secondary to trauma
Which classification system is used to identify the part of the cerebral circulation affected by a stroke?
Bamford classification
What are the features of a total anterior circulation stroke?
Hemiparesis and/or hemisensory deficit
Homonymous hemianopia
Higher cortical dysfunction (dominant: aphasia, non-dominant: neglect/apraxia)
NOTE: this affects carotid/MCA and ACA territory
What are the features of a partial anterior circulation stroke?
2/3 of the TACS criteria (usually homonymous hemianopia and higher cortical dysfunction)
What are the features of a posterior circulation stroke?
Cerebellar syndrome (DANISH)
Brainstem syndrome (cranial nerves - facial weakness, nystagmus, dysphagia, dysarthria)
Homonymous hemianopia
NOTE: affects the vertebrobasilar territory
How do lacunar infarcts manifest and how does it relate to the part of the brain affected?
Pure motor (posterior limb of internal capsule)
Pure sensory (posterior thalamus)
Mixed sensorimotor (internal capsule)
Dysarthria
Ataxia hemiparesis (anterior limb of internal capsule)
List some stroke mimics.
Space-occupying lesion
Head injury
Hyper/hypoglycaemia
Infection (encephalitis, meningitis)
Drugs (e.g. opiates)
Outline the typical first presentation of multiple sclerosis.
Two episodes separated by time and space
Tingling
Eyes (optic neuritis - pain on eye movement and reduced central vision)
Ataxia (and other cerebellar signs)
Motor (usually spastic paraparesis)
Which investigations may be used in suspected multiple sclerosis?
MRI (gadolinium-enhanced will show areas of active inflammation)
LP (oligoclonal bands)
Antibodies (anti-MBP)
Visual evoked potentials (optic neuritis)
What is internuclear ophthalmoplegia and what is it caused by?
Caused by damage to the medial longitudinal fasciculus which is responsible for allowing communication between the ipsilateral CN3 (adduction) and contralateral CN6 (abduction).
This leads to failure of adduction of the ipsilateral eye. Nystagmus in the abducting eye may be noted.
It is most commonly caused by multiple sclerosis (and stroke in older patients)
What is the difference between bulbar and pseudobulbar palsy?
Bulbar: lower motor neurone palsy of CN 9 to 12.
Pseudobulbar: upper motor neurone palsy affecting CN 5, 7, 9-12.
Both cause dysphagia and dysarthria but pseudobulbar palsy will also cause lack of facial expression, difficulty chewing and emotional lability.
NOTE: key difference is that bulbar palsy causes LMN signs (e.g. tongue fasciculations) whereas pseudobulbar causes UMN signs (e.g. exaggerated gag reflex)
What are the different types of motor neuron disease?
Amyotrophic lateral sclerosis (50%) - UMN and LMN signs
Primary lateral sclerosis - mainly UMN signs (spastic leg weakness and pseudobulbar palsy)
Progressive bulbar palsy - only affects CN 9-12
Progressive muscular atrophy - LMN signs only, affects distal to proximal (best prognosis)
List some lower motor neurone signs.
Muscle wasting
Fasciculations
Hypotonia
Hyporeflexia
List some causes of LMN signs.
DISTAL: Charcot-Marie-Tooth disease, paraneoplastic, lead poisoning, GBS, botulism
PROXIMAL: muscular dystrophy, myositis, Cushing’s, thyrotoxicosis, diabetic amyotrophy, alcohol
UNILATERAL: polio, mononeuropathy
List some causes of peripheral sensory neuropathy.
Diabetes mellitus
Alcohol abuse
B12 deficiency
Chronic renal failure
Hypocalcaemia
Vasculitis
Drugs (e.g. isoniazid)
What features of diabetic neuropathy can be seen in the lower limbs?
Distal sensory loss (gloves and stockings)
Bilateral loss of ankle jerk (due to sensory neuropathy)
Mononeuritis multiplex (foot drop)
List some manifestations of autonomic neuropathy in diabetes mellitus.
Postural hypotension
Gastroparesis
Diarrhoea
Urinary retention
Erectile dysfunction
List the main features of Charcot-Marie-Tooth disease.
Pes cavus
Symmetrical distal muscle wasting (claw hand, champagne bottle led)
Thickened nerves
High stepping gait
Weak foot and toe dorsiflexion
Absent ankle jerk
Variable loss of sensation
List some differentials for bilateral ptosis.
Myasthenia gravis
Myotonic dystrophy
Congenital
Senile
Bilateral Horner’s (RARE)
Describe the typical presentation of Guillain-Barre syndrome.
Symmetrical ascending flaccid paralysis and sensory disturbance (paraesthesia)
Can cause autonomic neuropathy (labile BP)
NOTE: Miller-Fisher variant is characterised by ophthalmoplegia, ataxia and areflexia
Which muscles are weak in a facial nerve palsy?
Fronatlis (raising eyebrows)
Orbicularis oculi (scrunching eyes)
Orbicularis oris (smiling)
NOTE: UMN lesion spares frontalis and orbicularis oculi - if UMN then it may be due to a stroke so do other neuro exams
List some causes of facial nerve palsy.
Idiopathic (Bell’s palsy) - 75%
Vascular (stroke)
Multiple sclerosis
Space-occupying lesion
Vestibular schwannoma
Meningioma
Ramsay-Hunt syndrome
Parotid tumour
Sarcoidosis
Lyme disease
NOTE: patients may complain of hyperacusis due to paralysis of stapedius and aguesia (loss of taste)
What causes Ramsay-Hunt syndrome?
Reactivation of VZV in the geniculate ganglion of CN7
List some causes of Horner’s syndrome.
Multiple sclerosis
Pancoast tumour
Trauma (central line, carotid endarterectomy)
Cavernous sinus thrombosis
What are the main features of oculomotor nerve palsy?
Ptosis (LPS)
Eye points down and out (unopposed superior oblique and lateral rectus)
Dilated pupils
May have ophthalmoplegia and diplopia
List some causes of third nerve palsy.
MEDICAL: mononeuritis (DM), MS, midbrain infarction, migraine
SURGICAL: raised ICP (transtentorial herniation), cavernous sinus thrombosis, posterior communicating artery aneurysm
What is a Holmes-Adie pupil?
Dilated pupil with no response to light and sluggish response to accommodation
Benign condition, more common in females
Also known as myotonic pupil and usually presents with sudden-onset blurred vision. Aetiology unknown.
What are Argyll-Robertson pupils?
Small, irregular pupils
Accommodation intact
Reaction to light is lost
Atrophied and depigmented iris
Causes include neurosyphilis and DM (lesion in pretectal lesion)
What is an RAPD (Marcus Gunn pupil)?
Minor constriction to direct light
Dilatation when moving light to abnormal light (due to defect in the afferent pathway)
List some causes of RAPD.
Optic neuritis (MS)
Ischaemic optic/renal disease (central retinal artery occlusion)
Severe glaucoma
Direct optic nerve damage (trauma, tumour)
Retinal detachment (diagnosed with ultrasound B scan)
Severe macular degeneration
Retinal infection (CMV, herpes)
List some features of optic atrophy.
Reduced visual acuity
Reduced colour vision
Central scotoma
Pale optic disc
RAPD
Outline the visual pathway.
Retina
Optic nerve
Optic chiasm (nasal fibres decussate)
Optic tract
Lateral geniculate nucleus of thalamus
Optic radiation (superior field = temporal; inferior field = parietal)
Visual cortex
A lesion at what point in the visual pathway causes homonymous hemianopia?
Contralateral defect beyond the optic chiasm (retrochiasmatic)
A larger defect suggests a larger lesion or it’s closer to the chiasm
NOTE: examine for ipsilateral hemiparesis and cerebellar signs
Which visual defect might you see in a middle cerebral artery stroke?
Homonymous hemianopia
NOTE: MCA supplies the optic radiation in the temporal and parietal lobes
Which visual defect might you see in a posterior cerebral artery stroke?
Homonymous hemianopia with macular sparing (branch of MCA supplies the visual cortex)
NOTE: patients will not have hemiparesis but may have cerebellar signs
List some causes of monocular blindness.
Eye problem (e.g. cornea, vitreous, retina)
Optic nerve (optic neuropathy)
List some causes of bitemporal hemianopia.
Pituitary tumours
Craniopharyngioma (benign suprasellar tumour from Rathke’s pouch)
What could cause a negative Rinne’s test?
Negative = BC > AC
True: conductive deafness
False: complete sensorineural hearing loss
How is Weber’s test interpreted?
SNHL: lateralises to normal ear
Conductive: lateralises to abnormal ear
List some causes of conductive hearing loss.
Canal obstruction (wax, foreign body)
Tympanic membrane perforation: trauma, infection
Ossicle defects: otosclerosis, infection, fluid in middle ear
List some causes of sensorineural hearing loss.
Presbyacusis
Drugs (gentamicin, vancomycin)
Infection (meningitis, measles)
Tumour (vestibular schwannoma)
Alport syndrome (SNHL + haematuria)
Describe how dysphasia can be tested.
Nominal dysphasia: name three objects
Receptive dysphasia: three-stage command
Conductive dysphasia: repeat a sentence
What is the difference between dysarthria and dysphasia?
Dysarthria: impaired articulation of sound
Dysphasia: impairment of language
List some causes of dysarthria.
Mouth lesions
Pseudobulbar palsy
Bulbar palsy
Cerebellar lesion
Describe the different types of dysphasia.
Expressive: Broca’s area damage (inferior frontal gyrus) - non-fluent speech but comprehension intact
Receptive: Wernicke’s area damage (superior temporal gyrus) - fluent but meaningless speech, comprehension impaired
Conductive: arcuate fasciculus damage - comprehension intact, unable to repeat words/phrases
Which areas of skin tend to be affected by plaque psoriasis?
Extensors
Behind the ears
Scalp
Umbilicus
Sites of trauma (Koebner phenomenon)
Auspitz sign (pinpoint bleeding at site of scraping)
DDx: fungal infection, lichen planus, Bowen’s disease, dermatitis
List some different subtypes of psoriasis.
Plaque
Guttate (drop lesions after Strep infection)
Pustular (generalised or palmo-plantar)
Erythrodermic
Flexural
What are the five patterns of psoriatic arthritis?
Symmetrical polyarthritis
Asymmetrical oligoarthritis
DIP involvement
Arthritis mutilans
Psoriatic spondylopathy
List some complications of neurofibromatosis.
Epilepsy
Sarcomatous change
Scoliosis
Learning difficulty
List some causes of cafe au lait spots.
NF1
Noonan syndrome
McCune Albright syndrome (cafe au lait spots, polyostotic fibrous dysplasia and endocrinopathy (precocious puberty))
What are the main features of Peutz-Jeghers syndrome?
Autosomal dominant mutation of STK11 gene on chromosome 19
Leads to multiple mucocutaneous macules (on lips and oral mucosa) and GI hamartomatous polyps (can bleed/intussusception)
They have an increased risk of colorectal cancer
List some causes of erythema multiforme.
Infection (HSV, mycoplasma, other (TB, histoplasmosis, Yersinia)
Drugs (sulphonamides, NSAIDs, allopurinol)
Severe form is called Stevens-Johnson syndrome (with mucosal ulceration and liver failure)
DDx: tinea, discoid eczema
List some causes of erythema nodosum.
Systemic: sarcoidosis, IBD, Behcet’s disease
Infection: streptococcal, TB
Drugs: sulphonamides, OCP
NOTE: the pain begins before the skin changes
List some extra-articular features of rheumatoid arthritis.
Eyes: episcleritis, keratoconjunctivitis sicca
Heart: pericarditis
Lungs: pulmonary fibrosis
Abdomen: splenomegaly (Felty)
Urine: amyloidosis from chronic inflammation
Skeletal: atlanto-axial subluxation
Skin: rheumatoid nodules
Which surgical procedures might patients with rheumatoid arthritis undergo?
Carpal tunnel decompression
Tendon repairs and transfers
Ulna stylectomy
Arthroplasty
What are the main side-effects of methotrexate?
Bone marrow suppression
Hepatotoxicity
Pulmonary fibrosis
What is Jaccoud arthropathy ?
Chronic non-erosive reversible joint disorder occurring due to repeated bouts of arthritis commonly associated with SLE
Mimics rheumatoid arthritis but is caused by tendon contractures which are reducible on extension
Describe the pattern of symptoms seen in ankylosing spondylitis.
Back pain that is worst in the morning and improves with exercise
NOTE: check for extra-articular manifestations as well (e.g. aortic regurgitation, ankylosing spondylitis, Achilles tendinitis, apical fibrosis, amyloidosis)
List some risk factors for gout.
Obesity
Hypertension
Drugs (thiazides, cytotoxic)
Lymphoproliferative disorder
Chronic renal failure
Alcoholism
Diet - purine rich foods
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
What are some key things that you should do when examining a patient with acromegaly?
Shake the patient’s hand feeling for doughy consistency and excessive sweating
Check blood pressure
Dipstick urine for glycosuria
Visual field testing for bitemporal hemianopia
Look at tongue and teeth
Examine cardiovascular system if time
Key questions: change in ring size, change in shoe size, changes in vision, ask for old photographs
How is acromegaly investigated?
IGF-1 levels
Glucose tolerance test and measure GH levels (should be undetectable in normal people)
Imaging: lateral skull X-ray, CT, MRI
What are the treatments for acromegaly?
Transphenoidal hypophysectomy
Pituitary irradiation
Medical (octreotide 100-200 mcg every 8 hours OR lanreotide monthly)
What are some key things that you should do when examining a patient with Cushing syndrome?
Examine face and skin looking for bruising and thin skin
Check blood pressure
Urine dipstick for glycosuria
Look for proximal myopathy (squat down and stand up) and abdominal striae
What are the main causes of Cushing syndrome?
Iatrogenic (exogenous steroids) - MOST COMMON
Pituitary adenoma (next most common)
Adrenal adenoma
Ectopic ACTH (small cell lung cancer)
Outline the treatment of Paget’s disease.
May not need treatment
Simple analgesia
IV pamidronate every 3 months (mainstay)
Regular oral alendronate
What are the main differences between the CSF findings of bacterial and viral meningitis?
Viral: clear, lymphocytes, normal glucose, normal/high protein
Bacteria: cloudy, neutrophils, low glucose, high protein
Which medication reduces vasospasm in subarachnoid haemorrhage?
Nimodipine
Describe the difference in the pathogenesis of pupil-sparing and non-pupil sparing 3rd nerve palsy.
Pupil-sparing: caused by diabetes mellitus, where damage to the vasa vasorum supplying the main trunk of the 3rd nerve causes ischaemia (but sparing of surrounding parasympathetic fibres)
NON-pupil sparing: caused by space occupying lesions (e.g. posterior communicating artery aneurysm) which put pressure on the parasympathetic fibres and the main trunk causing dilatation
Which key examinations should you do in a patient with suspected MS?
Fundoscopy - check for optic neuritis
RAPD
Check for UMN signs in other parts of the body
Check for cerebellar signs (cerebellum is often affected)
What causes clonus?
Hugely increased muscle tone (i.e. UMN sign)
List some poor prognostic features of MS.
Brainstem or cerebellar disease at onset
Onset over age of 40 years
Primary progressive MS
What are the main features of neurofibromatosis type 1?
Multiple (>5) cafe au lait patches
Axillary or inguinal freckling
Optic glioma
Lisch nodules (hamartomas on iris)
Other: meningioma, phaeochromocytoma, kyphoscoliosis, renal artery stenosis
NOTE: it is autosomal dominant (Chr17)
List some causes of lower motor neurone signs.
Motor neurone disease (also causes UMN signs)
Previous polio (destroys anterior horn cells)
Guillain-Barre syndrome
Peripheral nerve lesion (e.g. trauma around fibula causing footdrop)
List some causes of upper motor neurone signs.
Stroke
Multiple sclerosis
Brain tumour
Damage to spinal cord
What is a passive shoulder shrug used for?
Loss of swing of an arm is a sign of rigidity
This may be due to Parkinson’s disease or UMN lesion
What does a positive Romberg sign suggest?
The patient is heavily dependent on vision for balance (sensory ataxia)
i.e. proprioception in the feet is impaired (peripheral neuropathy)
What is an easy way of testing L4/5 and S1/2?
L4/5 - ask the patient to stand and raise their toes off the ground (like a penguin)
What gait abnormality would you expect to see in a patient with an UMN lesion?
Drags legs
Circumducts (unilatearl) or scissors (bilateral)
What gait abnormality would you expect to see in peripheral motor neuropathy?
Foot drop (high step)
What gait abnormality would you expect to see in patients with myopathy?
Waddling
Difficulty standing/squatting
Trendelenberg sign
What gait abnormality would you expect to see in patients with cerebellar disorders?
Ataxic - broad-based, variable cadence
What would an ataxic gait due to sensory impairment look like?
Broad-based
Stamping
Romberg sign positive
What gait abnormality would you expect to see in Parkinson’s disease?
Reduced arm swing
Stooped, shuffling gait
Freezing
Festination
Outline the MRC scale for grading muscle power.
0 - no movement
1 - flicker in muscle
2 - moves but not against gravity
3 - can overcome gravity
4 - weak but can overcome gravity
5 - normal
List the main reflexes tested in a limb neurological exam and the nerve roots involved.
Biceps (C5/6)
Brachioradialis (C6)
Triceps (C7/8)
Knee (L3/4)
Ankle (S1/2)
List some niche reflexes that you may be able to elicit in patients with upper motor neurone lesions.
Finger jerks
Hoffman reflex
Crossed adductors
Absent abdominal reflexes
Which sensory nerve is responsible for sensation at the nipple and belly button?
Nipple: C5/6
Belly Button: T10
NOTE: with cord lesions that cause a sensory loss up to a certain level - the level of the sensory loss is the lowest level the cord lesion could be at. Pain is a better sign for localising the lesion.
What is the difference in the pattern of neurological symptoms in extrinsic vs intrinsic compression of the spinal cord?
Extrinsic (disc prolapse): rising sensory level (hitting the outer most fibres first)
Intrinsic (syringomyelia): descending sensory level and may affect pain (hitting inner most fibres first)
At what level does the spinal cord end?
L1
Lesions below this will produced LMN signs
What are the main aspects of testing the cranial nerves involving the eyes?
Visual acuity
Visual fields
Pupillary responses
Fundoscopy
Eye movements
What conclusions can you draw from looking at the shoes of a neurology patient?
Laces - likely to be good upper limb function
Shoes are worn - the patient is walking
Shoes worn at the lateral front edges from circumducting legs (likely UMN lesion)
Shoes worn at the front - foot drop
Both shoes worn - bilateral problem
List some causes of ascending aorta aneurysms.
Aortic stenosis (post-stenotic dilatation)
Hypertension
Marfan syndrome
Syphilis
What does obscuring of the right heart border suggest?
Right middle lobe pathology
What does obscuring of the left heart border suggest?
Left upper lobe pathology (lingula)
List some causes of lobar collapse.
Mucus plugs in bronchiectasis
Tumour blocking the airway
Foreign body inhalation
Which cancers have a predilection for spreading to the lungs?
Breast
Renal
Thyroid
Choriocarcinoma
What is the difference between a mass and a nodule in terms of CXR interpretation?
Nodule < 3 cm
Mass > 3 cm
What is an important differential to consider in a CXR that looks like a pneumothorax?
Giant bulla
DO NOT PUT CHEST DRAIN IN
What is the 10-day rule with regards to using ionising radiation in women?
In women of child-bearing age, imaging of the abdomen/pelvis using ionising radiation should be restricted to the 10 days following the onset of menstruation (i.e. day 1-10 of the menstrual cycle)
NOTE: this can be overridden if their life is in danger
Outline the treatment of acute otitis externa and otitis media.
Otitis externa: topical antibiotics (e.g. sofradex)
Otitis media: 7-10 day course of amoxicillin
Mastoiditis: surgical decompression (cortical mastoidectomy)
NOTE: mastoiditis can lead to meningitis, facial nerve palsy, brain abscess and death
Outline the treatment of sudden sensorineural hearing loss.
Steroids (high dose)
Anti-virals (aciclovir)
Intratympanic steroid injections
How is facial nerve palsy treated?
High dose oral steroids (40-60 mg prednisolone)
Aciclovir 800 mg 5 per day
How is BPPV treated?
Epley manoeuvre
NOTE: it is tested for using the Dix-Hallpike manoeuvre
List some causes of vertigo.
Meniere’s disease
Acoustic neuroma
Trauma
Migraine
Central causes (CVA, cerebellar tumour)
How is bacterial tonsillitis treated?
Penicillin V 500 mg QDS for 10 days
List some symptoms of quinsy.
Trismus
Hot potato voice
Anorexia
Spiking fever
Stiff neck
Stertor
NOTE: needs drainage
What can cause a loud second heart sound?
Pulmonary or systemic hypertension
How is bronchial breathing different from vesicular breathing?
Vesicular: crescendo-decrescendo with no gap, inspiration longer than expiration
Bronchial: expiration same duration as inspiration with a gap in the middle
What does a low TLCO or Kco suggest?
Damage to lung parenchyma (e.g. fibrosis, emphysema)
NOTE: they are both a measure of the diffusion capacity of the lungs (TLCO is not adjusted for volume, Kco is adjusted for volume)
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)
List some causes of palmar erythema.
Cirrhosis
Hyperthyroidism
Rheumatoid arthritis
Pregnancy
Polycythaemia
List some causes of gynaecomastia.
Physiological (puberty)
Drugs (spironolactone, digoxin, cimetidine, finasteride)
Cirrhosis
Testicular tumour/orchidectomy
Kleinfelter’s and Kallman syndrome
List some clinical features of haemochromatosis.
Testicular atrophy
Diabetes mellitus (injection sites)
Congestive cardiac failure
Arthropathy
Chronic liver disease
What are the main indications for splenectomy?
Rupture (trauma)
Haematological (ITP, hereditary spherocytosis, sickle cell disease)
How do patients with polycystic kidney disease tend to present?
Hypertension
Recurrent UTI
Abdominal pain (bleeding into cyst or cyst infection)
Haematuria
End-stage renal failure
NOTE: may present with extra-renal manifestations such as subarachnoid haemorrhage, mitral valve prolapse and hepatic cysts
List some signs of interstitial lung disease.
Clubbing
Central cyanosis
Fine end-inspiratory crackles
Signs of autoimmune disease (e.g. rheumatoid arthritis, SLE, SS)
Grey skin (amiodarone)
List some causes of apical fibrosis.
TB
Radiation
Ankylosing spondylitis
ABPA
Sarcoidosis
Histoplasmosis
EAA
List some clinical signs of COPD.
Central cyanosis
Pursed lip breathing
CO2 retention flap/bounding pulse
Tar stained fingers
Expiratory polyphonic wheeze
Cor pulmonale (raised JVP, ankle oedema, RV heave, loud P2)
Outline the management of COPD.
Smoking cessation
Beta-agonists (salbutamol)
Tiotropium bromide
Inhaled corticosteroids
Vaccinations (influenza, pneumococcus)
Pulmonary rehabilitation
LTOT
List some surgical treatment options for COPD patients.
Bullectomy
Endobronchial valve placement
Lung reduction surgery (if heterogenous distribution of emphysema)
Single lung transplant
List some differentials for a wheezy chest.
COPD
Asthma
Bronchiectasis
Granulomatosis with polyangiitis (obliterative bronchiolitis)
Rheumatoid arthritis
List the criteria for starting long-term oxygne therapy.
Non-smoker
PaO2 < 7.3 kPa on air
PaO2 7.3-8 with secondary polycythaemia, peripheral oedema, or evidence of pulmonary hypertension
List some clinical signs of a pleural effusion.
Asymmetrically reduced expansion
Trachea deviated away from effusion
Stony dull percussion
Absence tactile vocal fremitus
Reduced breath sounds
Bronchial breathing above fluid level
List some complications of lung cancer.
Superior vena cava obstruction
Recurrent laryngeal nerve palsy
Horner’s syndrome
Wasting of small muscles of hand
Endocrine (gynaecomastia)
Neurological (Lambert-Eaton)
Dermatomyositis
List some differentials for systolic murmurs.
Aortic stenosis
Aortic sclerosis
Mitral regurgitation
HOCM
VSD
Aortic flow murmur
List some clinical signs of aortic stenosis.
Slow rising pulse
Narrow pulse pressure
Ejection systolic murmur
Thrill over aortic area
What is the EuroSCORE?
A risk model that calculates the risk of death after a cardiac operation
List some clinical signs of tricuspid regurgitation.
Raised JVP (giant V waves)
Pansystolic murmur loudest in tricuspid area
Thrill at left sternal edge
Pulsatile liver, ascites and peripheral oedema
Endocarditis signs (IVDU)
Pulmonary hypertension (loud P2)
List some indications for having an ICD.
Familial conditions with high risk of sudden cardiac death (long QT, ARVD, brugada, HCM)
Cardiac arrest due to VT/VF
Haemodynamically compromising VT
VT with LVEF < 35%
List some clinical signs of constrictive pericarditis.
Raised JVP
Right heart failure
Kussmaul sign (paradoxical increase in JVP on inspiration)
Pulsus paradoxus (>10 mm Hg drop in SBP on inspiration)
Hepatomegaly, ascites and peripheral oedema
List some causes of constrictive pericarditis.
TB
Trauma (or surgery)
Radiotherapy
Connective tissue disease (rheumatoid, SLE)
What murmur is caused by ASD?
Ejection systolic murmur with fixed split-second heart sounds
What murmur is caused by VSD?
Systolic murmur loudest at the left sternal edge (no radiation)
List some clinical signs of myotonic dystrophy.
Myopathic facies (long, thin, expressionless)
Wasting of facial muscles and SCM
Bilateral ptosis
Frontal balding
Dysarthria (myotonia of tongue and pharynx)
Test grip (wont be able to let go)
Cataracts
Cardiomyopathy
Testicular atrophy
What are dominant and non-dominant parietal lobe signs?
Dominant: dysphasia (receptive, expressive, global)
Non-Dominant: dressing/constructional apraxia, spatial neglect
List some causes of mononeuritis multiplex.
Diabetes mellitus
Connective tissue disease (SLE, rheumatoid)
Vasculitis (e.g. PAN)
Infection (e.g. HIV)
Malignancy
Mononeuritis multiplex: painful, asymmetrical, asynchronous sensory and motor peripheral neuropathy involving isolated damage to at least 2 separate nerve areas
Outline the management of Bell’s palsy.
Prednisolone if within 72 hours of onset of symptoms
Eye protection (artificial tears, tape eyes closed at night)
Outline the treatment of myasthenia gravis.
Acute: IVIG and plasmapheresis
Chronic: acetylcholinesterase inhibitor (e.g. pyridostigmine), steroids, thymectomy
List some signs of tuberous sclerosis.
Angiofibromata on the face
Periungual fibromas
Shagreen patch (roughened, leathery skin in lumbar region)
Ash leaf hypopigmentation
Other: cystic lung disease, renal enlargement due to angiomyolipoma/PKD (and features of renal replacement), seizures, developmental delay, signs of antiepileptic treatment
List some medical and surgical causes of 3rd nerve palsy.
Medical: mononeuritis multiplex (DM), midbrain infarction, MS, migraine
Surgical: posterior communicating arter aneurysm, cavernous sinus thrombosis, uncal herniation
List some causes of tunnel vision.
Papilloedema
Glaucoma
Choroidoretinitis
Migraine
Retinitis pigmentosa
Describe the appearance of retinal artery occlusion on fundoscopy.
Pale, milky fundus with thread-like arterioles
Cherry red macula
Describe the appearance of retinal vein occlusion on fundoscopy.
Flame haemorrhages (radiating out from swollen disc)
Engorged tortuous veins
Cotton wool spots
Look for diabetic or hypertensive changes
NOTE: causes include hypertension, diabetes, hyperviscocity and high IOP
List some differentials for Parkinson’s disease.
Parkinson’s plus (PSP, CBD, MSA, LBD)
Basal ganglia infarct
Encephalitis
Traumatic encephalopathy
Metabolic (Wilson’s)
Drugs (antipsychotics, metoclopramide)
List some causes of unilatearl spastic paraparesis.
Hemisphere: stroke, MS, SOL, cerebral palsy
Hemicord: MS, compression
What are the main clinical features of de Quervain’s tenosynovitis and what is it caused by?
Pain on radial side of wrist
Tender radial styloid process
Abduction of thumb against resistance is painful
Finkelstein test - examiner pulls thumb in ulnar deviation and longitudinal traction. It causes pain over radial styloid process
Tendons involved: extensor pollicis brevis + abductor pollicis longus
What is a major indication for NIV in a patient with an infective exacerbation of COPD?
Respiratory acidosis despite maximum medical treatment (PaCO2 > 6 kPa and pH < 7.35)
List some indications for non-invasive ventilation.
COPD with respiratory acidosis
Type 2 respiratory failure (e.g. due to neuromuscular disease)
Cardiogenic pulmonary oedema
Obstructive sleep apnoea
Weaning from endotracheal intubation
List some causes of spider naevi.
Chronic liver disease
Pregnancy
COCP
List some indications for CABG.
Left main stem disease
Triple vessel disease
Refractory angina
Unsuccessful angioplasty
NOTE: complications include MI, cardiac tamponade, haemothorax, post-op AF, graft stenosis
List some causes of high-output cardiac failure.
Thyrotoxicosis
Anaemia
Paget’s disease
Pregnancy
List some secondary causes of hypertension.
Renal artery stenosis
Coarctation of the aorta
Polycystic kidney disese
Conn’s, Cushing’s, Phaeochromocytoma, acromegaly, thyrotoxicosis
What are the indications for surgical valve replacement in aortic stenosis?
Symptomatic AS
Severe asymptomatic AS with reduced EF
Severe AS undergoing other operation (e.g. CABG)
List some causes of an S4 heart sound.
Thickened ventricular wall due to hypertension or aortic stenosis
Coronary artery disease
Cardiomyopathy
List some conditions that display Koebner phenomenon.
Psoriasis
Vitiligo
Lichen planus
Describe some symptoms and signs of subacute combined degeneration of the spinal cord.
Weakness (e.g. legs, arms, trunk)
Tingling and numbness
Bilateral spastic paresis
Impaired find touch and vibration
Upgoing plantars
Describe the classical features of lumbar spinal stenosis.
Back pain extending to buttocks and backs of thighs
Pain is worse when standing or walking
Pain relieved by sitting down and leaning forward
Lower limb weakness
Which investigations would you request in a patient with suspected thyroid disease?
TFTs (TSH, T3/4, antibodies)
Thyroid uptake scan (technetium 99m pertechnetate)
FBC, Calcium, ESR
List some differentials for thyroid enlargement.
Graves
Thyroiditis (Hashimoto’s, De Quervain’s, Riedel)
Multinodular goitre
Follicular adenoma
Thyroid cancer (papillary, follicular, medullar, anaplastic)
Iodine deficiency
What are the two different types of Charcot-Marie-Tooth disease?
HSMN1 - more common, demyelinating, autosomal dominant (PMP22 gene)
HMSN2 - axonal degeneration, autosomal dominant
NOTE: CMT can also be recessive
Outline the investigations that may be used in patients with suspected Charcot-Marie-Tooth disease.
Nerve conduction studies (demyelination will cause reduced velocity, axonal degeneration will cause reduced amplitude)
Genetic testing (PMP22 gene)
Outline the management options for patients with Charcot-Marie-Tooth disease.
MDT: GP, neurologist, specialist nurses, physiotherapist, OT, orthotics
Foot care and careful shoe choice
Orthotics
Describe the pathway of the direct and consensual light reflex.
Retina –> Optic Nerve –> Pre-Tectal Nucleus –> Edinger-Westphal Nucleus (both) –> Oculomotor Nerve –> Ciliary Ganglion –> Pupillary Sphincter
Lesions in which parts of the nervous system could cause symmetrical weakness?
Cord lesions
Neuromuscular junction pathology (MG, LEMS)
Muscle pathology (e.g. myositis)
What are the different patterns of sensory loss and which lesions are they typically associated with?
Distal sensory loss - peripheral neuropathy (e.g. DM, B12, alcohol)
Sensory level - cord lesion (e.g. cord compression)
Dissociated sensory loss (e.g. loss of pain/temp with conservation of light touch) - cervical cord lesions (e.g. syringomyelia
Describe the main features of an anterior cerebral artery stroke.
Contralateral motor/sensory loss in LEGS > arms
Face is spared
Describe the main features of a middle cerebral artery stroke.
Contralateral motor/sensory loss in FACE/ARMS > legs
Contralateral homonymous hemianopia
Cognitive changes (dominant = aphasia; non-dominant = neglect/apraxia)
Describe the main features of a posterior cerebral artery stroke.
Contralateral homonymous hemianopia with macula sparing
What are the different anatomical levels at which pathology can cause muscle weakness?
Cerebrum/Brainstem - stroke, SOL, MS
Cord - MS, injury
Anterior Horn - MND, Polio
Nerve Roots/Plexus - cauda equina, cord compression
Motor Nerve - compression, mononeuritis multiplex, CMT
NMJ - Myasthenia, LEMS
Muscle - myositis, muscular dystrophy
List some causes of bilateral foot drop.
Charcot-Marie-Tooth disease
Guillain Barre syndrome
Cauda equina
List some causes of unilateral lower limb spasticity.
Stroke
MS
SOL
NOTE: it will cause a circumducting gait
List some causes of bilateral lower limb spasticity.
Spinal Cord (compression, trauma, transverse myelitis)
Cerebral palsy (bihemispheric)
MS (bihemispheric)
List some causes of mixed UMN and LMN symptoms.
Motor neurone disease
Friedreich ataxia
SACD
Taboparesis (syphylis)
List some causes of sensory ataxia.
Vestibular - Meniere’s disease, viral labyrinthitis
Proprioceptive Loss - B12 deficiency, DM, alcohol
List some causes of a postural tremor.
Benign essential tremor
Endocrine (thyrotoxicosis, hypoglycaemia)
Alcohol withdrawal
Beta-agonists
Anxiety (physiological)
What is idiopathic focal dystonia?
Most common form of dystonia
Confined to one body part
E.g. spasmodic torticollis, blepharospasm, Writer’s cramp
List some causes of chorea.
Huntington’s chorea
Sydenham’s chorea (rheumatic fever)
Wilson’s disease
L-DOPA
Define dementia.
Chronically impaired cognition that affects multiple domains (memory, attention, language) without impairment of consciousness
List some causes of delirium.
Infection (UTI, sepsis)
Dehydration
Constipation
Drugs (e.g. opioids)
Metabolic (e.g. hyponatraemia, hypoglycaemia)
Intracranial pathology (e.g. subdural haemorrhage)
List some complications of subarachnoid haemorrhage.
Rebleeding
Cerebral ischaemia (vasospasm)
Hydrocephalus
Hyponatraemia
Which members of the MDT would be involved in the management of patients who have had a stroke?
Neurologist
Physiotherapist
SALT
Dietician
OT
Specialist nurse
Which investigations should be done to find a potential source of an embolus in a patient with a TIA?
ECG
Echocardiogram
Carotid artery doppler
Check Risk Factors: FBC, U&E, ESR, glucose, lipids
Which scoring system is used to assess the risk of future stroke in a patient who has had a TIA?
ABCD2
4 or more = TIA clinic within 24 hours
< 4 = TIA clinic within 1 week
What are the typical features of cerebral venous sinus thrombosis?
Headache
Vomiting
Seizures
Reduced visual acuity
Papilloedema
Proptosis (cavernous sinus thrombosis)
NOTE: DDx - SAH, meningitis, managed with LMWH/warfarin, fibrinolytics
List some risk factors for cerebral venous sinus thrombosis.
Pregnancy
OCP
Head injury
Dehydration
Malignancy
Thrombophilia
List some contraindications for lumbar puncture.
Raised ICP
Thrombocytopaenia
Coagulopathy
Infection at LP site
List some causes of provoked seizures.
Withdrawal (alcohol, opiates)
Metabolic (hypoglycaemia, hypocalcaemia)
Raised ICP (trauma, haemorrhage, SOL)
Infection (encephalitis)
Which investigations should be requested in a patient who has had a seizure?
FBC, U&E, Glucose
AED levels
Urine toxicology
ECG
EEG
MRI (if adult and risk of SOL)
What are the types of cerebral oedema?
Vasogenic (increased capillary permeability) - trauma, tumour, ischaemia, infection
Cytotoxic - e.g. hypoxia
Interstitial - e.g. obstructive hydrocephalus, hyponatraemia
Which sensory and motor signs might you see in a patient with multiple sclerosis?
MOTOR: spastic weakness, transverse myelitis (weakness + numbness)
SENSORY: paraesthesia, reduced vibration sense
NOTE: patients may also have cerebellar signs (e.g. ataxia, dysarthria)
What are some differentials for multiple sclerosis?
CNS sarcoidosis
SLE
Which signs might you see in a patient with spinal cord compression?
Back pain
Progressive UMN weakness and sensory loss below the lesion (e.g. bilateral spasticity in lower limbs)
Radicular pain in dermatomal distribution
NOTE: tone and reflexes are initially REDUCED in acute cord compression
Describe the clinical features of conus medullaris lesions.
Early constipation/retention
Mixed UMN/LMN weakness
Back pain
Sacral sensory disturbance
Which muscles are weak in the following nerve lesions?
C5fac
C6
C7
C8
C5 - deltoid, supraspinatus
C6 - biceps, brachioradialis (reduced biceps jerk)
C7 - triceps, finger extension (reduced triceps jerk)
C8 - finger flexors, intrinsic hand muscles
How does L5 radiculopathy manifest?
Weak hallux extension
Foot drop
Reduced sensation on inner dorsum of foot
NOTE: MRI lumbar spine would be useful to check for compression
How does S1 radiculopathy manifest?
Weak plantarflexion and eversion
Loss of ankle jerk
Reduced sensation over sole of foot and back of calf
NOTE: MRI lumbar spine would be useful to check for compression
What are some complications of Bell’s palsy?
Synkinesis (e.g. blinking causes upturning of mouth)
Crocodile tears (eating stimulates unilateral lacrimation)
What are the features of radial nerve palsy?
Finger drop (low)
Wrist drop (high)
Triceps paralysis (very high)
Loss of sensation of first dorsal web space
What are the features of sciatic nerve palsy?
Weakness of knee flexion
Weakness of all muscles below the knee
Loss of sensation below knee laterally and foot
What are the features of common peroneal nerve palsy?
Foot drop
Week dorsiflexion and eversion
Loss of sensation below knee laterally
What are the features of tibial nerve injury?
Weak plantarflexion (can’t stand on toes)
Weak toe flexion
Loss of sensation to sole of foot
List some causes of peripheral motor neuropathy.
Guillain Barre syndrome
Botulism
Charcot-Marie-Tooth
Lead poisoning
List some causes of autonomic neuropathy.
Diabetes mellitus
HIV
SLE
Guillain-barre syndrome
Outline the management of motor neurone disease.
MDT: neurologist, physio, OT, dietician, specialist nurse, GP
Medical: riluzole (antiglutamatergic)
Symptomatic: NG/PEG feeding, NIV for respiratory failure, analgesia, baclofen for spasticity
NOTE: most die of respiratory failure or infection
List some causes of bulbar and pseudobulbar palsy.
Bulbar: MND, GBS, myasthenia, central pontine myelinolysis
Pseudobulbar: MS, stroke, MND
Describe the typical clinical features of polio.
Asymmetrical LMN paralysis
No sensory involvement
What are the clinical features of fascioscapulohumeral muscular dystrophy?
Weakness of face, shoulders and upper arms (often asymmetrical)
Winging of the scapula
Foot drop
List some causes of cafe au lait spots.
NF1
McCune Albright syndrome
Noonan syndrome
Outline the management of NF1.
MDT approach
Epilepsy management
Excise some neurofibromas (cosmetic/sarcomatous)
Genetic counselling
NOTE: it is autosomal dominant
Outline the management of benign essential tremor.
Avoidance of exacerbating factors (coffee, stress)
Beta-blockers (e.g. propanolol)
Anti-epileptics (e.g. topiramate)
Benzodiazepines (e.g. clonazepam)
Botulinum injections
MRI-guided high intensity ultrasound
List some causes of a fixed dilated pupil.
3rd nerve palsy
Mydriatics (e.g. tropicamide)
Iris trauma
Acute glaucoma
List some causes of optic atrophy.
MS
Glaucoma
Congenital (LHON, CMT, Friedreich ataxia)
Toxins (ethambutol, B12 deficiency)
How can acute glaucoma be distinguished from anterior uveitis?
Cloudy cornea
Large pupil
Increased IOP
NOTE: both are painful
How can episcleritis and scleritis be distinguished?
Scleritis: vasculitis of the sclera, PAINFUL, worse on eye movement
Episcleritis: painless, acuity preserved, redness can be moved over sclera
Which imaging tool is used to give a 3D representation of the retina?
Optical coherence tomography
Outline the management options for wet ARMD.
Photodynamic therapy
Intravitreal VEGF injections (bevacizumab)
Anti-oxidants and zinc may help early ARMD
List some classes of medications that are used to reduced IOP in open angle glaucoma.
Beta-blockers (reduce production) - timolol
Prostaglandin analogue (increase uveoscleral outflow) - latanoprost
Alpha-agonists (reduce product and increase outflow) - brimonidine
Carbonic anhydrase inhibitors - acetazolamide
Miotics - pilocarpine
List some causes of cataracts.
Age
DM
Steroids
Congenital (Rubella, Wilson’s, myotonic dystrophy)
What is the normal duration of the following parts of an ECG?
PR interval
QRS complex
QTc
PR interval: 120-200 ms (3-5 small squares)
QRS complex: < 120 ms (3 small squares)
QTc: 380-420 ms (~2 big squares)
NOTE: normal ECG calibration is 25 mm/s
What is the difference between bifascicular and trifascicular block?
Bifascicular: RBBB + left anterior or posterior fascicular block
Trifascicular: RBBB + left anterior or posterior fascicular block + prolonged PR (1st degree)
What are escape rhythms?
Appear after an anticipated beat
Atrial Escape: SAN fails to depolarise leading to failed sinus beat, followed by atrial escape (narrow complex)
Ventricular Escape: atrial wave fails to conduct due to AV block, followed by ventricular escape (broad complex - weird and wide)
List some differentials for broad complex tachycardia.
VT
VF
Torsades de pointes
SVT with BBB
List some causes of VT.
Infarction
Myocarditis
Long QT syndrome
Cardiomyopathy
Iatrogenic (antiarrhythmics)
List some contraindications for thrombolysis.
GI bleeding
Recent haemorrhagic stroke
Severe hypertension
Trauma
List some differentials for chest pain.
ACS
Angina
Aortic dissection
Aortic aneurysm
GORD
Oesophageal spasm
Musculoskeletal
List some causes of heart failure.
SYSTOLIC: ischaemia, DCM, hypertension, myocarditis
DIASTOLIC: pericardial effusion, restrictive cardiomyopathy
ARRHYTHMIA: brady/tachy
Valve disease
HIGH OUTPUT: anaemia, thyrotoxicosis, pregnancy, Paget’s disease
List the main CXR features of heart failure.
Alveolar shaddowing
Kerley B lines
Cardiomegaly
Upper lobe diversion
Effusions
What are the main indications for pharmacological management of hypertension?
< 80 yrs, stage 1 hypertension (140/90-160/100) and one of:
- target organ damage (retinopathy, LVH)
- 10 yr CVD > 10% (QRISK)
- established CVD
- diabetes mellitus
- renal disease
Anyone with stage 2 hypertension and above
NOTE: statin should also be offered if QRISK > 10%
List some echocardiography features of severe mitral stenosis.
Valve orifice < 1 cm^2
Pressure gradient > 10 mm Hg
Pulmonary artery systolic pressure > 50 mm Hg
Which investigations should be requested insuspected infective endocarditis?
Bloods: ESR, blood cultures (3 x 12 hours apart), serology for unusual organisms
Urine: microscopic haematuria
ECG: AV block
Echo: vegetations
Which investigations should you request in a patient with suspected rheumatic fever?
Bloods: ASO titre, streptococcal antigen, FBC, ESR
Throat swab (if strep throat)
ECG
Echocardiogram (MR/AR)
List some causes of restrictive cardiomyopathy.
Amyloidosis
Haemochromatosis
Sarcoidosis
Primary endomyocardial fibrosis
List some causes of dilated cardiomyopathy.
Muscular dystrophy
Myocarditis
Alcoholism
SLE
Drugs (doxorubicin)
Thyrotoxicosis
List some complications of congenital heart disease.
Infective endocarditis
Pulmonary hypertension
Paradoxical emboli
Eisenmenger syndrome
List some features of Marfan syndrome.
Cardiac: aortic aneurysm, aortic dissection, aortic regurgitation, mitral valve prolapse
Lens dislocation
High-arched palate
Arm span > height
Pectus excavatum
Scoliosis
Hypermobility
List some features of Ehlers-Danlos syndrome.
Hyperelastic skin
Hypermobility (Beighton)
Cardiac (mitral prolapse, MR, AR, aneurysms)
Easy bruising (fragile blood vessels)
NOTE: cutis laxa is loose skin and hypermobile joints
List some complications of pneumonia.
Respiratory failure
Sepsis
AF
Pleural effusion
Empyema
List the different diseases that can be caused by aspergillosis.
Asthma
ABPA
Aspergilloma
Invasive aspergillosis
Extrinsic allergic alveolitis
List some causes of ARDS.
Pulmonary: pneumonia, aspiration, inhalational, contusion
Systemic: sepsis, pancreatitis, DIC, acute liver failure
List some causes of pulmonary oedema.
Heart failure
Renal failure
Liver failure
Iatrogenic fluid overload
Nephrotic syndrome
Lymphatic obstruction
ARDS (exudative)
What concentration of oxygen should be used in acutely unwell COPD patients?
80-90% 15 L/min through non-rebreathe mask initially and perform ABG
If PCO2 < 6 kPa: aim for target SaO2 94-98%
If PCO2 > 6 kPa: maintain target SaO2 88-92%
Outline the management of primary and secondary pneumothorax.
PRIMARY
- < 2 cm rim and not SOB - consider discharge
- otherwise: aspiration –> chest drain
SECONDARY
- > 2 cm rim OR SOB OR > 55 years –> chest drain
- otherwise: aspiration –> chest drain
- ALL patents should be admitted for at least 24 hours
List some features of sarcoidosis.
Constitutional upset
Respiratory (fibrosis, bilateral hilar lymphadenopathy)
Arthralgia
Peripheral/cranial neuropathy (e.g. Bell’s palsy)
Uveitis/keratoconjunctivitis
Restrictive cardiomyopathy
Hepatosplenomegaly
Lupus pernio
Erythema nodosum
What pulmonary artery pressure counts as pulmonary hypertension?
> 25 mm Hg
NOTE: normal is 8-20 mm Hg
Outline the management of pulmonary hypertension.
Treat underlying condition
LTOT
CCB
Sildenafil
Prostacyclin analogues
Heart failure treatment
Heart-lung transplant
List some secondary causes of diabetes mellitus.
Drugs (steroids, tacrolimus, ciclosporin)
Pancreatic (chronic pancreatitis, cystic fibrosis, hereditary haemochromatosis)
Endocrinology (phaeo, Cushing’s, phaeo)
What is usually checked at a routine diabetes check up?
Control (glycaemic) - HbA1c, BP, lipids, capillary blood glucose
Complications - BP, cardiac auscultation, fundoscopy, ACR, sensory testing
Competency - with treatment regime
Coping - psychosocial
What are the two main types of insulin regime in diabetes?
Biphasic - 30 mins before breakfast and dinner, good for patients with regular lifestyle (e.g. children, elderly)
Basal-Bolus - bedtime long-acting insulin + short-acting insulin before meals, good for patients with flexible lifestyle
NOTE: once-daily long-acting before bed is initially used in patients switching from tablets in T2DM
List some side-effects of insulin therapy.
Hypoglycamia (careful with alcohol and beta-blockers)
Lipohypertrophy
Weight gain
What should patients with diabetes be informed about regarding diabetes management when they are ill?
Insulin requirements usually increase
Check BMs more frequently than every 4 hours (and check urine for ketonuria)
Increase insulin dose if glucose is rising
Maintain calories as much as possible
Which investigation is used to check for proliferative diabetic nephropathy and wet ARMD?
Fluorescein angiography
List some complications of DKA.
Cerebral oedema (excess fluid administration)
Aspiration
Hypokalaemia
Hypophosphataemia (resp and skeletal muscle weakness)
VTE
List some causes of hypoglycaemia.
Inappropriate insulin
Drugs (sulphonylureas)
Pituitary insufficiency
Addison’s disease
Liver failure
Insulinoma
List some causes of hypothyroidism.
Atrophic hypothyroidism
Hashimoto’s hypothyroidism
Iodine deficiency
De Quervain’s thyroiditis
Drugs (thionamides, lithium)
Thyroidectomy
What are the main features of multiple endocrine neoplasia (MEN)?
MEN1: pituitary adenoma (prolactin, GH) + parathyroid adenoma/hyperplasia + pancreatic islet cell (gastrinoma, insulinoma)
MEN2: medullary thyroid cancer + phaeochromocytoma + parathyroid hyperplasia (2B - marfanoid body habitus)
Which diseases fall under the autoimmune polyendocrine syndromes?
Type 1 (recessive): Addison’s, candidiasis, hypoparathyroidism
Type 2 (polygenic): Addison’s, thyroid disease, T1DM
List some clinical features of acromegaly.
Prominent supraorbital ridges
Coarse facial features
Prognathism
Macroglossia
Wide-spaced teeth
Thenar wasting (and CTS symptoms)
Sweaty spade-like hands
What are the initial steps in the management of a patient with suspected coeliac disease and a high TTG?
Refer for gastroscopy and duodenal biopsies
Referral for bone density scan
Screening of first-degree relatives
Referral to dieticians for gluten-free diet advice
Which extra-GI manifestations of UC are related to the activity of colitis?
Erythema nodosum
Aphthous ulcers
Episcleritis
Acute arthropathy
Pyoderma gangrenosum
Anterior uveitis
List some medical treaments used for multiple sclerosis.
Steroids (IV methylprednisolone for optic neuritis)
1st line: Beta-interferon, glatiramer acetate
2nd line: natalizumab
Symptomatic: baclofen (spasticity)
List some causes of bloody diarrhoea.
Vascular: ischaemic colitis
Infective: shigella, salmonella, E. coli, C. difficile
Inflammatory bowel disease
Neoplastic: colorectal cancer, polyps
List the different types of laxative with examples.
Bulking: fybogel, methylcellulose
Osmotic: movicol, lactulose
Stimulant: senna, bisacodyl, docusate sodium, sodium picosulphate, co-danthramer
Softeners: liquid paraffin
Enemas: phosphate (osmotic)
Suppositories: glycerol (stimulant)
Outline the management options for achalasia.
Medical: CCBs, nitrates
Interventional: endoscopic balloon dilatation, botulinum toxin injection
Surgical: Heller cardiomyotomy
Outline the management of new-onset dyspepsia.
OGD if > 55 years and red flags (anorexia, weight loss, anaemia, recent onset, melaena, dysphagia)
Conservative measures for 4 weeks
- stop drugs (NSAIDs, CCB)
- lose weight, stop smoking, reduce alcohol
- OTC antacids and alginates
Test H. pylori if no improvement (breath or serology)
- positive –> eradication
- negative –> PPI for 4 weeks, consider OGD if no improvement
Describe the eradication therapy used to treat H. pylori.
Lansoprazole 30 mg BD + amoxicillin 1 g BD + clarithromycin 500 mg BD
Lansoprazole 30 mg BD + amoxicillin 1 g BD + metronidazole 400 mg BD
Outline the management of peptic ulcer disease.
CONSERVATIVE: lose weight, stop smoking, reduce alcohol, stop NSAIDs/steroids
MEDICAL: OTC antacids, H. pylori eradication, PPI/H2RA
SURGERY: vagotomy, antrectomy, subtotal gastrectomy
NOTE: antrum contains most gastrin-producing cells (types of operation: BIlroth 1 and 2)
List some causes of cirrhosis.
Alcoholic liver disease
Viral hepatitis
NASH
Genetic: Wilson’s, HH, a1AT
Autoimmune: PSC, PBC, AIH
Drugs: methotrexate, amiodarone, nitrofurantoin
Neoplasia: HCC, metastases
Vascular: Budd-Chiari, right heart failure, constrictive pericarditis
Outline the management of cirrhosis.
Alcohol abstinence
Cholestyramine for pruritus
Screening (HCC and varices)
Treat cause (interferon for HCV, ursodeoxycholic acid for PBC or penicillamine for Wilson’s disease)
List some causes of portal hypertension.
Pre-hepatic: portal vein thrombosis
Hepatic: CIRRHOSIS, schistosomiasis, sarcoidosis
Post-hepatic: Budd-Chiari, RHF, constrictive pericarditis
List some precipitants for decompensation of chronic liver failure.
Haemorrhage (e.g. varices)
Electrolyte abnormality (e.g. hypokalaemia)
Alcohol
HCC
Infection (SBP, pneumonia, UTI)
Constipation (MOST COMMON cause)
Hypoglycaemia
Drugs (e.g. sedatives, anaesthetics)
Which infections should patients be screened for before starting dialysis?
Hep B
Hep C
HIV
What is a key distinction between bullous pemphigoid and pemphigus vulgaris?
Pemphigus = oral involvement
Pemphigoid = NO oral involvement
Define the following terms used to describe skin lesions.
Macule
Nodule
Papule
Plaque
Vesicle
Macule - change in skin colour without change in elevation (called a patch if > 1 cm)
Nodule - raised lesion with a rounded surface > 1 cm
Papule - solid raised lesion < 1 cm in diameter
Plaque - elevated plateau of skin > 1 cm
Vesicle - fluid-filled lesion < 1 cm
Describe the criteria by which left ventricular hypertrophy by voltage criteria?
Sokolow-Lyon Criteria: Add the S wave in V1 plus the R wave in V5 or V6. If the sum is > 35 mm, then LVH is present
List some complciations of peptic ulcer disease.
Bleeding (haematemesis/melaenia)
Iron deficiency anaemia
Perforation and peritonitis
Malignancy
Which red flag symptoms would warrant an OGD in patients with suspected peptic ulcer disease?
Anaemia
Weight loss
Dysphagia
NOTE: if no red flags and < 55 years, investigate with H. pylori breath test, stool antigen test and bloods (FBC)
List some surgical management options for urinary tract calculi.
Extracorporeal shockwave lithotripsy (small stone < 20 mm)
JJ stent (hydronephrosis)
Ureteroscopy and laster/fragmentation (proximal stone)
Percutaneous nephrolithotomy/ureterolithotom (large stone > 20 mm)
Which medications are used to treat hepatitis C?
Pegylated interferon
Ribavirin
Boceprevir (protease inhibitor)
Sofosbuvir (NS5B inhibitor)
NOTE: all patients should be investigated to identify their HCV genotype
What treatment options are used for diabetic retinopathy with maculopathy and proliferative diabetic retinopathy?
With maculopathy - intravitreal anti-VEGF injections
Proliferative - panretinal photocoagulation
NOTE: you can’t use photocoagulation on the macula because it will impair vision
How is post-operative atelectasis treated?
Salbutamol nebulisers
Chest physiotherapy
NOTE: incentive spirometers are used to prevent atelectasis
Outline the treatment options for plaque psoriasis.
Avoid precipitants (alcohol, smoking, stress)
Emollients
Steroids - FIRST LINE
Vitamin D analogues (calcipotrol) - FIRST LINE
Coal tar
Dithranol
Phototherapy (PUVA)
Systemic (ciclosporin, methotrexate, retinoids and biologics (infliximab, etanercep))
NOTE: for PUVA, psoralens are either applied or given orally and then a UV lamp is shone over the affected skin
Outline the steps in the pharmacological management of COPD.
STEP 1: SABA
STEP 2 (steroid responsive): LABA + ICS
STEP 3 (steroid responsive): LABA + ICS + LAMA
STEP 2 (steroid non-responsive): LABA + LAMA
Use combo inhalers where possible
NOTE: conservative management includes stopping smoking, annual influenza and one-off pneumococcus vaccine, pulmonary rehab
Which causes of interstitial lung disease may respond to steroid treatment?
Sarcoidosis
Connective tissue diseases (e.g. rheumatoid arthritis)
Extrinsic allergic alveolitis
List some advantages and disadvantages of peritoneal dialysis.
PROS: simple to perform, can be done at home, less haemodynamic instability (good if cardiovascular disease)
CONS: body image, peritonitis, weight gain, exit site infection
List some pros and cons of Tesio lines.
PROS: well concealed (unliked fistula), can be used straight away
CONS: increased infections risk, lower flow rates, adverse events on insertion (pneumothorax, line infection, retraction)
Outline the aspects of managing chronic kidney disease.
General: correct reversible causes, stop nephrotoxic drugs, phosphate restriction
Hypertension: ACE inhibitor
Oedema: frusemide
Bone disease: phosphate binders, calcichew, vitamin D analogues
Anaemia: EPO
Outline the criteria for diagnosing DKA.
Glucose > 11
Ketones > 3
pH < 7.3
Bicarbonate < 15
Which infection is associated with tonsillar squamous cell carcinoma?
HPV
How should a patient on oral morphine with inadequate pain control have their dose changed?
Divide total daily dose by 2 (give you BD dose of oral morphine)
1/6 of the BD dose is the breakthrough dose
E.g. inadequate control with 30 mg BD + 10 mg PRN (used 3 times) = 90 mg per day –> 45 mg BD + 15 mg PRN
Which investigation can be used to explore the extent of skin involvement in vitiligo
Woods lamp inspection
Areas of hyper and hypopigmentation will fluoresce (e.g. vitiligo, pityriasis versicolor, tinea capitis)
Which medication is usually used first-line for patients with SLE primarily affecting the skin and joints?
Hydroxychloroquine
How does urine sodium help you assess fluid status?
< 20 mmol/L = hypovolemia
> 40 mmol/L = SIADH
Define cranial nerve.
Nerves that emerge directly from the brain (not the spinal cord)
Which cranial nerve supplies a contralateral innervation as opposed to an ipsilateral innervation?
Trochlear - it crosses the midline before innervating the contralateral superior oblique
NOTE: all cranial nerves are considered peripheral nerves
List some the components of a falls screen.
Bloods (FBC, U&E, CRP)
Glucose
ECG
Urinalysis
Lying-standing BP
Describe the mechanisms responsible for the following types of transfusion reaction:
Febrile non-haemolytic
Haemolytic
Allergic
Transfusion-related acute lung injury
Transfusion-associated circulation overload
Febrile non-haemolytic: host antibodies against donor leucocyte antigens/pre-formed cytokines within donor plasma
Haemolytic: host antibodies against donor RBC antigens
Allergic: allergic reaction to plasma proteins
Transfusion-related acute lung injury: activation of donated leucocytes in the lungs
Transfusion-associated circulation overload: rapid volume expansion
Which nerves innervate the lower limbs?
Femoral (L2-4)
Obturator (L2-4)
Sciatic (L3-S3)
Under which conditions in DKA do you avoid giving K+ supplementation with the fluids?
Anuria
K+ > 5.5 mmol/L
List some risk factors for falls in the elderly.
Muscle weakness
Gait abnormalities
Visual impairment
Postural hypotension
Arthritis
Cognitive impairment
Drugs (e.g. antihypertensives, sedative, anti-arrhythmics)
What are the main features of Yellow Nail Syndrome?
Yellow nails
Lymphoedema
Pleural effusion
Bronchiectasis
What are the main features of anterior cord syndrome?
Motor paralysis at the level of the lesion
Loss of pain/temp at and below the level of the lesion
Normal fine touch/proprioception (dorsal columns are fine)
Autonomic dysfunction (hypotension)
Areflexia
Flaccid anal sphincter
Urinary retention
NOTE: caused by anterior spinal artery infarction
List some differentials for Marfan syndrome.
Ehlers-Danlos syndrome
Pseudoxanthoma elasticum
Homocystinuria
What are the main aspects of managing non-alcoholic fatty liver disease?
Weight loss (aim for 10% over 6 months)
Good diabetes control
Good cholesterol control
Hepatitis immunisations
Alcohol abstinence
List some different types of long and short-acting insulin.
LONG: glargine (lantus), detemir (levemir), degludec (tresiba)
Short: actrapid, lispro (humolog), aspart (novolog), glulisine
What is pulsus paradoxus?
> 10 mm Hg drop in systolic blood pressure with inspiration
Associated with pericarditis and pericardial effusion
Interpreted as a sign of impending circulatory collapse due to tamponade
In which circumstance would a DPPIV inhibitor be considered a better second-line agent than a sulphonylurea?
Overweight patients - sulphonylureas cause weight gain
State the origin of each cranial nerve.
Cerebrum: I and II
Midbrain: IV
Midbrain-Pontine Junction: III
Pons - V
Pontine-Medulla Junction: VI, VII, VIII
Medulla: IX, X, XI, XII
Outline the steps in the management of asthma.
STEP 1: SABA
STEP 2: SABA + ICS
STEP 3: SABA + ICS + LTRA
STEP 4: SABA + ICS + LABA
STEP 5: Switch ICS/LABA to MART (continue SABA +/- LTRA)
STEP 6: Increase to moderate-dose ICS
Damage to which part of the brain causes apraxia?
Posterior parietal lobe
What are the main features of digoxin toxicity?
Nausea
Diarrhoea
Confusion
Bradycardia
Hyperkalaemia
WARNING: AKI can lead to digoxin toxicity
List some causes of bulbar palsy.
Brainstem stroke
Brainstem tumours
Syringomyelia
MND
Neurosyphylis
Poliomyelitis
GBS
NOTE: investigation include MRI, serology and CSF analysis
Which nerves pass through the cavernous sinus?
III
IV
V (1 and 2)
VI
Internal carotid artery
List some examples of seronegative spondyloarthitides.
Ankylosing spondylitis
Psoriatic arthritis
Enteropathic arthritis
Reactive arthritis
