Medicine Workbook Flashcards
What is the difference between a STEMI and an NSTEMI?
STEMI involves transmural infarction whereas NSTEMI is a partial infarction that does not affect the full thickness of the wall
What anticoagulant should be prescribed until discharge post-MI?
fondaparinux
Treatment for chronic HF?
ACEi
BB
Diuretics
Spironolactone
Digoxin
What are the 3 commonest causes of AF and how could they be investigated?
HF- echocardiogram
Hypertension - blood pressure measurement
IHD- coronary angiogram
What drugs are used in long term AF tx?
Beta blocker for rate control
Potentially DOAC (warfarin second line) depending on CHA2D2-VaSc
How does aortic stenosis present in the pulse, BP, and on auscultation?
Weak pulse
High systolic BP
Ejection systolic murmur louder on expiration
Common differentials for a systolic murmur?
Pulmonary/aortic stenosis
Tricuspid/mitral regurge
HOCM
Atrial septal defect
Key investigations for aortic stenosis?
CXR
ECG- LV strain
Doppler echo- pressure gradient across valve
Common complications of aortic stenosis?
LV hypertrophy/strain
Arrhythmias
Stroke
HF
Common causes of valvular heart disease?
Rheumatic fever
Infective endocarditis
Congenital valve disease
Age related degeneration
Common secondary causes of a high BP?
ROPE
Renal - renal artery stenosis, APCKD, glomerulonephritis
Obesity
Pregnancy
Endocrine - Cushing’s, hyperthyroidism, phaechromocytoma
Features of hypertensive retinopathy?
I- Arteriolar narrowing and tortuosity
Increased light reflex - silver wiring
II - Arteriovenous nicking
III - Cotton-wool exudates
Flame and blot haemorrhages
These may collect around the fovea resulting in a ‘macular star’
IV - Papilloedema
Side effects of insulin injections?
Hypoglycaemia
Infection/ lipodystrophy at injection site
Weight gain
How should you investigate and manage a diabetic ulcer?
Investigations:
Blood glucose levels
Wound swab for culture
X-ray foot
Management:
Debridement and abx if required
wound care and dressing
therapeutic shoes
referral to podiatrist
What organisms are commonly involved in infected diabetic foot ulcers and how are they treated?
Staph, strep, anaerobes
Benzylpenicillin
Flucloxacillin
Metronidazole
What causes a Charcot joint?
Trauma to a neuropathic extremity
Clinical features suggestive of osteomyelitis with a diabetic foot ulcer?
Deep ulcer - > 3mm
Wide ulcer - >2cm
Ulcer above a bony prominence
Dactylitis (sausage toe)
Purulent discharge
Why do patients develop HHS?
Missing doses of diabetic drugs or episodes of physiological stress which increase blood glucose
Risks of suboptimal diabetes control?
DKA
HHS
Diabetic neuropathy, nephropathy, retinopathy
Diabetic foot disease
Vascular disease - increased cardiovascular risk
what is Hba1c?
Glycated hb- gives a measure of blood glucose over past 90 days
What is ACR?
Albumin : creatinine ratio
Shows if there is elevated albumin in the urine- screens for microalbuminuria, an early sign of diabetic nephropathy
Give an example of an educational course available to diabetics
DESMOND - diabetes education and self management for ongoing and newly diagnosed
Helps patients to understand their condition and take control of their BM
How can crisis be prevented in patients with known and treated Addison’s?
Education on adherence
Double hydrocortisone when unwell
Hydrocortisone IM if vomiting consistently
What evidence can a patient carry if they are on long term steroids?
Steroid emergency card
Immediate management of acute hyponatraemia?
Give hypertonic saline
Transfer to HDU for monitoring
What tx can be used to rapidly improve low sodium levels?
ADH antagonist drugs e.g. tolvaptan
How can you assess a patient’s fluid balance?
Check fluid intake and urine output
Measure BP
Measure JVP and examine
How should you manage acute hypocalcaemia?
IV calcium gluconate (10ml 10% solution over 10 mins)
Constant ECG monitoring
Common causes of hypercalcaemia?
Primary hyperparathyroidism
Malignancy
Sarcoidosis
Vit D toxicity
Thyrotoxicosis
What malignancies can cause hypercalcaemia and by what mechanism?
Myeloma - malignancy of bone marrow
Bone mets- malignancy destroys bone, releases calcium
SCLC - PTHrp- increases osteoclast activity
What drugs lower calcium and how do they work?
Bisphosphonates- inhibit osteoclast activity
Calcitonin - like bisphosphonates but quicker onset of action
Furosemide- increases urinary excretion, should be given with fluids
Common signs of hyperthyroidism?
Palmar erythema
Fast irregular pulse - AF
Tachycardia
Exopthalmos
Hair thinning
Weight loss
Tx options for hyperthyroidism?
Drugs - propanolol for rate control, carbimazole, propylthiouracil
Radioiodine therapy
Thyroidectomy
Common signs of hypothyroidism?
Slow reflexes
Bradycardia
Cold extremities
Weight gain
Dry skin
Coarse hair
Common risk factors for GI bleeding?
Peptic ulcers
Oesophageal varices
Upper GI malignancy
Medications e.g. NSAIDs
High alcohol intake
Important clinical examination findings to document in suspected GI bleed?
Blood pressure
HR
Abdo exam findings - masses, areas of discomfort, hepatomegaly
What investigations should be done for suspected GI bleed?
Bloods - FBC, LFTs, U&Es (UREA!!!), clotting profile, crossmatch
CXR
Endoscopy
Pathophysiology of peptic ulcer disease?
Increased production of gastric acid or decreased gastroprotective mechanisms causes erosion through mucosal layers
What clinical findings on examination would you look for in someone with significant hx of diarrhoea?
Capillary refill
Pulse and BP
Pallor of conjunctiva
Mouth ulcers
Skin rashes e.g. erythema nodosum
Abdo masses/pain
Perianal disease e.g. skin tags
Investigations for someone with prolonged diarrhoea?
Bloods - FBC (anaemia), U&Es, CRP, ESR, ferritin
Stool sample and culture- infection
Colonoscopy
Differentials for bloody diarrhoea?
Infective gastroenteritis
IBD - UC
Bowel cancer
Polyps
Haemorrhoids
Key clinical findings to look for in someone with jaundice?
Palmar erythema
Hepatic flap
Spider naevi
Hepatomegaly
Abdo pain
Ascites- fluid thrill and shifting dullness
Important investigations in someone with jaundice?
Bloods- LFTs, U&Es, bilirubin, clotting profile
Serum paracetamol levels
USS liver and pancreas
Common differentials for jaundice?
Chronic liver disease
Pancreatic cancer (painless)
Cholangitis
Bile duct injury
Gallstones
Give 3 causes of malnutrition in patients with chronic liver disease.
How would you manage each one?
Alcoholism - reduced intake and vomiting - thiamine supplementation and referral to dieticians and support services
Decreased bile production- eat smaller meals, sit upright, limit fatty foods
Decreased protein production - dialysis
How should alcohol withdrawal be managed in hospital?
IV pabrinex
Nutritional Support and fluids
Supportive meds e.g. anti-emetics and anti-convulsants
What services are available to people with alcohol addiction?
CBT
AA
Disulfiram
Define NASH
Non-alcoholic steatohepatitis- fatty deposits in liver that cause cirrhosis
Symptoms of paracetamol poisoning?
Initially may be asymptomatic or vomiting and RUQ pain
Progresses to AKI, jaundice and encephalopathy
May have ALOC and respiratory depression
Investigations for suspected paracetamol poisoning?
Serum paracetamol conc
LFTs
Prothrombin time and INR (decreased clotting factors)
blood glucose (decreased gluconeogenesis)
Clinical tool to guide tx of paracetamol poisoning?
Paracetamol monogram
Can also refer to NPIS for info
Criteria for safe discharge of patient with paracetamol poisoning?
ALT and INR within range
Psychiatric risk assessment
Possible causes of malnutrition in a younger patient?
Eating disorder
Cancer
Acute illness
IBD
Alcoholism
Depression
Low income
What is refeeding syndrome?
Patients at risk?
Prevention?
Life threatening complication of re-introducing food too quickly after a period of starvation
Anorexic patients
Alcoholic patients
Artificial feeding after prolonged starvation
Identify patients at risk and monitor with refeeding bloods
Increase dose of pabrinex during refeeding window
What is the difference between meningitis and encephalitis?
Meningitis is inflammation of the meninges whereas encephalitis is inflammation of the brain parenchyma
Encephalitis is more likely to present with altered mental state - change in behaviour, confusion and disorientation, hallucinations, problems with speech or hearing etc
Fever, headache, photophobia and neck stiffness seen in both
Immediate management of suspected meningitis in GP?
IV Benzylpenicillin
Potentially dexamethasone for raised ICP
Inform ICU
Notify Local Health Protection Team and consider ciprofloxacin prophylaxis for close contacts
Investigations for suspected meningitis?
Blood culture
Blood glucose
Lumbar puncture- CSF analysis
CT head for swelling
Define notifiable disease
A disease that is legally required to be reported to government authorities if it is diagnosed in order to protect the general public
Most common bacterial cause of meningitis?
Strep. pneumoniae
Complications of delayed tx of meningitis?
Hearing loss
Sepsis
Seizures
Coma
Brain damage
Death
Investigations for fever in a returned traveller?
FBC, WCC, U&Es, CRP
Malaria blood film - 3 samples over 3 days
HIV and Hep serology
Stool culture
Where can be affected by TB besides the lungs?
Miliary - blood
Larynx, lymphnodes , pleura, kidneys, bones, brain
Investigations for suspected tuberculous meningitis?
NAAT test
Lumbar puncture- CSF microscopy, culture and cytology
CT/MRI
Common causes of constipation in the elderly?
Dehydration
Diabetes
Low fibre intake
Immobility
IBS
Hypothyroidism
Hypercalcemia
Neurological- Stroke, Parkinson’s
Colorectal cancer
Rectal prolapse
How should hard v soft stool impaction be managed?
hard- stool softeners, osmotic laxatives (e.g. lactulose/movicol), enemas
soft- stimulant laxatives e.g. senna
What increases risk of incontinence?
Older female
Obesity
Previous pregnancy
Prolapse
Smoking - chronic cough = strain
Constipation = strain
Neurological dysfunction
Medications
Non pharmacological interventions for incontinence?
Switch to decaff drinks
Improve bowel habit
Regular toileting
Pelvic floor exercises
Common drugs for treating overactive bladder?
Mirabegron
Oxybutinin
Tolterodine
What is the evidence for enteral feeding in dementia?
Only to be used in acute illness
No evidence of increased life span and increased risk of aspiration and infection
Define ‘feed at risk’
What discussions should be had about this?
When a patient can choose to continue eating and drinking despite known risk of aspiration
Discuss signs of aspiration and what to do in case of aspiration with family
Give choking advice
Common causes of falls?
Muscle weakness/sarcopenia
Poor balance/instability
Hypotension
Vision loss
Key investigations for underlying cause of a fall?
CGA - general frailty and functional ability
FBC - anaemia/bleeds
Lying and standing bp- orthostatic hypotension
ECG - arrhythmias
AXR- faecal impaction
CT head- subarachnoid haemorrhage
Multidisciplinary interventions for discharge post fall?
Pharmacist- review TTO
Physios - improve strength and mobility
Occupational therapists- AODL
GP follow up
Commonly prescribed drugs that increase falls risk?
Antihypertensives
Alpha blockers
Diuretics
Benzodiazepines
Investigations in acute confusion ?
Confusion screen bloods
FBC, U&Es, blood glucose
Urine dip (infection)
ECG
CT head
Examinations in acute confusion?
Check for signs of hypoxia
Fluid balance
Mini mental state examination
How do you carry out a fluid balance assessment?
Fluid intake and urine output
Cap refill
Pulses and JVP
BP
Skin turgor
Check mucous membranes
Causes of CKD?
Hypertension
Diabetes
APCKD
Immunologic glomerulonephritis
Pyelonephritis
Examination findings in CKD?
Flapping tremor- uraemia
Excoriations- pruritus
Hypertension
Pallor- anaemia
Ballotable kidneys - PCKD
Renal bruits
Tests to confirm cause of CKD?
Urine dip - proteinuria/haematuria
Hba1c, fasting glucose and random glucose - diabetes
Autoantibodies- suspected lupus
Renal USS
Renal biopsy
Define ‘controlled oxygen’
Oxygen therapy that is kept within a tight range for patients at risk of hypercapnia
What is an asthma management plan?
A plan made by the specialist team and the patient to:
control symptoms
return to normal activity levels
prevent future exacerbations
decrease mortality
Causes of COPD other than smoking?
Alpha-1 antitrypsin deficiency in young people
Pollutants from the air e.g. fumes and dust
Occupational exposure
Describe the MRCP dyspnoea scale
Outlines a grade of breathlessness related to activities and functional ability
- SOB on strenuous exercise
- SOB when hurrying/ on a slight hill
- Walking slower than peers/ stopping for breath at normal walking pace
- Stops for breath after 100m
- Too SOB to leave the house
Possible clinical signs of COPD?
peripheral cyanosis
tar staining
tachypnoea
tripod position / use of accessory muscles when breathing
Hyperinflation of lungs - hyperresonance on percussion, decreased cricosternal distance
What does the COPD care bundle consist of?
Review of medication and inhaler use
Emergency drug pack provided and written self management plan completed
Smoking cessation assessment
Assessment of suitability for pulmonary rehab
Follow up call arranged within 72 hours of discharge
What interventions alter prognosis in COPD?
Smoking cessation
O2 therapy
Non invasive ventilation
Anti-inflammatory drugs
Why can uncontrolled oxygen therapy cause hypercapnia in COPD?
peripheral receptors detect normalising O2 levels and it decreases hypoxic respiratory drive
What are the principles of the BTS guidelines for managing chronic asthma?
Stepladder of tx- step up or down based on symptom control
Regular preventer (SABA) + low dose ICS
SABA + low dose ICS + LABA
Step up to medium dose ICS or add LTRA
Escalate to specialist care
What drugs can cause cough?
ACEi - bradykinin cough
B blocker and leukotrienes - bronchospasm
Aspirin - bronchoconstriction
What is idiopathic cough?
Chronic cough lasting over 3 weeks with all other diagnoses excluded
What clinical features do patients requiring hospital admission for COVID often have? What tx is available?
SOB
ARDS
Abnormal CXR
Tx:
O2
Corticosteroids and dexamethasone (decrease mortality)
Anti-virals
LMWH
Signs of lung cancer on examination?
cachexia
clubbing
pallor of conjunctiva - anaemia
lymphadenopathy if metastasised
Horner’s syndrome (partial ptosis, miosis, anhydrosis) if pancoast tumour
What abnormalities may be seen on CXR of lung cancer other than a mass?
consolidation
collapse
pleural effusion
5 year survival rate for stage 1, 2 , 3 and 4 of lung cancer?
55%, 33%, 15%, 5%
Tx modalities for lung cancer?
Endobronchial therapy
Lobectomy
Chemotherapy/ radiotherapy
Palliative tx e.g. analgesia, anti-emetics, cough linctus
How can you investigate underlying cause of a pleural effusion?
USS guided aspiration
- aspirate assessed for: LDH, protein, glucose (bacillus decreases glucose), pH (low = empyema)
- Light’s criteria to distinguish between transudate and exudate
FBC and U&Es- hypoalbuminaemia
Echo - signs of HF
CXR- signs of pneumonia / lung cancer
Key symptoms of ILD?
non-productive paroxysmal cough
reduced exercise tolerance
extreme fatigue
Common types of ILD?
Primary:
idiopathic
acute interstitial pneumonia
Secondary:
connective tissue e.g. RA
infective e.g. mycoplasma
environmental e.g. asbestosis
drugs e.g. methotrexate
Common causes of bronchiectasis?
Genetic- CF, primary ciliary dyskinesia
Post-infective- whooping cough, TB, measles
Bronchial obstruction - lung cancer, foreign body
Immunodeficiency - e.g. hypogammaglobulinaemia
Common pathogens in bronchiectasis?
H. influenzae
Klesbiella
Pseudomonas aeruginosa
Key principles of managing bronchiectasis?
Airway clearance- chest physio and mucolytics
Bronchodilators
Corticosteroids
Surgery
Prevalence of CF? Mutated gene?
1/2000
Chromosome 7 CTFR gene
Common multisystemic complications of CF?
Resp- bronchiectasis, recurrent infections
GI- pancreatic insufficiency ( CF related diabetes), gallstones, meconium ileus in newborns
Repro- infertility
What joints are commonly affected in RA besides the hands?
wrists and ankles
cervical spine
Classical findings in the hands in RA?
Ulnar deviation
Z-deformity of the thumb
Swan neck
Boutonierre’s deformity
Radiological findings of RA in hands?
LESS
Loss of joint space
Erosions
See-through bones (osteopenia)
Soft tissue swelling
What monitoring is required for long term RA tx?
6 monthly review
Steroids- blood glucose, Cushing’s, osteoporosis
DMARDs/ biologics- immunosuppression, leukopenia
What features distinguish RA from other arthridities?
Worse in mornings and better with use unlike osteoarthritis
No fever unlike septic arthritis
Smaller joints
NSAIDs improve symptoms
Describe the SOAP BRAIN MD mnemonic for features of SLE
Serositis - pleurisy, pericarditis
Oral ulcers
Arthritis
Photosensitivity/ rash
Blood disorders
Renal involvement - lupus nephritis
Autoantibodies - antinuclear
Immunologic disorder
Neurological- psychiatric effects, seizures
Malar rash
Discoid rash
4/11 required for diagnosis
May also see sclerodactly and telangiectasia on examination
What examinations would you do in suspected DVT?
Circumference measurement 10cm below tibial tuberosity
Assess for pain and pitting oedema
Respiratory exam
Define massive PE
PE with sustained hypotension, pulselessness or bradycardia
Tx for anaphylactic reaction?
Remove the trigger if possible
Adrenaline 0.5mg (IM) - repeat dose after 5 mins if no improvement seen, if second dose fails then treat as refractory anaphylaxis
High flow O2 as soon as possible
Following stabilisation of the patient, a non-sedating oral antihistamine such as cetirizine hydrochloride may be considered, especially in patients with persistent cutaneous symptoms
Common causes of sepsis?
Pneumonia
Meningitis
Cellulitis
Bowel perf
Septic arthritis
UTI
