Mid / High Qs Flashcards
What is the most common reason total hip replacements need to be revised?
Aseptic loosening of hip replacement
Mx of secondary pneumothorax?
> 2cm + 50y+ = Insert chest drain
1-2cm = Aspiration, if this fails chest drain - admit 24hrs
<1cm - O2 + admit for 24hrs
When should you thrombolyse in a PE?
When there is haemodynamic instability
Hip fracture surgery - when should pts fully weight bear again?
Straight after surgery
Describe garden classification of NOFs
The Garden system is one classification system in common use.
Type I: Stable fracture with impaction in valgus
Type II: Complete fracture but undisplaced
Type III: Displaced fracture, usually rotated and angulated, but still has boney contact
Type IV: Complete boney disruption
Mx of NOF - Intracapsular / subcaptial ?
Undisplaced = internal fixation (or hemiarthroplastu if unfit)
Displaced = Total hip replacement (or Hemiarthroplasty - if not independent, cognitive impairment / not fit for procedure)
Mx of NOF - extracapsular
Extracapsular = subtrochanteric or trochanteric
Stable intertrochanteric = dynamic hip screw
Reverse oblique, transverse or subtrochanteric = intramedullary device
What medication should be avoided bowel obstruction? why?
Metoclopramide - has prokinetic properties and can stimulate persistalsis -> can worsen mechanical bowel obstruction and precipitate perforation
NSTEMI Mx?
Cluster headaches acute mx? prophylaxis?
High flow o2 + Subcut triptans
prophylaxis - Verapamil
ACS mx when should you avoid nitrates / use w caution? what should you give when medically mx instead?
PT is hypotensive as it causes widespread vasodilation
Aspirin + Ticagrelor + Fondaparinux
What to do in new onset AF presenting w/in 48h? after 48h?
Anticoagulate (heparin) + electrical cardioversion
48h+ - greater risk of clots hence anticoagulate for 3w before cardioversion
Mx of acute pericarditis?
Outpatient mx unless 38oC+ Or raised trop
NSAIDs + Colchinie are 1st line
Mx of acute pericarditis?
Outpatient mx unless 38oC+ Or raised trop
NSAIDs + Colchinie are 1st line
Acute mx of STEMI?
Analgesia
O2
Nitrates
Aspirin + Prasugrel (or clopidogrel if theyre already on a oral anticoagulant)
Acute relapse of MS - mx?
High dose oral steroids eg oral methylpred
Mx - fragility fracture in woman over 75?
DEXA scan isnt needed to dx osteoporosis - start bisphosphonate therapy
What is the treatment of choice in biliary colic?
Elective laparoscopic cholecystectomy
Inguinal hernia mx?
Assymptomatic = routine surgical referral
Signs of incarceration / strangulation = urgent surgical referral
Truss = If unfit for surgical referral
Surgery is usually open unless bilateral / recurrent in which case it is laparoscopic
Electrolyte abnormality in prolonged diarrhoea?
Met acidosis + hypokalaemia - loss of bicarb excretion from GI tract
Constant back pain + worse on movement + fever and anorexia + disc space narrowing on x-ray - dx? most common cause?
Discitis by staph aureus
What are the possible side effects of thyroxine therapy?
hyperthyroidism: due to over treatment
reduced bone mineral density -> osteoporosis
worsening of angina
atrial fibrillation
Possible interactions w thyroxine therapy and what to do?
Iron + calcium carbonate - reduces absorption of levothyroxine hence give 4 hrs apart
What is Phrens sign? what is positive in? how can you test for this?
Lifting scrotal skin from testes reduces pain - seen in epididymoorchitis -> urine void first sample for NAAT
What are the causes of normal anion gap met acidosis?
ABCD R
Addisons
Bicarb loss - eg diarhoea
Chloride
Drugs
R - renal tubular acidosis (High Cl and Low Bicarb)
What are the possible paraneoplastic features seen in each of the following lung cancers:
Small cell
Squamous cell
Adenocarcinoma
Small cell - excess ACTH, ADH and Lamert-Eaton syndrome
Squamous cell - PTH related protein -> hypercalcemia, hyperthyroidism to ectopic TSH
Adenocarcinoma - Gynaecomastia (most common in non-smokers)
Vomiting + Fever + Severe abdo pain relieved by leaning forward -> dx?
Acute pancreatitis
1st line mx of osteoarthritis?
Osteoarthritis - paracetamol + topical NSAIDs (if knee/hand) first-line
Which causes of CKD do not show small kidneys on USS?
CKD due to ADPKD or early stage diabetic nephropathy
When giving fibrinolysis to STEMI pts what should you do after?
ECG 60-90 mins post fibrinolysis to check if ST changes have resolved - if not suggests persistent ischaemia hence PCI needs to be considered
What are some absolute CI for laparoscopic surgery?
haemodynamic instability/shock
raised intracranial pressure
acute intestinal obstruction with dilated bowel loops (e.g. > 4 cm)
uncorrected coagulopathy
Ix for compartment syndrome?
Intracompartmental pressure measurements
What drug interaction can increase INR of warfarin pts?
Metronidazole - inhibits warfarin inhibition
What drug interaction can increase INR of warfarin pts?
Metronidazole - inhibits warfarin inhibition
Mx of RCC?
Less than 7cm = partial nephrectomy
More than 7cm = radical nephrectomy
testicular bag of worms + on RHS - possible dx?
Right sided varicocele unlikely normally however can be caused by malignancy due to compression of renal vein at nutcracker angle (between AA and SMA)
Features of cardiac tamponade?
Raised JVP, persistent hypotension and tachycardia despite fluid resus
Common side effect of metoclopramide?
Diarrhoea
Suspected PE but delay in imaging - what should you do?
Interim treatment dose apixaban + perform scan when possible
Where are metatarsal shaft fractures likely to happen?
2nd metatarsal shaft
Mx of mineral bone disease in CKD?
1st = Reduce dietary phosphate
2 = phosphate binders
3 = vit d
parathyroidectomy may be needed in some cases
What class of analgesics should be avoided in ACS? Why?
NSAIDs - due to interactions w antiplatelets
Which drugs can be used for chemical cardioversion and when?
Flecanide - if no structural heart abnormalities
Amiodarone - whenever
Squaring of thumbs - characteristic of which condition?
Osteoarthritis of the hand
Conservatively mx NSTEMI - what should be offered?
NSTEMI (managed conservatively) antiplatelet choice
aspirin, plus either:
ticagrelor, if not high bleeding risk
clopidogrel, if high bleeding risk
ECG changes in WPW
short PR interval
wide QRS complexes with a slurred upstroke - ‘delta wave’
left axis deviation if right-sided accessory pathway
in the majority of cases, or in a question without qualification, Wolff-Parkinson-White syndrome is associated with left axis deviation
right axis deviation if left-sided accessory pathway
How can you diagnose gout?
Check serum urate once inflammation has settled down (should remain high)
Preferred site for primary PCI?
Radial artery
Why does HOCM cause sudden death in young athletes?
Due to VT
What are the parts of the modified glasgow scale to calculate severity of pancreatitis?
PANCREAS
PaO2
Age
Neutrophilia
Calcium
Renal func
Enzymes
Albumin
Sugar
What type of lung cancer can cause a hoarse voice and how?
Pancoast tumours due to suppression of recurrent laryngeal nerve
Which drugs can cause SJS?
carbamazepine, lamotrigine, allopurinol, sulfonamide, phenobarbital
Phenytoin
Salicylates
Sertraline
Imidazole antifungal agents
Nevirapine
Which drugs can cause SJS?
carbamazepine, lamotrigine, allopurinol, sulfonamide, phenobarbital
Phenytoin
Salicylates
Sertraline
Imidazole antifungal agents
Nevirapine
Ix of Haemochromatosis?
General public = Transferrin sat > ferritin
Family = Genetic testing (HFE mutation)
How to distinguish between direct and indirect inguinal hernias?
Try to reduce hernia by pressing on deep inguinal ring (mid point of inguinal ligament)
If it stops protruding exit is in deep inguinal ring hence indirect
If it still protrudes it is direct
MX of osteoporosis if they cant have alendronate due to GI side effects?
Alendronate -> risedronate or etidronate
If bisphosphonates arent tolerated then you can provide them with strontium ranelate or raloxifene
Mx of sexual epididymoorchittis of unknown organism?
IM ceftriaxone + oral doxy 10-14d
Painful shoulder abduction 90-120 degrees - dx? how to distinguish from main differential?
Subacrominal impingement
Rotator cuff injuries also present w painful arc but differentiate as these show muscle weakness when compared to opposite arm + pain on palpation (painful arc is also usually first 60 deg)
USS of kidneys in chronic diabetic nephropathy?
Bilateral large / normal sized kidneys
Parkinsonianism + autonomic features (ED, postural hypotension and atonic bladder) + cerebellar sign - dx?
Multiple system atrophy
Mx of antiphospholipid syndrome?
Primary thromboprophylaxis - low dose aspirin
Secondary thromboprophylaxis:
- Initial VTE - lifelong warfarin INR 2-3
- Recurrent VTE - lifelong warfarin INR 3-4 (if clots whilst on warfarin consider adding aspirin)
- Arterial thrombosis - lifelong warfarin INR 2-3
Inguinal hernia, pigmented spots on mouth, palms and soles + intussusception @12y - what is likely dx and finding on colonoscopy?
Peutz-Jeghers syndrome - associated w hamartomas
Why is hyperphosphataemia in CKD an issue?
Can drag Ca from bones -> osteomalacia treat w bisphosphonates
Result of iron studies in haemochromatosis?
Raised transferrin saturation and ferritin, with low TIBC, high serum iron
How often is methotrexate taken?
Weekly
When anticoagulating for AF - which pts should be offered 2nd line mx and what is this mx?
1st line = DOAC - these are CI if pt has liver / renal dysfunction
2nd line = warfarin
Hypoglossal nerve injury - which way does tongue deviate?
Deviates to side of injury
What blood test to monitor effect of levothyroxine treatment?
TSH
Which fractures are most commonly associated w compartment syndrome?
Supracondylar and tibial shaft fractures
Analgesia for NOFs?
Iliofascial nerve block
Which wave in ECG is cardioversion syncd to?
Electrical cardioversion is synchronised to the R wave - its the biggest
T2DM mx of blood glucose post ACS?
Stop diabetes meds + start IV insulin
Total hip replacement + pt cant dorsiflex foot - what nerve is damaged?
Sciatic
CT head multiple ring enchanced leisons - dx? mx?
Toxoplasmosis - treat w/ Pyrimethamine (+ sulphadiazine if immunocompromised)
1st line ix for hip fractures according to NICE?
MRI hip
Salicylate poisoning - ABG finding
Resp alkalosis + Metabolic acidosis -> usually met acidosis + raised anion gap
Pt w T2DM develops CVD what should be done to their mx?
Add SGLT-2 inhibitor
1st line for ix of stable angina?
CT Coronary Angio
Mx of salicylate poisoning?
IV sodium bicarb
Pt on clopidogrel w/ acid reflux - mx?
Lansoprazole > Omep / esomep - as those drugs decrease efficacy of clopidogrel due to preventing conversion into active form
Constipation in IBS - mx?
1st line = bulk forming laxative eg ispaghula husk
On examination he has weak hip flexion, weak knee extension, and impaired quadriceps tendon reflex, as well as sensory deficit in the anteromedial aspect of the thigh - which nerve is affected?
Femoral
A 42-year-old woman complains of a burning pain of her anterior thigh which worsens on walking. There is a positive tinel sign over the inguinal ligament
Which nerve is affected?
Lateral cutaneous nerve of thigh
Which drug used in mx of prostate cancer can cause bone pain + bladder obstruction etc
Tumour flare - can be triggered by use of GnRH agonists eg Goserelin
ECG change seen in digoxin therapy in a pt w AF?
HOCM - inheritance, how likely is a sibling to have it?
AD - 50% risk of passed on to siblings
What are the echo findings in HOCM?
Mnemonic - MR SAM ASH
- mitral regurgitation (MR)
- systolic anterior motion (SAM) of the anterior mitral valve leaflet
- asymmetric hypertrophy (ASH)
Which drugs need to be avoided in HOCM?
Nitrates
ACEi
Inotropes
What are CIs for statin therapy?
Macrolide - ‘thromycins
Pregnancy
What are the antibodies in adult onset stills disease?
RF and ANA negative
(high ferritin and leucocytosis)
Indications for steroid use in Sarcoidosis?
patients with chest x-ray stage 2 or 3 disease who are symptomatic. Patients with asymptomatic and stable stage 2 or 3 disease who have only mildly abnormal lung function do not require treatment
hypercalcaemia
eye, heart or neuro involvement
Weakness of foot dorsiflexion and foot eversion - which nerve is affected?
Common peroneal nerve palsy
How to treat cerebral oedema in brain tumour pts?
Dexamethasone
Possible complication of total hip replacement?
Posterior dislocation - internal rotation and shortening of affected leg
Secondary prevention of strokes if clopidogrel intolerant?
Aspirin + modified release dipyridamole
Pt on long-term steroids - what bone protection should be offered?
Bisphosphonate + vit d + ca - no scan needed if 65+, if under 65 bone scan 1st
Blockage of which part of the biliary tree does not cause jaundice?
Cystic duct or gall bladder
Imaging of choice for PSC?
ERCP / MRCP
Hypercalcaemia - ECG abnormality
Short QT
ECG change caused by thiazides and why?
Flattening of t waves due to hypokalaemia
Signs of SVCO + Myasthenia gravis - dx?
Thymoma -> causes SVCO and can also cause production of antibodies against acetylcholine receptors
Thiazide diuretics - electrolyte abnormalities?
Hypercalcaemia (hypocalcuria), hyponatraemia, hypokalaemia
Acute heart failure not responding to treatment - consider what?
CPAP
mx of infective exacerbations of COPD? when should additional measures be used?
5 days of pred, add abx if purulent sputum / clinical signs of pneumonia
mx of infective exacerbations of COPD? when should additional measures be used?
5 days of pred, add abx if purulent sputum / clinical signs of pneumonia
mx of infective exacerbations of COPD? when should additional measures be used?
5 days of pred, add abx if purulent sputum / clinical signs of pneumonia
What needs to be corrected prior to bisphosphonate therapy + why?
Ca and vit d deficiencies as this can be worsened by bisphosphonates
What should be avoided in severe colitis (in UC) due to risk of perforation, do what instead?
Avoid colonoscopy - do flexible sigmoidoscoppy
UC / Crohns - which is associated w gallstones?
Crohns
Iron studies in anaemia of chronic disease
Low Fe, Low ferritin, low / normal TIBC
Test results in alcoholic ketoacidosis?
Normal / low glucose + met ketoacidosis
What is the most sensitive and specific lab finding for liver cirrhosis in CLD?
Reduced platelet count
An acute presentation of abdominal pain with peritonism in a patient with known peptic ulcer disease is highly suggestive of ….. - what is the ix required?
gastrointestinal perforation - erect CXR = ix of choice -> if +ve follow w CT
Haemochromatosis - inheritance?
AR
Mild elevation in ferritn + Abnormal LFTs + Obese = ?
NAFLD
Test of exocrine func in chronic pancreatitis?
Faecal elastase
Ix of choice pancreatic ca?
High res CT
Sudden onset abdo pain + AF + big meal - dx?
Mesenteric ischaemia
initial ix when suspecting mesenteric ischaemia?
ABG/ VBG - check for raised lactate
CT angio abdo + pelvis + contrast is needed definitively
Upper GI endoscopy, stop what medication and when?
Stop PPIs 2w before to identify any pathology
What part of GI tract normally has diverticula?
Sigmoid colon - outpouchings
Liver sign in RHF?
Firm smooth enlarged tender and pulsatile liver edge
AI liver disease - mx?
Steroids +- other immunosuppression (eg azathiprine)
Liver transplant?
Biopsy of which part of small intestine in coeliac is required?
Jejunem / duodenum
How should you mx diverticulitis flares?
Oral abx at home - if no improvement in 72h admit for IV ceftriaxone + metronidazole
Biliary colic - what are the LFTs and inflammatory markers like?
Normal
Oesophageal varicies - prophylaxis of bleeding?
Non-cardioselective BB eg propanolol
What the features of mild, moderate, severe and life-threatening C. diff?
Which anal fissures are concerning?
Lateral ones - should normally be in posterior midline
Mx of hepatic encephalopathy?
Lactulose - increased excretion of ammonia
Prophylaxis w rifamixin - adjust gut flora to decrease ammonia production
AXR w signs of small bowel obstruction + air in biliary tree - what is possible dx?
Gallstone ileus - gallstone enters ileocaecal valve
What should be given before endoscopy in pts w variceal haemorrhage?
Terlipressin + prophylactic abx
Why should folate be replaced after B12 in deficiency?
Folate replacement prior to B12 can precipitate subacute combined degeneration of the spinal cord.
What class of drug is terlipressin?
Vasopressin analogue
ix findings in PBC? mx?
Ix:
- Raised ALP + GGT
- Raised AMA titre >1:40
Mx:
1st - ursodeoxycholic acid - slows disease and improves sx
Pruritis - cholestyramine
Fat soluble vitamins
Liver transplant if >100 bilirubin
What is the most common cause of large bowel obstruction?
Colon cancer
When checking if there is any anastamotic leaks following bowel surgery what ix is used and why?
Gastrograffin enema > barium - less toxic than barium if it leaks into abdo cavity
Imaging of choice for PE if renal impairment?
V/Q scan
ECG - II, III and aVF ST elevation - what vessel is affected? what is a possible complication?
Supplies right coronary artery -> supplies AV node so can cause arrhythmias inc bradycardia and AV block
Which type of MI is more likely to cause RBBB?
LAD - as blocks below level of AV node
What should not be given alongside verapamil, why?
BB due to risk of complete heart block / bradycardia -> death
What causes U waves on ECG? an example of a medication that can cause this?
caused by hypokalaemia (also see prolonged PR interval 1st degree heart block) - can be caused by thiazide
What is the most specific ECG finding in acute pericarditis?
PR depression secondary to atrial injury
How long before elective surgery is warfarin stopped?
5d - aim to get INR below 1.5
Usually resumed on evening of surgery / next day if hemostasis is adequate
mid-late diastolic murmur - describes what?
mitral stenosis - most commonly cause by rheumatic fever
How should orthostatic hypotension be mx?
education and lifestyle measures such as adequate hydration and salt intake
discontinuation of vasoactive drugs e.g. nitrates, antihypertensives, neuroleptic agents or dopaminergic drugs
if symptoms persist, consider compression garments, fludrocortisone, midodrine, counter-pressure manoeuvres, and head-up tilt sleeping
What should be offered to pts on symptomatic stable angina that require addition of another drug already on CCB but CI against BB?
long-acting nitrate, ivabradine, nicorandil or ranolazine
What are some side effects of thiazide like diuretics?
Dehydration
Postural hypotension
Gout
Impaired glucose tolerance
Impotence
What is pulsus paradoxus?
Large drop in BP upon inspiration seen in cardiac tamponade
What are the reversible causes of cardiac arrest ?
4H + 4T
Hypoxia
Hypovolaemia
Hyper/po - kalaemia, hypoglyc, hypocalc
Hypothermia
Thrombosis (coronary or pulmonary)
Tension pneumothorax
Tamponade
Toxins
What electrical activity is likely to be seen in tension pneumothorax?
Pulseless electrical activity
What should be done in CPR if suspecting PE?
Prove thrombolytic drugs eg alteplase and continue CPR for 60-90 mins
Early diastolic murmur - high pitched and blowing in character describes what murmur?
Aortic regurg
Which drugs need to be used with caution in pts w statins and why?
Erythro / clarithromycin - inhibits p450 leading to raised levels of statin in the body -> increased risk of rhabdomyolysis
EVEN GREATER RISK IN CKD PTS
What should you do in AF pt if ChadVasc is below threshold to treat?
Do a transthoracic echo to rule out to exclude valvular heart disease
Which anti-HTN can cause hypocalcaemia?
Loop diuretics eg furesomide
Widespread joint hypermobility + MR - dx?
Collagen disorder eg marfans , ehlers-danlos
What are some causes of postural hypotension - how is this defined?
Causes
- Hypovolaemia
- Autonomic dysfunction: diabetes, Parkinson’s
- Drugs: diuretics, antihypertensives, L-dopa, phenothiazines, antidepressants, sedatives
- Alcohol
Postural hypotension = >20mmhg drop
What drugs should be avoided in AS due to the theoretical risk of hypotension?
Nitrates
Broad complex tachycardia - what medication is CI?
This is VT - Verapamil is CI due to risk of haemodynamic deterioration, VF and cardiac arrest
VF / pulseless VT - mx?
1 shock as soon as identified followed by 2 mins of CPR
If arrest is witnessed in monitored pt - up to 3 stacked shocks v 1 before CPR
1st line mx of trigeminal neuralgia?
Carbamzepine
Mx of medication overuse headaches?
Simple analgesia + triptans can be stopped abruptly
Opioids should be weaned gradually
What should you do if a pt w pneumothorax has persistent air leak or recurrent episodes?
Consider referral for VATS (video-assisted thoracopscopic surgery) to allow for mechanical/chemical pleurodesis +/- bullectomy
1st line ix for osteoporotic vertebral fractures?
X-ray Spine -> if theres a compression fracture may need a CT spine
Ca + breathlessness of exertion + upper lobe findings on CXR?
Radiation pneumonitis - causing upper zone fibrosis
how can you have a definitive diagnosis of medication overuse headaches?
Symptoms must resolve (or revert back to their original pattern) within 2 months of stopping the causative medication.
Effect of clarithromycin + warfarin together?
Increased effect of warfarin due to inhibition of P450 system leading to decreased break down
Gene mutation associated w hereditary non-polyposis colorectal carcinoma?
MSH2/MLH1 gene mutations
Rib fracture what to do if not controlled with normal analgesia? when might you consider further mx?
Nerve blocks
If conservative measures dont work after 12w consider surgical fixation or in the case of flail chest
What are the different rotator cuff muscles and what are their functions?
Effect of barbiturates and antiepileptics on warfarin?
P450 inducers - reduces concentration
Which is a mroe common cause of colorectal ca - HNPCC or FAP?what other ca does this increase risk of?
HNPCC -> endometrial
Diverticular sx + vaginal passage of faeces or flatus - dx?
Colovaginal fistula
Difference between diverticulosis and diverticulitis in presentation?
If symptomatic probs -itis
1st line osteoarthritis?
Paracetamol and NSAIDs - topical NSAIDs only if hand or knee
Tension pneumo mx - what size cannula and where?
14G cannula in 5th ICS MCL
Use of vibrating tools can cause what condition in the hands?
Raynauds
What foods should pts taking warfarin avoid?
Foods high in vit K - broccoli, spinach, kale and sprouts
What increases risk of chest infections in rib fractures?
Inadequate ventilation
Mx of acute confusional state?
Treating the underlying cause and environmental modification not working then haloperidol sometimes used - if parkinsonianism use atypical eg ozapines
What should you do for AF + TIA?
Start anti coagulation asap once haemmorhage is excluded - probs a DOAC
Cavitating upper lobe pneumonia in diabetic + alcoholic?
Kleb pneumoniae
Chronic steroid use + insidious development of anterior hip pain + stiffness - what should you be most worried about? what is the ix?
Avascular necrosis - MRI hip
On auscultation of the chest, what can you hear in the following conditions:
Asbestosis and Bronchiectasis
Asbestosis - inspiratory crackles
Bronchiectasis - coarse crackles and high-pitched inspiratory squeaks
How do you manage different types of seizures in men and women?
What are the clinical findings in ank spond?
Reduced:
- Chest expansion
- Lateral flexion
- Foward flexion
What should anticoagulant of choice be in a pt w/ AF who has a stroke / TIA?
Warfarin / direct thrombin / factor Xa inhibitor
What conditions do the following x-ray findings suggest:
- periarticular erosions and bone resorption
- Erosions with overhanging edges (‘rat-bite’ erosions)
- joint effusion
- loss of joint space, osteophytes, and subchondral sclerosis
- Widened, bulky physeal plates and irregularity
- periarticular erosions and bone resorption = Psoriatic arthritis (pencil in cup)
- Erosions with overhanging edges (‘rat-bite’ erosions) = Gout
- joint effusion = septic arthritis
- loss of joint space, osteophytes, and subchondral sclerosis = Osteoarthritis
- Widened, bulky physeal plates and irregularity = Osteopaenia
Ix for aki of unknown origin?
Renal tract US
What to do if considering SAH, CT is negative?
If CT was done w/in 6h -> consider another dx no need fro LP
If CT was done after 6h -> Do an LP 12h after onset of sx (done to check for xanthochromia - product of RBC breakdown)
How is ADPKD screened for?
US abdomen
What drug can reduce progression of ADPKD?
Tolvaptan
What vit d replacement should be offered to those with CKD - why?
Alfacalcidiol - doesnt require activation in kidneys
Which Ig is found quicker in infection IgM or IgG?
IgM then IgG
How can you distinguish between amoebic and pyogenic liver abscesses?
Both have similar US appearances - homogenous hypoechoic round leisons
Amoebic - associated w travellers diarrhoea
Pyogenic - Associated w hepatobiliary / pancreatic disease
What needs to be monitored in pts w HSP?
BP and Urinalysis - check for progressive renal involvement
Reddening and thickening of nipple and areola - possible dx? mx?
Pagets disease of breast - suggestive of breast ca hence requires urgent referral to breast clinic for punch biopsy, mammography and US breast
How to distinguish between pagets disease of breast and nipple eczema? mx?
Nipple - starts areola and goes to nipple
Pagets - starts nipple and goes to areola
mx = Emollients (mild), Corticosteroids (mod), Tacrolimus (refractory)
How much monitoring is recommened in T1DM? when is more frequent monitoring of blood glucose suggested?
recommend testing at least 4 times a day, including before each meal and before bed (5-7 in morning and 4-7 at other times = target levels)
more frequent monitoring is recommended if frequency of hypoglycaemic episodes increases; during periods of illness; before, during and after sport; when planning pregnancy, during pregnancy and while breastfeeding
Epilepsy + learning disability + bilateral flank masses w/ haematuria - overall dx? cause of flank masses?
Tuberous sclerosis - masses are angiomyolipomas
Mx of hypothyroidism in pregnancy?
Maternal free t4 needs to be in upper 1/3rd to avoid foetal hypothyroidism
1st trimester - propylthiouracil > carbimazole - due to reduced risk of congenital abnormalites
2nd trimester+ = carbimazole - less risk of severe hepatic injury
When may renal replacement therapies such as haemodialysis be offered in mx of AKI?
When pt is not responding to medical mx of complications eg hyperkalemia, pulmonary oedema, acidosis or uraemia
how is a thyrotoxic storm treated?
BB, anti-thyroid drugs + steroids
When can stage 1 and 2 CKD be diagnosed?
If GFR is within the correct ranges + markers of kidney disease including proteinuria, haematuria, electrolyte abnormalities or structural abnormalities detected
All patients with a CD4 count lower than 200/mm3 should receive what mx of HIV?
very active ART + PCP prophylaxis (co-trimoxazole)
Abx for MRSA???
Vancomycin
Assymptomatic bacteria in catheterised pts - to treat or not to treat?
dont traet
How can you confirm dx of post-streptococcal glomerulonephritis?
Anti-streptolysin O titre
What thyroid disease can smoking cause?
graves - (hyperthyroid)
Mx of paediatric inguinal hernias?
- Urgent referral if <1y due to increased risk of strangulation
- Older can be considered for elective repair
- Neonates and premature may be kept overnight due to increased risk of post op apnoea
3rd trimester UTI - what to use?
Amox / cefalexin for 7d
What defines the resolution of DKA? what if no resolution of ketonaemia + acidosis in 24h?
DKA resolution is defined as:
pH >7.3 and
blood ketones < 0.6 mmol/L and
bicarbonate > 15.0mmol/L
review by senior endocrinologist
When to send MSU in women w UTI?
Have symptoms that are persistent or do not resolve with antibiotic treatment.
Have recurrent UTI (2 episodes in 6 months or 3 in 12 months).
Have a urinary catheter in situ or have recently been catheterised.
Have risk factors for resistance or complicated UTI such as abnormalities of the genitourinary tract, renal impairment, residence in a long-term care facility, hospitalisation for more than 7 days in the last 6 months, recent travel to a country with increased resistance or previous resistant UTI.
Have atypical symptoms.
Have visible or non-visible (on urine dipstick) haematuria.
Pregnant
Age more than 65 years old.
Mx of testicular torsion surgery?
Definitive is emergency exploratory surgery + bilateral orchidopexy
If surgery is delayed 6h+ / prep is being made for it - can do emergency manual de-torsin (anti clockwise rotation) - buy more time for surgery
What should be done to steroid dose during illness + why?
Double the dose - due to risk of adrenal crisis
When is surgical mx of hiatus hernia required?
If it is a paraoesophageal hernia or signs of complication eg UGI haemorrhage / necrosis
How long to wait after prostatitis to measure PSA levels?
1 month
Obstructive urinary calculi + signs of infection -> mx?
Urgent surgical renal decompression + IV Abx due to risk of sepsis
Anal fistula dx - what to do now?
MRI pelvis - to characterise its course -> surgery may be needed in emergencies if pt is v unwell
Missing dialysis - effect on K+, what is a sign of this happening severly on ECG?
Can increase K+
Severe hyperkalaemia -> Sinusoidal wave pattern
T2DM dx in assymptomatic pts?
Need 2 positive results
What conditions can lead to higher-than-expected and lower-than-expected levels of HbA1c?
Higher - increase RBC lifespan:
- Vit b12 / folate deficiency
- IDA
- Splenectomy
Lower - reduced RBC lifespan:
- Sickle cell
- G6PD deficiency
- Hereditary spherocytosis
- Haemodialysis
What are the possible extra renal manifestations of ADPKD?
Hepatic cysts which manifest as hepatomegaly
Diverticulosis
Intracranial aneurysms
Ovarian cysts
What are the possible extra renal manifestations of ADPKD?
Hepatic cysts which manifest as hepatomegaly
Diverticulosis
Intracranial aneurysms
Ovarian cysts
Menstrual issues in hyper / hypothyroid?
Hyperthyroid = oligomennorhoea / amennorhoea
Hypothyroid = menorrhagia
Brainstem stroke vessels and their presenting sx:
- Anterior cerebral artery
- Anterior inferior cerebellar artery
- Basilar artery
- Posterior cerebral artery
- Posterior inferior cerebellar artery
What is a good induction anasthesia in someone who is hemodynamically unstable?
Ketamine
Which people should be referred via suspected ca pathway for breast ca?
aged 30 and over and have an unexplained breast lump with or without pain or - routine referral if below this age
aged 50 and over with any of the following symptoms in one nipple only: discharge, retraction or other changes of concern
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for breast cancer in people:
with skin changes that suggest breast cancer or
aged 30 and over with an unexplained lump in the axilla
Possible electrolyte abnormality w infusing large amounts of NaCl?
Hyperchloraemic acidosis - use hartmanns instead
Traumatic injury + LOC + Lucid interval -> what dx? what feature may you see?
Extradural haematoma
Cushings reflex - HTN and bradycardia
Shoulder dislocation - when is anteroir more common and when is posterior more associated? how does it present on examination?
anterior = FOOSH - locked in external rotation
posterior = seizures / electric shock - locked in internal rotation
Which manoeuvre to open airway is preferred if concerned about C-spine injury?
Jaw thrust > Head tilt / chin lift
What type of myopathy can corticosteroids cause?
Proximal myopathy
Mx of raised ICP?
Ix and tx underlying cause
- Raise head of bed to 30deg
- IV mannitol
- controlled hyperventilation-> reduced co2 -> vasoconstriction of cerebral arteries -> reduced ICP (caution in ischaemia)
Suspected visual loss in temporal arteritis - mx?
IV methylpred
What are some possible complications following SAH?
Re-bleeding normally 1st 12hrs
Hydrocephalus
Vasospasm - causes stroke like sx
Hyponatraemia - secondary to SiADH
Seizures
Causes of unilateral and bilateral hydronephrosis?
Unilateral = PACT
- Pelvic-ureteric obstruction (congenital or acquired)
- Aberrant renal vessels
- Calculi
- Tumours of renal pelvis
Bilateral = SUPER
- Stenosis of the urethra
- Urethral valve
- Prostatic enlargement
- Extensive bladder tumour
- Retro-peritoneal fibrosis
Mx of hydronephrosis?
Remove obstruction and drainage of urine
Acute upper urinary tract obstruction = nephrostomy tube
Chronic upper urinary tract obstruction = ureteric stent or pyeloplasty
All men w/ ED should have what levels checked?
Morning free testosteroen
What is normal anion gap?
8-14
Mx of small bowel obstruction?
Drip + Suck - NG tub insertion + IV fluids w/ extra K+
Swelling at DIP joints - what sign is this, what condition?
Herberdens nodes - features of osteoarthritis
Radiotherapy after wide-local excision / masectomy in breast ca mx?
- Whole breast radiation is recommended in wide local excision
- Radiotherapy in only T3 and T4 tumours or 4+ positive axillary nodes in those w/ masectomy
initial mx of limb threatening ischaemia?
IV analgesia + heparin + vascular review
What should happen to pts own insulin when mx of DKA?
Stop short acting insulin
Continue long acting insulin
Mx of primary hyperaldosteronism?
Mx w spironolactone
Osteomyelitis ix of choice?
MRI
What is a common cause of bilateral carpal tunnel syndrome?
RA
When to add insulin in mx of HHS?
Only if glucose level stops falling just giving iv fluids otherwise there is a risk of central pontine myelinolysis
consider vte
Complete heart block following a MI - what vessel?
Right coronary artery
What is the definition of AKI?
Detect acute kidney injury, in line with the (p)RIFLE, AKIN or KDIGO definitions, by using any of the following criteria:
* a rise in serum creatinine of 26 micromol/litre or greater within 48 hours
* a 50% or greater rise in serum creatinine known or presumed to have occurred within the past 7 days
* a fall in urine output to less than 0.5 ml/kg/hour for more than 6 hours in adults and more than
Mx of ileus?
NBM -> can progress to small sips of clear fluids
NG tube if vomiting
IV fluids to maintain normovolaemia
TPN - needed for prolonged / severe cases
What are the indications for a CT head within 1 hour and what are the indications for CT head within 8 hours
Insulin dependent diabetic - when should they check blood glucose re driving?
Check before driving and every 2 hrs whilst driving
Raised which hormone is increased risk of pseudogout?
PTH - hyperparathyroidism
Renal colic - contrast or non-contrast KUB?
non-contrast KUB
mechanism of action of tamsulosin?
a-1 antagonist
What are the red flag sx and signs that suggest a serious underlying cause for trigeminal neuralgia?
Sensory changes
Deafness or other ear problems
History of skin or oral lesions that could spread perineurally
Pain only in the ophthalmic division of the trigeminal nerve (eye socket, forehead, and nose), or bilaterally
Optic neuritis
A family history of multiple sclerosis
Age of onset before 40 years
What cause of n+v should the following medications be used for?
Ondansetron
Haloperidol
Prochlorperazine
Metoclopramide
Ondansetron for chemotherapy-induced nausea
Haloperidol for intracranial causes (raised ICP, direct effect of tumour)
Prochlorperazine for vestibular causes
Metoclopramide for gastrointestinal causes
Pt on steroids - has surgery what do you need to do and why?
The patient needs steroid cover with hydrocortisone or dexamethasone before and after major surgery to prevent adrenal crisis
Describe the different epilepsy localising features in terms of lobe affected?
What is the mx of neuropathic pain?
first-line treatment*: amitriptyline, duloxetine, gabapentin or pregabalin- if the first-line drug treatment does not work try one of the other 3 drugs
What are the causes of postural hypotension w/ compensatory tachycardia -what doesn’t have compensatory tachy?
The ‘4Ds’ can be useful in remembering causes of postural hypotension with compensatory tachycardia.
- Deconditioning.
- Dysfunctional heart: aortic stenosis.
- Dehydration: disease (acute illness, adrenal insufficiency), dialysis, drugs (diuretics, narcotics).
- Drugs: anti-anginals, anti-parkinsonian medications (levodopa), antidepressants, antipsychotics, anti–benign prostatic hyperplasia drugs (tamsulosin)
Autonomic failure eg in parkinsons
Why do you get long QT syndrome?
Usually due to loss of function / blockage of K+ channel
What is the new definition of a TIA?
New ‘tissue-based’ definition is now used: a transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischaemia, without acute infarction
Which pts should be offered urate lowering therapies (allopurinol / febuxostat) in mx of gout?
Those w 2 or more attacks per year, tophi, renal disease, uric acid renal stones and if on cytotoxic / diuretics
When prescribing this colchicine should be co-prescribed for 1st 6m (otherwise NSAIDs)
Which pts should be offered urate lowering therapies (allopurinol / febuxostat) in mx of gout?
Those w 2 or more attacks per year, tophi, renal disease, uric acid renal stones and if on cytotoxic / diuretics
When prescribing this colchicine should be co-prescribed for 1st 6m (otherwise NSAIDs)
What is the most common type of thyroid cancer, most likely complication of this type and prognosis?
Papillary
Spreads to cervical lymph nodes
Excellent prognosis
Mx of HAP?
Within 5 days of admission: co-amoxiclav or cefuroxime
More than 5 days after admission: piperacillin with tazobactam OR a broad-spectrum cephalosporin (e.g. ceftazidime) OR a quinolone (e.g. ciprofloxacin)
What is CK like normally in Rhabdomyolysis?
10,000+
Stroke + AF = mx?
Start anticoag w DOAC or Warfarin
Best ix to identify C spine fractures?
CT Spine
Needle biopsy: nuclei that are enlarged, hyperchromatic and pleomorphic - suggests what ca?
Carcinoma
OAB mx?
Oxybutinin - antimuscarinic
Incidental AF found what to do?
CHADVASC then decide if you need anticoagulation
Nose bleed - mx?
cautery -> minor bleeding + accessible site = cautery, anterior pack used for profuse bleeding w/ sites difficult to localise
MSM + Procitis + Lymphadenopathy - possible dx?
Lymphogranuloma venereum
Cord compression due to spinal mets + too frail for surgery possible mx?
External beam radiotherapy
what type of peptic ulcer is relieved by eating and worse on rest?
duodenal
Acute gout but NSAIDs are ruled out in CKD stage 4 what should you use?
Oral pred
Down and out eye - which nerve palsy, what if there’s pupil dilation?
3rd nerve - if dilation it is surgical 3rd nerve
What to do if severe hyperkalaemia in context of AKI?
Immediate discussion w/ crit care / nephrology to consider renal replacement therapies
Myasthenia gravis antibodies?
Anti-ACHr
How can you diagnose IgA nephropathy definitively?
Renal biopsy - shows diffuse mesangial IgA deposition
What are the main causes of non-gonococcal urethritis?
1 = Chlamydia trachomatis
If negative for chlamydia -> mycoplasma genitalium
Mx of subclinical hypothyroidism - raised TSH but normal T3/4?
If TSH >10 consider offering levothyroxine if levels remain like this at 2 occasions 3m apart
if TSH 5.5-10 depends on age
- 65> - measurements are true 2x 3m apart + sx -> consider supplementation
- older people (particularly 80+) - watch and wait
- Assymptomatic - observe and repeat in 6m
What common drugs can cause SJS?
Antibiotics such as penicillin, amoxicillin, erythromycin, ciprofloxin and sulfonamides
Anticonvulsants such as Lamotrigine, phenobarbital, valproic acid, phenytoin and carbamazepine
NSAIDs- Pain relievers such as acetaminophen, ibuprofen, naproxen sodium and allopurinol
Antifungals such as ketoconazole, itraconazole and fluconazole
Antivirals such as abacavir
What is Lights criteria for exudative v transudative pleural effusion and when should it be applied?
Applied when pleural fluid protein is 25-35
Criteria that suggest exudative is:
- pleural fluid protein divided by serum protein >0.5 (more than 1/2)
- pleural fluid LDH divided by serum LDH >0.6 (more than 60%)
- pleural fluid LDH more than two-thirds the upper limits of normal serum LDH - more than 150
What is the max metformin can be titrated up to - when does this need to be done?
Increase to 500mg TDS (3x daily) - before initiating SGLT-2 inhibitors
What bacteria does this describe:
- Gram -ve rod
- Non-lactose fermenting
- Oxidase +ve
Pseudomonas eurginosa
What bacteria does this describe:
- Gram -ve rod
- Non-lactose fermenting
- Oxidase +ve
Pseudomonas eurginosa
What blood pressure reading in clinic is the criteria for immediate tx?
180/120<
Medial epicondylitis - what aggrevates pain and what might this accompany?
pain is aggravated by wrist flexion and pronation
symptoms may be accompanied by numbness / tingling in the 4th and 5th finger due to ulnar nerve involvement
What form of encephalitis typically shows bilateral temporal lobe changes on CT? how do different causes of encephalitis varus?
this is textbook HSV encephalitis
Cryptococcus - weeks not days and CMV (CD <50) encephalitis occur in immunocompromised (HIV) pts
Painful 3rd nerve palsy + dilated eye suggests what?
Posterior communicating artery aneurysm - dilation suggests compressive leison
Diabetic foot ulcer + raised temp + raised HR -> suggests what? how to dx?
These are signs of systemic illness - suggestive of osteomyelitis
Dx is done using MRI - requires 6w of fluxcox
Which viruses are most likely to cause meningitis in adults?
Enterovirsuses eg coxsackie, echovirus
Breast Ca - post surgery adjuvant therapy choices if hormone +ve?
If post-menopausal - aromatase inhibitors eg anastrozole
If pre/peri-menopausal - tamoxifen (can increase risk of endometrial, VTE and menopausal sx)
Signs of hydrocephalus?
Wet weird wobbly
Signs of venous sinus thrombosis?
Risk factors for thrombosis, headache, reduced consciousness, vomiting
contralateral homonymous hemianopia with macular sparing and visual agnosia - what vessel
Posterior cerebral artery
What are the signs seen in lateral medullar syndrome?
cerebellar signs, contralateral sensory loss & ipsilateral Horner’s
Mx of VT - what drug is CI?
Verapamil
Pt w/ gonorrhoea - what can be offered if they refuse IM ceftriaxone?
Oral cefixime + oral azithromycin
Ejection systolic murmur - worse on inspiration (downs) -dx?
ASD
Spinal cord trauma + low BP + normal HR - suggests what? mx?
Neurogenic shock - low BP due to reduced sympathetic tone / increase parasympathetic tone + cannot produce tachycardia response
Will need vasopressers
Which lung ca can cause SiADH, ACTH rise and lambert eaton?
Small cell
Which lung ca can cause increased release of PTH-rp?
Squamous cell
Which lung ca can cause gynaecomastia?
Adenocarcinoma
What is a common complication of intraventricular haemorrhage? how can this be distinguished from expansion of hematomas?
Hydrocephalus - this is way more common and doesn’t cause midline shift
Treat w external ventricular drain
What electrolyte abnormality can Trimethoprim cause?
Trimethoprim -> tubular dysfunction -> HYPERKALAEMIA
Effect of Ca on QT interval?
Rising calcium shortens QT interval
In trauma - when fluid is draining from ear / nose - how can you check if its CSF?
Check glucose - present in CSF not in mucus
Beta-2-transferrin is gold standard
xanthachromia takes 12h to present
UTIs and breastfeeding - which abx is safe and which isn’t?
Both nitrofurantoin and trimethoprim are present in breast milk
Trimethoprim - isnt harmful for short term use
Nitrofurantoin - can cause haemolysis in G6PD infants
In diagnosing PSC - when may you prefer to use ERCP over MRCP?
ERCP is more invasive so generally avoided unless - MRCP is unsuitable eg metal implants
Differences and similarites between churg strauss and Granulomatosis w/ polyangiitis?
Similarities:
- Vasculitis
- Sinusitis
- Dyspnoea
Churg:
- Asthma
- pANCA
- Eosinophilia
Granulomatosis w/ polyangiitis (wegners):
- Renal failure
- cANCA
- Epitaxis / haemoptysis
What causes TLCO to be lower?
pulmonary fibrosis
pneumonia
pulmonary emboli
pulmonary oedema
emphysema
anaemia
low cardiac output
What causes TLCO to be raised
asthma
pulmonary haemorrhage (Wegener’s, Goodpasture’s)
left-to-right cardiac shunts
polycythaemia
hyperkinetic states
male gender, exercise
What are the most common causes of endocarditis?
Staph aureus - acute and IVDU - most common overall
Staph epidermis - most common 2m following valve replacement
Staph bovis - colorectal ca
Staph viridans - developing countries
HACEK - culture negative causes
Strongest RF for anal cancer?
HPV
Increasing age, smoking, HIV and multiple anal sex partners = other RFs
What worsens lateral epicondylitis pain?
Opposite of medial epicondylitis - resisted wrist extension and elbow extension/supination
This is tennis elbow
Thoracic kyphosis causes what type of lung disease?
Restrictive - raised FEV1/FVC ratio
Can cause reduced TLCO (measure of gas transfer from lung to alveoli) - chest wall deformeties affect how much alveoli can expand
KCO (measure of gas exchange efficiency) = TLCO / alveolar SA -> in this case alveolar SA would be reduced thus increasing KCO
What is the intervention of choice in pts w malignant distal obstructive jaundice due to unresectable pancreatic carcinoma?
Biiliary stenting
Signs of infants w/ hydrocephalus?
Increased head circumfrence + bulging fontanelle + sunsetting of eyes (impaired upward gaze)
MoA of fondaparinux?
Activates antithrombin III - similar to LMWH
bupropion - moa?
a norepinephrine and dopamine reuptake inhibitor, and nicotinic antagonist
CI in pregnancy, epilepsy (reduces seizure threshold) and breast feeding - Eating disorder = relative CI
What is pellagra - how does it present?
B3 (niacin) deficiency - presents w/ DDDD:
Dermatitis
Diarrhoea
Dementia / delusion
Leads to DEATH
What is BeriBeri - how does it present / get categorised?
B1 (thiamine) deficiency, split into wet and dry beriberi
Wet beriberi (presenting with tachypnoea, dyspnoea and pedal oedema)
Dry beriberi (presenting with pain, paresthesia and confusion).
-> Wernicke–Korsakoff syndrome is a subtype of dry beriberi
CMT disease inheritance pattern?
CMT1 + 2 = AD
CMT3 = AD / AR
CMT4 = AR
What are the ottowa rules for ankle injuries?
An ankle x-ray is required only if there is any pain in the malleolar zone and any one of the following findings:
* Bony tenderness at the lateral malleolar zone (from the tip of the lateral malleolus to include the lower 6 cm of posterior border of the fibular)
* Bony tenderness at the medial malleolar zone (from the tip of the medial malleolus to the lower 6 cm of the posterior border of the tibia)
* Inability to walk four weight bearing steps immediately after the injury and in the emergency department
What are the definitions of malnutrition?
BMI <18.5
BMI <20 + 5% unintentional weight loss in 3-6m
10% unintentional weight loss in 3-6m
Why might crohns cause intermittent jaundice?
Bile salts absorbed in terminal ileum -> if absorption is impaired due to crohns -> development of gallstones which can go into CBD and cause jaundice
What is mirizzi syndrome?
When gallstones compress bile duct directly -> one rare time cholecystitis presents w jaundice
What organ is most likely to be enlarged in ADPKD and why?
Hepatomegaly due to hepatic cysts
Do pts who have had catheter ablation for AF need long term anticoagulation?
Yes if their CHAD VASC score says so (>1 indicates this)
If score is 0, then 2 months of anticoagulation needed only
CKD + Urinary A:CR >30mg/mol - what mx is required?
Need to be started on ACEi / ARB
What is an alternative to long-term anticoagulation medication in pts w AF?
Left atrial appendage closure surgery
Pt w intracranial bleed -> becomes unresponsive - what ix is needed and why?
CT head needed to rule out hydrocephalus
How can you distinguish between CT heads of extra and subdural hematoma? which is this?
Extradural = Lemon - within suture lines cause life gives you (extra) lemons
Subdural = Banana - The banana is (sub) under the skin to eat
What do different ABPI results mean?
0.3 - critical limb ischaemia
<0.5 = severe arterial disease - PAD
0.5-0.8 = suggests presence of arterial disease or mixed arterial/venous disease - PAD or mixed PAD and PVD
0.8-1.3 = no evidence of significant arterial disease
> 1.3 = suggests presence of arterial calcification, such as in some people with diabetes, RA, systemic vasculitis, atherosclerotic disease and advanced chronic renal failure.
What needs to be co-administered w/ Izonisaid to prevent peripheral neuropathy?
Pyoxidine - Vit B6
When can you drive again following TIA?
When sx free for 1m no need to tell DVLA
Difference between low pressure and high pressure chronic urinary retention?
High pressure retention:
- impaired renal function and bilateral hydronephrosis
- typically due to bladder outflow obstruction
Low pressure retention:
- normal renal function and no hydronephrosis
When should darboetin be given to pts w CKD?
If they develop anaemia secondary to CKD
Should pts w/ CKD be on statins?
Yes - lipid-lowering therapy with a statin is also recommended for all patients with CKD <60 for the primary or secondary prevention of cardiovascular disease
What GFR means metformin is CI?
GFR <45 use w/ caution
GFR <30 stop using
Black and HTN w/ T2DM - 1st line?
ARBs - ‘-artans’
How can you distinguish between drug induced and idiopathic parkinsons?
Drug induced = bilateral sx
Idiopathic = unilateral
Goserelin - MoA?
GnRH AGONIST -> -ve feedback to anterior pituitary
Side effects of B-blockers?
Bronchospasm
Cold peripheries
Fatigue
Sleep disturbances + nightmares
ED
What drugs are the most common cause of drug-induced angioedema?
ACEi
Bromocriptine - galactorrhoea - does it cause it?
Galactorrhoea - no bro, no homo - its used to treat it
What monitoring is needed on statins?
LFTs at baseline, 3m and 12m
Fasting lipid profline can also be checked during monitoring to assess response to mx
What is the criteria for diagnosing RF?
Joints (migrating polyarthritis).
Obvious, the heart would be involved (carditis, pancarditis, pericarditis).
N (Subcutaneous Nodules).
E (Erythema marginatum).
S (Sydenham’s chorea).
Surgery + diabetes - what to do if a pt has poorly controlled diabetes ? who else should do this?
Usually require variable rate insulin infusion
- if more than one meal is to be missed
patients with poor glycaemic control - risk of renal injury (e.g. low eGFR, contrast being used)
Green-blue colour + chronic wound infection +offensive smell (esp in immunocompromised) - what organism?
Pseudomonas
What type of visual loss is associated w macular degeneration?
Central field loss
RFs for macular degeneration?
Older age - 75+
Smoking
FHx
Same as increased risk of ischaemic CVD
RFs for macular degeneration?
Older age - 75+
Smoking
FHx
Same as increased risk of ischaemic CVD
What type of hearing loss in Menieres?
Unilateral sensorineural
Oral pred + dendritic corneal ulcer -> likely dx and mx?
herpes simplex keratitits treated w topical aciclovir
What cause of conductive hearing loss is associated w chronic smelly ear discharge and recurrent glue ear?
Cholesteatoma
What causes chalky patch on tympanic membrane upon otoscopy? what type of hearing loss is this?
Tympanosclerosis - conductive hearing loss
What does abnormal fluorescin staining showing linear branching corneal ulcer suggest?
Herpes simplex keratitits - presents w painful red eye w/ photophobia and epiphora (excessive tearing)
How does spider naevi differ from teleangtasia?
Spider naevi can be differentiated from telangiectasia by pressing on them and watching them fill.
Spider naevi fill from the centre, telangiectasia from the edge
What side is the language centre in right-handed and left-handed people?
Left side for 95-99% of right handed people
Left side for 70% of left-handed people
When should BB be stopped in acute heart failure?
Only stopped if:
- HR <50bpm
- 2nd / 3rd degree AV block
- Shock
When should BB be stopped in acute heart failure?
Only stopped if:
- HR <50bpm
- 2nd / 3rd degree AV block
- Shock
Suspected GCA, pt is started on prednisolone but biopsy is clear - what is the mx?
Continue pred - regardless of biopsy result as complication is blindness and GCA has skip leisons which can show normal biopsy (ideally biopsy in 1st 7d of steroid mx)
How can cholera present?
Dehydration + Hypoglycaemia
What to do for pts on warfarin going to have emergency surgery?
If surgery can wait for 6-8 hours - give 5 mg vitamin K IV
If surgery can’t wait - 25-50 units/kg four-factor prothrombin complex
How much insulin is there in 1ml?
100 units
How can you differentiate between seizures and vasovagal syncope?
Syncopal episodes are associated with a rapid recovery and short post-ictal period.
Seizures are associated with a far greater post-ictal period
What is subacute combined degeneration of spinal cord cause by and what are its features?
Caused by B12 deficiency
Causes these features + peripheral parasthesia
What are the key indications for NIV?
What are the initial ix in acute limb threatening ischaemia?
Initial investigations should include a handheld arterial Doppler examination.
If Doppler signals are present, an ankle-brachial pressure index (ABI) should also be obtained.
Wilsons or Haemochromatosis? What causes cranial DI
Haeochromatosis
HOCM heart sounds?
S4 + mid-diastolic murmur (no radiation to carotids)
If a pt w/ parkinsons cant take levodopa - what can they take instead?
They can be given a dopamine agonist patch as rescue medication to prevent acute dystonia
co-careldopa -> can be given orally
What are the RFs for asystole in bradycardia - how should these be mx?
complete heart block with broad complex QRS
recent asystole
Mobitz type II AV block
ventricular pause > 3 seconds
They need transvenous pacing
What is the key parameter to monitor in HHS? how is this measured?
Serum osmolality - 2xna+glucose+urea
Will be more than 320
Secondary prevention in TIA?
1st line clopidogrel
2nd line aspirin + dipyridamole
What are some RFs for gallstones that arent the 4Fs?
DM
Crohns
Rapid weight loss
Drugs - fibrates, COCP
How much stenosis of internal carotid is required to be reffer for carotid endarterctomy?
> 70% + suffered stroke / TIA in carotid territory and not severely disabled
Why should B12 levels be checked and corrected before adjusting folate levels?
Can cause subacute degeneration of the spinal cord -> Loss of proprioception + vibration + muscle weakness + hyperreflexia (Spinocerebellar, lateral corticospinal and dorsal columns)
What are some x ray changes seen in avascular necrosis ?
Flattening, subchondral fractures and smaller size of bone
Remember MRI is ix of choice
How can SAH cause hyponatraemia?
due to SiADH
Mx of HSV in pregnancy - w/in 6w of delivery?
mother to take 400mg aciclovir til delivery + elective c-section recommended
How can vasopasm be prevented after SAH?
21d course of Nimodipine
How can aneurysms causing SAH be treated?
Coiling by interventional neuroradiologist
If symptomatic AV type 2 block - what is mx?
Surveilance
If symptomatic - can stop CCBs and BB -> then if still problematic pacemakers
what is the 1st line mx of parkinsons?
If the motor symptoms are affecting the patient’s quality of life: levodopa
If the motor symptoms are not affecting the patient’s quality of life: dopamine agonist (non-ergot derived), levodopa or monoamine oxidase B (MAO‑B) inhibitor
What should be given alonside insulin kit to diabetics?
Glucagon kit +- glucose
What is Felty syndrome? how can you distinguish between this and methotrexate use?
Both cause neutropaenia however no splenomegaly in methotrexate use
Felty syndrome occurs in RA and causes splenomegaly hence the hypersplenism -> increased RBC breakdown
What imaging is required in RA pts pre surgery and why?
AP + lateral C-spine radiographs - atlantoaxial subluxation is a complication of RA -> cervical cord compression
hence this needs to be checked for and if present -> wear C-spine collar + ensure neck isnt hyperextended on intubation
Ischaemic stroke - 6h+ after sx + limited infarct core on CT -> mx?
Thrombectomy
What is the most common organism found in bronchiectasis?
H influenzae
In status epilepticus what needs to be checked before thinking about other causes?
Hypoxia and hypoglycaemia
What is whipples triad of Insulinoma? Which type of MEN1 does this occur w?
- Hypoglycaemia w/ fasting / exercise
- Reversal of sx w/ glucose
- Recorded low BM at time of sx
MEN1 -PPP - parathyroid adenoma, pituitary tumour + pancreatic tumour
Ix? Mx of insulinoma?
Ix = Supervised prolonged fasting (upto 72h) + CT pancreas
Surgery - if not suitable diazoxide + somatostatin
Which pts in tachycardia require immediate DC (synchronised) cardioversion?
Unstable pts defined as the following signs:
- shock: hypotension (systolic blood pressure < 90 mmHg), pallor, sweating, cold, clammy extremities, confusion or impaired consciousness
- syncope
- myocardial ischaemia
- heart failure
What causes the following changes to S2:
- Loud S2
- Soft S2
- Widely split S2
- Fixed split S2
- Reverse split S2
What blood test abnormalities can be caused by TPN?
LFT derangement
What is the bone profile like in osteogenesis imperfecta?
All normal!
Ca, PTH, ALP and PO4- all normal
What is the mx of angina?
Aspirin and statin for all patients unless contraindicated
Sublingual glyceryl trinitrate for angina attacks
First-line: beta-blocker or calcium channel blocker (rate-limiting if on its own eg diltiazem / verapamil)
Second-line: increase dose of first-line drug or add another drug from the same class
Third-line: add one of these drugs: long-acting nitrate, ivabradine, nicorandil, ranolazine
Refer for PCI or CABG if still symptomatic after three drugs
What are the typical signs of acute interstitial nephritis? what can cause this?
The patient presents with typical symptoms of acute interstitial nephritis: fever and rash. Eosinophilia would likely be found on blood tests. HTN and mild impairment can also be seen
Medications including penicillin, rifampicin, NSAIDs, allopurinol and furosemide have been linked with acute interstitial nephritis
Increased SOB + Fever following stroke - likely dx? which part is likely affected?
Aspiration pneumonia - more likely in right lung
Blood stained discharge + no palpable lump + younger pt - likely dx?
Intraductal papilloma
What initial ix can be useful in identifying contributing factors to post op ileus?
U+Es - can often be triggered by underlying electrolyte abnormalities (K, Mg, PO4-)
Statins should be stopped when patients are on what type of abx?
Macrolides - Clarithromycin, erythromycin etc
Partial anterior circulation infarcts - 2 of the following:
unilateral hemiparesis and/or hemisensory loss of the face, arm & leg
homonymous hemianopia
higher cognitive dysfunction e.g. dysphasia
Differences between Brocas and Wernickes Aphasia -> What part of the brain is affected
Broca = FRONTAL LOBE - front of brain, near mouth hence used for language production
Wernickes = TEMPORAL LOBE - back of brain, near back of brain more thinking hence language comprehension
What to do if effective removal of milk hasnt improved sx of lactational mastitis after 12-24h ?
Oral fluclox 10-14d
If untreated becomes breast abscess -> needs I+D
Post-exposure prophylaxis for HIV - what and how long for?
4w of oral ART
Painless genital pustule → ulcer → painful inguinal lymphadenopathy → proctocolitis likely dx in an MSM?
Lymphogranuloma venerum
What is the general course of LGV?
LGV is a sexually transmitted infection caused by a type of bacteria called chlamydia
The first sign of LGV is a small blister or sore on the genitals or anus that may not hurt or itch and may go away quickly
The second sign of LGV is swollen and painful glands in the groin area, usually on one side but sometimes on both
The third sign of LGV is inflammation and bleeding from the rectum (the end of the bowel), especially if you have sex with men or have HIV
What is the most common cause of nephrotic syndrome in adults?
Membranous nephropathy
Renal biopsy shows: thickened basement membrane
Silver staining shows: subendothelial spikes
What is likely dx?
Membranous nephropathy
What abx is used for prophylaxis against infective exacerbations of COPD + what things need to be done before this can be done?
Azithromycin
Pt must:
- Not smoke + Optimised treatments and still have exacerbations
- CT thorax (exclude bronchiectasis) + sputum culture (exclude TB)
- LFT + ECG - exclude QT prolongation as macrolides can prolong it
What does raised T3 + T4 but normal fT3 + fT4 suggest?
Increased amounts of thyroid binding globulin - seen normally in pregnancy (dont be tricked by minor weight gain and fatigue)
Can you give fluclox in pregnancy if not whats the alternative?
Yes - Erythromycin if allergic (for cellulitis)
Outside of pregnancy its doxycycline 2nd line
Indwelling catheter -> Osteomyelitis - likely organism?
Staph aureus
NSAIDs + AKI - are they okay to continue?
No - except aspirin at cardio dose
NSAIDs + AKI - are they okay to continue?
No - except aspirin at cardio dose
What is Hedingers syndrome?
Carcinoid heart disease - Pulmonary stenosis in a pt w/ carcinoid tumour
Which drugs are safe to continue in AKI?
Paracetamol
Warfarin
Statins
Clopidogrel
BB
Aspirin @ 75mg
Broad complex tachycardia - likely dx? what drug should be avoided as it can percipitate severe hypotension, VF or cardiac arrest?
VT
Avoid verapamil!!
How can you distinguish between carotid and aortic dissection?
Both can cause neurological deficits (often Horners) however carotid doesnt cause marked chest pain
What anti-HTNsive is CI in renovascular disease?
ACEi - OPPOSITE OF CKD!!
Can amylase levels be raise in small bowel obstruction?
Yes - so be aware of this as a differential in pts w/ RFs for this
Mx of fibroadenomas?
Only needed if >3cm - surgical excision is the response
What drugs can cause PROXIMAL MYOPATHY?
PREDNISOLONE - corticosteroids
Bone pain + Low Ca, Low PO4-, High ALP and PTH - likely dx?
Osteomalacia -> low vit d -> needed for GI absorption of ca and po4- -> raised PTH -> increased bone resorption hence raised ALP
What is ostetis fibrosa cystica found in and what are the bone profile results?
Late primary hyperparathyroidism hence
Raised PTH -> Raised Ca, ALP + Low PO4-
Mx of severe cellulitis?
Only say the C word if its a SEVERE situation
Cellulitis Mx = Co-amox / Cefuroxime / Clindamycin / Ceftriaxone
(4 Letters in the C word 4 C drugs)
Effects of thiazides upon glucose control?
Worsens it
Seizures features and lobes involved?
Frontal = motor eg jacksonian march, hand/leg + post ictal weakness
Parietal = Parasthesia (sensory)
Occipital = Floaters / flashes (visual)
Temporal = everything else - aura, w or w/out impaired conciousness + automatisms
What is Todds paresis?
Post ictal weakness in a pt w/ focal seizure
how does orlistat work?
Orlistat works by inhibiting gastric and pancreatic lipase to reduce the digestion of fat
What drug acting on the kidneys can cause ototoxicity?
Loop diuretics eg Furosemide
Thyroid scintigraphy scan in subacute dequervains thyroiditis - shows what?
Decreased Iodine uptake
What is torsades de points? mx?
VT w/ long QT -> can become VF and hence lead to death
IV mag sulf
How to measure QT interval?
QT interval: Time between the start of the Q wave and the end of the T wave
What dose of statins should patients be on?
Primary prevention (T1DM, CKD <60, Qrisk >10) of CVD = 20mg of atorvastatin -> can increase dose if non-HDL doesnt reduce by 40%or more
Secondary prevention of CVD = 80mg of atorvastatin
Most common type of breast ca?
Invasive ductal carcinoma (no special type) is the most common type of breast cancer
What is the likely dx and tx?
A 54-year-old man presents with a persistent tremor. On examination there is 6-8 Hz tremor of the arms which is worse when his arms are outstretched. His father suffered from a similar complaint.
Essential tremor - made better by alcohol and propanolol (sometimes primidone)
RFs for avascular necrosis?
Long term steroids
Alcohol excess
Chemo
Trauma
Which nerve is commonly injured in posterior hip dislocations?
Sciatic - loss of sensation in sciatic nerve distrubution + foot drop (as sciatic nerve supplies common peroneal)
Femoral - can also be injured loss of sensation in the anterior and medial aspects of the thigh and leg, as well as weakness in hip flexion and knee extension
Which nerve is commonly injured in posterior hip dislocations?
Sciatic - loss of sensation in sciatic nerve distrubution + foot drop (as sciatic nerve supplies common peroneal)
Femoral - can also be injured loss of sensation in the anterior and medial aspects of the thigh and leg, as well as weakness in hip flexion and knee extension
Which nerve is commonly injured in posterior hip dislocations?
Sciatic - loss of sensation in sciatic nerve distrubution + foot drop (as sciatic nerve supplies common peroneal)
Femoral - can also be injured loss of sensation in the anterior and medial aspects of the thigh and leg, as well as weakness in hip flexion and knee extension
Which nerve is commonly injured in posterior hip dislocations?
Sciatic - loss of sensation in sciatic nerve distrubution + foot drop (as sciatic nerve supplies common peroneal)
Femoral - can also be injured loss of sensation in the anterior and medial aspects of the thigh and leg, as well as weakness in hip flexion and knee extension
What changes are seen in septic shock (interms of BP and Hr etc)
reduced SVR
increased HR
normal/increased cardiac output
decreased blood pressure
What changes are seen in cardiogenic shock (interms of BP and Hr etc)
increased SVR (vasoconstriction in response to low BP)
increased HR (sympathetic response)
decreased cardiac output
decreased blood pressure
Malignancy + raised CK - might suggest what condition? how might this present?
Polymyiositis - might present w/ proximal muscle weakness + tenderness
Headache that is worse when standing up and better lying down suggests what? name a cause? associated w?
Low ICP headache - can be caused by spontaneous intracranial hypotension
Connective tissue disorders eg marfans
A 38-year-old woman presents with fever, malaise and jaundice. On examination she has moderate hepatomegaly. Laboratory analysis confirms a positive anti-smooth muscle antibody and anti-nuclear antibody. likely dx?
AI hep
How is cellulitis diagnosed?
Clinically
Which ca is increased risk in a pt w/ hashimotos thyroiditis?
MALToma
Metastatic ca - effect upon adrenal gland?
Adrenal disorder - it can cause addisons (hyponatraemia, hyperkalaemia, hypotension etc)
Roughened red papules over the knuckles described what seen in what condition?
Grottons papules seen in Dermatomyositis - refer urgently to rheum
Vomiting + Addisons - how should mediactions be changed?
Take IM hydrocortisone until vomiting stops
Which valvular abnormality is associated w ADPKD?
Mitral valve prolapse
Which anti-epileptic causes peripheral neuropathy?
Phenytoin
What type of shock will cause warm peripheries?
Neurogenic, septic, and anaphylactic shock (together are all distributive shock) will cause warm peripheries, with the others causing cool peripheries
What are some local complications of gonnorhea infection?
male- urethral strictures, epididymitis and salpingitis (hence may lead to infertility)
female - PID and Bartholin’s abscesses
What are the 3 main presentations of basilar artery strokes?
Locked-in syndrome:
- An acute decreased GCS and advanced motor symptoms.
- Insidious, gradual deterioration in GCS and motor symptoms with a subsequent sudden advanced decrease in GCS and motor symptoms.
- A ‘herald hemiparesis’ with associated headache and vision changes prior to the onset of permanent symptoms of motor loss.
Ix of suspected spinal abscess?
MRI whole spine as there may be skip leisons
What anasthetic agent:
Reverses action of midazolam
Flumazenil
What anasthetic agent:
Is hepatotoxic
Halothane
What anasthetic agent:
Has antiemetic properties
Propofol
Prolonged incubation period + foreign travel + non-bloody diarrhoea - organism?
Giardasis -> can get lactose intolerance and malabsorption w it
A 48-year-old male presents with a 8 week history of epistaxis and nasal stuffiness. On examination there is evidence of nasal crusting. A chest x-ray demonstrates multiple cavitary lesions
Likely dx? antibody?
Wegners granulomatosis (granulomatosis w/ polyangiitis)
cANCA
Retro-orbital headache, fever, facial flushing, rash, thrombocytopenia in returning traveller →
Dengue
Which drug can reduce awareness of hypoglycaemic sx and thus increase risk of hypoglycaemia?
BB
How long after abx use does drug induced interstitial nephritis occur and is it common?
4-7d after abx exposure and it is still relatively rare
Hypermigmented + thickened waxy skin + brown discolouration (lipodermatosclerosis) + little pain ulcer = what type of ulcer?
Venous
Oxybutinin - can cause constipation or nah?
Yes
Increasing number of floaters in one eye, what is likely dx?
Retinal detachment
What is the most likely cause of developing fever in early post-op period + reduced O2 sats esp in a pt w/ abdo surgery + has pain?
Bibasal atelectasis
Most important prognostic factor in melanomas?
Breslow depth / thickness
hat is the purpose of cricoid pressure during anasthesia?
Prevent passage of gastric content into the airway
When is vestibular neuroniits more ikely thna BPPV and Vestibular migraine?
When its an isolated incident
Wasting of muscles instrins hand muscle? where is leison
T1
Painful eye w/ loss of acuity in primary care mx?
Needs urgent opthal assessment
Graves antibody?
Anti-TSH
What should be prescribed to all people w/ PBC?
Ursodeoxycholic acid
Multiple fractures followed by early onset (within 24 hours) of hypoxia, dyspnea, and
tachypnea are the most frequent findings. Neurologic manifestations range from the development of an acute confusional state and altered level of consciousness to seizures and focal deficits and usually follow respiratory symptoms. A petechial rash is the last component to appear and only appears in about a third of cases - What does this describe a case of?
Fat embolism syndrome
A 51 year old woman presents to her GP with 6 months of dry mouth and gritty eyes. She has had vitiligo for the last 10 years. Both parotid glands are mildly enlarged. What is the likely dx?
Sjogrens syndrome
Above what level do spinal cord lesions have to be in order to cause autonomic dysreflexia?
Above T6
Describe the COPD mx
What is the CXR finding in PE?
Usually normal
however if theres going to be anything it would be a wedge-shaped opacification of the lung -> might also see pleural effusion
What should pts w/ frequent infective exacerbations of COPD be offered to have at home?
Home supply of predniolone and abx
What blood results suggests atopic features in COPD?
High esinophil count
What are the features of anterior cord syndrome?
This is a specific cord lesion affecting the anterior 2/3 of the cord.
- complete motor paralysis below the level of the lesion
- loss of pain/temperature sensation
- intact proprioception/vibration sensation.
Which pts should be offered annual influenza vaccinations and 5 yearly pneumococcal?
CKD or Hyposplenism
What are the features of acetabular labral tear?
Hip/groin pain
Snapping sensation around hip
Occasionally may involve sensation of locking
Usually involved w/ trauma or degenerative change in older adults
Primary hypogonadism + High LH, FSH and Low Testosterone - likely dx?
Klinefelters syndrome - XXY
Usually taller than average, infertile and small firm tested
+ gynaecomastia + increased risk of breast ca
Mx of Bells palsy?
Oral pred w/in 72 hr + eye care
F/U
- Refer to ENT if no improvement in 3w
- If long standing weakness (months) may need referral to plastics
Mx of human and animal bites?
Abx - Co-amoxiclav or if allergic doxycyc + metronid
If skin is broken and blood is drawn OR if in high risk area (hands, feet, face, genitals, skin overlying cartilaginous structures or an area of poor circulation)
An x-ray spine shows vertebral wedge compression fractures and focal sclerotic bony lesions
Suggests what
Metastatic prostate ca
What are the most common tumours causing bone mets in order?
What are the most common sites of bony mets?
Prostate
Breast
Lung
Spine
Pelvis
Ribs
Skull
Long bones
Describe ALS pathways
What drug can induce neutrophilia?
Corticosteroids eg prednisolone
What organism is most likely to cause chest infections in CF?
Pseudomonas
What are the features of Wernickes encephalopathy + Korsakoffs syndrome?
Noa(H) was feeling too hot after drinking so he needed the AC on
Baby bilous vomiting + double bubble on xr -> ??
Intestinal / duodenal atresia
Absent corneal reflex - what nerve?
CN V1
A 68-year-old man, while talking to his wife, starts staring into space. He seems unresponsive to what his wife is saying to him, and he is also smacking his lips multiple times. After 1 minute, he stops and acts normally again, but denies any of this happened when his wife questions him.
What type of seizure?
Focal impaired awareness
What is the most common cause of brown-green nipple discharge?
Duct ectasia - may also be associated w small lump right under nipple
Acute HF mx?
All pts - IV loop diuretics
O2 - maintain sats 94-94
Vasodilators (nitrates) - if severe HTN, MI or regurg (A or M) - CI if hypotensive
If resp failure - CPAP
If hypotensive:
- Ionotropes (dobutamine) - LV dysfunction + versible cardiogenic shock
- Vasopressor (NE) - if insufficient response to above or evidence of end organ hypoperfusion
- Mechanical circulatory asistence also can be considered
Asthma - reversibility testing results?
in adults, a positive test is indicated by an improvement in FEV1 of 12% or more and increase in volume of 200 ml or more
in children, a positive test is indicated by an improvement in FEV1 of 12% or more
A CT chest, abdomen, and pelvis shows mural thickening of the colon and the presence of pericolic fat stranding in the sigmoid colon - suggests what dx?
Diverticulitis - esp since ct findings are limited to the sigmoid colon
EEG in absence seizures?
3 Hz spike and wave
When should ACEi be stopped in CKD pts?
A potassium above 6mmol/L should prompt cessation of ACE inhibitors in a patient with CKD (once other agents that promote hyperkalemia have been stopped)
Mx of rhabdomyolysis?
IV fluids
Maturity-onset diabetes of the young (MODY) - inheritance?
AD
Which abx used to treat UTIs CANNOT be given alongside methotrexate?
Trimethoprim
When should triptans be avoided in the Mx of cluster headaches ?
In pts w/ CAD as it has the potential to cause coronary vasospasm
What is a parapneumic effusion
Any effusion caused by pneumonia or lung abscess
What are the signs and sx of myxedema coma? How can this be mx?
confusion, bradycardia, hypothermia and profoundly hypothyroid
Mx = IV thyroid replacement + IV hydrocortisone (as giving thyroid replacement in a adrenal deficient person can perciptiate adrenal crisis so this needs to be given until this can be excluded)
In a patient with hypercalciuria and renal stones, calcium excretion and stone formation - how can this be decreased?
Thiazide diuretics
Raised CK in a person w/ recent initiation of Statins?
Rhabdomyolysis
What are some drugs that impair wound healing?
Non steroidal anti inflammatory drugs
Steroids
Immunosupressive agents
Anti neoplastic drugs
What are some complication of acromegaly?
HTN
Diabetes >10%
Cardiomyopathy
Colorectal Ca
Sx of claudication in femoral and iliac vessels?
Femoral = more calf pain
Iliac = more buttock pain
A wide-based gait with loss of heel to toe walking is called an ….. gait
Ataxic
What are some causes of cerebellar injury?
P - Posterior fossa tumour
A - Alcohol
S - Multiple sclerosis
T - Trauma
R - Rare causes
I - Inherited (e.g. Friedreich’s ataxia)
E - Epilepsy treatments
S - Stroke
Pastries
When is S3 normal? what are some pathalogical causes?
Caused by diastolic filling of ventricles - normal if <30y can be upto 50y in women
LVF (eg dilated cardiomyopathy), Constrictive pericarditis and mitral regurg
How remember difference between Galeazzi and Monteggia fractures?
MUgGeR
Montegia = Ulnar
Galaeazii = Radius
MonteggiA = M is A (proximal fracture w/ dislocation)
GalaeazZi = G is Z (distal fracture w/ dislocation)
Which patients need v urgent (48h) access Xray to assess for bone sarcoma?
Children and young people with unexplained bone swelling or pain
What is given to replace thiamine?
Pabrinex
Which anti-HTN meds are CI in pregnancy and why?
ACEi due to causing foetal abnormalities and renal failure
What is power like in limb girdles in polymyalgia rheumatica? CK?
There is no true weakness of limb girdles in polymyalgia rheumatica on examination. Any weakness of muscles is due to myalgia (pain inhibition)
Normal CK
What is power like in limb girdles in polymyalgia rheumatica? CK?
There is no true weakness of limb girdles in polymyalgia rheumatica on examination. Any weakness of muscles is due to myalgia (pain inhibition)
Normal CK
How much water, k, na, cl and glucose is needed for maintence fluids of adults?
25-30 ml/kg/day of water #
approximately 1 mmol/kg/day of potassium, sodium and chloride
approximately 50-100 g/day of glucose to limit starvation ketosis
Describe the mx of different amounts of splenic trauma:
Conservative:
- Small subcapsular haematoma
- Minimal intra abdominal blood
- No hilar disruption
Laparotomy w/ conservation:
- Increased amounts of intraabdominal blood
- Moderate haemodynamic compromise
- Tears or lacerations affecting <50%
Resection:
- Hilar injuries
- Major haemorrhage
- Major associated injuries
COPD o2 sats target?
88-92% + Do an ABG
If ABG doesnt show signs of hypercapnia -> then aim for 94-98%
Which type of hip dislocation is more common? how does this appear?
Posteerior hip dislocation - leg is internally rotated and appears shorter than the other one
Direct v indirect inguinal hernia - how to tell the diffrence?
Indirect = No reappearance during coughing when covering the deep inguinal ring
Direct = Reappearance during coughing when covering the deep inguinal ring
What are some possible complications of radical prostatectomy?
Late/ longterm complications = ED, incontinence and urethral stenosis
Warfarin - bleeding test results?
PT - Long
APTT - normal
Which abx for Leigionella?
Macrolides - clarithromycin
Pt presenting to GP w/in 7d of TIA -> mx?
300mg aspirin immediately (and be referred for specialist review within 24h)
Breathing problems in a pt w clear chest should warrant consideration of what dx?
PE
What are the features of INO (Internuclear ophthalmoplegia)?
Causes?
impaired adduction of the eye on the same side as the lesion
horizontal nystagmus of the abducting eye on the contralateral side
Causes = MS and Vascular diseas
What is plasma and urine osmolality like in DI?
HIGH plasma osmolality in DI
LOW urine osmolality in DI
U+E before and after ACEi - what is accepted and when should it be stopped?
Rise in creatinine and potassium may be expected after starting ACE inhibitors
Acceptable changes are:
- Increase in serum creatinine, up to 30% from baseline
- Increase in potassium up to 5.5 mmol/l.
What is the initial mx of open fractures?
Immediate wound debridement and application of spanning external fixation device
UTI in pregnancy - what should you do after treatment?
Test of cure MSU
Gold standard ix for intracrainal venous thrombosis? mx?
Non-contrast CT head
LMWH acutely then warfarin generally long term
‘empty delta sign’ seen on venography
Saggital sinus thrombosis - headache, diplopia, bilateral papilloedema
Management of atelectasis?
Chest physiotherapy with mobilisation and breathing exercise
Difference between HF-pEF and HF-rEF?
HFpEF = diastolic (heart filling issue) eg HOCM, restrictive cardiomyopathy, cardiac tamponade and constrictive pericarditis
HFrEF = IHD, Dilated cardiomyopathy, Myocarditis and Arrhythmias
affected eye is unable to look down as easily, therefore causing vertical diplopia, worst on looking down (whilst reading) - which nerve palsy?
Trochlear
What features are usually spared in MND?
doesn’t affect external ocular muscles
no cerebellar signs
abdominal reflexes are usually preserved and sphincter dysfunction if present is a late feature
How can local anasthetic toxicity be treated?
w/ 20% lipid emulsion
Which abx can cause trosardes du pointes?
Macrolides eg erythromycin
Proximal muscle weakness + raised CK + no rash - whatis dx?
Polymyositis - treated w/ corticosteroids and / or immunosuppressants such as methotrexate
PCP treatment abx?
Co trimoxazole
patient is noted to have persistent ST elevation 4 weeks after sustaining a myocardial infarction. Examination reveals bibasal crackles and the presence of a third and fourth heart sound = what dx? mx?
Left ventricular aneurysm - anticoagulation due to risk od stroke
Occurs around 1-2 weeks afterwards. Patients present with acute heart failure secondary to cardiac tamponade (raised JVP, pulsus paradoxus, diminished heart sounds).
what dx? mx?
Left ventricular free wall rupture - Urgent pericardiocentesis and thoracotomy are required
What does ECG show for posterior MI?
Tall R waves in lead V1-3
Why might a person w/ mycoplasma pneumoniae present w/ tiredness?
AIHA - causing anaemia raised LDH and raised unconjugaed bilirubin
What can cause a isolated fever in a pt 24h after surgery?
Physiological reaction to operation
A 40-year-old woman complains of a permanent ‘funny-bone’ sensation in her right elbow. This is accompanied by tingling in the little and ring finger. Her symptoms are worse when the elbow is bent for prolonged periods. What is the most likely diagnosis?
Cubital tunnel syndrome
Seminomas or tetromas which have a better prognosis?
Seminomas
What are the features of adhesive capsulitis?
Active and passive movement is painful / affected
External rotation is more affected than internal rotation and abduction
What are the features of adhesive capsulitis?
Active and passive movement is painful / affected
External rotation is more affected than internal rotation and abduction
Brain bleed w/ fluctuating levels of conciousness / confusion?
Subdural haematoma
in AS when is Aortic valve replacement required?
If assymptomatic the valvular gradient >40mmHg and features such as LV systolic dysfunction
If symptomatic replace
What can make the ejetion systolic murmur in aortic stenosis quieter?
Left ventricular systolic dysfunction - due to decreased flow rate
DCM and HOCM what causes S3 and what causes S4?
S3 - 3 so DCM
S4 - 4 so HOCM
Marfans inheritance?
AD
Rotator cuff injury
Painful arc of abduction between 60 and 120 degrees
Tenderness over anterior acromion
What do these sx suggest ?
Supraspinatus tendonitis (subacromial impingement, painful arc)
Give me a poem for the nerves involved for different reflexes
S1-2 buckle my shoes (ankle)
L3-4 kick open the door (knee)
C5-6 pick up the sticks (biceps)
C7-8 lay them straight (triceps)
Which diabetes drugs are CI in HF?
Thiazalidizones - “zones”
They can cause fluid retention
What test should be performed in NAFLD to check for liver fibrosis?
Enhanced liver fibrosis (ELF) blood test
How is barrets oesophagus mx?
High dose PPIs
Endoscopic surveilance w/ biopsies every 3-5 years
If dysplasia identified:
- Radiofrequency ablation (particularly for low-grade = 1st line)
- Endoscopic mucosal resection
What conditions are the following fundoscopy findings present in?
What does a headache related to valsalva manourve suggest (eg straining on toilet)? Ix?
Raised ICP - non contrast CT head
Which cerebral vessel is normally affected in strokes that show aphasia?
MCA
What is the mx of acute clot retention aki?
continuous bladder irrigation + catheter insertion
What liver problem are pts w/ haemochromatosis at risk of ?
HCC + liver cirrhosis
Reduced GCS, paralysis and bilateral pin point pupils - suggest what condition?
Pontine haemorrhage
If there is a high enough Wells score what ix should be ordered prior to CTPA?
CXR - to rule out other causes of chest pain eg pneumothroax
All house bound patients should be prescribed what?
Vit D
Salter harris fracture types
Definitive dx ix for small bowel obstruction?
CT abdo
How do you measure the severity of COPD?
Using FEV1
> 80% of predicted - mild
50-79 - moderate
30-49 - severe
<30 - v severe
Primary care w/ pt who has suspected UGI -mx?
Endoscopy in hospital w/in 24h
Do not give PPIs before endoscopy - after this you can give for variceal bleeds
If variceal give terlipressin and prophylactic abx
How can you know if acute limb ischaemia is due thrombis or embolus?
How can you distinguish between AKI and dehydration?
Both have raised creatinine and urea however rise in urea is greater than rise in creatinine
May also see a mild hypernatraemia
(In dehydration)
What to do if triple therapy doesnt work / isn’t tolerated in T2dm?
Switch a drug for a GLP-1 mimetic if BMI >=35 or insulin would have occupational implications
Can only add GLP-1mimetic to insulin under specialist care
What is a possible complication of radiotherapy for prostate ca?
Increased risk of bladder, colon and rectal cancer
Liver USS - There is a single 12cm x 9cm, hyperechoic lesion in the left lobe of the liver. No other abnormalities detected. No abnormalities noted in the biliary tree.
In another otherwise normal person suggests what?
Hepatic hemangioma
Pt recently diagnosed w/ parkinsons falls - what do you need to consider and how can you assess this?
Consider alternative dx of of parkinsons-plus syndromes such as PSP
can assess CN III, IV and VI - vertical supranuclear gaze palsy
Urine sodium and osmolality in pre-renal disease and ATN causing AKI?
pre-renal - Na <20, osmolality >500, good response to fluid challenge
ATN - Na >40, osmolality <350, poor response to fluid challenge
When calculating drug doses, what does 2% mean?
2g is dissolved in 100ml
What oesophageal ca is at increased risk in pts w/ achalasia?
SCC
If a pt w/ hypocalcaemia has had calcium adequately replaced but still remain hypocalcaemic what other electrolyte may be deficient?
Magnesium - important for Ca absorption
Mx of urinary retention in urethral injury?
Suprapubic catheter
Most common renal ca?
Renal adenocarcinoma
What are some reasons pts may fail to respond to erythropoietin therapy?
iron deficiency - pencil cells
inadequate dose
concurrent infection/inflammation
hyperparathyroid bone disease
aluminium toxicity
What to do in mx of bradycardia if atropine and transcutaneous pacing isn’t tolerated?
isoprenaline/adrenaline IV titrated to response
HNF-1 MODY diabetes mx ?
Sulfonureas (glicalazide)
For Ottowa fracture rules (ankle0 where is lateral and medial malleolar zones?
lateral malleolar zone (from the tip of the lateral malleolus to include the lower 6 cm of posterior border of the fibular)
medial malleolar zone (from the tip of the medial malleolus to the lower 6 cm of the posterior border of the tibia)
Postural headache but normal MRI suggests what?
Idiopathic intracranial HTN
Diverticulitis symptoms + pneumaturia or faecaluria → ???
Colovesical fistula
What are the 2 classifications of the aortic dissection?
Stanford classification
- type A - ascending aorta, 2/3 of cases
- type B - descending aorta, distal to left subclavian origin, 1/3 of cases
DeBakey classification
- type I - originates in ascending aorta, propagates to at least the aortic arch and possibly beyond it distally
- type II - originates in and is confined to the ascending aorta
- type III - originates in descending aorta, rarely extends proximally but will extend distally
Mx of Aortic dissection?
Type A - Ascending aorta - ASS
Aortic root replacement
Systolic BP target 100-120
Surgery
Type B - BooBs
Bed rest and Beta blockers
Sudden weight loss / starvation + ljaundice suggests what?
NAFLD
OSA findings:
Daytime somnolence
Compensated resp acidosis
HTN
When are nasopharyngeal airwaysCI?
Suspected base of skull fractures
PPI electrolyte abnormalities?
Hyponatraemia + hypomagnesiumaeia
Elderly, alcoholic, head injury, insidiuous onset symptoms
What dx is likely?
Subdural haematoma
Newly diagnosed dermatomyositis what ix is needed?
Malignancy screen
What drug can cause cold peripheries?
BB - baby your feet are cold!!!
Mx of hyperkalaemia - what is the role of clacium resonium?
RemovesK fromt the body
Renal biopsy shows: Podocyte fusion and effacement of foot processes on electron microscopy
Dx?
Minimal change disease
Which airway is bad if the pt hasnt fasted?
Laryngeal mask
SAH can cause what type of ECG changes?
Torsades du pointes - Polymorphic VT
Poor prognostic factors for ACS?
age
development (or history) of heart failure
peripheral vascular disease
reduced systolic blood pressure
Killip class*
initial serum creatinine concentration
elevated initial cardiac markers
cardiac arrest on admission
ST segment deviation
Which diabetes drug is CI in HF?
Thiazalidinones (-zone)
What durg scan be used in combination of triple therapy in T2DM?
If this fails, NICE recommends triple therapy with either
Metformin + gliclazide + gliptin/glifozin/pioglitazone or
Metformin + pioglitazone + glifozin or
Insulin +/- other drug
What should you do in T2DM if pt is on metformin and develops GI side effects
Switch to modified release metformin before trying anything else
Adrenaline dose in ALS?
1mg
What electrolyte abnormlaity can be caused by excessive fluid resus w/ NACL
Hyperchloraemic met acidosis
Who should not be givenHartmanns solution?
Hyperkalaemic pts - contains K
Visual field defect likely seen in pituitary tumours?
Bitemporal hemianopia -> if not big enough for full compressiojn - bitemporal superior quadrantanopia (only squashes the top)
Sex hormones in Kallmans syndrome?
LF, FSH - low / normal
Testosterone - low -> will need supplementation
What is the triad of budd chiari syndrome?
abdominal pain: sudden onset, severe
ascites → abdominal distension
tender hepatomegaly
Raised SAAG
Ix w/ doppler flow studies
Can you use multiple drugs for neuropathic pain?
No tends to be monotherapy if one doesn’t work you normally switch drugs
Amitripyline, pregabalin, gabapentin, duloxetine
What are the features of syringomelia?
a ‘cape-like’ (neck, shoulders and arms)
loss of sensation to temperature but the preservation of light touch, proprioception and vibration
classic examples are of patients who accidentally burn their hands without realising
this is due to the crossing SPINOTHALAMIC TRACTS in the ANTERIOR COMMISURE of the spinal cord being the first tracts to be affected
spastic weakness (predominantly of the lower limbs)
Distal transverse or descending colon cancer mx?
Left hemicolectomy
upper rectal tumours
low rectal tumours
mx?
High anterior resection
Low anterior resection
cecum, ascending or a proximal third of the transverse colon cancer mx?
Right hemicolectomy
Gold standard for dx and screening of HIV?
Combination tests (HIV p24 antigen and HIV antibody) @ 4w and 3m
What causes milky fluid drained from chest after surgery?
Chylothorax
- Cholesterol >9.0, triglycerides normal, HDL normal. Dx?
heterozygous Familial hypercholesteraemia
Amaaurosis fugas - what vessel is affected ?
Retinal / ophthalmic artery - usually caused by atherosclerosis of ipsilateral internal carotid
dizziness and palpitations. The ECG shows an irregular trace with a QRS complex of 130 ms, accompanied by a heart rate of 150/min. These are defining features of an irregular broad complex tachycardia.
What is the dx?
AF w/ bundle branch block - differernt from just AF due to presence of slightly longer QRS
Why can adenosine cause chest pain?
Due to its vasodilatory effects, it can cause flushing, nausea, sweating, bronchospasm and also chest pain
Mx of variceal haemorrhage?
Once terlipressin, abx(+- transfusions, FFP, vit k etc) have been administered
Endoscopic - variceal band ligation > sclerotherapy
If uncontrolled bleeding - sengstaken blakemore tube
TIPSS if these fail - however this can make hepatic encephalopathy worse
A 28-year-old female sex worker presents to her general practitioner with a sore throat, fever and fatigue which has been going on for two weeks. When examining the throat, the GP notices several white patches on the lateral borders of the tongue as well as the buccal mucosa. These lesions are not painful and had not been noticed by the patient until now. The patches can’t be removed by the application of light pressure.
Given the patient’s history, what is the most likely cause of the lesions on the tongue?
Oral hairy leukoplakia
What is the mx of latent tb?
3 months of isoniazid (with pyridoxine) and rifampicin, or
6 months of isoniazid (with pyridoxine)
What is a sign of L5 radiculopathy?
Pain upon straight leg raise + weak hip abductors
What are the main features of CJD?
Rapid onset dementia + myoclonus
DM - linked w/ united called CJD
Why should nitrates be used iw/ caution in patients w/ pneumothorax?
Can cause a tension pneumo
Why should nitrates be used iw/ caution in patients w/ pneumothorax?
Can cause a tension pneumo
When starting goserelin (gonadorelin analogue) for mx of prostate ca - what should be co prescribed and why?
Anti-androgen treatment such as cyproterone acetate -> due to the risk of tumour flare
What is the most common cause of HCC?
Hep B - worldwide
Hep C - Europe
most common symptom of Crohn’s disease in children?
Abdo pain
What else is H pylori infection associated w?
peptic ulcer disease - strongest associations
- 95% of duodenal ulcers
- 75% of gastric ulcers
gastric cancer
B cell lymphoma of MALT tissue (eradication of H pylori results causes regression in 80% of patients)
atrophic gastritis
What should invasive diarrhoea (causing bloody diarrhoea and fever) be treated w?
Ciprofloxacin
Whats live attenuated vaccines?
Mi BOOTY
M - MMR
I - Influenza (intranasal)
B - BCG
O - Oral rotavirus
O - Oral polio
T - Typhoid
Y - Yellow fever
What stoma can be used to defunction the colon to protect an anastomosis?
Loop ileostomy
What stoma is performed when when the colon is diverted or resected and anastomosis is not primarily achievable or desirable
End colostomy
What stoma is done following complete excision of colon or where ileocolic anastomosis is not planned. It may be used to defunction the colon, but a reversal is more difficult.
End ileostomy
What stoma is used for gastric decompression or feeding.
Gastrostomy
Loop ileostomy is a method to divert bowel contents away from a distal anastomosis. It is often indicated in rectal cancers. And can be reversed to restore bowel continuity?
Loop ileostomy
AR murmur + Inferior MI ECG changes suggests what?
II, III and aVF ST elevation + AR murmur suggests ascending aortic dissection (proximal aortic dissection)
Bilateral hydronephrosis - mx?
If stone based = bilateral nephrostomy
If UTi baed = Urethral catheter
Urea breath test - what should be done prior to test to improve accuracy?
No ABX in 4w before
No anti-secretory drugs 2w before (eg PPI)
What isthe ECG finding that is sometimes found in PE and why?
S1Q3T3 pattern (deep S in lead I, pathological Q waves in lead III, and T wave inversion in lead III) - acute right heart strain
Mx of primary hyperparathyroidism?
Parathyroidectomy
TFTs in sick euthyroid?
Normal TSH
Low T3/T4
What antibody is most specific for pdermatomyositis?
anti-jo-1 antibody
80% = ANA positive as well
What ca is likely to cause myasthenia gravis?
Thymomas
What is the most sensitive scan to diagnose diffuse axonal injury
MRI brain
What is the nipple discharge associated w prolactinoma likely to look like?
bilateral + often cream coloured
What do the following tests test for?
Lachmanns
Empty can
McMurrays
Posterior Draw
Sweep test
Lachmanns - ACL
Empty can - Supraspinatus integrity
McMurrays - Meniscus
Posterior Draw - PCL
Sweep test - Knee effusion
Fundoscopy finding in temporal arteritis?
Ischaemia to anterior optic nerve
- Anterior ischemic optic neuropathy accounts for the majority of ocular complications in temporal arteritis
In ALS if there is no amiodarone, what drug can be used instead?
Lidocaine
What are some recognised complications of enteral feeding?
Diarrhoea
Aspiration
Metabolic - Hyperglycaemia and refeeding syndrome
On examination, her observations are heart rate 85/minute, respiratory rate 18/min, blood pressure 124/82mmHg, temperature 38.5ºC. There is a 1cm wound on her lower right calf. It is surrounded by an area of prominent erythema and swelling that is approximately 15cm at its widest diameter. There is also a very dark purple area around the wound. There is one blister with foul-smelling discharge. The wound is very tender.
An emergency x-ray demonstrates air bubbles in the tissues.
Swabs are taken and broad-spectrum antibiotics are started. What is the most likely organism to be isolated? What is the condition called? what increases the risk?
Gas gangrene caused by Clostridium perfringens
Having peripheral vascular disease increases your risk
Why is nephrotic syndrome associated w ith a hypercoagulable state?
due to loss of antithrombin III via the kidneys
When should you surgical mx of dupuytrens contracture?
MCP cant be straightened and cant be lied flat on table
What is kussmauls sign and what is it sseen in ?
Raised JVP upon inspiration and seen in constrictive pericardiits
What is the main benefit of epidural form of analgesia compared to alternative forms?
Fasster return to normal bowel func following abdo surgery
What test should be offered to all people w TB?
HIV test
What are some possible complications of axillary node clearance?
arm lymphedema and functional arm impairment
Intercostobrachial nerve damage
What is a possible comlication that can occur if a pleural effusion is drained too quickly?
re-expansion pulmonary oedema
An x-ray confirms a fracture of the surgical neck of the humerus. Which nerve is at risk?
Axillary nerve
What is klumpkes paralysis?
Classically there is weakness of the hand intrinsic muscles. Involvement of T1 may cause a Horner’s syndrome. It occurs as a result of traction injuries or during delivery.
Involves brachial trunks c8-t1
What is Erbs palsy?
Clinically his arm is hanging loose on the side. It is pronated and medially rotat
C5-6
Smiths fracture possble nerve injury - weakness of thumb opposition?
Median
hot solitary nodule indicates what thyroid pathology
Toxic adenoma
pain and swelling of the left shoulder. There is a large radiolucent lesion in the head of the humerus extending to the subchondral plate.
x-ray have a ‘soap bubble’ appearance. They present as pain or pathological fractures. They commonly metastasize to the lungs.
Giant cell umour
reduces Glasgow coma score, quadriplegia, miosis, and absent horizontal eye movements - waht type of stroke
Pontine stroke?
ppearance (progressive, erythema and oedema of the breast in the absence signs of infection such as fever, discharge or elevated WCC and CRP) and an elevated CA 15-3
dx?
Inflammatory breast ca
What is the triad of fat embolism syndrome?
Respiratory
Neurological
Petechial rash (tends to occur after the first 2 symptoms)
How can you distinguish between unilateral adenoma and bilateral hyperplasia in primary hyperaldosteronism?
Adrenal venous sampling
HOCM is associated w/ what other heart sondition?
WPW
After starting an ACE inhibitor, significant renal impairment may occur if ….
the pt has undiagnosed bilateral renal stenosis
Reactive arthritis - synovial fluid resulsts?
Develops after an infection where the organism cannot be recovered from the joint - Will normally be sterile synovial fluid where organism cannot be recovered from the joint
Even thought its normally caused by chlamydia trachomatis
Mechanism behind carpal tunnel
Carpal tunnel syndrome causes action potential prolongation in both sensory and motor axons
What are the RFs for testicular cancers?
Infertility (increases risk by a factor of 3)
cryptorchidism
family history
Klinefelter’s syndrome
mumps orchitis
……………………….. is characterised by fever, hypotension and a rash → desquamation
Staphylococcal toxic shock syndrome
Tetanus vaccine history last dose <10y what to do?
no vaccine nor tetanus immunoglobulin is required, regardless of the wound severity
Patient has had a full course of tetanus vaccines, with the last dose > 10 years ago
if tetanus prone wound: reinforcing dose of vaccine
high-risk wounds (e.g. compound fractures, delayed surgical intervention, significant degree of devitalised tissue): reinforcing dose of vaccine + tetanus immunoglobulin
If vaccination history is incomplete or unknown
If vaccination history is incomplete or unknown
reinforcing dose of vaccine, regardless of the wound severity
for tetanus prone and high-risk wounds: reinforcing dose of vaccine + tetanus immunoglobulin
What is conduction aphasia and what causes it?
A stroke affecting the arcuate fasiculus - the connection between wernickes and brocas area
Here the speech is fluent but repitition is poor
What is global apahasia and what causes it?
A large stroke affecting - broca, wernickes and the arucate fasiculus
Causes severe expressive + receptive apahasia - may be able to communicate using gestures
Questionnaire to assess frailty?
Frailty should be specifically assessed through the evaluation of gait speed, self-reported health status, or the PRISMA-7 questionnaire
Which CNs can be affected vestibular schwannoma?
CN VIII, VII, V
Vestibular schwannoma - cant hear you right so they thought 578 ml in a pint
Gold standard ix for small bowel obstruction?
CT abdo
The following are all NICE criteria for referring a patient to secondary care for consideration of interventional treatment of varicose veins as laid out in the NICE CKS summary:
Symptoms associated with varicose veins such as ‘heavy’ or ‘aching’ legs.
Skin changes associated with chronic venous insufficiency such as venous eczema or haemosiderin deposition.
Superficial vein thrombosis.
A venous leg ulcer (a break in the skin below the knee that has not healed in 2 weeks), either active or healed.
Mx of nephrogenic DI?
Thiazides + low salt / protein diets
A 19-year-old woman presents to the emergency department with new-onset chest pain and shortness of breath.
The pain started today and is centrally located, sharp in nature and doesn’t change with breathing or position.
She has been unwell for the past week, with fever and joint pains.
She has no past medical history of note.
On examination, she has bibasilar crackles, with dull heart sounds with no added sounds. Her vital signs are normal apart from a respiratory rate of 24/min.
An ECG is performed and shows diffuse T-wave inversion.
What is the most likely diagnosis?
Myocarditis - The dull heart sounds are due to the myocardium being inflamed and thickened. The shortness of breath and bibasilar crackles are likely due to myocardial dysfunction causing pulmonary congestion
Upper GI bleed: the xxxxxxxx score is used after endoscopy and provides a percentage risk of rebleeding and mortality
Rockall
Surgery / sulfonylureas on day of surgery:
- Omit on the day of surgery
- Exception is morning surgery in patients who take BD - they can have the afternoon dose
xxxxxx lesion features = Sensory loss of posterolateral aspect of leg and lateral aspect of foot, weakness in plantar flexion of foot, reduced ankle reflex, positive sciatic nerve stretch test
S1
HF + Fluid overload + low BP what is mx?
This is cardiorenal syndrome
IV loop diuretics / increased dose - to ensure there’s enough conc in the tubules
What are the features of small intestine bacterial overgrowth syndrome? ix? mx?
It should be noted that many of the features overlap with irritable bowel syndrome:
- chronic diarrhoea
- bloating, flatulence
- abdominal pain
ix = hydrogen breath test
mx = abx - rifaximin
CK levelsin temporal arteritis?
Normal
Hep B PEP?
accelerated course of hep b vaccine + hep b Ig
EBV associated ca?
Burkitt’s lymphoma*
Hodgkin’s lymphoma
nasopharyngeal carcinoma
HIV-associated central nervous system lymphomas
Hypothyroid taking levothyroxine- Right T3/4 + HIGH TSH - dx?
They have poor compliance w/ meds
What to do before giving TB vaccines?
It is important that a tuberculin skin test is performed (to exclude past exposure to tuberculosis) prior to giving the vaccine.
What to do before giving TB vaccines?
It is important that a tuberculin skin test is performed (to exclude past exposure to tuberculosis) prior to giving the vaccine.
On the soles of both feet you notice a waxy yellow rash + swollen joints - dx? what is the rash?
Rash = Keratoderma blenorrhagic
Dx = Reactive arthritis
Neuroleptic malignant syndrome more common in newly initiated treatment or prolonged treatment?
Prolonged
What is the latest time that HIV post-exposure prophylaxis may be given?
72 h after
What is Zollinger Ellison syndrome?
multiple gastroduodenal ulcers causing abdominal pain and diarrhoea - this is seen in pts w/ MEN1
Contraindications to thrombolysis?
active internal bleeding
recent haemorrhage, trauma or surgery (including dental extraction)
coagulation and bleeding disorders
intracranial neoplasm
stroke < 3 months
aortic dissection
recent head injury
severe hypertension
Mx of lung ca?
Low grade disease - T1-2a, N0, M0 = surgery
High grade = Chemo + radio
Factors which may affect the result of egfr?
pregnancy
muscle mass (e.g. amputees, body-builders)
eating red meat 12 hours prior to the sample being taken
Renal transplant + infection ?
CMV
Features of aortic stenosis?
narrow pulse pressure
slow rising pulse
a thrill palpable over the cardiac apex
a fourth heart sound (S4) indicative of left ventricular hypertrophy
a soft/absent S2
The flu-like symptoms, bilateral consolidation and erythema multiforme point to a diagnosis of …….
Mycoplasma pneumoiniae
How does yellow fever present?
flu like illness → brief remission→ followed by jaundice and haematemesis
DPP4 inhibitors and weight gain /loss?
Dont cause weight gain
Sx of sinusitis a few weeks ago –> headache, fever and focal neurology - possible complication?
Brain abscess - use CT to confirm
will need a craniotomy , iv abx and intracranial pressure mx (dex)
Which anasthetic can cause addisonian crisi? and how?
Etomidate may result in adrenal suppression - potentiating of GABAa receptors
What is the presentation of entamoeba histolytica?
dysentery (bloody diarrhoea, fever, and abdominal cramps) following travelling.
There has been a long incubation period, along with profuse bloody diarrhoea, fevers, and right upper quadrant pain (suggesting liver involvement and the potential formation of a liver abscess)
Productive cough + choking after feeds + aspiration pneumonia in a long term vintaltion pt suggests what?
Tracheo eosophageal fistula
What is seen in a CN IV leison?
Trochlear leison = Defective downward gaze + vertical diplopia
What is drug is used to treat schistosomiasis?
Praziquantel - anti helminth
How do you check for malignancy in dermatomyositis@?
CT chest, abdo and pelvis
What cardiac features can be caused by carcinoid tumours?
Affected right side of heart - The valvular effects are tricuspid insufficiency and pulmonary stenosis
Mx of asymptomatic gallbladder stones??
Reassure people with asymptomatic gallbladder stones.
Stones that are found incidentally, as a result of imaging investigations unrelated to gallstone disease in people who have been completely symptom-free for at least 12 months before diagnosis do not require intervention.
They must be found in a normal gallbladder and normal biliary tree. Symptomatic patients or those with stones within the common bile duct (CBD) do require intervention to clear the CBD.
This can be done:
Surgically at the time of laparoscopic cholecystectomy or
With endoscopic retrograde cholangiopancreatography (ERCP) before or at the time of laparoscopic cholecystectomy.
Mx of cardiac arrest due to hypothermia?
In cases of hypothermia causing cardiac arrest, defibrillation is less effective and only 3 shocks should be administered before the patient is rewarmed to 30 degrees centigrade
Drugs should be withheld until the patient is 30 degrees and then should be given at double time intervals until the patient is reaching normothermia or has the return of spontaneous circulation (ROSC)
What are the indications for indications for adjuvant ipsilateral chest wall and regional lymph node radiotherapy following masectomy?
positive axillary lymph nodes and residual tumour at resection margins post-mastectomy a
Mx of women with breast cancer and no palpable lymphadenopathy, w/ pre-operative axillary ultrasound is positive
sentinel node biopsy to assess the nodal burden
axillary node clearance if extensive nodal burden identified at SNB
Returning traveller fever + bradycardia =?
Typhoid!!
What side effects are seen to the different chemotherapy agents - remember toxicity bear!
finger abduction weakness - what nerve leison?
T1
What is the preferred way to support nutrition in MND?
Using a percutaneous gastrostomy tube (PEG)
Use of BB in acute HF?
Beta-blockers should only be stopped in acute heart failure if the patient has heart rate < 50/min, second or third degree AV block, or shock
Addisons causes what effect on blood glucose?
hypogycaemia
Most common cause of addisons in the UK?
AI
Sudden hypoxia and increased ventilation ipresure in a pt w/ flail chest being treated w/ intubation + ventilation may suggest what?
Tension pneumothorax
What drug can increase survival rates in MND?
Riluzole
Which endo hormones are increased in response to stress and which are decreased?
Increased:
GH
Cortisol
Renin
ACTH
Aldosterone
Prolactin
ADH
Glucagon
Decreased
Insulin
Testosterone + Oestrogen
mx of chronic subdural?
Burr hole
What does high SAAG suggest?
Portal HTN
What tests are required before TB meds?
Urea and Electrolytes, LFTs, vision testing, FBC
57%
What vessel is affected in subdural haemorrhage?
Bridging veins between cortex and venous sinuses
How should diabetic nephropathy be screened for?
all patients should be screened annually using urinary albumin:creatinine ratio (ACR)should be an early morning specimenACR > 2.5 = microalbuminuria
fundoscopy typically shows a swollen pale disc and blurred margins in what condition?
Anterior ischaemic optic neuropathy
Peptic ulceration, galactorrhoea, hypercalcaemia suggest what condition
MEN1
Right-sided tenderness on PR exam - dx?
think appendicitis
How does Malignant hyperthermia pressent? What anasthetic can cause it? Mx?
autosomal dominant disorder presenting as a hypermetabolic crisis characterised by an increased end-tidal carbon dioxide [ETCO2] (hypercapnia), tachycardia, muscle rigidity, rhabdomyolysis, hyperthermia, and arrhythmia
Associated w/ volatile inhalational anasethetics + suxamethonium (succinylcholine)
treat w/ dantrolene
How long is treatment of graves carried out for?
Carbimazole is given for 12-18 m to induce remission
Rheumatoid + nail changes =?
Psoriatic arthritis
Rheumatoid + nail changes =?
Psoriatic arthritis
Effect of the following drugs on QT interval?
Salbutamol
Solatol
Salbutamol = shortened QT (all SABAs do this)
Solatolol = prolonged QT (only BB that does this)
Wernickes and Brocas - locationin the brain?
Wernicke and Broca make me STIF
Wernicke ‘sends’ to Broca’s -> Superior Temporal gyrus then Inferior Frontal
What location of the brain is affected by what ataxia?
Gait v finger-nose?
gait ataxia = cerebellar vermis
finger-nose = cerebellar hemisphere
Hypersenitivity in SLE?
Type 3
The rash consists of a raised purple plaque of indurated skin that affects the tip of her nose and the skin around the right nostril.
It is neither itchy or painful however the patient is distressed by its appearance.
What does this describe and what condition causes it?
Lupus pernio - sarcoidosis
C-peptide production does NOT fall on exogenous insulin injection in patients with xxxxxx
insulinoma
Which NM blocker is CI in pts w/ hyperkalaemia? (particularly inmportant in trauma and burns pts?
Suxamethonium
NF1 v NF2 easiest way to notice different?
Both cause cafe-au-lait spots
however NF2 is the one that casues bilateral vestibular schwannomas -> sensorineural hearing loss
How are murmurs graded?
Levine scale
Grade 1 - Very faint murmur, frequently overlooked
Grade 2 - Slight murmur
Grade 3 - Moderate murmur without palpable thrill
Grade 4 - Loud murmur with palpable thrill
Grade 5 - Very loud murmur with extremely palpable thrill. Can be heard with stethoscope edge
Grade 6 - Extremely loud murmur - can be heard without stethoscope touching the chest wall
What must be assessed in pts w/ potential bilateral urinary tract obstruciton?
Renal function - U+E
Mx of pituitary incidentaloma?
If a pituitary incidentaloma is found within the sellar, laboratory investigation must be done to determine if it is functional or non-functional
Which diabetes drugs are ahypoglycaemics??
Sulphonylureas,
Metformin,
Glitazones
GLP receptor agonists
DPP-4 inhibitors
What is the definition of a UGI?
Haemorrhage w/ orgigin proximal to ligament of treitz
Which organism causes type1 and type2 nec fac?
type 1 = clostridium perfringens
type 2 = strep pyogenes
Which type of motor neuron disease carries the worst prognosis?
Progressive bulbar palsy
Painful shin rash + cough = ????
Sarcoidosis
homonymous quadrantanopias: which part causes inferior and which part causes superior?
PITS (Parietal-Inferior, Temporal-Superior)
Fever, facial spasms, dysphagia in an intravenous drug use? - what if the facial paralysis was flaccid?
Clostridium tetani
Clostridium botulinum
allergic bronchopulmonary aspergillosis mx of choice?
Oral pred
itraconazole 2nd line sometimes
What tumour can cause cranial DI? what is the visual field defect seen?
Lower bitemporal hemianopia
What nerve is used for finger adduction?
Ulnar
What nerver is used for finger extension?
Radial
What type of hernia can go into the testicles?
Indirect inguinal
Mx of renal stones?
What test can you do to help distinguish between ATN and dehydration?
Fluid challenge - ATN = poor response
How can you distinguish between emphysema in a1at deficiency and copd?
Emphysema is most prominent in the lower lobes in A1AT deficiency and the upper lobes in COPD
What is the main mx of wilsons?
Pencillamine
What might pPeriureteric fat strandin on CT KUB suggest?
Recently passed ureteric stone
Young female who develops AKI after starting ACEi - consider what dx?
Fibromuscular dysplasia
