Misc 4 Flashcards
Most common ocular manifestation for RA
Keratoconjunctivitis sicca
Aphasia
Non-fluent
Intact comprehension
Brocas aphasia
* Understanding intact but speech is effortful and slow
* Usually repetition is poor too
Lesion on lateral part of frontal lobe - the inferior frontal gyrus
Aphasia
Fluent speech and comprehension is intact
Repetition is impaired
Conduction aphasia
Lesion affecting arcuate fasciculus
Aphasia
Fluent speech
Comprehension impaired
Wernicke’s aphasia
* Nonsensical speech, word salad, word substitution, neologisms
* Fluency is not affected because arcuate fasciculus still there
* Repetition is impaired
* This is a lesion on the temporal lobe
Distinguish between shin lesions
Pyoderma grangrenosum
Necrobiosis lipoidica diabeticorum
Pyoderma gangrenosum
* initially small red papule
* later deep, red, necrotic ulcers with a violaceous border
* idiopathic in 50%, may also be seen in inflammatory bowel disease, connective tissue disorders and myeloproliferative disorders
Necrobiosis lipoidica diabeticorum
* shiny, painless areas of yellow/red skin typically on the shin of diabetics
often associated with telangiectasia
Management of urinary problems
Stress vs urge incontinence
Stress incontinence
* Pelvic floor exercises
* Surgical colposuspension
* Duloxetine if decline surgery which increases enhance contraction of urethral sphincter
Urge incontinence predominant
* Bladder retraining - gradual increase intervals between voiding
* Anti-muscarinics - oxybutinin IR, tolterodine
* Avoid oxybutinin in elderly womaen
* Mirabegron for elderly
Usual outcome for cohort study is
Relative risk
a statistical term that refers to your own risk of a disease compared to your risk if you do not have certain factors.
Normal pressure hydrocephalus
A classical triad of features is seen
1. urinary incontinence
2. dementia and bradyphrenia
3. gait abnormality (may be similar to Parkinson’s disease)
Reversible cause of dementia - reduced CSF absorption at arachnoid vilu
LADA vs MODY
Age for cut off for dx of T2DM is 45
MODY should be in <25 year olds
LADA - normal body habitus, autoimmune related DM, slower autoimmune process.
What is able to demonstrate publication bias in meta-analyses?
Funnel plot - scatter plot
* y axis study size, x axis treatment effect
* unbiased studies will scatter widely at bottom of graph with spread narrowing for larger studies
* If there is bias, asymmetrical appearance.
Management of atrial flutter
is similar to that of atrial fibrillation although medication may be less effective - amiodarone can be used.
atrial flutter is more sensitive to cardioversion however so lower energy levels may be used
* radiofrequency ablation of the tricuspid valve isthmus is curative for most patients - re-entrant circuit is in right atrium, will interrupt circuits re-entry.
Dentistry in warfarinarised patients
- Admit to hospital and switch to LMWH
- Switch to aspirin
- Check INR 72h before and proceed if INR <4 or INR <2.5
- Check INR 27H before
- Proceed if iNR <4
What is NNT?
If NNT is 20, what is the NNT for 1000 patients?
NNT is a time-specific epidemiological measure of the number of patients who need to be treated in order to prevent one adverse outcome. A perfect NNT would be 1, where everyone improves with treatment, thus the higher the NNT, the less effective the treatment.
If NNT is 20, 1000 patients treated, there would be 50 fewer adverse outcomes
PNH best diagnostic test vs hereditary spherocytosis
- PNH - Flow cytometry for CD59, CD55, gold standard
- HS - EMA binding test
Juvenile myoclonic epilepsy
- Generalised seizures in morning
- Adolescent females with sleep deprivation or stress
- Daytime absence seizure
- Sudden, shock like myoclonic seizure may develop before GTN seizures
What is the pathophysiology behind loss of pubic hair and decreased libido in Addisons disease
Loss of libido and loss of pubic hair in Addisons disease is caused by DHEA deficiency
* Adrenal glands are main source of DHEA in females
* Loss of functioning adrenal tissue leads to androgen deficiency
Localisation of stroke
Contralateral hemiparesis and sensory loss
lower extremity >upper - what stroke is this?
anterior cerebral artery
Contralateral hemiparesis and sensory loss
Contralateral homonymous hemianopia +
upper extremity > lower extremity
Aphasia
Middle cerebral artery
Mercury poisoining
- paraesthesia
visual field defects
hearing loss
irritability
renal tubular acidosis
Lead poisoning
- Type 2 RTA
Features
abdominal pain
peripheral neuropathy (mainly motor)
neuropsychiatric features
fatigue
constipation
blue lines on gum margin (only 20% of adult patients, very rare in children)
Methanol poisoning
Visual symptoms blindness
Doesnt cause RTA
Distinguish between mitral and tricupsid regurgitation
Both cause pansystolic murmur
- Mitral regurgitation loudest on expiration
- Tricuspid regurgitation louder on inspiration (increase in venous return)
Investigating TB
When to use Mantoux test and when to use Quantiferon
Mantoux test is used to screen for latent TB
Quantiferon - if Mantoux is positive or equivocal, in high chance of flase negative tuberculin test
Down syndrome, risk increases with maternal age
What are the risks from age 20, 30, 35, 40, 45
Which genetic disease is associated with increased risk of Crohns disease?
Turners
Downs
Fragile X
Patau
Edwards
Turner syndrome
Significance tests
Type I error
- null hypothesis is rejected when it is true - i.e. Showing a difference between two groups when it doesn’t exist, a false positive.
Significance tests
Type II error
the null hypothesis is accepted when it is false - i.e. Failing to spot a difference when one really exists, a false negative.
Significance test
What is the power of the study
The power of a study is the probability of (correctly) rejecting the null hypothesis when it is false, i.e. the probability of detecting a statistically significant difference
How do we calculate the power of a study
power = 1 - the probability of a type II error
power can be increased by increasing the sample size
Upgaze palsy
Conjugate nystagmus
Lid retraction
Light near dissociation on exam
Which lesion is this in the brain?
Parinaud syndrome
Lesion at dorsal midbrain
MLF affected which results in upward gaze palsy
Can be caused by brain tumours in midbrain or pineal gland
MS
Midbrain stroke
When might you consider pseudohyperkalaemia?
High cell counts in a ptient ie with malignancy
* A serum potassium rise that occurs due to leakage from cells during or after blood is taken
* Artefact - wont represent true serum K+ conc
* Large number of platelets aggregate and degranulate
Angina management
First line - GTN prn, BB or CCB (verapamil or diltiazem)
Second line - BB + nifedipine MR
Third line - increase atenolol to max dose 100mg OD
Fourth line - ivabradine, isosorbide mononitrate, nicorandil or ranolazine.
Defect in AIP vs PCT
Acute intermittent porphyria - porphobilinogen deaminase
PCT - uroporphyrinogen decarboxylase
Factor V leiden
Caused by resistance to activated protein C
Causing prothrombotic state
Turners syndrome vs CAH
Turner syndrome : short + primary amenorrhoea, 45 XO
CAH - primary amenorrhoea 46 X,Y with no dysmorphic features
Congenital adrenal hyperplasia
Describe underlying pathophysiology
Overview
* group of autosomal recessive disorders
* affect adrenal steroid biosynthesis
* in response to resultant low cortisol levels the anterior pituitary secretes high levels of ACTH
* ACTH stimulates the production of adrenal androgens that may virilize a female infant
CAH
Describe 21-hydroxylase deficiency presentation
virilisation of female genitalia
precocious puberty in males
60-70% of patients have a salt-losing crisis at 1-3 wks of age
Management of bullous pemphigoid
Management
referral to a dermatologist for biopsy and confirmation of diagnosis
oral corticosteroids are the mainstay of treatment
topical corticosteroids, immunosuppressants and antibiotics are also used
Pre-requisites of urea breath test
- No PPI for 2 weeks
- No antibiotics for 4 weeks
Antibiotic management of C. Jejuni infections
Clarithromycin
Management of aspergilloma
Surgical resection of lesion
What shin lesion is ulcerative colitis more likely to have?
Pyoderma gangrenosum
Arthralgia in a man with haemochromatosis - what is the likely dx?
Pseudogout
Drug eluting stent in IHD on DAPT - suitable for surgery?
Operations should be delayed unless limb or life threatening as importance of 12 months on DAPT following DES is too high
Features suggesting VT rather than SVT with aberrant conduction
AV dissociation
fusion or capture beats
positive QRS concordance in chest leads
marked left axis deviation
history of IHD
lack of response to adenosine or carotid sinus massage
QRS > 160 ms
Management of a membranous glomerulonephritis
What are characteristic biopsy findings?
Corticosteroids by themselves have not been shown to be effective in membranous glomerulonephritis. ACE inhibitors have however been shown to reduce proteinuria.
Spike and dome appearance with subpeihtleial electron dense deposits
Describe how progressive supranuclear palsy would present
impairment of vertical gaze (down gaze worse than up gaze - patients may complain of difficultly reading or descending stairs)
in an old man with dementia like symptoms and parkinsonism
Genetic inheritance
Expressivity vs penetrance
- Expressivity refers to the extent to which a particular genotype is expressed in the phenotype of an individual. Marfan’s disease has a very varied expressivity, meaning different people affected by it can be affected very differently.
- Penetrance refers to the proportion of the population who have a particular mutation also having the associated disease. An example would be BRCA-1, a mutation of which causes breast cancer in 80% of those affected, giving it a penetrance of 80%.
Z score vs T score
The T-score is a measure of the bone mineral density compared to a healthy young adult. The T-score can be used to diagnose osteoporosis (if less than -2.5), or osteopenia (if between -1 and -2.5).
The Z-score is a measure of bone mineral density compared to the average of those of the same age, ethnicity, and gender. The Z-score is not used to diagnose osteoporosis, but is still useful in males under the age of 50 or premenopausal women, as a score of less than -2 suggests bone mineral density below the expected range.
Medical management for phaeochromocytoma
Surgery is the definitive management. The patient must first however be stabilized with medical management:
* alpha-blocker (e.g. phenoxybenzamine), given before a
* beta-blocker (e.g. propranolol)
Budd chiari syndrome
- Abdo pain and swelling, acute development of ascites + tender hepatomegaly
- Underlying malignancy or procoagulant condition
- Hepatic vein thrombosis
- Ultrasound with doppler flow is very sensitive
Organophosphate poisoning
Organophosphates inhibit acetylcholinesterase enzymes, leading to upregulation of cholinergic transmission. As acetylcholine is the principal neurotransmitter for postganglionic neurons in the parasympathetic nervous system, a number of features of organophosphate poisoning represent over-activation of the parasympathetic nervous system (e.g. the excessive urination, defaecation, borderline bradycardia and miosis seen in this patient). In addition to this, the post-ganglionic fibres of sweat glands use cholinergic transmission, explaining the presence of diaphoresis in this patient.
Organophosphate poisoning
Features can be predicted by the accumulation of acetylcholine (mnemonic = SLUD)
Salivation
Lacrimation
Urination
Defecation/diarrhoea
cardiovascular: hypotension, bradycardia
also: small pupils, muscle fasciculation
Alports syndrome - inheritance pattern
X-linked dominant
Describe radiological appearance of cystine vs urate+xanthine stones
Renal stones on x-ray
cystine stones: semi-opaque- may be seen
urate + xanthine stones: radio-lucent - wont be seen
Which one of the following drugs cannot be cleared by haemodialysis?
Aspirin, TCA, lithium, barbiturates, aminophylline
Tricyclic antidepressants (TCAs) are not effectively removed by haemodialysis due to their large volume of distribution and high protein binding. The volume of distribution is a measure of how well the drug spreads throughout the body, and drugs with a large volume of distribution like TCAs are distributed into various body tissues, rather than remaining in the blood where they could be cleared by dialysis. Also, drugs that have high protein binding, such as TCAs, remain attached to proteins in the blood and thus cannot be filtered out by dialysis.
How does ethanol work in treatment of ethylene glycol toxicity?
How does fomepizol work?
Ethanol
* works by competing with ethylene glycol for the enzyme alcohol dehydrogenase
* this limits the formation of toxic metabolites (e.g. glycoaldehyde and glycolic acid) which are responsible for the haemodynamic/metabolic features of poisoning
Fomepizol -an inhibitor of alcohol dehydrogenase, is now used first-line in preference to ethanol
Lung cancers
Types and classification
Non small cell: adenoca, large cell, squamous
Adenocarcinoma
* Non smoker, peripheral lesion
Squamous cell lung cancer
* Associated with smoking, hyperca, paraneoplastic features
Alveolar cell carcinoma
* Productive cough, copious sputum
Small cell lung cancer
* Most aggressive, usually mets at diagnosis, hyponat, central lesion, ACTH, ADH, Lambert eaton
Standard deviation in a normally distributed graph - what % of values lie within 1SD, 2SD, 3SD
Properties of the Normal distribution
symmetrical i.e. Mean = mode = median
68.3% of values lie within 1 SD of the mean
95.4% of values lie within 2 SD of the mean
99.7% of values lie within 3 SD of the mean
this is often reversed, so that within 1.96 SD of the mean lie 95% of the sample values
Myeloma
Smouldering myeloma
MGUS
SMM is the same as MGUS with respect to no CRBA symptoms. The difference is that one or more of the following is present: bone marrow aspirate shows >10% of plasma cell infiltrate, serum monoclonal protein > 30 g or urinary monoclonal protein >500 mg/24 h.
MGUS
Difference between LA toxicity and adrenaline induced ischaemia
LA toxicity - use lipid emulsion
Adrenaline induced ischaemia - phentolamine
Hepatorenal syndrome
Type 1 vs Type 2
Type 1:
* Rapidly progressive
Doubling of serum creatinine to > 221 µmol/L or a halving of the creatinine clearance to less than 20 ml/min over a period of less than 2 weeks
Very poor prognosis
Type 2
* Slowly progressive
Prognosis poor, but patients may live for longer
