Mixed practice review 2 Flashcards
NSTEMI DAPT:
If not high bleeding risk
If high bleeding risk
ASPIRIN plus
Ticagrelor
Clopidogrel
Ankylosing spondylitis
Features
‘A’ features
Reduced lateral flexion, reduced forward flexion, reduced chest expansion
Apical fibrosis
Anterior uveitis
Aortic regurgitation
Achilles tendonitis Amyloidosis
AV node block
Skin disorders associated with malignancy
1) Acanthosis nigricans
2) Acquired ichthyosis
3) Hypertrichosis lanuginosa
4) Dermatomyositis
5) Erythema gyratum repens
6) Migratory thrombophlebitis
7) Tylosis
1) Gastric cancer = acanthosis nigricans
2) Lymphoma = acquired ichthyosis
3) GI or lung cancer = hypertrichosis lanuginosa
4) Ovarian and lung cancer = dermatomyositis
5) Lung cancer = Erythema Graytum repens
6) pancreatic cancer - migratory thrombophlebitis
7) Oesophageal cancer - tylosis
Heart failure:
First line management:
Second line:
Third line:
ACEi and Beta Blocker (generally one started at a time)
Aldosterone antagonist
Ivanradine
Sacubitril and Valsartan
Digoxin strongly indicated if patient has AF
Oxford stroke classification: 3 core initial symptoms
1) unilateral hemiparesis
2) homonynous hemianopia
3) higher cognitive dysfunction - dysphasia
All 3 for total anterior circulation
2 for partial
Lacunar strokes: one of three of these symptoms
1) Unilateral weakness of face and/or leg and/or arm
2) pure sensory stroke
3) ataxic hemiparesis
Posterior circulation stroke
Involves:
Symptoms:
Basilar arteries
1) cerebellar or brainstem syndromes
2) loss consciousness
3) isolated homonynous hemianopia
Acute otitis media
Common bugs:
Streptococcus pneumoniae, Haemophilus influenzae, moraxella catarrhalis
Prevention of renal stones:
Calcium
Oxalate
Uric acid
Calcium: thiazide diuretics increase tubular calcium secretion
Oxalate stones: cholestyramine, pyridoxine
Uric acid: allopurinol, urinary alkalinisation
Key features of PROLIFERATIVE diabetic retinopathy that distinguishes it from non-proliferative
Retinal neovascularisation (50% are blind in 5 years)
Maculopathy
Non-proliferative diabetic retinopathy features:
Microaneurysms
Blot haemorrhages
Hard exudates
Cotton wool spots
Bed wetting - at which age do you intervene
Management
Under 5 years reassurance and advice.
Look for causes
Reward systems
Enuresis alarm
Desmopressin - short term control mostly.
Epididymo-orchitis management
Most commonly caused by:
Chlamydia trachomatus and Neisseria gonorrhoea
Management: if STI most likely - organism unknown: IM ceftriaxone single dose plus 100mg Doxycycline PO for 10-14 days
Surfactant deficient lung disease:
Seen in:
Other risk factors:
XR shows:
Management:
Premature babies (risk decreases with gestational age)
Male sex, diabetic mothers, C-sections
Ground glass with in distinct heart border
Maternal corticosteroids to induce fetal
lung maturity.
Oxygen
Assisted ventilation (caffeine helps wean)
Exogenous surfactant via ET tube
Anatomical differentiation between inguinal and femoral hernias
Definitions
Incarceration vs strangulation
Femoral = inferolateral to the pubic tubercle
Inguinal = superomedial to pubic tubercle
Incarceration = cannot be reduced
Strangulation = likely non-reducible, follows on from incarceration. Causes systemic upset
Causes of increased ferritin WITHOUT iron overload:
Inflammation (acute phase reactant)
Alcohol excess
Liver disease
CKD
Malignancy
Increased Ferritin WITH iron overload
Hereditary haemochromatosis
Secondary iron overload: repeated transfusions
B symptoms:
Weight loss >10% in last 6 months
Fever >38 degrees
Night sweats
CRABBI mnemonic for myeloma
Calcium (increased)
Renal (damage which causes thirst and dehydration)
Anaemia
Bleeding (bone marrow crowding = thrombocytopenia)
Bones (may present as pain in the back)
Infection - reduction in normal immunoglobulins -> increased susceptibility to infection
Myeloma investigations findings: Peripheral blood film:
UEs
Bone profile
Rouleaux formation
Renal failure
Hypercalcaemia
Electrolyte disturbance in rhabdomyloysis/long lie
Hypocalcaemia
Calcium binds to myoglobulin released from damaged muscles causing hypocalcaemia)
ECG features of hypokalaemia
U waves
Small/absent T waves
Prolonged QT interval
ST depression
Long QT
Commonest cause of glomerulonephritis worldwide?
How to differentiate this from Post-streptococcal nephropathy?
Treatment:
IgA nephropathy
Develops 1-2 WEEKS after strep infection (IgA develops in 1-2 days)
Post-streptococcal has low complement typically
Both involve haematuria and recent URTI
Only if persistent proteinuria - Give ACEi if this does not respond - give immunosuppression with corticosteroids
Hair loss in response to severe stress name:
Telogen effluvium
Treatment of choice in capillary haemangioma
Propranolol
DVT pathway:
Wells score of X means DVT ‘likely’
Actions on:
DVT ‘unlikely’ score
Actions on:
If scan us negative but D-dimer is positive:
2 points or more
proximal leg ultrasound should be carried out within 4 hours.
If US cannot be carried out within 4 hours, D-dimer should be sent and interim anticoagulation commenced.
1 point or less
D-dimer -> If positive, proximal leg ultrasound should be arranged within 4 hours
Stop interim therapeutic anticoagulation, offer a REPEAT leg vein ultrasound 6 to 8 days later
Anti-depressant which is most likely to increase QT interval -> cause torsades du point
Citalopram
Treatment of congenital inguinal hernia in paediatrics
congenital inguinal hernias should be REPAIRED promptly once identified
More common in babies and boys
COCP:
Protective against which cancers?
Increases risk of which cancers?
Protective: Colorectal, ovarian, endometrial
Not-protective: Breast, cervical
Breast feeding on anti-epileptics: Which are safe?
Breast feeding is acceptable with nearly ALL AEDs
Spider naevi vs talengectasias
What are spider naevi common in ?
Spider naevi fill from the centre (think of a spider -> Central body with legs spreading outwards)
Talengectasia fill from the edge
Liver disease
Pregnancy
COCP
Kallman syndrome gonadotrophins:
FSH/LH
Testosterone
Height
Key finding
X-linked recessive
LH/FSH low
Testosterone low
Height: Normal or above avergae (contrary to belief)
Lack of smell
Effect on pupil with:
third nerve palsy
Holmes-Adie pupil
traumatic iridoplegia
phaeochromocytoma
congenital
Drugs:
Atropine, amphetamines, cocaine, TCAs
Mydriasis -> dilated pupil
If blood sugar readings still not met on metformin on pregnancy, what should happen and why?
Start insulin -> increasing metformin and waiting to see response will delay necessary control of patients glucose
Scabies:
How long may itch persist after treatment
Treatment:
6 weeks
Permethrin is first line
Malathion lotion is second line
Household contacts should all the treated
Psoriasis treatment laddder
Regular emollients may help to reduce scale loss and reduce pruritis
1) Potent topical corticosteroid once daily plus vitamin D analogue applied once daily -> Up to 4 weeks for initial treatment
2) If no improvement in 8 weeks -> Vitamin D analogue twice daily
3) No improvement after 8-12 weeks then offer potent corticosteroid twice daily or COAL TAR applied 1/2 times weekly.
Management of Crohn’s:
Inducing remission
Maintaining remission
Glucocorticoids (5-ASAs mesalzine may be used but are less effective)
Azathioprine or mercaptopurine (methotrexate is second line or first if TPMT)
Live attenuated vaccines:
mnemonic and vaccines:
‘MY BOO’
MMR
Yellow fever
BCG
Oral typhoid
Oral polio/rotavirus
Vestibular schwannoma:
Affected nerves - symptoms
CNV
CNVII
CNVIII
CNV: Absent corneal reflex
CNVII: Facial nerve palsy
CNVIII: vertigo, unilateral sensorineural hearing loss, unilateral tinnitus
Respiratory alkalosis causes:
CHAMPS mnemonic:
CNS disease: Stroke, SAH
Hypoxia - PE
Anxiety
Mechanical over ventillation
Progesterone, pregnancy
Salicylate poisoning
Anxiety leading to hyperventilation
Pulmonary embolism
salicylate poisoning*
CNS disorders: stroke, subarachnoid haemorrhage,
Encephalitis
Altitude
Pregnancy
*salicylate overdose leads to a mixed respiratory alkalosis and metabolic acidosis. Early stimulation of the respiratory centre leads to a respiratory alkalosis whilst later the direct acid effects of salicylates (combined with acute renal failure) may lead to an acidosis
Drug to administer in confirmed SAH:
What does it do?
Nimodipine
Calcium channel blocker that is specifically indicated for the prevention of cerebral vasospasm following subarachnoid haemorrhage
Where does Crohn’s most commonly affect:
Terminal ileum
Vesicoureteric reflux
Initial investigation:
Investigation to look for scarring:
Micturating cystourethrogram
DMSA
Management of whooping cough:
Management of whooping cough if child <6 months
Is prophylaxis needed?
Azithromycin if within 21 days on on-set
Admit to hospital
Yes
Useful blood test to investigate whether true anaphylaxis has occurred:
Serum tryptase
Most common cause of hirsutism:
Other causes of hirsutism:
Assessment tool for hirsutism:
PCOS
Cushing’s syndrome
congenital adrenal hyperplasia
androgen therapy
obesity: thought to be due to insulin resistance
adrenal tumour
androgen secreting ovarian tumour
drugs: phenytoin, corticosteroids
Ferriman-Gallwey scoring system: 9 body areas are assigned a score of 0 - 4, a score > 15 is considered to indicate moderate or severe hirsutism
If on COCP or any hormonal contraception, how long after taking:
1) Levonorgestrel
2) Ulipristal
should you wait before re-starting COCP
In which common condition is Ulipristal Acetate contraindicated in
1) immediately restart
2) Advised to wait for 5 days
Asthma
Vit D, Calcium, phosphate, ALP levels in:
Osteomalacia -
Pagets -
Hypoparathyroid -
Primary hyperparathyroid -
Osteomalacia- low vit d, low calcium, low phos. High ALP
(the bone is trying but has poor supplies)
Pagets - Isolated ALP rise
(bone is just doing its own thing)
Hypoparathyroid- low ca, high phos, normal ALP
(ca/phos affected but bones aren’t really involved)
Primary hyperparathyroid- high ca, low phos, high ALP
(the parathyroid is demanding calcium to the blood, so bones have to break down)
Phaeochromocytomas presents with triad of what?
headache, palpitations, hyperhidrosis
Commonest cause of UTI in
Children:
Adults:
E.coli
E.coli
After giving birth, how long are women protected without additional contraception
21 days
Shaken baby triad:
Retinal haemorrhages
Subdural haemorrhage
Encephalopathy
How long should antidepressants continue, despite ‘resolution’ to reduce risk of relapse:
6 months
When should OGTT be checked in pregnancy?
If prev. GDM ?
16-18 weeks
AS soon as possible after booking
M/C cause of hypercalcaemia:
Causes of hyperparathyroidism?
Bloods in primary hyperparathyroidism:
Hyperparathyroidism
85% solitary parathyroid adenoma
raised calcium, low phosphate
PTH may be raised or (inappropriately, given the raised calcium) normal
Blistering skin conditions: Difference between pemphigoid and pemphigus
no mucosal involvement: bullous pemphigoid
mucosal involvement: pemphigus vulgaris
Excess fluid resus with saline - electrolyte disturbance?
Hyperchloraemic ACIDOSIS
Coeliac -> Hyposplenism on blood film:
target cells
Howell-Jolly bodies
Pappenheimer bodies
siderotic granules
acanthocytes
Iron deficiency anaemia on blood film:
target cells
‘pencil’ poikilocytes
if combined with B12/folate deficiency a ‘dimorphic’ film occurs with mixed microcytic and macrocytic cells
Myelofibrosis on blood film
‘tear-drop’ poikilocytes
Intravascular haemolysis on blood film
schistocytes
which finding is an indication that kidney disease is chronic and not acute
Hypocalcaemia
Addisons disease investigations:
If primary test is unavailable?
Short SYNACTHEN
9am serum cortisol (>500 makes addisons very unlikely)
<100 definitely abnormal
Tests to confirm Cushing’s syndrome:
Overnight (low dose) dexamethasone suppression test (patients with Cushings do NOT have their morning cortisol spike suppressed
24 hour urinary free cortisol (2 measurements required)
Bedtime salivary cortisol (2 measurements required)
Cushing’s syndrome: Localisation tests
1) 9am and midnight plasma ACTH (and cortisol) levels -> if acth is suppressed then a non-acth dependent cause is likely such as adrenal adenoma
2) High dose dexamethasone suppression test:
3) CRH stimulation - if pituitary source, then cortisol rises
4) if ectopic then no change in cortisol
Petrosal sinus sampling of ACTH may be needed to differentiate between pituitary and ectopic acth secretion.
Primary hyperaldosteronism investigations
1) Renin:Aldosterone ratio is first line investigation
Following this, a high resolution CT abdomen and adrenal vein sampling is used to differentiate between unilateral and bilateral sources of aldosterone excess
If this is normal, adrenal venous sampling can differentiate between unilateral a denial and bilateral hyperplasia
Acromegaly investigations
1)
2)
What levels are used to monitor disease
1) Serum IGF-1 with serial GH measurements
2) OGTT recommended to confirm the diagnosis if IGF-1 levels are raised
Also serum IGF-1
Gastroenteritis: organism which causes constipation as well as diarrhoea
Which other manifestation is associated with this disease:
Typhoid
‘rose spots’
Dizziness, electric shock sensations and anxiety can occur on the cessation of which widely prescribed medication:
SSRIs
(SSRI discontinuation syndrome)
Need for contraception after the menopause:
12 months after the last period in women > 50 years
24 months after the last period in women < 50 years
UTI in pregnancy: Tx. to be AVOIDED near term:
Nitrofurantoin. First line antibiotic for UTI in pregnancy but is to be avoided near term
UTI antibiotic to avoid in FIRST TRIMESTER of pregnancy
Trimethoprim (teratogenic)
Osteomalacia ->
Calcium:
Phosphate:
PTH:
ALP:
Calcium: decreased
Phosphate: decreased
PTH: increased
ALP: increased
Primary hyperparathyroidism ->
Calcium:
Phosphate:
PTH:
ALP:
Calcium: high
Phosphate: low
PTH: high
ALP: high
Chronic kidney disease (→ secondary hyperparathyroidism)
Calcium:
Phosphate:
PTH:
ALP:
Calcium: low
Phosphate: high
PTH: high
ALP: high
Paget’s disease ->
Calcium:
Phosphate:
PTH:
ALP:
Calcium: normal
Phosphate: normal
PTH: normal
ALP: increased
Anti-diabetes drug if not tolerating metformin and QRISK > 10% or established CV disease
Add/start SGLT2 inhibitory monotherapy
Most common causative organism of infective endocarditis:
Previous most common bug:
Staph aureus
Strep viridans -> think dental procedure
What constitutes severe UC:
severe: >6 bloody stools per day
+ features of systemic upset (pyrexia, tachycardia, anaemia, raised inflammatory markers)
Commonest ocular manifestation of SLE
Keratoconjunctivitis sicca
- dry eyes
Common condition in which meconium ileus is common.
When does meconium ileus present:
Cystic fibrosis
Typically in first 24-48 hours of life with abdominal distension and bilious vomiting
When does necrotising enterocolitis present?
How does it present?
typically in second week of life
Dilated bowel loops on AXR, pneumatosis and portal venous air
AXR shows double bubble sign, contrast study may confirm -> presents in first few hours of life
Duodenal atresia
When does Malrotation with volvulus present
Usually 3-7 days after birth
volvulus with compromised circulation may result in peritoneal signs and haemodynamic instability
What should be offered post-WLE in breast cancer
Whole breast radiotherapy is recommended after a woman has had a wide-local excision as this may reduce the risk of recurrence by around two-thirds
Breast cancer screening:
When is this offered
What does it consist of
women between the ages of 50-70 years
Mammogram every 3 years
Define fibroadenosis (fibrocystic disease, benign mammary dysplasia)
Most common in middle-aged women
‘Lumpy’ breasts which may be painful. Symptoms may worsen prior to menstruation
Common in women under the age of 30 years
Often described as ‘breast mice’ due as they are discrete, non-tender, highly mobile lumps
fibroadenoma
All patients with PVD should be on which 2 drugs
Statin and clopidogrel
What is Asherman’s syndrome
Asherman’s syndrome is a rare condition that occurs when scar tissue forms in the uterus or cervix.
Causes secondary amenorrhoea.
Commonly after an intra-uterine/cervical procedure
What is Sheehan’s syndrome?
Sheehan syndrome is a rare condition that occurs when the PITUITARY gland is damaged during childbirth due to severe blood loss
Sheehan syndrome describes hypopituitarism caused by ischemic necrosis due to blood loss and hypovolaemic shock.
1) Where is Broca’s area
2) Where is Wernicke’s area
1) Frontal lobe - assoc with difficulty in speech PRODUCTION
2) temporal lobe - assoc. with impaired comprehension of speech but intact production
Four phases of subacute (De Quervains thyroiditis)
What is seen on scintigraphy
phase 1 (lasts 3-6 weeks): hyperthyroidism, painful goitre, raised ESR
phase 2 (1-3 weeks): euthyroid
phase 3 (weeks - months): hypothyroidism
phase 4: thyroid structure and function goes back to normal
Globally reduced uptake of contrast
Seen m/c post/during viral illness
Group B streptococcus in pregnancy antibiotics: when given?
Antibiotics at time of diagnosis AND INTRAPARTUM antibiotics
Which blood dyscrasia does antiphospholipid syndrome cause
Antiphospholipid syndrome: (paradoxically) prolonged APTT + low platelets
Next line of treatment for lung abscess failing to respond to antibiotics?
Percutaneous drainage
Glucose requirement for patients NBM per day in g
50-100g regardless of body mass
If patient has stage 1 hypertension, is less than 80 years-old and has QRISK <10, do they need antihypertensives?
No
Electrolyte disturbance seen in sarcoidosis:
Hypercalcaemia
