Monday [04/10/2021] Flashcards
What is achalasia? [3]
Failure of oesophageal peristalsis and relaxation of the LOS due to degenerative loss of ganglia from Auerbach’s plexus i.e. LOS contracted, oesophagus dilated above
Clinical features of achalasia [5]
dysphagia of BOTH liquids and solids
typically variation in severity of symptoms
heartburn
regurgitation of food
may lead to cough, aspiration pneumonia etc
malignant change in small number of patients
What do people with achalasia struggle to swallow? [1]
BOTH liquids and solids
Ix for achalasia [3]
oesophageal manometry
- excessive LOS tone which doesn’t relax on swallowing
- considered the most important diagnostic test
barium swallow
- shows grossly expanded oesophagus, fluid level
- ‘bird’s beak’ appearance
chest x-ray
- wide mediastinum
- fluid level
Barium swallow of achalasia [2]
- shows grossly expanded oesophagus, fluid level
- ‘bird’s beak’ appearance
First-line Tx for achalasia [2]
pneumatic (balloon) dilation is increasingly the preferred first-line option
less invasive and quicker recovery time than surgery
patients should be a low surgical risk as surgery may be required if complications occur
Other Tx for achalasia [3]
surgical intervention with a Heller cardiomyotomy should be considered if recurrent or persistent symptoms intra-sphincteric injection of botulinum toxin is sometimes used in patients who are a high surgical risk drug therapy (e.g. nitrates, calcium channel blockers) has a role but is limited by side-effects
CT patient with breast cancer severe headache, nausea and vomiting Dx? [1]
Headache caused by raised ICP [or mets] can be palliated by dexamethasone
What is IV mannitol used for? [1]
IV mannitol can be prescribed to treat raised intracranial pressure, but would not be used for cerebral metastases
What does ondansetron act on? [2]
Ondansetron is an antiemetic that acts as a serotonin (5-HT3) antagonist. It is usually prescribed for chemotherapy-related nausea and vomiting
Finding of the film? [1]
Right middle and lower lobe consolidation:
The presence of consolidation above the horizontal fissure and the obscured right heart border suggest the presence of right middle lobe consolidation. There is some loss of definition (silhouette sign) of the medial aspect of the right hemidiaphragm suggesting some right lower lobe consolidation as well
Causes of white shadowing in the lungs [6]
consolidation pleural effusion collapse pneumonectomy specific lesions e.g. tumours fluid e.g. pulmonary oedema
What could cause trachea to be pulled toward the white-out? [3]
Pneumonectomy
Complete lung collapse e.g. endobronchial intubation
Pulmonary hypoplasia
What could cause the trachea to be central but there still to be a white-out part of the lung? [3]
Consolidation
Pulmonary oedema (usually bilateral)
Mesothelioma
Trachea pushed away from white-out [3]
Pleural effusion
Diaphragmatic hernia
Large thoracic mass
Dx?
Lung collapse - notice how the trachea is pulled toward the side of the white-out
Dx?
Pleural effusion - note how the trachea (blue) is pushed away the side of the white-out. The other signs of a positive mass effect include leftward bowing of the azygo-oesophageal recess (yellow) and splaying of the ribs on the right (red)
What is Urea breath test used for? [1]
may be used to check for H. pylori eradication
How is a urea breath test conducted? [4]
patients consume a drink containing carbon isotope 13 (13C) enriched urea
urea is broken down by H. pylori urease
after 30 mins patient exhale into a glass tube
mass spectrometry analysis calculates the amount of 13C CO2
When should urea breath tests not be done? [2]
4 weeks of treatment with an antibacterial or within 2 weeks of an antisecretory drug (e.g. a proton pump inhibitor)
Other tests for H/pylori [5]
Rapid urease test (e.g. CLO test)
biopsy sample is mixed with urea and pH indicator
colour change if H pylori urease activity
sensitivity 90-95%, specificity 95-98%
Serum antibody
remains positive after eradication
sensitivity 85%, specificity 80%
Culture of gastric biopsy
provide information on antibiotic sensitivity
sensitivity 70%, specificity 100%
Gastric biopsy
histological evaluation alone, no culture
sensitivity 95-99%, specificity 95-99%
Stool antigen test
sensitivity 90%, specificity 95%
How long does insomnia have to go on for to be diagnosed as chronic? [1]
Chronic insomnia may be diagnosed after three months, if a person has trouble falling asleep or staying asleep at least three nights per week
Define insomnia according to the DSM-V [3]
In the DSM-V, insomnia is defined as difficulty initiating or maintaining sleep, or early-morning awakening that leads to dissatisfaction with sleep quantity or quality. This is despite adequate time and opportunity for sleep and results in impaired daytime functioning
How many times a week for chronic insomnia? [2]
Chronic insomnia may be diagnosed if a person has trouble falling asleep or staying asleep at least three nights per week for 3 months or longer
Ix of insomnia [3]
Diagnosis is primarily made through patient interview, looking for the presence of risk factors.
Sleep diaries and actigraphy may aid diagnosis. Actigraphy is a non-invasive method for monitoring motor activity.
Polysomnography is not routinely indicated. It may be considered in patients with suspected obstructive sleep apnoea or periodic limb movement disorder, or when insomnia is poorly responsive to conventional treatment
Short-term Mx of insomnia [4]
Identify any potential causes e.g. mental/ physical health issues or poor sleep hygiene.
Advise the person not to drive while sleepy.
Advise good sleep hygiene: no screens before bed, limited caffeine intake, fixed bed times etc.
ONLY consider use of hypnotics if daytime impairment is severe
Why are hypnotic drugs often not considered? [2]
There is good evidence for the efficacy of hypnotic drugs in short-term insomnia. However, there are many adverse effects e.g. daytime sedation, poor motor coordination, cognitive impairment and related concerns about accidents and injuries. In addition, tolerance to the hypnotic effects of benzodiazepines may be rapid (within a few days or weeks of regular use)
Which hypnotics are recommended for sleep? [2]
The hypnotics recommended for treating insomnia are short-acting benzodiazepines or non-benzodiazepines (zopiclone, zolpidem and zaleplon).
When can Diazepam but useful? [1]
Use the lowest effective dose for the shortest period possible
Which drugs are not recommended for managing insomnia? [1]
Other sedative drugs (such as antidepressants, antihistamines, choral hydrate, clomethiazole and barbiturates) are not recommended for managing insomnia
A 69-year-old woman undergoes a radical mastectomy for a T3 triple-negative carcinoma in her left breast. The pathology report shows cancerous cells at the margins of the resected specimen.
What, if any, further non-surgical management should the patient receive? [2]
Ipsilateral chest wall and regional LN radiotherapy
Why is adding letrozole or trastuzumab to Tx of triple negative breast Ca not appropriate? [2]
Adding in a course of letrozole is not appropriate in this patient who has a triple-negative carcinoma. Letrozole is an aromatase inhibitor used in the treatment of ER+ cancers.
Adding in a course of trastuzumab is not appropriate, as this monoclonal antibody is used in the treatment of HER2+ cancers
5 ways of Tx breast Ca [5]
surgery radiotherapy hormone therapy biological therapy chemotherapy
How should women with no palpable axilallary lymphandenopathy be Mx? [2]
women with no palpable axillary lymphadenopathy at presentation should have a pre-operative axillary ultrasound before their primary surgery
if positive then they should have a sentinel node biopsy to assess the nodal burden
How should women with a palpable axilallary lymphandenopathy be Mx? What could this lead to? [2]
in patients with breast cancer who present with clinically palpable lymphadenopathy, axillary node clearance is indicated at primary surgery
this may lead to arm lymphedema and functional arm impairment
What is offered after a wide-local excision and why? [2]
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.
What is used as hormonal therapy for ER+ve pre-menopausal women? [1]
Adjuvant hormonal therapy is offered if tumours are positive for hormone receptors. For many years this was done using tamoxifen for 5 years after diagnosis. Tamoxifen is still used in pre- and peri-menopausal women.
What is used as hormonal therapy for ER+ve post-menopausal women? [1]
In post-menopausal women, aromatase inhibitors such as anastrozole are used for this purpose*
IMportnat SE of tamoxifen? [3]
Important side-effects of tamoxifen include an increased risk of endometrial cancer, venous thromboembolism and menopausal symptoms.
What is the most common biological therapy and which cancers is it used for? [2]
The most common type of biological therapy used for breast cancer is trastuzumab (Herceptin). It is only useful in the 20-25% of tumours that are HER2 positive.
When is Trastuzumab CI in breast Ca patients? [1]
Trastuzumab cannot be used in patients with a history of heart disorders.
When is chemo used in breast Ca patients? [2]
Cytotoxic therapy may be used either prior to surgery (‘neoadjuvanant’ chemotherapy) to downstage a primary lesion or after surgery depending on the stage of the tumour, for example, if there is axillary node disease - FEC-D is used in this situation.
What is scabies spread by? [1]
Scabies is caused by the mite Sarcoptes scabiei and is spread by prolonged skin contact. It typically affects children and young adults.
How do scabies cause pruritis? [2]
The scabies mite burrows into the skin, laying its eggs in the stratum corneum. The intense pruritus associated with scabies is due to a delayed-type IV hypersensitivity reaction to
How long is the delay between scabies biting and hypersensitivity? [1]
The intense pruritus associated with scabies is due to a delayed-type IV hypersensitivity reaction to mites/eggs which occurs about 30 days after the initial infection.
Features of scabies [4]
widespread pruritus
linear burrows on the side of fingers, interdigital webs and flexor aspects of the wrist
in infants, the face and scalp may also be affected
secondary features are seen due to scratching: excoriation, infectio
Mx of scabies first-line [1]
permethrin 5% is first-line
Other Mx of scabies [4]
permethrin 5% is first-line
malathion 0.5% is second-line
give appropriate guidance on use (see below)
pruritus persists for up to 4-6 weeks post eradication
Guidance on Tx for scabies [3]
avoid close physical contact with others until treatment is complete
all household and close physical contacts should be treated at the same time, even if asymptomatic
launder, iron or tumble dry clothing, bedding, towels, etc., on the first day of treatment to kill off mites.
What and how should be applied to all patients with scabies? [3]
The BNF advises to apply the insecticide to all areas, including the face and scalp, contrary to the manufacturer’s recommendation. Patients should be given the following instructions:
apply the insecticide cream or liquid to cool, dry skin
pay close attention to areas between fingers and toes, under nails, armpit area, creases of the skin such as at the wrist and elbow
allow to dry and leave on the skin for 8-12 hours for permethrin, or for 24 hours for malathion, before washing off
reapply if insecticide is removed during the treatment period, e.g. If wash hands, change nappy, etc
repeat treatment 7 days later
When are crusted scabies seen? [1]
Depressed immunity, like HIV, crusted skin with 100,000s of orgnaisms
Where does inflammation start and end in UC? [2]
Inflammation always starts at rectum (hence it is the most common site for UC), never spreads beyond ileocaecal valve and is continuous
Peak incidence of UC? [2]
The peak incidence of ulcerative colitis is in people aged 15-25 years and in those aged 55-65 years.
Initial presentation of UC? [5]
bloody diarrhoea urgency tenesmus abdominal pain, particularly in the left lower quadrant extra-intestinal features (see below
Extra-intestinal features of both CD and UC related to disease activity [4]
Arthritis: pauciarticular, asymmetric
Erythema nodosum
Episcleritis
Osteoporosis
Extra-intestinal features of both CD and UC unrelated to disease activity [4]
Arthritis: polyarticular, symmetric Uveitis Pyoderma gangrenosum Clubbing Primary sclerosing cholangitis
[uveitis and PSC more common UC]
Pathology of UC [7]
red, raw mucosa, bleeds easily
no inflammation beyond submucosa (unless fulminant disease)
widespread ulceration with preservation of adjacent mucosa which has the appearance of polyps (‘pseudopolyps’)
inflammatory cell infiltrate in lamina propria
neutrophils migrate through the walls of glands to form crypt abscesses
depletion of goblet cells and mucin from gland epithelium
granulomas are infrequent
Barium enema of UC? [3]
loss of haustrations
superficial ulceration, ‘pseudopolyps’
long standing disease: colon is narrow and short -‘drainpipe colon’
Thyroid blood test of majority of hypothyroid patients? [2]
Primary hypothyroidism: high TSH, low T4
Common causes of primary hypothyroidism [4]
Autoimmune (Hashimoto’s disease, atrophic)
Iodine deficiency
Thyroiditis (post-viral, post-partum)
Iatrogenic (thyroidectomy, radioiodine, drugs)
TFT for secondary hypothroidism [1]
Secondary hypothyroidism is very rare and results in a low TSH and low T4
Ix of secondary hypothyoidism why? [1]
In these cases, pituitary insufficiency is most likely and therefore an MRI of the gland should be performed.
Thyrotoxicosis TFT [1]
Low TSH, high T4
Subclinical hypothyroidism TFT [1]
High TSH, normal T4
Poor compliance with thyroxine TFT [1]
High TSH, normal T4
Steroid therapy TFT [1]
Low TSH, normal T4
Definition of schizoid personality disorder
Schizoid personality disorder is characterized by at least 3 of the following:
Few, if any, activities, provide pleasure;
Emotional coldness, detachment or flattened affectivity;
Limited capacity to express either warm, tender feelings or anger towards others;
Apparent indifference to either praise or criticism;
Little interest in having sexual experiences with another person (taking into account age);
Almost invariable preference for solitary activities;
Excessive preoccupation with fantasy and introspection;
Lack of close friends or confiding relationships (or having only one) and of desire for such relationships;
Marked insensitivity to prevailing social norms and conventions.
Definition of antisocial PD [8]
Failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest;
More common in men;
Deception, as indicated by repeatedly lying, use of aliases, or conning others for personal profit or pleasure;
Impulsiveness or failure to plan ahead;
Irritability and aggressiveness, as indicated by repeated physical fights or assaults;
Reckless disregard for safety of self or others;
Consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations;
Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another
Avoidant PD characteristics [5]
Avoidance of occupational activities which involve significant interpersonal contact due to fears of criticism, or rejection.
Unwillingness to be involved unless certain of being liked
Preoccupied with ideas that they are being criticised or rejected in social situations
Restraint in intimate relationships due to the fear of being ridiculed
Reluctance to take personal risks doe to fears of embarrassment
Views self as inept and inferior to others
Social isolation accompanied by a craving for social contact
BPD characteristics [5]
Efforts to avoid real or imagined abandonment
Unstable interpersonal relationships which alternate between idealization and devaluation
Unstable self image
Impulsivity in potentially self damaging area (e.g. Spending, sex, substance abuse)
Recurrent suicidal behaviour
Affective instability
Chronic feelings of emptiness
Difficulty controlling temper
Quasi psychotic thoughts
Dependent PD characteristics [5]
Difficulty making everyday decisions without excessive reassurance from others
Need for others to assume responsibility for major areas of their life
Difficulty in expressing disagreement with others due to fears of losing support
Lack of initiative
Unrealistic fears of being left to care for themselves
Urgent search for another relationship as a source of care and support when a close relationship ends
Extensive efforts to obtain support from others
Unrealistic feelings that they cannot care for themselves
Histrionic PD [5]
Inappropriate sexual seductiveness
Need to be the centre of attention
Rapidly shifting and shallow expression of emotions
Suggestibility
Physical appearance used for attention seeking purposes
Impressionistic speech lacking detail
Self dramatization
Relationships considered to be more intimate than they are
Narcissistic PD [5]
Grandiose sense of self importance Preoccupation with fantasies of unlimited success, power, or beauty Sense of entitlement Taking advantage of others to achieve own needs Lack of empathy Excessive need for admiration Chronic envy Arrogant and haughty attitude
OCD PD characterisitcs [5]
Is occupied with details, rules, lists, order, organization, or agenda to the point that the key part of the activity is gone
Demonstrates perfectionism that hampers with completing tasks
Is extremely dedicated to work and efficiency to the elimination of spare time activities
Is meticulous, scrupulous, and rigid about etiquettes of morality, ethics, or values
Is not capable of disposing worn out or insignificant things even when they have no sentimental meaning
Is unwilling to pass on tasks or work with others except if they surrender to exactly their way of doing things
Takes on a stingy spending style towards self and others; and shows stiffness and stubbornness
Paranoid PD [5]
Hypersensitivity and an unforgiving attitude when insulted
Unwarranted tendency to questions the loyalty of friends
Reluctance to confide in others
Preoccupation with conspirational beliefs and hidden meaning
Unwarranted tendency to perceive attacks on their character
Schizotypal PD [8]
Ideas of reference (differ from delusions in that some insight is retained) Odd beliefs and magical thinking Unusual perceptual disturbances Paranoid ideation and suspiciousness Odd, eccentric behaviour Lack of close friends other than family members Inappropriate affect Odd speech without being incoherent
Name all 10 PD [10]
Antisocial, avoidant, BPD, dependent, histiorinic, narcissistic, OCD, paranoid, schizoid, schizotypal
Mx of PD [2]
PDs are often thought to be ‘untreatable’ by definition
however, a number of approaches have been shown to help patients, including:
psychological therapies: dialectical behaviour therapy
Blood profile of antiphospholipid syndrome [2]
The combination of a prolonged APTT and thrombocytopenia make antiphospholipid syndrome the most likely diagnosis
What is antiphospholipid syndrome? [3]
Antiphospholipid syndrome is an acquired disorder characterised by a predisposition to both venous and arterial thromboses, recurrent fetal loss and thrombocytopenia. It may occur as a primary disorder or secondary to other conditions, most commonly systemic lupus erythematosus (SLE)
