MRCP all Flashcards
What drug should be avoided in IBS?
Lactulose
What blood markers suggest Alcoholic liver disease OR non alcoholic liver disease?
ALD - AST: ALT >2
non alcoholic liver disease
ALT>AST
how is severe alcoholic hepatitis managed? what criteria is used for this ?
Corticosteroids
Maddreys discriminant function - uses PT and billirubin. if >32 then use steroids
what are the scoring systems for upper GI bleed?
Glasgow blatchford
Rockall - after endoscopy
what is the prophylaxis for reducing risk of variceal upper GI bleed?
Propanolol
What Ix is needed in Budd Chiari syndrome?
USS dopler of liver - very sensitive
What Abx prophylaxis is given in spontaneous bacterial peritonitis and when?
Ciprofloxacin/ norfloxacin if ascites + - previous SBP - protein fluid <15g/l - child pugh of 9 - hepatorenal syndrome
how is spontaneous bacterial peritonitis diagnosed? what is the most common organism found?
neutrophils >250
Ecoli
what drugs cause cholestasis?
COCP steroids fluclox erythromycin fibrates sulphonylureas
what change is seen in barrets oesophagus?
sqaumous –> columnar
when is barrets oesophagus treated?
metaplasia - endoscopic surviellence 3-5yrs
dysplasia - endoscopic mucosal resection/ radiofreq ablation
what is the target of clopidogrel?
P2Y ADP receptor
what drug makes clopidogrel less effective?
PPI
what does hypercalcaemia do to an ECG?
Short QT
also causes HTN
what are the causes of long QT?
hypo K, Mg, Ca, hypothermia
antidepressants (SSRI (citalopram), tricyclics),
antiarrhythmics (amiodarone, sotolol) ,
antibiotics - ciprofloxacin, erythromycin
other - SAH, myocarditis
Romeo ward
Jervall lange nielson
what are the ecg changes in hypo K
no T/ flat long PR long QT ST depression U waves
what is the treatment for mitral stenosis?
percutaneous mitral commissuratomy
What is the equation for sensitivity?
Out of the positive people how many of them test positive
What is the equation for positive predictive value?
OF all the positive tests, how many actually have the disease?
How are DNA, RNA and proteins investigated?
DNA - southern blot
RNA - northern blot
protein - western blot
Which Ab is most abdunant in the serum?
IgG
which Ab is most abdundant in breast milk and muscosal lining?
IgA
which Ab is first to respond to infection?
IgM
which antibody activates B cells?
IgD
which HLA is coeliacs, haemochromatosis and behcets? (each a separate one)
HLA DQ2 - coeliacs
HLA A3 - haemachromatosis
HLA b51 - behcets
which medication is first line for trigeminal neuralgia?
Carbemazepine
which Abx should be used for septic arthritis and how long?
IV fluclox
4-6 weeks
after 2 weeks can be made oral
which organism most commonly causes septic arthritis?
S.aureus
N.gonorrhoea - most common in young sexually active
how is septic arthritis most commonly acquired?
haematogenous spread
which is the most common site for septic arthritis?
knee
How are cluster headaches managed?
S/C sumatriptan + 100% O2
what are the triggers/ associateion of cluster headaches?
males
smokers
alcohol is a trigger
how can cluster headaches be prevented?
verapamil
how does radial tunnel syndrome present?
signs and symptoms like lateral epiconylitis however pain is about 4-5cm disatal to lateral epicondyl
what ECG change is seen in a subarachnoid haemorrhage?
ST elevation
what are the predictive factors for the outcome of SAH?
level of consciousness
age
amount of blood on CT
How does drug induced parkinsonism present differently to parkinsons?
motor symptoms rapid onset and bilateral
less rigidity and tremor in comparison
mask like face, flexed posture and restlessness - seen in both
what is the most common psych issue in parkinsons?
depression
Marfans is complicated by dural ectasia, how does this present?
ballooning or dural sac in lumbar level.
headaches, lower back pain, leg weakness, bladder/bowel changes
which Antibody is associated with dermatomyositis?
anti Mi2 - most specific
ANA - more common
Which malignancy is sjorgrens more at risk of?
lymphoid malignancy
which Ab are seen in sjogren, which is most common?
Ro> La
low C4
How is bells palsy managed?
oral pred within 72 hours of onset
which malignancy and antibody is stiff persons syndrome associated with?
anti GAD
colorectal, breast, small cell
how long does Driving need to be banned for after stroke/ TIA?
one TIA - one month
multiple TIA / stroke - 3 months + tell DVLA
what treatment best prolongs life expectancy in MND?
NIV > riluzole
what screening is needed on patients using hydroxychloroquine and why? what advice would you give pregnant women?
fundoscopy and visual tests before and annually.
Due to risk of bulls eye retinopathy
can be used in pregnancy
For bitemporal hemianopias how can we identify where a lesion is depending on the quadrant affected?
upper quadrants - pituitary
lower quadrants - craniopharygioma
which disease is HLA DR4 associated with?
diabetes
RA (DRB1 gene particularly)
Which Ab are associated with HLA DR2 ?
Nacrolepsy
goodpastures
What statistical test is used in cohort and case control studies?
cohort - relative risk
case control - odd ratio
For parametric data which tests can be used and when?
T test
pearson - correlation
for non parametric data which test can be used and when ?
man whitney - compares intervals/ ratios
wilcox - before and after
chi squared - compares % proportion
spearmans rank - correlation
list the translocations seen in haematological malignancy…
t(9:22) - CML , ALL (poor prog) - BCR ABL
t (14:18) - follicular lymphoma - BCL2
t(11:14 ) - mantle - cyclin D
T(8:14) - burkitts - myc
t(15:17) - promyelocytic - RAR-PML
what is the function of vWF?
stabilises factor VIII
what changes are there to clotting factors in von willebrand disease?
low factor 8
what is the treatment for von willebrand disease?
Desmopressin - stimulates release of vWF
what is the dose adrenaline for anaphylaxis by age?
<6 months: 100-150
6m-6yr 150microG
6-12yr: 300 microG
>12: 500microG
all 1 in 1000
what are the different cryoglobulinaemia immunoglobulins and what diseases are they associated with?
type 1 - monoclonal IgG or IgM. associated with muliple myeloma/ waldenstorm. only one with raynauds
type 2 - mixed mono/ polyclonal. hep C, RA, sjorgrens , lymphoma
type 3 - polyclonal. RA and sjogrens
what is the treatment for ITP?
oral prednisolone
what is evans syndrome?
ITP + autoimmune haemolytic anaemia
state the mechanism and side effect of: cyclophosmide bleomycin doxorubicin vincistrine
cyclophosmadie - cross link DNA, haemorrhagic cystitis, transitional cell carcinoma, myelosupression
bleomycin - degrades DNA, lung fibrosis
doxorubicin - stabilises topoisomerase - cardiomyopathy
vincistrine - microtubule inhibition. peripheral neuropathy,, paralytic ileus
state the mechanism and side effect of: docetazxel irinotecan cisplatin hydroxyurea?
docetaxel - microtubule inhibitrion. neutropenia
irinotecan - topoisomerase inhibitor - myelosupression
cisplatin - cross links DNA. HypoMg, periperal neuropathy, ototoxic
hydroxyurea - inhibits ribonucleotide reductase
what is the best marker for diagnosis of hereditary angioedema between attacks?
low C4
what immunoglobulins are seen in cold and warm haemolytic anaemias?
cold - IgM
Warm - IgG
what infection gives burkitts?
MAlaria
which haematological malignancy is HIV linked to?
high grade B cell lymphoma
what is seen in methamoglobinaemia in terms of oxygenation?
low sats
normal pO2
what is the test for hereditary spherocytosis ?
EMA binding test
which drugs have 0 order kinetics?
salicyclates
ethanol
phenytoin
heparin
how does methanol poisoning present and how is it treated?
Like alcohol intox + visual changes
managed with fomepizole
what is the dose of adrenaline in adults in anaphylaxis vs cardiac arrest?
500micrograms - anaphylaxis (0.5 ml) (1 in 1000)
1mg in cardiac arrest (0.1ml) (1 in 10,000)
(or for cardiac arrest can use 1 in 1000, 1ml)
when can gastric levage and charcoal be used?
both within 1 hour of ingestion
what can be given for tricyclic OD And when?
IV bicarb if..
pH<7.1 , QRS >160 or arrhythmia
what are the side effects of sulphonylureas?
Hypoglycaemic episodes
Increased appetite and weight gain
Syndrome of inappropriate ADH secretion Liver dysfunction (cholestatic)
what are the side effects of glitazones?
Weight gain
Fluid retention
Liver dysfunction
Fractures
What is the kings college criteria for liver transplant?
pH <7.3 ORRR…
Creatinine > 300
PT > 100 s
Hepatic encephalopathy 3 or 4
What is the mechanism of rifampicin , isoniazid and pyrazinamide?
Rifampicin - inhibits DNA dep RNA pol
Isoniazid - reduces mycolic synthesis
Pyrazinamide - inhibits fatty acids
What are the ADRs of rifampicin
Orange secretions
Hepatitis
Flu like symptoms
Liver enzyme inducer
What are the side effects of isoniazid ?
Peripheral neuropathy - give pyroxidine
Hepatitis
Agranulocytosis
What are the side effects of pyrazinamide?
Gout
Arhralgia, myalgia
Hepatitis
What is side effects of ethambutol
Optic neuritis
What drugs should not be taken with statins ?
Macrolides - erythromycin / clarithromycin
These inhibit p450 so statin levels rise to toxic
Which electrolyte can promote digoxin toxicity
HypoK
Because digoxin competes for pottasium binding site on Na/ K ATPase
What are the complications of transtuzumab?
Transtuzumab = herceptin
Cardiomyopathy
Do ECHO before starting
Don’t take with antracyclines e.g doxorubicin as these also cause cardiomyopathy
What are the side effects of dopamine agonists
Fibrosis - pulmonary , retrroperitoneal Sleepiness Hallucination Nausea Postural hypotension
what organism is most commonly seen in animal bites and what is the management?
Pasteurella multicida
Mx:
co-amox
or doxy + metronidazole
what blood test suggests poor compliance to levothyroxine?
high TSH - has been trying to compensate for a while
normal T3/4 - has taken drug recently - short term fix before blood test
what are the ADRs of sulphonylureas?
weight gain
hypoglycaemia
SiADH
bone marrow sup
hepatotoxic
peripheral neuropathy
dont use in preg/ breast feeding
what inheritance is kallmans? what are the features?
X linked recessive
small testis, tall, anosmia
low / normal LH and FSH
what are the causes of euvolaemic hyponatraemia?
siADH
hypothyroid
urinary sodium high >20
which electrolyte is associated with low K?
low Mg
what inheritance does familial hyperlipidaemia have?
auto dominant
what are the complications of acromegaly?
HTN, CRC, diabetes, cardiomyopathy
what are the causes of gynaecomastia?
testicular failure - mumps
klinefelters , kallmans
seminoma - HCG secreting
haemodialysis
hyperthyroid
drugs = spironolactone, goreselin , digoxin, cimetidine, cannabis, finasteride, steroids
what is HbA1c 6% equivalent too?
42
1% = 11 increase
who are fibroids more common in?
afrocaribeans
what blood abnormality is seen with fibroids?
high Hb
fibroids produce EPO
What are the ADRs of SGLT2 inhibitors? what are thes drugs called?
Gliflozins
forniers gangrene
UTI
normoglycaemic ketoacidosis
limb amputation
what is the most common cause of primary hyperaldosteronism?
bilateral adrenal hyperplasia
what is the mechanism of action of thiazolinediones (TZDs) and the ADRs
PPARg receptor (intracellular receptor) - increases insulin sensitivity e.g. pioglitazone
ADRs - fluid retention - shouldnt be used in HF
- weight gain
- increased risk of fractures
- increased risk of bladder Ca with pioglitazone
- liver impairment - monitor LFTs
(fluid retention worse if also taking insulin)
How is SIADH initially managed?
fluid restriction
what is the management for diabetic nephropathy?
duloxetine, gabapentin, amitriptyline
tramadol for rescue therapy
how can you distinguish klinefelters and kallmans?
klinefelters - high LH/ FSH
Kallmans - normal/ low FSH / LH
Which genes are mutated in MODY
Type 3 - HNF1a - most common
Type 2 - glucokinase
Type 5- HNF1b - associated with cyst
Which type of malignancy does hashimotos predispose to ?
MALT lymphoma
What is the most common cause of Cushing’s syndrome
What is the most common cause of Cushing’s syndrome
How is gestational diabetes managed
If bm less than 7 can try diet and metformin but if targets are still not met with this then start insulin
If more than 7 - start insulin straight away
If any effects of diabetes e.g. macrosomia - start insulin
What is the first line for fertility in PCOS
Clomifene
Which antibodies are associated with Graves’ disease
Anti TSH r - stimulating -90%
Anti thyroid peroxidase - 70%
what is temporal arteritis assocaited with?
polymyalgia rheumatica
visual changes - anterior ischaemic optic neuropathy
what are the CK and EMG results in temporal arteritis? how is this condition managed?
normal results
high dose steroids
how is neuropathic pain managed?
what is max dose of amitriptyline
monotherapy
switch if not working
max dose amitriptyline = 75mg
try for 6-8 weeks or 2 weeks at max dose
what is miller fisher and what antibody is associated with this?
variant of guillian barre
Anti GQ1b
ataxia, areflexia and ophthalmoplegia
descending paralysis (reverse than normal)
who does polyarteritis nodosa affect? any other associations?
middle age men
Hep B
(not always ANCA positive)
what is the first line medication for stroke/ TIA?
clopidogrel
when is a carotid endartectomy performed?
when >70% stenosis
which part of lungs does ank spondylosis affect?
apical fibrosis
what is the prognosis of absence seizures?
excellent, 95% gone by adolescence.
which drugs make myasthenia gravis wose?
B blockers lithium gentamicin, tetracyclines, macrolides phenytoin penicilliamine quinidine , procainamide
what are the classical signs of normal pressure hydrocephalus?
gait disturbances - magnetic/ parkinsonism
dementia
urinary incontinence
what is the management of general and focal seizures?
general inc myoclonic- sodium val
focal - carbemazepine
which seizures does carbemazepine make worse?
absence and myoclonic
how is an acute ischaemic stroke treated when within 4.5 hours?
thrombectomy - within 6
thrombolysis - within 4.5
if within 4.5hours can offer both of the above
how does CJD disease present?
rapid onset
dementia
rigidity
myoclonus
what improves prognosis for motor neuron disease?
riluzole - 2 to 3 years improvement
NIV - best outcome overall
which bacteria is most strongly associated with guillian barre?
campylobacter
what are the DVLA rules regarding seizures?
first seizure, unprovoked, normal EEG and imaging –> no driving 6 months and inform DVLA
otherwise 12 months seizure free
how is catheterised patients with positive urine dip treated?
not treated
what is the prophylaxis for meningitis in close contacts?
ciprofloxacin or rifampicin
what is webers syndrome?
stroke of branches of posterior cerebral artery that supplies the midbrain
ipsilateral CNIII
contralateral weakness of upper and lower limbs (internal capsule)
what is wallenberg syndrome? (aka lateral medullary)
posterior inferior cerebral artery
ipsilateral spinothalamic of the face
contralateral spinothalamic of the limbs
ataxia and nystagmus too
how is parkinsons managed depending on motor symtpoms?
motor symptoms affecting daily living - L dopa
not affecting daily living but having motor symptoms - ropinerole (dopamine agonist)
how is spasticity managed in MS?
gabapentin
baclofen
how are bladder issues in MS manaaged?
USS - if there is residual volume then intermitent self catheterisation.
if there is no residual vol then use an anti-cholinergic
How does tuberculoid leprosy differ from lepromatous leprosy?
Tuberculoid:
- hair loss
- assymetric nerve involvement
- limited skin
- high cell mediated immunity
lepromatous:
- symmetrical nerve involvemnt
- extensive skin involvment
- low level cell immediated immunity
what skin and neuro changes are seen in leprosy?
hypopigmentation
sensory loss
what is the incubation period for amoebiasis like?
long period
what is the most common cause of viral meningitis?
enterovirus - coxsackie and echovirus
how does anthrax present cutaneously?
black painless eschar
how is anthrax treat?
ciprofloxacin or doxy
what is the most common complication of measles?
otitis media
pneumonia is most common cause of death
how does measles present?
rash starts behind ears
kolpik spots in mouth
conjunctivitis
what are the diagnostic features of bacterial vaginosis?
high pH (less lactobacilli)
clue cells
white thin fishy discharge
positive whiff test
how is bacterial vaginosis managed? and in pregnancy?
metronidazole
also in preg
what blood test finding is associated with glandular fever?
atypical lymphocytes
how is glandular fever diagnosed?
FBC and monospot test in 2nd week of illness
Monospot = heterophil Ab
how is pneumocytis jiroveci managed?
co-trimoxazole
steroids if hypoxic
IV pentamidine if severe
what is the most common organism of central line infections?
s. epidermidis
what do the following Abx target?
- macrolides and cloramphenicol
- aminoglycosides and tetracyclines?
- macrolides and cloramphenicol - 50S ribosomes
- aminoglycosides and tetracyclines - 30S ribo
what time frame does tetanus vaccine need to be complete by for no further mx ?
if complete within 10 yrs no further doses or immunoglobulins regardless of wound type
what are the side effects of phenytoin?
gingival hyperplasia
lymphodenopathy
peripheral neuropathy
megaloblastic anaemia - secondary to folate deficiency
haemorrhagic disease of new born - bleeding mucus membrane, bleeding umbilicus and GI tract
teratogen
which spinal cord sections are affected in subacute degeneration of the cord?
dorsal columns
lateral corticospinal tracts - limb movement
what is the lateral and anterior corticospinal tracts responsible for?
lateral - limb movement
anterior - trunk movement
what is facioscapulohumeral muscular dystrophy?
auto dominant
face weakness, shoulder weakness,
presents by 20 yrs
what is multiple systems atrophy?
parkinsonism plus
autonomic issues - impotence, postural hypotension
cerebellar signs
how is serotonin syndrome and neuroleptic malignant syndrome differentiated?
Only in serotonin: myoclonus faster onset increased reflexes dilated pupils
in NMS:
- rigidity
- reduced reflexes
what drugs cause gingival hyperplasia?
phenytoin
ciclosporin
calcium channel blockers
Acute myeloid leukaemia
for BPPV which manoevers are used to diagnose and treat?
dix halpike - diagnosis - vertigo and rotational nystagmus
epley - treatment
brandt- doroff exercises - at home exercises
which drug is used for SVT in asthmatics?
adenosine is contraindicated
use verapamil
how is future SVT prevented?
B blocker
radioablation
what heart sounds are heard in pulmonary HTN?
loud S2
which drugs are contraindicated in WPW?
adenosine and verapamil
what happens to the murmur in eisenmenger syndrome?
original murmur may disappear when shunt reverses
what are the features of takaysa arteritis?
asians
females
aorta and causes occlusion
typical Q refers to absent limb pulses
what is syndrome X? how is it managed?
presents like angina
but normal coronary arteries on angio
ST dep on exercise stress
nitrates to manage
what are the poor prognostic factors for HOCM?
septal wall thickness >3cm non sustained VT young age at presentation BP chnages with exercise FHx of sudden death syncope
which drugs are preferred for BP control in afrocaribeans?
ARBs > ACEi
Which drugs during pregnancy are linked to ebstein anomoly?
lithium and benzos
how is severe eclampsia managed?
restrict fluids - risk of pulmonary/ cerebral oedema
IV MgSO4
how is aortic dissection managed?
type A - surgery + IV labetolol
type B - IV labetolol/ conservative
how is COPD managed (chronic)?
1st line - SABA/ SAMA
2nd line - check if asthma symptoms/ Hx of atopy/ eosinophilia/ variation in FEV1
- if yes - LABA + ICS (can later add LAMA if still no control)
- if no - LAMA + LABA
how does lichen planus present?
itchy rash, polygonal rash with white lines
on soles of feet/ palms, flexor surface, genitalia
white lace on oral mucosa
how is lichen planus managed?
potent topical steroids
how does DRESS syndrome present?
multi organ - e.g. high LFTs high eosinophils morbilliform skin rash fever following 2-8 weeks after offensive drug
what is TLCO and KCO?
TLCO - rate of diffusion across alveolar membrane
KCO - as above but corrected for lung volume
what are the causes of increased TLCO?
pulmonary haemorrhage polycythaemia left to right shunt asthma hyperkinetic state exercise
how are bullous pemphigoid and phemigoid vulgaris differentiated?
bullous - no mucosal involvement
pemphigoid - mucosal invovlment
what antibody is found in pemiphoid vulgaris? who is it most common in?
anti desmoglein 3
Jews
which opioids are used in palliative patients with renal impairment?
oxycodone - mild renal failure
alfentanil - severe (or fentanyl / buprenorphine patch)
how are TRALI and TACO differentiated?
TRALI - hypotension, fever, increased leucopenia
TACO - hypertension, more common
which Ab are involved in acute haemolytic reaction after ABO mismatch?
IgM
what are the features of african sleeping sickness? which organism and vector
typanosoma gambiese
tstes fly
chancre, fever, posterior cervical nodes, sleepiness, headaches, mood change
what are the features of american trypanosomiasis/ chagas disease? which organism
typanosoma cruzi
acute - chagoma and periorbital oedema
cardiomyopathy - dilated cardiomegaly
megacolon/ oesophagus - constipation etc
how is american trypanosomiasis treated?
Benznidazole
how is african sleeping sickness treated?
IV pentamidine - early
IV metasoprol - later
what are the causes of aortic stenosis by age?
<65 - bicuspid valve
>65 - calcification
how is mural invasion best assessed with oesophageal/ gastric cancer?
endoscopic USS
what is the function of docetaxel?
microtubule inhibitor
what is the best predictor of COPD severity?
FEV1
most common symptom of P.E
tachypnoea
if an ECG still shows changes 90 mins after thrombolysis, what is the next stage?
if <50% resolution then PCI
where is BNP secreted from ?
left ventricle
what heart sounds are found in complete heart block?
variable S1
what is first line treatment for HF?
B B and ACEi in all patients - shown to improve mortality (only for those with reduced ejection fraction)
only bisoprolol or carvedilol have shown to improve mortality. no change for other BB
how is major bleed + a high INR managed?
5mg IV vit K
prothrombin complex concentrate
what are the features of hyperosmotic hyperglycaemic state?
osmolarity >320
glucose high
dehydration, low Na/low K
hypovolaemia
how do DKA and HHS compare?
HHS higher mortality
DKA - ketones
DKA - more acute
HHS - slow and insidious, worse electrolyte changes, more dehydrated
How is HHS managed?
fluid replacement
dont give insulin unless ketones are high
what are the different types of renal tubular acidosis?
T1 - inability to secrete H+, leads to hypokalaemia. associated with RA/SLE/ Sjogrens
T2 - inability to reab HCO3 at PCT , leads to hypoK
associated with fanconi and wilsons
T3 - rare carbonic anhydrase II deficiency.
T4 - hyperkalaemia, not enough aldosterone
how does a strongyloides infection present?
pruiritic rash on bum and soles of feet
abdo pain, bloating , diarrhoea
(worm penetrates skin)
how does progressive nuclear palsy present?
parkinsonism
vertical gaze impairment
postural instability and falls
cognitive impairment
how does progressive supranuclear palsy respond to levo dopa?
poor response
name the different diabetic drugs and give example.
sulphonylurea - gliclazide DDP4 inhibitors - gliptins SGLT2 inhibitors - gliflozin metformin GLP 1 - exanatide TZDs - pioglitazone
what are the causes of nephrogenic diabetes insipidus?
low K high Ca lithium, demeclocycline sickle cell pyelonephritis/ obstruction
what are the immune test findings in primary biliary cirrhosis? who is it most common in?
anti mitochondrial Ab
high IgM
middle aged women, sjogrens
also RA/ Systemic sclerosis, thyroid disease
how is primary biliary cirrhosis managed?
ursodeoxycholic acid
what is the mode of marfans inheritence and which gene is affected?
fibrillin 1
auto dom
how does altitude sicknes present?
tired, headache, sickness
can lead to pulmonary or cerebral oedema.
how is altitude sickness prevented? and treated?
prevented - acetazolamide (carbonic anhydrase inhibitor)
treated - descent.
cerebral oedema = dexamethasone
which anti depressant is most at risk of giving discontinuation syndrome?
paroxetine
what is peutz jeghers syndrome?
auto dominant
intestinal hamartomas polyps in GIT
frackles on lips, face, palms and soles
risk of intussusception, GI bleeding, cancer
how does wilsons disease present?
liver - hepatitis/ cirrhosis
neuro - basal ganglia - chorea, dementia, parkinsons
kayser fleischer rings
blue nails
what are the blood test findings in wilsons?
reduced serum caeroplasmin
reduced serum copper
increased 24 hour urinary copper
what is the management for wilsons?
penicillamine
which life style choice increases risk of thyroid eye disease?
smoking
which clotting factors are affected by warfarin?
1972 –> 10, 9, 7, 2
what happens in fanconi syndrome?
inadequate absorption in PCT
leads to renal tubular acidosis type 2
which is the most important HLA to match when giving a transplant?
HLA DR
how is QT measured?
start of Q
end of T
list the P450 inducers
phenytoin, carbemazepine
chronic alcohol
smoking
rifampicin
list the P450 inhibitors
cipro, erythromycin
acute alcohol
sodium valproate
isoniazid
how is complete heart block after an MI managed?
inferior MI - conservative management
anterior - temporary pacing
which drugs cause photosensitivity?
thiazides tetracyclines (doxy) amiodarone NSAIDs sulphonylureas
how is prinzmental angina managed?
Calcium channel blockers
what is bicalutamide?
androgen receptor antagonist
used in prostate Ca
which Chromosome is HLA found on?
6
how does Behcets present?
middle east
oral and genital ulcers, painful
how long should antidepressants be trialed before stopping?
6 months
how does plummer vinson syndrome present?
dysphagia, glossitis, iron def anaemia
what are the ADRs of ondansetron?
constipation
long QT
which drug reverses dabigatron?
idarucizumab
what are the poor prognostic features of RA?
RF positive CCP posistive HLA DR4 early erosions on Xray nodules insideous onset poor functionality at the start
which vit D is used in CKD?
alfacalcidol and calcitriol
how is angina managed?
aspirin, statin, GTN B blocker e.g. atenolol \+ CaB - nifedipine increase to max dose long acting nitrates (nicorandil, ivabradine, ranolazine)
how is orbital cellulitis managed (before anything)?why?
IV abx
risk of venous sinus thrombosis and intracranial spread
which type of blood transfusion carries highest risk of bacterial infection?
platelets
what is the chronic management of asthma?
SABA \+ ICS \+ LRTA (montelukast) \+ LABA switch to medium dose ICA switch to high dose/ extra drug
which is the most common renal stone?
calcium oxaloate
which are the radiolucent stones?
xanthine and uric acid
what is the most diagnostic Ix for CLL?
immunophenotyping
what is the most common cause of peritoneal dialysis infection?
s. epididermis
how is peritoneal dialysis infection managed?
vanc + ceftazidine - added to dialysis
how does NAC help in paracetamol OD?
precursor for glutathione
what is the kings college criteria for liver transplant post paracetamol OD?
pH <7.3
PT >100 s
Creat >300
hepatic enceph grade 3 or 4
what is the function of bisphosphonates?
inhibit osteoclasts
what is the mechanism of action of baclofen?
GABA agonist
how are pubic lice managed?
Permethrim or malathion cream
reapply 3-7 days later
what is a common side effect of oral Mg?
diarrhoea
what are the causes of erythema nodosum?
pregnancy strept infection sarcoid IBD Behcet malignancy COCP/ penniclins
what drugs should be avoided in HOCM?
ACEi
nitrates
Ionotropes
which type of hepatitis is very severe in pregnancy?
E
what are the stages of diabetic nephropathy?
- hyperfiltration (high eGFR)
- latent
- incipient nephropathy - microalbuminaemia
- overt nephropathy - increase BP, increase protein, glomerulosclerosis
- End stage
what are the causes of nephrotic vs nephritic?
nephrotic - minimal change, focal segmental glomerulosclerosis, membranous and amyloidosis
nephritic - mesangial glomerulonephritis, rapidly progessive, IgA and alports
what are the symptoms of vit B3 deficiency?
niacin deficinecy
pellegra - dermatitis (rash on neck usually dark), dementia, diarrhoea
what is the most common complication of chagas disease?
dilated cardiomyopathy
how is urge incontinence managed?
bladder training- 6weeks
anticholinergics (oxybutynin, tolderidone)
- avoid in old women - risk of dementia
- instead mirabegron
how is stress incontinence managed?
pelvic floor training - 3 months
duloxetine
mid uretral tape
what does alcohol binging do to urination freq?
increased due to inhibition of ADH
what is cotard syndrome?
psych syndrome where person thinks they are dead
what is dermatitis artefacta?
self inflicted skin lesions
what are the causes of increased ferritin?
increased: CKD, Liver disease, alcohol excess, inflammation, malignancy
with iron overload - haemochromatsis or repeated transfusion
how is hospital acquired pneumonia managed?
Within 5 days of admission: co-amoxiclav or cefuroxime
More than 5 days after admission: tazocin
what is the treatment for actinic keratoses?
5 flurouracil cream - goes red and inflamed so can use steroid cream on top
what is the management and prophylaxis of a migraine? what is the mechnism of action of triptans.
acute: triptan + NSAID or triptan + paracetamol
prophylaxis: topiramate or propranolol
triptans are 5HT2 agonists
what is the action of mycophenolate mofetil
• inhibits inosine monophosphate dehydrogenase, which is needed for purine synthesis
which treatments reduce mortality in HF with a reduced ejection fraction?
ACEi
B blockers
spironolactone
nitrates and hydralazine
(not furosemide)
what are the stages of sarcoidosis on CXR? what other Ix findings are there?
Sarcoidosis CXR 1 = BHL 2 = BHL + infiltrates 3 = infiltrates 4 = fibrosis
high ACE
high Ca
high ESR
non caseating granulomatosis
what are the examples of ADP receptor inhibitors?
- Clopidogrel
- Prasugrel
- Ticagrelor
- Ticlopidine
what is the main side effect of ticagrelor?
dyspnoea due to poor clearance of adenosine
should be used with caution in asthmatics
what is the treatment for methaglobinaemia?
NADH - methaemoglobinaemia reductase deficiency: ascorbic acid
IV methylthioninium chloride (methylene blue) if acquired
which thyroid cancer occurs in older woman, grows aggeessively and can cause pressure symptoms?
Anaplastic
which thyroid is most common in younger females?
papillary - good prognosis
what would give a false negative result in coeliacs?
IgA deficiency
what HbA1c value is diagnostic of diabetes?
6.5% (48mM)
prediabetes (6-6.5)
what factors can affect eGFR?
eating red meat 12 hrs before
exercise
pregnancy
what is akathsia?
severe restlessness
seen in patients taking antipsychotics
which are the poor prognostic factors of infective endocarditis ?
staphylococcus aureus - organism with highest mortality
culture negative
prosthetic valve
low complement levels
what is the management of infective endocarditis?
Initial therapy if… - Native valve: Amoxicillin - Penicillin allergy/ MRSA Vancomycin + low dose gentamicin - Prosthetic valve Vancomycin + low dose gent + rifampicin Staphylococcal infection, if… - Native valve § Flucloxacillin - Pen allergy / MRSA: § Vanco + rifampicin - Prosthetic valve: § Fluclox + rifampicin + low dose gent Streptococci: - Native valve § Benzylpenicillin - MRSA/ pen allergy: § Vancomycin + low dose gent
what are the indications for surgery in infective endocarditis?
severe valvular incompetence
aortic abscess (often indicated by a lengthening PR interval)
infections resistant to antibiotics/fungal infections
cardiac failure refractory to standard medical treatment
recurrent emboli after antibiotic therapy
what is the treatment for pityriasis versicolor
ketonazole shampoo
what is pityriasis versicolor?
fungal - Malassezia furfur
affects trunks/arms following sun tan
what drug reduces PSA? (and can cause a false negative result)?
Finasteride
what factors increase PSA?
vigorous exercise ejaculation prostatitis/ UTI instrumentation e.g. catheterisation urinary retension BPH
what investigations are used in acromegaly?
IGF1 levels
if raised - OGTT + serial GH levels
MRI pituitary
what type of hypersensitivity does scabies cause?
type 4
what are the features of horners syndrome?
miosis
anhydrosis
ptosis
enopthalmos
heterochromia (difference in eye colour) - seen in congential horners
what is relapsing polychondritis?
inflammatory disease of cartilage.
signs and symptoms - auricular chondritis, nasal chondtritis, respiratory issues (wheeze, horseness etc), joint arthralgia.
manage with steroids/ DMARDs
what is the discharge criteria for anaphylaxis?
Fast tract if..
- Good response to one adrenaline dose
- Complete resolution of symptoms
- Has been given autoinjector and trained how to use it
Minimum 6 hours after symptoms resolution
○ 2 doses of IM adrenaline
○ Previous biphasic reaction
Minimum 12 hours after symptoms resolved
○ Severe reaction >2 injections needed
○ Has severe asthma
○ Late at night presentation
○ Difficult access to ED
○ Possibility of ongoing reaction - e.g. slow release allergen medication
what are the two types of polycystic kidney disease and how do they differ?
PKD1 - earlier renal failure, more common. PKD1 on chrom 16
PKD2 on chrom 4
what is the management of polycystic kidney disease?
ADH receptor ANTAGONIST
- Tolvaptan
slows progression of cyst
what is the diagnosis for li fraumeni syndrome? what is the genetics behind this syndrome?
sarcoma under age or 45yrs
OR
relative with sarcoma <45yrs AND 1st degree with any cancer <45yrs
li fraumeni = auto dom and p53 mutation
what is the main indication for cryoprecipitate use?
low fibrinogen
what part of lung does amiodarone affect?
lower zone fibrosis
what causes lung fibrosis in upper zones?
CHARTS C - Coal worker's pneumoconiosis H - Histiocytosis/ hypersensitivity pneumonitis A - Ankylosing spondylitis R - Radiation T - Tuberculosis S - Silicosis/sarcoidosis
what causes lung fibrosis in lower zones?
idiopathic pulmonary fibrosis
most connective tissue disorders (except ankylosing spondylitis)
drug-induced: amiodarone, bleomycin, methotrexate
asbestosis
what triad is seen in haemolytic uraemic syndrome?
AKI
micro-angiopathic haemolytic anaemia
thrombocytopenia
what is the cause of haemolytic uraemic syndrome?
Shiga toxin producing Ecoli
pneumococcal
HIV
drugs
cancer
who is sarcoidosis more common in?
Africans
what are the poor prognostic features of sarcoidosis?
insidious onset >6 m
absence of erythema nodosum
extrapulmonary manifestations - lupus/ splenomegaly
CXR III or IV
black people
how is retinitis pigmentosa characterised?
Retinitis pigmentosa - night blindness + tunnel vision
what symptoms are common in posterior vitreous detachment?
flashes and floaters
what is conversion disorder?
Conversion disorder - typically involves loss of motor or sensory function. May be caused by stress
what antibodies are seen in bullous pemphigoid
antibodies against hemidesmosomal proteins BP180 and BP230.
how does retinal detachment present?
painless visual loss
sudden
dense dark shadow from peripheral to centre
how does optic neuritis present?
loss of vision - often transient
painful eye movmeents
what are the features of asperigilloma?
rounded opacification with a cresent sign air cavity
more common in people with TB
what is the most common cause of hyperparathyroidism?
parathyroid adenoma - 80%
hyperplasia
mutliple adenoma
carcinoma
PTH doesnt have to be high in parathyroid adenoma but can be inappropriately normal (i.e. should be low if Ca is high)
what happens to INR target if patient has has a thrombosis on warfarin ?
increase INR target e.g. 2-3 to 3-4 and make warfarin life long
if pain not controlled in palliative patients, how much should morphine be increased by?
30-50%
How are Dermatophyte nail infections treated? e.g. Trichophyton rubrum
- use oral terbinafine 12 weeks
what prophylaxis is given to meningococcal contacts?
ciprofloxacin within 7 days
only for meningococcal disease. no need for pneumococcal
what are the risk factors for statin induced myopathy?
advanced age
female sex
low body mass index
presence of multisystem disease such as diabetes mellitus.
Myopathy is more common in lipophilic statins (simvastatin, atorvastatin) than relatively hydrophilic statins (rosuvastatin, pravastatin, fluvastatin)
what is seen on JVP in tricuspid regurg?
prominant V waves
when are the following seen?... cannon A waves absent A waves prominent X descent absent X descent
irregular Cannon A waves = complete heart block
Absent A waves = atrial fibrillation
Prominent x descent is = acute cardiac tamponade and constrictive pericarditis
Absent x descent = atrial fibrillation
which drug are patients with MODY nromally given?
dont usualy require insulin
normally given sulphonylureas
which drugs enhance/ reduce the effects of adenosine?
Adenosine
dipyridamole enhances effect
aminophylline reduces effect
what drugs are used in alcohol withdrawel?
chlordiazepoxide or diazepam.
Lorazepam may be preferable in patients with hepatic failure.
what are the features of severe aortic stenosis?
narrow pulse pressure
slow rising pulse
delayed ESM
soft/absent S2
S4
thrill
duration of murmur
left ventricular hypertrophy or failure
what are the topical steroids strengths order?
Topical steroids
mild - hydrocortisone
moderate: Clobetasone butyrate 0.05% (Eumovate)
potent: Betamethasone valerate 0.1% (betnovate)
very potent: Clobetasol propionate 0.05% (Dermovate)
What are the different medications that can be used in smoking cessation and their mechnaism?
nicotine replacemnt
varenicline - nicotine partial agonist
Bupropion - NA and dopamine reuptake inhibitor and nicotinic antagonist
what is sick euthyroid?
during illness T3/4 go low, TSH is normal or low
reversible
how is IgA nephropathy and post streptococcal syndrome differentiated ?
post-streptococcal glomerulonephritis
- associated with low complement levels
- occurs 2 weeks after infection
- mainly proteinuria (although haematuria can occur)
IgA nephropathy
- haematuria
- 2 days post infection
which cancers are seen in MEN type 1, 2a and 2b?
1a = 3 Ps
- parathyroid (95%)
- pituitary
- pancreas
IIa = 2ps
- parathyroid (60%)
- pheochromocytoma
- mainly medullary thyroid (70%)
IIb = 1p
- pheochromocytoma
- mainly medullary thyroid cancer
- marfanoid
- neuromas
which genes are mutated in MEN 1/2a/b?
men type 1 = MEN 1
Men 2a - RET oncogene
Men 2b - RET oncogene
what are the features of polycystic kidney disease?
HTN, haematuria, UTI , renal stones, abdo pain, CKD
extra renal:
liver cysts
berry aneurysm
cardiac - mitral valve prolapse, aortic root dilation, aoritc dissection, mitral/tricuspid incompetence
how is non-falciparium malaria managed?
artemisinin-based combination therapy (ACT) or chloroquine
in areas which are known to be chloroquine-resistant an ACT should be used
ACTs should be avoided in pregnant women
patients with ovale or vivax malaria should be given primaquine following acute treatment with chloroquine to destroy liver hypnozoites and prevent relapse
how does non-falciparium malaria present?
headache
hepatosplenomegaly
cyclical fever - vivax and ovale every 48hrs, malarie every 72 hours.
malarie also associated with nephrotic syndrome
what is the commonest form of malaria
falciparium - and most severe
what are the features of severe falciparium infection?
Feature of severe malaria • schizonts on a blood film • parasitaemia > 2% • hypoglycaemia • acidosis • temperature > 39 °C • severe anaemia • complications
how is falciparium managed?
Artemisinin-based combination therapies (ACTs) as first-line therapy
examples include artemether plus lumefantrine
if severe - IV artusunate
if parasite count 10% or more - exchange transfusion
how is minimal change glomerulonephritis managed?
oral prednisolone
where are iron and calcium absorbed?
duodenum
what are the features of ataxia telangiectasia? which mode of inheritance
cerebellar ataxia
telangiectasia (spider angiomas)
IgA deficiency resulting in recurrent chest infections
10% risk of developing malignancy, lymphoma or leukaemia, but also non-lymphoid tumours
auto recessive - mutation in ATM repair gene
what are the features of dengue?
Fever, headache (often retro-orbital), myalgia, bone pain and arthralgia (‘break-bone fever’)
pleuritic pain
facial flushing (dengue)
maculopapular rash
haemorrhagic manifestations e.g. positive tourniquet test, petechiae, purpura/ecchymosis, epistaxis
which cell type is associated with hodgkins lymphoma and which marker does it have?
reed sternberg
CD15 and CD30
what is the first line treatment for lymes disease?
First line treatment for early Lyme disease is a 14-21 day course of oral doxycycline
what are the symptoms of lymes disease?
erythema migrans - bulls eye rash at site of tick bite.
develops 1-4 weeks post bite. usually painless
fever, headache, arhralgia
later - heart block, myocarditis, facial nerve palsy, meningitis
what is the mechanism of action of donepezil? memantine?
anti-cholinergic - donepazil
memantine - NMDA receptor antagonist
what is the contraindication of taking donepezil ? what are the ADRs of donepezil?
contraindicated in patients with bradycardia
ADR - insomnia
what feature suggests that haematuria is glomerular in origin?
dysmorphic RBC on microscopy
when are fatty urinary casts seen?
nephrotic syndrome
how is oral morphine converted to subcut?
divide by 2
how does TTP present?
pentand: fever, neuro signs, thrombocytopenia, haemolytic anaemia and renal failure
what protein is involved in TTP?
reduced von Willebrand factor-cleaving proteases (ADAMTS13).
thrombi form from platelets
which type of macular degeneration carries worst prognosis?
wet macular degeneration
what blood electrolyte finding is found in cushings syndrome?
hypokalaemic metabolic alkalosis
what is the management of gout?
NSAIDs or colchicine 1st line
NSAIDs avoided in elderly
urate lowering agents can be offered after 1st attack e.g. allopurinol - start at 100mg and titrate to aim for urate <300
what is the most common side effect of colchicine?
diarrhoea
In SLE, which Ab is associated with congenital heart block?
SLE - antibodies associated with congenital heart block = anti-Ro
which Ab is associated with drug induced lupus?
anti-histone
what are the symptoms of discontinuation syndrome for antidepressants?
icreased mood change restlessness difficulty sleeping unsteadiness sweating gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting paraesthesia
what is Uhthoff ’s phenomenon?
Uhthoff ’s phenomenon where neurological symptoms are exacerbated by increases in body temperature is typically associated with multiple sclerosis
what is the most common presenting symptom of MS?
tiredness
which drugs precipitate G6PD deficiency?
primaquine
ciprofloxacin
sulphate containing drugs - sulphonamides etc
e.g. sulphonylureas - gliclazide, glimepiride
which viral meningitis has a low CSF glucose?
MUMPS
which antibody is dermatitis herpetiformis associated with?
HLA DR3
what are the features of sleep paralysis?
Paralysis - this occurs after waking up or shortly before falling asleep
hallucinations - images or speaking that appear during the paralysis
what antibody is seen in goodpastures?
anti- glomerular basement membrane
IgG
which electrolyte disturbance can lead to cataracts?
hypocalcaemia
what is the most common cause of congenital adrenal hyperplasia?
21 hydroxylase deficiency
what pattern of inheritance is liddles? what are the features?
auto dominant - disorder of sodium channels in DCT
hypertension
hypokalaemic alkalosis
which Abx causes Clostridium difficile?
Clindamycin
what receptor does tamsulosin act on?
Alpha 1a
what is charles bonnet syndrome?
hallucinations - visual or auditory
occur in normal consciousness/ cognition
what is the equation for power of a study?
1 - type 2 error probability
when in varienicline contraindicated? what is the mechnism of action?
self harm/ depression
pregnancy
breast feeding
nicotinic receptor partial agonist
how does mercury poisoning present?
paraeshtesia visual changes sensorineural hearing loss irritable renal tubular acidosis
what is fabry disease?
X-linked recessive
deficiency of alpha-galactosidase A
Features burning pain/paraesthesia in childhood angiokeratomas lens opacities proteinuria early cardiovascular disease
which other drug should be avoided in aspirin allergy?
sulphasaalazine
which recreational drug can lead to ischaemic colitis? How does this present?
cocaine (vasoconstrictor and can reduce blood flow to the gut)
abdo pain, bloody diarhoea
tachycardic , mydriasis (dilated pupil) - due to cocaine
how is cocaine toxicity managed?
- benzos
add
- GTN for chest pain
- sodium nitroprusside for HTN
what are the features of hereitary haemorrhagic telangiectasia?
nose bleeds
telangiectasia around nose and lips
GI/pulmonary telangiectasia - can lead to bleeds
FHx
(autosomal dominant)
what are the drug causes of retinopathy?
ethambutol, vigabatrin and amiodarone and hydroxychloroquine
what is DC cardiovarsion synchronised with?
R wave
what are the features of mastocytosis? How is this investigated?
- urticaria pigmentosa - produces a wheal on rubbing (Darier’s sign)
- flushing
- abdominal pain
- monocytosis on the blood film
raised urinary histamine
raised serum tryptase
what is the first line Ix for lymes disease?
(ELISA) antibodies to Borrelia burgdorferi
repeat after 4-6 weeks if negative but high suspicion of lymes
immunoblot test for lymes can be done later to confirm
if erythema migrans is present - no need
what is calciphylaxis? what drug exacerbates this?
linked to dialysis and high Ca/PO4/PTH
necrosis of skin secondary to arterial occlusion by calcium deposits.
painful skin lesions that are necrotic
exacerbated by warfarin
what is sweets syndrome?
Sweet’s syndrome is also known as acute febrile neutrophilic dermatosis has a strong association with acute myeloid leukaemia
Small red bumps on The arms, neck, head and trunk
Sudden onset of fever
Bumps grow rapidly
Painful rashes
which skin conditions are associated with diabetes?
Necrobiosis lipoidica - shiny, painless areas of yellow/red/brown skin typically on the shin. often associated with surrounding telangiectasia
Infection- candidiasis, staphylococcal Neuropathic ulcers Vitiligo Lipoatrophy Granuloma annulare= papular lesions that are often slightly hyperpigmented and depressed centrally
how does bullous pemphigoid present?
itchy rash
then develop into tense blisters
no mucosal invovlement
usually older patients
when are platelet transfusions contraindicated?
TTP
heparin induced thromocytopenia
ITP
chronic bone marrow failure
when are platelet transfusions adviced?
levels <10
levels <30 with bleeding / planned proceedure
levels <100 if severe bleeding/ intracranial bleed
how are baby blues, post natal depression and puerpural psychosis differentiated?
baby blues 3-7days post birth - reassure
post natal depression - peaks at 3 months - reassure, CBT
peurpural psychosis- 2-3 weeks, mood swings, hallucinations/ dellusions - admit to hospital , mum and baby unit
what are the causes of pulmonary eosinophilia?
- Churg-Strauss syndrome
- allergic bronchopulmonary aspergillosis (ABPA)
- Loffler’s syndrome - parasitic infection and accumulation of eosinophils in lungs
- eosinophilic pneumonia
- hypereosinophilic syndrome
- tropical pulmonary eosinophilia
- drugs: nitrofurantoin, sulphonamides
- less common: Wegener’s granulomatosis
NOT EXTRINSIC ALLERGIC ALVEOLITS
what is the most common type of glomerulonephritis in adults and how does it present?
membranous
nephrotic usually
which Ab is the idiopathic cause of membranous glomerulonephritis associated with?
anit-phospholipase A2
how is membranous glomerulonephriits managed?
ACEi
steroids
+ cyclophosphamide if severe
what is the mechanism of aciclovir?
inhibits DNA polymerase
activated by virally infected cells
what are the predisposing factors for pagets disease?
age, male, northern lattitude, FHx
what are the Ix findings in pagets?
high ALP
normal Ca/PO4
urinary hydroxyproline
Xray - osteolysis early , later thickening and osteoporosis. (pagets is due to excess osteoclasts followed by osteoblasts)
what are the complications of pagets?
fractures
deafness
bone sarcoma
high output cardiac failure
how does subacute thyroiditis present?
tender goitre
hyperthyroid clinical and bloods
reduced uptake via scan
high ESR
then euthyroid
then hypothryroid
all post infection
what is ARVC (Arrhythmogenic right ventricular cardiomyopathy)? how does it present?
auto dominant - desmosome protien
right ventricle replaced by fibrofatty tissue
second most common cause of sudden cardiac death in young (after HOCM)
palpitations, syncope, sudden death
what is Naxos disease?
autosomal recessive variant of ARCV .
triad of ARCV, palmoplantar ketatosis and woolly hair
which zones does extrinsic allergic alvolitis affect? (e..g bird fanciers lung/ farmers lung)
upper / mid zone fibrosis
what is the most common subtype of renal cell cancer?
clear cell
what is the management for torsades de pointes?
IV MGSO4
drugs to avoid in renal failure?
antibiotics: tetracycline, nitrofurantoin
NSAIDs
lithium
metformin
Drugs likely to accumulate in chronic kidney disease - need dose adjustment most antibiotics digoxin, atenolol methotrexate sulphonylureas furosemide opioids
How do we test for Non fatty alcoholic liver disease?
ELF - enhanced liver fibrosis blood test - looks at a collection of markers to assess risk
how is leprosy managed?
rifampicin, dapsone and clofazimine 12 months - for 6 or more lesions - multibacilary leprosy
For paucibacillary leprosy (5 or less lesions) you should give rifampicin and dapsone for 6 months.
when does neuroleptic malignant syndrome happen?
usually from starting anti-psychotic
suddenly stopping dopaminergic drugs
how is neuroleptic malignant syndrome managed?
stop antipsychotic
IV fluids
sometimes dantrolene
dopaminergic drugs- bromocriptine
which HPV types are at risk of developing cervical cancer?
16,18,33
other risks:
smoking, human immunodeficiency virus, early first intercourse, many sexual partners, high parity, lower socioeconomic status and the use of the combined oral contraceptive pill.
what is post concussion syndrome?
Post-concussion syndrome is seen after even minor head trauma
Typical features include headache fatigue anxiety/depression dizziness
what is bumetanide?
loop diuretic
what are the ECG changes in constrictive cardiomyopathy?
low voltage QRS
how does wernickes and korsakoff present?
wernickes - opthalmoplegia (lateral rectus palsy and/or nystagmus), confusion and ataxia
korsakoff - anterograde amnesia and confabulation as well as above
what is the management of acute angle glaucoma?
Alongside eye drops, IV acetazolamide is used in the initial emergency medical management of acute angle-closure glaucoma
how is metastatic bone pain managed?
opioids, dexamethasone, radiation
which proteins are affected in HOCM?
B myosin heavy chain or myosin binding protein C
what are the features of HOCM?
Features: Exertional syncope Angina Sudden death Jerky pulse Ejection systolic murmur - increases with valsalva
when should pneumococcal vaccine be given for splenectomys? which other vaccines are needed and which Abx prophylaxis?
2 weeks before op
- Hib, Men A &C - Annual influenza - Pneumococcal every 5 years
life long penicillin V
what is the most common type of cyanotic CHD and when does it present?
tetralogy of fallot
presents around 1-2 months
which organism is most common cause of osteomyeliits?
S.aureus
in sickle cell patients - salmonella species
what is potts disease?
spinal TB - history of TB, back pain, fevers, weight loss
more common in thoracic and upper lumbar vertebrae
how is epidiymo-orchitis managed?
• if the organism is unknown BASHH recommend:
ceftriaxone 500mg intramuscularly single dose, plus doxycycline 100mg by mouth twice daily for 10-14 days
how does toxoplasmosis present?
lymphadenopathy , fever and malaise in immunocompetent host - self limiting
in immunocompromised - chorioretinitis, cerebral lesion
how is cerebral toxoplasmosis managed?
pyrimethamine plus sulphadiazine for at least 6 weeks
how does congential toxoplasmosis present?
• neurological damage ○ cerebral calcification ○ hydrocephalus ○ chorioretinitis • ophthalmic damage ○ retinopathy ○ cataracts
how does optic neuritis present?
unilateral decrease in visual acuity over hours or days
poor discrimination of colours, ‘red desaturation’
pain worse on eye movement
relative afferent pupillary defect
central scotoma
associated with MS, diabetes and sphyllis
how is optic neuritis managed?
high dose steroids
what is the first line Ix for stable angina?
CT coronary angiography
what are the ADRs of lithium?
nausea/vomiting, diarrhoea
fine tremor
nephrotoxicity: polyuria, secondary to nephrogenic diabetes insipidus
thyroid enlargement, may lead to hypothyroidism
ECG: T wave flattening/inversion weight gain idiopathic intracranial hypertension leucocytosis hyperparathyroidism and resultant hypercalcaemia
what is the management of PTSD?
watchful waiting - for mild symptoms lasting less than 4 weeks
trauma-focused cognitive behavioural therapy (CBT) or eye movement desensitisation and reprocessing (EMDR) therapy may be used in more severe cases
venlafaxine or a selective serotonin reuptake inhibitor (SSRI), such as sertraline should be tried.
severe - risperidone
what are the features of whipples disease?
HLA B27 , men
caused by infection
malabsorption, diarrhoea, large joint arthralgia hypopigmentation neurology opthalmoplegia
what are the Ix findings in whipples and what is the management?
jejunal biospy –> macrophages containing periodic acid schiff (PAS) granules
Mx:
- Co-trimoxazole - 1 year
which antihistamines are non sedating/sedating?
sedating - chlorampheniramine
non - certirizine and loratidine
certirizine is more sedating than loratidine
How does pompholyx eczema present?
type of eczema which causes tiny blisters to arise across the fingers, palms of the hands and in some cases the soles of the feet.
It commonly affects adults under 40 years old.
factors such as stress, sensitivity to metal compounds, sweating can aggravate it.
what are the risks of chicken pox in pregnnacy?
fetal vericella syndrome
mother - pneumonitis
neonatal varicella - if mum gets chicken pox 5days before birth- 2 days after
when is risk of fetal varicella syndrome highest and what are the symptoms?
- Highest risk when exposure is before 20 weeks
Skin scarring, micropthalmia, limb hypoplasia, microcephaly and learning disability
how is maternal chicken pox exposure managed?
check ab
<20 weeks - give VZIG asap
>20 weeks - give VZIG 7-14 days after
what are the different types of amyloidosis?
AL - most common. associated with MGUS/ myeloma.
AA - associated with inflammation- TB/ RA
B2 microglobulin - associated with dialysis
how is amyloidosis diagnosis?
congo red staining - apple green birefringence
what is the treatment for facial hirsuitism?
topical eflornithine
what is the management of spontaneous bacterial peritonitis?
IV cefotaxime
what is the ECG changes in pericarditis?
PR depression - most specific
ST elevation saddle shaped, wide spread
what are the aDRs of clozapine?
agranulocytosis
neutropaenia
reduced seizure threshold -
constipation
myocarditis: a baseline ECG should be taken before starting treatment
hypersalivation
what are the main ADRs of ati-typical antipsychtocis?
increased stroke risk
VTE risk
weight gain
high prolactin
clozapine - agranulocytosis
olanzapine - higher risk of dyslipidaemia and obesity
what colour is gram negative?
pink
which Ab is seen in Wegners (granulomatosis with polyangiitis)?
cANCA
how is mycoplasma pneumonia diagnosed?
serology
what are the causes of papilloedema?
space occuping lesion malignant hypertension idiopathic intracranial HTN hydrocephalus hypercapnia
rare - vit A toxicity, hypo PTH/ hypoCa
What are the ADRs of SSRIs?
GI symptoms
GI bleed - take with PPI if also on NSAIDs. avoid if on warfarin
hyponatraemia
citalopram - increase QT
which SSRI has greatest risk in pregnancy?
risk of pulmonary HTN if used in T3.
paroexetine has most risk of congenital malformations
what type of bacteria in klebsiella? Who is it most common in? and what distinguishing feature is present in patients?
gram neg rod
common in alcoholic/diabetic/ aspiriation
red current jelly sputum. Affects upper lobes
what type of pneumothorax is seen in menstruating women?
catamenial pneumothorax
what are the side effects of phosphodiesterase inhibitors?
visual disturbances - blue discolouration
non-arteritic anterior ischaemic neuropathy
nasal congestion flushing gastrointestinal side-effects headache priapism
what are the features of leptospirosis?
fever, flu like , subconjunctival haemorhage/
AKI
hepatitis / hepatomegaly
aseptic meningitis
Bilateral conjunctivitis, bilateral calf pains and high fevers
how is leptospirosis managed?
high dose benzylpenicillin doxy
how does japenese encephalitis present?
The majority of infection is asymptomatic.
Clinical features are headache, fever, seizures and confusion.
Parkinsonian features indicate basal ganglia involvement.
It can also present with acute flaccid paralysis.
which medication for paliative patients can treat bowel colic?
respiratory secretions & bowel colic may be treated by hyoscine hydrobromide, hyoscine butylbromide, or glycopyrronium bromide.
can be put in syringe driver
which drug is incompatiable with many other drugs in a syringe driver?
cyclizine
what is the genetics behind osteogenesis imperfecta?
auto dom
type 1 collagen
what are the features of osteogenesis imperfecta?
blue sclera
fractures
deafness - otosclerosis
dental imperfections
what are the different occular problems associated with RA?
keratoconjunctivitis sicca - most common
episcleritis - erythema, no pain
scleritis - erythema and pain
corneal ulcers
keratitis
what is pathogenesis of PKU?
auto recessive
phenylalanine hydroxyalase mutation
(normally converts phenylalanine to tyrosine)
what are the features of PKU?
developmental delay fair hair and blue eyes seizures - infantile spasms musty odour to urine and sweat eczema
how is dermatitis herpetiformis. manaaged?
dapsone
what is most common cause of pneumonia in COPD?
Haemophilus influenza
what causes papilloedema of one optic disc and atrophy of the other?
frontal lobe lesion - ipsilateral atrophy of optic disc and contralateral papilloedema = Foster-Kennedy syndrome
usually caused by meningioma
what is the normal QTc in men and women?
men <450
women <470
what are the features of chinchonism?
quinine toxicity
- long QT/ QRS –> VT VF
- pulmonary oedema
- tinnitus
- blurring of vision
- dry skin, abdo pain
- hypglycaemia
- metabolic acidosis
- hypotension
what is the functions of terbinifene, azoles, nystatin?
azoles - Inhibits 14α-demethylase which produces ergosterol
terbinifene - Inhibits squalene epoxidase
nystatin - Binds with ergosterol forming a transmembrane channel that leads to monovalent ion leakage
what is the secondary prevention after MI?
dual antiplatelet:
- ticagrelor and aspirin (stop ticagrelor after 12 months)
- if PCI then prasugrel or ticagrelor + aspirin.
ACEi, B blocker, statin.
if HG - left ventricular dysfunction then add in aldosterone antagonist (epleronone)
What are the features of frontotemporal lobar dementia ?
onset <65
insidious
preserved memory and visuospatial skills
personality change and social conduct problems
often family Hx.
what is picks disease?
most common type of frontotemporal dementia
characterised by imparied social impairment, personality change, disinhibition, increased appetite
Atrophy of frontal and temporal lobes
what is the condition called where there is compression of the lateral cutaneous nerve of the thigh?
meralgia paraesthesia
list different haemorrgahic fever causes
dengue, yellow fever
Lassa fever
Ebola virus, Marburg virus
Hantaviruses, Crimean-Congo haemorrhagic fever, Rift Valley fever
what organism carries lassa fever?
rats
in africa
(also spreafd person to person)
what organism carries marburg virus?
in caves
bats and primates
which animal carries leishmaniasis?
sandflies
beta carotine is an anti-oxidant. who shouldnt take this and why?
smokers - increases risk of lung cancer
what is the best blood marker of severity of acute pancreatitis?
CRP now recomended
correlates with necrosis
what are the ECHO findings of HOCM?
mitral regurgitation (MR)
systolic anterior motion (SAM) of the anterior mitral valve leaflet
asymmetric hypertrophy (ASH)
which diabetic meds are linked to severe pancreatitis and renal impairment?
Exanatide
how is lewy body dementia and parkinsons diagnosed?
SPECT scan
which blood test is important for restless leg syndrome?
serum ferritin
how does an iliopsoas abscess present?
fever and pain on hip extension
which organism is most common in iliopsoas abscesses?
S.aureus
which is the most common type of glomerulonephritis in wegners/ granulomatosis with polyangiitis? how does it present? what is seen on biopsy?
rapidly progressive glomerulonephritis, with its severe and rapid loss of kidney function, haematuria and proteinuria. A renal biopsy demonstrates glomerular crescents.
what are the ADRs of bisphosphonates?
- oesophageal reactions: oesophagitis, oesophageal ulcers (especially alendronate)
- osteonecrosis of the jaw
- increased risk of atypical stress fractures of the proximal femoral shaft in patients taking alendronate
- acute phase response: fever, myalgia and arthralgia may occur following administration
- hypocalcaemia: due to reduced calcium efflux from bone. Usually clinically unimportant
which antibody is found in mixed connective tissue disease?
anti-RNP
how can the cause of horners determine the location of compression (central, pre ganglionic, post ganglionic)
Anhidrosis of the face, arm and trunk = central lesion = stroke, syrignomyelia, MS, tumour, encephalitis
Anhidrosis of the face = preganglionic lesion - pancoast tumour, thyroidectomy, trauma, cervical rib
No anhidrosis = post ganglionic - Carotid artery dissection, Carotid aneurysm, Cavernous sinus thrombosis, Cluster headache
what is the first line for guillian barre?
IV IG
what are the contraindications to breast feeding?
galactosaemia
certain viral infections
The following drugs should be avoided: antibiotics: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides lithium, benzodiazepines aspirin carbimazole methotrexate sulfonylureas cytotoxic drugs amiodarone
how does otosclerosis present?
Onset is usually at 20-40 years - features include: conductive deafness tinnitus normal tympanic membrane* positive family history
which drugs cause steven johnson syndrome?
penicillin sulphonamides - any sulphur containing stuff lamotrigine, carbamazepine, phenytoin allopurinol NSAIDs oral contraceptive pill
what is the pathogenesis behind porphyria cutanea tarda?
uroporphyrinogen decarboxylase defect - inherited
OR acquired from hepatocyte damage
defect in haem production
what are the symptoms of porphyria cutanea tarda?
photosensitive blistering rash
hypertrichosis (hair growth)
hyperpigmentation
how long is serum tryptase elevated after anaphylaxis?
12 hours
which drugs lead to glucose intolerance?
Steroids tacrolimus / ciclosporin nicotinic acid thiazides IFNa antipsychotics (B blockers)
what are the complications of plasma exchange:
- hypocalcaemia
- metabolic alkalosis
- removal of systemic medications
- coagulation factor depletion
- immunoglobulin depletion
what are the features of goodpastures? what is found on biopsy?
pulmonary haemorrhage
rapidly progressive glomerulonephritis- this typically results in a rapid onset acute kidney injury
○ nephritis → proteinuria + haematuria
IgG deposits on BM
what murmur is found in an ASD?
ejection systolic , louder on inspiration
what is the management of organophosphate poisoning?
atropine
what are the symptoms of organophosphate poisoning?
headache, disorientation, weakness, vomiting, and muscarinic effects such as miosis, bradycardia and increased urination, lacrimation
what Abx is used in tetanus?
metronidazole
what medication can be used in acute delirium?
haloperdol (not benzos - can worsen)
what are the associations to WPW?
Associations with WPW:
- Thyrotoxicosis
- Mitral valve prolapse
- Ebstein anomaly
- HOCM
- Secundum ASD
what are the features of von hippau lindau?
cerebellar haemangiomas: these can cause subarachnoid haemorrhages
retinal haemangiomas: vitreous haemorrhage
renal cysts (premalignant)
phaeochromocytoma
extra-renal cysts
clear-cell renal cell carcinoma
how much should non-HDL be reduced by after starting statins?
> 40%
what are the symptoms of visceral leishmaniasis?
fever, sweats, rigors massive splenomegaly. hepatomegaly poor appetite*, weight loss grey skin - 'kala-azar' means black sickness pancytopaenia secondary to hypersplenism
What are the ADRs of azothioprine?
bone marrow depression
consider a full blood count if infection/bleeding occurs
nausea/vomiting
pancreatitis
increased risk of non-melanoma skin cancer
can azothioprine be used in pregnancy?
yes, as well as mesalazine and sulfasalazine
what are the features of alports syndrome? what is the genetic defect?
- Microscopic haematuria
- Bilateral sensorineural hearing loss
- Renal failure
- Lenticonus - protrusion of lens
- Retinitis pigmentosa
Renal biopsy - splitting of lamina densa seen on electron microscope
X linked dominant - collagen IV
what are the ADRs of ciclosporin?
nephrotoxicity
hepatotoxicity
everything increased: fluid retention hypertension hyperkalaemia hypertrichosis gingival hyperplasia tremor impaired glucose tolerance hyperlipidaemia increased susceptibility to severe infection
which lens dislocation is seen in marfans/ homocysteinuria?
marfans - upward
homocysteinuria - downward
which antibodies are present in dermatomyositis?
the majority of patients (around 80%) are ANA positive
around 30% of patients have antibodies to aminoacyl-tRNA synthetases (anti-synthetase antibodies), including: anti jo, Anti SRP, anti-Mi-2 antibodies
how does acne roseca present and how is it treated?
typically affects nose, cheeks and forehead flushing is often first symptom telangiectasia are common rhinophyma ocular involvement: blepharitis sunlight may exacerbate symptoms/
Management
topical metronidazole may be used for mild symptoms more severe disease is treated with systemic antibiotics e.g. Oxytetracycline
what are the side effects of EPO?
HTN bone aches flu like symptoms red cell aplasia skin rash/urticaria
iron deficiency secondary to erythropoeisis
what is seen on renal biopsy in alports?
ongitudinal splitting of the lamina densa of the glomerular basement membrane, resulting in a ‘basket-weave’ appearance
how often is lithium checked? what else should be checked?
weekly until stable and then every 3 months
thyroid and renal function every 6 months
what is blocked in cyanide poisoning and what are the features?
cytochrome c oxidase
brick red skin
bitter smell
hypoxia. hypotension, headache
how is relative risk calculated?
How is relative risk reduction calculated?
% of new drug effect/ % of placebo
RRR = % of new drug - % placebo / % placebo
what blood result is found in chronic Hep B infection?
The negative IgM anti-HBc points to a chronic rather than acute infection.
Positive anti-HBc IgG, negative anti-HBc IgM
postive HBs antigen
anti HBs = immunity. This is negative in chronic disease
which scoring system is used for liver cirrhosis and what paramets does it include?
Child pugh - for severity.
billiruubin, albumin, PT, encephalopathy, ascites
Model for end stage liver disease (MELD) scoring = predicts survival (INR, bilirubin,creatinine)
what is the classic symptoms of pre-eclampsia?
new-onset blood pressure ≥ 140/90 mmHg after 20 weeks of pregnancy
AND 1 or more of the following:
proteinuria (oedema)
other organ involvement e.g. renal insufficiency (creatinine ≥ 90 umol/L), liver, neurological, haematological, uteroplacental dysfunction
How is initial RA diagnosis managed? how is the response to treatment monitored?
DMARD monotherapy + steroids
monitored via CRP and DAS28
howis absolute risk reduction calculated and numbers needed to treat?
absolute RR = % test - %control
NNT = 1/ ARR
how is MS managed?
high dose steroids (IV / oral methylpred) - 5 days (this shortens relapse)
Reducing relapse - B IFN
fatigue - amantidine
spacsticity - baclofen/ gabapentin.
Oscillopsia - gabapentin.
how does polyarteritis nodosa present?
Fever, malaise, arthralgia weight loss hypertension mononeuritis multiplex, sensorimotor polyneuropathy testicular pain livedo reticularis haematuria, renal failure pANCA hepatitis B serology positive in 30% of patients
what is lithium toxicity precipitated by?
dehydration
renal failure
drugs: diuretics (especially thiazides), ACE inhibitors/angiotensin II receptor blockers, NSAIDs and metronidazole.
what drug should be used if patients cant tolerate alendronate?
switching to risedronate or etidronate in patients unable to tolerate alendronate
what should be checked before starting azothioprine?
thiopurine methyltransferase deficiency (TPMT) before treatment
deficiency leads to toxicity
which tumour is associated with anti NMDA (autoimmune encephalitis). what are the features of this?
ovarian teratoma
psychiatric features including agitation, hallucinations, delusions
how does eosinophilic oesophagitis present?
young men with symptoms of dysphagia and in patients with a history of food allergy, eczema and asthma
what are the hormonal changes in annorexia?
Low FSH, LH, oestrogens and testosterone
raised cortisol and growth hormone
what features suggest it will be an VT rather than SVT?
- 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
how can eye drops be used to distinguish between the lesion of horners?
Apraclonidine eye drops are initially used to confirm a Horner’s pupil. Apraclonidine stimulates both alpha-1 and alpha-2 receptors. When added to the affected eye, it causes pupil dilation by >2mm because of the relative supersensitivity of this pupil to alpha-1 receptor activity. In a normal pupil, however, it causes constriction due to the more potent activity at the alpha-2 receptor which triggers reuptake of noradrenaline in the synaptic cleft.
Hydroxyamphetamine is then used to distinguish between first/second or third order neurones. In a normal pupil or a first/second order Horner’s, the pupil will dilate. In a third order neurone lesion, this will not occur.
what are the contraindications to TB vaccine?
• previous BCG vaccination
• a past history of tuberculosis
• HIV
• pregnancy
• positive tuberculin test (Heaf or Mantoux)
The BCG vaccine is not given to anyone over the age of 35, as there is no evidence that it works for people of this age group.
wahat is malingering?
faking illnes for gain - e.g. financial gain (whiplash) or pain releif meds
causes of raised anion gap?
lactate: shock, hypoxia
ketones: diabetic ketoacidosis, alcohol
urate: renal failure
acid poisoning: salicylates, methanol
5-oxoproline: chronic paracetamol use
causes of normal anion gap?
gastrointestinal bicarbonate loss: diarrhoea, ureterosigmoidostomy, fistula renal tubular acidosis drugs: e.g. acetazolamide ammonium chloride injection Addison's disease
what are the poor prognostic factors of schizophenia?
low IQ family Hx insideious onset prodromal phase of social withdrawl lack of obvious precipitant
what leads to coagulation in nephrotic syndrome?
loss of ATIII
strongest risk factor for dry age related macular degeneration?
smoking
what are the ADRs of aromatase inhibitors?
osteoporosis- NICE recommends a DEXA scan when initiating
hot flushes
arthralgia, myalgia
insomnia
what is mechanism and side effect of tamoxifen?
Tamoxifen is a SERM which acts as an oestrogen receptor antagonist and partial agonist.
Adverse effects menstrual disturbance: hot flushes - venous thromboembolism endometrial cancer
what is an example of an aromatase inhibitor?
Anastrazole
what causes cannon a waves?
- Caused by right atrium contracting against a closed tricuspid valve
- Regular:
○ VT
○ AVNRT - Irregular
○ Complete heart block
- Regular:
how do B blockers (timolol) in acute angle glaucoma work?
by reducing aqueous production
what is seen in Seborrhoeic dermatitis?
otitis externa and blethritis
eczematous lesions on the sebum-rich areas: scalp (may cause dandruff), periorbital, auricular and nasolabial folds
what is the mechanism of action of acarbose?
Acarbose is an inhibitor of intestinal alpha glucosidases, which results in decreased absorption of starch and sucrose.
common side effect = flatulence
what type of cancer is schistosomiasis infection linked to ?
squamous cell bladder
How does schistosomiasis infection present acutely?
swimmers’ itch
acute schistosomiasis syndrome (Katayama fever)
fever, urticaria/angioedem, arthralgia/myalgia, cough, diarrhoea, eosinophilia
what are the chronic issues of schistosomiasis?
Schistosoma mansoni and Schistosoma japonicum - liver/ colon infestation, hepatomegaly, splenomegaly. cirrhosis, variceals, cor-pulmonale.
Schistosoma haematobium - bladder cancer
who is benign ethnic neutropenia seen in?
Benign ethnic neutropaenia is common in people of black African and Afro-Caribbean ethnicity
isolated neutropenia - no issues
which infection is associated with struvite stones?
Proteus mirabilis
what is the genetics behind freidrich ataxia?
autorecessive
trinucleotide repeat
doesnt have anticipation
what are the features of friedrich ataxia?
absent ankle jerks/extensor plantars
cerebellar ataxia
spinocerebellar tract degeneration
optic atrophy
high arched palate
HOCM
diabetes
10-15yrs
what is the difference in impaired fasting glucose and impaired glucose intolerance pathophysiology?
Impaired fasting glucose (IFG) - due to hepatic insulin resistance
impaired glucose tolerance (IGT) - due to muscle insulin resistance
patients with IGT are more likely to develop T2DM and cardiovascular disease than patients with IFG
which occular pathology is associated with charles bonnet syndrome?
Age-related macular degeneration is associated with Charles-Bonnet syndrome (visual hallucinations, patient aware and no psych problems)
what is the conversion of oral morphine to s/c diamorphine?
divide by 3
what is the most common sign on USS in gout?
double-contour sign
= a hyperechoic, irregular band over the superficial margin of the joint cartilage, produced by deposition of monosodium urate crystals on the surface of the hyaline cartilage,
what is the power of a study?
probability of detecting a significant difference.
i.e. rejecting the null correctly
what is the investigation for pheochromocytoma?
Phaeochromocytoma: do 24 hr urinary metanephrines, not catecholamines
what is mcardles disease?
autosomal recessive type V glycogen storage disease
this causes decreased muscle glycogenolysis
Features muscle pain and stiffness following exercise muscle cramps myoglobinuria low lactate levels during exercise
what is the treatment for cryptosporidiosis for immunocompromised patients?
Nitazoxanide
what happens to clotting factors in liver disease?
most low
factor 8 is normal/ raised
what conditions are associated with IgA nephropathy?
alcoholic cirrhosis
coeliac disease/dermatitis herpetiformis
Henoch-Schonlein purpura
what does the A wave on JVP present and what abnormalities are associated with it?
atrial contraction (first wave on JVP)
large if there is high atrial presssure e.g. tricuspid/pulmonary stenosis, pulomnonary HTN.
cannon a waves - contracts against closed tricuspid e.g. complete heart block
Absent in AF.
what does the C wave on JVP present?
2nd wave on JVP
closure of tricuspid. not always visible
what does the V wave on JVP present and what abnormalities are associated with it?
Third increase wave on JVP .
due to passive filling of atria .
giant v waves in tricuspid regurg.
what does the x and y descent represent on JVP?
X decent - after c wave.
fall in pressure due to ventricular systole
y decent after v wave - opening of tricuspid valve
what is rieldel thyroiditis?
rare cause of hypothyroidism
dense fibrois tissue replaces normal thyroid
appears hard and painless goitre
middle aged women
either euthyroid (most cases) or hypothyroid.
what is reidels thyroiditis associated with?
retroperitoneal fibrosis
after starvation, how is food reintroduced to avoid refeeding syndrome?
NICE recommend that if a patient hasn’t eaten for > 5 days, aim to re-feed at no more than 50% of requirements for the first 2 days.
when is calcification of lung mets seen?
only if there is chondrocarcinoma or osteosarcoma
when are eruptive xanthomas most common?
high triglycerides - familial hypertriglyceridaemia
also lipoprotein lipase deficiency
what organism causes syphilis?
Treponema pallidum
how is syphilis tested for?
non-treponemal tests
(cardiolipin test) - e.g. RPR and VDRL - these become negative after treatment.
Treponemal specific tests - TPHA and TP-EIA - stay positive after treatment.
how can the syphilis tests be interupted?
Positive non-treponemal test + positive treponemal test
• consistent with active syphilis infection
Positive non-treponemal test + negative treponemal test
• consistent with a false-positive syphilis result e.g. due to pregnancy or SLE
Negative non-treponemal test + positive treponemal test :
• consistent with successfully treated syphilis
what are the causes of false positive non-treponemal tests?
SLE pregnnacy HIV TB Malaria leprosy
what is the mechanism of pilocarpine?
Pilocarpine is a muscarinic receptor agonist
used in gaulcoma
increases uveoscleral outflow by constricting the pupil.
how is metformin initiated?
start at 500mg and titrate slowly. minimum interval for titration = 1 week
what are the risk factors for adenocarcinoma of oesophagus and squamous cell carcinoma?
squamous: smoking, alcohol, achalasia and plummer vinson
adeno - smoking, alcohol, barrets
how do angioid retinal steaks appear?
what conditions is this associated with?
irregular dark red streaks from optic nerve
associated with ehlers danlos, acromegaly, pagets, sickle cell, pseudoxanthoma elasticuum
what is hungry bone syndrome?
after srugery to treat hyperparathyoidism there is a sudden drop in PTH
this results in bones absorbing a lot of calcium
hypoCa
which antiepileptics are safe in breast feeding?
Most are safe
except barbiturates
how does primary infection with herpes present?
gingivostomastitis - ulcers and oral inflammation. swelling of submandibular gland.
plus fever/ unwell
how are SSRIs stopped?
withdraw slowly over 4 weeks
not necessary with fluoexetine due to longer half life
what is the genetics behind gilberts?
autorecessive.
defective bilirubin conjungation
deficiency in UDP glucuronosyltransferase
how is gilberts tested for?
rise in bilirubin following prolonged fasting or IV nicotinic acid
how are babies who’s mum has chronic hep B managed?
can mum breast feed?
vaccine and IVIG given to baby
little evidence for need for c section
cant be transmitted via breast milk
What organism causes rocky mountain fever ? how does it present?
Rocky mountain fever = Rickettsia ricketsii
headache, fever, rash (starts on peripheries and spreads centrally)
What organism causes Q fever ? how does it present?
Q fever= Coxiella burnetti
No rash but causes pneumonia
What organism causes endemic typhus ? how does it present?
ndemic typhus Rickettsia typhi
Rash starts centrally then spreads to the peripheries
What organism causes epidemic typhus ? how does it present?
Epidemic typhus
Rickettsia prowazekii
what are the poor prognostic factors following 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
what is the killip class?
risk straification post MI 1 - no HF signs 2- lung crackles, S3 3 - frank pulmonary oedema 4 - cardiogenic shock
what is the management of acne?
topical retiniod topical antibiotic oral therapy - tetracyclines - use for max 3 mont COCP oral isotretinoin
which antibiotics for ACNE are safe in pregnancy?>
erythromycin
which acne medication causes irreversible pigmentation?
minocycline
what are the indications for steroids in sarcoidosis?
CXR 2 or 3 disease and symptomatic
hypercalcaemia
eye, heart, or neuro involvement
how is haemochromatosis diagnosed?
transferrin saturation
ferritin levels
(low total iron binding content)
family members - HFE gene mutation
which cancer are the following skin conditions associated with?
Erythema gyratum repens acanthosis nigricans dermatomyosis migratory thrombophlebitis necrolytic migratory erythema
erythema gyratum repens - lung cancer
acanthosis nigricans - gastric cancer
dermatomyositis - ovarian and lung cancer
Migratory thrombophlebitis - Pancreatic cancer
Necrolytic migratory erythema Glucagonoma
what is the mechanism of warfarin?
inhibits epoxide reductase - stops vit K reduction inhibits factors (1972)
can warfarin be used in pregnancy and breastfeeding?
yes breastfeeding
what factors can increase warfarin?
liver disease
P450 enzyme inhibitors, e.g.: amiodarone, ciprofloxacin
cranberry juice
drugs which displace warfarin from plasma albumin, e.g. NSAIDs
inhibit platelet function: NSAIDs
what is the target for statin therapy in primary prevention?
In the primary prevention of CVD using statins aim for a reduction in non-HDL cholesterol of > 40%
which type of testicular tumour is associated with rise in hCG?
seminoma - just hCG raised
choriocarcinoma - but much rarer than above
yolk sac tumours - hCG and alpha fetoprotein both rasised
how is phenytoin toxicity/ levels measured?
just before next dose
which scoring system is used for appendaidictis?
The Alvarado score can be used to suggest the likelihood that a patient has acute appendicitis
which Ab are found in SLE
ANA - 95% - sensitive, not specific
Anti DsDNA/ anti smith - specific not sensitive
what are the ECG changes in arryhthmogenic RV cardiomyopathy?
ECG abnormalities in V1-3, typically T wave inversion. An epsilon wave is found in about 50% of those with ARV - this is best described as a terminal notch in the QRS complex
what are the features of ebstein anomoly?
cyanosis
prominent ‘a’ wave in the distended JVP,
hepatomegaly
tricuspid regurgitation - giant V wave in JVP
pansystolic murmur, worse on inspiration
right bundle branch block → widely split S1 and S2
how are wounds treated in regards to tetanus if they completed vaccine >10yrs ago?
tetanus prone wound - reinforcing vaccine dose
high risk wound - reinforcing vaccine dose + Ig
what are the causes of avascular necrosis of the hip?
steroids
chemo
alcohol
trauma
which anti-epileptic can cause agranulocytoiss?
carbemazepine
how does a left venticular aneurysm post MI present?
persistent ST elevation
no chest pain
signs of HF
how long is needed for a fistula to develop?
6-8 weeks
How is cryptosporidium diagnosed
Cryptosporidium can be diagnosed by modified Ziehl-Neelsen staining of stool to reveal red cysts
what mode of inheritance is alports?
auto dominant
collagen type 4
what are the features of alports?
microscopic haematuria
progressive renal failure
bilateral sensorineural deafness
lenticonus: protrusion of the lens surface into the anterior chamber
retinitis pigmentosa
renal biopsy: splitting of lamina densa seen on electron microscopy - basket weave appearance
whats the difference between docetaxel and vincistrine?
docetaxel - prevents microtubule dissasembly
vincistrine - prevents microtubule formation
In patients with low K and HTN, how can we differentiate the causes?
renin:aldosterone
- both high = renal artery stenosis
- aldosterone high, renin low = primary hyperaldosteronism
- neither high = liddles.
what are the characteristics of Argyll robertson pupils? what are the cuases?
small, irregular pupils
no light response
but there is accomodation response
causes - diabetes and syphillis
when is vitamin D deficiency treated?
<30
which movement is most classically impaired in adhesive capsulitis?
external rotation
how long after initial infection of C.diff is oral vanc used again?
1st line = oral vanc
reinfection after 12 weeks - oral vanc
within 12 weeks - oral fidaxomicin
what is the diagnosis for obstructive sleep apnoea?
Polysomnography
what are the secondary causes of hypercholesterolaemia over hypertriglyceridaemia?
nephrotic syndrome, cholestasis, hypothyroidism
what is the action of dipyrimadol?
inhibits phosphodiesterase, elevating platelet cAMP levels which in turn reduce intracellular calcium levels
other actions include reducing cellular uptake of adenosine and inhibition of thromboxane synthase
what abnormal observation should not be treated following acute stroke?
HTN
when are angiod retinal streaks seen?
pseudoxanthoma elasticum Ehler-Danlos syndrome Paget's disease sickle-cell anaemia acromegaly
what is Bevacizumab
monoclonal against VEGF
what is the management of eosinophilic oesophagiits?
Dietary modification and topical steroids are used in the management of eosinophilic oesophagitis
what are the side effects of ECT?
Short-term side-effects headache nausea short term memory impairment memory loss of events prior to ECT cardiac arrhythmia
Long-term side-effects
some patients report impaired memory
Which Abx promotes MRSA?
ciprofloxacin
what is pseudohypoparathyroidism ?
Pseudohypoparathyroidism is caused by target cell insensitivity to parathyroid hormone (PTH) due to a mutation in a G-protein.
autosomal dominant fashion*
what are the features of pseudohypoparathyroisim?
Bloods
PTH: high
calcium: low
phosphate: high
Features short fourth and fifth metacarpals short stature cognitive impairment obesity round face
how is raynauds managed?
CAB - nifedipine
Epoprostenol (amongst other prostaglandins)
what is the cause of endocarditis in prosthetic valves?
<2 month hx of surgery - epidermidis
>2 month - S.aureus
what defines pulmonary artery HTN?
Pulmonary arterial hypertension is defined as an elevated pulmonary arterial pressure of greater than 25mmHg at rest or 30mmHg after exercise
what medication should all SLE patients take?
hydroxychloroquine
which operations are available for weight loss and when?
Primarily restrictive operations
laparoscopic-adjustable gastric banding (LAGB)
it is normally the first-line intervention in patients with a BMI of 30-39kg/m^2
produces less weight loss than malabsorptive or mixed procedures but as it has fewer complications
Primarily malabsorptive operations
biliopancreatic diversion with duodenal switch
usually reserved for very obese patients (e.g. BMI > 60 kg/m^2)
Mixed operations
Roux-en-Y gastric bypass surgery
is both restrictive and malabsorptive in action
which zones of the lung does asbestosis causing fibrosis affect?
lower zone
how is occulogyric crisis managed?
intravenous antimuscarinic: benztropine or procyclidine
at what pottasium level is ramipril stopped?
stop ramipril at K+ >6
how is a cerebral abscess managed?
IV antibiotics: IV 3rd-generation cephalosporin + metronidazole
intracranial pressure management: e.g. dexamethasone
what are the contraindications to lung cancer surgery?
SVC obstruction, FEV < 1.5, MALIGNANT pleural effusion, and vocal cord paralysis
what type of glomerulonephritis is heroin associated with?
focal segmental glomerulosclerpsois
what are the genetics behind bruguda syndrome?
mutation in the SCN5A gene which encodes the myocardial sodium ion channel protein
autosomal dominant
what are the features and management of bruguda?
convex ST segment elevation V1-V3 followed by a negative T wave
partial right bundle branch block
the ECG changes may be more apparent following the administration of flecainide
ICD= management
what is the inheritance of myotonic dystrophy?
auto dominant
Trinucleotide repeat
DM1 and DM2
what are the features of myotonic dytrophy?
distal weakness - DM1
proxinal weakness - DM2
myotonic facies, diabetes, bilateral ptosis , cataracts, dysarthria, heart block
which drugs precipitate acute intermittent porphyria?
barbiturates halothane benzodiazepines alcohol oral contraceptive pill sulphonamides
what blood test abnormalities are associated with antiphospholipid syn?
thrombocytopenia
prolonged APTT
what are the ADRs of PPIs?
hypo Mg/ Na
microscopic colitis
Cdif
osteoporosis
what are the features of cholesterol emboli?
eosinophilia
purpura
renal failure
livedo reticularis
what should be checked if a man has osteoporosis?
testosterone
what anti-psychotic is contraindicated in parkinsons?
Haloperidol
what viruses could cause eczema herpeticum?
HSV and less commonly coxsackie
which is the most common and severe form of renal diseae in SLE?
diffuse proliferative glomerulonephritis
how long can you not drive for after angioplasty?
1 week
what are the genetics behind familial mediterranean fever?
auto recesive
in turkey/ arabic decent
what are the features of familial mediterraean fever?
pyrexia, abdo pain, pleurisy, pericarditis, artritis, rash
colchicine helps
what is the most common type of hodgkins lymphoma?
nodular sclerosing
what type of hodgekin lymphoma has worst prognosis?
lymphocyte deplete
what arises first in MI?
myoglobin
what conditions are associated with sebhorreic dermatitis and how is it treated?
HIV
parkinsons
topical ketonazole
what is the treatment for campylobacter?
clarithromycin if severe
how does acute cerebellar haemorrahage present?
sudden-onset gait unsteadiness, vomiting and headache, followed by increasing drowsiness.
i.e. raised ICP symptoms
A post-marketing observational study of a new drug was conducted on 5000 patients following clinical trials.
What best describes the data generated from this type of study?
profile of adverse effects
/ post authorisation safety study
what is seen on renal biopsy in henoch schloin purpura?
mesangial deposition of IgA
which form of gastroenteritis can often have a negative stool culture?
giardiasis
what are the genetics of alpha 1 antitrypsin deficiency?
normal: PiMM
heterozygous: PiMZ - low risk of emphysema in non smokers
homozygous PiSS: 50% normal A1AT levels
homozygous PiZZ: 10% normal A1AT levels
what is the first line Ix for insulinoma?
Measuring prolonged (72-h) fasting glucose levels is the gold standard initial test for insulinoma.
how can you differentiate between common peroneal and L5 lesion?
Weakness of inversion is not seen in common peroneal nerve lesion but may be present with L5 lesion
which antihypertensive should be used in people taking lithium?
CaB
ACE inhibitors, angiotensin II receptor antagonists and thiazide diuretics can all cause lithium toxicity by reducing renal lithium clearance.
hyperacute rejection reactions are mediated by which Ab?
IgG
The combination of headache, increasing drowsiness (suggesting increasing intracranial pressure), focal neurological signs and seizures in a woman shortly post partum is highly suggestive of …
venous sinus thrombosis.
what are the sympotms of acute closed angle glaucoma?
Symptoms include headaches, eye pain, nausea, halos and reduction of visual acuity. Ciliary vessel hyperaemia is an early sign.
which Abx cause tendon damage?
Tendon damage including rupture can occur rarely after use of quinolones. Quinolones are contraindicated in patients with a history of tendon disorders related to quinolone use. e.g. ciprofloxacin
what is the PEP for needle stick of HIV patient
Post-exposure prophylaxis (PEP) of HIV requires a three-drug antiretroviral for 1 month
what is Intention-to-treat method?
include anyone who drops out
when is oxygen saturation by four-wavelength spectrophotometry low compared to sats/PO2?
CO poisoning
what is a common cause of MI related to pregnancy?
coronary artery dissection
what are the parameters of the waterlow score?
t uses the following parameters to risk-stratify the patient: body weight, nutritional status, continence, skin type, mobility, age and sex.
how can we assess cvs risk with patients with renal disease/ HTN?
Proteinuria is an independent predictor of cardiovascular risk in patients with diabetes mellitus and/or hypertension.
what complication is most strongly associated with H.pylori?
duodenal ulcer
which Abx cause long QTc?
Antimicrobials that cause QT prolongation are: erythromycin, clarithromycin, moxifloxacin, fluconazole and ketoconazole.
at what age can polymyalgia rheumatica be diagnosed?
> 55
which Ab is raised in autoimmune hepatitis?
IgG
what ECG change indicates posterior MI and which artery is invovled?
3-mm ST-segment depression in leads V1 to V3, with upright T waves and tall R waves
Circumflex
how is cellulitis with penicillin allergy treated?
clindamycin
what is Yersinia enterocolitica infection indicated in?
mesenteric adenitis
what does aciclovir do to the kidneys?
crystaluria
Ferritin is very high in a rare condition that causes fever, joint pain/inflammation and evanescent macular rash
Still’s disease
what increases and decreases pulmonary vascular resistance?
It is increased by hypoxia, noradrenaline (norepinephrine) and endothelin.
decreased by epoprostenol (prostacyclin).
what oncogene is in neuroblastoma?
n-myc
which form of hodgkins carries best prognosis?
Hodgkin’s lymphoma - best prognosis = lymphocyte predominant
what is the vital capacity?
Vital capacity - maximum volume of air that can be expired after a maximal inspiration
how is TTP managed?
steroids, immunosupressants
Plasma exchange
NOT IVIG
what is the typical presentation of methaglobinaemia?
SoB, headache, cyanosis
low sats, normal pO2
can be triggered by meds - co-trimoxazole, sulphonamides, dapsone
which part of hypothalamus is invaded by craniopharygiomas?
ventromedial area of the hypothalamus
which features of haemachromatosis are reversible upon treatment?
cardiomyopathy
skin pigmentation
other irreversible features: diabetes, liver cirrhosis, arthropathy, hypogonadism
what are the features of neurofibromatosis type 1 and 2
type 1 Café-au-lait spots (>= 6, 15 mm in diameter) Axillary/groin freckles Peripheral neurofibromas Iris hamatomas (Lisch nodules) in > 90% Scoliosis Pheochromocytomas
type 2
Bilateral vestibular schwannomas
Multiple intracranial schwannomas, mengiomas and ependymomas
whatis the differece in amiodarone induced thyrotoxicosis type 1 and 2?
type 1 - iodine excess, goitre present, treat with carbimazole or pottasium perchlorate
type 2 - amiodarone induced destruction, no goitre, treat with steroids./
what is the treatement for restless legs and cramping legs?
restless legs - ropinerole
cramping - quinine
what is the mechanism behind heparin induced thrombocytopenia?
antibodies form against complexes of platelet factor 4 (PF4) and heparin
how are early keloid scars treated?
early keloids may be treated with intra-lesional steroids e.g. triamcinolone
which cause of pneumonia is associated with cold sores?
strept pneumonia
how is bacterial vaginosis managed?
oral metronidazole
which type of acute myeloid leukaemia carries best prognosis?
promyelocytic - t(15;17)
what are the features of tuberous sclerosis?
depigmented ‘ash-leaf’ spots which fluoresce under UV light
roughened patches of skin over lumbar spine (Shagreen patches)
adenoma sebaceum (angiofibromas): butterfly distribution over nose
fibromata beneath nails (subungual fibromata)
café-au-lait spots
retinal hamartomas: dense white areas on retina
rhabdomyomas of the heart
