MSRA Flashcards
what is the dose of adrenaline in anaphylaxis depending on age?
<6month - 100 to 150microgram
6m - 6y = 150mcg
6y-12y = 300mcg
adults >12yr = 500mcg
1 in 1000
how often can adrenaline be repeated?
every 5 mins
what is refractory anaphylaxis?
anaphylaxis despite 2 doses of adrenaline. May need IV adrenaline
what is the management of anaphylaxis?
adrenaline
Chlorphenamine - for urticaria and angioedmea thats ongoing
mast cell tryptase
discharge with special allergy clinic referral and epipen x2
when can patients with anaphylaxis be discharged?
rapid discharge - if rapid resolution to single dose of adrenaline , has someone at home
6 hours of monitoring - if previous biphasic reaction or if 2 doses of adrenaline were needed
12 hour of monitoring - if >2 doses of adrenaline needed, prolonged reaction e.g. if slow release allergen, remote area of living, presented late at night, severe asthma
what is a mediator of DIC?
Tissue factor
what are the causes of DIC?
sepsis , truama, malignnacy, obstetric (amniotic fluid embolism, HELLP syndrome)
what are the blood finding in DIC?
low platelets, low fibrinogen, high PT and APTT
schistocytes secondary to microangiopathic haemolytic anaemia
what are indications for HRT?
vasomotor symptoms - headaches, flushing etc
early menopause - up until 50 to protect bones (also protects against colorectal Ca)
how do you prescribe correct HRT?
Is there a uterus - if yes - must have progesterone
Is the woman perimenopausal - if yes then cyclical regime
is there a high risk of VTE ? - if yes - transdermal preferred to oral
what is the two levels well score for DVT?
each scores 1 point:
- cancer, paralysis, plaster immobilisation, bed ridden 3days, surgery in last 12 weeks
- entire leg swollen, tenderness along deep saphenous vein, >3cm size differnece, pitting oedema , supervicial veins enlarged
- previous DVT
-2 for other diagnosis more likely
DVT likely - 2 points or more
How is a 2 level wells score for DVT of 2 and above managed?
USS within 4 hours, if positive start DOAC
If cant be done in 4 hours, start DOAC while waiting
DOAC = apixaban/rivaroxaban
if scan negative, D dimer positive, stop anticoag and can offer repeat scan in 5 days
How is WELLS score of 1 for DVT managed?
d dimer
if positive, USS leg
How is WELLS score of 1 for DVT managed?
d dimer
if positive, USS leg
Do we screen for malignancy in those with VTE?
No
what is hypospadias?
congential abnormality of penis
ventral placement of urethra
How is hypospadias managed?
surgery after 1 year
do not circumcise before as may need foreskin for surgery
what is hypospadius associated with?
usually sporadic
can be associated with cryptochordism and inguinal hernia
what is the management of VTE for different patient groups?
Doac first line – apixaban and rivaroxaban
If egfr <15 then LMWH followed by warfarin
If antiphospholipid then LMWH followed by warfarin
Haemodynamic instability – thrombolysis
how long is VTE treated?
provoked - 3 months
unprovoked - 3 to 6 months (use ORBIT score to assess bleeding risk)
How do you assess if P.E can be managed in community?
use PESI score (pulmonary embolism severity index
how is hyperhidrosis managed?
Excess sweat
Topical aluminium chloride = 1st line (Skin irritation as side effect)
- Iontophoresis
- Botulinum for axillary
- Transthoracic sympathectomy
How does pataus syndrome present (chrom 13)
Microcephalic, small eyes
Cleft lip/palate
Polydactyly
Scalp lesions
How does edwards syndrome (chrom 18) present?
Micrognathia
Low-set ears
Rocker bottom feet
Overlapping of fingers
how does fragile X present?
Learning difficulties
Macrocephaly
Long face
Large ears
Macro-orchidism
how does noonans present?
Webbed neck
Pectus excavatum
Short stature
Pulmonary stenosis
how does pierre robin syndrome present?
Micrognathia
Posterior displacement of the tongue (may result in upper airway obstruction)
Cleft palate
how does williams syndrome present?
Short stature
Learning difficulties
Friendly, extrovert personality
Transient neonatal hypercalcaemia
Supravalvular aortic stenosis
whats the most common acyanotic CHD?
VSD
what are the 3 most common cyanotic CHD and when do they present?
ToF - most common , at 1-2 months
transposition of great arteries - at 1-2 days
tricuspid atresia
how is capacity assessed?
- a. understand the information relevant to the decision
- b. retain that information
- c. use or weigh that information as part of the process of making the decision
- d. communicate the decision made by talking, sign language or other means
also need o have an impairment/disturbance to mind - permanent or temporary
when do different types of contraceptives become effective?
- instant: IUD
- 2 days: POP
- 7 days: COC, injection, implant, IUS
what vision and hearing problems are seen in downs patients?
- Vision:
o Strabismus
o Cataracts
o Recurrent blethritis
o Glaucoma - Hearing – otits media
how does tympanic membrane look in otitis media with/without effusion?
acute otitis media - bulging
otitis media + effusion - retracted
what is patellofemoral syndrome also known as ? how does this present?
chondromalacia patellae
- Anterior knee pain walking up and down stairs and rising from prolonged sitting
- Most common in teenage girls
how do viral labrynthitis and vestibular neuritis differ?
labyrnthitis:
Recent viral infection
Sudden onset
Nausea and vomiting
Hearing may be affected
vestibular neuritis:
Recent viral infection
Recurrent vertigo attacks lasting hours or days
No hearing loss
how does menieres disease present?
Associated with hearing loss, tinnitus and sensation of fullness or pressure in one or both ears
which drug can cause hearing loss/ dizziness?
gentamicin
what are the phases of subacute thyroiditis?
- Phase 1 – hyperthryroid, raised ESR, tender goitre
- Phase 2 – euthyroid
- Phase 3 – hypothyroid
how does subacute thyroiditis / dequervains present?
high ESR
hyperthryoid
tender goitre
recent illness
reduced iodine uptake
how is subacute thyroiditis managed?
NSAIDs
how is nocturnal enuresis defined?
as the ‘involuntary discharge of urine by day or night or both, in a child aged 5 years or older, in the absence of congenital or acquired defects of the nervous system or urinary tract’
how is enuresis managed?
look for possible underlying causes/triggers (constipation, diabetes mellitus, UTI )
advice: fluid intake, toileting patterns, reward systems
enuresis alarm - 1st line
desmopressin - for sleepovers/ one off
what are the features of non-proliferative diabetic retinopathy?
mild - microaneurysm
moderate - above + blot haemorrhages, hard exudates, cotton wool spots , venous beeding
severe - blot haemorrhages/ microaneurysm in 4 quadrants OR venous beeding in 2 quadrants
what are the features of proliferative diabetic retinopathy?
neovascularisations
fibrous tissue forming anterior to retinal disc
which type of diabetes is maculopathy more common in?
type 2
how is diabetic retinopathy managed?
glycaemic control
yearly review
maculopathy - intravitreal VEGF inhibitors (if there’s a change in visual acuity)
non proliferative - if severe laser photocoagulaton
proliferative - laser photocoagulation + VEGF inhibitors
if severe vitreous haemorrhage - vitreoretinal surgery
How can you differentiate between different eye problems?
keratitis - red eye, photophobia, gritty sensation
anterior uveitis - acute red eye, associated with inflammatory disorders
acute closed angle glaucoma - red painful eye, headache, N&V, halos in vision, fixed mid dilated pupil , corneal haze, hard eyeball
blethritis - gritty sticky eyes, esp in morning
who is most at risk of keratitis?
contact lens wearers
how is keratitis managed?
topical quinolones
cyclophenolate for pain releif
what should all patients with peripheral vascular disease take?
clopidogrel , statin (atorvastatin 80mg)
exercise training
what is the most common hereditary haemolytic anaemia?
spherocytosis
what is the genetics of hereitary spherocytosis?
auto dominant
what are clinical features of hereiditary spherocytosis?
jaundice and gall stones
splenomegaly and splenic rupture
aplastic crisis precipitated by parvovirus
how is hereditary spherocytosis diagnosed?
EMA binding test
but those with symptoms + high Mean corpuscular haemoglobin concentration [MCHC], increase in reticulocytes and spherocytes - do not need testing
what is the genetics behind G6PD deficiency?
X linked recessive
males
african and mediterrean
what is finasteride used for and how long before it starts to work?
BPH
can take up to 6 months
who is BPH most common in ?
black >white>asian
which scale is usedto classifying the severity of lower urinary tract symptoms (LUTS) and assessing the impact of LUTS on quality of life in BPH?
International Prostate Symptom Score (IPSS)
from 0 to 35, the higher the worse
How is BPH managed?
watchful wait
alpha 1a antagonist - tamsulosin, alfuzosin
5 alpha reductase - finasteride
surgery - transurethral resection of prostate
how do alpha 1a antagonists for BPH work?
decrease smooth muscle tone of prostate and bladder
how do 5 alpha reductase inhibitors work? (finasteride)
stop conversion of testosterone to DHT
what are the ADRs of finasteride?
erectile dysfunction, reduced libido, ejaculation problems, gynaecomastia
what is used as prophylaxis for cluster headaches?
verapamil
what is used for migraine prophylaxis?
propanolol
or topimarate - but not usefule for women of child bearing age (teratogenic)
what triggers cluster headaches?
alcohol, noctunal sleep
more common in men and smokers
how are animal bites managed (abx in pen allergy too)
co-amoxiclav
pen allergy - doxy and metro
dont suture / close a puncture wound unless cosmesis at risk
which bacteria is present in animal bites?
Pasteurella multocida
what Abx for human bites?
co-amox
what are the causes of dupytrens contractures?
manual labour
phenytoin treatment
alcoholic liver disease
diabetes mellitus
trauma to the hand
which fingers are mostly affected by dupytrens?
rign and little
how is a flare of UC categorised?
mild: < 4 stools/day, only a small amount of blood
moderate: 4-6 stools/day, varying amounts of blood, no systemic upset
severe: >6 bloody stools per day + features of systemic upset (pyrexia, tachycardia, anaemia, raised inflammatory markers)
how do you induce remission in UC?
proctitis: rectal aminosalicyclate (mesalazine). if not induced after 4 weeks, can add oral mesalazine. If still not after 4 weeks, add oral steroid
proctosigmoiditis:
topical (rectal) aminosalicylate
if remission is not achieved within 4 weeks, add a high-dose oral aminosalicylate OR switch to a high-dose oral aminosalicylate and a topical corticosteroid
if remission still not achieved stop topical treatments and offer an oral aminosalicylate and an oral corticosteroid
extensive disease:
topical (rectal) aminosalicylate and a high-dose oral aminosalicylate
if remission is not achieved within 4 weeks, stop topical treatments and offer a high-dose oral aminosalicylate and an oral corticosteroid
severe collitis - IV hydrocortisone and admission. can add IV ciclosporin after 72 hours
how is remission maintained in UC?
proctitis/ sigmoiditis - topical aminosalicyclates/oral or both
left sided colitis/ extensive - oral aminosalicyclate
Following a severe relapse or >=2 exacerbations in the past year
oral azathioprine or oral mercaptopurine
NOT METHOTREXATE
which virus causes bronciolitis?
RSV
which virus causes croup?
parainfluenza
what does H.influenzae cause?
community acquired pneumonia
most common cause of bronchiectasis exacerbations
acute epiglottis
which bacterial infection often causes pneumonia after influenza?
s.aureus
how does mycoplasma pneumonia present?
Flu-like symptoms classically precede a dry cough. Complications include haemolytic anaemia and erythema multiforme
how does legionella pneumonia present?
Classically spread by air-conditioning systems, causes dry cough. Lymphopenia, deranged liver function tests and hyponatraemia may be seen
how does pneumocystitis jiroveci present?
exertional dyspnoea
few chest signs
HIV patients
what occurs in age related macula degeneration?
degeneration of retinal photoreceptors results in drusen that can be seen on fundoscopy
who is age related macula degen more common in ?
females
smoking
Fhx
what is the difference between wet and dry age related macular degen?
dry macular degeneration
- 90% of cases
- also known as atrophic
- characterised by drusen - yellow round spots in Bruch’s membrane
wet macular degeneration
- 10% of cases
- also know as exudative or neovascular macular degeneration
- characterised by choroidal neovascularisation
leakage of serous fluid and blood can subsequently result in a rapid loss of vision
carries worst prognosis
how do patients with age related macula degen present?
worse vision particularly of nearby objects and ability to adapt at night
can get flashing lights/ glare around objects
distortion of line perception may be noted on Amsler grid testing
Fundoscopy reveals the presence of drusen, yellow areas of pigment deposition in the macular area, which may become confluent in late disease to form a macular scar.
in wet ARMD well demarcated red patches may be seen which represent intra-retinal or sub-retinal fluid leakage or haemorrhage
how is age related macular degen managed?
VEGF
laser photocoagulation
what is the management of latent TB?
3 months of isoniazid (with pyridoxine) and rifampicin, or
6 months of isoniazid (with pyridoxine)
when should a referral for developmental problems be made?
doesn’t smile at 10 weeks
cannot sit unsupported at 12 months
cannot walk at 18 months
if a child has a hand preference before 12 months what might this indicate?
this is abnormal to have left/right handedness before 12 months
could mean cerebral palsy
how should meds be changed in illness in addisons?
double hydrocortisone
keep fludrocortisone the same
what is the name of the rash seen in lymes disease?
erythema migrans - bulls eye appearance at the centre. red non itchy
what are the complications of lymes disease?
CVS: heart block, myocarditis
neurological: cranial nerve palsies, meningitis
polyarthritis
what Abx is given for meningitis? for generic infection i.e. unknown
IM benzylpenicillin - pre hosp
<3months : IV cefotaxine and amoxicillin / ampicillin
>3months to 50: IV ceftriaxone - at hosp
>50 - ceftriaxone and ampicillin/amox
which Abx are given for specific causes of meninigitis?
meningococcal - IV benzylpenicillin or cefotaxime (or ceftriaxone)
Pneuomococcal meningitis OR haemophilus influenzae - IV cefotaxime (or ceftriaxone)
Meningitis caused by Listeria Intravenous amoxicillin (or ampicillin) + gentamicin
other than Abx what else can be given in meningitis?
IV dexamethasone unless…
septic shock, meningococal septicaemia, immunocompromised, meningitis following surgery
what prophylaxis is used for meningitis?
oral ciprofloxacin or rifampicin
those who have had contact within 7 days of onset of confirmed bacterial meningitis
what is first line to improve fertility in PCOS?
clomifene
how is hirsutism and acne managed in PCOS?
COCP
Topical eflornithine
spironolactone, finasteride, flutamide
what is the most common pscyh issue in parkinsons?
depression
what sleep issues do parkinsons patients get?
REM sleep disorder
how does drug induced parkinsosn differ?
motor symptoms rapid onset and bilater
tremor and rigidity are less common
what is a pharyngeal pouch?
A pharyngeal pouch (also known as Zenker’s diverticulum) is a posteromedial diverticulum through Killian’s dehiscence. Killian’s dehiscence is a triangular area in the wall of the pharynx between the thyropharyngeus and cricopharyngeus muscles
more common in older pts and men
how is H.pylori eradication confirmed?
urea breath test
when can a urea breath test be performed?
after 2 weeks of no PPI and 4 weeks of no Abx
What precipitates thrombotic crisis/ vasoocclusive crisis in sickle cells?
deoxygenation
infection
acidosis
dehydration
what happens to reticulocyte count in sequestration crisis?
increases
worsening anaemia because red cells are trapped in lung/spleen
how does acute chest syndrome present in sickle cell? whats the pathology behind this?
vaso-occlusion within the pulmonary microvasculature → infarction in the lung parenchyma
dyspnoea, chest pain, pulmonary infiltrates on chest x-ray, low pO2
how is acute chest syndrome in sickle cell managed?
pain relief, oxygen
antibiotics
transfusion can help
what happens to reticulocyte count in aplastic crisis?
reduced (bone marrow supression)
what is charcots cholangitis triad?
fever, RUQ pain, jaundice
at which age are children unable to consent for sexual intercourse?
under 13 - would automatically be rape
13-16 - assess capacity
when can emergency contraception be used?
levonelle - levonogestrel - up to 72hrs, can be used more than once in a cycle
ellaone = urlipristal - up to 120hours, can be used multiple times, dont take with levonelle
what should you advice women of if taking ellaone?
need to use barrier contraception after as it distrubs efficacy of COCP
not to be used in severe asthma
delay breastfeeding for 1 week after using the drug
how does ellaone work?
selective progesterone receptor modulator
how many days can IUD be used as emergency contraception?
copper IUD up to 120 hours
most effective option
How are type 1 and 2 diabetes distinguished?
C peptide (high in type 2)
auto antibodies - in type 1
which autoantibodies are found in T1DM?
anti GAD
islet cell
insulin autoantibodies
what is the diagnostic criteria for diabetes?
fasting glucose >7
oral glucose >11.1
HbAC1 >6.5 (48)
fasting 6-7 and oral 7.8-11.1 = im[paired glucose tolerance
where is pain felt in medial and lateral epicondylitis?
lateral - extensor, supination, tennis elbow
medial - flexion, pronation, golf
how does radial tunnel syndrome present?
similar to lateral epicondylitis
pain 5-6cm distal to lateral epicondyle
sensory changes around 1st webspace
how do vulval carcinomas present?
itching irritation
followed by ulceration
inguinal lymphadenopathy
around 65 yrs
what are the risk factors for vulval carcinoma?
HPV, Vulval neoplasma insitu , lichen sclerosus
what are the symptoms of ovarian cancer?
Clinical features are notoriously vague
abdominal distension and bloating
abdominal and pelvic pain
urinary symptoms e.g. Urgency
early satiety
diarrhoea
what is the most common type of ovarian cancer?
epithelial - serous
what conditions can raise Ca125?
endometriosis
cysts
menstrations
at which level is ca125 high and what is offered next?
35
abdo USS
what are the side effects of chloroquine, how often is it taken and when is it contraindicated?
chloroquine for malaria taken once/week
side effects - headache
contraindicated in epilepsy
what are the side effects of doxycycline? when should it be taken for malaria prophylaxis?
photosensitivity
oesophagitis
1 to 2 days before. 4 weeks post
what are the side effects of malarone (antimalaria)? when should it be taken?
GI upset
1 to 2 days before travel
7 days post travel
what are the side effects of mefloquine (lariam) for malaria? how often is it taken and when is it contraindicated?
dizziness, neuropsychiatric issues
taken once a week
contraindicated in epilepsy
which antimalarial is best in pregnancy?
chloroquine
progaunil can be taken with 5mg folate supplements
how is major bleeding on warfarin managed?
stop warfarin
IV vit K
IV prothrombin complex
how is INR >8 managed?
minor bleeding - stop warfarin, IV vit K 1-3mg, restart warfarin when INR <5
no bleeding - stop warfarin, oral vit K, restart when <5
how is INR 5-8 managed?
minor bleed - stop warfarin, IV vit K 1-3mg, resrt when <5
no bleeding - withhold warfarin 1-2 doses
what can be given for smoking cessation and how long for?
NRT, varenicline or bupropion should normally be prescribed as part of a commitment to stop smoking on or before a particular date (target stop date)
Normally, this will be after 2 weeks of NRT therapy, and 3-4 weeks for varenicline and bupropion,
never give in combination
what are the ADRs of nicotine replacement therapy?
N&V, headache, flu like
how does varenicline work and what are the side effects?
nicotine receptor partial agonist
nausea, headache, insomnia, weird dreams
increased suicidal behavior
contraindicated in pregnancy and breast feeding
what is the mechanism of bupropion? what are the risks/contraindications?
Norepinephrine and dopamine reuptake inhibitor, and nicotinic antagonist
risk of seizures
contraindicated in epilepsy, breastfeeding and preg
eating disorders - relative contraindication
what is the management of otitis externa?
topical antibiotic or a combined topical antibiotic with a steroid
what action should be taken in a cardiac arrest is witnessed at the beginning?
3 shocks, then CPR
(for shockable rhythms)
what are the shockable and non-shockable rhythms?
non-shockable - asystole, PEA
shockable - pulseless VT and VF
what are the 4Hs and 4Ts
hypoxia, hypovolaemia, hyperkalaemia, hypothermia
toxins, tamponade, thrombus, tension pneumothorax
when are adrenaline and amiodarone given in arrest?
adrenaline 1mg asap for non-shockable
adrenaline 1mg after 3rd shock and then every 3-5mins
only shockable rhythms..
amiodarone 300mg after 3rd shock
further 150mg can be given after 5th shock
what are the ADRs of statins?
myopathy: includes myalgia, myositis, rhabdomyolysis and asymptomatic raised creatine kinase.
Liver impairment
what are the risk factors for myopathy with statins?
Advanced age, female sex, low body mass index and 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 bloods should be taken for treatment with statins?
LFTs at baseline, 3 months and 12 months.
Treatment should be discontinued if serum transaminase concentrations rise to and persist at 3 times the upper limit of the reference range
what are the contraindication to statins?
Macrolides (e.g. erythromycin, clarithromycin) are an important interaction. Statins should be stopped until patients complete the course
pregnancy
what does grapefruit juice do to statins?
inhibitor of cytochrome system
increases statins
who should be given statins?
Q risk score >10%
anyone with T1DM for >10 yrs or are >40yrs or have neuropathy
(type 2 are asessed with q risk like eveyrone else)
what advice is given for those taking PPIs prior to 2ww endoscopy for GI cancer?
stop taking 2 weeks before endoscopy
what are indications for 2 ww upper GI endoscopy?
All patients who’ve got dysphagia
All patients who’ve got an upper abdominal mass consistent with stomach cancer
Patients aged >= 55 years who’ve got weight loss, AND any of the following:
upper abdominal pain
reflux
dyspepsia
what are different abnormalities that can be seen on CTG and what do they suggest?
baseline bradycardia - HR <100, could be due to maternal B blockers, increased fetal vagal tone
baseline tachy >160 - hypoxia, premiturity, chorioamniotis, maternal pyrexia
loss of baseline variablity <5beats/min - prematurity, hypoxia
Early deceleration - Deceleration of the heart rate which commences with the onset of a contraction and returns to normal on completion of the contraction Usually an innocuous feature and indicates head compression
Late deceleration Deceleration of the heart rate which lags the onset of a contraction and does not returns to normal until after 30 seconds following the end of the contraction Indicates fetal distress e.g. asphyxia or placental insufficiency
Variable decelerations Independent of contractions May indicate cord compression
what does St johns wart do to cytochrome P50
inducer
when do babys with sickle cell develop symptoms?
4-6 months once fetal Hb replaced
which genetic blood condition can cause recurrent priapism?
sickle cell
what are the features of common peroneal nerve palsy?
weakness of foot dorsiflexion, eversion, extensor hallucis longus
sensory loss over the dorsum of the foot and the lower lateral part of the leg
wasting of the anterior tibial and peroneal muscles
what causes common peroneal nerve palsy?
injury to neck of fibula
diabetes
what is first line in management of N&V in pregnancy?
antihistamines e.g. cyclizine/ promethazine
what is the cause of N&V in pregnancy?
high bHCG
what is the cause of N&V in pregnancy?
high bHCG
associated with
multiple pregnancies
trophoblastic disease
hyperthyroidism
nulliparity
obesity
what decreases risk of N&V in pregnancy?
smoking
when is Hyperemesis gravidarum is most common?
8 to 12 weeks but can be up to 20 weeks
how is hyperemesis gravidum defined?
N&V, 5% weight loss, dehydration, electrolyte imblance
how is menorrhagia managed?
Those that dont want contraception:
- mefanamic acid 500mg TDS or transexamic acid 1g TDS - start on first day of period
requires contraception
- mirena IUD is 1st line
- COCP
what are fibroadenomas of the breast?
mobile breast lump
under 30yrs
non tender
what is fibroadenosis?
middle aged women, lumpy breasts, may be tender
symptoms may worsen prior to menstration
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
how should bisphosphonates be taken?
Twith plenty of water while sitting or standing;
to be given on an empty stomach at least 30 minutes before breakfast (or another oral medication); patient should stand or sit upright for at least 30 minutes after taking table
which blood test should be corrected before giving bisphosphonates?
calcium/ vit D
what reverses dabagatran
Idarucizumab
what is the mechanism of action of dabagatran, apixaban, rivaroxaban and edoxaban
all factor Xa inhibitors except dabagatran which is a direct thrombin inhibitor
when can clozapine for schizophrenia be issued ?
lack of clinical improvement following sequential use of at least two antipsychotics for 6-8 weeks, with at least one of these antipsychotics being from the atypical class.
what are the side effects of clozapine?
weight gain
excessive salivation
agranulocytosis
neutropenia
myocarditis
arrhythmias
what can be used as prophylaxis for oesophageal varices?
propanolol
how is a variceal haemorrhage managed?
ABCDE
terlipressin - vasoactive
prophylactic IV Abx - quinolones e.g. ciprofloxacin
then endoscopy after the above
endoscopy and band ligation
Sengstaken-Blakemore tube if uncontrolled haemorrhage
Transjugular Intrahepatic Portosystemic Shunt (TIPSS) if above measures fail
what is a Transjugular intrahepatic portosystemic shunt (TIPSS) proceedure? what does it increase the risk of?
connects the hepatic vein to the portal vein
risk of hepatic encephalopahy
when is prophylactic endoscopic band ligation offered for varices?
For those who have medium - large varices
What are the causes of optic neuritis?
MS
diabetes
sphylis
What are the features of optic neuritis?
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
what is the management of optic neuritis?
high dose steroids
what is a holmes aide pupil?
benign
responds to accomodation but poorly to light and dilates slowly after
often women
associated with absent knee/ankle reflexes
how should 1 missed COCP be managed?
take pill asap even if it means taking 2 pills in one day
no additional contraception needed
how are 2 missed COCP managed?
take the last pill even if it means taking two pills in one day, leave any earlier missed pills and then continue taking pills daily, one each day
the women should use condoms or abstain from sex until she has taken pills for 7 days in a row.
if pills are missed in week 1: emergency contraception if unprotected sex in the pill-free interval or in week 1
if pills are missed in week 2: no need for emergency contraception
if pills are missed in week: omitting the pill free interval
what are the symptoms of necrotising enterocolitis?
premature babies
initially: feeding intolerance, abdominal distension and bloody stools
can quickly progress to abdominal discolouration, perforation and peritonitis.
what is seen in an abdo Xray in enterocolitis?
dilated bowel loops (often asymmetrical in distribution)
bowel wall oedema
pneumatosis intestinalis (intramural gas)
portal venous gas
pneumoperitoneum resulting from perforation
air both inside and outside of the bowel wall (Rigler sign)
air outlining the falciform ligament (football sign)
what are the hallmarks of intussusception on examination?
on examination -sausage-shaped mass in the right hypochondrium and emptiness in the right lower quadrant (Dance’s sign) where not present in this patient
How is chlamydia managed?
doxycycline 7 days - 1st line
2nd line - azithromycin 1g stat OR 500mg BD 2 days
pregnancy - azithromycin/ erythromycin
dont wait results if exposure has been confirmed
which partners need to be notified with those who have chlamydia?
men with urethral symptoms - all partners in last 4 weeks prior to onset of symtoms
for women and assymptomatic men - all partners in last 6 monhts
how are contacts of those with chlamydia treated?
sample, treat and then results
Do we test for cure for treating chlamidya?
pregnant women - tested 6 weeks post azithromycin
non pregnant women/ men - not tested.
what are the live attenuated vaccines?
BCG
MMR
oral polio
yellow fever
oral typhoid
what are the toxoid vaccines?
Toxoid (inactivated toxin)
tetanus
diphtheria
pertussis
what is a conjugate vaccine?
vaccine attached to immunogenic part to enhance immunity pneumococcus (conjugate)
haemophilus (conjugate)
meningococcus (conjugate)
what is blethritis, stye, chalazion
blepharitis: inflammation of the eyelid margins typically leading to a red eye
stye: infection of the glands of the eyelids
chalazion (Meibomian cyst)
what is entropion and ectropion
entropion: in-turning of the eyelids
ectropion: out-turning of the eyelids
what is the management of a stye?
Hot compresses and analgesia. CKS only recommend topical antibiotics if there is an associated conjunctivitis
what rashes are associated with pregnancy?
Atopic eruption of pregnancy - most common, eczematous, itchy red rash. no specific treatment is needed
Polymorphic eruption of pregnancy - pruritic condition associated with last trimester, often first appear in abdominal striae
managed with steroids - topical or oral
Pemphigoid gestationis - pruritic blistering lesions
often develop in peri-umbilical region, later spreading to the trunk, back, buttocks and arms
usually presents 2nd or 3rd trimester and is rarely seen in the first pregnancy
oral corticosteroids are usually required
how does guillian barre present?
Hx of gastroenteritis
initially - leg or back pain (65% of people)
proggressive symmetrical weakness of limbs - ascending
few sensory signs
absent/weak reflexes
can get cranial nerve/ autonomic nerve involvement
How is guillian barre diagnosed?
LP - rise in protein, normal WCC
nerve conduction study - decreased motor nerve conduction velocity (due to demyelination)
prolonged distal motor latency
increased F wave latency
what is the management of asthma in adults?
SABA
SABA +ICS
SABA + ICS + LTRA (montelukast)
SABA + ICS + LABA (cont LTRA if working)
The above but with ICS and LABA as a MART
increase the ICS to medium lose
increase ICS to high dose / add thiophylline
what are the features of frontotemporal dementia?
often Fhx
Onset before 65
Insidious onset
Relatively preserved memory and visuospatial skills
Personality change and social conduct problems
what are the 3 types of frontotemporal lobar degeneration?
Frontotemporal dementia (Pick’s disease) - most common
Progressive non fluent aphasia (chronic progressive aphasia, CPA)
Semantic dementia
what are the clinical featurss of picks disease?
personality change and impaired social conduct. Other common features include hyperorality, disinhibition, increased appetite, and perseveration behaviours.
what are the macroscopic and microscopic features of picks disease?
Focal gyral atrophy with a knife-blade appearance is characteristic of Pick’s disease.
Macroscopic: Atrophy of the frontal and temporal lobes
Microscopic:
Pick bodies - spherical aggregations of tau protein (silver-staining)
Gliosis
Neurofibrillary tangles
Senile plaques
how is picks disease managed?
Ach receptor inhibitors
memantine
how does chronic progressive aphasia present?
non fluent speech. They make short utterances that are agrammatic. Comprehension is relatively preserved.
how does semantic dementia present?
fluent progressive aphasia. The speech is fluent but empty and conveys little meaning. Unlike in Alzheimer’s memory is better for recent rather than remote events.
what are the red flags of a headache?
Compromised immunity
< 20 years and a history of malignancy
a history of malignancy known to metastasis to the brain
vomiting without other obvious cause
worsening headache with fever
‘thunderclap’
new-onset neurological deficit
new-onset cognitive dysfunction
change in personality
impaired level of consciousness
recent head trauma
headache triggered by cough, valsalva, sneeze or exercise
orthostatic headache (chnages with posture)
symptoms suggestive of giant cell arteritis or acute narrow-angle glaucoma
a substantial change in the characteristics of their headache
how does metformin work?
acts by activation of the AMP-activated protein kinase (AMPK)
increases insulin sensitivity
decreases hepatic gluconeogenesis
may also reduce gastrointestinal absorption of carbohydrates
what are the ADRs of metformin?
gastrointestinal upsets are common (nausea, anorexia, diarrhoea), intolerable in 20%
reduced vitamin B12 absorption - rarely a clinical problem
lactic acidosis with severe liver disease or renal failure
when is metformin contraindicated?
eGFR <30 or creatinine <150
lactic acidosis if taken when there is tissue hypoxia (e.g. MI, sepsis, AKI, dhydration)
iodine containing contrast
alcohol missuse - relative contraindication
what is sweets syndrome?
Sweet’s syndrome is also known as acute febrile neutrophilic dermatosis has a strong association with acute myeloid leukaemia
which skin disorders 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 medial epiconylitis present?
pain and tenderness localised to the medial epicondyle
pain is aggravated by wrist flexion and pronation
symptoms may be accompanied by numbness / tingling in the 4th and 5th finger due to ulnar nerve involvement
what is cubital tunnel syndrome?
compression of ulnar nerve
initially intermittent tingling in the 4th and 5th finger
may be worse when the elbow is resting on a firm surface or flexed for extended periods
later numbness in the 4th and 5th finger with associated weakness
How is chronic HF managed?
ACEi and B blockers - first line - start one at a time (bisoprolol, carvedilol) (not good for HF with preserved ejection fraction).
second line - aldosterone antagonist - monitor K
Third-line treatment should be initiated by a specialist. Options include ivabradine, sacubitril-valsartan, hydralazine in combination with nitrate, digoxin and cardiac resynchronisation therapy
furosemide - symptomatic control - no effect on mortality
influenza vaccine yearly
one off pneumococcal (unless CKD, asplenic then every 5 yrs)
what is the criteria for starting ivabradine ?
sinus rhythm > 75/min and a left ventricular fraction < 35%
what is the criteria for starting sacubitril in HF?
left ventricular fraction < 35%
considered in heart failure with reduced ejection fraction who are symptomatic on ACE inhibitors or ARBs
should be initiated following ACEi or ARB wash-out period
when is digoxin used in HF?
digoxin has also not been proven to reduce mortality in patients with heart failure. It may however improve symptoms due to its inotropic properties
it is strongly indicated if there is coexistent atrial fibrillation
who is hydralazine with nitrites in HF mainly used in (i.e. patient subgroup)?
this may be particularly indicated in Afro-Caribbean patients
cardiac resynchronisation therapy
indications include a widened QRS (e.g. left bundle branch block) complex on ECG
when is cardiac resynchronisation therapy used in HF?
widened QRS (e.g. LBBB)
what is the main ADR of colchicine?
diarrhoea
how is acute gout managed?
NSAIDs / colchicine
oral steroids if above is contraindicated
if already taking allopurinol - continue this
when is urate lowering therapy recommended? which is first line? how is it started?
to anyone after 1st acute attack of gout
allopurinol - initial dose 100 OD and then titrate every few weeks until urate <300
colchicine / NSAIDs used to cover whilst starting
how does allopurinol and febuxostat work?
Xanthine oxidase inhibitors
what is dermatitis herpetiformis?
extensor surface itchy rash
associated with coeliacs
blistering
IgA deposits
how is dermatitis herpetiformis managed?
dapsone
gluten free diet
what are the two types of dystrophinopathy ? which gene is mutated?
beckers - milder
duchennes
dystrophin gene - X linked recessive
how does duchennes muscular dystrophy present?
Progressive proximal muscle weakness from 5 years
calf pseudohypertrophy
Gower’s sign: child uses arms to stand up from a squatted position
30% of patients have intellectual impairment
when does beckers muscular dystrophy develop?
at 10 years
Do men who have had a vasectomy need to be followed up?
yes at 16 and 20 weeks for semen analysis to check its worked.
what type of bacteria is C diff?
gram + rod
which Abx is typically a cause of C diff?
clindamycin
how is C diff diagnosed?
C diff toxin in stool
how is C diff managed?
First episode of C. difficile infection
first-line therapy is oral vancomycin for 10 days
second-line therapy: oral fidaxomicin
third-line therapy: oral vancomycin +/- IV metronidazole
recurrent episodes
within 12 weeks of symptom resolution: oral fidaxomicin
after 12 weeks of symptom resolution: oral vancomycin OR fidaxomicin
life threatening - IV metro + oral vanc
what are the risk facotrs to achillis tendon problems?
quinolone use (e.g. ciprofloxacin) is associated with tendon disorders
hypercholesterolaemia (predisposes to tendon xanthomata)
what is the sign for achilis tendon rupture?
simmonds test - calf squeeze and no movement
what is vestibular neuritis?
follows viral infection
recurrent vertigo
horizontal nystagmus
no hearing loss/ tinnitus
N&V may be present
how is vestibular neuritis managed?
oral prochlorperazine
what is the cause of confusion several weks post head injury?
subdural haemorrhage can present several weeks later
what monitoring is required for those on amiodarone?
LFTs and TFTs every 6 months
what are the ADRs of amiodarone?
thyroid dysfunction: both hypothyroidism and hyper-thyroidism
corneal deposits
pulmonary fibrosis/pneumonitis
liver fibrosis/hepatitis
peripheral neuropathy, myopathy
photosensitivity
‘slate-grey’ appearance
thrombophlebitis and injection site reactions
bradycardia
lengths QT interval
what are the drug drug interactions of amiodarone?
increased digoxin
reduced metabolism of warfarin therefore high INR
how is COPD managed?
smoking cessation
annual flu, one off pneumoccacal
pulmonary rehab if MRC grade is 3 or above
SABA or SAMA as 1st line
second step depends on if asthma features:
- check for any prev asthma/ atopy/ high eosinophil/ variation in FEV1/ peak flow
- if no add LABA and LAMA (stop SAMA, cont SABA)
- if yes add LABA + ICS (can add LAMA too if still symptomatic)
what antibiotic prophylaxis is used for COPD?
azithromycin is used for some patients
- do not smoke
- ECG to exclude QT prolongation
- LFTS
which Mx options improve survival in COPD?
smoking cessation
LTOT
lung reduction surgery
which COPD are given a home supply of oral Abx and steroids?
frequent exacerbations e.g. 3 in 1 yr
what is the PHQ-9 scoring?
for depression
0-4 no depression
5-9 mild
10-14 moderate
14-19 mod/severe
>19 severe
what nerve route are for ankle, knee, bicep and tricep reflex?
S1-2 ankle
L3-4 - knee
C5-6 - elbow
tricep - C7-8
what is the most common cause of post coital bleeding?
cervical ectropian
what are the causes of parotid swelling?
Bilateral causes
viruses: mumps
sarcoidosis
Sjogren’s syndrome
lymphoma
alcoholic liver disease
Unilateral causes
tumour: pleomorphic adenomas
stones
infection
How can patients with poor oral compliance/ overdose to antipsychotcis be managed?
IM depo antipsychotic injections
what are the ADRs of atypical antipsychotics?
weight gain
clozapine is associated with agranulocytosis (see below)
hyperprolactinaemia
what is the risk of atypical antipsychotics in elderly?
increased stroke and VTE
what does onlanzapine carry higher risk of compared to other atypical antipsychotics?
onlanzapine
when can clozapine be used?
if others have been tried - two or more for atleast 6-8 weks each
what are the ADRs of clozapine?
agranulocytosis
reduced seizure threshold
constipation
myocarditis - baseline ECG before
hypersalivation
why might the dose of clozapine need to be adjusted?
if patient starts/ stops smoking
how are palpitations investigated?
ECG
bloods - inc TFTs, UEs, FBC
holter monitor
how does williams syndrome in children present?
supravalvular aortic stenosis
upturned nose
long philtrum (gap between nose and lip)
wide mouth, full lips, small chip
puffy eyes
very friendly
what conditions cause aortic stenosis in chidlren?
williams
coarctation
turners
what is the preferred management of bilateral adrenal hyperplasia causing primary hyperaldosteronism? what about a unilateral adenoma?
spironolactone
unilateral - surgery
what are the features of primary hyperaldosteronism?
HTN
hypoK - muscle weakness
alkalosis
what is the most common cause of primary hyperaldosteronism?
bilateral idiopathic adrenal hyperplasia
how is primary hyperaldosteronism investigated?
aldosterone : renin ratio - shows high aldosterone, low renin
then high resolution CT abdo and adrenal vein sampling
how are pregnant women who have previously had gestational diabetes tested? when is the test performed if no previous diabetes?
oral glucose tolerance test as soon as possible after booking
otherwise oral glucose tolerance test at 24-28 weeks
what are the risk factors for gestational diabetes?
BMI >30
previous macroscomic baby >4.5kg
prev. gestational diabetes
1st degree relative with diabetes
family origin of high prevalence
what are the diagnostic thresholds for gestational diabetes?
fasting glucose >/= 5.6
2 hour glucose >/= 7.8
how is gestational diabetes managed?
attend joint diabetes/antenatal clinic within 1 week
education - food and BMs
if fasting glucose <7mM - trial of diet and exercise offered.
if targets not met within 1-2 weeks - metformin.
if still not med - insulin (short acting only)
if >7mM at booking - start insulin.
if 6-6.9 but evidence of macrosomia, hydramnios - insulin
how is gestational diabetes managed?
attend joint diabetes/antenatal clinic within 1 week
education - food and BMs
if fasting glucose <7mM - trial of diet and exercise offered.
if targets not met within 1-2 weeks - metformin.
if still not med - insulin (short acting only)
if >7mM at booking - start insulin.
if 6-6.9 but evidence of macrosomia, hydramnios - insulin
how is pre-existing diabetes managed in pregnancy?
stop meds except metformin
start insulin
folic acid 5mg/day from pre-conception to 12 weeks
anomoly scan at 20 weeks
how are epileptic women who want to get pregnant managed?
carbamazepine / lamotrigine
stop valproate
phenytoin - associated with cleft lip
start 5mg of folic acid / day
if taking phenytoin then give vitamin K in last month of preg
what advise is given to mothers who are epilpetic and breastfeding?
antiepileptics are safe
what is CHADSVASc?
C - congestive heart failure
H - HTN
A - Age >75 (2), age >65 (1)
D - diabetes
S - stroke/TIA/VTE - 2 points
V - vascular disease - IHD/PVD
S - Sex (female)
anticoagulation if 2 or more
if 1 in males consider anticoag
How is PTSD managed?
watchful waiting may be used 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
If drug treatment is used then venlafaxine or a selective serotonin reuptake inhibitor (SSRI), such as sertraline should be tried. In severe cases, NICE recommends that risperidone may be used
how often do women have cervical smear?
Age 25 years: first invitation.
Age 25-49 years: screening every 3 years.
Age 50-64 years: screening every 5 years.
what does the cervical smear invovle?
looks for high risk HPV
if positive tests cytology
how does trichomonas vaginalis present?
vaginal discharge: offensive, yellow/green, frothy
vulvovaginitis
strawberry cervix
pH > 4.5
in men is usually asymptomatic but may cause urethritis
how is trichomona vaginalis managed?
oral metro 5-7 days
what are the features of syphilis? and phases of infection?
primary: painless ulcer, local non tender lymphodenopathy
latency
secondary (6 -10 weeks later) - rash on trunk/palms/soles, fevers, buccal ulcers, condylomata lata (painless warty lesions on penis)
tertiary:
gummas (granulomatous lesions of the skin and bones)
ascending aortic aneurysms
general paralysis of the insane
tabes dorsalis
Argyll-Robertson pupil
what are the features of congenital syphilis?
blunted upper incisor teeth (Hutchinson’s teeth), ‘mulberry’ molars
rhagades (linear scars at the angle of the mouth)
keratitis
saber shins
saddle nose
deafness
what are the ADRs of methotrexate?
mucositis
myelosuppression
pneumonitis
pulmonary fibrosis
liver fibrosis
what monitoring is recommended for patients using methotrexate?
FBC, UEs, LFTs
repeat weekly until stablised
then 2-3 months
what should be prescribed with methotrexate?
folic acid
take >24hours after methotrexate
how is paracetamol OD managed?
activated charcoal if <1hr
NAC
liver transplantation
How is salicylate OD managed?
urinary alkalinisation
haemodialysis
how are benzo OD managed? what are the risks of this?
flumazentil
however risk of seizures with this so only if severe
How are tricyclic OD managed?
IV bicarb
avoid class 1a / flecainide as these prolong QT
How is lithium OD managed?
saline if mild/mod
haemoldialysis if severe
How is B blocker OD managed?
atropine for brady
glucagon if resistent
how is methanol poisoning managed?
fomepizole or ethanol
haemodialysis
how is organophosphate insecticide managed?
atropine
How is digoxin OD managed?
antibodies to fragments of digocin
How is iron OD managed?
desferrioxamine
how is lead OD managed?
dimercaprol
calcium edetate
how is cyanide OD managed?
hydroxocobalamin
when is obstetric cholestasis seen ? what are the symptoms?
a.ka. intrahepatic cholestasis
seen in 3rd trimester
pruritis often palms and soles
no rash
raised bilirubin
how is obsteritic cholestasis managed?
ursodeoxycholic acid for symptom relief
weekly LFTs
induce at 37 weeks
what are the complications of obstertic cholestasis?
still birth
prematurity
passage of meconium
post partum haemorrhage
what are the features of acute fatty liver of pregnancy?
abdominal pain
nausea & vomiting
headache
jaundice
hypoglycaemia
severe disease may result in pre-eclampsia
3rd trimester or immediately after delivery
high ALT
what does a significatn drop in renal function post starting ACEi indicate?
renal artery stenosis
what causes renal artery stenosis?
predominately atherosclerosis
in young women - fibromuscular dysplasia
what are the side effects of ACEi?
dry cough - due to increase bradykinin
hyperkalaemia
angiooedma - even after 1 yr of starting
hypotension
what monitoring is needed for those on ACEi?
U&Es before treatment and after increasing dose
if creatinine >30% of baseline or K >5.5 , may need to stop
how is acute prostatitis managed?
quinolone - e.g. ciprofloxacin or oflaxacin
or trimethroprim
which Abx is used for hospital acquired pneumonia?
wihin 5 days of admission: co-amoxiclav or cefuroxime
More than 5 days after admission: piperacillin with tazobactam OR a broad-spectrum cephalosporin (e.g. ceftazidime) OR a quinolone (e.g. ciprofloxacin)
which Abx is used to treat cellulitis?
flucloxacillin OR clarithromycin/doxy/erythromycin if pen allergy
if near eyes/nose - co-amox (or clarithro + metro if pen allergy)
which Abx is used for gonorrhoea?
IM ceftriaxone
which Abx is used for PID?
Oral ofloxacin + oral metronidazole or intramuscular ceftriaxone + oral doxycycline + oral metronidazole
which Abx is used for syphilis?
benzylpen or doxy or erythromycin
which Abx for bacterial vaginosis?
oral /topical metronidazole
which type of stroke presents as purely motor or purely sensory deficit?
lacunar
who should be referred for urgent cancer pathway in breast cancer?
aged 30 or over and have unexplained breast lump
aged 50 and over with any of the following in one nipple only - retraction, discharged, other change of concern
how does developmental dysplasia of the hip present in children?
usually found on new born exam
barlows and ortolani test positve
unequal skin folds/ leg length
how does transient synocitis of the hip present?
usually 2-10yrs of age
usually associated with viral infection
sudden onset hip pain and limping
gets better
what is perthes disease?
avascular necrosis of femoral head - occurs in 4-8yrs olds
more common in boys. can be bilateral
what are the symptoms of perthes?
hip pain - over few weeks
limp
stiffness
what are the symptoms of slipped upper femoral epiphysis?
typically ages 1–15
overweight
often boys
knee or distal thigh pain
loss of internal rotation of leg in flexion
which cancer is Ca 19-9 associated with?
pancreatic
which Ab tumour marker is breast cancer associated with?
Ca 15-3
which cancer is alpha fetoprotein associated with?
HCC (liver), teratoma
which cancer is S-100 associated with?
melanoma, schwanomas
which cancer is bombesin tumour marker associated with?
Small cell lung
gastric
neuroblastoma
what is the difference between hypertrichosis and hirsutism ?
hirsuitism - caused by excess androgens
hypertrichosis - excess hair growth in areas that would normally not have hair
what causes hypertrichosis?
porphyria cutanea tarda
anorexia nervosa
drugs: minoxidil, ciclosporin, diazoxide
how is hirsutism managed?
topical eflornithine (contraindicated in preg/breast feeding)
what Ix is required before starting biologics for autoimmune conditions?
CXR - look for TB (risk of reactivation)
what is the management for RA for those newly diagnosed?
DMARD monotherapy + short course of bridging steroids
monitor CRP and disease actiivty (DAS28)
when are TNF inhibitors indicated in RA management?
inadequate response to atleast 2 DMARDs
how can ewings sarcoma and osteosarcoma be differentiated?
osteosarcoma - adolescents - long bones. xray shows codman triangle and sunburst pattern.
ewings sarcoma - children/adolescent. pelvis and long bones. severe pain. xray shows onion skin appearance
which drugs should be avoided in HOCM?
ACEi
inotropes
nitrates
What is the management of HOCM?
amiodarone
B blockers
Cardioverter defib
Dual chamber pacemaker
Endocarditis prophylaxis - no longer
ABCDE
what are the features of hepres keratitis?
dendritic corneal ulcer
red painful eye
photophobia
epiphora
visual acuity reduced
what is the cause of breast abscesses in lactating women?
S.aureus
what can new LBBB suggest?
MI, HTN, aortic stenosis, cardiac myopathy
how long before an on should COCP be stopped?
4 weeks before
