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
which meds increase risk of VTE?
combined oral contraceptive pill
hormone replacement therapy: more for those on O+P
raloxifene and tamoxifen
antipsychotics esp olanzapine
what is the GRACE score?
a scoring mechanism to assess the 6 month mortality of those with MIs. Includes age, ECG, troponin and renal function, killip class (i.e. HF), HR and BP, cardiac arrest at presentation
how are ACS managed?
MONA
morphine 10mg oral
oxygen if low sats
GTN spray - only used in ongoing chest pain.
aspirin 300mg
anything over 6% is high mortality
what is the criteria for a STEMI?
symptoms >20mins
ECG changes >20 mins
2 contiguous leads of
- more than 2.5 small squares of ST elevation in V2-3 in men <40yrs or >2 small squares in over 40yrs
- >1.5 small squares in women
- 1 small square ST elevation in other leads
- new LBBB
How are STEMIs managed?
- aspirin 300mg
- is PCI possible within 120 mins
if yes –> give prasugrel , unfractionated heparin + bailout glycoprotein IIb/IIIa inhibitor (radial access)
if femoral access instead bivalirudin + bailout GPI
if no - fibrinolysis with antithrombin (fondaparinux/ unfractionated heparin). after give ticagrelor
what is the time frame for fibrinolysis to be offered in STEMI? what should be done 90mins after treatment?
12 hours of symptoms onset if PCI cant be offered within 120mins
do ecg 90mins after and if no resolution of ST elevation , then transfer for PCI
when can PCI be offered?
should be offered if the presentation is within 12 hours of the onset of symptoms AND PCI can be delivered within 120 minutes of the time when fibrinolysis could have been given
which NSTEMI patients should have coronary angiography + PCI?
immediately - if unstable
within 72 hours - if GRACE >3%
further ischaemic event after admission
what is the conservative management of NSTEMI/ unstable angina?
aspirin + further antiplatelet
ticagrelor if not high risk bleed
clopidogrel if high risk bleed
what is the classification of aortic dissection?
type A - ascending - majority of cases
type B - descending
what are the investigation findings of aortic dissection?
BP in all 4 limbs - difference of >20mmHg between left and right arm (right arm is higher).
dimished femoral pulses - more so on the right
CXR - widened mediastinum
D dimer - raised a lot
CT angio
TOE - more suitable for unstable patients who cant go for scan
How is aortic dissection managed?
type a - surgical - maintain BP at 100-120mmHg whilst waiting
type B - IV labetalol to prevent progression, conservative management - bed rest
what are the complications of aortic dissection?
Complications of backward tear
aortic incompetence/regurgitation
MI: inferior pattern is often seen due to right coronary involvement
Complications of a forward tear
unequal arm pulses and BP
stroke
renal failure
how are venous ulcers managed?
compression dressing
need to do ABPI before to check no arterial disease
what Ankle brachial pressure index (ABPI) values can indicate arterial disease
normal ABPI = 0.9 to 1.2
below 0.9 or 1.3 and above can indicate arterial disease
when is a carotid endartectomy considered?
stroke/ TIA symptoms in territory of carotid artery that has 70% or more stenosis
How is stroke managed?
Once haemorrhage has been excluded:
- aspirin 300mg asap
- BP should not be lowered in acute phase unless complications such as hypertensive encephalopathy
- thrombolysis within 4.5 hours
- thrombectomy
if AF - anticoagulation started 14 days later
if cholesterol >3.5, statins started 48hours after (risk of haemorrgage)
what are the absolute contraindications to thrombolysis?
- Previous intracranial haemorrhage
- Seizure at onset of stroke
- Intracranial neoplasm
- Suspected subarachnoid haemorrhage
- Stroke or traumatic brain injury in preceding 3 months
- Lumbar puncture in preceding 7 days
- Gastrointestinal haemorrhage in preceding 3 weeks
- Active bleeding
- Pregnancy
- Oesophageal varices
- Uncontrolled hypertension >200/120mmHg
what are the relative contraindications to thombolysis?
- Concurrent anticoagulation (INR >1.7)
- Haemorrhagic diathesis
- Active diabetic haemorrhagic retinopathy
- Suspected intracardiac thrombus
- Major surgery / trauma in the preceding 2 weeks
what are the guidelines for thrombolysis/thrombectomy in stroke?
confirmed PAC stroke - offer thrombectomy asap (if within 6 hours of symptom onset) and with IV thrombolysis (if within 4.5 hours.
confrimed PAC stroke with potential salvagable brain tissue - offer thrombectomy if within 6 and 24 hours (inc wake up strokes)
confirmed proximal posterior stroke + salvagable brain tissue - thrombectomy if within 24hours (+ thombolysis if wihtin 4.5 hrs)
what are the guidelines for thrombolysis/thrombectomy in stroke?
confirmed PAC stroke - offer thrombectomy asap (if within 6 hours of symptom onset) and with IV thrombolysis (if within 4.5 hours.
confrimed PAC stroke with potential salvagable brain tissue - offer thrombectomy if within 6 and 24 hours (inc wake up strokes)
confirmed proximal posterior stroke + salvagable brain tissue - thrombectomy if within 24hours (+ thombolysis if wihtin 4.5 hrs)
what is the secondary prevention of a stroke?
clopidogrel
if contraindicated - asprin + dipyridamole
carotid artery endartectomy
how does lichen planus present?
itchy papular rash on palms, soles, flexor surfaces, genitalia
polygonal in shape
white lines pattern (typically white lace pattern on buccal mucosa)
how is lichen planus managed?
topical steroids
benzydamine mouthwash
what are the basic 1st investigations for fertility?
semen analysis
serum progesterone 7 days prior to expected next period (should be >30 to indicate ovulation)
how is epididymo -orchitis managed?
ceftriaxone 500mg IM plus doxycycline 100mg BD 10-14days
what are the differences in xray finding in RA and osteoartritis?
OA: LOSS
loss of joint space, osteophytes, subchondral cysts, subchondral sclerosis
RA: LESS
loss of joint space, erosions, soft tissue swelling, soft bones (osteopenia - juxta-articular osteoporosis)
what screening is recommended for hepatocellular carcinoma?
for those at high risk e.g. liver cirrhosis secondary to hep B/C or haemochromatosis OR men with cirrhosis secondary to alcohol
screening with USS +/- alpha fetoprotein
what is the most common cause of HCC in europe and worldwide?
worldwide - hep B
europe - hep C
how are fungal nail infections managed?
dermatophyte infetion:
oral terbinafine
toe nails - treat 3 months - 6months
finger nails - 6 weeks to 3 months
candida infection - topical antifungals. but if severe oral itraconazole 12 weeks
how is bacterial vaginosis in pregnancy managed?
oral metronidazole
which microbe causes bacterial vaginosis?
gardnerella vaginalis
what is the criteria for diagnosing bacterial vaginosis?
Amsel’s criteria for diagnosis of BV - 3 of the following 4 points should be present
thin, white homogenous discharge
clue cells on microscopy: stippled vaginal epithelial cells
vaginal pH > 4.5
positive whiff test (addition of potassium hydroxide results in fishy odour)
why is PH high in bactrial vaginosis?
overgrowth of gardnerella means less lactic acid producing bacteria.
what is management of bacterial vaginosis?
metro 5-7 days (in preg too)
How is COPD diagnosed?
anyone >65 with chronic cough, productive, exertional breathlessness
FEV/FEV1
CXR
blood test - check for polycythaemia
BMI
How is COPD severity graded?
all should have FEV/FEV1 <0.7
mild - FEV1 <0.8% predicted
moderate - 50-79% predicted
severe - 30-49%
very severe - <30%
Is HIV a notifiable disease?
No
what pattern on spirometry does ARDS give?
restrictive
which antidepressant is used in children/ adolescents?
fluoxetine
which antidepressant is safest post MI?
sertraline
what are the ADRs of SSRIs?
Gastrointestinal symptoms are the most common side-effect
there is an increased risk of gastrointestinal bleeding in patients taking SSRIs.
anxiety and agitation after starting a SSRI
hyponatraemia
when starting antidepressants when should patients be reviewed?
2 weeks after starting
if <30 - 1 week as higher risk of suicide
how are SSRIs stopped?
only 6 months after symptoms resolved
stop slowly over 4 week period (not needed with fluoexetine)
what is discontinuation syndrome with SSRIs?
increased mood change
restlessness
difficulty sleeping
unsteadiness
sweating
gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting
paraesthesia
which SSRI has highest incidence of discontinuation syndrome?
paroextine
Can SSRIs be used in preganncy?
BNF says to weigh up benefits and risk when deciding whether to use in pregnancy.
- Use during the first trimester gives a small increased risk of congenital heart defects
- Use during the third trimester can result in persistent pulmonary hypertension of the newborn
- Paroxetine has an increased risk of congenital malformations, particularly in the first trimester
what are the features of horners syndrome?
miosis (small pupil)
ptosis
enophthalmos* (sunken eye)
anhidrosis (loss of sweating one side)
what is seen in congential horners?
heterochromia (difference in iris colour) i
How are the causes of horners distinguished?
central lesion - anhydrosis of the arms, trunk, face
e.g.stroke, Syringomyelia, Multiple sclerosis, Tumour, Encephalitis
pre ganglionic lesion - anhydrosis of face
Pancoast’s tumour, Thyroidectomy, Trauma, Cervical rib
post ganaglionic lesion - no anhydrosis
Carotid artery dissection, Carotid aneurysm, Cavernous sinus thrombosis, Cluster headache
how do epididymal cysts present?
separate from the body of the testicle
found posterior to the testicle
when are infantile hydroceeles repeaired?
if they do not regress spontaneously in 1-2 yrs
what significant complication do varicoceles have?
associated with infertility
What are the ADRs of isotretinoin?
teratogenicity
dry skin, eyes and lips/mouth- most common side-effect
low mood
depression and other psychiatric problems
raised triglycerides
hair thinning
nose bleeds (caused by dryness of the nasal mucosa)
intracranial hypertension: isotretinoin treatment should not be combined with tetracyclines for this reason
photosensitivity
how is BPPV diagnosed?
positive Dix-Hallpike manoeuvre, indicated by:
patient experiences vertigo
rotatory nystagmus
how is BPPV managed?
epley manoeuvre - treats 80%
Brandt-Daroff exercises
what can parvovirus B19 do to pregnant women?
hydrops fetalis
parvovirus B19 in pregnant women can cross the placenta in pregnant women
this causes severe anaemia due to viral suppression of fetal erythropoiesis → heart failure secondary to severe anaemia → the accumulation of fluid in fetal serous cavities (e.g. ascites, pleural and pericardial effusions)
treated with intrauterine blood transfusions
what are the extra features of ank spondylitis?
Apical fibrosis
Anterior uveitis
Aortic regurgitation
Achilles tendonitis
AV node block
Amyloidosis
and cauda equina syndrome
peripheral arthritis (25%, more common if female)
how are aspergillomas formed?
fungal mass in preformed cavities
associated with TB , sarcoidosis, bronchiectasis, and ankylosing spondylitis, lung cancer, CF. all of these diseases create cavities
How does aspergillomas present? including Ix
cavitating lung mass on CXR
. A crescent sign may be present
high titres Aspergillus precipitins
cough and sometimes haemoptysis
how is secondary dysmenorrhoea managed?
refer any secondary dysmenorrhea (period pains that start later) to gynae
what are the major risk factors of osteoporosis?
history of glucocorticoid use
rheumatoid arthritis
alcohol excess
history of parental hip fracture
low body mass index
current smoking
others
sedentary lifestyle
premature menopause
chronic kidney disease
what predisposes to gluttate psoriasis?
streptococcal infection 2-4 weeks before
what is the difference between acute cholecystitis and ascending cholangitis?
acute cholecystitis - infection of common bile duct
ascending cholangitisi - infection of common hepatic duct
Right upper quadrant (RUQ) pain, fever and raised inflammatory markers suggests acute cholecystitis or ascending cholangitis. The abnormal liver function tests (LFTs) suggest ascending cholangitis rather than cholecystitis (according to Charcot’s triad of RUQ pain, fever and jaundice for cholangitis).
what are the absolute contraindications to COCP?
more than 35 years old and smoking more than 15 cigarettes/day
migraine with aura
history of thromboembolic disease or thrombogenic mutation
history of stroke or ischaemic heart disease
breast feeding < 6 weeks post-partum
uncontrolled hypertension
current breast cancer
major surgery with prolonged immobilisation
positive antiphospholipid antibodies (e.g. in SLE)
How does otosclerosis present?
Onset is usually at 20-40 years - features include:
conductive deafness
tinnitus
normal tympanic membrane*
positive family history - auto dominant
what are the side effects of tamoxifen and anastrazole?
tamoxifen
menstrual disturbance: vaginal bleeding, amenorrhoea
hot flushes
venous thromboembolism
endometrial cancer
anastrazole
osteoporosis
NICE recommends a DEXA scan when initiating a patient on aromatase inhibitors for breast cancer
hot flushes
arthralgia, myalgia
insomnia
what is anastrazole?
aromatase inhibitor - for breast cancer in post menopausal women
what is talipes equinovarus?
club foot, describes an inverted (inward turning) and plantar flexed foot
diagnosed at newborn exam
what are the assocaitions to talipes equinovarus
males
spina bifida
cerebral palsy
Edward’s syndrome (trisomy 18)
oligohydramnios
arthrogryposis - congenital contractures
50% are bilateral
how is talipes equinovarus managed?
conservative methods such as the Ponseti method - manual manipulation
Achilles tenotomy is required in around 85% of cases but this can usually be done under local anaesthetic
how is acute dystonic reaction managed?
IV procyclidine
how does degenerative cervical myelopathy present?
Pain (affecting the neck, upper or lower limbs)
Loss of motor function (loss of digital dexterity, arm or leg weakness/stiffness leading to impaired gait and imbalance)
Loss of sensory function causing numbness
Loss of autonomic function
Hoffman’s sign
how is degenerative cervical myelopathy diagnosed?
MRI cervical spine
How is degenrative cervical myelopathy managed?
Urgently referred for assessment by specialist spinal services due to the importance of early treatment.
any existing spinal cord damage can be permanent.
Early treatment (within 6 months of diagnosis)
how is cocaine toxicity managed?
Chest pain: benzodiazepines + glyceryl trinitrate. If myocardial infarction develops then primary percutaneous coronary intervention
hypertension: benzodiazepines + sodium nitroprusside
how does cocaine toxicyt present?
Cardiovascular effects include:
coronary artery spasm → myocardial ischaemia/infarction
both tachycardia and bradycardia may occur
hypertension
QRS widening and QT prolongation
aortic dissection
Neurological effects
seizures, mydriasis., hypertonia, hyperreflexia
Psychiatric effects
agitation. psychosis. hallucinations
metabolic acidosis , rhabdomyolysis, hyperthermia
How are patients with paroxysmal AF managed by anticoagulation?
chadsvasc
warfarin even after dc cardioversion cont life long
how is DC cardioversion performed?
synchronised to the R wave to prevent delivery of a shock during the vulnerable period of cardiac repolarisation when ventricular fibrillation can be induced
what anticoag is needed for those with cardioversion?
<48hr of AF
- heparinised before DC
> 48hr of AF
- 3 weeks of anticoag prior
- or transoesophageal echo to cjeck for thrombus
continue anticoag after for those who have chadsvas>1 but atleast 4 weeks of anticoag
what are the methods of cardioversion?
DC electrical
pharmacological - amiodarone / flecainde (amiodarone is chosen if structural heart disease)
what is the action of finasteride?
inhibitor 5a reductase - metabolises testosterone to DHT
what are the indications of finasteride?
male patern baldness
BPH
what are the ADRs of finasteride?
impotence
decrease libido
ejaculation disorders
gynaecomastia and breast tenderness
what does finasteride do to PSA levels?
decrease
what is the curb 65?
C Confusion (abbreviated mental test score <= 8/10)
U urea > 7 mmol/L
R Respiration rate >= 30/min
B Blood pressure: systolic <= 90 mmHg and/or diastolic <= 60 mmHg
65 Aged >= 65 years
how is pneumonia managed?
based on curb65
0-1 - at home, amoxicillin
2 - hospital for oral Abx
3 - IV Abx
moderate and high-severity community acquired pneumonia
dual antibiotic therapy is recommended with amoxicillin and a macrolide. a 7-10 day course is recommended
a repeat chest X-ray at 6 weeks after clinical resolution
what are the 4 features of tetralogy of fallot?
ventricular septal defect (VSD)
right ventricular hypertrophy
right ventricular outflow tract obstruction, pulmonary stenosis
overriding aorta
when is tetralogy of fallot picked up?
1-2 months
what determines the severity of Tetralogy of fallot?
severity of the right ventricular outflow tract obstruction
what are the symptoms of tetralogy of fallot?
cyanosis
episodic hypercyanotic ‘tet’ spells - tachypnoea and severe cyanosis that may occasionally result in loss of consciousness
they typically occur when an infant is upset, is in pain or has a fever
ejection systolic murmur due to pulmonary stenosis
what is seen on a cxr in tetralogy of fallot?
a right-sided aortic arch is seen in 25% of patients
chest x-ray shows a ‘boot-shaped’ heart, ECG shows right ventricular hypertrophy
who is BPH most common in?
black >asian>white
what is the management of BPH?
watchful waiting
alpha-1 antagonists e.g. tamsulosin, alfuzosin
decrease smooth muscle tone of the prostate and bladder
considered first-line: NICE recommend if moderate-to-severe voiding symptoms (IPSS ≥ 8)
5 alpha-reductase inhibitors e.g. finasteride
indicated if the patient has a significantly enlarged prostate and is considered to be at high risk of progression.
combinations can be used.
if there is a mixture of storage symptoms and voiding symptoms that persist after treatment with an alpha-blocker alone, then an antimuscarinic (anticholinergic) drug such as tolterodine or darifenacin may be tried
surgery
transurethral resection of prostate (TURP)
what are the ADRs of alpha 1 antagonists?
dizziness, postural hypotension, dry mouth, depression
how do 5a reductase inhibitors differ to alpha 1 antagonists in BPH?
unlike alpha-1 antagonists causes a reduction in prostate volume and hence may slow disease progression. This however takes time and symptoms may not improve for 6 months
what is the IPSS?
International Prostate Symptom Score (IPSS)
tool for classifying the severity of lower urinary tract symptoms (LUTS) and assessing the impact of LUTS on quality of life
Score 20–35: severely symptomatic
Score 8–19: moderately symptomatic
Score 0–7: mildly symptomatic
how is BPH assessed?
dipstick urine
U&Es: particularly if chronic retention is suspected
PSA: should be done if there are any obstructive symptoms, of if the patient is worried about prostate cancer
urinary frequency-volume chart - should be done for at least 3 days
what are the symptoms of acoustic neuroma?
vertigo, hearing loss, tinnitus and an absent corneal reflex.
how are acoustic neuromas investigated?
MRI of the cerebellopontine angle
which drugs cause toxic epidermal necrolysis?
phenytoin
sulphonamides
allopurinol
penicillins
carbamazepine
NSAIDs
what genetic issue caues CF?
due to a defect in the cystic fibrosis transmembrane conductance regulator gene (CFTR), which codes a cAMP-regulated chloride channel
how are patients with controlled asthma stepped down?
3 months at a time
reduce steroids by 25-50%
which antisickness is contraindicated in parkinsons?
metaclopramide
what are the ADRs of metoclopramide?
extrapyramidal effects: oculogyric crisis. This is particularly a problem in children and young adults
hyperprolactinaemia
tardive dyskinesia
parkinsonism
what re the strokes to taking sildenafil (PDE V inhibitor)
concurrent use of nitrites
hypotension
previous stroke/ MI
what are the side effects of sildenafil?
visual disturbances- blue discolouration
non-arteritic anterior ischaemic neuropathy
nasal congestion
flushing
gastrointestinal side-effects
headache
priapism
How are spider naevi and telangectasia differentiated?
Spider naevi can be differentiated from telangiectasia by pressing on them and watching them fill. Spider naevi fill from the centre, telangiectasia from the edge.
what are the causes of hydroceles?
communicating hydrocele - opening of processus vaginalis - present in new born
those that present in adults :
epididymo-orchitis
testicular torsion
testicular tumours
How is hydrocele managed?
in new born - watch and wait, usually resolve in few months. repaiered if still present after 1-2 yrs
in adults if testicle cant be examined - urgent USS
How is HIV in pregnancy managed?
No breastfeeding
vaginal delivery is recommended if viral load is less than 50 copies/ml at 36 weeks, otherwise caesarian section is recommended
a zidovudine infusion should be started four hours before beginning the caesarean section
zidovudine is usually administered orally to the neonate if maternal viral load is <50 copies/ml. Otherwise triple ART should be used. Therapy should be continued for 4-6 weeks.
where do majority of nose bleeds arise?
anterior - kisselbach plexus
what % of those with positive faecal occult blood test have colorectal cancer?
5-15%
30-40% chnace of adenoma
what is the national screening programe for Colorectal cancer?
every 2 years to all men and women aged 60 to 74 years in England, 50 to 74 years in Scotland. Patients aged over 74 years may request screening
FIT test - uses Ab to detect human hb
what visual field defects occur in lesions affecting optic chiasm?
upper quadrant defect > lower quadrant defect = inferior chiasmal compression, commonly a pituitary tumour
lower quadrant defect > upper quadrant defect = superior chiasmal compression, commonly a craniopharyngioma
what visual defect occurs for acute angled gluacoma?
loss of peripheral vision
How can we distinguish between episcleritis and scleritis?
Phenylephrine 10% eye drops can be used to distinguish between episcleritis and scleritis. It blanches the redness in episcleritis but doesn’t in scleritis
scleritis causes photophobia and reduced acuity (episcleritis doesnt)
how does episcleritis present?
red eye
classically not painful (in comparison to scleritis), but mild pain/irritation is common
watering and mild photophobia may be present
50% bilateral
what are the different types of malaria prophylaxis?
chloroquine
doxyxyline
malarone (Atovaquone + proguanil)
Mefloquine (Lariam)
what are the side effects of malarone and when is it started / stoped?
GI upset
started 1-2 days beofre , stopped 7 days fater
what are the side effects of chloroquine and when is it started / stoped?
headache, contraindicated in epilepsy
started 1 week before, stopped 4 weeks later
only taken once / week
what are the side effects of doxycylcine and when is it started / stoped for malaria?
photosensitivity/ oesophagiits
take 1 - 2 days before and stop 4 weeks later
only for those >12 yrs
what are the side effects of lariam and when is it started / stoped?
dizziness, neuropsych
contraindicated in epielpsy
taken once a week
take 2-3 weeks before and stop 4 weeks after
how are pregnant women travelling to malaria regions managed?
advised not too as the parasite can be sequestratedd in placenta and undetectable
if cant be avoided - chloroquine prophylaxis is best
doxy contrindicated
proguanil - need a folate supplement
what is malingering?
Lying or exaggerating for financial gain is malingering, for example someone who fakes whiplash after a road traffic accident for an insurance payment
what is factitious disorder?
also known as Munchausen’s syndrome
the intentional production of physical or psychological symptoms
how does legionella present clinically?
Legionella include flu-like symptoms and a dry cough, relative bradycardia and confusion. Blood tests may show hyponatraemia
bibasal pneumonia
deranged LFTs
how is legionella managed?
erythromycin/ clarithromycin
how do Thiazolidinediones work?
PPARg agonists (intranuclear receptor) - reduce insulin resistance
what are the examples of TZDs used in diabetes?
pioglitazone
what are the side effects of TZDs?
weight gain
liver impairment: monitor LFTs
fluid retention - therefore contraindicated in heart failure. The risk of fluid retention is increased if the patient also takes insulin
recent studies have indicated an increased risk of fractures
bladder cancer: pioglitazone
how is opiod detoxification managed?
Methadone or buprenorphine
compliance is monitored using urinalysis
detoxification should normally last up to 4 weeks in an inpatient/residential setting and up to 12 weeks in the community
What asthma meds can be used in pregnancy?
‘inhaled drugs, theophylline and prednisolone can be taken as normal during pregnancy and breast-feeding
when should infertility be investigated for?
in <35yrs - after regular intercourse for 12 months
>35yrs - after regular intercourse for 6 months
Regular sexual intercourse is defined as intercourse every 2-3 days.
what male/ female factors warant early fertility investigation referral?
MEN:
previous surgery on genitalia, Varicocele, Previous STI, Significant systemic illness, Abnormal genital examination
FEMALE
Abnormal genital examination
Amenorrhoea Previous STI
Previous pelvic surgery
what are the basic fertility investigations?
semen analysis
serum progesterone 7 days prior to expected next period. For a typical 28 day cycle, this is done on day 21.
< 16 nmol/l Repeat, if consistently low refer to specialist
16 - 30 nmol/l Repeat
> 30 nmol/l Indicates ovulation
what is a keratocanthoma?
benign lesion
papulue with keratin filled crater
often spontaneously regresses after 3 months
how is keratocanthoma managed?
urgent derm referral and excision to rule out Squamous cell carcinoma
What is the secondary prevention for MI?
statin, B blocker, ACEi, aspirin, clopidogrel/ prasugral/ticagrelor
medeterean diet advice
light exercise
sex after 1 month
post acute coronary syndrome (medically managed): add ticagrelor to aspirin, stop ticagrelor after 12 months
post percutaneous coronary intervention: add prasugrel or ticagrelor to aspirin, stop the second antiplatelet after 12 months
Patients who have had an acute MI and who have symptoms and/or signs of heart failure and left ventricular systolic dysfunction - start aldosterone antagonist (e.g. eplerenone) within 3-14 days of the MI, preferably after ACE inhibitor therapy
what conditions are associated with coeliacs?
dermatitis herpetiformis (a vesicular, pruritic skin eruption) and autoimmune disorders (type 1 diabetes mellitus and autoimmune hepatitis
whic HLA is coeliacs associated with?
HLA-DQ2 (95% of patients) and HLA-DQ8 (80%).
what are the complications of coeliacs?
anaemia: iron, folate and vitamin B12 deficiency (folate deficiency is more common than vitamin B12 deficiency in coeliac disease)
hyposplenism
osteoporosis, osteomalacia
lactose intolerance
enteropathy-associated T-cell lymphoma of small intestine
subfertility, unfavourable pregnancy outcomes
rare: oesophageal cancer, other malignancies
what are the biopsy histology findings in coeliacs?
Duodenal biopsy from a patient with coeliac disease. Complete atrophy of the villi with flat mucosa and marked crypt hyperplasia. Intraepithelial lymphocytosis. Dense mixed inflammatory infiltrate in the lamina propria.
what are examples of thiazide like diuretics?
Indapamide
chlortalidone
when should HTN be treated?
ambulatory/ home reading consistently…
>135/85mmHg: treat if < 80 years of age AND any of the following apply; target organ damage, established cardiovascular disease, renal disease, diabetes or a 10-year cardiovascular risk equivalent to 10% or greater
>150/95 mmHg - regardles of age
how is HTN managed?
<55yrs OR diabetic = ACEi/ ARB
>55yr OR black = Calcium channel blocker
second step - add on ACEi/ CaB/ thiazide likediuretic
step 3 - add on final one missing of above
step 4:
confirm elevated clinic BP with ABPM or HBPM
assess for postural hypotension.
discuss adherence.
check pottasium - if <4.5 can add spironolactone. if >4.5 add alpha/ b blcoker
what are the blood pressure targets?
<80yrs
home - 135/85
surgery - 140/90
> 80
home - 145/85
surgery - 150/90
what are the ADRs of loop diuretics?
hypotension
hyponatraemia
hypokalaemia, hypomagnesaemia
hypochloraemic alkalosis
ototoxicity
hypocalcaemia
renal impairment (from dehydration + direct toxic effect)
hyperglycaemia (less common than with thiazides)
gout
what are the causes of cataracts?
Smoking
Increased alcohol consumption
Trauma
Diabetes mellitus
Long-term corticosteroids
Radiation exposure
Myotonic dystrophy
Metabolic disorders: hypocalcaemia
what are the symptoms of cataracts?
reduced vision - esp night
Faded colour vision: making it more difficult to distinguish different colours
Glare: lights appear brighter than usual
Halos around lights
Defect in the red reflex
what are the complications following cataracts surgery ?
Posterior capsule opacification: thickening of the lens capsule
Retinal detachment
Posterior capsule rupture
Endophthalmitis: inflammation of aqueous and/or vitreous humour
when is a referral made for sciatica?
after 4-6 weeks of conservative treatment failing
What are the features of L3 nerve root compression ?
Sensory loss over anterior thigh
Weak quadriceps
Reduced knee reflex
Positive femoral stretch test
What are the features of L4 nerve root compression?
Sensory loss anterior aspect of knee
Weak quadriceps
Reduced knee reflex
Positive femoral stretch test
What are the features of L5 nerve root compression?
Sensory loss dorsum of foot
Weakness in foot and big toe dorsiflexion
Reflexes intact
Positive sciatic nerve stret
What are the features of S1 nerve root compression?
Sensory loss posterolateral aspect of leg and lateral aspect of foot
Weakness in plantar flexion of foot
Reduced ankle reflex
Positive sciatic nerve stretch test
what happens to body temp during menstration?
falls prior to ovulation due to oestrogen
rising in luteal phase due to progesterone
How does cervical mucus chnage throughout cycle?
Following menstruation the mucus is thick
Just prior to ovulation the mucus becomes clear, acellular, low viscosity. It also becomes ‘stretchy’
in luteal phase - thick mucus
who is offered bone protection on steroids?
> 15mg steoids for >3 months or equivalent e.g. newly diagnosed polymyalgia rheumatica
who is offered bone protection on steroids?
> 15mg steroids for >3 months or equivalent e.g. newly diagnosed polymyalgia rheumatica
when are bisphosphonates offered?
- > 65yrs
- previous fragility fracture
- <65ys and T score of <-1.5
how are patients managed depending on T score for bone protection?
> 0 - reassure
0 to -1.5 rearragnge DEXA in 1-3 yrs
<-1.5 bone protection
first line alendronate + calcium + vit D
what are the initial investigations for incontinence?
bladder diaries should be completed for a minimum of 3 days
vaginal examination to exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles (‘Kegel’ exercises)
urine dipstick and culture
urodynamic studies
How is stress incontinence managed?
pelvic floor muscle training- at least 8 contractions performed 3 times per day for a minimum of 3 months
surgical procedures: e.g. retropubic mid-urethral tape procedures
duloxetine may be offered to women if they decline surgical procedures
how does duloxetine work for stress incontinece?
a combined noradrenaline and serotonin reuptake inhibitor
mechanism of action: increased synaptic concentration of noradrenaline and serotonin within the pudendal nerve → increased stimulation of urethral striated muscles within the sphincter → enhanced
what is the management of Urge incontinece?
bladder retraining (lasts for a minimum of 6 weeks)
bladder stabilising drugs: antimuscarinics are first-line
NICE recommend oxybutynin (immediate release), tolterodine (immediate release) or darifenacin (once daily preparation)
Immediate release oxybutynin should, however, be avoided in ‘frail older women’
mirabegron (a beta-3 agonist) may be useful if there is concern about anticholinergic side-effects in frail elderly patients
how does the cervical screening programme work ?
women aged 25 to 49
every 3 years
smear for HPV
if negative - repeat in 3 years as normal
if positive , samples are sent for cytology
- normal cytology - repeat smear in 1 year
- if still abnromal in 12 months - repeat again in 12 months.
- if abnormal on 2nd repeat - then colposcopy
- abnormal - refer for colposcopy
inadequate sample - repeat in 3 months.
2 consecutive inadequate samples - colposcopy
which cytology results of cervical smear are regarded as abnormal?
borderline changes in squamous or endocervical cells.
low-grade dyskaryosis.
high-grade dyskaryosis (moderate).
high-grade dyskaryosis (severe).
invasive squamous cell carcinoma.
glandular neoplasia
How is CIN treated?
Large loop excision of transformation zone (LLETZ)
which scoring system is used to assess:
a) seveirity of liver cirrhosis
b) severity of anxiety
c) alchol screening
a) Child pugh
b) HAD or GAD (HAD for hospitals)
c) AUDIT, CAGE or FAST*
which questionaire is used to detect eating disorders and aid treatment
SCOFF
which scoring system indicates prognosis in prostate cancer?
Gleason
what is the bishop and APGAR score?
bishop - assess abiluty to induce labour
APGAR - assess health of a newborn immediately
what is the ranson criteria used for?
acute pancreatitis
which vlave does infective endocartiditis most commonly affect?
mitral
tricuspid in IVDU
what is the most common organism cause of I.E?
S.aureus
what are the different organisms in I.E associated with?
S.viridans = streptococcus mitis and Streptococcus sanguinis - usually following dental work
S.auresu - IVDU
S epidermidis - indwelling lines/ prosthetic valve surgery
streptococus bovis and particularly S.gallolyticus is most linked with colorectal cancer
how are janeway lesions and oslers nodes differentiated?
janeway lesions (erythematous macular or nodular lesions caused by septic emboli) - usually on palms
osler nodes (painful erythematous lesions caused by immune complex deposition) - usually on fingers
what are the side effects of
a) penicillamine
b) Etanercept
c) Gold
d) hydroxychloroquine
Penicillamine - Proteinuria and Exacerbation of myasthenia gravis
Etanercept - Demyelination, Reactivation of tuberculosis
Gold - proteinuria
hydroxychloroquine- retinopathy, corneal deposits
what are the side effects of
a) leflunomide
b) sulphasalazine
c) methotrexate
leflunomide: liver impairment, ILD, HTN
methotrexate:Myelosuppression, Liver cirrhosis, Pneumonitis
Sulfasalazine: Rashes, Oligospermia, Heinz body anaemia, Interstitial lung disease
How can you distinguish between IgE and non-IgE mediated allergies?
IgE mediated:
pruritus, erythema, urticaria, angioedema
Gastrointestinal system: nausea, colicky abdominal pain, vomiting, diarrhoea
nasal itching,sneezing, rhinorrhoea or congestion (with or without conjunctivitis). cough, chest tightness, wheezing or shortness of breath
Symptoms of anaphylaxis
Non IgE
pruritus, erythema, atopic eczema
gastro-oesophageal reflux disease
loose or frequent stools
blood and/or mucus in stools
abdominal pain
infantile colic
food refusal or aversion
constipation
perianal redness
pallor and tiredness
faltering growth plus one or more gastrointestinal
how is non- IgE allergies managed?
eliminate the suspected allergen for 2-6 weeks, then reintroduce.
use food ladder e.g. egg ladder - start with egg baked in biscuits and evntually scrambled eggs would be high up
when is cardiac resynchronisation therapy recommended?
- for patients with heart failure and wide QRS
Indicated in patients with left ventricular dysfunction, ejection fracture <35% and QRS duration >120ms.
what is the outcome of exercise training in HF?
improves symptoms but not hospitalisation
how is cardiac resyndronisation achived and what are the outcomes?
achieved by biventricular pacing
leads to improved symptoms and reduced hospitalisation in NYHA class III patients
when is an implantable ICD indicated?
An Implantable cardiac defibrillator (ICD) is indicated in patients with previous sustained ventricular tachycardia, ejection fraction <35% and symptoms no worse than class III of of the New York Heart Association functional classification.
what are the outcomes of digoxin in HF?
Digoxin reduces hospitalisation but not mortality in heart failure
what supplements should all pregnant woman take
All pregnant women should take a daily supplement containing 10micrograms of vitamin D
what are the risk factors for developing gluce ear (otitis media with effusion)?
Risk factors
male sex
siblings with glue ear
higher incidence in Winter and Spring
bottle feeding
day care attendance
parental smoking
what is the management of glue ear?
rommet insertion - to allow air to pass through into the middle ear and hence do the job normally done by the Eustachian tube. The majority stop functioning after about 10 months
adenoidectomy
what are the different types of head trauma in new borns?
Caput succedaneum is a swelling due to pressure of the presenting part on the cervix. It is present from birth with poor margins and crosses suture lines. It typically resolves in 1-2days and does not usually require treatment. due to ventouse or prolonged delivery.
Cephalohaematoma is caused by ruptured blood vessels e.g. forceps causing a subperiosteal swelling limited by the suture lines. takes months to resolve. develops 1-2 hours post birth
Subgaleal haematoma is swelling between the periosteum and the epicranial aponeurosis. This typically presents as a swelling 12-72hours post delivery and is associated with ventouse assisted deliveries.
what promotes and inhibits galactorrhoea?
prolactin - increases galactorrhoea
dopamine inhibits it (e.g. dopamine agonist bromocriptine)
what are the features of excess prolactin?
men: impotence, loss of libido, galactorrhoea
women: amenorrhoea, galactorrhoea
what are the causes of excess prolactin?
prolactinoma
pregnancy
oestrogens
physiological: stress, exercise, sleep
acromegaly: 1/3 of patients
polycystic ovarian syndrome
primary hypothyroidism (due to thyrotrophin releasing hormone (TRH) stimulating prolactin release)
drugs
which drugs cause excess prolactin?
metoclopramide, domperidone
phenothiazines
haloperidol
very rare: SSRIs, opioids
what is the most common site for a keloid scar?
sternum
how can you make a keloid scar less likely to develop?
incision along tension line
How are keloid scars managed?
Early keloids may be treated with intra-lesional steroids e.g. triamcinolone
what is the most common cause of small bowel obstruction? vs large bowel?
small bowel:
surgery / adhesions
followed by hernias
large bowel : malaignancy
what serum enxyme can be raised in small bowel obstruction>?
amylase
what is the recommended adrenaline dose in anaphylasxis and cardiac arrest?
anaphylaxis: 0.5mg - 0.5ml 1:1,000 IM
cardiac arrest: 1mg - 10ml 1:10,000 IV or 1ml of 1:1000 IV
what does adrenaline do to the pulse pressure?
causes vasoconstriction in the skin and kidneys causing a narrow pulse pressure
how is molluscum contangiosum managed?
self-limiting condition.
Spontaneous resolution usually occurs within 18 months
Explain that lesions are contagious, and it is sensible to avoid sharing towels, clothing, and baths with uninfected people (e.g. siblings)
Encourage people not to scratch the lesions.
Exclusion from school, gym, or swimming is not necessary
Cryotherapy may be used in older children or adults
when is referral for molluscum contangiosum recommended?
For people who are HIV-positive with extensive lesions urgent referral to a HIV specialist
For people with eyelid-margin or ocular lesions and associated red eye urgent referral to an ophthalmologist
Adults with anogenital lesions should be referred to genito-urinary medicine, for screening for other sexually transmitted infections
how does idiopathic pulmonary fibrosis present?
usually 50-70yrs
more common in men
SoB
bibaseal fine end inspiratory crackles
dry cough
clubbing
what are the Ix findings in idiopathic pulmonary fibrosis?
Spirometry: restrictive picture (FEV1 normal/decreased, FVC decreased, FEV1/FVC increased)
impaired gas exchange: reduced transfer factor (TLCO)
imaging: bilateral interstitial shadowing - ‘ground-glass’ - later progressing to ‘honeycombing’) may be seen on a chest x-ray
high-resolution CT scanning is the investigation of choice and required to make a diagnosis of IPF
ANA positive in 30%, rheumatoid factor positive in 10%
How many tetanus vaccines do children recive?
5 doses - 2 months, 3 months, 4 months, 3-5yr, 13-18yrs
How are wounds managed with regards to tetanus?
Patient has had a full course of tetanus vaccines, with the last dose < 10 years ago
no vaccine nor tetanus immunoglobulin is required, regardless of the wound severity
Patient has had a full course of tetanus vaccines, with the last dose > 10 years ago
if tetanus prone wound: reinforcing dose of vaccine
high-risk wounds (e.g. compound fractures, delayed surgical intervention, significant degree of devitalised tissue): reinforcing dose of vaccine + tetanus immunoglobulin
If vaccination history is incomplete or unknown
reinforcing dose of vaccine, regardless of the wound severity
for tetanus prone and high-risk wounds: reinforcing dose of vaccine + tetanus immunoglobulin
which joint does septic arthritis most commonly aggect?
knee - adults
hip - kids
how is septic arthritis managed?
aspirate knee first
flucloxacillin or clindamycin if penicillin allergic
wash out
what is Trichomonas vaginalis? features?
protazoa, STI
features: vaginal discharge: offensive, yellow/green, frothy
vulvovaginitis, strawberry cervix, pH > 4.5, urethritis in men
how is trichomonas vaginalis managed?
oral metronidazole for 5-7 days
what time period includes maternal mortality classification?
Maternal mortality includes any death in pregnancy and labour as well as up to six weeks post partum
what is the cut of for miscarriage / still borth classification?
24 weks
what is the cut of age for being classified as a neonate?
28 days
how does trimethroprim work?
interferes with DNA synthesis by inhibiting dihydrofolate reductase
what are the ADRs of trimethroprim?
myelosuppression
transient rise in creatinine: trimethoprim competitively inhibits the tubular secretion of creatinin
how are patients at risk of tumour lysis managed?
high risk - IV allopurinol or IV rasburicase immediately prior to and during the first days of chemotherapy.
lower risk - should be given oral allopurinol during chemotherapy cycles in an attempt to avoid the condition
how does rasburicase work?
Rasburicase is a recombinant version of urate oxidase, an enzyme that metabolizes uric acid to allantoin. Allantoin is much more water-soluble than uric acid and is, therefore, more easily excreted by the kidneys.
why can’t allopurinol and rasburicase be given together?
reduces effect of rasburicase
what electrolyte abnormalities are seen in tumour lysis syndrome?
high PO4
high K
low Ca
high urate
what antimuscarinic drugs can be used in urge incontinence?
Examples of suitable antimuscarinic drugs include oxybutynin, tolterodine and darifenacin.
How are men with urinary tract symptoms managed?
urine dip, PSA, DRE, IPSS
pelvic floor muscle training, bladder training, prudent fluid intake and containment products
if ‘moderate’ or ‘severe’ symptoms offer an alpha-blocker
if the prostate is enlarged and the patient is ‘considered at high risk of progression’ then a 5-alpha reductase inhibitor should be offered
if the patient has an enlarged prostate and ‘moderate’ or ‘severe’ symptoms offer both an alpha-blocker and 5-alpha reductase inhibitor
if there are mixed symptoms of voiding and storage not responding to an alpha blocker then a antimuscarinic (anticholinergic) drug may be added
what are the effects of BNP
vasodilator
diuretic and natriuretic
suppresses both sympathetic tone and the renin-angiotensin-aldosterone system
what reduces BNP?
Factors which reduce BNP levels include treatment with ACE inhibitors, angiotensin-2 receptor blockers and diuretics.
what causes raised BNP?
use of left ventricular dysfunction such as myocardial ischaemia or valvular disease may raise levels. Raised levels may also be seen due to reduced excretion in patients with chronic kidney disease.
what are the guidelines for folic acid in pregnancy?
all women should take 400mcg of folic acid until the 12th week of pregnancy
women at higher risk of conceiving a child with a NTD should take 5mg of folic acid instead
e.g. either partner has a NTD, they have had a previous pregnancy affected by a NTD, or they have a family history of a NTD
the woman is taking antiepileptic drugs or has coeliac disease, diabetes, or thalassaemia trait.
the woman is obese (defined as a body mass index [BMI] of 30 kg/m2 or more).
when does contract induced nephrophathy occur?
2-5 days after
what are the risk factors to developing contrast induced nephropathy?
known renal impairment (especially diabetic nephropathy)
age > 70 years
dehydration
cardiac failure
the use of nephrotoxic drugs such as NSAIDs
how is a TIA defined?
Symtpoms of stroke lasting less than 25 hours (but typically less than 1 he)
a transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischaemia, without acute infarction.
how is a TIA managed?
give aspirin 300 mg immediately, unless
- bleeding disorcder/ DOAC
- already on low-dose aspirin regularly: continue the current dose of aspirin until reviewed by a specialist
- Aspirin is contraindicated
Specialist review withing 7 days
however if more than 1 TIA within 1 week then within 24 hours
Advise the person not to drive until they have been seen by a specialist.
after seing specialist - clopidogrel first line
How is a patient managed who has had a TIA but is on DOAC/ anti coag?
urgent CT head to exclude haemorrhage
What is the algorithm for managing T2DM?
HbA1c 6.5 or more - metformin - can titrate up and manage with life style up to 7.5%
if >7.5% - add 2nd drug - sulphonylyrea/ DDP4/glitazone
if still high add 3rd drug or start insulin
can also add GLP1 if 3rd drug doesnt work and BMI is >35 or insulin has occupational issues
if CVD risk/CVD// HF - add SGLT2 to metformin - does not depend on HbA1c. metformin should be titrated up and established before starting SGLT2
what are the HbA1c targets for patients?
lifestyle alone - 6.5%
metformin - 6.5%
other mrfd - 7%
what is the criteria to continue GLP1?
only continue if there is a reduction of at least 11 mmol/mol [1.0%] in HbA1c and a weight loss of at least 3% of initial body weight in 6 months
what are the HbA1c targets for patients?
lifestyle alone - 6.5%
metformin - 6.5%
other drugs - 7%
what is Seborrhoeic keratoses?
benign lesions in older people - looks bit like a mole
can get multiple of them
large variation in colour from flesh to light-brown to black
have a ‘stuck-on’ appearance
keratotic plugs may be seen on the surface
clue to differntiating from mole is it develops in later life
what is the management of a nosebleed?
- adequate first aid for 20 minutes (squeeze both nasal ala firmly and sit forward. Ice in the mouth can help)
- topical adrenaline/local anaesthetic
- topical tranexamic acid
- nasal packing (e.g. with Rapid Rhino. Initially insert into the affected nostril. If unsuccessful, a pack in the other nostril may help. Posterior bleeds can be packed with a posterior pack, or with a Foley catheter).
- surgical intervention (sphenopalatine artery ligation).
which area do anterior nosebleeds arise
kisselbach
what is atrophic vaginitis and how is it managed?
women who are post-menopausal women. It presents with vaginal dryness, dyspareunia and occasional spotting.
Treatment is with vaginal lubricants and moisturisers
topical oestrogen
what happens in the following vitamin deficiencies? retinoids, thiamine, niacin , pyridoxine
vitamin A - retinoids - night time blindness
B1 - thiamine - beriberi (polyneuropathy, wernickes, HF)
B3 - niacin - pellagra - dermatitis, dementia and diarrhoea
B6 - pyridoxine - anaemia, irritability, seizures
what happens in the following vitamin deficiencies? B7, B9, B12 , C
B7 - biotin - dermatitis
B9 - folic acid - anaemia, neural tube
B12 - cyanocobalamin - anaemia, neuroathy
C - scurvy
what happens in the following vitamin deficiencies? D, E, K
D - rickets/ osteomalacia
E - haemolytic anaemia of new born, ataxia, peripheral neuropathy
K - haemorrhoagic disease of new born, coagulopathy
what are the complications of diabetes in pregnancy?
polyhydramnios - due to polyuria
preterm - associated with polyhydramnios
macrosomia
hypoglycaemia
RSD- surfactant delay
polycythamia
still birth
hypoMg/Ca
shoulder dystocia
what is the mechism and side effect of
a)cyclophosphamide
b)bleomycin
c) doxorubicin (antracycline)
a) cross links DNA. haemorrhagic cyctitis, transistional cell carcinoma, myelosupression
b) degrades DNA. lung fibrosis
c)stabilisies DNA topoisomerase II complex, cardiomyopathy
what is the mechanism and side effect of
a) methotrexate
b) 5 flurouracil
c) 6 mercaptopurine
d) cytarabine
methotrexate - folate analgoe. myelosupression, liver, lung fibrosis, mucositis
5 flurouracil - pyridimine analogue - myelosupression, mucositis, dermatitis
6-mercaptopurine Purine analogue. Myelosuppression
Cytarabine pyridimine antagonist. myelosupression
what is the mechanism and side effects of vincristine, docetaxel?
Vincristine Inhibits formation of microtubules
Peripheral neuropathy (reversible) , paralytic ileus
Docetaxel Prevents microtubule depolymerisation & disassembly
Neutropaenia
preswhat is the mechanism and side effect of cisplatin?
Cisplatin cross-linking in DNA
Ototoxicity, peripheral neuropathy, hypomagnesaemia
what is presbycusis? what is found on auditometry
age related sensorineural hearing loss
auditometry shows bilateral high freq hearing loss
how does otosclerosis present?
Fhx (auto dom0
20-40yrs
conductive hearing loss
tinnitus
how does menieres disease present?
recurrent episodes of vertigo, tinnitus and hearing loss (sensorineural). Vertigo is usually the prominent symptom
a sensation of aural fullness
other features include nystagmus and a positive Romberg test
episodes last minutes to hours
what are the associations of primary biliary ?
Sjogren’s syndrome (seen in up to 80% of patients)
rheumatoid arthritis
systemic sclerosis
thyroid disease
what Ab is seen in primary biliary cholangitis?
IgM
anti mitochondrial
what are the features of primary biliary cholangitis?
females
often asymptomatic - raised ALP
jaundice
what is the first line treatment for primary biliary cholangitis?
first-line: ursodeoxycholic acid
slows disease progression and improves symptoms
pruritus: cholestyramine
fat-soluble vitamin supplementation
liver transplantation
e.g. if bilirubin > 100 (PBC is a major indication)
what is the long term mangaement of angina?
all patients - aspirin and a statin
sublingual glyceryl trinitrate PRN
beta-blocker or a calcium channel blocker first-line - increase to max tolerated dose and if still symptomatic can use combo
if a calcium channel blocker is used as monotherapy a rate-limiting one such as verapamil or diltiazem should be used
if used in combination with a beta-blocker then use a longer-acting dihydropyridine calcium channel blocker (e.g. amlodipine, modified-release nifedipine)
what do biochem results show in iron deficiency anaemia?
Total iron-binding capacity (TIBC) + transferrin levels are typically raised in iron-deficiency anaemia
low ferritin
low transferrin saturation
low serum iron
what are the features of kawasaki disease?
high-grade fever which lasts for > 5 days. Fever is characteristically resistant to antipyretics
conjunctival injection
bright red, cracked lips
strawberry tongue
cervical lymphadenopathy
red palms of the hands and the soles of the feet which later peel
how is kawasaki disease treated?
high dose aspriin
immunoglobulins
echo - look for aneuryms
what does the neonatal foto prick test for?
congenital hypothyroidism
cystic fibrosis
sickle cell disease
phenylketonuria
medium chain acyl-CoA dehydrogenase deficiency (MCADD)
maple syrup urine disease (MSUD)
isovaleric acidaemia (IVA)
glutaric aciduria type 1 (GA1)
homocystinuria (pyridoxine unresponsive) (HCU)
what are the causes of polycythaemia?
Relative causes
dehydration
stress: Gaisbock syndrome
Primary
polycythaemia rubra vera
Secondary causes
COPD
altitude
obstructive sleep apnoea
excessive erythropoietin: cerebellar haemangioma, hypernephroma, hepatoma, uterine fibroids*
what are the symptoms of polycythameia?
The classic symptom of this condition is intense itching which usually occurs after exposure to hot water or hot and humid weather
tinnitius
DVT
flushing
headaches
what is the most common extra intestinal manifestation of IBD?
arthritis
what issues do IBD patients get that are not related to disease activity?
arthritis: polyarticular, symmetric
Uveitis (mainly UC)
Pyoderma gangrenosum
Clubbing
Primary sclerosing cholangitis (mainly UC)
what issues do IBD patients get that are related to disease activity?
Arthritis: pauciarticular, asymmetric
Erythema nodosum
Episcleritis
Osteoporosis
how are AF patients assessed for anticoag ?
chadsvasc
for bleeding - has bleed/ ORBIT
what is given to patients were aspirin and clopi are both contraindicated?
MR dipyrimidole
what is the centor criteria?
The Centor criteria are: score 1 point for each (maximum score of 4)
presence of tonsillar exudate
tender anterior cervical lymphadenopathy or lymphadenitis
history of fever
absence of cough
how is tonsilitis / streptococcus infection of throat managed?
either phenoxymethylpenicillin or clarithromycin (if the patient is penicillin-allergic) should be given. Either a 7 or 10 day course should be given
what is rosecea?
typically affects nose, cheeks and forehead
flushing is often first symptom
telangiectasia
later develops into persistent erythema with papules and pustules
rhinophyma
ocular involvement: blepharitis
sunlight may exacerbate symptoms/
how is rosacea managed?
mild - topical metronidazole
severe/resistant: oral tetracycline
what is the most common type of breast cancer?
Invasive ductal carcinoma (no special type)
what is pagets disease of the nipple
Paget’s disease of the nipple is an eczematoid change of the nipple associated with an underlying breast malignancy
what is the mechanims of cocaine?
cocaine blocks the uptake of dopamine, noradrenaline and serotonin
how does primary herpes infection present?
severe gingivitis / mutuliple genital vesivcles
lymphadenopathy
fever
how is herpes simplex managed?
gingivostomatitis: oral aciclovir, chlorhexidine mouthwash
cold sores: topical aciclovir
genital herpes: oral aciclovir.
how is herpes in pregnancy managed?
if primary attack occurs during pregnancy after 28 weeks - C section
recurrent herpes whilst pregnant - supressive therapy
how are DVTs managed?
DOAC - apixaban/rivaroxaban
provoked - 3 months
unprovoked -6 months
cancer patients - 6 month
if neither apixaban or rivaroxaban are suitable then either LMWH followed by dabigatran or edoxaban OR LMWH followed by a vitamin K antagonist (VKA, i.e. warfarin)
if renal impairment is severe (e.g. < 15/min) then LMWH, unfractionated heparin or LMWH followed by a VKA
if the patient has antiphospholipid syndrome then LMWH followed by a VKA should be used
which organism is a strawberry cervix associated with?
Trichomonas vaginalis
what are the symptoms of cholangioscarcinoma?
Persistent biliary colic symptoms, associated with anorexia, jaundice and weight loss. A palpable mass in the right upper quadrant (Courvoisier sign), periumbilical lymphadenopathy (Sister Mary Joseph nodes) and left supraclavicular adenopathy (Virchow node) may be seen
what is the main side effect of hydroxychloroquine?
bull’s eye retinopathy - may result in severe and permanent visual loss
baseline opthalmology exam recommended
can hydroxychloroquine be used in pregnancy?
yes
which test is for addisons disease?
short synacthen
plasma cortisol is measured before and 30 minutes after giving Synacthen 250ug IM. Adrenal autoantibodies such as anti-21-hydroxylase may also be demonstrated.
what electrolyte abnormalites are seen in addisons?
hyperkalaemia
hyponatraemia
hypoglycaemia
metabolic acidosis
how is 9am cortisol used to diagnose addisons?
> 500 nmol/l makes Addison’s very unlikely
< 100 nmol/l is definitely abnormal
100-500 nmol/l should prompt a ACTH stimulation test to be performed
what are the first rank symptoms of schizophrenia?
Auditory hallucinations of a specific type:
two or more voices discussing the patient in the third person
thought echo
voices commenting on the patient’s behaviour
Thought disorders: thought insertion, withdrawal or broadcasting
Passivity phenomena:
bodily sensations being controlled by external influence
actions/impulses/feelings - experiences which are imposed on the individual or influenced by others
Delusional perceptions
e.g. ‘The traffic light is green therefore I am the King’.
how is urine infection managed in preganncy?
nirtofurantoin first line (avoid near term)
2nd line axocillin/cefalexin
7 days
urine culutre
how is UTI managed in men?
7 days nitro/trimethroprim
when is a urine culture sent for UTI?
if haematuria / >65yrs
how are catheterised UTI patients managed?
assymptomatic - no treatment
symtpomatic - 7 days , change catheter
what is a lack of red reflex in newborn indicative of?
retinoblastoma
urgent opthal referral
in terms of breast cancer history , what are the contraidicatations for COCP?
only if brca positive
how is ectopic pregnancy investigated?
positive BHCG
transvaginal USS - shows mass not in uterus
when is expectant, medical, surgical options used for ectopic pregnancy?
expectant - <35mm, no heart beat, assymptomatic, no rupture, hcg <1000,
medical - as above but symptoms as long as no significant pain. hcg <1500
surgical - >35mm, pain, heart beat, ruputred, hcg >5000
what is the surgical manged of ectopic pregnancy?
salpingectomy or salpingotomy
Salpingectomy is first-line for women with no other risk factors for infertility
Salpingotomy should be considered for women with risk factors for infertility such as contralateral tube damage
what is the medical manged ment of ectopic?
methotrexate
what are the differences between iliostomy and colostomy?
ilieostomy - spouted (more irratating), liquid content, right sided
colostomy- not spouted, solid content, left side
which type of stoma is used for defunctioning to allow anatomoses to heal after bowel resection?
A loop ileostomy can be used to defunction the colon to protect an anastomosis
what are the side effects of Calcium channel blockers?
ankle oedema, flushing, headache
which SSRI has risk of long QT?
citalopram
which law overides MCA or MHA?
The Mental Health Act overrides the Mental Capacity Act and enables people with capacity to be given treatment against their will
what are the symptoms of blethritis?
symptoms are usually bilateral
grittiness and discomfort, particularly around the eyelid margins
eyes may be sticky in the morning
eyelid margins may be red.
styes and chalazions a
secondary conjunctivitis may occur
more common in patients with roscea
what is the management of blethritis?
softening of the lid margin using hot compresses twice a day
‘lid hygiene’ - mechanical removal of the debris from lid margins
artificial tears for those with dry eys
what is used for management of migraines?
first-line: offer combination therapy with an oral triptan and an NSAID, or an oral triptan and paracetamol
what are the features of life threatening asthma
SpO2 <92%
PEF <33% best or predicted
Silent chest
Poor respiratory effort
Agitation
Altered consciousness
Cyanosis
who should be assessed for osteoporosis and how?
all women aged >= 65 years and all men aged >= 75 years should be assessed.
using FRAX tool
reassess if chnage in risk factor
what is the management of ankylosing spondylitis ?
exercise
NSAIDs
anti TNF
when in radioiodine therapy contraindicated in graves?
pregnancy
<16yrs old
thyroid eye disease - can worsen
what are the features of a colles fracture?
fall onto outstretched hand
dinner fork deformity - dorsal diplacement
radial fracture
what are the features of a colles fracture?
fall onto outstretched hand
dinner fork deformity - dorsal diplacement
radial fracture
what is a smiths fracture?
refverse of colles - falling onto back of hand . volar displacement
what are the features of scaphoid fracture?
Risk of fracture associated with fall onto outstretched hand (tubercle, waist, or proximal 1/3)
The main physical signs are swelling and tenderness in the anatomical snuff box, and pain on wrist movements and on longitudinal compression of the thumb.
what is a bennets, montageggi , galeazzi and bartons fracture?
bennets - fracture of thumb
montagegi - fracture of ulnar and dislocation of proximal radio-ulnar joint
galeazzi - radius fracture and distal radio-ulnar joint
bartons- radius fracture + radiocarapal dislocation
hwo is parkinsons managed?
if the motor symptoms are affecting the patient’s quality of life: levodopa
if the motor symptoms are not affecting the patient’s quality of life: dopamine agonist (non-ergot derived), levodopa or monoamine oxidase B (MAO‑B) inhibitor
what are the ADRs of dopamine
excessive sleepiness, hallucinations and impulse control disorders
dopamine agonists e.g. ropinerole have highest risk of hallucinations and impulse control disorders
how are parkinson patients with excessive sleepiness or orthostatic hypotension managed?
sleepiness - medafenil
orthostatic - midodrine
what is cocareldopa?
levo dopa with decarboxylase inhibitor - prevents peripheral conversion to dopamine - fewer side effects
what are the side effects of levodopa?
dry mouth
anorexia
palpitations
postural hypotension
psychosis
on off
dyskinesias at peak dose: dystonia, chorea and athetosis (involuntary writhing movements)
give examples of dopamine agonists and their ADRs
bromocriptine, ropinirole, cabergoline, apomorphine
which parkinson drugs are associated with fibroiss?
ergot-derived dopamine receptor agonists (bromocriptine, cabergoline) have been associated with pulmonary, retroperitoneal and cardiac fibrosis. echocardiogram, ESR, creatinine and chest x-ray should be obtained prior to treatment and patients should be closely monitored
what type of drug is selegiline
MOA - B inhibitor - for parkinosn
what class of drug are entacapone, tolcapone
COMT inhibtiros - parkinsons
what are the B type symptoms ?
weight loss > 10% in last 6 months
fever > 38ºC
night sweats
what is the most common type of hodkins lymphoma ? is prognosis good or bad?
nodular sclerosing
good prog
what is the worst prognosis type of hodgkins lymphoma?
lymphocyte deplete
how can hodgkins and non-hodkins be differentiated via symptoms?
alcohol induced pain - hodgkins
which type of cell is characteristic of hodgkins ?
Reed sternberg
what is surgical management of pancreatic cancer?
Whipple’s resection (pancreaticoduodenectomy) is performed for resectable lesions in the head of pancreas.
what is double duct sign seen on CT?
suggests pancreatic cancer
double duct’ sign - the presence of simultaneous dilatation of the common bile and pancreatic ducts
what organism causes Typhoid and paratyphoid ?
salmonella typhi/parathyhi (cause of enteric fever)
what are the features of enteric fever (thyoid/ parathypoid)?
nitially systemic upset
relative bradycardia
abdominal pain, distension
constipation: although Salmonella is a recognised cause of diarrhoea, constipation is more common in typhoid
rose spots: present on the trunk in 40% of patients, and are more common in paratyphoid
which pathogen cuauses osteomyelitis in sickle cell?
salmonella
what are features of mild, moderate and severe acne?
mild: open and closed comedones with or without sparse inflammatory lesions
moderate acne: widespread non-inflammatory lesions and numerous papules and pustules
severe acne: extensive inflammatory lesions, which may include nodules, pitting, and scarring
what is the step by step management of acne?
single topical therapy (topical retinoids, benzoyl peroxide)
topical combination therapy (topical antibiotic, benzoyl peroxide, topical retinoid)
oral antibiotics:
tetracyclines: lymecycline, oxytetracycline, doxycycline
cocp
oral isotretinoin
can use topical retinoid and oral Abx together
oral antibiotics 3 months max
whcih acne medications are contraindicated in pregnancy?
retinoids - oral and topical
tetracyclines (use erythromycin instead)
what is the mechanism of metaclopromide?
D2 receptor antagonist - prokinetic
what are the ADRs of metaclopromide?
extrapyramidal effects
acute dystonia e.g. oculogyric crisis
this is particularly a problem in children and young adults
diarrhoea
hyperprolactinaemia
tardive dyskinesia
parkinsonism
which antiemetic cant be used in bowel obstruction?
metoclopramide (may be useful in paralytic ileus)
how is menopause defined?
no periods for 12 months
what are the contraindications of HRT?
Contraindications:
Current or past breast cancer
Any oestrogen-sensitive cancer
Undiagnosed vaginal bleeding
Untreated endometrial hyperplasia
how is HRT chosen for women?
uterus - need O+P
no uterus - O along (oral or transdermal)
risk to VTE - use transdermal patch
what are the non-HRT options of menopause?
Vasomotor symptoms
fluoxetine, citalopram or venlafaxine
Vaginal dryness
vaginal lubricant or moisturiser
Psychological symptoms
self-help groups, cognitive behaviour therapy or antidepressants
Urogenital symptoms
if suffering from urogenital atrophy vaginal oestrogen can be prescribed.
how is premature ovarian failure defined?
onset of menopausal symptoms and elevated gonadotrophin levels before the age of 40 years.
how is premature ovarian failure managed?
hormone replacement therapy (HRT) or a combined oral contraceptive pill should be offered to women until the age of the average menopause (51 years)
what is pheochromocytoma associated with?>
MEN type II, neurofibromatosis and von Hippel-Lindau syndrome
what Ix is used for pheochromocytoma?
24 hour urinary catecholamine
what is the management of pheochromocytoma?
alpha-blocker (e.g. phenoxybenzamine), given before a
beta-blocker (e.g. propranolol)
what are the risk factors of idiopathic intracranial hypertension?
obesity
female sex
pregnancy
drugs*
combined oral contraceptive pill
steroids
tetracyclines
vitamin A
lithium
what is the management of idiopathic intracranial HTN?
weight loss
diuretics e.g. acetazolamide
topiramate
what is the management of trigeminal neuralgia?
carbemazepine
what ECG changes are found in hypokalaemia?
U waves
small or absent T waves
prolonged PR interval
ST depression
which electrolyte abnormality precipitates digoxin toxicity
hypokalaemia
which disease characteristically shows raised APTT and low platelets?
antiphospholipid syndrome
what is the management of antiphospholipid syndrome?
primary thromboprophylaxis - low-dose aspirin
secondary thromboprophylaxis
initial venous thromboembolic events: lifelong warfarin with a target INR of 2-3
recurrent venous thromboembolic events: lifelong warfarin; if occurred whilst taking warfarin then consider adding low-dose aspirin, increase target INR to 3-4
arterial thrombosis should be treated with lifelong warfarin with target INR 2-3
what causes blurring of vision years after cataracts surgery?
blurring of vision again years after cataract surgery can occur due to posterior capsule opacification
who does ALL most commonly affect?
he peak incidence is at around 2-5 years of age and boys are affected slightly more commonly than girls
what are the poor prognostic factors of ALL?
age < 2 years or > 10 years
WBC > 20 * 109/l at diagnosis
T or B cell surface markers
non-Caucasian
male sex
which malignancy causes SiADH?
small cell lung cancer
what are the causes of siADH?
stroke
subarachnoid haemorrhage
subdural haemorrhage
meningitis/encephalitis/abscess
tuberculosis
pneumonia
Drugs
positive end-expiratory pressure (PEEP)
porphyrias
small cell lung cancer
how is SiADH managed?
fluid restriction
demeclocycline: reduces the responsiveness of the collecting tubule cells to ADH
ADH (vasopressin) receptor antagonists
what is the antibiotic management of salmonella, campylobacter and shigellosis
Campylobacter enteritis Clarithromycin
Salmonella (non-typhoid) Ciprofloxacin
Shigellosis Ciprofloxacin
what is the abx management for acute prostacitis?
quinolone or trimethroprim
how are impetigo, cellulitis managed?
Impetigo Topical hydrogen peroxide, oral flucloxacillin or erythromycin if widespread
Cellulitis Flucloxacillin (clarithromycin, erythromycin or doxycycline if penicillin-allergic)
Cellulitis (near the eyes or nose) Co-amoxiclav
how is mastitis during breast feeding managed?
flucloxacilin
how are renal stones manged?
<2cm in aggregate -Lithotripsy
<2cm in pregnant females - Ureteroscopy
Complex renal calculi and staghorn calculi Percutaneous nephrolithotomy
Ureteric calculi less than 5mm Manage expectantly
ureteric obstruction + infection - surgical emergency e.g. nephrostomy tube placement, insertion of ureteric catheters and ureteric stent placement.
what are the DVLA rules for hypertension
can drive unless treatment causes unacceptable side effects, no need to notify DVLA
if Group 2 Entitlement the disqualifies from driving if resting BP consistently 180 mmHg systolic or more and/or 100 mm Hg diastolic or more
what are the DVLA rules for angio and CABG and ACS?
angioplasty (elective) - 1 week off driving
CABG - 4 weeks off driving
acute coronary syndrome- 4 weeks off driving
1 week if successfully treated by angioplasty
angina - driving must cease if symptoms occur at rest/at the wheel
what are DVLA rules for pacemaker and ICD insertion?
pacemaker insertion - 1 week off driving
implantable cardioverter-defibrillator (ICD)
if implanted for sustained ventricular arrhythmia: cease driving for 6 months
if implanted prophylactically then cease driving for 1 month. Having an ICD results in a permanent bar for Group 2 drivers
what is the DVLA rules for aortic aneutryms and heart transplants?
aortic aneurysm of 6cm or more - notify DVLA. Licensing will be permitted subject to annual review.
an aortic diameter of 6.5 cm or more disqualifies patients from driving
heart transplant: do not drive for 6 weeks, no need to notify DVLA
which age does croup and bronchiolitis peak?
croup : 6m - 3y
brocnchiolitis - 1-9m
what is the management of croup?
single dose oral prednisolone
which groups of patients should not be given haloperidol?
parkinsons
which drugs can cause lung fibrosis?
amiodarone
cytotoxic agents: busulphan, bleomycin
anti-rheumatoid drugs: methotrexate, sulfasalazine
nitrofurantoin
ergot-derived dopamine receptor agonists (bromocriptine, cabergoline, pergolide)
what are the features of disseminated gonoccoal infection?
tenosynovitis
migratory polyarthritis
dermatitis
what is a nexplanon and how often is it changed?
implantable contraceptive
every 3 years
which drugs reduce eficacy of nexplanon (implantable contraceptive)?
certain antiepileptic and rifampicin
what are the ADRs of loop diuretics ?
low electrolytes (inc Ca)
gout
ototoxic
what is the mechanism of metformin (biguanide)?
acts by activation of the AMP-activated protein kinase (AMPK)
increases insulin sensitivity
decreases hepatic gluconeogenesis
may also reduce gastrointestinal absorption of carbohydrates
when should metformin be stopped and why?
recent myocardial infarction, sepsis, acute kidney injury and severe dehydration
risk of lactic acidosis
how is metfomrin changed with use of iodinating contrast?
metformin should be discontinued on the day of the procedure and for 48 hours thereafter
which lobes and virus are mainly affected in encephalitis? how is it managed/
HSV
temporal and inferior frontal lobes
IV aciclovir
how do antipsychotics work?
dopamine antagonists
how is squamous cell carcinoma managed?
Surgical excision with 4mm margins if lesion <20mm in diameter. If tumour >20mm then margins should be 6mm.
who fits criteria for colorectal cancer 2ww?
patients >= 40 years with unexplained weight loss AND abdominal pain
patients >= 50 years with unexplained rectal bleeding
patients >= 60 years with iron deficiency anaemia OR change in bowel habit
tests show occult blood in their faeces (see below)
how is acute asthma managed?
o2
ipratropium/ salbutamol nebs
prednisolone - 5 days
if no response - IV MgSO4,
then IV aminophyline
then intubation
what is the criteria for dischatrge after asthma attack?
been stable on their discharge medication (i.e. no nebulisers or oxygen) for 12–24 hours
inhaler technique checked and recorded
PEF >75% of best or predicted
how does erythema nodusum present?
symmetrical, erythematous, tender, nodules which heal without scarring
what is Necrobiosis lipoidica diabeticorum?
shiny, painless areas of yellow/red skin typically on the shin of diabetics
often associated with telangiectasia
which crystals are seen in pseudogout?
calcium pyrophosphate
weak postive rhomboid
what are the risk factors of pseudogout?
haemochromatosis
hyperparathyroidism
low magnesium, low phosphate
acromegaly, Wilson’s disease
which joints are mainly affected by pseudogout? how do they appear on xray?
knee, shouldr, wrist
chondrocalcinosis
what are the two types of polycystic kidney disease? what type of inheritance?
both auto dom
ADPKD1 - more common, renal failure earlier
ADPKD2 - less common
how are relatives screened for polycystic kidnesys?
uss
if <30yrs and 2 cysts in 1 or 2 kidneys
if <60 and 2 cysts in both kidney
if >60 and 4 cysts in both kidneys
how is polycystic kidney disease managed?
tolvaptan - vassopressin receptor 2 antagonist
how is allergic rhinitis managed?
intranasal antihisatimines
intranasal steroids
oral steroids
what indicates poor prognosis for schizophrenia?
low IQ
gradual onset
strong family history
social withdrawal
when is scarlet fever most common?
age 2-6
what organism causes scarlet fever?
group A strept (pyogenes)
what are the features of scarlet fever?
fever
strawberry tongue
sore throat
rash - torso, sandpaper texture, flushed appearance
how is scarlet fever managed ?
pen V 10days
can return to school 24hours after starting Abx
notifiable disease
what are the complications of scarlet fever?
otitis media: the most common complication
rheumatic fever: typically occurs 20 days after infection
acute glomerulonephritis: typically occurs 10 days after infection
what vessles bleed in subdural haemorrhages?
Subdural haemorrhage results from bleeding of damaged bridging veins between the cortex and venous sinuses
what is the treatment for hamsey hunt?
high dose aciclovir
high dose steroids
eye protection
which drugs need to be stopped for H.pylori test?
Abx - 4 weeks ago
PPI - 2 weeks ago
what is seen in the cushings reflex in head injuries?
bradycardia
hypertension
wide pulse pressure
how is cerebral perfusion pressure defined?
CPP= Mean arterial pressure - Intra cranial pressure
how are hep B serology used to work out if patient has chronic infection, immunity , previous infection etc?
HBsAg normally implies acute disease (present for 1-6 months)
if HBsAg is present for > 6 months then this implies chronic disease (i.e. Infective)
anti HBs - previous vaccine or infection (immunity)
antiHBc - previous infection
HbeAg - marker of infectivity
how are hep B serology used to work out if patient has chronic infection, immunity , previous infection etc?
HBsAg normally implies acute disease (present for 1-6 months)
if HBsAg is present for > 6 months then this implies chronic disease (i.e. Infective)
anti HBs - previous vaccine or infection (immunity)
antiHBc - previous infection
HbeAg - marker of infectivity
what LFT patterns are seen in non alcholic fatty liver disease?
ALT >AST
how is non alcoholic fatty liver disease monitored/screened for?
at risk patients / incidental finding of increased echogenicity on USS - Enhnaced liver fibrosis test
what LFT pattern is seen in acloholic liver disease?
Alcoholic liver disease is typically associated with an AST:ALT ratio >2 i
which drugs cause pancreatitis?
azathioprine, mesalazine, bendroflumethiazide, furosemide, pentamidine, steroids, sodium valproate
what is the triad of pathology seen in shaken baby syndrome?
Retinal haemorrhages, subdural haematoma and encephalopathy
what is the management of MND?
Riluzole
prevents stimulation of glutamate receptors
used mainly in amyotrophic lateral sclerosis
prolongs life by about 3 months
Respiratory care
non-invasive ventilation (usually BIPAP) is used at night
studies have shown a survival benefit of around 7 months
Nutrition
percutaneous gastrostomy tube (PEG) is the preferred way to support nutrition and has been associated with prolonged survival
when is HIV antiretroviral therapy started?
ASAP , doesnt matter what CD4 count is
how can duodenal and gastric ulcers be distinguished ?
Duodenal ulcers: more common than gastric ulcers, epigastric pain relieved by eating
Gastric ulcers: epigastric pain worsened by eating
what are the different scoring systems for alcholics?
MUST, FAST, CAGE
how many questions and scoring does FAST questionaire consist of?
4 questions
max score 16
3 or more = hazardous drinking
how many questions in the AUDIT questionnaire for alcoholics?
10 questions. max score 40
how does thyroglossal cyst present?
Usually midline, between the isthmus of the thyroid and the hyoid bone
Moves upwards with protrusion of the tongue
May be painful if infected
what is a cystic hygroma ?
A congenital lymphatic lesion (lymphangioma) typically found in the neck, classically on the left side
what is a brachial cyst?
An oval, mobile cystic mass that develops between the sternocleidomastoid muscle and the pharynx
who are cervical ribs more common in?
females
how is hypothyroid managed?
start with levothyroxine 50 and titrate depending on TSH (check every 8-12 weeks until stable dose)
in elderly (>50)/ IHD start at 25 insterad
how is levothyroxine dose changed in pregnancy?
increased by 25-50mic
what are the ADRs of levothyroxine?
hyperthyroidism: due to over treatment
reduced bone mineral density
worsening of angina
atrial fibrillation
what other medication reduces absorption of levothyroxine?
calcium carbonate, iron
take 4 hours apart
how is diabetic neuropathy managed?
when painful, same as other forms of neuropathy
rst-line treatment: amitriptyline, duloxetine, gabapentin or pregabalin
if the first-line drug treatment does not work try one of the other 3 drugs - monotherapy
tramadol may be used as ‘rescue therapy’ for exacerbations of neuropathic pain
topical capsaicin may be used for localised neuropathic pain (e.g. post-herpetic neuralgia)
what can GI neuropathy in diabetics present with ?
chronic diarrhoea, gastropparesis, GORD
how is gastroparesiss in diabetics present and managed>?
bloating,
erratic BMs
metoclopramide
what is the main action of implantable progesterones?
inhibit ovulation
what are the ADRs of PPIs?
hyponatraemia, hypomagnasaemia
osteoporosis → increased risk of fractures
microscopic colitis
increased risk of C. difficile infections
what is the most common cause of arrest following MI?
VF
what are the ways pericarditis can occur following MI ? how do tehese present?
within first 48hours
dresslers - within 2-6 weeks following - leuritic pain, fever, effusion, biconcave ST elevation
how is dresslers managed?
NSAIDS
how does LV aneurysm post MI present? what precautions are taken?
no pain
ST elevation
tiredness / signs of HF
need to be anticoagulated
what are the ADRs of sodium valproate?
teratogenic
neural tube defects
P450 inhibitor
gastrointestinal: nausea
increased appetite and weight gain
alopecia: regrowth may be curly
ataxia
tremor
hepatotoxicity
pancreatitis
thrombocytopaenia
hyponatraemia
when toxicity is suspected, when is digoxin levels monitored?
8-12 hours post last dose
what are the ADRs of digoxin?
generally unwell, lethargy, nausea & vomiting, anorexia, confusion, yellow-green vision
arrhythmias (e.g. AV block, bradycardia)
gynaecomastia
which precipitate digoxin toxicty?
hypoK
renal failure
myocardial ischaemia
hypomagnesaemia, hypercalcaemia, hypernatraemia, acidosis
hypoalbuminaemia
hypothermia
hypothyroidism
drugs: amiodarone, quinidine, verapamil, diltiazem, spironolactone (competes for secretion in distal convoluted tubule therefore reduce excretion), ciclosporin. Also drugs which cause hypokalaemia e.g. thiazides and loop diuretics
how is primary pneumothorax managed?
<2cm and no SoB discharge
if this fails, aspitate
>2cm/ sob- chest drain
how are secondary pneumothoraces managed?
if the patient is > 50 years old and the rim of air is > 2cm and/or the patient is short of breath then a chest drain should be inserted.
1-2cm - aspiration
If aspiration fails - a chest drain should be inserted.
if the pneumothorax is less the 1cm then the BTS guidelines suggest giving oxygen and admitting for 24 hours
what discharge advise is given to people with pneumothorax?
never dive
dont smoke
can fly after 2 weeks if succesful drainage and no residual air/ can fly after 1 week if CXR check
which hormones are raised in anorexia ?
cortisol / GH
what happens to cardio system in anorexia?
bradycardia, hypotension
most common cause of nephrotic disease in children and managemnr?
minimla change
steroids
what investigation is needed for epidural abscess?
MRI whole spine - look for skip lesions
what is the main causative organism of spinal epidural abscess?
s. aureus
what is first line medication for depression ?
SSRI
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 is the management of aortic stenosis?
if asymptomatic then observe
if symptomatic then valve replacement
if asymptomatic but valvular gradient > 40 mmHg and with features such as left ventricular systolic dysfunction then consider surgery
what is the choice of contraception in young people i.e. 16yrs?
progesterone implant
which drugs can cause urinary retention?
tricyclic antidepressants e.g. amitriptyline
anticholinergics e.g. antipsychotics, antihistamines
opioids
NSAIDs
disopyramide
how long does it take for different contraceptives to be effective?
IUD - instant
POP - 2 days
everything else inc mirina - 7 days
what is cataplexy?
sudden loss in muscle tone brought on by emotion
e.g. laughter causing syncope
linked strongly to narcolepsy
what is implaired fasting and implaired glucose tolerance secondary too ? which is worse?
impaired fasting glucose (IFG) - due to hepatic insulin resistance
impaired glucose tolerance (IGT) - due to muscle insulin resistance
IGT more likley to develop IHD
what re the side effects of TB drugs?
rifampicin - flu like, orange secretions, liver enzyme inducer
isoniazid - peripheral neuropathy (treat with pyridoxine),hepatitis, agranulocytosis, liver enzyme inhibitor
pyrazinamide - gout, arthralgia/myalgia, hepatitis
ethanbutol - optic neuritis
who is more prone to sigmoid volvulus ?
older patients
chronic constipation
Chagas disease
neurological conditions e.g. Parkinson’s disease, Duchenne muscular dystrophy
psychiatric conditions e.g. schizophrenia
what is more common sigmoid or caecal volvulus?how do they differ clinically?
sgmoid more common
sigmoid presents as large bowel obstruction
caecal presents as small bowel obstruction
what is a hordeolum internum
internal style
what is the name of the common Cradle cap rash seen in babies - It is characterised by an erythematous rash with coarse yellow scales.?
seborrhoeic dermatitis
what is a common cause of knee pain in runners?
Iliotibial band syndrome
pain lateral side of knee
what is the strongest risk factor for a psycotic disorder?
family history i.e. a parent with scizophrenia
what is telogen effluvium?
hair loss following stressful period e.g. surgery
which nutritional deficiencies can cause hair loss?
iron
zinc
what is the most common cause of thrombophilia?
facotr V leiden
what cause of thrombophilia has highest risk of clots?
antithrombin 3
what is becks triad for cardiac tamponade?
fall in BP, raised JVP, muffled heart sounds
what does the ecg show in carfiac tamponade?
electrical alternans
what is the diagnostic criteria for diabetes?
glucose > 11 mmol/l or known diabetes mellitus
pH < 7.3
bicarbonate < 15 mmol/l
ketones > 3 mmol/l or urine ketones ++ on dipstick
how is DKA managed?
fluids
0.1units/kg/hr insulin fixed
when glucose <15 give 5% dextrose too
cont long acting inulin
give pottasium if K+ <5.5
how is resolution of diabetes defined?
pH >7.3 and
blood ketones < 0.6 mmol/L and
bicarbonate > 15.0mmol/L
what should SK and EMG show in temporal arteritis ?
normla
what are the issues of temporal arteritis ?
headache
jaw claudication
anterior ischemic optic neuropathy
polymyalgia rheumatica
what are the most common ype of ovarian cyst?
follicular
common in menstrual women
physiological cyst
what is the most common ovarian tumour in <30yrs? what are the risks associated?
dermoid cyst
benign - germ cell
torsion is more common
what is the most common ovarian tumour in <30yrs? what are the risks associated?
dermoid cyst
benign - germ cell
torsion is more common
what are the different epithelial and germ cell ovarian tumours?
germ cell - dermoid
epithelial - serous or mucinous
what is the most common ovarian carcinoma>?
serous carcinoma
how can psoriatic arthritis present?
symmetric polyarthritis - most common type
asymmetrical oligoarthritis: typically affects hands and feet
sacroiliitis
DIP joint disease (10%)
arthritis mutilans
what has a better prognosis RA or psoriatic arthritis?
psoriatic
give breif overvie w of different types of hypersensitiviyt ?
type 1 - IgE/ mast cells - anaphylaxis, atopy
type 2 - IgG/M bind antigen on cell surface e.g. autoimmune haemolytic anaemia, ITP, pernicious anaemia
tyope 3 - free antigen and antibody form complexes - SLE, post strept glomeulonephritis
type 4 - T cell - TB , scabies, allergic contact dermatitis, MS
type 5 - Ab to cell surface receptor - graves
what causes a non-haemolytic febrile reaction in blood transfusion? how does it present and how is it managed?
Thought to be caused by antibodies reacting with white cell fragments in the blood product and cytokines that have leaked from the blood cell during storage
causes fever and tachy
managed by slowing and giving paracetamol
what causes a minor allergic reaction during blood transfusion? how does it present and how is it managed?
plasma protieuns
uritcaria
temporarily slop , antihistaines
what causes anaphylaxis in blood transfusion?
those with anti IgA ab
what causes a acute haemolytic reaction during blood transfusion? how does it present and how is it managed?
ABO incompatible
fever, abdo pain, hypotension
A to E , check identity, send blood back
what is the difference between TRALI and TACO?
TRALI - Non-cardiogenic pulmonary oedema thought to be secondary to increased vascular permeability caused by host neutrophils that become activated by substances in donated blood. presents as hypoxia, infiltrates, fever, hypotension
TACO - overload, HYPERTENSION
how is SVT managed?
valsalva/ carotid massage
adenosine 6mg, 12mg, 18mg
adenosine is contraindicated in asthmatics, use verapamil instead
when can nexplanon be inserted post termonation?
immediately
what types of surgical resection is used for rectal cancers?
anterior resection for anything more than 5cm from anal verge
below this is an abdomino perineal resection
what types of surgical resection is used for rectal cancers?
anterior resection for anything more than 5cm from anal verge
below this is an abdomino perineal resection
is breast feeding contraindicated in hep C?
no
what are the complications of chronic hep C?
rheumatological problems: arthralgia, arthritis
eye problems: Sjogren’s syndrome
cirrhosis
hepatocellular cancer
cryoglobulinaemia: typically type II (mixed monoclonal and polyclonal)
porphyria cutanea tarda (PCT)
membranoproliferative glomerulonephritis
how long after hep C treatment can women not get pregnant?
6 months
ribivirin is teratogenic
do port wine stains and strawberry naevus resolve?
port wine stains - no
strawberry naevus - develop in first month, grow up to 9 months and then spontaneuously go
what ecg changes are seen in hyperkalaemia?
tall-tented T waves, small P waves, widened QRS leading to a sinusoidal pattern and asystole
how is lymes disease managed? what can be seen after starting abx?
14 -21 days doxycycline
Jarisch-Herxheimer reaction-worsening of symptoms
How does threadworm infection present and how is it trested?
perianal itching, particularly at night
girls may have vulval symptoms
mebendazole is used first-line for children > 6 months old and household members. A single dose is given unless infestation persists
what is the recommended alcohol intake?
14 units/week
best to spread out over 3 or more days
what are the risk factors for shoulder dystocia?
fetal macrosomia (
high maternal body mass index
diabetes mellitus
prolonged labour
how is shoulder dystocia managed?
mcroberts manouevre
episiotomy
what tumour markers are elevated in testicular cancer?
seminomas: seminomas: hCG may be elevated in around 20%
non-seminomas: AFP and/or beta-hCG are elevated in 80-85%
LDH
what is gold standard Ix for endometriosis?
laproscopy
how does anterior uveitis present?
acute onset
ocular discomfort & pain (may increase with use)
pupil may be small +/- irregular due to sphincter muscle contraction
photophobia (often intense)
blurred vision
red eye
lacrimation
ciliary flush: a ring of red spreading outwards
hypopyon; describes pus and inflammatory cells in the anterior chamber, often resulting in a visible fluid level
how is anterior uveitis managed?
urgent opthal review
