My Go To Notes 2 Flashcards
1
Q
- Dyspepsia:
URGENT REFERRAL
:
-dysphagia
-Upper abdominal mass consistent with stomach Ca.
-Aged =>55 year + Weight loss + One of the following
either upper abdominal pain or reflux or dyspepsia
A
Dyspepsia Mx:
-Review medications
-Lifestyle
-Trial of PPI for 1 month OR Test and Treat for Pylori
-Pylori test include C-13 Urea breath test OR Stool antigen OR serology for initial diagnosis.
-Triple therapy for 2 weeks
- Repeat test usually non needed if symptoms resolved
-if Repeat test needed»_space;do C-13 Urea breath test
2
Q
- Ferritin
Low is <30 seen in Iron deficiency
High is >300 in post-menopausal women and men and >200 in pre-menopausal woman
A
High ferritin Causes
-hemochromatosis
-inflammation
-Liver disease
-Alcohol excess
-CKD|
-Malignancy
3
Q
Cbd stones
A
- CBD stones
‹5mm may be left alone to be passed spontaneously.
Cholesterol stones — by far the most common in western countries (approximately 90%).
4
Q
260.Gastric Cancer:
- occurs in old age
A
Risk Factors-
H. PENAS
H- Pylori|
P. Pernicious anemia
E- Ethnicity Japan and China
N- Nitrates
A- A blood group
S- Smoking, Salt preserved food
5
Q
Gastric cancer
A
Diagnosis:
OGD and biopsy»_space; signet ring cells»_space; worse prognosis
staging: CT chest abdomen and pelvis, Endoscopic US, FDG-PET CT, staging laparoscopy
Treatment:
-Endoscopic mucosal resection
-partial gastrectomy
-Total gastrectomy
-Chemo
6
Q
261.GERD
Indications for Endoscopy:
A
-dysphagia
-weight loss
-age >55
-symptoms > 4 weeks or persistent despite PP| treatment
-relapsing symptoms
-Anemia
7
Q
Treatment; of GERD
A
A trial of PPI for 4-8 weeks if fails then endoscopy
if endoscopy negative then 24-hour PH monitoring which is gold standard for GERD.
8
Q
262.Hemochromatosis:
A
-Autosomal recessive»_space;more common than CF
HFE gene»_space;
C282Y mutation»_space;
Dec. Hepcidin»_space;
Inc. Iron absorption»_space;
iron deposit i issue >
Reversible complication are
Don’t forget Panhypopituitarism and hypogonadotropic hypogonadism
cause infertility and erectile dysfunction
9
Q
Hemochromatosis treatment
A
Investigations:
-Iron Studies, Ferritin, iron, Transferrin saturation all increased and TIBC decreased
-Genetic testing
-Liver biopsy
Treatment:
-therapeutic phlebotomy
-Iron chelators- deferoxamine
10
Q
263.H. Pylori
Antibiotics should be stopped 4 weeks before and
PPI should be stopped 2 weeks before
testing for Pylori.
A
Investigation:
-best non-invasive test is C-13 Urea breath test
-best invasive test is rapid urease test on biopsy sample
-others are serology (remains positive after eradication), stool antigen, gastric biopsy culture and histology
Treatment:
According to NICE, give the following for 7 days:
- Lansoprazole 30mg BD OR omeprazole 20-40mg BD
- Amoxicillin 1g BD
-Clarithromycin 500mg BD OR metronidazole 400mg BD
11
Q
- Hepatic Encephalopathy
Precipitating factors:
A
Infection e.g. spontaneous bacterial peritonitis
GI bleed
TIPS
Constipation
Drugs: sedatives, diuretics
Hypokalemia
Renal failure
Increased dietary protein (uncommon)
12
Q
Hepatic encephalopathy RX
A
Treatment:
-Remove precipitating factors
-Lactulose is first line
-Rifaximin is added for 2rdy prophylaxis
-Liver transplant
13
Q
265.HCC
Chronic hepatitis B is the most common cause of HCC worldwide while chronic
hepatitis C is the most common cause in Europe.
Risk Factors:
A
ABCDE
A-Alcohol, aflatoxin, A1AT deficiency
B-Hep B, Biliary cholangitis (PBC)
D- DM, Drugs (anabolic steroids)
E-elevated Iron, Erection (Male)
Screening:
with ultrasound (+/-alpha-fetoprotein) should be considered for high-risk groups such as:
-All patients with liver cirrhosis secondary to hepatitis B & C or haemochromatosis
-Men with liver cirrhosis secondary to alcohol
14
Q
HCC mng
A
Management:
Hepatocellular carcinoma (HCC) should be managed according to the Barcelona Classification for Liver Cancer Treatment System.
Child-Pugh A Cirrhosis:
• No Portal HTN.
• Single lesion <2cm.
= Surgical resection.
Child-Pugh A/B Cirrhosis:
• 2-3 tumors ≤ 3 cm / 1 tumor ≤5 cm.
• No Vascular / Extrahepatic spread.
= Liver transplantation (Bridge: RFA or TACE).
Child-Pugh A/B Cirrhosis:
• Good performance status.
• Vascular/ Lymphatic / Extrahepatic spread.
= Tyrosine Kinase inhibitor (Sorafenib).
Child-Pugh C Cirrhosis:
• End-stage liver disease.
• Poor candidates for therapy.
= Treat symptomatically; best supportive care.
15
Q
- Hepatorenal syndrome:
Type 1» rapidly progressive with rise in creatinine to >221 Umol/L or
fall in creatinine clearance to <20 ml/min in less than 2 weeks.
very poor prognosis
Type 2»_space; slowly progressive,
prognosis is still poor
but survival is longer
A
Treatment:
-Terlispressin»_space; splanchnic vasoconstriction
leading to Inc. Renal perfusion
-Volume expansion with 20% Albumin
-TIPS
-Liver transplant
16
Q
- GI Adenomas:
A
1.villous adenoma»_space;
sessile tumor»_space;
secretary diarrhea»_space;
hypokalemic, hypochloremia metabolic alkalosis
2.Adenomatous Polyps»_space;pedunculated tumors
- tubular adenomas»_space; less likely to be malignant compared to above two
17
Q
- WILSON’S DISEASE:
A
- WILSON’S DISEASE:
-AR, mutation in ATP7B gene
-Inc. Copper absorption from Gl and Dec. Copper excretion by liver
-Liver»_space;hepatitis, cirrhosis
-Eyes»_space; Keyser Fleischer rings (green brown)
-Brain»_space; basal ganglia, esp. putamen and globus pallidus.
speech, behavioral,
psychiatric problems are first presentation.
Asterixis, CHOREA, dementia
parkinsonism develops later
-RTA
-Hemolysis
-Blue nails
18
Q
- WILSON’S DISEASE:
A
Diagnosis:
-Slit lamp examination of eyes
-Low ceruloplasmin level
-High 24 hours urinary copper level
-Total serum copper is low but free copper is high
-confirmed by Genetic analysis
Treatment:
-Penicillamine first line
-Trientine Hydrochloride alternative to above
-Tetrathiomolybdate (investigational drug)
-Zinc can be used for Maintenace therapy and asymptomatic
19
Q
A
20
Q
Whipple’s disease:
A
FOAMY WHIP
F-Fever
O-Ocular problems
A-Arthralgia
M-Myocardial involvement
Y-Young male
W-weight loss
H-Hyperpigmentation
I-Intestinal malabsorption
P-Paresthesia’s
21
Q
Diagnosis treatment of whipple disease
A
Diagnosis:
Jejunal Biopsy shows PAS +ve macrophages
Treatment:
A course of IV ceftriaxone or doxycycline
followed by oral co-trimoxazole for 1 year
22
Q
- Vit B-6 deficiency
A
caused by isoniazid
peripheral neuropathy
sideroblastic anemia (microcytosis, ringed sidreoblasts)
23
Q
A
24
Q
- Vit B-1 deficiency:
A
caused by alcohol intake
-Wernicke encephalopathy (altered consciousness, ataxia, nystagmus, ophthalmoplegia)
-Korsake off syndrome (confabulation, amnesia)
-Dry and wet beriberi (dry- peripheral neuropathy, wet-CHF)
25
281. B-12 deficiency
-Pernicious anemia
-Diphyllobothrium latum
-Crohn's disease
-Ileal resection
Investigations:
-Vit B-12 level >>low
-Homocysteine level >>high
-Methylmalonic acid level >>high
Treatment:
Lifelong I/M vit B-12 injections
26
280.Variceal Bleeding
Mangement:
-ABC
-Two large bore iv cannula for bloods and drugs
-arrange 6 units of O-ve blood
- send blood for type and cross, send routine bloods
-IV terlipressin
-IV antibiotics
-Correct coagulopathy with FFP, Vit K, Platelets
-Endoscopy and band ligation
-Band ligation is superior to sclerotherapy
-Sangston -Blakemore tube as a temporary measure if uncontrolled hemorrhage
-TIPS if above fails
27
prophylaxis
Variceal bleeding
-Propranolol
-Prophylactic endoscopy and band ligation in cirrhosis patients every 2 weeks until all varices removed. P
- PPI is given AFTER to prevent endoscopy induced ulceration
28
29
279.SBP
Diagnosis:
-Diagnostic paracentesis >250 Neutrophils
-Most common organism on culture of ascitic fluid is E. coli
Treatment:
-ciprofloxacin or norfloxacin
-Albumin infusion to increase
circulatory volume and prevent
hepatorenal syndrome in select cases.
30
278. Small bowel bacterial overgrowth syndrome
Ix:
-Hydrogen breath test
-Trial of antibiotics
-Small bowel aspiration & culture (less often used)
Rx:
-correct underlying disorder
-Rifaximin first line or co-amoxiclav, metronidazole
31
277.PPI Side effects
HOMI
H-hyponatremia, hypomagnesaemia
O-Osteoporosis
M-Microscopic colitis
I-Inc. Risk of c.difficile infection
32
276. Primary Sclerosing cholangiti
Male
Inta and extra hepatic sclerosis and cholestasis
Associated with UC, HIV
Inc. Risk of Cholangiocarcinoma and CRC
Ix:
-US
-MRCP/ERCP
-P-ANCA
-Biopsy?
Rx:
-Ursodeoxycholic acid
Cholestyramine for itching
ERCP_balloon dialtion of strciture
Liver transplant
33
Primary sclerosis cholangitis screening
***Screening
- At diagnosis, all patients require colonoscopy for IBD. If IBD +VE Endo/colonoscopy annually
If IBD-VE scopes every 5 years
- Ca19-9 + USS/MRI every 6/12 months to look for cholangiocarcinoma
- USS surveillance is also recommended every 6-12 months
to assess for gallbladder polyps (if polyp >0.8cm consider cholecystectomy)
34
35
275. Primary biliary cholangitis
M rule middle age female mitochondrial antibody M2
IgM is raised
sMooth muscle antibody (in 30%)
Ix:
-LFTs
-Serology
-Imaging (RUQ US, MRCP)
Rx:
-first line is ursodeoxycholic acid
-2nd line is obeticholic acid for UDCA non-responders.
-cholestyramine for pruritis
-Fat soluble vit supplementation
-Liver transplant
*** 20- fold increased risk of HCC***
*** Itching, Jaundice, fatigue, Hyperpigmentation***
36
274. Peutz Jeghers syndrome:
Mutation in LKB1/STK11-tumor suppressor gene
-hamartomatous polyps (most common in small bowel)-benign
-pigmented macules on lips, buccal mucosa and digits
-Inc. risk of GI cancer (polyps are itself benign)
Polyps can cause obstruction, intussception, bleeding
Mx: Screening- starting at 8-18 years depending upon family hx, manage complications.
37
273. Cowden Syndrome
Inherited cancer syndrome >> PTEN-tumor suppressor gene mutation
THOMCE (read like Thomas)
Thyroid cancer
Hamartomas
Ovarian
Melanomas
Colorectal cancer
Endometrial cancer
38
272. Pernicious anemia
-lemon tinge
-Atrophic glossitis
-Associated with other autoimmune disease
-intrinsic factor antibodies are more specific than parietal cell antibodies
-Increased risk of gastric Cancer
Rx:
-No neurologic features >> I/M B12 injection 3 times a week for 2 weeks then every 3 months thereafter for lifetime.
-Neurologic features >> I/M B12 every other day until improvement of symptoms then every 2 months for lifetime.
39
271.Dumping syndrome:
complication of Whipple and gastric bypass surgery
Early symptoms 15-30 mint after food
>> rapid dumping of food from stomach to small intestine >>
hyperosmolar food cause fluid shifts from bloodstream into intestines >>
causes nausea, vomiting, abd cramps,
sweating, dizziness, hypotension, tachycardia etc.
Late symptoms 1-3 hours after food
>> caused by exaggerated insulin release due to rapid increase in blood glucose >>
symptoms of hypoglycemia develop.
40
271. Pancreatic Cancer:
Associated with BRCA2, KRAS, HNPCC, MEN1
-New onset diabetes might be a presentation of Pancreatic Ca and warrants CT-abdomen.
-migratory thrombophlebitis (Trousseau syndrome) is more common than with other cancers
Ix:
-US first test
-HrCT is best diagnostic test
A double duct sign on imaging is suggestive of cancer (indicating dilation of both CBD and pancreatic duct)
Rx:
-Whipple procedure for operatable cancer with adjuvant chemotherapy
-ERCP and stenting as part of palliative care.
41
270. Oesophageal Cancer
Ix:
- OGD and biopsy to diagnose
-for staging, EUS, CT chest, abdomen and pelvis, FDG-PET CT, staging Laparoscopy
Tx:
-If T1NOMO then operate >> Ivor -Lewis esophagectomy + adjuvant chemotherapy
-Advanced disease >> supportive and palliative Tx
-poor prognosis
42
269. NAFLD
- Associated with metabolic syndrome, type 2 DM where mechanism is mainly insulin resistance »
Inc. Circulating FFA due to fat mobilization which deposit in liver +/-increased FA synthesis in liver
-In sudden weight loss/starvation, again circulating FFA deposit in liver n
Jejunoileal bypass (bariatric surgery)
deficiency of certain nutrient esp. choline leads' Iter bile acid metabolism
and Inc. Fat deposit in liver
NO ALCOHOL INTAKE HERE
Investigation;
-LFTS (ALT > AST)
-USG
-Non-invasive tests for grading of NAFLD and assess severity of cirrhosis including;
ELF (elevated liver fibrosis) Score
FIB4 Score and NAFLD fibrosis score combined with Fibroscan.
if advanced fibrosis is suspected then refer to Liver specialist for
-Biopsy for accurate staging of cirrhosis
Treatment:
-Mainn Tx is Lifestyle changes (weight loss) and monitoring
-there is ongoing research into the role of gastric banding and insulin-sensitizing drugs (e.g. metformin, pioglitazone)
43
268.IBS
Management:
>>>First-line pharmacological treatment - according to predominant symptom
Pain: antispasmodic agents
Constipation: laxatives but avoid lactulose
Diarrhea: loperamide is first-line
>>›If constipation not treated with maximal doses of laxatives and been present for atleast 12 months then
LINACLOTIDE can be used.
>>>2nd Line is Antidepressant - low dose TCA >SSRI
>>> If no response to medical Tx for 12 months
then consider referral for psychological intervention- CBT,
Hypnotherapy, psychotherapy.
>>> Change in lifestyle and diet in addition to pharmacological Tx.
44
267. Hyperbilirubinemia
Unconjugated:
Gilbert's syndrome
Crigler-Najjar syndrome
Conjugated:
Dubin-Johnson syndrome
Rotor syndrome
-Crigler Najjar type 2 is treated with phenobarbital as it induces the enzyme activity.
-Dubin Jhonson causes black liver
45
266. Hepatorenal syndrome:
Type 1>> rapidly progressive with rise in creatinine to >221 Umol/L
or fall in creatinine clearance to <20 ml/min in less than 2 weeks. very poor prognosis
Type 2 >> slowly progressive, prognosis is still poor but survival is longer
Treatment:
-Terlispressin >> splanchnic vasoconstriction leading to Inc. Renal perfusion
-Volume expansion with 20% Albumin
-TIPS
-Liver transplant
46
287.Acromeegaly
Complications:
_hypertension'
-Cardiomyopathy
-DM Type 2
-Colorectal Cancer
Diagnosis:
-IGF-1 Level _ best initial test
-GH glucose suppression test _confirmatory test
-MRI to visualize tumor
Treatment:
-Trans-sphenoidal surgery is first line if no Cl
-Medical treatment if unfit for surgery
* Somatostatin analogue - Octreoride first line medicine.
* GH receptor antagonist - Pegvisomant
* Dopamine agonist - bromocriptine
-if both medical and surgical Tx fail, external radiation therapy is sometimes used
47
287.Acromeegaly
Complications:
_hypertension'
-Cardiomyopathy
-DM Type 2
-Colorectal Cancer
Diagnosis:
-IGF-1 Level _ best initial test
-GH glucose suppression test _confirmatory test
-MRI to visualize tumor
48
49
288. Addisons disease:
-hyperpigmentation is a feature of primary and not secondary Addison's disease.
-Vitiligo is often seen
Causes:
-TB, HIV, Meningococcal Septicemia (water-house Fredrikson syndrome)
-Metastasis
-Antiphospholipid Antibody syndrome
Diagnosis:
_Primary care: 9am Serum Cortisol level
* If <100 nmol/L, abnormal, Addison likely
* If 100-500, borderline, confirm with Synacthen test
* if >500, Addison unlikely
50
51
Acromegaly treatment
Treatment:
-Trans-sphenoidal surgery is first line if no Cl
-Medical treatment if unfit for surgery
* Somatostatin analogue - Octreoride first line medicine.
* GH receptor antagonist - Pegvisomant
* Dopamine agonist - bromocriptine
-
if both medical and surgical Tx fail, external radiation therapy is sometimes used
52
288. Addisons disease:
-hyperpigmentation is a feature of primary and not secondary Addison's disease.
-Vitiligo is often seen
Causes:
-TB, HIV, Meningococcal Septicemia (water-house Fredrikson syndrome)
-Metastasis
-Antiphospholipid Antibody syndrome
53
288. Addisons disease:
-hyperpigmentation is a feature of primary and not secondary Addison's disease.
-Vitiligo is often seen
Diagnosis:
_Primary care: 9am Serum Cortisol level
* If <100 nmol/L, abnormal, Addison likely
* If 100-500, borderline, confirm with Synacthen test
* if >500, Addison unlikely
54
Investigation of addisons
_Confirmatory test is ACTH Stimulation test (Synacthen test), cortisol is measured before and 30 mint after 250ug I/M Synacthen.
_Serum ACTH test to confirm primary vs secondary normal/high in primary, low in secondary.
_ CT-abdomen (in certain situation), CT/MRI brain if secondary Addison suspected.
55
Addisons treatment
Treatment:
_Hydrocortisone in 2-3 divided dose 20-30mg _fludrocortisone
**Give Hydrocortisone and Syringes to be kept at home for Tx of adrenal crisis.
**double the dose of Hydrocortisone but not fludrocortisone in stress e-g intercurrent illness.
56
289. ANTI-Thyroid Drugs:
Carbimazole:
-TPO inhibitors >>dec. synthesis of T3, T4
High dose is given for 6 weeks to make the patient euthyroid after which dose is reduced.
-Can cause ** Agranulocytosis (ANC <0.5) **
check FBC before starting and ask patient to return if develops fever/sore throat etc.
-can cause cholestasis and liver injury
- Avoid in pregnancy and breast feeding
57
289. ANTI-Thyroid Drugs:
PTU
PTU:
-Inhibits both TPO and 5 deiodinase and therefore decreases both synthesis and conversion of T4 to T3
- Hepatocellular Injury
-Agranulocytosis
- Gl upset
-drug induced lupus
-Hair loss (rare)
58
290. Corticosteroids
Fivestar Hotels Provide Delicious Breakfast (order of dec. mineralocorticoid activity)
Fludrocortisone is
Full of minerals
Hydrocortisone is
High on minerals
Prednisone is
Poor in minerals
Dexa/Betamethasone Deprived of minerals
59
290. Corticosteroids
-Leukocytosis,
insomnia,
anxiety,
depression,
mania,
psychosis are also side effects of steroids
Gradual Withdrawal
-if >40mg/day prednisone for more than 1 week
-if more than 3 weeks of treatment. recent repeated courses of steroids
60
61
291.Cushing Syndrome:
-most common cause is exogenous steroids
-most common endogenous cause is pituitary adenoma
Diagnosis;
1st test:
-Low dose (1mg) dexamethasone suppression test (first line) OR
-24-hour urinary cortisol (2 measurements) OR
-Bedtime salivary cortisol (2 measurements)
LDT >> Cortisol low -normal, no need to do further test
>> Cortisol high, Cushing syndrome likely, do further test to confirm & localize
62
291.Cushing Syndrome:
-most common cause is exogenous steroids
-most common endogenous cause is pituitary adenoma
2nd test:
-High dose (8mg) dexamethasone suppression test
HDT >> Cortisol High, ACTH Low _ Adrenal cause
>>Cortisol Low, ACTH Low _Pituitary cause
>> Cortisol High, ACTH High _ Ectopic ACTH
63
64
291.Cushing Syndrome:
-most common cause is exogenous steroids
-most common endogenous cause is pituitary adenoma
3rd Test:
Imaging
Adrenal cause >> abdominal CT/MRI
Pituitary cause>> CT/MRI brain
Ectopic ACTH >> CT chest (SCLC)
Treatment:
-Treat underlying cause
-ketoconazole, metyrapone, etomidate
65
292.Diabetes Mellitus:
Type 1 DM
-Young
-Low BMI <25
-Ketosis
-rapid weight loss
-Acute onset
***Tests:
Criteria for diagnosis
- Fasting ≥7
-OGTT ≥ 11.1
-Symptomatic patient
>> above criteria apply on asymptomatic patients if repeated measurements show the
same results
66
***Differentiating Type 1 from Type 2 DM:
-C-peptide levels _ low in Type 1
-Autoantibodies_ positive in Type 1
* Anti-GAD
* ICA
* IAA
*IA-2A
67
TYPE 2 DM
-Old >50
-Obese
-High C-Peptide levels esp. in early disease
-Stronger genetic predisposition than Type 1
-FASTIGN ≥ 7
-OGTT ≥ 11.1
-Symptomatic
>>if asymptomatic, two measurements are needed.
68
292.Diabetes Mellitus:
Type 2 DM
HbA1C:
Normal =<41
DM => 48
Prediabetes 42-47
Fasting Glucose
Normal $6
DM ≥7
IFG 6.1- 6.9
OGTT
Normal =<7.7
DM => 11.1
IGT 7.8-11
69
70
293. Management of Type 1 DM:
-Target HbA1c is < 48
-HbA1c should be checked every 3-6 months until stable
-Glucose should be checked 4 times a day at least (on waking up, and before each meal)
-Target Glucose levels
* Fasting 5-7 (4-7 in children and young adolescents)
* Before meal 4-7
* Post-prandial 5-9
* If driving
=>5
* Rest of the levels are same in children and Youngs.
71
Insulin Regimen:
* Basal-bolus regimen is superior to Mixed regimen
* Basal: first line is twice daily detemir, alternative is once daily glargine or degludec.
* Bolus: Rapid-acting insulin analogues are superior to rapid-acting human and animal insulin.
** Add Metformin if BMI ≥ 25 **
72
294. Management of Type 2 DM:
Step 1:
HDA1C 48-57 Lifestyle OR Metformin
Target is <48
* If lifestyle >> Review in 3-6 months >> if still above 48 then Add Metformin and titrate up
† Metformin Cl, Monotherapy with SGLT-2 (if criteria met) OR one of t ioglitazone/sulfonylurea/DPP
73
Type 2 DM
Step 2:
HbA1C ≥58 on Lifestyle+one drug therapy
Target is 53
* Start Dual therapy - add one of the following:
Metformin + DPP-4 inhibitor
Metformin + pioglitazone
Metformin + sulfonylurea
Metformin + SGLT-2 inhibitor (if NICE criteria met)
74
Step 3 DM
Step 3:
HbA1C >= 58 on dual therapy
Target is 53
If a patient does not achieve control on dual therapy, then the following options are possible:
* Metformin + Any Two drugs from pioglitazone/sulfonylurea/DPP-4 Inhibitors / SGLT-2
depending on certain criteria.
OR
* Insulin-based treatment
75
Further step t2 DM
Further Step:
HbA1C failed to reduce after TRIPLE therapy,
*Add GLP-1 Analogue if BMI > 35
*Add GLP-1 Analogue if BMI <35 and
Insulin has significant occupational implications so can't be used.
** Do not add insulin and GLP-1 together without specialist opinion**
76
Starting Insulin:
NICE recommend starting with human NPH insulin (isophane, intermediate-acting) taker at bed-time or twice daily according to need
-Metformin should be continued.
77
SGL-2 Indication Criteria:
-Established CVD
OR
-CVD risk >10%
OR
-CHF
78
Mx of Hypertension in DM:
-ACEI/ARBs first line
-Target BP
<80 yr 140/90 clinic, 135/85 ABPM
>80 yr 150/90 clinic, 145/85 ABPM
79
Statins Indications:
Primary Prophylaxis:
-Most type 1 Diabetics
-10year CVD risk > 10%
-CKD with eGFR <60
80
Statin indication
Secondary Prophylaxis:
-Established CVD
81
295.DKA
Diagnostic criteria:
-Glucose >11 or known DM
-Acidosis PH <7.3, HCO3 <15
-Blood
Ketones > 3
-Urine
Ketones ++ on dipstick
Investigations:
- Routine bloods (FBC, U&E, ESR/CRP) |
-Blood Glucose and Ketones
-Urine dipstick
-ABGs
-ECG
-CXR-PA view if indicated
82
Management:
-V Fluids to correct fluid deficit, 5-6 L in 24 hours
-Start with IV NACL 0.9% and ADD 10% Dextrose once blood glucose is <14 at 125ml/hr
-IV insulin infusion to correct ketosis at the rate of 0.1U/Kg/hour.
-Manage K+
if >5.5
don't Add K+
if 3.5-5.5
Add 40 mmoll K+ in first 24 hours
if <3.5
senior review to decide how much
83
-Ongoing Monitoring
Glucose
initially 1 hour then 2-4 hour
Ketones and K+ 1-2 hour
ABGs
2-4 hours
- Known diabetic should continue taking LONG-ACTING INSULIN but short acting insulin should be stopped.
- Start S/C Insulin once eating and drinking
84
DKA Resolution Criteria:
-PH|
>7.3
-HC03- >15
-Blood Ketones < 0.6
85
Complications: of DKA
-Cerebral edema
-Hypokalemia/ hyperkalemia
-Hypoglycemia
-VTE
-ARDS
-AKI
86
296.Neuropathic Pain:
-First-line treatment: Amitriptyline, alternatives are duloxetine, gabapentin or pregabalin.
-if the first-line drug treatment does not work try one of the other 3 drugs.
-Tramadol for exacerbations of pain
Orefer to pain clinic if not controlled
87
297. Gastroparesis:
Prokinetic drugs like metoclopramide, domperidone, erythromycin should be used
88
298.HbA1c
NICE recommend 'HbA1c should be checked every 3-6 months until stable, then 6 monthly'.
Falsely Low:
>>>>>SCA, G6PD, HS, Hemodialysis
Falsely High:
>>>>> Iron/B12/Folate deficiency anemia, splenectomy
89
What does it tell?
HbA1c
Average plasma glucose level over last 3 months more accurately over last 2-4 weeks
How to know average plasma glucose level from HbA1c?
- if HbA1c in percentage use this formula (2* HbA1c) - 4.5
- if HbA1c in mmol/mol use this formula
HbA1c / 5.6
90
299. Graves's disease:
Management:
-ATD carbimazole is first line
-Propranolol is given along with carbiamzole to control symtoms until Thyroxine levels fall.
-if ATD fails >>> Radioactive lodine (RAI)
91
Contraindication of RAI:
-Pregnancy (should be avoided until 4-6 month after tx)
-Age <16
-Graves's ophthalmopathy
Most patients with RAI need thyroxine replacement after 5 years
92
300.Drug causes of gynecomastia:
Spironolactone (most common drug cause)
Cimetidine
Digoxin
Cannabis
Finasteride
GRH agonists e.g. goserelin, buserelin
Estrogens, anabolic steroids
93
301.Hashimoto Thyroiditis:
-Anti TPO and anti-Thyroglobulin antibodies
-Hyperthyroidism followed by hypothyroidism
-Painless Goiter
-Thyroxine replacement
94
Subacute (De Quervain) Thyroiditis:
-painful goiter, raised ESR, After a viral infection
and Granulomatous inflammation
-Hyperthyroidism then Hypothyroidism then Normal function.
-Self limiting
-Propranolol for Hyper, Thyroxine for Hypo if symptomatic
-Aspirin/Nsaids for pain
-Steroids for severe disease
95
Reidel Thyroiditis:
-dense fibrous tissue replaces normal thyroid tissue
-hard fixed painless goiter
-causes hypothyroidism
-Tx with thyroxine
96
Postpartum thyroiditis:
-similar to Hashimoto but mostly self-limited
-Anti TPO and Thyroglobulin antibodies present
-painless subacute thyroiditis within 12 months of pregnancy/miscarriage or an abortion.
-can rarely cause permanent hypothyroidism
-Thyroxine replacement
97
302.Unusual causes of Hypercalcemia:
-Acromegaly
-Thyrotoxicosis
-Adddison's disease
98
303.Mechanism of Contraction Alkalosis
-Angiotensin Il stimulates Na+-H+ exchange in the proximal tubule r>> H+ secretion.
-Aldosterone stimulates the apical V-type H+-ATPase in the distal segments >> H+|
secretion.
99
304.HHS:
Features:
-Hypovolemia
-Glucose very high (>30 mmol/l)
-High serum osmolality >320
-Ketones < 3
-NO acidosis
100
Management:
304.HHS:
Management:
-IV 0.9% sodium chloride solution 0.5-1L/hour depending on assessment of dehydration
-Monitor and add K+ to Fluids
-Insulin should not be given unless blood glucose stops falling while giving IV fluids
- Patients are at risk of thrombosis due to hyper viscosity >>> consider VTE prophylaxis
101
305. Hypoglycemia:
Glucose < 4mmol/l
Management:
-If able to swallow:
Oral glucose gel (dextrogel, glucogel) 10-20g if in hospital, in community can use high sugar juice or candy or food.
-If unconscious:
-IV dextrose 75-100 ml of 20% or 150-200ml of 10%
-If IV access not possible S/C or I/M Glucagon
102
306.Hypoparathyroidsim:
>>Hypocalcemia
-circumoral numbness
-Tetany
-Chvostek sign
-trousseau sign
-confusion, seizures
-prolonged OT
Rx: alfacalcidol
103
Pseudohypoparathyroidism:
congenital abnormality in G protein
>>non-responsive PTH receptors
low ca, high p, high PTH
104
307. drugs causing Hypothyroidism??
-Amiodarone
-lithium
105
106
308. Levothyroxine
-Starting dos is 25mcg in cardiac disease, >50 yr old, and severe hypothyroidism, titrate up
-rest of the patient 50-100mcg, titrate up
-Target TSH range 0.5-2.5
-TFTs checked 8-12 weeks after starting thyroxine
-In pregnancy increase dose by at least 25-50mcg due to increased demands
**Iron, calcium carbonate reduces absorption of levothyroxine, give at least 4 hours apart
107
309. Beta-blockers
reduce hypoglycaemic awareness.
Patents taking insulin need to take extra precaution
108
310.Kallman's syndrome:
-failure of Grh secreting neurons to migrate to hypothalamus.
-Hypogonadotropic hypogonadism »delayed puberty
-cryptorchidism
-ANOSMIA
-Cleft lip/palate, visual/hearing problems is some patients
109
Management of Kallman syndrome
-testosterone supplements
-gonadotrophin supplements
110
311. MEN syndromes:
MEN-1 men-1 gene
(Pituitary, parathyroid, pancreas)
MEN-2A Ret Gene
(MCT, pheochromocytoma, parathyroid)
MEN-2B Ret Gene
(MCT, Pheochromocytoma, Marfanoid, neuromas)
111
312.Myxedema Coma (severe form of hypothyroidism)
Mx:
-IV thyroid
-IV fluids
-IV steroids
112
313. OBESITY
BMI classification:
Underweight
<18.5
Normal
18-25
Overweight
25-30
Obesity Class!
30-35
Obesity classil
35-40
Obesity Class III|
>40
Management:
-Diet and exercise first line
113
Obesity medication and surgery
-Medications
* Orlistat- Pancreatic lipase inhibitor
if BMI >=30 or BMI >=28 with risk factors for CVD
* Liraglutide GLP-1 analogue
if BMI >=35 or prediabetic hyperglycemia
-Surgery if BMI >40
if BMI >35 and medical Tx failed or comorbidities
114
314.Pheochormocytoma:
Investigations:
-24 H urinary free metanephrines levels first line
-plasma free metanephirne levels
-CT/MRI
-MIBG scan
Treatment:
-a-blocker (phenoxybenzamine) BEFORE
-B-blockers (propranolol)
-surgery
115
315.Prediabetes /IFG/IGT:
-IFG is 6.1 - 6.9 fasting due to hepatic insulin resistance
-IGT is 7.8- 11.1 OGGT due to muscle insulin resistance
Treatment:
-First line is lifestyle -diet, exercise, weight loss
-Patients who continue to have progression towards type 2 DM despite lifestyle intervention »>start metformin
116
117
316. Primary hyperaldosteronism:
-Hypertension with hypokalemia or treatment resistant hypertension >>> consider testing for PHA
Causes:
-B/L adrenal hyperplasia 60-70%
-Adrenal adenoma (Conn Syndrome) 20-30%
Investigations:
-Plasma Aldosterone/renin is first line investigation
-High A/R ration >> PHA
-Low A/R ration >> SHA (reninoma, renal hypoperfusion)
-HrCT Abdomen to localize
-Adrenal vein sampling to differentiate U/L adenoma vs B/L adrenal hyperplasia
Treatment:
-Adrenal adenoma >> surgery
-Adrenal hyperplasia>> spironolactone
118
316. Primary hyperaldosteronism:
-Hypertension with hypokalemia or treatment resistant hypertension >>> consider testing for PHA
Causes:
-B/L adrenal hyperplasia 60-70%
-Adrenal adenoma (Conn Syndrome) 20-30%
Treatment:
-Adrenal adenoma >> surgery
-Adrenal hyperplasia>> spironolactone
119
317.Primary Hyperparathyroidism:
-symptoms of hypercalcemia
(bones, stones, moans, groans)
-hypertension and pancreatitis
Investigations:
-Blood High Ca, Low P, High or normal PTH
-Technetium MIBI subtraction scan to localize
- X-ray (pepper pot skull, Osteitis fibrosa cystica)
120
317.Primary Hyperparathyroidism:
-symptoms of hypercalcemia (bones, stones, moans, groans)
-hypertension and pancreatitis
Investigations:
-Blood High Ca, Low P, High or normal PTH
-Technetium MIBI subtraction scan to localize
- X-ray (pepper pot skull, Osteitis fibrosa cystica)
-Surgery is first line if no Cl
-If not fit for surgery >> cinacalcet
-Conservative Tx if Ca+ <0.25 mmol/L above ULN
and age >50 and no end organ damage
121
318. Prolactinoma
-Microadenoma < 1cm
-Macroadenoma >1 cm
Ix: MRI
Rx: -Dopamine agonist (cabergoline, bromocriptine)
-Trans-sphenoidal surgery for macroadenoma and for microadenoma if medical Tx fails.
122
319. Side effects of SGLT-2 inhibitors
-Inc. Risk of urinary and genital infection
-Inc. Risk of necrotizing fasciitis of genitalia and perineum (Fournier gangrene)
-Euglycemic DKA
-Inc. Risk of LL amputation
123
320.Sick euthyroid syndrome
Either low T3, T4 and Low TSH or Low T3, T4 and normal TSH in the presence of an acute illness
No treatment needed treat the underlying illness
124
321.Subclinical Hypothyroidism:
-TSH raised but T3, T4 normal
-No obvious symptoms
Management:
**TSH >10
-Repeat TSH in 3 months
-if TSH still >10, give levothyroxine
125
**TSH 5.5 - 10
**TSH 5.5 - 10
-Repeat TSH in 3 months
-if TSH still between 5.5 - 10 then next step is based on symptoms or no symptoms
-If asymptomatic, Repeat TSH in 6 months
-If symptomatic next step based on age if <65 yr old, offer thyroxine if >80 yr old, watch& Wait if 65-80 yr old, use clinical judgement
126
322. Sulphonylureas:
-K-ATPase inhibition and Inc. Insulin release
Sulfonylureas should be avoided in breastfeeding and pregnancy.
Side effects:
common >> weight gain, hypoglycemia
rare>>Hyponatremia (SIADH),
B.marrow suppression,
cholestatic hepatotoxicity,
Peripheral neuropathy
127
323. Pioglitazone:
-PPAR-gamma receptors agonist »> Dec. Insulin resistance
Side effects: weight gain, liver impairment, Inc. Risk of FRACTURE and BLADDER CANCER.
Cl in CHF
128
324. Thyroxine
Should not be taken together with ferrous sulphate as FeSo4 decrease Absorbtion of thyroxin.
Should be taken at least 4 hours apart.
129
325. AML
(>60 yr old)
-Pancytopenia, hepatosplenomegaly, bone pain,
- Peripheral smear shows blast cells (MPO+, Aure rods)
-Bone marrow biopsy >20% blast cells
-Cytogenetics
-Acute promyelocytic leukemia M3, t15:17, younger than typical AML, good prognosis, excellent response to ATRA.
130
326.Antiphospholipid antibody syndrome in pregnancy
>> Low dose aspirin once pregnancy confirmed by upt.
>>LMWH until week 34 of pregnancy
131
327. Autoimmune hemolytic anemia:
Warm: Lupus, Lymphoma,
Lymphocytic Leukemia (CLL)
methyldopa, b-Lactams
Cold: Mycoplasma,
EBV, lymphoma
Ix: Direct coombs test
Rx: AIHA
A - Anti-inflammatory (steroids - prednisolone)
I - Incision (splenectomy)
H - Hemoglobin replacement (blood transfusion)
A - Antibody (monoclonal antibody - rituximab)
132
328. Blood products transfusion complication:
-FNHR_cytokines released from WBC >>>>> Paracetamol
-AHR_ABO incompatibility >>>> IV fluids
-Minor allergic, reaction to plasma proteins >>>>>> oral antihistamine
-Anaphylaxis, IgA deficient recipient >>>>>>> I/M adrenaline
-TACO (transfusion related acute circulatory overload), due to excessive transfusion, cardiogenic pulmonary edema >>>>>>> Tx with 02 and consider IV Furosemide
-TRALI, host neutrophil activation, non-cardiogenic Pulmonary edema, ARDS >>>>>Tx with 02 and ventilatory support.
-Red cell can transmit HIV, HBV, HCV
-Platelets can cause bacterial infection e-g stap.epidermidis, B.cereus
-leukocytes can transmit CMV and vCJD but most blood products are leukocyte depleted so it's rare.
133
329.FFP:
contains clotting factors, albumin and IGs.
used for severe hemorrhage in liver failure can also be used before surgery if high risk of bleeding
Cryoprecipitate
Factor VIll, WBF, Fibrinogen
used for severe bleeding in Hemophilia
A and WBD disease and severe active bleeding with fibrinogen <1.5
134
PCC
vit-K dependent clotting factors
used for reversal of warfarin induced major bleeding
(reversal occurs within 1 hour compared to 6 hours for Vit K injection)
also used for reversal of LMWH in emergency surgery
135
330. Hematology tests:
Bleeding Time: Platelet function
Clotting (Thrombin) Time: Thrombin
PT (factors I, II, V, VII, X) 1,2,5,7,10
aPTT (VIII, IX, XI, XII) 8,9,11,12
All inc. in DIC
Warfarin inc. PT
Hemophilia inc. APTT
136
137
331. High INR due to warfarin management
Major bleed (GIT, Intracranial bleed):
regardless of INR >>>
- stop warfarin
-PCC first, if not available then FFP
-IV vit K
138
331. High INR due to warfarin management
INR >8 + minor bleed
-stop warfarin
-IV vit K
INR 5-8 + minor bleed
-stop warfarin
-IV vit K
-check INR in 24 hours
-restart warfarin when INR<5
INR 5-8, No bleed
-oral vit K
-Stop warfarin
-check INR in 24 hours
-restart when INR <5
INR <5
-reduce or omit one or two doses
-check INR in 2-3 days
139
140
332. Blood transfusion
332. Blood transfusion
Hb < 7 with or without symptoms
Hb <8 with symptoms
Hb <9 in CVD
141
333. MC lymphoma in HIV+
is diffuse large B-cell lymphoma (NHL)
followed by Burkitt lymphoma
142
334.G6PD deficiency:
-Hx of neonatal Jaundice
-Intravascular hemolysis (
triggered by primaquine,
ciprofloxacin, sulfa drugs)
-Heinz bodies and Bite cells on peripheral film
-G6PD levels checked 3 months after the attack of hemolysis.
-Rx: Supportive (02, IV fluids, Blood transfusion if severe)
143
335. CML
-t(9:22) >> Philadelphia chromosome >> BCR-ABL fusion gene >> Inc. tyrosine kinase activity
-Leukocytosis +thrombocytosis + Anemia + Marked splenomegaly
Ix: Peripheral blood film shows granulocytes in all stages of maturation
Rx: Imatinib (MAB against Tyrosine kinase) is the first line
-hydroxyurea, IF-al
-BMT|
144
336.CLL:
-Lymphocytosis (dysfunctional lymphocytes >> Hypogammaglobulinemia >> infections)
-Anemia
-Thrombocytopenia
Ix: Peripheral blood film shows smudge cells (aka smear cells)
Tx: Chemo
Ritcher's transformation
occurs when leukemia cells enter the lymph node and change into a high-grade, fast-growing non-Hodgkin's lymphoma.
The patient becomes suddenly unwell and develops B-symptoms of NHL.
145
337.Burkitt's Lymphoma:
-Rx: chemo (can cause Tumor lysis syndrome- give rasburicase)
-Endemic (African form) >> maxilla and mandible
-Sporadic (HIV patients) >> abdomen (ileo-cecal)
-ass with EBV
-Starry-Sky appearance on microscopy
146
147
148
338. Hodgkin's Lymphoma:
-Reed-Sternberg cells on biopsy
-Lymphocytes predominant subtype has best prognosis
-Lymphocyte depleted subtype has worst prognosis
-Nodular sclerosing subtype is most common (70%)
-B-symptoms (fever, weight loss, night sweats) imply a poor prognosis.
149
339.ITP
Management:
Platelets <30 OR symptomatic ITP regardless of count OR
additional risk factors for bleeding >>>>> Treat
Platelet >30 and asymptomatic >>>>observation and monitoring
Rx: first line is oral prednisone, IVIG 2'' line
150
Lead poisoning
340.Lead Poisoning:
LEAD
-Lines (blue) on gingivae (Burton lines) and metaphysis of long bones
-Encephalopathy: neuropsychiatric disturbance
-Abdominal pain, Anemia
-Drops: Wrist and Foot drop
151
LEAD
-Lines (blue) on gingivae (Burton lines) and metaphysis of long bones
-Encephalopathy: neuropsychiatric disturbance
-Abdominal pain, Anemia
-Drops: Wrist and Foot drop
Ix: Inc. Serum lead and d-ALA levels.
-Inc. Urinary coproporphyrin levels.
-P.Smear basophilic stippling and clover leaf cells
Rx: DMSA, D-pencillamine
152
346. ITP:
Treat if
1.symptomatic and <30k
2.asymptonatic <10-20k
3.signifcant bleeding regardless of count
Treatment.
Corticosteroids
IVIG
Platelet transfusion
153
345.ALL:
-Childhood leukemia
-Pancytopenia with lymphoblasts on peripheral smear
-Lymphoblasts are cALLA and tdt positive
-Chemo with Imatinib for philadelphia chromosome-positive ALL, SCT.
154
344. Von Willebrand's disease:
-platelet type bleeding-epistaxis, menorrhagia
Ix: -Prolonged bleeding time and aPTT
-dec. Factor VIII level
-VWF assay
Rx: -Tranexamic acid for mild bleeding
- DDAVP (desmopressin)
- Factor VIll concentrate
155
343. Essential thrombocytosis:
-JAK2 mutation
-platelets >600
-Inc. risk of thrombosis
-Chemo with Hydroxyurea
156
342.PRV:
-JAK2 mutation
-Aquagenic itching, splenomegaly, hyperviscosity syndrome-Inc. Risk of thrombosis
-Phlebotomy/venesection is first line Tx.
-Aspirin for thrombosis
-Chemo: Hydroxyurea
157
341. Anemias
Microcytic:
-Iron deficiency >> iron studies abnormal
-Thalassemia >>Family hx, Target cells, normal iron studies
-Sideroblastic >>ringed sideroblasts on prussion blue stain
-Anemia of chronic disease >>CKD (mostly normocytic)
158
Macrocytic:
-B-12 deficiency >>anemia +neurological symptoms, Inc.Homocysteine + MMA levels
-Folate deficiency >>No neurological symptoms, Inc. Homocysteine but normal MMA level
159
Normocytic:
-Sickle cell >>painful vaso-occlusive crises
-Acute chest syndrome
-Priapism
-Aplastic crisis caused by Parvovirus B19 (dec. Reticulocytes),
-Splenic sequestration crisis (inc. Reticulocytes),
Acute attack: 02, painkillers, IV fluids, Blood transfusion
Prevention: Hydroxyurea
**sickle cell patients should receive the pneumococcal polysaccharide vaccine every 5 years**
160
-Hereditary spherocytosis:
Spherocytes on peripheral smear, splenomegaly
161
PNH:
intravascular hemolysis, dark colored urine, can cause aplastic nemia/pancytopenia,
Inc. Risk of thrombosis (budd-chiari syndrome
Dx: flow cytometry
Rx: Blood transfusion, Eculizumab
-AIHI (already covered)
-G6PD (already covered)
162
163
347. Drugs causing Peripheral Neuropathy
Mnemonic _I AM Very Numbed
I- isoniazid
A- amiodaron
M- metronidazole
V- vincristine
N - nitrofurantoin
164
348. Cranial nerve palsies:
IV CN_Diplopia on downward gaze towards opposite side
V CN _Jaw deviates towards the side of lesion
VII CN_Angle of mouth deviates towards the opposite side of the lesion
X CN_uvula deviates away from side of lesion
XII CN_ tongue deviates towards side of lesion
165
349. Cluster headaches:
Alcohol may trigger an attack
Acute attack:
-100% oxygen|
-age > 18
SC sumatriptan
age < 18
nasal spray zolmitriptan
Prophylaxis:
verapamil is the drug of choice
166
350.Carbamazepine Side Effects:|
CARBA MEAN
C- confusion
A- Ataxia
R- Rashes [Steven Johnson syndrome]
B- Blurred vision/diplopia
A- Aplastic anemia
M- Marrow suppression
E- Eosinophilia
A- ADH release - hyponatremia
N- Neutropenia
167
351.Ataxia-Telangectasia
Triad
-Cerebellar ataxia
-Oculocutaneous telangiectasia
-Recurrent infection
168
169
351.Ataxia-Telangectasia
Triad
-Cerebellar ataxia
-Oculocutaneous telangiectasia
-Recurrent infection
170
352.Aphasia:
Broca on top of Nicke (PG 18 Mnemonic)
|
means inf.frontal.gyrus on top of sup. Temporal gyrus
Broca is on top but can't express himself (Expressive/ Broca's aphasia)
Nicki is in receptive position but can't receive (Receptive/Wernicke aphasia)
171
353. Duchenne muscular dystrophy
Frameshift mutation in Dystrophin gene-severe disease
Progressive proximal muscle weakness from 5 years
Gower sign, pseudohypertrophy of calf
172
Becker muscular dystrophy
Non-frame shift mutation-less severe disease
Develops after the age of 10 years
173
354.Anti-epileptic drugs:
Generalized tonic-clonic seizure
Males: sodium valproate
Females: lamotrigine or levetiracetam
174
Focal seizures
First line: lamotrigine or levetiracetam
Second line: carbamazepine, oxcarbazepine or zonisamide
175
Absence seizures (Petit mal)
First line: ethosuximide
Second line:
Male: sodium valproate
Female: lamotrigine or levetiracetam
Carbamazepine may exacerbate absence seizures
176
Myoclonic seizures
Males: sodium valproate
Females: levetiracetam
177
Tonic or atonic seizures
Males: sodium valproate
Females: lamotrigine
**Primidone is not a Na-channel blocker unlike other AE, it is a barbiturate and safe to use in cardiac patient. **
178
355. Causes of bilateral facial nerve palsy
Sarcoidosis
Guillain-Barré syndrome
Lyme disease
Bilateral acoustic neuromas (as in neurofibromatosis type 2)
Bell's palsy
179
356. Miller Fisher syndrome:
-variant of Guillain-Barre syndrome
-descending paralysis rather than ascending
-associated with ophthalmoplegia, areflexia and ataxia
-anti-GQ1b antibodies are present in 90% of cases
180
357.GBS
ascending paralysis
albuminoprotein dissociation on CSF
Anti-GM1 antibodies in 25%
Rx:
IVIG or plasmapheresis, corticosteroids not helpful
181
358. Drugs causing Benign ICH
A LOST Cause:
Vitamin A
Lithium
OCP/HRT
Steroids
Tetracyclines
Cimetidine.
182
359. Internuclear ophthalmoplegia:
Lesion of the MLF (medial longitudinal fasciculus)
Impaired adduction of the eye on the same side as the lesion
Horizontal nystagmus of the abducting eye on the contralateral side
183
360. Lambert Eaton syndrome:
Treatment:
- Treat underlying cause
-Drug of choice is 3-4 diaminopyridine
(Binds and blocks K+ channels on nerve terminal > prolonged duration of AP > Prolonged ca+ influx and Ach release)
-Steroids &azathioprine to suppress immune system
-IVIG and plasmapheresis if above fails.
184
361.Meningitis:
Sensorineural hearing loss is the most common complication of meningitis
185
362. Migraine Diagnostic Criteria:
PUMA: Pulsating
Unilateral
Moderate-Severe Pain
Aggravated by or avoidance of routine physical activity
5-4-3-2-1-0
25 attacks
4 hours - 3 days duration
22 or more pain features: 'PUMA'
≥1 associated symptoms: N&V OR Photophobia AND phonophobia
O other explanations
186
363. Migraine Management:
Acute attack:
Triptan + NSAIDS or
Triptan + PCM
if above fails then non oral metoclopramide/prochlorperazine + non oral nsaids
187
188
363. Migraine Management:
Prophylaxis (only if frequent, affecting QOL or ADL)
- Propranolol, topiramate, amitriptyline
secondary options are acupuncture and riboflavin 400mg
189
363. Migraine Management:
Menstrual migraine:
frovatriptan or zolmitriptan
190
364.MND:
both upper and lower MN signs
no sensory symptoms
Ix:
clinical dx
NCS is normal
EMG shows abnormal function of neurons
MRi to exclude cervical cord compression or myelopathy
Tx:
_Riluzole
_NIV (BIPAP)
_PEG for nutrition
_prognosis is poor
191
365. Multiple sclerosis:
-optic neuritis
-internuclear ophthalmoplegia
-Uhthoff's phenomenon: worsening of vision following rise in body temperature
-Lhermitte's syndrome: sharp shooting sensation down the back before experiencing the paresthesia in the limbs, on flexion of neck
192
365. Multiple sclerosis
Investigation
Investigation:
MRI- Periventricular plagues and Dawson fingers
CSF-Oligoclonal bands, Inc. Intrathecal IgG
Visual evoked potential
193
365. Multiple sclerosis:
194
365. Multiple sclerosis:
Treatment:
Acute Attack:
Oral or IV methylprednisolone
Prevention of relapse:
MS - FINGO
Fingolimod
IFN-beta
Natalizumab
Glatiramer acetate
Ocrelizumab
195
365. Multiple sclerosis:
Symptomatic Tx:
Fatigue- Amantadine, mindfulness, CBT
Spasticity- Baclofen 1st line, gabapentin 2nd line
Bladder dysfunction:
if significant RV- Intermittent Self Catheter
if no significant RV- Oxybutynin
Oscillopsia- Gabapentin
196
367. Drugs causing exacerbation of MG
Myasthenia Patients support LGBTQ
M-Macrolides
P-Penicillamine, phenytoin
L-Lithium
G-Gentamicin
B-B-blockers
T-Tetracycline
Q-Quinidine
197
366.Shy dragger syndrome:
nemonic: He is shy because he can't stand (orthostatic hypotension),
drags his fe taxia), can't get a boner (erectile dysfunction) and wets his pants (Incontinenc
So, parkinsonism + Cerebellar signs +autonomic dysfunction
198
199
368. Myotonic dystrophy (AD):
CTG trinucleotide repeat disorder
DM1 - DMPK gene-distal weakness
DM2- ZNF9 gene-proximal weakness
Ix: Genetic testing, EMG, Muscle biopsy
Tx: Physio, OT, ST
Features:
-onset 20-30 years
-skeletal muscle-spastic weakness
-smooth muscle- dysphagia
-Heart muscle-cardiomyopathy, Heart block
-DMI
-testicular atrophy
-B/L cataracts
-Mild mental impairment
200
201
Neurofibromatosis
369. Neurofibromatosis:
NF-1- Cafe lait spots, axillary freckles, Lisch nodules, Peripheral
neurofibroma, pheochromocytoma
NF-2- B/L acoustic schwannomas, meningioma
202
370.Tuberous sclerosis:
Ash leaf spots
, shegreen patches
, adenoma sebaceum,
seizures
203
371. Wiskot Aldrich Syndrome:
WATER
WA= wiskot aldrich
T=Thrombocytopenia
E=Eczema
R=Recurrent infection (combined B & T cell deficiency)
204
372. Parkinson's disease:
Management:
-First line is Levodopa+ Carbidopa
-2nd line are dopamine agonists, MAO-I, COMT-I
-Anticholinergics e-g procyclidine, benztropine, trihexyphenidyl used in Drug induced parkinsonism.
-Surgery- Deep brain stimulation for refractory cases
205
Levodopa side effects:
Levodopa side effects:
L-DOOPA
L-Lunacy (psychosis)
D- Dyskinesia (add amantadine)
O- Orthostatic hypotension (add midodrine)
O-On-off phenomenon (add DA, MAOI, COMTI)
P- Palpitations
A- Anorexia
206
Parkinson’s disease
-Sudden withdrawal of L-dopa can cause NMS
-Dopamine agonist have higher risk of causing hallucinations than other drugs.
-Bromocriptine and cabergoline should not be used as first line do pamine agonists.
207
373. Phenytoin side effects:
PHENYTOIN
Peripheral neuropathy
Hirsutism
Enlarged gum and hands (Gin. Hyperplasia, Dupuytren's contracture)
Nystagmus
Yellow skin (hepatitis)
Teratogenicity
Osteomalacia
Inducer(p450)
Necrolysis (TEN)
208
374. Progressive supranuclear palsy
a Parkinson plus syndrome
-Cognitive impairment
-postural instability (tendency to fall backwards)
-impaired vertical gaze
-parkinsonism
209
375.Pseudoseziures:
Psychogenic Non-Epileptic Attack Disorder (PNEAD), also known as Psychogenic Non-epileptic Seizures (PNES)
>> Video telemetry to differentiate from epilepsy
210
376.Status Epilepticus
Management: NICE
A single seizure lasting >5 minutes, or
≥ 2 seizures within a 5-minute period without the person returning to normal between
then.
211
376.Status Epilepticus
FIRST LINE:
Give a benzodiazepine (buccal midazolam or rectal diazepam) immediately as first-line treatment in the community or
use intravenous lorazepam if intravenous access and resuscitation facilities are immediately available.
Give a second dose of benzodiazepine if the seizure does not stop within 5 to 10 minutes of the first dose.
212
376.Status Epilepticus
2ND LINE:
If convulsive status epilepticus does not respond to 2 doses of a benzodiazepine,
give any of the following medicines intravenously as a second-line treatment:
levetiracetam
phenytoin
sodium valproate.
213
376.Status Epilepticus
3RD LINE:
If convulsive status epilepticus does not respond to the second-line treatment options tried,
consider the following third-line options under expert guidance:
phenobarbital or anesthesia
214
376.Status Epilepticus
SUMMARY:
> Benzo
> Benzo
> Levetiracetam/Phenytoin/Na-valproate
> Phenobarbital/Anesthesia
215
377.Lacunar stroke syndromes:
Perforating or lenticostriate branches of MCA
Pure motor _ post. Limb of internal capsule
Pure sensory _ Thalamus
Motor/sensory _ above two combined
Ataxic hemiparesis _ pons, internal capsule
Clumsy hand dysarthria _ paramedian pons
216
378. Stroke syndromes localization:
ACA
_ Contralateral Hemiparesis and sensory loss
LL > UL
217
MCA
Contralateral hemiparesis and sensory loss +
contralateral homonymous hemianopsia +
aphasia
(left hemineglect if right MCA infarct)
UL >LL
218
PCA
_ contralateral homonymous hemianopsia with macular sparing, visual agnosia
219
Weber
_branches of PCA supplying Midbrain
Ipsilateral 3rd nerve palsy contralateral hemiparesis
220
Wallenberg/ PICA / LMS _
PICA (from vertibral artery)
Ipsilateral loss of pain and temp on face
contralateral loss of pain and temp on body
Ipsilateral ataxia ipsilateral horner syndrome
DYSPAHGIA
221
AICA/LPS _AICA (from basilar artery)
same as above plus
Ipsilateral FACIAL PALSAY
Deafness
222
CRA /Opthalmic artery
_ Amaurosis fugax
223
AICA/LPS _AICA (from basilar artery)
same as above plus
Ipsilateral FACIAL PALSAY
Deafness
223
Basilar Artery
locked in syndrome (complete body paralysis except eye movements, consciousness
224
379. Storke Assessment score:
FAST_ face, arm, speech, time to call 999
ROSIER SOCRE:
LOC
-ve 1
Seizure
-ve 1
Asymmetric facial weakness +ve 1
Asymmetric arm weakness
Asymmetric Leg weakness
visual field defect
Speech disturbance
+ve 1
+ve 1
+ve 1
+ve 1
if rosier > 0, stroke likely
225
380. Management of acute ischemic stroke:
THROMBOLYSIS (ATLEPLASE) IF:
- Presents within 4.5h since symptom onset
- Also, it can be offered within 4.5-9h of symptom onset If imaging shows potential to salvage tissue.
- If woken with symptoms: Within 9h of midpoint of sleep AND potential to salvage tissue on imaging.
(Assuming no contraindications, and hemorrhagic stroke excluded and BP lowered to 185/110)
226
MECHANICAL THROMBECTOMY IF:
- Within 6h of symptom onset, with occlusion of proximal anterior circulation
- Between 6-24h of symptom onset/wellness, with occlusion of proximal anterior circulation AND potential to salvage brain tissue on imaging.
- Within 24h of symptom onset/wellness, with occlusion of proximal posterior circulatior (i.e. basilar / posterior cerebral artery) AND potential to salvage brain tissue on imagin
(Assuming adequate pre-stroke functional status i-e modified Rankin scale score <3 and
NIHSS score >5).
If a person meets criteria for thrombolysis and mechanical thrombectomy, both can be given.
227
ASPIRIN GUIDELINS:
Aspirin 300mg is given if hemorrhagic stroke is excluded and presentation >4.5 hour fror nset (so tPA can't be giver
if presenting within 4.5 hours of onset then wait 24 hours after thrombolysis before starting aspirin
continue aspirin for 2 weeks then switch to clopidogrel.
228
BLOOD PRESSURE IN STROKE:
only lower BP acutely if Hypertensive encephalopathy or ischemic stroke that is going to receive tPA.
229
Carotid Endarterectomy:
if carotid doppler show >50 stenosis, then CEA should be done ASAP within 7 days of stroke or TIA.
230
Secondary Prophylaxis:
clopidogrel for life
Atorvastatin 80mg
controlling risk factors
231
381.Management of TIA:
_ aspirin 300mg before CT if not other Cl while awaiting specialist review _if TIA within last 1 week, refer for same day (24 hours) assessment by specialist
_if TIA more than 1 week ago, refer for urgent assessment (within 7 days) by a specialist
232
381.Management of TIA:
_ aspirin 300mg before CT if not other
Cl while awaiting specialist review _if TIA within last 1 week, refer for same day (24 hours) assessment by specialist
_if TIA more than 1 week ago, refer for urgent assessment (within 7 days) by a specialist
_After specialist review DAPT (aspirin + clopidogrel) for 21 days followed by Clopidogrel monotherapy for life.
_ Urgent (within 24 hours of assessment) Carotid doppler or CTA or MRA if carotid territory stroke/TIA,
and
if indicated (>50% stenosis as per NASCET) perform carotid endarterectomy within 7 days.
233
382. Trigeminal neuralgia:
first line carbamazepine
2nd line gabapentin, amitriptyline, duloxetine.
234
383. Triptans are Cl in CVD and uncontrolled HTN.
side effects are
Tingling
Temperature
Tightness
235
384. Acoustic Schwannoma
Deafness, vertigo, tinnitus (DVT)
Absent corneal reflex
ipsilateral fascial palsy
B/L tumors in NF-2
236
385.Visual field defects:
Homonymous hemianopia:
Incongruous defects_ lesion of optic tract (incongruous means visual field defects are not identical on both sides)
Congruous defects_ lesion of optic radiation or occipital cortex
Macula sparing_lesion of occipital cortex
237
Homonymous quadrantanopia's:
mnemonic _ PITS (Parietal-Inferior, Temporal-Superior)
238
Bitemporal hemianopia:
Lesion of optic chiasm
Upper quadrant defect > lower quadrant defect = inferior chiasmal compression,
commonly a pituitary tumor
Lower quadrant defect > upper quadrant defect = superior chiasmal compression,
commonly a craniopharyngioma
239
386.Acute confusional State/Delirium:
-first line is haloperidol
-if Parkinson's patient then avoid haloperidol, instead try careful reduction of Parkinson's medication, and if delirium symptoms require urgent treatment, then use quetiapine or clozapine.
-BDZ (lorazepam/clonazepam) can be used in severe agitation not responding to quetiapine/clozapine
but generally BDZ should also be avoided in Parkinson.
240
387.Alzheimer's disease:
Pathological changes:
Macroscopic: widespread cerebral atrophy, particularly involving the cortex and hippocampus
Microscopic: cortical plaques due to deposition of type A-Beta-amyloid protein and intraneuronal neurofibrillary tangles caused by abnormal aggregation of the tau protein
Biochemical: deficiency of Ach
241
Alzheimer’s
Genetics
GENETICS:
5% of cases are inherited as an autosomal dominant trait.
_mutations in the amyloid precursor protein, presenilin 1 and presenilin 2 genes are thought to cause the inherited form
_ApoE4 allele, encodes a cholesterol transport protein, associated with an increased risk of Alzheimer's.
242
Management of Alzheimer’s
MANAGEMENT:
Acetylcholinesterase inhibitors:
-Galantamine
-Rivastigmine
-Donepezil
NMDA Antagonist
-Memantine
DO NOT USE ANTIDPERESSENTS
Use HALOPERIDOL for Acute agitation. don't use long term antipsychotics
243
388. Dementia assessment:
assessment tools recommended by NICE for the non-specialist setting includes;
10-Cognitive screen, 6-Cognitive impairment test
assessment tools not recommended by NICE for the non-specialist setting includes
AMTS (abbreviated mental test score), GPCOG (General Practitioner assessment of Cognition), MMSE
244
245
389. Frontotemporal lobar degeneration/ FTD:
Pick's disease is the most common type where personality changes
(Hyperorality, disinhibition, increased appetite, and perseveration behaviors) first before memory loss.
Macro changes:
Focal gyral atrophy with a knife-blade appearance
Atrophy of the frontal and temporal lobes
Micro changes:
Pick bodies - spherical aggregations of tau protein (on silver-staining)
Gliosis, Neurofibrillary tangles, Senile plaques
246
Frontotemporal lobar degeneration
RX
Treatment:
Selective serotonin reuptake inhibitors (SSRIs) or trazodone may be used to manage behavioral symptoms.
Non-pharmacological management
CST (cognitive stimulation therapy), CRT (cognitive remediation therapy), PT
(Physiotherapy), OT 90ccupational therapy), SLT (speech and language therapy) etc
247
248
390. Lewy body dementia:
Also called Dementia with Lewy bodies (DLB):
390. Lewy body dementia:
Also called Dementia with Lewy bodies (DLB):
is a disorder characterized by limbic and neocortical Lewy body pathology and
dementia occurring before or WITHIN 1 YEAR after the onset of motor parkinsonism'
(Triad of Fluctuating cognitive loss + Parkinsonism + Visual hallucinations)
_Dx is usually clinical or SPECT scan is used.
_Rx is cholinesterase inhibitors and memantine
antipsychotics should be avoided in DLB.
249
Parkinsons Disease Dementia (PDD):
Parkinsonism + dementia that develops AFTER 1 year of Parkinson symptoms.
Lewy bodies first in substantia nigra then in limbic and neocortical areas.
250
391. Vascular dementia:
Several months or several years of history of a sudden or stepwise deterioration of cognitive function.
Dx is made from Hx and Exam, cognitive screen, MRi
No effective Tx
aim is to recognize and prevent the progression of disease by controlling risk factors.
251
392. West syndrome/ infantile spasm:
salaam attacks (suddenly bends their arms, legs, and head forward resembling a salaam)
Ix.
EEG -> Hypsyrrthymia
Ct -> localized or diffuse disease
Rx.
vigabatrin is first line
ACTH also used
252
393. 3rd nerve palsy
CT Angio brain to look for Pos.commun.artery aneurysm if no identifiable cause
253
394. Restless leg syndrome:
check iron/ferritin if low >>> treat iron deficiency even
if Hb normal if ferritin normal >>>Dopamine agonist
254
395. when to inform DVLA??
TIA:
255
395. when to inform DVLA??
Stroke:
Stroke >> stop driving for 1 month and inform DVLA
After 1 month decision is made by DVLA depending on any residual deficit.
256
395. when to inform DVLA??
Seizure:
-Epileptic Seizure >> car driver » stop driving and inform DVLA can resume driving when seizure free for 1 year
- Epileptic Seizure >>Lorry driver >>stop driving and inform DVLA can resume driving when seizure free for 5 years.
if Stopping epileptic drugs, stop driving during withdrawal and until 6 months after the las dose of anti-epileptic drug
257
395. when to inform DVLA??
TIA:
Single episode of TIA >> CAR diver >>> stop driving for 1 month, no need to inform DVLA Multiple TIA in a short time
>> stop driving for 3 months and inform DVLA Single TIA»>LORRY driver
»> stop driving for 1 year and inform DVLA
258
Dvla
Syncope
Syncope:
-Single episode, explained and treated > stop driving for 1 month and inform DVLA if lorry driver
-single unexplained episode >> stop driving for 6 months and inform DVLA
-2 or more unexplained episode >>stop driving for 1 year and inform DVLA
259
260
261
396.CYP 450 Drug interactions:
clarithro + methadone = QT prolongation
clarithro + warfarin = bleeding
clarithro statins = Rhabdomyolysis
clarithro +salbutamol = hypokalemia
262
Metronidazole plus alcohol
metronidazole+ alcohol = Disulfiram-like reaction, avoid alcohol until 48 hours after treatment
263
397. Pain-killers in palliative care:
-change from oral codeine to subcutaneous morphine or buprenorphine patch
-change from oral morphine to fentanyl patch or oxycodone.
-Oral oxycodone = IV morphine
264
Conversion formula from one type to another:
oral morphine to subcutaneous morphine = divide by 2
oral morphine to subcutaneous diamorphine= divide by 3
oral morphine to oral oxycodone= divide by 2
oral tramadol to oral morphine = divide by 10
265
Breakthrough dose
Breakthrough dose:
calculate the total dose in 24 hours and divide by 10= given every 4 hours
e-g if total dose in 24 hours is 60mg, then 60/10 = 6mg every 4 hours is breakthrough dose
266
398. Falls in elderly:
-ACEI >> PH (Postural hypotension)
-thiazide diuretics >>PH
-Citalopram, fluoxetine, duloxetine
>>Hyponatremia confusion >falls
-clozapine >>PH
-zopiclone >>ataxia, imbalance >falls
267
399. normal Hb level in pregnancy
1st trimester
11
2nd and 3rd trimester
10.5
post-partum
10
268
400. Antiemetics:
-Renal failure, toxin, drug induced, hypercalcemia >>>Haloperidol >>>>if Parkison's>>>Levomepromazine
-Inc.ICP and Complete bowel obstruction >>> Cyclizine
-partial bowel obstruction, delayed gastric emptying >>>Metoclopramide
269
Antiemetic chemotherapy
-Chemotherapy, radiotherapy, Surgery >>>Ondansetron
270
271
Hyperemesis
-Hyperemesis gravdiarum>>>
1st line Cyclizine, promethazine, doxylamine/pyridoxine combination
2nd line metoclopromide, ondansetron
3rd line steroids
272
273
401. Corticosteroids side effects:
Short term use:
Short term use:
-INSMONIA
-Irritability
-Indigestion
274
CS side effects
Long term use:
-GI bleed
-Osteoporosis
-Weight gain
-Myopathy
-Thinning of skin
-Diabetes
-Cataract/Glaucoma
Oral Thrush=Most common with ICS
275
Sickfaces.com
Sickfaces.com
Sodium valproate
Isoniazid
Cimetidine
Ketoconazole
Fluconazole
Alcohol
Chloramphenicol
Erythromycin
Sulphonamide
Ciprofloxacin
Omeprazole
Metronidazole
276
Crap gps
Inducers
Carbamazepine
Rifampicin
Alcohol
Phenytoin
Griseofulvin
Phenobarbitone
Sulphonylurea
277
Drugs commonly tested for CYP interactions
TCA
Corticosteroids
Statin
Theophylline
Pethidine
Warfarin
Cocp
278
402. Paracetamol Poisoning:
Management:
• Activated charcoal if presents within 1-2 hours of ingestion and alert (avoid if signs of liver toxicity)
• Check paracetamol levels at 4 hours post-ingestion and plot them on Rumack Matthew nomogram
If paracetamol level on or above the treatment line >> Give IV N-acetylcysteine.
279
Indications for N-acetylcysteine:
-If confirmed intake of a toxic dose ≥ 150mg/kg in adults and children and presents within 8 hours of ingestion
-if >12 g total dose in an adult over 24 hours
-if the timing of intake or amount taken is not known
-if staggered overdose (over >24 hours)
-if signs of liver injury
280
Dose of N-acetylcysteine:
150mg/kg IV over 1 hour
50mg/kg over next 4 hours
100mg/kg over next 16 hours
281
King's College London Criteria for liver Transplant:
ABCD
A - Acidosis (pH <7.30)|
B - Bleeding (INR >6.5 or PT >100)|
C-Creatinine >300umol/L or 3.4mg/di
D - Drowsiness (Grade Ill or IV hepatic encephalopathy)
282
403.Allergy and anaphylaxis:
skin prick test:
for food allergies and pollen allergy, fast and simple, results within 15 min
283
Radioallergosorbent test (RAST):
-Measures the amount of IgE that reacts with the allergens e-g IgE to egg protein
-used when skin prick test is not suitable (extensive eczema, taking antihistamines).
-used for food allergies, pollen allergy, wasp/bee venom
284
Skin patch test:
-keep it applied for 48 hours and then read by dermatologist after another 48hours.
-for contact dermatitis allergens and irritants.
285
Dose of Adrenaline in anaphylaxis:
(1:1000 adrenaline, can be repeated every 5 minutes)
<6 months = 0.1-0.15 ml
6 months to 6 years= 0.15ml
6-12 years=0.3 ml
>12 year and adults= 0.5ml
286
Refractory anaphylaxis:
No improvement after 2 appropriate doses of I/M Adrenaline
-Give IV bolus of 0.9% normal saline AND start IV Adrenaline infusion at a rate of 0.5-1 ml/kg and titrate according to response.
287
404.Opioids antagonists:
Buprenorphine / methadone: 1st line to detoxify heroine (opioid) addiction
Naltrexone: to prevent relapse of opioid addiction
Naloxone: in acute opioid poisoning
288
405. Valproate Side effects:
VALPROATE:
V- Vomiting
A- Alopecia
L- Liver toxicity
P- Pancreatitis
R- Retention of Fat
O- Oedema
A- Appetite increase
T- Tremor
E- Enzyme Inhibitors
289
406. Beta blocker overdose Managment:
-Activated charcoal > within 1hr
-Symptomatic bradycardia > atropine
-Heart failure, severe hypotension,
cardiogenic shock> glucagon
-Seizures > diazepam
290
407. Chemotherapy Drugs side effects:
Chemo-Tox Man:
Cisplatin/Carboplatin - Ototoxicity & Nephrotoxicity
Bleomycin/Busulfan - Pulmonary Fibrosis
Doxorubicin - cardiotoxicity
Cyclophosphamide - Hemorrhagic Cystitis
5-FU & 6-MP - Myelosuppression Methotrexate - Myelosuppression
Vincristine - Peripheral Neuropathy
291
408. Marcus gun Pupils:
RAPD or Marcus gun pupils >>>> swinging light reflex
-Lesion of retina or optic nerve
Causes:
-Acute angel closure glaucoma
-Retinal detachment
-Optic neuritis
292
409.Argyl-Robertson Pupils:
-Respond to accommodation but don't respond to light
-seen in Tertiary syphilis
293
410. Acute angle closure glaucoma:
(immediate referral to hospital)
Management:
-Pilocarpine drops
-timolol drops
-IV acetazolamide
-steroid drops
-antiemetics and analgesics
294
Myopia
hypermyopia is a Risk factor for AACG
411. Myopia:
is a Risk factor for
-Cataract
-Retinal detachment
-Open angle glaucoma
hypermyopia is a Risk factor for AACG
295
412. Monocular vision loss
-CRAO
-CRVO
-Retinal detachment
-Optic neuritis
296
413 - chalazion Vs hordeolum:
Chalazion is painless meibomian gland cyst
-apply warm compresses for 4 weeks
-still present >>refer to opthamlo
Hordeolum (stye) is painful
Tx is pain killers + topical antibiotics, I/D if fails.
297
ARMD
414. Age related macular degeneration:
- >70 yr old
-Progressive deterioration of vision esp. at night
-trouble recognizing faces
-micropsia>>. objects appear smaller than they are
-metamorphopsia> straight lines appear wavy
298
Rx: no specific Tx, diet and lifestyle
Dry -most common and characterized by drusen-yellow round spots in bruchs
Membrane
299
Wet form
wet from >>>less common but more severe and characterized by
Neovascularization Rx: Anti-VEGF injections, photodynamic therapy, diet and lifestyle
300
ACCG
415.Opthalmology:
ACCG: acute painful red eye, dilated non-reactive pupils>>>> Tonometry,
Gonioscopy
>>>> timolol & pilocarpine drops, IV acetazolamide, antiemetics, painkillers, steroids, laser peripheral iridotomy.
301
Allergic conjunctivitis
Allergic conjunctivitis: B/Litchy, red and swollen eyes >>>>
first line is topical or oral antihistamines,
2nd line is topical mast cell stabilizers
302
Retinitis pigmentosa
night blindness, tunnel vision, Family hx, black bone spicule shaped pigmentation on fundoscopy
303
Optic neuritis
Optic Neuritis:
Female with sudden U/L decrease in vision, red-color blindness, painful eye movements,
RAPD, central scotoma >>>MRI with contrast >>>Steroids
304
Open angle glaucoma
Open angle glaucoma: Gradual loss of peripheral vision-tunnel vision, glaring, halos>>>
first line is laser trabeculoplasty,
2nd line Latanoprost,
3'" line timolol/brimonidine/pilocarpine drops. >>>if all fail trabeculectomy
305
Hypertensive retinopathy
Hypertensive Retinopathy: stage-1 tortuous vessels, silver wiring
>>>stage-2 arteriovenous nipping
>>>> stage-3 flame hemorrhages, cotton wool spots, macular star
>>>stage-4 papilledema
306
Scleritis
Marked redness
Pain
Blurry vision
Phneylephrine drops don’t improve
Redness
IST line
Oral nsaids
Oral steroids and immunosuppressants if severe
307
Episcleritis
Episcleritis: mild redness and irritation, vision normal
>> Dx: phenylephrine drops improves redness which differentiates it from scleritis >> artificial tears, topical steroids
308
Diabetic Retinopathy:
NPDR: Mild- aneurysms, Moderate-aneurysms blot hemorrhage+ cotton wool spots+hard exudates, Severe-same as moderate but involve more area >>>Panretinal laser photocoagulation
PDR: neovascularization, vitreal hemorrhage >>>panretinal laser, intravitreal VEGF
309
Corneal ulcer
Corneal Ulcers: contact lens (infections), Vit A deficiency (exposure keratitis) >>>Topical antibiotics
310
Ant uveitis
int.Uveitis: HLAB27, Acute painful red eye, irregular small pupils, ciliary flust ypopyon>>>> cycloplegics (atropine, cyclopentolate) and steroids drop:
311
Blepharitis
Blepharitis: B/L swollen eyelids, sticky eyes >>> hot compresses, lid hygiene.
312
Cataract
Cataracts: Gradual decrease in vision, loss of color vision, glaring, halos>>> absentred reflex on ophthalmoscopy, slip lamp
>>> Surgery-Phacoemulsification, extracapsular cataract extraction.
313
CRAO
CRAO: sudden painless monocular vision loss, cherry red spot on a pale retina >>> Tx: intraarterial thrombolysis
314
CRVO
CRVO: sudden painless monocular vision loss, retinal hemorrhages-stormy sunset
>>intravitreal VEGF injections, laser photocoagulation
315
Chorioretinitis
Chorioretinitis: decreased vision, floaters, white-retinal lesion in toxoplasmosis, pizza pie fundus in CMV
>>>> pyrimethamine sulfadiazine for toxoplasmosis, ganciclovir for CMV, steroids for autoimmune cause.
316
Corneal ulcer and abrasion
Corneal abrasion: Hx of eye trauma >>fluorescein staining >> topical antibiotics
Corneal Ulcers: contact lens (infections), Vit A deficiency (exposure keratitis) >>>Topical antibiotics
317
416. Menier's disease:
acute attacks >>>>prochlorperazine (promethazine, cyclizine, cinnarizne)
prevention of further attacks >>> Betahistine
319
320
321
322
323
417. Ear diseases:
OME:
-Tympanic membrane is bluish grey, dull or yellow with air fluid level
-a child <2 yr with B/L CHL (conductive hearing loss)
-Hx of Recurrent OM, URTI, Adenoids
Rx: wait for 3 months if no hearing loss, grommets, hearing aids
324
Otosclerosis
Otosclerosis:
-TM shows flamingo pink blush (Shwartz sign)
-15-45 yr old with B/L CHL with family history
Rx: stapedectomy or stapedotomy or hearing aids
325
Acute suppurative OM
Acute Suppurative OM:
-Inflamed TM with cartwheel appearance
-Most common organisms:
RSV/rhinovirus, H.influenza- strep.pneumo-strep pyogenes.
-antibiotics
326
Tympanosclerosis
Tympanosclerosis:
-B/L CHL
-Chalky with patches/deposits on TM
327
Cholesteatoma:
-proliferation of keratinizing squamous epi
-pearly white mass behind TM
-chronic foul smelling purulent discharge
-CHL
-Urgent referral to ENT
328
418. Tonsillectomy indications:
>7 epi in one year
>5 epi/year for 2 years
>3 epi/year for 3 years
Sleep apnea
329
419. Audiologic tests in children:
< 6 months = audiological brainstem response + Otoacoustic emission
6-18 month = distraction test + visual reinforcement audiometry
2-4years = condition response audiometry + speech discrimination
>5 years = pure tone audiometry
330
420.Lateral neck mass:
Cystic Hygroma: cystic mass in post. Triangle of neck, transillumination +ve
Brachial cyst: soft, fluctuant mass in ant. Triangle of neck, transillumination -ve
Reactive Lymphadenopathy: recent infection
Lymphoma: painless, rubbery, ass symptoms such as night sweats, weight loss etc.
331
421. Sore throat:
Interpretation:
0-1 No antibiotics
2 consider antibiotics
3-4 must give antibiotics
1 CENTOR Criteria: 1 point for each (max score 4)
C - Cough absent
E - Exudates
N- Nodes (lymphadenopathy)
T - Temperature >38°C
332
333
• FeverPAIN criteria: 1 point for each (max score
F-Fever over 38°0
P -Purulence (pharyngeal/tonsillar exudate).
A -Attend rapidly (3 days or less)
I -Inflamed tonsils
N-No cough or coryza
Interpretation:
0-1 no antibiotics
2-3 consider antibiotics
4-5 must give antibiotics
Treatment:
Phenoxymethylpenicillin, if Pen allergic
then erythromycin or clarithromycin.
334
422.Epistaxis:
Management:
Management:
-First Aid -›pinch the soft cartilaginous part of nose for 10-15 mints
-if first aid successful --> apply naseptin cream or mupirocin cream
-if first aid not successful. then either Cautery with silver nitrate if point of bleeding is visible (one side at a time to prevent septal perforation)
OR
- Nasal packing if B/L profuse bleeding.
-if all fails sphenopalatine ligation in OT.
335
336
Malignant otitis externa
423.ENT:
Malignant Otitis Externa:
DM >> Pseudo.Auroginosa
>> severe infection >>
CT-scan>>
IV antibiotics that cover pseudomonas.
337
Nasal septal hematoma
Nasal septal hematoma:
B/L boggy swelling >> Surgical drainage,
IV antibiotics >> if left untreated it can cause septal necrosis.
338
Bppv
BPPV:
vertigo with change in head position, lasts few seconds to minutes
>>Dix Hallpike to diagnose
>> Eppley maneuver for Tx, self-limiting
339
Vestibular neuritis
Vestibular neuritis: recent viral infection,
vertigo lasts hours-days, no hearing loss >>self-limiting
340
Labrinthitis
Labyrinthitis:
viral infection, vertigo, tinnitus
, hearing loss > symptomatic Tx, self-limiting
341
Vestibular schwannoma
Vestibular schwannoma:
DVT + fascial palsy+ absent corneal reflex >>urgent referral to ENT.
342
424. When to use antibiotics in acute otitis media:
Mnemonic_43210
4= more than 4 days or worsening symptoms
3= NEWS > 3|
2= < 2years and bilateral
1= Immunocompromised
0= PerfOration
343
424. drugs causing gingival hyperplasia
_Phenytoin
_cyclosporin
_calcium channel blockers
344
Cyclical Mastalgia:
B/L painful, tender breasts during the menstrual cycle
>>>>reassure, analgesia, well-fitted bras, COCP if severe.
345
Lactation mastitis
Lactation Mastitis:
lactating women with inflamed breast
>>> continue breastfeeding, analgesia, warm compresses, antibiotics (flucloxacillin) if infection suspected (Stap.aureus)
346
Periductal mastitis
Periductal Mastitis: smoker, periareolar inflammation, discharge, nipple inversion >> antibiotics (co-amoxiclav)
347
Duct ectasia
Duct ectasia:
green nipple discharge, subareolar mass,
inverted nipple >> reassure, excision if symptomatic
348
Breast abscess
Breast abscess: Red fluctuant mass with signs of infection > antibiotics + I/D
349
Fibroadenoma
Fibroadenoma:
young women, benign, smooth, mobile, rubbery lump >>excision if >3 cm
350
Fibrocystic changes/Fibroadenosis/Lumpy breast:
Fibrocystic changes/Fibroadenosis/Lumpy breast:
benign, tender lumpy breasts that are often cyclical
>> analgesia, supportive bras, COCP if severe
351
Fat necrosis
Fat Necrosis:
hard lump that mimics cancer, hx of trauma to breast >> FNAC >> reassure
352
Duct papilloma
Duct papilloma:
bloody nipple discharge, periareolar mass
>> FNAC>>excision if symptomatic.
353
Breast cancer types and diagnosis
Breast Cancer:
Histologic subtypes: DCIS, LCIS, Invasive lobular carcinoma, invasive ductal carcinoma, special subtypes.
Dx: Triple assessment
-Clinical examination
-Imaging (<40 yr old USG, >40 yr old Mammography)
-Biopsy -core biopsy/Sentinel lymph node biopsy
354
Treatment of breast cancer
Tx:
-Hormonal therapy:
ER/PR +ve: 1. SERM >>Tamoxifen (inc. risk of endometrial cancer), raloxifene
2. Aromatase inhibitors>> anastrozole, letrozole (inc. Risk of osteoporosis)
Her2-neu +ve: Trustuzumab (Herceptin) »>causes dilated cardiomyopathy
Triple negative: worse prognosis
-Surgery: Lumpectomy, mastectomy, wide local excision, Axillary clearance
-Radiotherapy
-Chemotherapy
355
425. Type of biopsy for breast lesions:
F → FNAC → Fibroadenoma
P→ Punch → Paget's
C → Core → Cancer
356
426. Chancroid
Hemophylis.Ducrei>>Painful genital ulcers, painful lymph nodes
Rx: A single IM dose (250 mg) of ceftriaxone
OR a single IM dose (1 gram) of azithromycin OR
an oral (500 mg) of erythromycin four times a day for seven days.
357
427.Chlamydia:
-doxycycline (7-day course) is first-line
-if pregnant then azithromycin, erythromycin or amoxicillin may be used.
-Asymptomatic men and all women, notify all partners in last 6 months or most recent partner.
-Symptomatic men, notify all partners since onset and 4 weeks before onset of symptoms.
358
428. Cryptosporidium:
-Self-limiting diarrhea in immunocompetent and Severe diarrhea with weight loss in HIV patients.
-Ziehl Neilsen satin > red cysts
Rx: Nitazoxanide OR Rifaximin
359
429. Cutaneous larva migrans:
Ancylostoma genus (e.g. Ancyclostoma braziliense)
-Animal faecal-contaminated soil or sand
-intensely pruritic, 'creeping', serpiginous rash
-Rx: anthelmintic agents, such as ivermectin or albendazole
360
430. Enteric Fevers (typhoid/paratyphoid):
INVESTIGATIONS
- Widal test (antibody to O and H antigen) (not specific)
- Blood culture (1st week) - can establish diagnosis
- Stool culture (2nd, 3rd week)
TREATMENT
- Drug of choice - Ciprofloxacin x 2 weeks
- Chronic carrier - Ciprofloxacin x 4 weeks = cholecystectomy
- Typhoid vaccination for travellers to endemic areas
361
431. Genital warts:
HPV 6 & 11
-topical podophyllum or cryotherapy are commonly used as first-line
-imiquimod second line
362
432. Giardiasis:
-stool antigen detection assay is the best test
-stool microscopy for trophozoite and cysts has sensitivity around 65%.
Rx: Metronidazole
363
433. Gonorrhea:
Diagnosis:
-Do a NAAT swab to confirm gonorrhea
-Culture on Thyer Martin or charcoal agar
Reinfection is common due to antigen variation of type IV pili (proteins which adhere to surfaces)
and Opa proteins (surface proteins which bind to receptors on immune cells)
364
365
366
Gonorrhoea
Treatment:
-The new first-line treatment is a single dose of IM ceftriaxone 1g (i.e. no longer add azithromycin)
-if cetriaxone is refused then oral cefixime 400mg (single dose) + oral azithromycin 2g
(single dose)
-If sensitivities are known (and the organism is sensitive to ciprofloxacin) then a single dose of oral ciprofloxacin 500mg should be given.
-A test of cure in 1 week (NAAT)
-Disseminated gonococcal infection (DGI) is a triad of tenosynovitis, migratory polyarthritis and dermatitis.
Tx with IV Ceftriaxone for 7 days
-Complications;
urethral strictures,
epididymitis, PID and
Fitz Hugh Curtis,
Gonococcal Arthritis
, Endocarditis if DGI.
367
368
Viral hepatitis
Tx
434. Viral Hepatitis:
Hep A: single dose vaccine, booster in 6-12 months
369
Hep B:
-Associations; MN, MPGN, FSGS, Ig-nephropathy, PAN, Cryoglobulinemia
- Vaccine 0,1,2 months (3 doses)
What does different antigen or antibody mean??
-HBeAg indicates infectivity
-Anti-HBs and anti-HBc IgG positivity indicates immunity from previous infection
-Anti-HBs without anti-HBc IgG indicates immunity by vaccination
-Anti-HBc IgM indicates acute infection
370
Hep B:
-Associations; MN, MPGN, FSGS, Ig-nephropathy, PAN, Cryoglobulinemia
- Vaccine 0,1,2 months (3 doses)
371
Hep B:
-Associations; MN, MPGN, FSGS, Ig-nephropathy, PAN, Cryoglobulinemia
- Vaccine 0,1,2 months (3 doses)
Diagnosis:
-testing for anti-HBs is only recommended for those at risk of occupational exposure (i.e.
Healthcare workers) and patients with chronic kidney disease.
In these patients anti-HBs levels should be checked 1-4 months after primary immunization.
-If Anti-HBS >100, booster in 5 years
-if 10-100, suboptimal, additional dose of vaccine
-if <10, repeat the 3-dose course, if still fails then HBIG for PEP.
372
Hep B RX
Treatment:
-first line still Peg-INF alpha
-Tenofovir and entecavir also used
373
Hep C:
Diagnosis:
HCV RNA is the investigation of choice to diagnose acute infection (55-85%) will develop chronic hepatitis C
Extrahepatic Findings:
-eye problems: Sjogren's syndrome
-cryoglobulinemia, porphyria cutanea tarda, MPGN
Treatment:
-the aim of treatment is sustained virological response (SVR), defined as undetectable serum HCV RNA six months after the end of therapy
-First line Sofosbuvir+daclatasvir OR Sofosbuvir+Simprevirm +/- Ribavirin
-2nd line Peg INF alpha
374
Herpes simplex
435.Herpes Simplex:
-Oral acyclovir only given if within 5 days since start of symptoms.
-Suppressive therapy if at least 6 occurrences per year. (Herpes has 6 letters so 6 occurrences per year)
375
Antiretroviral treatment
436.HIV, Anti-retroviral Drugs
Treatment:
Triple therapy involves a combination of 3 drugs,
2 NRTI + 1 NNRTI or PI
NRTI= nucleoside reverse transcriptase inhibitors
P|= Protease Inhibitor
NNRT|= Non-nucleoside Reverse transcriptase inhibitors
376
377
MOA antiretroviral
Mechanism of action:
Drugs ending with Navir=P| (example- Indinavir)
Drugs ending with tegravir=integrase inhibitors (example- raltegravir)
Maraviroc=CCR5 (entry inhibitor)|
Enfuvirtide=GP41 (fusion inhibitors)
nevirapine, efavirenz = NNRTI|
ALL others= NRTI (example Zidovudine)
378
Antiretroviral tested side effects
Commonly tested side effects:
indinavir: renal stones
zidovudine: anaemia, myopathy, black nails
didanosine: pancreatitis
tenofovir: renal impairment and osteoporosis
NRTI: peripheral neuropathy
PI: Metabolic syndrome
379
437.PCP Pneumonia
Diagnosis:
-CD4 count < 200/mm3
-CXR-bilateral interstitial pulmonary infiltrates
-Confirmatory test -bronchoalveolar lavage (BAL)
Treatment:
-Co-tri first line
-IV pentamidine in severe cases
-Steroids if Pa02 <9.3kPa
380
438.HIV Testing:
if symptomatic:
-Test with Anti-HIV (ELISA for screening, western blot for confirmation)
and P24 antigen combined
-if positive check viral load with PCR
If asymptomatic:
-Test after 4 weeks of exposure
-if negative, repeat test at 12 weeks
381
382
439.HPV Vaccination:
Who should receive the vaccine??
-All 12- and 13-year-olds (girls AND boys) in school Year 8 are offered the human papillomavirus (HPV) vaccine (single dose)
-Children Can receive against the parents' wishes if they want.
-eligible GBMSM <25yr old, single dose (GBMSM=Gay, bisexual, men having sex with men)
-eligible GBMSM 25-45 yr old, 2-doses
-HIV/immunosuppressed 3 doses
383
440.Infectious Mononucleosis:
-EBV, also known as human herpesvirus 4, HHV-4
-Triad of fever, sore throat, lymphadenopathy
- Ass with hemolytic anaemia secondary to cold agglutinins (IgM)
Diagnosis:
EBV Serology for <12 yr old and immunocompromised in 1st week
FBC and monospot test for >12 years and immunocompetent in 2nd week
Treatment:
Treatment is supportive
avoid contact sports for 4 weeks
384
Influenza vaccine
441.Influenza Vaccine:
-Children at 2-3 years and then annually, intranasal flu vaccine, live attenuated
-elderly >65 and at-risk group annual injectable killed vaccine
-also killed vaccine in pregnancy
385
Legionella
442. Legionella:
-Pneumonia + lymphopenia + hyponatremia + deranged LFTS
-urinary antigen test
-erythro/clarithro
386
Weils disease is a severe form characterized by
triad of Jaundice,
AKI, and
hemorrhages (e-g pulmonary hemorrhage)
Dx: is made by serology and PCR
Tx: is with high-dose benzylpenicillin or doxycycline
443. Leptospirosis:
• spirochete Leptospira interrogans
• being spread by contact with infected rat urine.
• seen in sewage workers, farmers, vets or people who work in an abattoir, also, a tropical disease.
387
444.Lyme Disease:
spirochaete Borrelia burgdorferi
Ixodes tick
Late disease:
• cardiovascular
• heart block|
• peri/myocarditis
• neurological
o facial nerve palsy o radicular pain
• Meningitis
388
444.Lyme Disease:
spirochaete Borrelia burgdorferi
Ixodes tick
Late disease:
• cardiovascular
• heart block|
• peri/myocarditis
• neurological
o facial nerve palsy o radicular pain
• Meningitis
389
444.Lyme Disease:
spirochaete Borrelia burgdorferi
Ixodes tick
Late disease:
• cardiovascular
• heart block|
• peri/myocarditis
• neurological
o facial nerve palsy o radicular pain
• Meningitis
Investigations:
(1) If Erythema migrans present, diagnosis done, Rx with abx
(2) If EM absent, first line is Elisa for Borrelia antibodies
> if Elisa negative but Lyme disease suspected repeat elisa 4-6 weeks after first test
> if Elisa -ve but Lyme still suspected after 12 weeks of symptom onset then Immunoblot test
> if Elisa positive/equivocal confirm with Immunoblot test
390
444.Lyme Disease:
spirochaete Borrelia burgdorferi
Ixodes tick
Treatment:
-First line for mild-moderate disease is doxycycline
-If Pregnancy, Amoxicillin
-If above two can't be used, Azithromycin
-If sever disease (heart &brain), ceftriaxone
391
445. Malaria Management:
Diagnosis: Thick and thin smear, RDTs
Treatment:
-Falciparum: Artemether+Lumafentrine
-
P.Vivax/Ovale: AM+LF followed by Primaquine to prevent relapse
-Tx in Pregnancy: mefloquine
Malaria prophylaxis:
-chloroquine, Atovaquon-proguanil, mefloquine, doxycycline
In Pregnancy: Chloroquine
In children: Deet mosquito repellent, Doxy if >12 yr old
392
446.Meningitis:
• if < 3 months _IV cefotaxime+ IV amoxicillin or ampicillin
• if 3 m-60 yr _ IV cefotaxime (ceftriaxone) + steroids
• if > 60yr _IV Cefotaxime or ceftriaxone + Amoxicillin or ampicillin + steroids
-Avoid dexamethasone in septic shock, meningococcal septicemia, immunocompromised, or in meningitis following surgery.
-continue steroids if s.pneumo or H.influenza, otherwise stop it.
-if in primary care and meningococcal sepsis is suspected, I/M benzylpenicillin
-
if Pen allergic, chloramphenicol
-If meningococcal, prophylaxis of close contacts with ciprofloxacin or rifampicin.
393
447.Complications of Mumps:
POEMS of Moms
447.Complications of Mumps:
POEMS of Moms
Pancreatitis
Orchitis
Encephalitis
Meningitis
SNHL (transient)
394
448.Schistosomiasis:
Acute infection:
• swimmers' itch (short term allergic contact dermatitis
• Katavama fever (fever + FLI + eosinophilia
DX:
-for asymptomatic patients' serum schistosome antibodies are generally preferred
-for symptomatic patients the gold standard for diagnosis is urine or stool microscopy looking for eggs
Rx:
-single oral dose of praziquantel
395
Schistosoma haematobium:
-chronic bladder infection, psedupapiloma seen as calcification on x-ray
-inc. Risk of squamous cell cancer of bladder
Schistosoma haematobium:
-chronic bladder infection, psedupapiloma seen as calcification on x-ray
-inc. Risk of squamous cell cancer of bladder
396
397
449.Sepsis:
qSOFA (Quick Sequential Organ Failure Assessment) score:
-RR >22/mint
-BP <100mmhg
-Altered Mentation
A score of ≥2 indicates a heightened risk of mortality from sepsis and warns early escalation and intervention.
398
Sepsis 6
Sepsis 6:
-O2
-IV fluids
-IV antibiotics
-Blood cultures (taken before starting antibiotics)
-Serum Lactate
-Urine output 1 hourly monitoring
399
450.Syphilis:
Primary: painless chancre
Secondary: rash on trunk, palms and soles, condyloma lata, systemic symptoms
Tertiary: Gummas (granulomatous lesions), ascending aortic aneurysms, argyll robertson pupil, tabes dorsalis
Congenital Syphilis;
Hutchinson's teeth,
mulberry molars,
saber shins,
saddle nose,
rhagades (linear scar at the angle of mouth), deafness.
Jarisch-Herxheimer reaction (syphilis, leptospirosis, Lyme) is
fever, rash, hypotension,
tachycardia and flu like illness
that occurs within 24 hours of taking antibiotics.
400
Syphilis
Treatment:
-I/M benzathine Penicillin single dose for primary and secondary early latent
-secondary late latent and tertiary once weekly for 3 weeks
-Doxy if pen allergic 14 days for primary and early latent and 28 days for late latent and tertiary
401
451. Tuberculosis:
Management:
451. Tuberculosis:
Management:
Pulmonary TB:
-4 drugs for 2 months (RIPE)
-2 drugs for 4 months (INH + Rifampin) |
Meningeal TB:
-RIPE for 12 months with steroids
Latent TB:
-a positive tuberculin skin test OR Interferon-Gamma Release Assay (IGRA
combined with a normal chest x-ray, helping to exclude active tuberculosis.
-INH +Rifampicin for 3 months OR
-INH for 6 months
402
Dots
Directly observed therapy (DOT):
-Three times a week dosing regimen
-For Homeless, prisoners and those likely to have poor compliance.
403
Side effects of anti tb drugs
Side Effects of anti-TB drugs:
Rifampicin = Rifam-pissin -> Orange piss
Isoniazid = I'm-so-numb-azid ->
Peripheral neuropathy (Numb)
Pyrazinamide = hyperuricemia
Ethambutol = Eye-thambutol -> Optic neuritis
RIP to the liver (hepatotoxicity of Rifampicin, Isoniazid, Pyrazinamid
404
452.UTI in adults:
Non-pregnant women:
-first line is nitrofurantoin or trimethoprim for 3 days.
Pregnant women:
- First line is nitrofurantoin (avoid near term) for 7 days
-2nd line is amoxicillin or cefalexin
-trimethoprim is teratogenic and should be avoided in pregnancy.
-Asymptomatic bacteriuria should be treated in pregnant women
405
406
452.UTI in adults:
UTI in Men:
-first line is nitrofurantoin or trimethoprim for 7 days if prostatitis is not suspected
-single uncomplicated LUTI doesn't need referral
Catheterized patients:
-do not treat asymptomatic bacteriuria
-if symptomatic treat for 7 days and remove/change the catheter.
407
452.UTI in adults:
Acute Pyelonephritis:
-3'ª gen cephalosporins or Fluoroquinolones for 10-14 days
Acute prostatitis:
-ciprofloxacin/ofloxacin or doxycycline for 2 weeks
408
453.Brucellosis:
-exposure to cattle, sheep or pig.
-Undulant fever + Flu-like illness + splenomegaly
Ix:
Rose Bengal or serum agglutination test best is blood culture
Rx:
Doxy+ rifampicin for 6 weeks
409
410
454. Pertussis
Dx Criteria:
Cough for 14 days, absence of other cause plus one of following;
Paroxysmal cough
Inspiratory whoop
Post tussive vomiting
Apnea attack
Treatment:
oral macrolide if onset of cough within previous 21 days
All household contacts prophylaxis
School exclusion
48 hours after starting antibiotics or 21 days after onset of symptoms if no antibiotics.
Vaccine for pregnant Women a
16-32weeks
411
455.Lithium:
Side effects
LITHIUM
L=lethargy
I=diabetes insipidus
T=Tremor
H=hyper/hypothyroid
I=insides (Gl upset)
U=increased urine (due to DI)
M=metallic taste
412
Lithium monitoring
Lithium levels are checked 12 hours after last dose
• Within 48 hours after starting
• Weekly until stable concentration
• 3 monthly once stable for 1 year
• Then 6 monthly thereafter
-Check Thyroid and RFTs every 6 months
- Avoid NSAIDS AND DIURETICS with lithium
413
456. Side Effects of SSRI:
"HANDS REST"
H: Headache
A: Anxiety or Agitation
N: Nausea
D: Diarrhea
S: Sexual dysfunction (e.g., decreased libido, anorgasmia)
R: Restlessness (including insomnia)
E: Energy changes (e.g., fatigue or increased energy)
S: Sweating
T: Tremor
414
457. SSRI withdrawal symptoms:
FINISH
FINISH
F: Flu-like symptoms (e.g., fatigue, muscle aches, chills)
I: Insomnia
N: Nausea
I: Imbalance (dizziness, vertigo, coordination problems)
S: Sensory disturbances (e.g., "brain zaps," tingling)
H: Hyperarousal (anxiety, agitation
415
458. General Side Effects of antipsychotics:
SAWPPINS
Sedation
Weight gain
Prolactin raised
Antimuscarinic (dry mouth, blurred vision, Urinary retention, constipation)
Prolonged QT (esp. haloperidol)
Impaired glucose tolerance
Neuroleptic malignant syndrome (pyrexia and muscle stiffness)
Seizure threshold is reduced (greater with atypical)
416
459. Extrapyramidal SE of antipsychotics:
Acute dystonia: Procyclidine, Benztropine, trihexyphenidyl
Akathisia: Propranolol
Tardive dyskinesia: Tetrabenazine
Parkinsonism: Benztropine, procyclidine, Bromocriptine,
417
460.Mx of Neuroleptic Malignant syndrome:
-Dantrolene
-Bromocriptine/pramipexol/ropinirole
418
461. MHRA has warned that antipsychotics increase risk of stroke and VTE in elderly patients
461. MHRA has warned that antipsychotics increase risk of stroke and VTE in elderly patients
419
462. S/E of Atypical antipsychotics:
Aripiprazole: generally good side-effect profile, particularly for prolactin elevation
Olanzapine: Weight gain and obesity
Clozapine: Agranulocytosis
420
463. how to withdraw benzodiazepines:
The dose should be withdrawn in steps of about 1/8 of the daily dose every fortnight.
A suggested protocol for patients experiencing difficulty is given:
Switch patients to the equivalent dose of diazepam
Reduce dose of diazepam by 1-2mg every 2-4 weeks,
Benzodiazepine withdrawal symptoms= Alcohol withdrawal
421
464. Clozapine S/E:
CLOZAPINE
C - constipation
Lo - lower seizure threshold
Z - zzz sedation
A - agranulocytosis
P - phat weight gain
I- increased salivation
N - neutropenia
E - ECG changes (myocarditis)
422
465.ADHD:
-easily distracted
-forgetful
-difficulty organizing tasks
-difficulty maintaining concentration
-Can't sit still (restless)
-Can't wait for his turn at canteen or while playing
-excessive talking
-bursting out answers in the class
423
ADHD
Diagnosis:
-6 symptoms in children <17 yr old, 5 symptoms in adults ≥17
-observe over 10 weeks
-if persistent symptoms --> refer to child specialist or CAMHS to confirm the diagnosis and Tx.
424
ADHD
Treatment:
-First line Tx is training and education programs for parents and children
-if that fails, next is pharmacotherapy
>5-year-old
-first line is methylphenidate
-2nd line is lisdexamphetamine
- 3' line is dexamphetamine
-In adults, methylphenidate or lisdexamphetamine can used
425
466.SSRI:
-First review after starting SSRI in 1 week if <25 yr old or inc.
Risk of suicide
-First review in 2 weeks in all others to check for side effects
-2nd review in 6 weeks after starting SSRI to see if it's working
-if no improvement in symptoms after 6 weeks, then either increase the dose or switch to another SSRI.
-Review again after 4 weeks and if still no improvement,
then switch to another class of antidepressants such as TCA, MAO-I, COMT-I, or mirtazapine.
426
SSRI
-Fluoxetine is the SSRI of choice in pregnancy, children and adolescents
-Paroxetine should not be used in pregnancy (congenital heart defect).
-Post-MI, sertraline is doc
-In breastfeeding, Sertraline is doc
427
467.Cottard Syndrome:
-Occurs in extremely severe depression or psychosis
-the person thinks he is dead and needs to be buried or cremated.
428
Nihilistic Delusions:
-very similar and are part of cotard syndrome but here the person thinks
that he has lost a limb or a body organ.
429
Phantom Limb:
neurological condition where patient
has persistent pain in the limb that has been amputated.
430
468.Management of Depression:
Diagnostic Criteria:
-Low mood or anhedonia
+ 5 of the SIGE CAPS symptoms for more than 2 weeks
431
SIGE CAPS
S= Sleep (dec or Inc)
I=Interest
G=Guilt
E=Energy
C=concentration
A=appetite (dec or inc)
P=Psychomotor retardation
S=suicidal ideation
432
Treatment:
Depression
Now, classified based on PHQ-9 (patient health questionnaire) score
PHQ-9 has 9 questions and each question has a max score of 3
Less Severe depression (PHQ Score <16)
-First line is behavioral therapy (Group CBT, group BA, individual CBT, individual BA, etc.)
-2" line is SSRI
More Severe depression (PHQ ≥16)
-First line is combination of CBT + SSRI
433
469.ECT indications:
ECT
E=Euphoria -Mania
C=Catatonia
T=Treatment resistant Depression (including post-natal depression) and psychosis
Absolute Cl: Cochlear implants
Relative CI: Raised ICP
S/E: nausea, vomiting,headache, memory disturbance usually short term (rarely long term)
434
470.Management of GAD:
-First line is low intensity psychological interventions such as individual non-facilitated self-help, individual guided self-help or psychoeducation etc.
-2nd line is high intensity psychological interventions such as CBT +/- SSRI/SNRI
435
471.Panic attacks:
-Acute attack...> Benzo for short term
-Prevention > either SSRI OR CBT
436
472.PTSD Vs ASD:
Post-traumatic stress disorder:
-Severe life threatening or violent stressor such as rape, being robbed on gun-point etc.
-Flashbacks, memories, nightmares, hypervigilance, avoidance, disturbed sleep and appetite, low mood, anxiety.
-Onset of symptoms can be any time after the stressor and Symptoms last for >1 month
Treatment: Debriefing, Eye movement desensitization, CBT, SSRI/SNRI
437
472.PTSD Vs ASD:
Acute stress disorder:
- Stressor is life changing but not life threatening such as loss of job, change of house, change of school etc.
-Symptoms of anxiety and depression that don't fit in any other mental health disorder.
-Onset of symptoms within 3 days to 1 month of stressful event and symptoms lasting less than 1 month.
Treatment: CBT, SSRI/SNRI
438
Acute stress disorder:
- Stressor is life changing but not life threatening such as loss of job, change of house, change of school etc.
-Symptoms of anxiety and depression that don't fit in any other mental health disorder.
-Onset of symptoms within 3 days to 1 month of stressful event and symptoms lasting less than 1 month.
Treatment: CBT, SSRI/SNRI
439
473.Mania: _
DIG FAST
-Elevated mode + DIG FAST symptoms for ≥ 7 days and functional impairment.
DIG FAST
D= Distractibility l=Irritability/insomnia
G=Grandiosity
F=Flight of ideas
A=Activity
S=Sexual promiscuity
T=Talktive
Treatment:
Acute attack of Mania: First line are antipsychotics such as olanzapine, risperidone
Long term mood stabilizer: First line is Lithium
440
441
Hypomania
Hypomania:
similar symptoms to mania but for <7 days and without delusions, hallucination and without functional impairment.
442
474. Serotonin Syndrome vs Neuroleptic malignant syndrome vs Malignant hyperthermia:
Serotonin Syndrome:
Serotonin Syndrome:
-taking SSRI/SNRI/MAO-I
-Hyperthermia, tachycardia, HTN, agitation, confusion, myoclonus, hyperreflexia
-Stop the offending drug, cool IV fluids, Benzo for agitation
-Cyproheptadine (serotonin antagonist) in severe cases
443
Neuroleptic malignant syndrome:
-taking antipsychotics
-rigidity, hyperthermia, tachycardia, hypotension/hypertension, agitation, confusion,
elevated CPK
-stop the offending drug, cool iv fluids, dantrolene or bromocriptine
444
474. Serotonin Syndrome vs Neuroleptic malignant syndrome vs Malignant hyperthermia:
Malignant Hyperthermia:
-genetic predisposition triggered by suxamethoniun or volatile anesthesia agents
-rigidity, hyperthermia, tachycardia, hypertension, metabolic acidosis
-discontinue the offending drug, dantrolene, cool ivfluids
445
475.SSRI:
SSRI may precipitate an episode of Mania in Bipolar disorder.
446
447
476. Refeeding syndrome:
-rapid correction of malnutrition (e-g in anorexia nervosa patients)
Hypo Phosphatemia
Hypo Magnesemia
Hypo Kalemia
Hypo glycemia
448
477.Biochemical disturbance in :
Alzheimer = low acetylcholine
Parkinson's = low dopamine
depression = low serotonin
Schizophrenia = high dopamine
449
