Neuro, GI, Uro Flashcards

Question

How do varicoceles present on examination?

Answer 1

A scrotal mass that feels like a “bag of worms” More prominent on standing Disappears when lying down Asymmetry in testicular size if the varicocele has affected the growth of the testicle

Answer 2

Retroperitoneal tumours obstructing the drainage of the renal vein = urgent referral to urology

Answer 3

Soft, round lump Typically at the top of the testicle Associated with the epididymis Separate from the testicle May be able to transilluminate large cysts (appearing separate from the testicle)

Answer 4

Testicular cancer typically arises from the germ cells in the testes. Germ cells are cells that produce gametes (sperm in males).

Answer 5

15-35 years

Answer 6

Seminomas and non-seminomas

Answer 7

Undescended testes Male infertility Family history Increased height

Answer 8

The typical presentation is a painless lump on the testicle. Occasionally it can present with testicular pain.

Answer 9

The lump will be: Non-tender (or even reduced sensation) Arising from testicle Hard Irregular Not fluctuant No transillumination

Answer 10

Stage 1 – isolated to the testicle Stage 2 – spread to the retroperitoneal lymph nodes Stage 3 – spread to the lymph nodes above the diaphragm Stage 4 – metastasised to other organs

Answer 11

Surgery to remove the affected testicle (radical orchidectomy) – a prosthesis can be inserted

Answer 12

Lower urinary tract infections (UTIs) involve infection in the bladder, causing cystitis (inflammation of the bladder).

Answer 13

Fever Loin/back pain Nausea/vomiting (triad) Renal angle tenderness on examination

Answer 14

Nitrites are a better indication of infection than leukocytes. The NICE clinical knowledge summaries (2020) suggest that the presence of nitrites or leukocytes plus red blood cells indicate that the patient is likely to have a UTI. If both are present, the patient requires treatment for a UTI. If only nitrites are present, it is worth treating as a UTI. If only leukocytes are present, the patient should not be treated as a UTI unless there is clinical evidence they have one.

Answer 15

Pregnant patients Patients with recurrent UTIs Atypical symptoms When symptoms do not improve with antibiotics

Answer 16

Nitrites – gram-negative bacteria (such as E. coli) break down nitrates, a normal waste product in urine, into nitrites. The presence of nitrites suggests bacteria in the urine.

Answer 17

Nitrofurantoin needs to be avoided in the third trimester as there is a risk of neonatal haemolysis (destruction of the neonatal red blood cells).

Answer 18

NICE guidelines (2018) recommend the following first-line antibiotics for 7-10 days when treating pyelonephritis in the community: Cefalexin Co-amoxiclav (if culture results are available) Trimethoprim (if culture results are available) Ciprofloxacin (keep tendon damage and lower seizure threshold in mind)

Answer 19

Blood lactate level Blood cultures Urine output Oxygen to maintain oxygen saturations of 94-98% (or 88-92% in COPD) Empirical broad-spectrum IV antibiotics (according to local guidelines) IV fluids

Answer 20

Dimercaptosuccinic acid (DMSA) scans involve injecting radiolabeled DMSA, which builds up in healthy kidney tissue. When imaged using gamma cameras, it indicates scarring or damage in areas that do not take up the DMSA. They are used in recurrent pyelonephritis to assess for renal damage.

Answer 21

Interstitial cystitis is a chronic condition causing inflammation in the bladder, resulting in lower urinary tract symptoms and suprapubic pain. It is also called bladder pain syndrome and hypersensitive bladder syndrome. There is no simple explanation for the symptoms, and the pathophysiology is likely a complex combination of various factors, including dysfunction of the blood vessels, nerves, immune system and epithelium.

Answer 22

The typical presentation is more than 6 weeks of: Suprapubic pain, worse with a full bladder and often relieved by emptying the bladder Frequency of urination Urgency of urination Symptoms may be worse during menstruation

Answer 23

Urinalysis for urinary tract infections Swabs for sexually transmitted infections Cystoscopy for bladder cancer Prostate examination for prostatitis, hypertrophy or cancer

Answer 24

In the urothelium

Answer 25

Smoking and increased age are the main risk factors for bladder cancer. Aromatic amines are worth noting as a carcinogen that causes bladder cancer. Aromatic amines were used in dye and rubber industries but have been heavily regulated or banned for many years. They are also found in cigarette smoke and seem to be the reason smoking causes bladder cancer. Schistosomiasis causes squamous cell carcinoma of the bladder in countries with a high prevalence of the infection.

Answer 26

Transitional cell carcinoma (90%) Squamous cell carcinoma (5% – higher in areas of schistosomiasis) Rarer causes are adenocarcinoma (2%), sarcoma and small-cell carcinoma

Answer 27

Painless haematuria is the symptom to remember for your exams.

Answer 28

Aged over 45 with unexplained visible haematuria, either without a UTI or persisting after treatment for a UTI Aged over 60 with microscopic haematuria (not visible but positive on a urine dipstick) PLUS: Dysuria or; Raised white blood cells on a full blood count The NICE guidelines also recommend considering a non-urgent referral in people over 60 with recurrent unexplained UTIs.

Answer 29

Cystoscopy (a camera through the urethra into the bladder) can be used to visualise bladder cancers. The cystoscope can be rigid or flexible. Cystoscopy can be performed under local or general anaesthetic.

Answer 30

Transurethral resection of bladder tumour (TURBT) may be used for non-muscle-invasive bladder cancer. The involves removing the bladder tumour during a cystoscopy procedure.

Answer 31

Intravesical chemotherapy (chemotherapy given into the bladder through a catheter) is often used after a TURBT procedure to reduce the risk of recurrence.

Answer 32

may be used as a form of immunotherapy. Giving the BCG vaccine (the same one as for tuberculosis) into the bladder is thought to stimulate the immune system, which in turn attacks the bladder tumours.

Answer 33

Radical cystectomy involves the removal of the entire bladder.

Answer 34

C – CUT DOWN? Ever thought you should? A – ANNOYED? Do you get annoyed at others commenting on your drinking? G – GUILTY? Ever feel guilty about drinking? E – EYE OPENER? Ever drink in the morning to help your hangover/nerves?

Answer 35

Alcohol Use Disorders Identification Test (AUDIT)

Answer 36

Can be used to check the elasticity of the liver by sending high frequency sound waves into the liver. It helps assess the degree of cirrhosis.

Answer 37

6-12 hours: tremor, sweating, headache, craving and anxiety 12-24 hours: hallucinations 24-48 hours: seizures 24-72 hours: “delirium tremens”

Answer 38

Delirium tremens is a medical emergency associated with alcohol withdrawal with a mortality of 35% if left untreated.

Answer 39

Alcohol stimulates GABA receptors in the brain. GABA receptors have a “relaxing” effect on the rest of the brain. Alcohol also inhibits glutamate receptors (also known as NMDA receptors) having a further inhibitory effect on the electrical activity of the brain. Chronic alcohol use results in the GABA system becoming down-regulated and the glutamate system becoming up-regulated to balance the effects of alcohol. When alcohol is removed from the system, GABA under-functions and glutamate over-functions causing an extreme excitability of the brain with excess adrenergic activity.

Answer 40

Acute confusion Severe agitation Delusions and hallucinations Tremor Tachycardia Hypertension Hyperthermia Ataxia (difficulties with coordinated movements) Arrhythmias

Answer 41

Chlordiazepoxide for 5-7 days Intravenous high-dose B vitamins (pabrinex). This should be followed by regular lower dose oral thiamine.

Answer 42

Alcohol excess leads to thiamine (vitamin B1) deficiency. Thiamine is poorly absorbed in the presence of alcohol and alcoholics tend to have poor diets and rely on the alcohol for their calories. Wernicke’s encephalopathy comes before Korsakoffs syndrome. These result from thiamine deficiency.

Answer 43

Confusion Oculomotor disturbances (disturbances of eye movements) Ataxia (difficulties with coordinated movements)

Answer 44

Memory impairment (retrograde and anterograde) Behavioural changes

Answer 45

Wernicke’s encephalopathy is a medical emergency and has a high mortality rate if untreated. Korsakoffs syndrome is often irreversible and results in patients requiring full time institutional care. Prevention and treatment involve thiamine supplementation and abstaining from alcohol.

Answer 46

Alcoholic liver disease Non Alcoholic Fatty Liver Disease Hepatitis B Hepatitis C Lots of inflammation leads to fibrotic changes

Answer 47

The score indicates the severity of the cirrhosis and the prognosis.

Answer 48

The MELD score is recommended by NICE to be used every 6 months in patients with compensated cirrhosis. It is a formula that takes into account the bilirubin, creatinine, INR and sodium and whether they are requiring dialysis. It gives a percentage estimated 3 month mortality and helps guide referral for liver transplant.

Answer 49

Regular meals (every 2-3 hours) Low sodium (to minimise fluid retention) High protein and high calorie (particularly if underweight) Avoid alcohol

Answer 50

Liver cirrhosis increases the resistance of blood flow in the liver. As a result, there is increased back-pressure into the portal system. This back-pressure causes the vessels at the sites where the portal system anastomoses with the systemic venous system to become swollen and tortuous. These swollen, tortuous vessels are called varices.

Answer 51

Propranolol reduces portal hypertension by acting as a non-selective beta blocker Elastic band ligation of varices Injection of sclerosant (less effective than band ligation) Transjugular Intra-hepatic Portosystemic Shunt (TIPS) last line

Answer 52

Resuscitation Vasopressin analogues (i.e. terlipressin) cause vasoconstriction and slow bleeding in varices Correct any coagulopathy with vitamin K and fresh frozen plasma (which is full of clotting factors) Giving prophylactic broad spectrum antibiotics has been shown to reduce mortality Consider intubation and intensive care as they can bleed very quickly and become life threateningly unwell Urgent endoscopy Injection of sclerosant into the varices can be used to cause “inflammatory obliteration” of the vessel Elastic band ligation of varices

Answer 53

Ascites is basically fluid in the peritoneal cavity. The increased pressure in the portal system causes fluid to leak out of the capillaries in the liver and bowel and in to the peritoneal cavity. The drop in circulating volume caused by fluid loss into the peritoneal space causes a reduction in blood pressure entering the kidneys. The kidneys sense this lower pressure and release renin, which leads to increased aldosterone secretion (via the renin-angiotensin-aldosterone system) and reabsorption of fluid and sodium in the kidneys.

Answer 54

Low sodium diet Anti-aldosterone diuretics (spironolactone) Paracentesis (ascitic tap or ascitic drain) Prophylactic antibiotics against spontaneous bacterial peritonitis (ciprofloxacin or norfloxacin) in patients with less than 15g/litre of protein in the ascitic fluid

Answer 55

This occurs in around 10% of patients with ascites secondary to cirrhosis and can have a mortality of 10-20%. It involves an infection developing in the ascitic fluid and peritoneal lining without any clear cause (e.g. not secondary to an ascitic drain or bowel perforation).

Answer 56

Firstly, the functional impairment of the liver cells prevents them metabolising the ammonia into harmless waste products. Secondly, collateral vessels between the portal and systemic circulation mean that the ammonia bypasses liver altogether and enters the systemic system directly.

Answer 57

By giving laxatives, e.g. lactulose, we help clear the ammonia from the gut before it is absorbed and by giving antibiotics we reduce the number of bacteria in the gut producing ammonia.

Answer 58

Enhanced Liver Fibrosis (ELF) blood test. This is the first line recommended investigation for assessing fibrosis but it is not currently available in many areas. It measures three markers (HA, PIIINP and TIMP-1) and uses an algorithm to provide a result that indicates the fibrosis of the liver: < 7.7 indicates none to mild fibrosis ≥ 7.7 to 9.8 indicates moderate fibrosis ≥ 9.8 indicates severe fibrosis

Answer 59

NAFLD fibrosis score is the second line recommended assessment for liver fibrosis where the ELF test is not available. It is based on an algorithm of age, BMI, liver enzymes, platelets, albumin and diabetes and is helpful in ruling out fibrosis but not assessing the severity when present.

Answer 60

Abdominal pain Fatigue Pruritis (itching) Muscle and joint aches Nausea and vomiting Jaundice Fever (viral hepatitis)

Answer 61

Typical biochemical findings are that liver function tests become deranged with high transaminases (AST / ALT) with proportionally less of a rise in ALP. Transaminases are liver enzymes that are released into the blood as a result of inflammation of the liver cells. Bilirubin can also rise as a result of inflammation of the liver cells. High bilirubin causes jaundice.

Answer 62

an iron storage disorder that results in excessive total body iron and deposition of iron in tissues. The human haemochromatosis protein (HFE) gene is located on chromosome 6. The majority of cases of haemochromatosis relate to mutations in this gene, however there are other genes that can cause the condition. The haemochromatosis genetic mutation is autosomal recessive.

Answer 63

Chronic tiredness Joint pain Pigmentation (bronze / slate-grey discolouration) Hair loss Erectile dysfunction Amenorrhoea Cognitive symptoms (memory and mood disturbance)

Answer 64

The main diagnostic method is to perform a serum ferritin level. Ferritin is an acute phase reactant, meaning that it goes up with inflammatory conditions such as infection. Performing a transferrin saturation is helpful in distinguishing between a high ferritin caused by iron overload (in which case transferrin saturation is high) from a high ferritin due to other causes such as inflammation or non alcoholic fatty liver disease. If serum ferritin and transferrin saturation is high and there is no other reason then genetic testing can be performed to confirm haemochromatosis.

Answer 65

Type 1 Diabetes (iron affects the functioning of the pancreas) Liver Cirrhosis Iron deposits in the pituitary and gonads lead to endocrine and sexual problems (hypogonadism, impotence, amenorrhea, infertility) Cardiomyopathy (iron deposits in the heart)

Answer 66

Venesection (a weekly protocol of removing blood to decrease total iron) Monitoring serum ferritin Avoid alcohol Genetic counselling Monitoring and treatment of complications

Answer 67

The initial investigation of choice is serum caeruloplasmin. A low serum caeruloplasmin is suggestive of Wilson disease. This is the protein that carries copper in the blood. It can be falsely normal or elevated in cancer or inflammatory conditions. It is also not specific to Wilson disease. Liver biopsy for liver copper content is the definitive gold standard test for diagnosis

Answer 68

Treatment is with copper chelation using: Penicillamine Trientene

Answer 69

Alpha-1-antitrypsin deficiency is a condition caused by an abnormality in the gene for a protease inhibitor called alpha-1-antitrypsin.

Answer 70

Elastase is an enzyme secreted by neutrophils. This enzyme digests connective tissues. Alpha-1-antitrypsin (A1AT) is mainly produced in the liver, travels around the body and offers protection by inhibiting the neutrophil elastase enzyme. A1AT is coded for on chromosome 14. In A1AT deficiency, there is an autosomal recessive defect in the gene for A1AT. It leads to: Liver cirrhosis after 50 years old Bronchiectasis and emphysema in the lungs after 30 years old

Answer 71

Low serum-alpha 1-antitrypsin (screening test of choice) Liver biopsy shows cirrhosis and acid-Schiff-positive staining globules (this stain highlights the mutant alpha-1-antitrypsin proteins) in hepatocytes Genetic testing for the A1AT gene High resolution CT thorax diagnoses bronchiectasis and emphysema

Answer 72

Stop smoking (smoking dramatically accelerates emphysema) Symptomatic management NICE recommend against the use of replacement alpha-1-antitrypsin, however the research and debate is ongoing regarding the possible benefits Organ transplant for end-stage liver or lung disease Monitoring for complications (e.g. hepatocellular carcinoma)

Answer 73

Primary biliary cirrhosis is a condition where the immune system attacks the small bile ducts within the liver. This causes obstruction of the outflow of bile, which is called cholestasis. The back-pressure of the bile obstruction and the overall disease process ultimately leads to fibrosis, cirrhosis and liver failure.

Answer 74

Liver Function Tests Alkaline phososphatase is first liver enzyme to be raised (as with most obstructive pathology) Other liver enzymes and bilirubin are raised in later disease Liver biopsy can be used to diagnose and stage the disease

Answer 75

Ursodeoxycholic acid reduces the intestinal absorption of cholesterol Colestyramine is a bile acid sequestrate in that it binds to bile acids to prevent absorption in the gut and can help with pruritus due to raised bile acids Liver transplant in end stage liver disease Immunosuppression (e.g. with steroids) is considered in some patients

Answer 76

A condition where the intrahepatic or extrahepatic ducts become strictured and fibrotic. This causes an obstruction to the flow of bile out of the liver and into the intestines. Sclerosis refers to the stiffening and hardening of the bile ducts, and cholangitis is inflammation of the bile ducts. Chronic bile obstruction eventually leads to liver inflammation (hepatitis), fibrosis and cirrhosis.

Answer 77

Liver function tests show a “cholestatic” picture. This means alkaline phosphatase is the most deranged LFT and may be the only abnormality at first. There may be a rise in bilirubin as the strictures become more severe and prevents bilirubin from being excreted through the bile duct. Other LFTs (i.e. transaminases: ALT and AST) can also be deranged, particularly as the disease progresses to hepatitis.

Answer 78

The gold standard investigation for diagnosis is an MRCP, which is short for magnetic resonance cholangiopancreatography. This involves an MRI scan of the liver, bile ducts and pancreas. In primary sclerosis cholangitis it may show bile duct lesions or strictures.

Answer 79

Liver transplant can be curative but is associated with its own problems (around 80% survival at 5 years). ERCP can be used to dilate and stent any strictures Colestyramine is a bile acid sequestrate in that it binds to bile acids to prevent absorption in the gut and can help with pruritus due to raised bile acids Monitoring for complications (such as cholangiocarcinoma, cirrhosis and oesophageal varices)

Answer 80

There are two main types: hepatocellular carcinoma (80%) and cholangiocarcinoma (20%).

Answer 81

Viral hepatitis (B and C) Alcohol Non alcoholic fatty liver disease Other chronic liver disease

Answer 82

Hepatocellular carcinoma.

Answer 83

Cholangiocarcinoma & pancreatic cancer

Answer 84

Haemangiomas are common benign tumours of the liver. They are often found incidentally. They cause no symptoms and have no potential to become cancerous. No treatment or monitoring is required.

Answer 85

Focal nodular hyperplasia is a benign liver tumour made of fibrotic tissue. This is often found incidentally. It is usually asymptomatic and has no malignant potential. It is often related to oestrogen and is therefore more common in women and those on the oral contraceptive pill. No treatment of monitoring is required.

Answer 86

H. pylori is a gram negative aerobic bacteria. It lives in the stomach. It causes damage the epithelial lining of the stomach resulting in gastritis, ulcers and increasing the risk of stomach cancer. It avoids the acidic environment by forcing its way into the gastric mucosa. The breaks it creates in the mucosa exposes the epithelial cells underneath to acid. It also produces ammonia to neutralise the stomach acid. The ammonia directly damages the epithelial cells. Other chemicals produced by the bacteria also damage the epithelial lining.

Answer 87

We offer a test for H. pylori to anyone with dyspepsia. They need 2 weeks without using a PPI before testing for H. pylori for an accurate result. Tests Urea breath test using radiolabelled carbon 13 Stool antigen test Rapid urease test can be performed during endoscopy.

Answer 88

Improves the pain

Answer 89

Bleeding from the ulcer is a common and potentially life threatening complication. Perforation resulting in an “acute abdomen” and peritonitis. This requires urgent surgical repair (usually laparoscopic). Scarring and strictures of the muscle and mucosa. This can lead to a narrowing of the pylorus (the exit of the stomach) causing difficulty in emptying the stomach contents. This is known as pyloric stenosis. This presents with upper abdominal pain, distention, nausea and vomiting, particularly after eating.

Answer 90

Oesophageal varices Mallory-Weiss tear, which is a tear of the oesophageal mucous membrane Ulcers of the stomach or duodenum Cancers of the stomach or duodenum

Answer 91

Haematemesis (vomiting blood) “Coffee ground” vomit. This is caused by vomiting digested blood that looks like coffee grounds. Melaena, which is tar like, black, greasy and offensive stools caused by digested blood

Answer 92

The Glasgow-Blatchford Score is used as a scoring system in suspected upper GI bleed on their initial presentation. It scores patient based on their clinical presentation. It establishes their risk of having an upper GI bleed to help you make a plan (for example whether to discharge them or not). A score > 0 indicates high risk for an upper GI bleed.

Answer 93

The reason urea rises in upper GI bleeds is that the blood in the GI tract gets broken down by the acid and digestive enzymes. One of the breakdown products is urea and this urea is then absorbed in the intestines.

Answer 94

The Rockall Score is used for patients that have had an endoscopy to calculate their risk of rebleeding and overall mortality. It provides a percentage risk of rebleeding and mortality.

Answer 95

A – ABCDE approach to immediate resuscitation B – Bloods A – Access (ideally 2 large bore cannula) T – Transfuse E – Endoscopy (arrange urgent endoscopy within 24 hours) D – Drugs (stop anticoagulants and NSAIDs)

Answer 96

“Group and save” is where the lab simply checks the patients blood group and keeps a sample of their blood saved in case they need to match blood to it. “Crossmatch” is where the lab actually finds blood, tests that it is compatible and keeps it ready in the fridge to be used if necessary.

Answer 97

N – No blood or mucus (less common) E – Entire GI tract S – “Skip lesions” on endoscopy T – Terminal ileum most affected and Transmural (full thickness) inflammation S – Smoking is a risk factor (don’t set the nest on fire) Crohn’s is also associated with weight loss, strictures and fistulas.

Answer 98

C – Continuous inflammation L – Limited to colon and rectum O – Only superficial mucosa affected S – Smoking is protective E – Excrete blood and mucus U – Use aminosalicylates P – Primary Sclerosing Cholangitis

Answer 99

There are two antibodies to remember: anti-tissue transglutaminase (anti-TTG) and anti-endomysial (anti-EMA). These antibodies relate to disease activity and will rise with more active disease and may disappear with effective treatment.

Answer 100

Inflammation affects the small bowel, particularly the jejunum. It causes atrophy of the intestinal villi.

Answer 101

Remember for your exams that we test all new cases of type 1 diabetes even if they don’t have symptoms as the conditions are often linked.

Answer 102

Anti-TTG and anti-EMA antibodies are IgA. Some patients have an IgA deficiency. When you test for these antibodies, it is important to test for total Immunoglobulin A levels because if total IgA is low because they have an IgA deficiency then the coeliac test will be negative even when they have coeliacs. In this circumstance, you can test for the IgG version of anti-TTG or anti-EMA antibodies or simply do an endoscopy with biopsies.

Answer 103

? blood transfusion Terlipressin Prophylactic broad spectrum antibiotics

Answer 104

Prothrombin complex concentrate can be given to patients taking warfarin that are actively bleeding

Answer 105

(OHSS) is a complication of ovarian stimulation during IVF infertility treatment. It is associated with the use of human chorionic gonadotropin (hCG) to mature the follicles during the final steps of ovarian stimulation.

Answer 106

The primary mechanism for OHSS is an increase in vascular endothelial growth factor (VEGF) released by the granulosa cells of the follicles. VEGF increases vascular permeability, causing fluid to leak from capillaries. Fluid moves from the intravascular space to the extravascular space.

Answer 107

Oedema, ascites and hypovolaemia Abdo pain and bloating N&V Diarrhoea Hypotension Pleural effusions Renal failure

Answer 108

Haematocrit may be monitored to assess the volume of fluid in the intravascular space. Haematocrit is the concentration of red blood cells in the blood. When the haematocrit goes up, this indicates less fluid in the intravascular space, as the blood is becoming more concentrated. Raised haematocrit can indicate dehydration.

Answer 109

Toxic megacolon is an acute form of colonic distension, usually as a complication of IBD

Answer 110

Abdominal X-ray with the features of Air-fluid level can be shown or CT Scan with Contrast can be done if the patient is stable

Answer 111

The objective of treatment is to decompress the bowel and to prevent swallowed air from further distending the bowel. If decompression is not achieved or the patient does not improve within 24 hours, a colectomy (surgical removal of all or part of the colon) is indicated.

Answer 112

The foregut includes the stomach and part of the duodenum, biliary system, liver, pancreas and spleen. This is supplied by the coeliac artery.

Answer 113

The midgut is from the distal part of the duodenum to the first half of the transverse colon. This is supplied by the superior mesenteric artery.

Answer 114

The hindgut is from the second half of the transverse colon to the rectum. This is supplied by the inferior mesenteric artery.

Answer 115

Central colicky abdominal pain after eating (starting around 30 minutes after eating and lasting 1-2 hours) Weight loss (due to food avoidance, as this causes pain) Abdominal bruit may be heard on auscultation

Answer 116

CT angiography

Answer 117

Contrast CT

Answer 118

Metabolic acidosis and raised lactate level due to ischaemia

Answer 119

Acute mesenteric ischaemia presents with acute, non-specific abdominal pain. The pain is disproportionate to the examination findings. Patients can go on to develop shock, peritonitis and sepsis.

Answer 120

In the DIP joints of the hand

Answer 121

In the PIP joints of the hand

Answer 122

RA patients

Answer 123

Rheumatoid factor Anti-CCP antibodies (can pre-date the development of RA)

Answer 124

This involves self limiting short episodes of inflammatory arthritis with joint pain, stiffness and swelling typically affecting only a few joints. The episodes only last 1-2 days and then completely resolve. Having positive antibodies (RF and anti-CCP) may indicate that it will progress to full rheumatoid arthritis.

Answer 125

DIP joints

Answer 126

RA. Due to a tear in the central slip of the extensor components of the fingers. This means that when the patient tries to straighten their finger, the lateral tendons that go around the PIP (called the flexor digitorum superficialis tendons) pull on the distal phalynx without any other supporting structure, causing the DIPs to extend and the PIP to flex.

Answer 127

The DAS28 is the Disease Activity Score. It is based on the assessment for 28 joints and points are given for: Swollen joints Tender joints ESR/CRP result It is useful in monitoring disease activity and response to treatment.

Answer 128

Adalimumab, infliximab, etanercept, and rituximab

Answer 129

Bone marrow suppression, leukopenia and highly teratogenic

Answer 130

Psoriasis Epidemiological Screening Tool (PEST) NICE recommend patients with psoriasis complete the PEST tool to screen for psoriatic arthritis. This involves several questions asking about joint pain, swelling, a history of arthritis and nail pitting. A high score triggers a referral to a rheumatologist.

Answer 131

This is the most severe form of psoriatic arthritis. This occurs in the phalanxes. There is osteolysis (destruction) of the bones around the joints in the digits. This leads to progressive shortening of the digit. The skin then folds as the digit shortens giving an appearance that is often called a “telescopic finger”.

Answer 132

Similar to RA, so NSAIDs, DMARDs, Anti-TNF medications

Answer 133

These features of reactive arthritis (eye problems, balanitis and arthritis) lead to the saying “can’t see, pee or climb a tree”

Answer 134

The typical exam presentation is a young adult male in their late teens or 20s. The main presenting features are lower back pain and stiffness and sacroiliac pain in the buttock region. The pain and stiffness is worse with rest and improves with movement. The pain is worse at night and in the morning and may wake them from sleep. It takes at least 30 minutes for the stiffness to improve in the morning and it gets progressively better with activity throughout the day.

Answer 135

This is a test used as part of a general examination of the spine to assess how much mobility there is in the spine. Have the patient stand straight. Find the L5 vertebrae. Mark a point 10cm above and 5cm below this point (15cm apart from each other). Then ask the patient to bend forward as far as they can and measure the distance between the points. If the distance with them bending forwards is less than 20cm, this indicates a restriction in lumbar movement and will help support a diagnosis of ankylosing spondylitis.

Answer 136

Bamboo spine

Answer 137

Hydroxychloroquine

Answer 138

A non-cancerous chronic skin condition. It is more common in women and usually presents in young adults between ages 20 to 40. It is more common in darker-skinned patients and smokers. Can lead to SCC.

Answer 139

The lesions typically occur on the face, ears and scalp. They are photosensitive, meaning that they are made worse by exposure to sunlight. They are associated with scarring alopecia (hair loss in affected areas that does not grow back) and hyper-pigmented or hypo-pigmented scars.

Answer 140

Skin biopsy

Answer 141

C – Calcinosis R – Raynaud’s phenomenon E – oEsophageal dysmotility S – Sclerodactyly T – Telangiectasia

Answer 142

Sclerodactyly describes the skin changes in the hands. As the skin tightens around joints it restricts the range of motion in the joint and reduces the function of the joints. As the skin hardens and tightens further the fat pads on the fingers are lost. The skin can break and ulcerate.

Answer 143

Telangiectasia are dilated small blood vessels in the skin. They are tiny veins that have dilated. They have a fine, thready appearance.

Answer 144

Antinuclear antibodies (ANA) are positive in most patients with systemic sclerosis. They are not specific to systemic sclerosis. Anti-centromere antibodies are most associated with limited cutaneous systemic sclerosis. Anti-Scl-70 antibodies are most associated with diffuse cutaneous systemic sclerosis. They are associated with more severe disease.

Answer 145

Avoid smoking Gentle skin stretching to maintain the range of motion Regular emollients Avoiding cold triggers for Raynaud’s Physiotherapy to maintain healthy joints Occupational therapy for adaptations to daily living to cope with limitations

Answer 146

Nifedipine

Answer 147

Bilateral shoulder pain that may radiate to the elbow Bilateral pelvic girdle pain Worse with movement Interferes with sleep Stiffness for at least 45 minutes in the morning

Answer 148

Initially patients are started on 15mg of prednisolone per day. Assess 1 week after starting steroids. If there is a poor response in symptoms it is probably not PMR and an alternative diagnosis needs to be considered. Stop the steroids. Assess 3-4 weeks after starting steroids. You would expect a 70% improvement in symptoms and inflammatory markers to return to normal to make a working diagnosis of PMR. Then, long process of weaning off

Answer 149

DON’T – Make them aware that they will become steroid dependent after 3 weeks of treatment and should not stop taking the steroids due to the risk of adrenal crisis if steroids are abruptly withdrawn S – Sick Day Rules: Discuss increasing the steroid dose if they become unwell (“sick day rules”) T – Treatment Card: Provide a steroid treatment card to alert others that they are steroid dependent in case they become unresponsive O – Osteoporosis prevention: Consider osteoporosis prophylaxis whilst on steroids with bisphosphonates and calcium and vitamin D supplements P – Proton pump inhibitor: Consider gastric protection with a proton pump inhibitor (e.g. omeprazole)

Answer 150

Temporal arteritis presents with headache: Severe unilateral headache typically around temple and forehead Scalp tenderness my be noticed when brushing hair Jaw claudication Blurred or double vision Irreversible painless complete sight loss can occur rapidly

Answer 151

Steroids: Start steroids immediately before confirming the diagnosis to reduce the risk of permanent sight loss. Start 40-60mg prednisolone per day. 60mg is given depending where there are jaw claudication or visual symptoms. Review the response to steroids within 48 hours. There is usually a rapid and significant response to treatment. Other medications: Aspirin 75mg daily decreases visual loss and strokes Proton pump inhibitor (e.g. omeprazole) for gastric prevention while on steroids Referrals: Vascular surgeons for a temporal artery biopsy in all patients with suspected GCA Rheumatology for specialist diagnosis and management Ophthalmology review as an emergency same day appointment if they develop visual symptoms

Answer 152

Polymyositis is a condition of chronic inflammation of muscles. Dermatomyositis is a connective tissue disorder where there is chronic inflammation of the skin and muscles.

Answer 153

The key investigation for diagnosing myositis is a creatine kinase blood test. Creatine kinase is an enzyme found inside muscle cells. Inflammation in the muscle cells (myositis) leads to the release of creatine kinase. Creatine kinase is usually less than 300 U/L. In polymyositis and dermatomyositis, the result is usually over 1000, often in the multiples of thousands.

Answer 154

Rhabdomyolysis AKI MI Statins Strenuous exercise

Answer 155

They can be caused by underlying malignancies

Answer 156

Muscle pain, fatigue and weakness Occurs bilaterally and typically affects the proximal muscles Mostly affects the shoulder and pelvic girdle Develops over weeks

Answer 157

Gottron lesions (scaly erythematous patches) on the knuckles, elbows and knees Photosensitive erythematous rash on the back, shoulders and neck Purple rash on the face and eyelids Periorbital oedema (swelling around the eyes) Subcutaneous calcinosis (calcium deposits in the subcutaneous tissue)

Answer 158

Anti-Jo-1 antibodies: polymyositis (but often present in dermatomyositis) Anti-Mi-2 antibodies: dermatomyositis. Anti-nuclear antibodies: dermatomyositis.

Answer 159

It is associated with antiphospholipid antibodies: Lupus anticoagulant Anticardiolipin antibodies

Answer 160

Low molecular weight heparin (e.g. enoxaparin) plus aspirin (warfarin is contraindicated in pregnancy)

Answer 161

Anti-Ro and anti-La

Answer 162

The Schirmer test

Answer 163

Purpura. These are purple-coloured non-blanching spots caused by blood leaking from the vessels under the skin. Joint and muscle pain Peripheral neuropathy Renal impairment Gastrointestinal disturbance (diarrhoea, abdominal pain and bleeding) Anterior uveitis and scleritis Hypertension

Answer 164

Inflammatory markers (CRP and ESR) are usually raised in vasculitis Anti neutrophil cytoplasmic antibodies (ANCA) is the blood test to remember for vasculitis.

Answer 165

HSP is an IgA vasculitis that commonly presents with a purpuric rash affecting the lower limbs or buttocks in children, often triggered by an upper airway infection (e.g. tonsillitis) or a gastroenteritis

Answer 166

The four classic features are purpura (100%), joint pain (75%), abdominal pain (50%) and renal involvement (50%). HSP affects the kidneys in about 50% of patients, causing an IgA nephritis

Answer 167

Management is typically supportive, such as simple analgesia, rest and proper hydration. The benefits of steroids are unclear. The abdominal pain usually settles within a few days. Patients without kidney involvement can expect to fully recover within 4-6 weeks. A third of patients have a recurrence of the disease within 6 months. 1% of patients will go on to develop end stage renal failure.

Answer 168

Small and medium vessel vasculitis. It often presents with severe asthma in late teenage years or adulthood. A characteristic finding is elevated eosinophil levels on the full blood count.

Answer 169

Microscopic polyangiitis is a small vessel vasculitis. The main feature of microscopic polyangiitis is renal failure. It can also affect the lungs causing shortness of breath and haemoptysis.

Answer 170

Granulomatosis with polyangiitis is a small vessel vasculitis. It was previously known as Wegener’s granulomatosis. It affects the respiratory tract and kidneys. In the upper respiratory tract, it commonly affects the nose causing nose bleeds (epistaxis) and crusty nasal secretions, ears causing hearing loss and sinuses causing sinusitis. A classic sign in exams is the saddle-shaped nose due to a perforated nasal septum. This causes a dip halfway down the nose. In the lungs, it causes a cough, wheeze and haemoptysis. A chest x-ray may show consolidation, and it may be misdiagnosed as pneumonia. In the kidneys, it can cause rapidly progressing glomerulonephritis.

Answer 171

A medium vessel vasculitis. It is most associated with hepatitis B but can also occur without a clear cause or with hepatitis C and HIV. It affects the medium sized vessels in locations such as the skin, gastrointestinal tract, kidneys and heart. This can cause renal impairment, strokes and myocardial infarction.

Answer 172

Kawasaki disease is a medium vessel vasculitis. It affects young children, typically under 5 years of age. There is no clear cause. Clinical features are: Persistent high fever > 5 days Erythematous rash Bilateral conjunctivitis Erythema and desquamation (skin peeling) of palms and soles “Strawberry tongue” (red tongue with prominent papillae)

Answer 173

Aspirin and IV immunoglobulins

Answer 174

Pulseless disease, as large vessels can swell and form aneurysms or become narrow and blocked

Answer 175

It is diagnosed using CT or MRI angiography. Doppler ultrasound of the carotids can be useful in detecting carotid disease.

Answer 176

Behçet’s disease is a complex inflammatory condition. It characteristically presents with recurrent oral and genital ulcers.

Answer 177

The pathergy test involves using a sterile needle to create a subcutaneous abrasion on the forearm. This is then reviewed 24 – 48 hours later to look for a weal 5mm or more in size. It tests for non-specific hypersensitive in the skin. It is positive in Behçet’s disease, Sweet’s syndrome and pyoderma gangrenosum.

Answer 178

No bacterial growth Needle shaped crystals Negatively birefringent of polarised light Monosodium urate crystals

Answer 179

NSAIDs (e.g. ibuprofen) are first-line Colchicine second-line Steroids can be considered third-line

Answer 180

A notable side effect is gastrointestinal upset. Diarrhoea is a very common side effect. This is dose-dependent meaning lower doses cause less upset than higher doses.

Answer 181

Allopurinol is a xanthine oxidase inhibitor used for the prophylaxis of gout. It reduces the uric acid level. Do not use in acute gout. Lifestyle changes can reduce the risk of developing gout. This involves losing weight, staying hydrated and minimising the consumption of alcohol and purine-based food (such as meat and seafood).

Answer 182

No bacterial growth Calcium pyrophosphate crystals Rhomboid shaped crystals Positive birefringent of polarised light

Answer 183

Older age Female Reduced mobility and activity Low BMI (<18.5 kg/m2) Rheumatoid arthritis Alcohol and smoking Long term corticosteroids. NICE suggest the risk increases significantly with the equivalent of more than 7.5mg of prednisolone per day for more than 3 months) Other medications such as SSRIs, PPIs, anti-epileptics and anti-oestrogens

Answer 184

Supplementary vitamin D

Answer 185

Paget’s disease of bone refers to a disorder of bone turnover. There is excessive bone turnover (formation and reabsorption) due to excessive activity of both osteoblasts and osteoclasts. This excessive turnover is not coordinated, leading to patchy areas of high density (sclerosis) and low density (lysis). This results in enlarged and misshapen bones with structural problems that increase the risk of pathological fractures. It particularly affects the axial skeleton (the bones of the head and spine).

Answer 186

Bisphosphonates are the main treatment. They are generally very effective. They interfere with osteoclast activity and seem to restore normal bone metabolism. They improve symptoms and prevent further abnormal bone changes.

Answer 187

Monitoring involves check the serum alkaline phosphatase (ALP) and reviewing symptoms. Effective treatment should normalise the ALP and eliminate symptoms.

Answer 188

Osteosarcoma is a type of bone cancer with a very poor prognosis. It presents with increased focal bone pain, bone swelling or pathological fractures. The risk is increased in Paget’s disease and patients need to be followed up to detect it early. They can usually be seen on a plain xray. Spinal stenosis may occur where deformity in the spine leads to spinal canal narrowing. If this presses on the spinal nerves it causes neurological signs and symptoms. This is diagnosed with an MRI scan and is often treated effectively with bisphosphonates. Surgical intervention may be considered.

Answer 189

ROSIER is a clinical scoring tool based on clinical features and duration. Stroke is likely if the patient scores anything above 0.

Answer 190

Diffusion-weighted MRI is the gold standard imaging technique. CT is an alternative.

Answer 191

Clopidogrel 75mg once daily (alternatively dipyridamole 200mg twice daily) Atorvastatin 80mg should be started but not immediately Carotid endarterectomy or stenting in patients with carotid artery disease Treat modifiable risk factors such as hypertension and diabetes

Answer 192

Subdural haemorrhage is caused by rupture of the bridging veins in the outermost meningeal layer.

Answer 193

They occur between the dura mater and arachnoid mater.

Answer 194

Extradural haemorrhage is usually caused by rupture of the middle meningeal artery in the temporo-parietal region.

Answer 195

It occurs between the skull and dura mater

Answer 196

On a CT scan they have a crescent shape and are not limited by the cranial sutures (they can cross over the sutures).

Answer 197

On a CT scan they have a bi-convex shape and are limited by the cranial sutures (they can’t cross over the sutures).

Answer 198

This is usually the result of a ruptured cerebral aneurysm.

Answer 199

Subarachnoid haemorrhage involves bleeding in to the subarachnoid space, where the cerebrospinal fluid is located, between the pia mater and the arachnoid membrane.

Answer 200

Nifedipine

Answer 201

Demyelination of the myelinated neurones in the central nervous system. This is caused by an inflammatory process involving the activation of immune cells against the myelin.

Answer 202

Multiple sclerosis typically only affects the central nervous system (the oligodendrocytes), rather than the Schwann cells in the PNS. There is inflammation around myelin and infiltration of immune cells that cause damage to the myelin.

Answer 203

Optic neuritis (loss of vision in one eye) Internuclear opthalmoplegia Ataxia Focal weakness (Bells palsy, Horners syndrome, Limb paralysis) Focal sensory (Trigeminal neuralgia, numbness)

Answer 204

electric shock sensation that travels down the spine and into the limbs when flexing the neck. It indicates disease in the cervical spinal cord in the dorsal column. It is caused by stretching the demyelinated dorsal column.

Answer 205

MRI scans can demonstrate typical lesions Lumbar puncture can detect “oligoclonal bands” in the cerebrospinal fluid (CSF)

Answer 206

Central scotoma. This is an enlarged blind spot. Pain on eye movement Impaired colour vision Relative afferent pupillary defect

Answer 207

Muscle wasting Reduced tone Fasciculations Reduced reflexes

Answer 208

Increased tone or spasticity Brisk reflexes Upgoing plantar responses

Answer 209

Cogwheel rigidity, bradykinesia, restless tremor Symptoms are characteristically asymmetrical, with one side more affected than the other

Answer 210

Progressive reduction of dopamine in the basal ganglia of the brain

Answer 211

Asymmetrical vs symmetrical Worse at rest vs improves at rest Intentional bs non-intentional No change w/ alcohol vs improves with alcohol

Answer 212

Dystonia: This is where excessive muscle contraction leads to abnormal postures or exaggerated movements. Chorea: These are abnormal involuntary movements that can be jerking and random. Athetosis: These are involuntary twisting or writhing movements usually in the fingers, hands or feet.

Answer 213

Propanolol and primidone (a barbiturate anti-epileptic medication)

Answer 214

First line: sodium valproate Second line: lamotrigine or carbamazepine

Answer 215

First line: carbamazepine or lamotrigine Second line: sodium valproate or levetiracetam

Answer 216

Start in the temporal lobes They affect hearing, speech, memory and emotions. There are various ways that focal seizures can present: Hallucinations Memory flashbacks Déjà vu Doing strange things on autopilot

Answer 217

It is a medical emergency. It is defined as seizures lasting more than 5 minutes or more than 3 seizures in one hour.

Answer 218

Buccal midazolam, or rectal diazepam

Answer 219

ABCDE IV lorazepam 4mg, repeated after 10 minutes if the seizure continues If seizures persist: IV phenobarbital or phenytoin

Answer 220

Carbamazepine as first-line for trigeminal neuralgia and if that does not work to refer to a specialist.

Answer 221

Amitriptyline is a tricyclic antidepressant Duloxetine is an SNRI antidepressant Gabapentin is an anticonvulsant Pregabalin is an anticonvulsant

Answer 222

If patients present within 72 hours of developing symptoms, NICE guidelines recommend considering prednisolone as treatment, either: 50mg for 10 days 60mg for 5 days followed by a 5-day reducing regime of 10mg a day Patients also require lubricating eye drops to prevent the eye on the affected drying out and being damaged. If they develop pain in the eye they need an ophthalmology review for exposure keratopathy. Tape can be used to keep the eye closed at night.

Answer 223

It presents as a unilateral lower motor neurone facial nerve palsy. Patients stereotypically have a painful and tender vesicular rash in the ear canal, pinna and around the ear on the affected side. This rash can extend to the anterior 2/3 of the tongue and hard palate.

Answer 224

Varicella zoster virus

Answer 225

Prednisolone and aciclovir, preferably within 72 hours of symptom onset; and lubricating eye drops

Answer 226

A popular exam question describes a patient that has had an unusual change in personality and behaviour. This indicates a tumour in the frontal lobe. Remember that the frontal lobe is responsible for personality and higher-level decision making.

Answer 227

To block prolactin-secreting tumours

Answer 228

E.g. ocreotide, to block growth hormone-secreting tumours

Answer 229

Hearing loss Tinnitus Balance problems

Answer 230

Huntington’s chorea is a “trinucleotide repeat disorder” that involves a genetic mutation in the HTT gene on chromosome 4.

Answer 231

Anticipation is a feature of trinucleotide repeat disorders. This is where successive generations have more repeats in the gene, resulting in: Earlier age of onset Increased severity of disease

Answer 232

Chorea (involuntary, abnormal movements) Eye movement disorders Speech difficulties (dysarthria) Swallowing difficulties (dysphagia)

Answer 233

There is a strong link between thymoma (tumours of the thymus gland) and myasthenia gravis. 10-20% of patients with myasthenia gravis have a thymoma. 20-40% of patients with a thymoma develop myasthenia gravis.

Answer 234

In around 85% of patients with myasthenia gravis, acetylcholine receptor antibodies are produced by the immune system. These bind to the postsynaptic neuromuscular junction receptors. This blocks the receptor and prevents the acetylcholine from being able to stimulate the receptor and trigger muscle contraction.

Answer 235

Extraocular muscle weakness causing double vision (diplopia) Eyelid weakness causing drooping of the eyelids (ptosis) Weakness in facial movements Difficulty with swallowing Fatigue in the jaw when chewing Slurred speech Progressive weakness with repetitive movements

Answer 236

Acetylcholine receptor (ACh-R) antibodies (85% of patients) Muscle-specific kinase (MuSK) antibodies (10% of patients) LRP4 (low-density lipoprotein receptor-related protein 4) antibodies (less than 5%)

Answer 237

Patients are given an IV dose of edrophonium chloride (or neostigmine). Normally, cholinesterase enzymes in the neuromuscular junction break down acetylcholine. Edrophonium block these enzymes and stop the breakdown of acetylcholine. As a result the level of acetylcholine at the neuromuscular junction increases. It briefly and temporarily relieves the weakness. This establishes a diagnosis of myasthenia gravis.

Answer 238

Reversible acetylcholinesterase inhibitors (usually pyridostigmine or neostigmine) increases the amount of acetylcholine in the neuromuscular junction and improve symptoms Immunosuppression (e.g. prednisolone or azathioprine) suppresses the production of antibodies Thymectomy can improve symptoms even in patients without a thymoma

Answer 239

Myasthenic crisis is a severe complication of myasthenia gravis. It can be life threatening. It causes an acute worsening of symptoms, often triggered by another illness such as a respiratory tract infection. This can lead to respiratory failure as a result of weakness in the muscle of respiration. Patients may require non-invasive ventilation with BiPAP or full intubation and ventilation.

Answer 240

Medical treatment of myasthenic crisis is with immunomodulatory therapies such as IV immunoglobulins and plasma exchange.

Answer 241

Lambert-Eaton syndrome typically occurs in patients with small-cell lung cancer. It is a result of antibodies produced by the immune system against voltage-gated calcium channels in small cell lung cancer (SCLC) cells. These antibodies also target and damage voltage-gated calcium channels in the presynaptic terminals of the neuromuscular junction where motor nerves communicate with muscle cells.

Answer 242

Charcot-Marie-Tooth disease is an inherited disease that affects the peripheral motor and sensory nerves. They cause dysfunction in the myelin or the axons. The majority of mutations are inherited in an autosomal dominant pattern.

Answer 243

High foot arches (pes cavus) Distal muscle wasting causing “inverted champagne bottle legs” Weakness in the lower legs, particularly loss of ankle dorsiflexion Weakness in the hands Reduced tendon reflexes Reduced muscle tone Peripheral sensory loss

Answer 244

A – Alcohol B – B12 deficiency C – Cancer and Chronic Kidney Disease D – Diabetes and Drugs (e.g. isoniazid, amiodarone and cisplatin) E – Every vasculitis

Answer 245

Campylobacter jejuni, cytomegalovirus and Epstein-Barr virus

Answer 246

Guillain-Barré is thought to occur due to a process called molecular mimicry. The B cells of the immune system create antibodies against the antigens on the pathogen that causes the preceding infection. These antibodies also match proteins on the nerve cells. They may target proteins on the myelin sheath of the motor nerve cell or the nerve axon.

Answer 247

A diagnosis of Guillain-Barré syndrome is made clinically. The Brighton criteria can be used for diagnosis. Diagnosis can be supported by investigations: Nerve conduction studies (reduced signal through the nerves) Lumbar puncture for CSF (raised protein with a normal cell count and glucose)

Answer 248

IV immunoglobulins Plasma exchange (alternative to IV IG) VTE prophylaxis (pulmonary embolism is a leading cause of death)

Answer 249

Neurofibromatosis type 2

Answer 250

The characteristic feature is the development of hamartomas. These are benign neoplastic growths of the tissue that they origin from. Hamartomas cause problems based on the location of the lesion. They commonly affect the: Skin Brain Lungs Heart Kidneys Eyes

Answer 251

Ash leaf spots are depigmented areas of skin shaped like an ash leaf Shagreen patches are thickened, dimpled, pigmented patches of skin Angiofibromas are small skin coloured or pigmented papules that occur over the nose and cheeks Subungual fibromata are fibromas growing from the nail bed. They are usually circular painless lumps that grow slowly and displace the nail Cafe-au-lait spots are light brown “coffee and milk” coloured flat pigmented lesions on the skin Poliosis is an isolated patch of white hair on the head, eyebrows, eyelashes or beard

Answer 252

Fever, photophobia or neck stiffness (meningitis or encephalitis) New neurological symptoms (haemorrhage, malignancy or stroke) Dizziness (stroke) Visual disturbance (temporal arteritis or glaucoma) Sudden onset occipital headache (subarachnoid haemorrhage) Worse on coughing or straining (raised intracranial pressure) Postural, worse on standing, lying or bending over (raised intracranial pressure) Severe enough to wake the patient from sleep Vomiting (raised intracranial pressure or carbon monoxide poisoning) History of trauma (intracranial haemorrhage) Pregnancy (pre-eclampsia)

Answer 253

Aura is the term used to describe the visual changes associated with migraines. There can be multiple different types of aura: Sparks in vision Blurring vision Lines across vision Loss of different visual fields

Answer 254

Hemiplegic migraines can mimic stroke. It is essential to act fast and exclude a stroke in patients presenting with symptoms of hemiplegic migraine. Symptoms of a hemiplegic migraine can vary significantly. They can include: Typical migraine symptoms Sudden or gradual onset Hemiplegia (unilateral weakness of the limbs) Ataxia Changes in consciousness

Answer 255

Triptans are used to abort migraines when they start to develop. They are 5HT receptors agonists (serotonin receptor agonists

Answer 256

Propranolol Topiramate (this is teratogenic and can cause a cleft lip/palate so patients should not get pregnant) Amitriptyline

Answer 257

Vitamin B2 (riboflavin)

Answer 258

Symptoms are typically all unilateral: Red, swollen and watering eye Pupil constriction (miosis) Eyelid drooping (ptosis) Nasal discharge Facial sweating

Answer 259

Acute management: Triptans (e.g. sumatriptan 6mg injected subcutaneously) High flow 100% oxygen for 15-20 minutes (can be given at home)

Answer 260

Verapamil Lithium Prednisolone (a short course for 2-3 weeks to break the cycle during clusters)

Answer 261

Carcinoembryonic antigen, CEA

Answer 262

Lactulose helps reduce encephalopathy by facilitating nitrogenous waste loss through the intestines; however, intravenous mannitol is indicated in the context of reduced consciousness.

Answer 263

IV mannitol

Answer 264

The statement described above suggests gastroparesis, which is associated with diabetes mellitus due to autonomic neuropathy. Metoclopramide is a prokinetic agent that is indicated for the management of gastroparesis.