New diseases Flashcards
1
Q
What is an RAPD
A
Relative Afferent Pupillary Defect (RAPD) is a condition in which pupils respond differently to light stimuli shone in one eye at a time (swinging light test) due to unilateral or asymmetrical disease of the retina or optic nerve.
Ex// Upon performing the swinging light there is a normal constriction of both pupils when the light is shone into the right eye. When the light is shone into the left eye there is a reduced constriction of both pupils (i.e. left afferent defect)
2
Q
Causes of RAPD
A
- Acute glaucoma -> aqueous humour drainage becomes occluded.
Severe pain, N+V, red eye, reduced vision. (usually bilateral disease i.e. APD but
if one damaged more then can cause RAPD) - Vitreous haemorrhage -> Haemorrhage into vitreous humour. Painless, unilateral floaters. +/- visual loss.
- Retinal detachment -> painless flashes, floaters, curtain over part of vision - stiffer, slower than vitreous haemorrhage.
- Optic neuritis -> reduced acuity, poor discrimination of colours ‘red desaturation’, pain worse on eye movement, central scotoma
3
Q
What are the sx of Meniere’s disease and how tx
A
EPISODIC, SUDDEN ATTACKS of vertigo, AURAL FULLNESS, tinnitus, ataxia, unilateral or bilateral sensorineural hearing loss.
- Management relies on prophylactic use of betahistine to reduce the frequency of attacks, and the acute use of prochlorperazine.
4
Q
What are the sx of Vestibular schwannoma (acoustic neuroma)
A
- Vertigo - usually comes on slowly and GRADUALLY gets worse over time, Unilateral Sensorineural hearing loss, ataxia, tinnitus, ABSENT CORNEAL REFLEX.
- Associated with neurofibromatosis type 2
5
Q
What is the presentation of benign paroxysmal positional vertigo
A
- ELDERLY, calcium deposits within semicircular canals
- BPPV is provoked by MOVEMENTS of the head usually to one side when turning in bed or on looking upwards.
- These sudden attacks of ROTATIONAL VERTIGO last for 30s to 1 minute and are provoked the changing position of the head.
- There are no auditory symptoms for BPPV.
Episodes will usually disappear within a few weeks or months, but they often recur.
6
Q
Dx and Mx of benign paroxysmal positional vertigo
A
The diagnostic test is the Dix-Hallpike manoeuvre
The therapeutic manoeuvre is the Epley manoeuvre.
7
Q
Px of Viral labyrinthitis vs Vestibular neuronitis
A
Both: recent viral infection, vertigo/N+V
Viral labyrinthitis: HEARING LOSS
Vestibular neuronitis: NO HEARING LOSS
8
Q
Causes of LMN facial nerve palsy and Tx
A
Bells -> idiopathic. Prednisolone (<72hrs) + lubricating eye drops. Paralysis no improvement after 3 weeks, then refer urgently to ENT.
Ramsey Hunt -> VZV. Vesicular rash around their ear, hearing loss/tinnitus/vesicles in ear (abnormal ENT) and a facial nerve palsy. prednisolone + aciclovir + eye lubricating drops
9
Q
Px of Multiple Sclerosis
A
- YOUNG ADULTS, COMMONLY WOMEN
- Episodes of sensory and/or motor weakness, most commonly UNILATERAL.
- FOCAL weakness i.e. left arm, bells palsy, horners
- FOCAL sensory i.e. numbness, Lhermitte’s sign
- Optic neuritis -> pain on eye movement, loss of visual acuity, color desaturation
- Ataxia
- Uthoffs phenomenon: neurological symptoms are exacerbated by increases in body temperature is typically associated with multiple sclerosis
10
Q
Ix and Tx of MS
A
- Ix: MRI, LP - oligoclonal bands in CSF
- Mx: Acute relapse: Methylprednisolone (high dose steroid)
Remission: Natalizumab, fingolimod (only oral - fingers)
Spasticity -> baclofen, gabapentin
11
Q
Px of cervical spondylosis
A
- OLDER AGE
Neck pain +/- Lhermittes. Worse with movement
Radiculopathy - LMN signs
Myelopathy - UMN signs
Headache
12
Q
Px of eczema
A
- Itchy, erythematous rash
repeated scratching may exacerbate affected areas - Face + trunk (infants), Extensor surfaces (young children), Flexor surfaces + creases (older children)
13
Q
Mx of eczema
A
- avoid irritants + simple emollients
- topical steroid - emollient should be applied first followed by waiting at least 30 minutes before applying the topical steroid
14
Q
What is Eczema Herpeticum and tx
A
- Eczema herpeticum describes a severe primary infection of the skin by herpes simplex virus 1 or 2.
-> child with atopic eczema and widespread vesicular rash with systemic symptoms such as fever, lethargy, irritability and reduced oral intake. There will usually be lymphadenopathy (swollen lymph nodes). - Tx: As it is potentially life-threatening children should be admitted for IV aciclovir
15
Q
What is Asherman’s syndrome
A
- cause of SECONDARY amennorhea
- Characterised as uterine adhesions, commonly as a result of previous uterine surgery.
- Hysteroscopy is gold standard
16
Q
What is Sheehans syndrome
A
- cause of SECONDARY amennorhea, complication of PPH
= avascular necrosis of anterior pituitary
Sx:
Reduced lactation (lack of prolactin)
Amenorrhea (lack of LH and FSH)
Adrenal insufficiency and adrenal crisis, caused by low cortisol (lack of ACTH)
Hypothyroidism with low thyroid hormones (lack of TSH)
17
Q
Causes of secondary amenorrhea
A
- Pregnancy (most common cause) and breastfeeding
- Menopause or premature ovarian insufficiency -> RAISED FSH, raised LH, decreased oestrogen
- Intrauterine adhesions causing outflow tract obstruction (Asherman’s syndrome)
- PCOS -> raised LH and LH:FSH ratio
- Drug-induced amenorrhoea (e.g. oral contraceptive)
- Physical stress, excess exercise and weight loss
- Pituitary gland pathology such as Sheehan syndrome or hyperprolactinaemia
- Hypothyroidism or hyperthyroidism
18
Q
What is the Pierre Robin sequence
A
Pierre Robin sequence or syndrome is a genetic condition in which an infant is born with micrognathia (small jaw), glossoptysis (posterior tongue) and often cleft palate. As a result the infant may have breathing or feeding difficulties shortly after birth.
19
Q
What is the classic triad of Henoch Schonlein Purpura
A
Purpura or petechiae on the buttocks and lower limbs
Abdominal pain
Arthralgia
20
Q
What important test need to look for in Henoch Schonlein Purpura
A
Urine dipstick for 12 months - renal impairment is a common complication
21
Q
Causes of acute confusional state
A
D - Drugs and Alcohol
E - Eyes, ears and emotional
L - Low Output state (MI, ARDS, PE, CHF, COPD)
I - Infection
R - Retention (of urine or stool)
I - Ictal
U - Under-hydration/Under-nutrition
M - Metabolic (Electrolyte imbalance, thyroid, wernickes
(S) - Subdural, Sleep deprivation
22
Q
What type of drugs most commonly cause delirium and Mx of delirium
A
- Anti-cholinergics: Amitriptyline, Antihistamines - chlorpheniramine, Oxybutinin (dont use for urge incontinence in elderly - mirabegron)
- Opiates
- Anti-convulsants
- Recreational
- STEROIDs
- Mx: Treat the underlying cause. Maintaining an environment with good lighting and frequent reassurance is helpful.
-> HALOPERIDOL (1st), olanzapine
-> If pt. has parkinsons or lewy-body dementia, then avoid antipsychotics (cause EPSE’s) and use benzo’s
23
Q
Features suggesting delirium over dementia
A
- impaired consciousness
- Fluctuates and worse at night
- Abnormal perception - illusions and hallucinations
- Agitation, Fear
- delusions
24
Q
Px + Dx of Acute lymphoblastic leukaemia
A
- Bruising, enlarged lymph nodes/lymphadenopathy and systemic illness
- may have hepatospleenomegaly, epistaxis, fatigue
- dx = bone marrow biopsy
- Urgent referral to hospital
25
Sepsis 6 in paeds
Sepsis 6:
1)High flow O2 If indicated 2) Obtain IV and take blood cultures, glucose 3) Give IV or IO Abx 4) Consider Fluid resuscitation 5) Involve senior clinicians early 6) Consider inotropic support
26
RF's for DDH
Female
Firstborn
Family history
Fanny first (breech)
Fluid (oligohydramnios).
27
Maneouvres for DDH + Imaging?
The manoeuvres to screen for DDH are Barlow (posterior dislocation) and Ortalani (relocation on abduction of the hip) manoeuvres.
Mnemonic to remember Barlow and Ortolani:
Barlow's is Bad (dislocate) -
ORTolani- ORThopaedic doctors relocate joints
- US
28
How does an amniotic fluid embolism present
The majority of cases occur in labour , though they can also occur during caesarean section and after delivery in the immediate postpartum.
Symptoms include: chills, shivering, sweating, anxiety and coughing.
Signs include: cyanosis, hypotension, bronchospasms, tachycardia. arrhythmia and myocardial infarction.
29
What is infantile colic and how manage?
Infantile colic describes a relatively common and benign set of symptoms seen in young infants. It typically occurs in infants less than 3 months old and is characterised by bouts of excessive crying and pulling-up of the legs, often worse in the evening.
- Reassurance and support
30
What is polyneuropathy
Disorder that involves damage to multiple peripheral nerve fibres. Distal nerves usually affected most prominently. Usually symmetrical, bilateral.
31
What is mononeuropathy
Damage to single peripheral nerve e.g. carpal tunnel syndrome
32
What is mononeuritis multiplex
- Damage to multiple nerves in an asymmetrical distribution i.e. cranial nerve palsy + foot drop
- Associated with vasculitis, diabetes, infections, immune mediated diseases.
33
Types of polyneuropathy that are predominantly motor loss and predominantly sensory loss
Predominately motor loss:
Guillain-Barre syndrome
Charcot-Marie-Tooth
Chronic inflammatory demyelinating polyneuropathy (CIDP)
diphtheria
Predominately sensory loss:
diabetes
vitamin B12 deficiency
alcoholism
uraemia
34
Complications of diabetes
Diabetic neuropathy:
- typically sensory loss in 'glove and stocking' distribution, with lower legs affected first.
GI neuropathy - gastroparesis, chronic diarrhoea, GORD.
Diabetic retinopathy:
- reduced vision/blindness due to vascular disease
Heart disease
CKD
Dementia
35
Sx of following peripheral nerve palsies:
Peroneal nerve palsy
Radial nerve palsy
Ulnar nerve palsy
Median nerve palsy
Bell's (LMN) palsy
- Peroneal nerve palsy: (branch of sciatic) Foot drop or sensory changes in foot
- Radial nerve palsy: Wrist drop, + cant extend/numbness fingers or wrist
- Ulnar nerve palsy: clawing/tingling/weakness of 4th,5th fingers, disability to abduct/adduct fingers of hand
- Median nerve palsy: inability to abduct and oppose thumb (ape hand), weakened finger flexion, loss of sensation to thumb, Index and middle finger, the lateral half of ring finger
- Bell's palsy: LMN facial nerve palsy, forehead affected
36
What signs in a blood test may indicate sepsis
- Lactate: high + metabolic acidosis
- CRP: high
- FBC: abnormal neutrophils
- Blood culture
- Lumbar puncture
37
What is subacute combined degeneration of the cord
= vitamin B12 deficiency
Bilateral/symmetrical:
- Dorsal column loss (sensory + LMN)
-> propriception, vibration, fine touch, pressure sensation
lost first: imbalance/ataxia +
parenthesia
- Corticospinal tract loss (motor + UMN)
Classic triad: Extensor plantar response/babinski sign, brisk knee jerks, absent ankle jerks (LMN signs more distally)
- Clinical picture is often complicated by a coexistent peripheral neuropathy, optic atrophy and cognitive impairment.
38
Features of alcohol withdrawal + tx
- symptoms start at 6-12 hours: tremor, sweating, tachycardia, anxiety
Mx: PO chlordiazepoxide + IV thiamine (pabrinex)
- seizures at 36 hours
- peak incidence of delirium tremens is at 48-72 hours: coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia
- tx of tremens = IV pabrinex (vtiamin B1 to offset kortsokoffs) + high dose benzodiazepine
39
What is Wernicke's-Korsakoff's
COAT-RACK -> when go parties hang coat on the rack
Confusion, Opthalmoplegia/Nystagmus, Ataxia, Thymine deficiency
Retrograde amnesia, Anterograde amnesia, Confabulation, Korsakoff
40
Tx of ADHD
Methylphenidate
41
Sx of serotonin syndrome
SHIVERS
- shivering
- hyper-reflexia and myoclonus
- Increased temperature
- vital sign abnormalities - Tachycardia, tachypnea, and labile blood pressure
- encephalopathy: Mental status changes such as agitation, delirium, and confusion
- Restlessness/rigidity: Common due to excess serotonin activity
- Sweating: Autonomic response to excess serotonin. This symptom can help differentiate from anticholinergic toxicity in which the patients would present with increased temperature but dry to the touch
- dilated pupils
42
Side effects of Antipsychotics
1. EPSE (anti dopamine - block motor fn): parkinsonism, acute dystonias -> sustained muscle contraction, akathisia (severe restlessness), tardive dyskinesia
2. Endocrine pathway blocked -> Increased prolactin = Gynaecomastia/ galactorrhoea, block mACH = cant see, cant pee, cant spit, cant shit, block H1 receptors = sedation (like antihistamines), 5-HT (increased weight gain)
3. QT interval
4. Neuroleptic malignant syndrome -> Fever, Encelapothay - confusion/mental retardation, Vital signs unstable (hyperthermia, sweating), Enzymes elevated (creatinine kinase increased), Rigidity of muscles - lead pipe. Pupils normal.
43
Ex. of acute dystonias
- involuntary upward eye movements (oculogyric = eye)
- Muscle spasms of neck = torticollis (tortoise neck), tongue, face
- mx: procyclidine
44
Ex. of tardive dyskinesia
(Tardive = slowly developing/late + dyskinesia + Dyskinesia = involuntary movements) Irreversible.
- Involuntary movements of face, tongue, jaw movements.
-> Commonly is chewing and pouting of jaw.
45
Adverse effects of atypical antipsychotics
- Weight gain, hyperprolactinaemia
- Clozapine -> agranulocytosis, neutropenia. Introduced if not controlled despite use of 2+ antipsychotic drugs (1 of which is a atypical). Increases risk of seizures, myocarditis, CONSTIPATION, INCREASED SALIVATION
46
Side effects of lithium
Lethargy, Insipidus (diabetes) - thirst/urination, Tremor, Hypothyroidism, Impaired memory + cognition, Upset stomach, Muscle weakness
47
Features and Likely blood results in someone with anorexia nervosa
- Oral: dental caries/decay
- CVS: hypotension, long QT, arrhythmia, bradycardia, cardiomyopathy
- Endocrine: low sodium/potassium/glucose/body temp/T3 hormone. High cortisol/growth hormone/cholesterol. Osteoporosis
Low sex hormones - amenorrhea/delayed puberty
- Derm: dry scaly skin, brittle hair, fine body hair
- Haem: anaemia, leukopenia, thrombocytopenia
48
What is an Osteosarcoma
1. Femur 2. Tibia + Humerus
- persistent bone pain, particularly worse at night time
- bone swelling, a palpable mass and restricted joint movements
- XRAY: periosteal reaction (irritation of the lining of the bone) that is classically described as a “sun-burst” appearance.
49
What is Ewings sarcoma + what are features of xray
- It most commonly affects teenagers and young adults with the pelvis, thigh bone and shin bone being the most commonly affected areas.
- Bone pain particularly occurring at night
- A mass or swelling, restricted movement in a joint
- XRAY: onion skin appearance. Small, round blue cell tumour.
50
What type of HRT to give to peri/post menopausal women
+ Risks with HRT
Perimenopausal: give cyclical combined HRT
Postmenopausal (more than 12 months since last period): give continuous combined HRT
- The risk of endometrial cancer is greatly reduced by adding progesterone (combined) in women with a uterus
- The risk of VTE is reduced by using patches rather than pills
- Increased risk of breast cancer (particularly combined HRT – oestrogen-only HRT has a lower risk)
51
What are the phases in 1st stage of labour and what is classed as delay/fail to progress
1. Latent: 0-3cm dilation cervix. 0.5cm/hr + irregular contractions
2. Active: 3-7cm dilation. 1cm/hr + regular contractions
3. Transition: 7-10cm dilation. 1cm/hr + regular contractions
Delay = Less than 2cm of cervical dilatation in 4 hours or Slowing of progress in a multiparous women
52
What happens in 2nd stage of labour and what is classed as delay/fail to progress
Lasts from 10cm dilatation of cervix to delivery of the baby. Success depends on the 3 P's (power/contractions, passenger/size/pres/position, passage/shape/size of pelvis)
Delay = 1hr in multiparous, 2hr in nulliparous
53
What happens in 3rd stage of labour and what is classed as delay/fail to progress
From delivery of baby to delivery of placenta.
30+ minutes with active mx
60+ minutes with physiological mx
Active mx: INTRAMUSCULAR oxytocin/ergometrine, controlled cord traction
54
Breastfeeding contraindications
LAMBAST Mothers Ceen taking:
Lithium
Amiodarone
Methotrexate
Benzos
Aspirin
Sulphonamides
Tetracyclines
Carbimazole, Ciprofloxacin, Chloramphenicol, Cytoxics
55
Breast fibroadenoma/ breast cyst
- Develop from a whole lobule, common in younger women. Resolve after menopause
- MOBILE, firm, SMOOTH breast lump - a 'breast mouse'
- No increase in risk of malignancy
- If >3cm surgical excision is usual
56
What is mammary duct ectasia
- INFLAMMATION + dilation of the large breast ducts, leads to clogging.
- It commonly presents with thick, GREEN/yellow/white nipple DISCHARGE
- FIRM, PAINFUL MASS under the nipple
- Most common in PERIMENOPAUSAL women
- Tx not usually necessary
57
Features of mastitis
- Inflammation of breast tissue +/- infection.
- Localised symptoms include a painful, tender, red and hot breast
- Systemic symptoms include fever, rigors, myalgia, fatigue, nausea and headache
- development of a breast abscess which presents as a fluctuant, tender mass with overlying erythema.
- (younger, breastfeeding woman - than inflammatory breast cancer)
58
Mx of mastitis
- Reassure lactating women that they can continue to breastfeed
- Advise on methods to facilitate milk removal e.g. manual expression
- Analgesia
Consider a course of oral antibiotics according to local protocol - fluclox (1st), erythromycin
- If condition does not improve, may require intravenous antibiotics or surgical management, particularly if a breast abscess develops
59
What is a fibrocyst/ breast cyst
- Usually presents as a smooth discrete lump - 'lumpy breasts'
- FLUCTUATES during menstrual cycle. Usually resolves after menopause.
- Can be PAINFUL.
60
What is a galactocele
MILK RETENTION CYST, during or after BREASTFEEDING
- They present with a firm, mobile, painless lump, usually beneath the areola.
- Tx not usually necessary
61
What is fat necrosis
Painless
Firm
Irregular
Fixed in local structures
- commonly triggered by localised trauma, radiotherapy or surgery
62
When are investigations indicated with a couple that cant conceive + what investigations?
After 1 year of regular UPSI
- semen analysis
- serum progesterone 7 days prior to expected next period.
RESULTS:
(< 16 nmol/l)= Repeat, if consistently low refer to specialist
(16 - 30 nmol/l) = Repeat
(> 30 nmol/l)= Indicates ovulation
63
Chronic asthma pathway in children
1. SABA
2. SABA + ICS (beclamethasone or budenoside)
3. SABA + ICS + LTRA (or LABA if >5)
4. SABA + ICS higher dose
64
Tx of PID
IM ceftriaxone +
Doxycycline +
Metronidazole
65
What is transient tachypnoea of newborn. Dx and Tx.
- Commonly occurs after a C-section - NEONATE
- Px: Respiratory distress (tachypnoea, increased work of breathing and potentially desaturated/cyanotic)
- Dx: Hyperinflated lungs and a fluid level on chest X-ray
- Tx: observation, supportive care - most cases, resolve on its own. Some cases may require O2
66
Ductal vs Lobular breast carcinoma
- Ductal (most common) in milk ducts -> irregularly distributed cells with atypically large nucleus.
- Lobular -> small, round lobular cells in a uniform pattern
- If basement membrane not breached = in situ (e.g. DCIS). Breached = invasive.
67
Px of breast carcinoma
Clinical features that may suggest breast cancer are:
- Lumps that are hard, irregular, painless or fixed in place
- Lumps may be tethered to the skin or the chest wall
- Nipple retraction
- Skin dimpling or oedema (peau d’orange)
- Lymphadenopathy, particularly in the axilla
68
Pagets Disease of the nipple
Paget’s Disease of the Nipple = condition associated with breast cancer
- Looks like eczema of the nipple/areolar
- Erythematous, scaly rash
- Indicates breast cancer involving the nipple
- May represent invasive breast cancer or DCIS
69
Inflammatory breast cancer
- Presents similarly to a breast abscess or mastitis (mastitis = younger, lactating women)
- Swollen, warm, tender breast with pitting skin (peau d’orange)
- Does not respond to antibiotics
- Worse prognosis than other breast cancers
70
Hormonal receptors on breast cancer
- Oestrogen (ER) -> tx: Tamoxifen (premen.), Anastrozole (postmen.)
- Progesterone (PR)
- HER2 (human epidermal growth factor receptor type 2) -> tx: Trastuzumab (Herceptin)
- Absence of ER or PR is a poor prognostic factor
- Being "triple negative" (ER/PR/HER2) is associated with a younger age of diagnosis and worse overall survival.
71
Section mental health laws
Section 2
- admission for assessment for up to 28 days, not renewable
an Approved Mental Health Professional (AMHP)
- treatment can be given against a patient's wishes
Section 3
- admission for treatment for up to 6 months, can be renewed
-treatment can be given against a patient's wishes
Section 4
- 72 hour assessment order
used as an emergency, when a section 2 would involve an unacceptable delay
- often changed to a section 2 upon arrival at hospital
Section 5(2)
- a patient who is a voluntary patient in hospital (except emergency department) can be legally detained by a doctor for 72 hours
Section 5(4)
- similar to section 5(2), allows a nurse to detain a patient who is voluntarily in hospital (except emergency department) for 6 hours
Section 136
- someone found in a public place who appears to have a mental disorder can be taken by the police to a Place of Safety
can only be used for up to 24 hours, whilst a Mental Health Act assessment is arranged
72
What is syncope and types?
- loss of consciousness with rapid onset, short duration and spontaneous complete recovery
1. Reflex syncope -> Vasovagal (emotion, pain, stress, after prolonged standing or sitting), Situational (triggered by urination, swallowing or coughing), carotid sinus (turning head to one side)
2. Orthostatic syncope -> immediately with sitting or standing
3. Cardiac -> arrhythmias, valvular, MI, PE
73
Causes of foot drop and differentials
-> Foot drop (loss of dorsiflexion) can be caused by Deep peroneal nerve, common peroneal nerve, sciatic nerve, L5 root.
- Most Commonly by Common peroneal nerve + L5 radiculopathy
-> Peroneal = 2 E's = responsible for Eversion
-> Tibial = 2 I's = Inverts ankle. But doesnt cause dorsiflexion
-> L-fIvE = L5 supplies ankle both Inversion and Eversion
Distinguish L5 from Common Peroneal -> INVERSION -> Footdrop with inversion weakness is from an L5 lesion, and footdrop witohut inversion weakness is more likely peroneal.
- L5 also get sensory changes -> sciatica type shooting pain.
74
When to give anti D immunoglobin prophylaxis
- if mother is rhesus D negative (i.e. no rhesus D antigen on mothers RBC's)
- give prophylaxis at 28wks + always within 72hrs if sensitisation occurs:
Antepartum haemorrhage, Placental abruption, Abdominal trauma, External cephalic version, Invasive uterine procedures such as amniocentesis and chorionic villus sampling, Rhesus positive blood transfusion to a rhesus negative woman, Intrauterine death, miscarriage or termination Ectopic pregnancy, Delivery (normal, instrumental or caesarean section)
- If sensitisation occurs before prophylaxis at 28wks, then give Anti D within 72hrs also
75
Interactions/contraindications to SSRI
- NSAIDs + asprin: NICE guidelines advise 'do not normally offer SSRIs', but if given co-prescribe a proton pump inhibitor
- warfarin / heparin: NICE guidelines recommend avoiding SSRIs and considering mirtazapine
- triptans: avoid SSRIs
76
Clinical features of spinal cord compression + causes
- Cord compression typically presents with acute (or less commonly subacute) upper motor neuron signs and sensory disturbance below the level of the lesion.
- Deep and localised back pain is often also present, along with a stabbing radicular sensory disturbance at the level of the lesion. Bladder and bowel involvement is also commonly seen.
- Causes: Trauma, Neoplasia, Infection, Disc prolapse, Epidural haematoma
77
S/E of dementia first line drugs
- Donepezil + Rivastigimine (= anticholinesterase inhibitiors = cholinergics = opposite to anticholinergics [tricyclics, oxybutinin]) blurred vision, incontinence, excess saliva, diarrhoea.
78
What are the hearing tests in neonates
- Otoacoustic emission test -> All newborns should be tested as part of the Newborn Hearing Screening Programme. A computer-generated click is played through a small earpiece. The presence of a soft echo indicates a healthy cochlea
- Auditory Brainstem Response test -> May be done if otoacoustic emission test is abnormal
79
Px and Mx of cluster headaches
- Intense, sharp, stabbing pain around one eye. Can have redness, lacrimation, lid swelling.
- Onset: 1-2 a day + last 15mins-2hrs. Clusters last 4-12 weeks.
- Tx: Acute = O2, triptans
Prophylaxis = verapamil
80
What is Kallmans syndrome
- congenital form of hypogonadotropic hypogonadism, caused by an abnormally functioning hypothalamus.
- more common in boys
- blood results would show low GnRH, FSH, and LH.
- failure to start puberty + absence of the sense of smell
- Cleft lip/palate and visual/hearing defects are also seen in some patients
81
Categories of C section
-Category 1
an immediate threat to the life of the mother or baby
examples indications include: suspected uterine rupture, major placental abruption, cord prolapse, fetal hypoxia or persistent fetal bradycardia
delivery of the baby should occur within 30 minutes of making the decision
-Category 2
maternal or fetal compromise which is not immediately life-threatening
delivery of the baby should occur within 75 minutes of making the decision
-Category 3
delivery is required, but mother and baby are stable
-Category 4
elective caesarean
82
CTG features
Dr C BRaVADO
- DR Define Risk
- Contractions: 4-5/10 minutes
- Baseline RAte: 110-160 bpm (NR = >100, <180)
- Variability: 5-25 bpm
(NR = <5 for 30-50 mins, >25 15-25 mins)
- Accelerations: present
- Decelerations (hypoxia):
Early = normal - head compression,
Late = lags onset contraction - fetal distress e.g. asphyxia or placental insufficiency
Variable = independent of contraction - intermittent cord compression
- Overall impression: Normal = all features reassuring, suspicious = 1 non-reassuring, 2 reassuring, pathological is 1 abnormal or 2 non-reassuring
83
Red flags in febrile under 5
RUSH G!
- Recessions (moderate or severe) - indicating increased work of breathing
- Unarousable - indicating reduced consciousness
- Skin colour changes (blue/mottled) - indicating severe cyanosis
and Sixty+ RR
- Hydration - reduced skin turgor - indicating severe dehydration
- Grunting - increased work of breathing
84
Type of ovarian cysts
- Physiological cysts/functional:
1. follicular (most common) - non-rupture of dominant follicle. Regress after several menstrual cycles
2. Corpus luteum cyst - copus luteum doesnt break down and may fill with blood/fluid
- Benign germ cell tumours:
1. Dermoid cyst - most common benign ovarian tumour in woman under 30. Inner lining contains masses projecting from wall towards centre of cysts - rokitansky protuberance
85
Brown-Sequard vs Subacute combined degeneration of spinal cord
Brown-Sequard - caused by hemisection of spinal cord (trauma, tumour, infection)
1. Ipsilateral spastic paresis below lesion
2. Ipsilateral loss of proprioception and vibration sensation
3. Contralateral loss of pain and temperature sensation
Subacute combined degeneration of spinal cord (vit B12 & E deficiency)
1. Bilateral spastic paresis
2. Bilateral loss of proprioception and vibration sensation
3. Bilateral limb ataxia
86
What is Lambert eaten Mysasthenic syndrome
- The patient presents with weakness of the lower limbs in a lower motor neuron pattern (weakness, areflexia) but this improves on exercise (unlike myasthenia gravis)
- hyporeflexia
- association with small cell lung caner
87
Parkinsonism with autonomic disturbance - atonic bladder, postural hypotension, erectile dysfunction is likely to be what condition rather than parkinsons?
Multiple system atrophy
88
Features of cystic fibrosis + Mx
- Neonatal period: MECONIUM ILEUS (fail to pass thickened meconium in first 24 hours, bowel distension, bilious vomting)
- Recurrent chest infections
- Malabsorption - steatorrhea, failure to thrive
- Mx:
twice daily chest physiotherapy and drainage
high calorie diet, high fat intake
pancreatic enzyme supplementation
vitamin supplements
89
Less common features of cystic fibrosis
- Nasal polyps
- Diabetes mellitus
- short stature
- rectal prolapse
- infertility
- clubbing
90
Cystic fibrosis diagnosis
- Sweat test -> abnormally high sweat cholride
91
Anterior vs posterior vs central cord syndrome
Anterior cord syndrome (cause = ischemia) causes complete loss of movement, and pain and temperature loss below lvl of ischemic infarction, but it preserves light touch sensations.
Posterior cord syndrome produces the opposite effect: It causes loss of light touch sensation, but it preserves movement, and pain and temperature sensation.
Central cord syndrome (injury to cervical spine) is the most common form of INCOMPLETE spinal cord injury characterized by impairment in the arms and hands and to a lesser extent in the legs.
92
Px of Huntington's
- Symptoms manifest between ages 20-50
- Athetosis -> Snake-like slow writhing movements, especially in fingers
- Chorea -> Sudden, jerky, purposeless movements, Involuntary “dance-like” movements
- Facial grimacing and ataxia may also be seen
- Dementia, Decreased memory, attention, and concentration
- Aggression and depression
- Personality changes are often the first signs of disease
- Tx: Suppress disordered movement -> tetrabenazine
93
Features of an brain abscess and Mx
- pus-filled swelling in the brain. Usually occurs when bacteria enter brain tissue after an infection
- headache, fever, focal neurology, raised ICP -> nausea, papilloedema, seizures, cushings triad
- Mx: IV abx: cephalosporin + metronidazole or craniotomy and debridement
94
Difference between Marasmus and Kwashiorkor
- 2 variations of severe protein-energy undernutrition
- Marasmus = deficiency of all macronutrients
-> wasted + shrivelled
- Kwashiorkor = deficiency of protein (MEALS)
-> Malnutrition, Edema (face and abdomen), Anemia, Liver malfunction, Skin lesions
95
Temporal arteritis vs Trigeminal neuralgia
- Temporal arteritis: unilateral headache. Tender, palpable temporal artery. Jaw claudication. VISUAL LOSS (DDx is eye pain/cluster). Association w/ polymyalgia rheumatica.
Ix: Temporal artery biopsy - multinucleated giant cells. Mx: steroids.
- Trigeminal neuralgia: severe unilateral pain. Electric shock-like. Evoked by light touch (shaving, smoking). Mx: carbamazepine
96
Examination of ROM and what marker found in amniotic fluid
1. Sterile speculum exam (look for pooling in posterior vaginal vault). Digital exam avoided.
2. US useful to show oligohydramnios
IGFBP1
97
What happens in refeeding syndrome and what is management
If nutritional intake is resumed too rapidly after a period of relatively low caloric intake, the patient is at high risk of refeeding syndrome. Rapidly increasing insulin levels lead to shifts of potassium, magnesium and phosphate from extracellular to intracellular spaces. This is potentially fatal if refeeding is too rapid.
Symptoms of refeeding syndrome may include oedema, confusion and tachycardia. Blood tests initially show hypophosphataemia and it is
- treated with phosphate supplementation.
98
Mx of overdoses: paracetamol, opiates, benzo's, TCA's, Lithium, Warfarin
- Paracetamol Management: activated charcoal if ingested < 1 hour ago, N-acetylcysteine (NAC), liver transplantation
- Opioid/opiates: Naloxone
- Benzodiazepines: Flumazenil (if severe - as risk of seizures) [benzo car - fumes]
- Tricyclic antidepressants - IV bicarbonate may reduce the risk of seizures and arrhythmias in severe toxicity
- Lithium: mild-moderate toxicity may respond to volume resuscitation with normal saline, haemodialysis may be needed in severe toxicity
- Warfarin: Vitamin K, prothrombin complex
99
What is a raised intracranial pressure headache
Headaches which are worse in the morning/after lying down and upon bending over. May be associated with neurological deficits e.g. seizures due to compression of cranial structures by a space-occupying lesion, such as a tumour or haemorrhage.
100
What is idiopathic intracranial hypertension + Mx
- young, overweight females.
- headache and visual disturbance.
- The headache is classically non-pulsatile, bilateral, and worse in the morning (after lying down or bending forwards).
- Visual disturbances include transient visual darkening or loss, probably due to optic nerve ischaemia, and bilateral papilloedema is seen on fundoscopy.
- Mx: WEIGHT LOSS. Acetazolamide. Topiramate (prophylaxis). Repeated lumbar puncture/VPS shunt
101
What cranial nerves are involved in vestibilar schwannoma
5,7,8
102
What is Erbs palsy
injury to the C5/C6 nerves (upper BPI). It is associated with shoulder dystocia, traumatic or instrumental delivery and large birth weight.
Damaged to the C5/C6 nerves leads to weakness of shoulder abduction and external rotation, arm flexion and finger extension. This leads to the affected arm having a “waiters tip” appearance:
Internally rotated shoulder
Extended elbow
Flexed wrist facing backwards (pronated)
Lack of movement in the affected arm
Mx: Function normally returns spontaneously within a few months. If function does not return then they may required neurosurgical input.
103
Types of brain tumour
- Glioblastoma most common primary tumour in adults and is associated with a poor prognosis (~ 1yr). On imaging - solid tumours with central necrosis and a rim that enhances with contrast. Disruption of the blood-brain barrier and therefore are associated with vasogenic oedema. Mx: surgical with postop chemotherapy and/or radiotherapy. Dexamethasone is used to treat the oedema.
- Meningioma = second most common primary brain tumour in adults. Typically benign, extrinsic tumours of the central nervous system. They arise from the arachnoid cap cells of the meninges and are typically located next to the dura and cause symptoms by compression rather than invasion. Investigation is with CT (will show contrast enhancement) and MRI, and treatment will involve either observation, radiotherapy or surgical resection.
- Pilocytic astrocytoma = The most common primary brain tumour in children
- Metastatic brain cancer is the most common form of brain tumours. They are often multiple and not treatable with surgical intervention. Tumours that most commonly spread to the brain include: lung (most common), breast, bowel, skin (namely melanoma), kidney.
- Oligodendroma = Benign, slow-growing tumour common in the frontal lobes
* Histology: Calcifications with 'fried-egg' appearance
104
Factors predisposing to pressure ulcers and test used to identify patients at risk of pressure sores
malnourishment
incontinence
lack of mobility
pain (leads to a reduction in mobility)
The Waterlow score is widely used to screen for patients who are at risk of developing pressure areas. It includes a number of factors including body mass index, nutritional status, skin type, mobility and continence.
105
Mx of pressure ulcers
- a moist wound environment encourages ulcer healing. Hydrocolloid dressings and hydrogels may help facilitate this. The use of soap should be discouraged to avoid drying the wound
- wound swabs should not be done routinely as the vast majority of pressure ulcers are colonised with bacteria. The decision to use systemic antibiotics should be taken on a clinical basis (e.g. Evidence of surrounding cellulitis)
- surgical debridement may be beneficial for selected wounds
106
When is Electroconvulsive therapy indicated
- used only to achieve rapid and short-term improvement of severe symptoms after an adequate trial of other treatment options has proven ineffective and/or when the condition is considered to be potentially life-threatening, in individuals with:
catatonia
a prolonged or severe manic episode
severe depression that is life-threatening
107
Tx of Acute ischaemic stroke
- Immediate aspirin (if not giving alteplase)
- <4.5hrs = alteplase thrombolysis + thrombectomy <6hrs. + Aspirin 24 hrs after alteplase.
- <24 hrs = thrombectomy if confirmed occlusion of the proximal anterior circulation + potential to salvage brain tissue
108
What anti emetic also has EPSE side effects
Metoclopramide (is a dopamine blocker - like antipsychotics)
109
Gold standard diagnosis of APH/placenta praevia
- In suspected placenta praevia, digital vaginal examination should not be performed before an ultrasound as it may provoke a severe haemorrhage
- tvus is gold standard
110
DDx px's of dementia
- Alzheimer’s: 60+. Impairment in memory, intellect, speech and orientation.
-Vascular dementia: progresses in a stepwise fashion. Succeeding cerebrovascular infarcts. HTN, smoking, Diabetes, obesity. Classically presents cognitive impairment (acutely or subacutely) following the event. Mood disturbances.
- Lewy body dementia mostly affects those over the age of 50. It affects slightly more men than women. It is rapidly progressive but FLUCTUATES. Lewy body dementia often involves visual hallucinations and Parkinson-like symptoms. Problems multitasking and performing complex cognitive actions are commonly the primary issue (rather than memory).
- Frontotemporal dementia is less common, but responsible for a significant number of diagnoses of dementia in under 65s. Change in behaviour, altered emotional responsiveness, apathy, disinhibition, impulsivity. Cognitive impairment, apahsia.
111
What is Meckel's diverticulum
Meckel's diverticulum is a congenital disorder causing malformation in the small intestine. There is an out-pouching from the small intestine, formed by the remnant of the umbilical cord.
- Often this disorder is asymptomatic
- PAINLESS MASSIVE GI BLEEDING requiring transfusion in UNDER 2 YEAR OLDS, - presenting with bright red rectal bleeding, constipation, nausea and vomiting
- Dx: if the child is haemodynamically stable = Meckel technetium scan
112
SSRI discontinuation syndrome + how to prevent
Sx of SSRI discontinuation syndrome - FINISH:
Flu-like sx (headache, myalgia, lethargy)
IMBALANCE (vertigo, lightheadedness)
Nausea (vomiting, diarrhoea)
Insomnia
SENSORY DISTURBANCE (electric shocks, paraesthesia, numbness)
Hyperarousal (agitation, tremor).
If a patient makes a good response to antidepressant therapy they should continue on treatment for at least 6 months after remission as this reduces the risk of relapse.
When stopping a SSRI the dose should be gradually reduced over a 4 week period (this is not necessary with fluoxetine). Paroxetine has a higher incidence of discontinuation symptoms.
113
What is retinoblastoma
- Age ~18months
- Genetic - autosomal dominant
- Sx: Absence of red-reflex, replaced by a white pupil (leukococria). Strabismus. Visual problems.
- Mx: enucleation, external beam radiation
114
What medication is most closely associated with cleft lip palate during pregnancy
Maternal Antiepileptics (partic. phenytoin) during pregnancy,
115
Features of bulimia
- recurrent episodes of binge eating + sense of a lack of control over eating during the episode
- compensatory behaviour such as self-induced vomiting, misuse of laxatives, fasting, or excessive exercise
- signs: erosion of teeth, Russells sign (calluses on knuckles)
116
Alcohol, Opioid and smoking dependence tx
Alcohol
- Chlordiazepoxide (benzo): alcohol detoxification
- Disulfiram/antabuse: deterrant to prevent alcohol relapse
- Acamprosate/Campral; anti craving
Opioids
- naloxone: reverse an overdose
- methadone: opiate replacement therapy, for those dependent
- naltrexone: relapse prevention/maintenance. Not first line.
- Buprenorphone: alternative to methadone (less sedating)
Smoking
- stop smoking cigs - NRT, reduce - craving - varenicline (champix)
117
Epilepsy DVLA rules
Gp1 (cars/motorcycle):
1st -> no driving 6mth, reapply
Established epilepsy -> no driving 1 yr, reapply
no LOC/nocturnal seizures -> ask DVLA
Gp2 (heavy goods)
1st -> no driving 5 years
>1 yr -> no driving 10 years
118
Sx of Cerebellar syndrome, Ix and Mx
Dysdiadochokinesis, Ataxia, Nystagmus, Intention tremor, Scanning speech, Hypotonia/hyporeflexia
Ix: MRI
Mx: underlying cause
119
What does a bishops score indicate and what are the methods for induction of labour
- < 5 = labour unlikely to start without induction
- ≥ 8 = cervix is ripe, or 'favourable' + high chance of spontaneous labour, or response to interventions made to induce labour
Methods:
1. membrane sweep
2. vaginal prostaglandin E2
3. maternal oxytocin infusion
4. amniotomy/ARM
(amniotomy + oxytocin should not be used as primary method of IOL, unless specific reason not to use PE2 such as uterine hyperstimulation
120
What is the main complication of IOL + what is Mx
Uterine hyperstimulation =
refers to prolonged and frequent uterine contractions - sometimes called tachysystole
- intermittent interruption of blood flow to the intervillous space over time may result in fetal hypoxemia and acidemia
uterine rupture (rare)
- Mx: removing the vaginal prostaglandins if possible and stopping the oxytocin infusion if one has been started.
tocolysis with terbutaline.
121
Drugs that increase risk of postural hypotension and Dx:
- Nitrates
- Diuretics
- Anticholinergic medications
- Antidepressants
- Beta-blockers
- L-Dopa
- Angiotensin-converting enzyme inhibitors - (ACE) inhibitors
- Lying-standing BP test: A drop of more than 20 mmHg in the systolic or a drop of more than 10 mmHg in the diastolic.
122
Caput Succedaneum vs Cephalohaematoma
Caput Succedaneum: Crosses Sutures, takes days to resolve (Caput SucceDAYneum)
Cephalohaematoma: Several hours after birth, doesn't cross suture lines, can take months to resolve (CephalohaematoMONTH)
123
Causes of anaemia in infancy
1. physiological anaemia of infancy - high levels at birth cause -ve feedback and a normal dip at 6-9 weeks of age
2. anaemia of prematurity
3. Haemolytic disease of newborn - incompatibility between rhesus antigens or ABO (direct coombs test)
4. Twin-twin transfusion
5. Hereditary spherocytosis
6. G6PD deficiency
124
Causes of microcytic anaemia
Thalassaemia
Anaemia of chronic disease
Iron def
Lead poisoning
Sideroblastic
125
Signs of iron def. anaemia
- Koilonychia (spoon shaped nails)
- Angular chelitis
- Atrophic glossitis (smooth tongue - atrophy of papillae)
- Brittle hair and nails
- Pica (dietary cravings for abnormal things)
126
Signs/symptoms + Dx of Thalassaemia
- Microcytic anaemia
- Fatigue, pallor, jaundice, gallstones
1. Splenomegaly -> RBC's more fragile
2. Susceptibility to fractures
3. Pronounced forehead and malar eminences (cheek bones)
- Dx: FBC, Haemoglobin electrophoresis
127
Mx of Alpha thalassaemia
- blood transfusions
- splenectomy
- bone marrow transplant can be curative
128
Mx of Beta thalassaemia
- minor: carriers of abnormal beta globin gene. 1 normal and 1 abnormal. -> mild microcytic anaemia only requires monitoring
- Intermidea: 2 abnormal copies (2 defective/1 defective and one deletion) -> more significant requires occasional blood trasnfusions
- Major: significant abnormalities in both beta globin genes. -> regular transfusions, iron chelation and splenectomy. Bone marrow transplant is curative.
129
Presentation of sickle cell anaemia crisis'
- autosomal recessive -> sickle shaped rbc's = haemolytic anaemia.
- Vaso-occlusive crisis -> distal ischaemia - pain, priapism (painful+persistent erection) = urological emergency
- Splenic sequestration crisis -> enlarged and painful spleen. Severe anaemia + shock.
- Aplastic crisis -> loss of the creation of new blood cells. This is most commonly triggered by infection with parvovirus B19. Significant anaemia. Mx: +/- transfusions
- ACS -> dx: fever/resp sx with new infiltrates seen on CXR. Can be due to infection or non-infective (vaso-oclusion).
- Pulmonary HTN
- CKD
130
Mx of sickle cell
- Abx prophylaxis - penicillin 5
- hydroxycarbamide - stimulate HbF production
- blood transfusion for severe anaemia
- bone marrow transplant can be curative
131
Causes of vaginal vault prolapse vs rectocele vs cystocele
+ Px
- Vaginal vault prolapse = after a hysterectomy (+ get antero-posterior repair) the vaginal vault (top of vagina) can descend into vagina
- Rectoceles = caused by a defect in the posterior vaginal wall, allowing the rectum to prolapse forwards into the vagina. Rectoceles are particularly associated with constipation - due to faecal loading into rectocele.
- Cystocele = Cystoceles are caused by a defect in the anterior vaginal wall, allowing the bladder to prolapse backwards into the vagina.
Px:
A feeling of “something coming down” in the vagina
A dragging or heavy sensation in the pelvis
Urinary symptoms, such as incontinence, urgency, frequency, weak stream and retention
Bowel symptoms, such as constipation, incontinence and urgency
Sexual dysfunction, such as pain, altered sensation and reduced enjoyment
132
Varicocele vs Hydrocele
Varicocele
A varicocele is an abnormal enlargement of the testicular veins.
Px: usually asymptomatic, bag of worms, subfertility
Dx: ultrasound with Doppler studies
Mx: usually conservative, surgery if pain
Hydrocele
A hydrocele describes the accumulation of fluid within the tunica vaginalis.
Px: soft, non-tender swelling of the hemi-scrotum. Usually anterior to and below the testicle. transilluminates with a pen torch
Mx: infantile hydroceles are generally repaired if they do not resolve spontaneously by the age of 1-2 years.
in adults a conservative approach may be taken depending on the severity of the presentation. Further investigation (e.g. ultrasound) is usually warranted however to exclude any underlying cause such as a tumour
133
Ex. of tocolytics
Betamimetics (such as terbutaline)
Magnesium sulfate.
Prostaglandin inhibitors (like indomethacin, ketorolac)
Calcium channel blockers (such as nifedipine)
Nitrates (like nitroglycerine)
Oxytocin receptor blockers (such as atosiban)
