Notes from MCQs Flashcards
Area of the heart supplied by leads V1-2? V3-4? V5-6? V1-6? Leads II, III and aVF?
Anterior
Septal
Lateral
Anterolateral
Inferior
Artery supplying anterior area of the heart (leads V1-2)? Septal area (leads V3-4)? Lateral area (leads V5-6)? Anterolateral area (V1-6)? Inferior area (leads II,III and aVF)?
LCA: diagonal LAD branch
LCA: septal LAD branch
LCA: left circumflex artery
LCA: left main stem disease
RCA: posterior descending branch
Signs of LVF? RVF? AF usually sign of what valvular dysfunction?
Pulmonary oedema(bibasal crepitations, pleural effusions on CXR, upper lobe blood diversion, Kerley B lines
Raised JVP, bilateral pedal oedema
Mitral stenosis- enlarged atrium disrupts the normal electrical pathways
Murmur loudest on inspiration points to what? Signs associated with aortic regurgitation? Narrow pulse pressure signifies what?
Right-sided valve lesion
Corrigan’s (visibly exaggerated pulsating carotids,) de Mussets, Traubes, Quinkes, Duroziez
Aortic stenosis
Management for CHAD2 score of 0? 1? 2 or above?
Aspirin
Warfarin or aspirin
Warfarin unless CI
Signs of myocardial ischaemia on ECG? Infarction? What is an aborted MI?
Inverted T waves and ST depression
ST elevation, Q waves and raised troponin
A patient with STEMI who goes on to have negative troponin
Signs of a PE? Scoring system for predicting the risk of a PE? Mild, moderate and high scores? RFs?
Pleural rub, coarse crackles and AF
Massive= raised JVP, RR, HR and hypotension
Geneva: <=3, 4-10 and >11
>65 y/o, previous DVT/PE, surgery/ fracture<=4 weeks, malignancy, unilateral leg pain, unilateral oedema, haemoptysis, HR 75-94, HR>95
What is heard with Barlow syndrome(mitral valve prolapse)? Austin flint murmur? Graham Steell murmur?
Mid-systolic click followed by a late systolic murmur heard at the apex as the thickened mitral valve leaflet is displaced into the left atrium during systole
What is a pleural rub common in?
Pleurisy, PE and pneumonia
What can PSA levels be raised by in men? What is raised in testicular cancer? What are they raised by?
Prostate cancer, BPH, older age, UTIs and prostatitis
AFP and B-hCG- yolk sac elements/ seminomas
What is raised in colorectal cancers? What can CA-125 be raised by? What is raised in bladder cancer?
CEA
Ovarian cancer, endometriosis, liver disease, PID and fibroids
Fibrin
Gold standard Ix for diagnosing bladder cancer?
Cystoscopy
Serum creatinine and urine output criteria for stage 1 AKI? Stage 2? Stage 3?
Increased level >/=0.3 mg/dl or 150-200% increase from baseline + production <0.5ml/kg/hr for >6 hours
Increased creatinine>200-300% + production <0.5ml/kg/hour for >12 hours
Increased creatinine from baseline or >/=4mg/ dl(acute increase of >/=0.5mg/dl) + urine<0.3ml/kg/hour x 24 hours or anuria in 12 hours
Persistent ARF= complete loss of RF>4 weeks
ESKD>3 months
Topical Abx used to treat otitis externa? Plus what if really inflamed/ stenosed/ obscured by debris/ fever/ lymphadenopathy?
Ciprofloxacin or gentamicin
Steroids
Tx for otitis media?
Analgesia, amoxicillin after 2-3 days if no sx improvement/ perforation/ systemically unwell
Myringotomy and drainage if no improvement after 1-2 weeks
Tx for mastoiditis?
Broad-spec IV ABx, not getting better/ intracerebral spread–> mastoidectomy and grommets, COMPS= VI/ VII palsy, abscess
Type of nystagmus seen on Dix-Hallpike test for BBPV?
Rotary nystagmus
Large volumes of 0.9% saline lead to an increased risk of what? Hartmann’s should not be used in patients with what?
Hyperchloraemic metabolic acidosis
Hyperkalaemia- contains potassium
O2 is only indicated for MI if SATs are below what %? What drugs should be indicated following an MI?
94%
ACEi/ ARB, dual antiplatelet therapy- clopidogrel and aspirin, Beta blocker, statin- CCBs only if Beta blockers are CI
What things may show ST elevation on an ECG?
Prinzmetal angina, STEMI and pericarditis
What 2 things are used during an episode of bradycardia to speed the heart up?
Atropine and adrenaline
2 most common heart murmurs? 2 less common murmurs?
Aortic stenosis–> ejection-systolic murmur and mitral regurg–> pan-systolic murmur
Aortic regurg–> early diastolic murmur, mitral stenosis–> mid-diastolic murmur
Resus council’s algorithm for anaphylaxis?
1) ABCDE 2) Check for obvious potential diagnosis 3) Call for help 4) Adrenaline (500mcg of 1:1000 IM) 5) Establish airway/ high flow O2/ IV fluid challenge/ chlorphenamine(antihistamine takes 15-20 minutes to work)/ hydrocortisone
What is terbutaline sulfate? What is formoterol fumarate?
A selective Beta2-adrenergic agonist
Long-acting β2 agonist (LABA)
What is a common cause of HAP?
Pseudomonas aeruginosa
Who are most likely to suffer from a spontaneous PE? What also increases the risk?
Young males with a low BMI, Marfan’s syndrome
Where is the most appropriate site for a needle thoracostomy for tension pneumothorax?
Over the upper edge of the rib in the 5th IC space on the MC line on the same side as the pneumothorax
Which signs would support a diagnosis of tension pneumothorax?
Tracheal deviation away from the affected lung, hypotension and hypoxia
How does large SBO present compared to LBO?
Constipation before vomiting due to being more distal in the tract
SBO= shorter hx of constipation and vomiting before the constipation
What is Mirrizi’s syndrome? Sx?
Common hepatic duct obstruction caused by extrinsic compression from an impacted stone in the cystic duct or infundibulum of the gallbladder
Jaundice, fever, and right upper quadrant pain
What is UC associated with?
PSC- >75% patients with PSC have UC
Most common antibiotics causing c.diff infections?
Clindamycin, cephalosporins, quinolones, co-amoxiclav and aminopenicillins
Which drugs are known to cause drug-induced hepatitis?
NSAIDs, paracetamol, statins, methotrexate, antibiotics
Mnemonic for APL syndrome? 3 main associated antibodies? Primary thromboprophylaxis? Secondary thromboprophylaxis?
CLOT: coagulopathy, livedo reticularis, obstetric emergencies, thrombocytopenia
Anticoagulant, anti-cardiolipin, anti beta2-GP1
How do complex partial seizures compare to simple partial seizures?
Complex= awareness affected and confused after, simple= don’t affect awareness and there are no post-ictal symptoms
What is complicated malaria characterised by?
Vascular occlusion which can affect different organs therefore causing specific sx e.g. cerebral malaria= micro-infarcts and sx= drowsiness, increased intracerebral pressure causing seizures and coma
What is imatinib? What is rituximab given in? What is dexamethasone used in treating?
A tyrosine kinase inhibitor given in CML alongside chemo
CLL
Multiple myeloma
Which condition elevates bilirubin levels?
TTP- deficiency in ADAMTS13 enzyme causes the vWF to form thromboses, the body breaks down these clots down to prevent ischaemic damage to organs–> haemolytic anaemia
When should systemic treatment with oral antibacterials be used? What about topical/ oral erythromycin or clindamycin? What about systemic antibacterial (e.g. oral tetracycline)? Oral retinoid?
Moderate- severe acne or when topical preparations are not tolerated/ ineffective
If non-antibiotic antimicrobials e.g. benzoyl peroxide/ azelaic acid aren’t effective
Inflammatory acne if topical tx is ineffective/ CI
For systemic tx of severe acne(TERATOGENIC)
Flow of psoriasis tx?
Emollient–> topical steroid (e.g. hydrocortisone) and a vitamin D analogue (e.g. calcitriol)–> derm referral for phototherapy or oral drugs (e.g. methotrexate, cyclosporin)–> biological immunotherapy- NOT NSAIDs
Most common cause of cellulitis (2/3 cases)?
S.pyogenes, 2nd= s.aureus
1st and 2nd line treatment for eczema?
Topical corticosteroids, 2nd= topical calcineurin inhibitor
What can raised RBCs? What can cause neutrophilia?
Smoking, drinking alcohol or conditions such as PV
Chemo comp, viral infection e.g. Hep B/C, HIV, meds e.g. antipsychotics, carbimazole, AI disorders
When is the 6-in-1 vaccine given? What is in the 6-in-1 vaccine? MMR vaccine?
8 weeks, 12 weeks and 16 weeks in the thigh(8w= DTaP/ IPV/ Hib/ Hep B/ Men B, Rotavirus, 12w= DTaP/ IPV/ Hib/ Hep B, PCV, Rotavirus, 16w= DTaP, IPV, Hib, Hep B, Men B)
1 and 3 y/o
When is the Men B booster given? When is the 4th dose of DTap/ IPV given? When is 4th dose of Hib and Men C also given? PCV booster?
1 y/o
3 y/o
1 y/o
1 y/o
When is the HPV vaccine given? Tetanus/ diphtheria/ polio, Men ACWY? When is the influenza vaccine given?
12-13 y/o, 14 y/o
Children of primary school age and those in year 7, also from 6m to those at high risk
What is congenital adrenal hyperplasia?
An autosomal recessive disorder where there is reduced production of cortisol and aldosterone, adrenal crisis–> metabolic acidosis/ hyperkalaemia and hyponatraemia
What is the first component of the extrinsic pathway of the coagulation cascade? How can the severity of haemophilia A be assessed?
By looking at % factor VIII functionality and severity of bleeding
Who is Non-Hodgkin lymphoma more common in? What about Hodgkin lymphoma?
Childhood, adolescence
Examples of B symptoms?
Unexplained fever, unexplained weight loss, drenching sweats (particularly at night)- can be seen in HIV too
1st line tx for acute manic/ mixed episode in bipolar affective disorder? For a depressive episode? Long-term maintenance? What can be added if this doesn’t work?
Atypical antipsychotic
Atypical antipsychotic + SSRI i.e. olanzapine and fluoxetine
Lithium
Valproate
What is midazolam and what could it be prescribed in? Once alcohol detoxification is established, what should be started? When should be started to prevent relapse?
Rapid-acting benzo- status epilepticus or as an adjunct in a confused and agitated psych patient
Acamprosate and disulfiram- 6-12 months
Tx for delirium tremens?
IV Pabrinex (Vitamin B1) and high dose Benzo
1st rank sx of schizophrenia?
3rd person auditory hallucinations and/ or thought echo, passivity phenomenon(believing thoughts/ actions are being controlled by external force,) thought alienation, encompassing withdrawal, broadcast or insertion and delusional perception
Results you’d expect in neuroleptic malignant syndrome?
Raised CK due to muscle rigidity, raised WCC, deranged LFTs, acute renal failure–> abnormal U&Es, metabolic acidosis–> low pH, low HCO3
Tx for mild PID?
Start ABx immediately before swab rsults
Prescribe doxycycline, metronidazole + IM ceftriaxone
Leave in recently inserted coil
No response in 48 hours, remove the coil and prescribe any other necessary emergency contraceptives
Risk of nitrofurantoin in the 3rd trimester? Sulfonamides? Tetracyclines in general? Trimethoprim in the 1st trimester?
Haemolytic anaemia in neonate with G6PD deficiency
Kernicterus
Permanent staining of the baby’s teeth, issues with skeletal development
Neural tube defects
1st line tx for stress incontinence? If this doesn’t work?
3 months of pelvic floor training
Duloxetine/ surgery
If after 48 hours you see Beta hCG doubling what is it? If this is seen, what is done in 1-2 weeks to confirm? Rising but not doubling? Falls by half or more?
Intrauterine pregnancy- USS scan
Ectopic- needs further monitoring
Miscarriage
Clinical sx of chorioamnionitis?
Fetal tachycardia, maternal tachycardia, maternal pyrexia, rising leucocyte count, rising CRP, irritable or increased tender uterus
What does the Wolffian duct develop into? Testes develop due to the influence of what gene on the Y chromosome?
Rete testis, the ejaculatory ducts, the epididymis, the ductus deferens and the seminal vesicles
SRY gene- doesn’t require the presence of androgen nor a functional androgen receptor–> testicular development
What are the genetics and phenotype in androgen sensitivity syndrome?
Male/ female
What sx do you get with secondary syphilis? How soon after infection?
Widespread rash, neurological sx and GN
6-8 weeks
To diagnose syphilis, non-specific enzymes are looked using what? React how for a +ve result? What tests look for IgG which remains after tx to confer immunity? Features of congenital syphilis?
Cardiolipin based tests(e.g. VDRL)
With cardiolipin to be positive–> negative after tx
Specific treponemal antibody tests
Generalised lymphadenopathy, hepatosplenomegaly, rash, skeletal malformations
Comps of chlamydia in pregnancy? Neonatal meningoencephalitis can be caused by what?
Chorioamnionitis, neonatal conjunctivitis, neonatal pneumonia, prelabour rupture of membranes
Group B strep
Common sx of NEAs?
Arms flexing and extending, pelvic thrusting, eyes are usually closed, prolonged often>30 minutes, sx wax and wane
Why is there a weak left-sided pulse in aortic dissection?
Due to involvement of the subclavian artery
Signs of PE on a CXR? ECG features?
Fleischner sign= dilated pulmonary vessel, Westermark sign= collapse of vasculature distal to PE, Hampton’s hump= wedge-shaped infarct
Sinus tachycardia and/ or ST depression
When is colchicine given in pericarditis?
Recurrent/ continued sx beyond 14 days
How can post- ACS meds be remembered?
Block An ACS: Beta blocker, ACE-i, aspirin, clopidogrel, statin
Presentation of a Wilm’s tumour?
Between the age of 5-10 y/o, abdominal mass and painless haematuria
What is used to reverse the sedative effects of benzos?
Flumazenil
What heart abnormality is lithium associated with? Sx and tx of lithium toxicity?
Ebstein’s anomaly- enlarged atrium, shrunken right ventricle + pansystolic murmur caused by defective tricuspid valve
Fine tremor, dry mouth, GI dis, increased thirst and urination, drowsy, thyroid dys
12 hours or more- coarse tremor, CNS dis, arrhythmias, visual disturbance
Serious tox= >2mmol/ litre
Ix= serum lithium, electrolyte levels, TFTs, U&Es, ECG
Elec balance, U&Es, seizure control, IV fluid therapy and urine alk, benzos- agitation and seizures, haemodialysis if poor renal function/ haemodialysis, cons gastric lavage/ whole-bowel irrigation
How does placental abruption present compared to placenta praevia, uterine rupture and vasa praevia?
Abdominal pain with mild vaginal bleeding- can get concealed abruption with maternal distress and haemorrhage much greater than vaginal loss
You would only test for FSH, LH and serum karyotype if there was what? Testicular biopsy?
Azoospermia (no sperm present)
Suspect arrested spermatogenesis= less common than abnormal semen
How does a missed miscarriage present? Cervix open or closed? USS findings?
Variable presentation from no sx–> light vaginal bleeding, pregnancy sx may decrease
Closed
Non- viable fetus
How does a inevitable miscarriage present? Cervix open or closed? USS findings?
Vaginal bleeding, uterine cramps, possible intrauterine fetus w/ HB
Open
Fetus with possible HB
How does a incomplete miscarriage present? Cervix open or closed? USS findings?
Vaginal bleeding with passage of large clots/ tissue, uterine cramps, products of conception often visualised in dilated cervical os
Open
Products of conception often in cervix
How does a threatened miscarriage present? Cervix open or closed? USS findings?
Variable amount of vaginal bleeding, pregnancy can proceed to viable birth
Closed
Viable pregnancy
How does a septic miscarriage present? Cervix open or closed? USS findings?
Fever, malaise, signs of sepsis, foul-smelling vaginal discharge, cervical motion + uterine tenderness, rarely after spontaneous abortion, usually with induced abortions can be life-threatening
Usually retained products of conception
1st line tx of Alzheimer’s and Lew body dementia?
Donepezil, rivastigmine
For most paediatric cases, what bolus is given in shock? In DKA + HF due to fluid comps e.g. cerebral oedema? Estimated weight? For non-shocked patients with DKA calculation for hourly rate? If they were in DKA and shocked, then you would not do what? Assume what fluid deficit in mild DKA? Moderate? Severe?
20ml/kg, 10ml/ kg 0.9% saline over 15 minutes/ 60 minutes
(Age+4) x2
((Deficit- initial bolus)/ 48 hours) + maintenance per hour
Minus the initial bolus
5%, 7%, 10%
Fluid choice? Holliday- Segar formula for maintenance fluids? Neonates?
0.9% NaCl with 20mmol KCl in 500ml (40mmol per litre) until blood glucose levels are less than 14 mmol/l
1st 10kg= 100ml/ kg/ day, next 10kg= 50ml/kg/day, >20kg= 20ml/kg/day
Birth to day 1: 50-60 ml/kg/day
Day 2: 70-80 mL/kg/day
Day 3: 80-100 mL/kg/day
Day 4: 100-120 mL/kg/day
Days 5-28: 120-150 mL/kg/day
High prolactin prevents the release of which hormone? This decreases the release of what hormones?
GnRH
FSH + LH
Bi temporal inferior quadrantanopia is caused by what? Classically associated with what? Most common presentation?
Lesion of the optic chiasm
Craniopharyngioma
Amenorrhoea
What is homonymous hemianopia with macular sparing seen in? Why does macular sparing occur?
Posterior circulation stroke affecting the contralateral occipital lobe
Collateral flow from the MCA
What is homonymous inferior quadrantanopia caused by?
A lesion in the parietal lobe affecting the upper division of the optic radiations- parietal stroke/ tumour(same quadrant in each eye)
What causes homonymous superior quadrantanopia?
Temporal lobe lesion affecting the lower division of the optic radiations (Meyer’s loop)- stroke/ tumour
What anti-anginal medication do patients commonly develop tolerance to?
Standard release isosorbide mononitrate
What are the two shockable rhythms? Tx how? What for non-shockable rhythms? What is given to those who are in VF/ pulseless VT after 3 shocks?
VF and pulseless VT- with unsynchronised defibrillation at 120-200 J immediately, single shock followed by 2 minutes of CPR
Adrenaline 1mg ASAP- once chest compressions have restarted after the 3rd shock during a VF/VT cardiac arrest
Amiodarone 300mg, further 150mg after 5 shocks administered
Following successful resus, oxygen should be titrated to achieve sats of what? Reversible causes of cardiac arrest (the Hs and Ts)?
94-98%
Hypoxia, hypovolaemia, hyperkalaemia, hypokalaemia, hypoglycaemia, hypocalcaemia, acidaemia, hypothermia
Thrombosis, tension pneumothorax, tamponade- cardiac, toxins
What is trifascicular block also known as? It means there are signal problems with what? What about a bifascicular block? What are they characterised by?
Complete heart block- with the right bundle branch and both left fascicles making up the left bundle branch
The right bundle branch and one of the two left fascicles
RBBB with left axis deviation, features of bifascicular + a 1st-degree heart block- PR interval prolongation
Causes of RBBB?
Normal variant- more common with increasing age, RVH, chronically increased right ventricular pressure e.g. cor pulmonale, PE, MI, atrial septal defect, cardiomyopathy or myocarditis
Way of remembering LBBB and RBBB?
WiLLiaM MaRRoW–> RBBB= ‘M’ in V1 + ‘W’ in V6 and vice versa for LBBB
When is ivabradine as a third-line option for HF tx? 1st + 2nd line txs?
When EF<35%
ACE-i= ramipril, Beta-blocker= bisoprolol, aldosterone antagonist= spironolactone
ACE-i and Beta-blockers have no effect on mortality in HF with what? ACE-i and beta blockers cause what?
Preserved ejection fraction
Hyperkalaemia- K+ should be monitored
When is digoxin strongly indicated in HF?
If there is co-existent AF
What is S1 heart sound caused by? S2? S3? S4?
Closure of mitral and tricuspid valves, soft if long PR/ mitral regurg, loud in mitral stenosis
Closure of aortic and pulm valves, soft in aortic stenosis, splitting during inspiration is normal
Diastolic filling of the ventricle- normal if <30 y/o, may persist in women up to 50 y/o, in LVF e.g. dilated cardiomyopathy, constrictive pericarditis + mitral regurg
Aortic stenosis, HOCM, HTN, atrial contraction against a stiff ventricle- P wave on ECG
Tx for symptomatic bradycardia?
Atropine infusion 500mcg IV - up to max 3mg, transcutaneous pacing, isoprenaline/ adrenaline infusion titrated to response
Specialist help for transvenous pacing if no response
Sx of labyrinthitis?
Hearing loss, vertigo, may experience tinnitus
Peripheral causes of vertigo? Central causes? 3 components of the HINTS test? CIs for head-impulse test?
BPPV, vestibular neuronitis, Meniere’s disease
Stroke, MS, medication toxicity, trauma, posterior fossa tumours, migraine(more in elderly)
Head impulse test, evaluation of nystagmus, test of skew
Head & neck trauma, severe cervical spine osteoarthritis
Positive head impulse test means what? Unilateral nystagmus? Changes direction or is vertical? Bidirectional nystagmus?
Issue with vestibulocochlear nerve on ipsilateral side
Peripheral origin/ central pathologies
Stroke- movement beats in direction looking, then changes direction with gaze
How to perform skew test? Associated with what and specific for what?
Look at your nose, cover one of their eyes, then move hand to cover other eye- look for movement in uncovered eye, repeat on other eye
Vertical diplopia- central cause of vertigo
Genes ass w/ Parkinson’s? Alzheimer’s? MND? Drugs to help?
SNCA, Parkin
Apolipoprotein E4 variant
TARDBP, FUS
Cholinesterase inhibitors e.g. donepezil, galantamine
NMDA receptor partial antagonists e.g. memantine
CIs for thrombolysis?
Seizure at onset of stroke, sx suggestive of SAH, LP in previous week, previous IC haemorrhage, major surgery or serious trauma within 2 weeks
Possible positive antibodies in MG? Tests?
Anti-MuSK, anti-LRP4
Tensilon test, ice test, repetitive nerve stimulation, mediastinal imaging
1st, 2nd and 3rd generation cephalosporin examples?
Cefazolin and cephalexin
Cefuroxime and cefoxitin
Ceftriaxone and ceftazidime
Abnormal gene and translocation of Philadelphia chromosome?
t(9:22)
BCR/ ABL
Medical & surgical tx for Cushing’s?
Metyrapone, others= Ketonazole, Mifepristone and Pasireotide, steroid replacement post-operatively
Pituitary surgery or radiotherapy
Glasgow score of what indicates transfer to ITU/ HDU for intensive monitoring and aggressive fluid resus? Based on degree of what potential complications? PANCREAS mnemonic?
Necrosis of surrounding tissues & saponification, reduced hormone output & ARDS
PaO2<8kPa, age> 55 y/o, neutrophils WBC>15 x 109/L, calcium<2mmol/L, urea>16 mmol, AST/ALT>200iu/L or LDH>600 IU/L, albumin<32g/L, glucose>10mmol/L
Tx for acute pancreatitis? Chronic?
Fluid resus urine output>30ml/hour, catheterisation, analgesia, anti-emetics, IV ABx for necrotising pancreatitis, calcium if hypocalcaemia, insulin in hyperglycaemia
Ethanol abstinence & good diet, analgesia, insulin, enzyme replacement, coeliac plexus block/ pancreatectomy
Ix for acute vs chronic pancreatitis? Other causes raised amylase?
Bloods FBC, U&Es, LFTs, lipase> amylase(amylase x3 upper limit suggestive,) USS, MRCP, ERCP, CT at later for comps
AXR, CT- both calcification, faecal elastase and fasting glucose/ OGTT test
Duodenal ulcer, cholecystitis, mesenteric infarction
FATSHEEP drug cases of pancreatitis?
Furosemide, azathioprine/ asparaginase, thiazides/ tetracyclines, statins/ sulfonamides/ sodium valproate/ hydrochlorothiazide, estrogens, ethanol, protease inhibitors & NRTIs
Tx of grade 1, 2, 3 and 4 haemorrhoids?
(No prolapse)- conservatively +/- topical corticosteroids
(Prolapse on straining which spontaneously reduces)- rubber band ligation, sclerotherapy or infrared photocoagulation
(Prolapse and requires manual reduction)- rubber band ligation
(Prolapse and can’t be manually reduced)- not responding to less invasive= surgical haemorrhoidectomy, diet rich in fibre and fluids
4x tx for hyperkalaemia?
Insulin 15 units + dextrose 50% 50mls, 10% calcium gluconate, calcium resonium, salbutamol nebs
SEs of alpha-1 blockers? 5 alpha reductase inhibitors?
Hypotension, retrograde ejaculation
Diminished libido, ED
Tx for non-muscle and muscle invasive bladder cancer?
TURBT, chemo, BCG immunotherapy
(T2+)- cystectomy with urinary diversion(w/o co-morbidities + no mets) + urinary diversion after removal- ileal conduit, neo-bladder, mitrofanoff
Non-surgical= radiotherapy or chemo
GnRH analogues and androgen antagonists for prostate cancer? GnRH antagonists?
Goserelin, Leuprolide
Bicalutamide and enzalutamide
Degarelix
Classification system of open fractures?
Gustilo and Anderson
Lymph nodes enlarged in tonsillitis?
Jugulodigastric lymph nodes
Branches of facial nerve?
Zygomatic, temporal, buccal, marginal mandibular, cervical branch
Stages of wound healing?
Haemostasis, inflammation, proliferation, remodelling
Grades 1, 2, 3 and 4 of hypertensive retinopathy?
Vascular attenuation, 2= above and AV nipping, 3= above and retinal haemorrhages, hard exudates and cotton wool spots
4= above and optic nerve oedema
RFs for miscarriage? Ectopic pregnancy? HG?
Foetal= genetics, placental failure
Maternal= uterine abnormality, PCOS, poorly controlled diabetes/ thyroid disease
PID, genital infection, IUD/ IUS, assisted reproduction, previous ectopic, old age, smoking
More severe in molar pregnancies and multiple pregnancies, 1st pregnancy, overweight and obese, urinary infection
RFs for molar pregnancy? VTE?
Maternal age>20 or >35 y/o, previous gestational trophoblastic disease/ miscarriage, use of COCP
Pre-existing= thrombophilia, co-morbidities, age>35, BMI> 30, parity>3, smoking/ obstetric= multiple pregnancy, pre-eclampsia, C-section, prolonged labour, stillbirth
Transient= any surgical procedure of puerperium, dehydration
RFs for GD? Pre-eclampsia? Abruption? Praevia/ accreta/ increta? Vasa praevia?
Previous GD, macrosomic>4kg, BMI>30, previous stillbirth/ perinatal death
Moderate= nulliparity, maternal age>40, maternal BMI>35, family hx, multiple pregnancy
High= chronic HTN, pre-eclampsia/ eclampsia in previous pregnancy, diabetes, SLE/ APS
Previous abruption, pre-eclampsia/HTN, bleeding early on, IUGR, increased maternal age, smoking
APH, emergency C-section, emergency hysterectomy, maternal anaemia, preterm birth, stillbirth
Accreta= previous curettage procedures, previous C-section, multigravida, increased maternal age, low-lying placenta/ praevia
Low-lying placenta, IVF, pregnancy, multiple pregnancy
RFs for APH? Shoulder dystocia? Cord prolapse?
Praevia, abruption, vasa praevia, uterine rupture, pre-eclampsia, smoking, IUGR
Large foetus, previous dystocia, high maternal BMI/ oxytocin, prolonged 1st & 2nd stage of labour
Polyhydramnios, abnormal lie, breech, ARM
5 components of the Bishop score? Apgar score?
Cervical dilatation, position, effacement and consistency of cervix, station of foetal head
Appearance, pulse, grimace, activity, respiration
4 or more RFs in pregnancy warrant what VTE tx? 3 RFs? If DVT shortly before delivery, continue for how long? Avoid what in pregnancy?
Immediate LMWH until 6 weeks post-natal
LMWH from 28 weeks until 6 weeks postnatal
At least 3 months(same as provoked DVTs)
Where do dermoid cysts typically occur?
Midline of the neck, external angle of the eye and posterior to the pinna of the ear
SEs of lithium? Avoid what when taking lithium? ECG?
LITHIUM: lethargy, insipidus- nephrogenic, fine tremor, hypothyroidism- thyroid enlargement, insides- GI N&V/ diarrhoea, urine- increased, metallic taste
NSAIDs, breastfeeding
T wave flattening/ inversion, idiopathic intracranial hypertension, leucocytosis, hyperparathyroidism and resultant hypercalcaemia
Baseline Ix for antipsychotics? Clozapine monitoring? What can increase levels?
ECG, BP & pulse, BMI, FBC, U&Es, LFTs, HbA1C, lipids, baseline trop for clozapine
Weekly FBC–> fortnightly after 18w
Smoking
If major bleeding on warfarin- tx?
Stop
Give IV vit K 5mg
Prothrombin complex concentrate- not available–> FFP(takes time to defrost)
(On warfarin,) INR>8.0 and minor bleeding?
Stop
IV Vit K 1-3mg
Repeat dose if INR still too high after 24 hours
Restart warfarin when INR<5.0
(On warfarin,) INR>8.0 and no bleeding?
Stop
Oral vit K 1-5mg by mouth, repeat dose if too high after 24 hours
restart when INR<5.0
(On warfarin,) INR 5-8 and minor bleeding?
Stop warfarin
IV Vit K 1-3mg
Restart when INR<5.0
(On warfarin,) INR 5-8 and no bleeding?
Withhold 1 or 2 doses warfarin
Reduce subsequent maintenance dose
Management of diabetic nephropathy?
Dietary protein restriction, tight glycaemic control, BP control<130/80 mmHg, ACE-i or angiotensin-II receptor antagonist- start if urinary ACR of 3mg/ mmol or more (don’t start ACE-i and angiotensin-II receptor antagonist dual therapy,) control dyslipidaemia e.g. statins
When is insertion of a chest drain contraindicated? Complications?
INR>1.3, platelet count<75, pulmonary bullae, pleural adhesions
Failure of insertion, bleeding, infection, penetration of the lung, re-expansion pulmonary oedema
Senior review for meningococcal septicaemia?
Rapidly progressive rash, poor peripheral perfusion, RR<8 or >30/ min or pulse <40 or >140/ min
pH<7.3 or WBC<4x 10^9/L or lactate > 4mmol/ L, GCS<12 or a drop of 2 points
When should LP be delayed in meningococcal septicaemia?
Signs of severe sepsis or rapidly evolving rash
Severe resp/ cardiac compromise
Significant bleeding risk, signs of raised ICP, papilloedema, continuous or uncontrolled seizures, GCS</=12
Who is adenosine contraindicated in?
Asthmatics
How does TGA present? Presentation on CXR, ECG, echo and hyperoxia (nitrogen washout) test?
Low SpO2, loud single S2, murmur only if associated septal defect or patent ductus arteriosus
‘Egg on side appearance’
Normal
Anatomical abnormalities, septal defects and patency of ductus arteriosus
Ix cyanotic heart disease in neonates
Tx TGA?
Prostaglandin infusions to maintain ductal patency
Balloon atrial septostomy
Definitive= arterial switch 1st few weeks life
Reduced or increased reticulocytes in aplastic crises? Sequestration crises? Presentations?
Reduced
Increased
Sudden fall in Hb (infection with parvovirus)
Worsening of anaemia
How many risk factors warrants treatment with LMWH in pregnancy? Until when? What if 3 RFs?
4/ more until 6 weeks post-natal
From 28w–> 6w post-natal
Tx for epistaxis?
If not stopped after 10-15 minutes?
Sit with torso forward and mouth open, pinch cart area–> topical antiseptic, self-care advice and possible admission if co-morbidities
Cautery/ packing- if visible/ not visible
Admit if HD unstable
Failed emergency department–> sphenopalatine ligation
When is HG most common?
Between 8 and 12 weeks- may persist up to 20 weeks
Causes of LBBB?
MI, HTN, aortic stenosis, cardiomyopathy
Cause, sx and tx acute haemolytic reaction? Comps?
Mismatch blood group–> intravascular haemolysis= RBC destruction by IgM-type antibodies
Fever, abdo pain, hypotension
Stop transfusion, check patient ID/ name on blood product, send blood for direct Coombs test, repeat typing and cross-matching, fluid resus
DIC & renal failure
Cause, sx and tx non-haemolytic febrile reaction?
WBC HLA antibodies
Sensitisation by previous pregnancies or transfusions
Slow or stop transfusion, paracetamol, monitor
Cause, sx and tx transfusion associated acute lung injury(TRALI)?
ARDS within 6 hours transfusion
Hypoxia, pulm infiltrates on CXR, fever, hypotension
Stop transfusion
Oxygen, supportive care
Cause, sx and tx transfusion-associated circulatory overload (TACO)?
Excessive rate of transfusion, pre-existing HF
Pulm oedema, HTN
Slow or stop transfusion
Consider IV Loop diuretic and O2
Sx and tx minor allergic reaction–> blood transfusion?
Pruritus, urticaria
Temp stop transfusion, antihistamine, monitor
When is peritoneal lavage indicated? Absolute contraindication?
Blunt abdominal trauma with haemodynamic instability
Stab wound to abdomen penetrating fascia
Multiple trauma with shock of unclear aetiology
Obvious clinical indications for laparotomy
Where to place ECG limb leads? Chest leads?
Ride Your Green Bike- clockwise from right wrist (ulnar styloid process)
V1= 4th IC space at right sternal angle
V2= 4th IC left sternal angle
V3= between V2 and V4
V4= 5th IC space in midclavicular line
V5= same as V4 left anterior axillary line
V6= left mid-axillary line same as V4 and V5
ACPVU?
Alert
Confusion- new or worsening
Voice- responds to verbal stimulus
Pain- responds to pain stimulus
Unresponsive- to verbal or pain stimulus
ACVPU- new onset/ deteriorating confusion is what?
Score on NEWS scale who are CVPU(not fully awake)? Score below 8 GCS?
Red flag- use A-E approach
3- consider calculating GCS
Urgent assessment by anaesthetics
Tx of reactive arthritis?
NSAIDs, severe= oral or intraarticular corticosteroids
Persistent= conventional synthetic DMARDs
Mnemonic for lytic bone lesion?
FEGNOMASHIC- fibrous dysplasia, enchondroma, giant cell tumour, non-ossifying fibroma, osteoblastoma, mets/ myeloma, aneurysmal bone cyst, hyperparathyroidism, infection/ infarction, chondroblastoma
Meds that may worsen osteoporosis?
SSRIs, antiepileptics, PPIs, glitazones, long-term heparin therapy, aromatase inhibitors e.g. anastrozole
Ix for osteoporosis?
Hx & exam, FBC, U&Es, LFTs, bone profile, CRP, TFTs
Ix for osteomalacia? Tx?
Bloods- vitamin D, calcium, phosphate, U&Es, bone biopsy= GOLD standard
Imaging e.g. X-rays for pseudofractures or other bone abnormalities
Replenishing vitamin D, calcium, phosphate, addressing causes of deficiency, regular monitoring
Most common cause of primary hyperaldosteronism? 1st line Ix?
Idiopathic adrenal hyperplasia, adrenal adenoma- Conn’s syndrome
Aldosterone/ renin ratio–> high aldosterone alongside low renin levels
High res CT abdomen and adrenal vein sampling
Sx of myxoedema coma? Tx?
Hypothermia and confusion
IV thyroid replacement, fluids, IV corticosteroids, electrolyte imbalance correction, sometimes rewarming
What is Kallman syndrome caused by? Hormone levels?
Failure of GnRH- secreting neurons to migrate to the hypothalamus
Sex hormones low, LH, FSH low/ normal
General findings in Cushing’s syndrome? Ix?
Hypokalaemic metabolic alkalosis w/ IGT, ectopic ACTH= very low K+
Overnight low-dose dex test, 24hr urinary free cortisol x2
Bedtime salivary cortisol- x2
When are localisation tests for Cushing’s? Other?
9am and midnight plasma ACTH and cortisol levels
ACTH suppressed= adrenal adenoma
CRH stimulation- cortisol rises if pituitary source, ectopic/ adrenal= no change
Petrosal sinus sampling- pituitary vs ectopic ACTH
Insulin stress test true vs pseudo-Cushing’s
Ix in SLE?
Autoantibodies: ANA, anti-dsDNA= highly specific, anti-Sm
FBC- anaemia of chronic disease and reduced platelets and WCCs
Reduced C3 & C4
Urinalysis and urine protein: creatinine ratio= proteinuria in lupus nephritis
Renal biopsy for lupus nephritis
Drugs causing drug-induced lupus? Antibodies?
Sulfadiazine, hydralazine, procainamide, isoniazid, methyldopa, quinidine, minocycline, chlorpromazine
ANA, anti-histone
Comps of Sjogren’s syndrome? Histology from salivary gland biopsy?
Pneumonia
Bronchiectasis
Non-Hodgkins lymphoma
Peripheral neuropathy
Vasculitis
Renal impairment
Focal lymphocytic infiltration
Meds that may worsen osteoporosis?
SSRIs, antiepileptics, PPIs, glitazones, long-term heparin therapy, aromatase inhibitors
Causes osteomalacia?
Vit d deficiency, lack of sunlight, diet, CKD, drug induced- anticonvulsants, inherited- hypophosphataemic rickets, liver disease e.g. cirrhosis, coeliac disease
Sx of granulomatosis with polyangiitis? Tx?
Epistaxis, hearing loss, sinusitis, saddle-shaped nose due to nasal bridge collapse, cough/ wheeze/ haemoptysis, glomerulonephritis
CXR= cavitating lesions
Renal biopsy= epithelial crescents in Bowman’s capsule
Steroids, cyclophosphamide, plasma exchange
Sx of eosinophilic granulomatosis with polyangiitis? What might precipitate disease?
Severe asthma, sinusitis, allergic rhinitis
Raised eosinophilia on FBC
LTRAs
Main feature of microscopic polyangiitis?
Renal failure with glomerulonephritis, cough/ dyspnoea/ haemoptysis
What is Goodpasture’s syndrome?
Anti-GBM antibodies against type IV collagen- more common in men
Bimodal incidence
HLA DR2
Pulm haemorrhage, rapidly progressive GN- rapidly onset AKI–> proteinuria, haematuria
Ix and tx of Goodpasture’s?
Renal biopsy- linear IgG along basement membrane
Raised transfer factor secondary to pulm haemorrhages
Plasma exchange, steroids, cyclophosphamide
What can polyarteritis nodosa be secondary to? Sx?
Idiopathic or secondary to infections- particularly hepatitis B, more in middle-aged men
Renal impairment, HTN, tender erythematous skin nodules, MI, stroke, mesenteric adenitis, unilateral orchitis, livedo reticularis
Ix, tx and comps of polyarteritis nodosa?
·↑ESR and/or CRP
·HBsAg
·Biopsy: shows transmural fibrinoid necrosis
·If Hep B negative – corticosteroids + cyclophosphamide
·If Hep B positive – antiviral agent, plasma exchange and corticosteroids
●GI perforation & haemorrhages, Arthritis, Renal infarcts, Strokes, MI
Sx of Kawasaki’s disease?
High fever> 5 days, widespread red maculopapular rash, skin peeling palms and soles, bilateral conjunctivitis, strawberry tongue, cervical lymphadenopathy
High dose aspirin, IV IGs, ECHO screening for coronary artery aneurysms
Peak incidence of GCA? Features?
70s
Rapid onset<1 month, headache, jaw claudication, vision testing for AION- may–> amaurosis fugax, tender palpable temporal artery
raised ESR, CRP, temporal artery biopsy- may show skip lesions, Duplex USS= hypoechoic halo sign and stenosis of temporal artery
High dose pred before biopsy/ IV methylpred if evolving visual loss w/ PPI, aspirin, bisphosphonates, calcium, vitamin D
Urgent oph review
Bisphos, low-dose aspirin
Sx PMR?
Rapid onset<1m, aching morning stiffness in proximal limb muscles- shoulders, pelvic girdle, neck
Worse after rest
Raised ESR- before steroids= FBC, U&Es, LFTs, calcium, serum protein electrophoresis, TSH, CK, RF, urine dip
Prednisolone, 1w follow-up reducing regime
When does Takayasu’s arteritis first present? Ix? Tx?
Before age 40 in younger females and Asian people- fever, malaise, muscle aches, may be claudication sx, aortic regurg, renal artery stenosis
CT/ MRI angiography
Steroids
Gene related to Behcet’s disease? How often mouth ulcers?
HLA B51- more in men and eastern Mediterranean/ young adults
At least 3 times a year- painful sharply circumscribed with a red halo occurring on the oral mucosa and heal over 2-4 weeks, genital= similar, with anterior uveitis
Thrombophlebitis and DVT, arthritis, neurological involvement, erythema nodosum
Positive pathergy test–> erythema and induration (also Sweet’s syndrome or pyoderma gangrenosum)
Topical steroids, systemic steroids, colchicine, topical anaesthetics, immunosuppressants, biologics
Comps of Behcet’s?
Vision loss, ruptured pulm aneurysms, bowel perforation, neuro-Behcet’s disease
Most common and least severe of Ehlers- Danlos syndrome? What can result? What are classical prone to? Vascular prone to?
Hypermobile- autosomal dominant–> POTS
Also stretchy skin- hernias, prolapses, mitral regurg, aortic root dilatation, abnormal wound healing= autosomal dominant
GI perforation and spontaneous pneumothorax
Sx of kyphoscoliotic Ehlers- Danlos? Score to support Ix?
Initially hypotonia–> kyphoscoliosis as grow, joint hypermobility, joint dislocation more common, AUTOSOMAL RECESSIVE
Beighton score= one point for each side of body with max of 9
Palms flat on floor with straight legs (score 1)
Elbows hyperextend
Knees hyperextend
Thumb can bend to touch the forearm
Little finger hyperextends past 90 degrees
Ix for EDS? Tx?
Clinical for hypermobile and genetic for other types= helpful
Physio, OT, moderating activity, psychology
What is subclinical hyperthyroidism? Repeat TFTs after how often if suspected?
TSH is suppressed below the normal reference range- FT4 and FT3 are within the normal reference range
3 months
Comps of hyperthyroidism?
Graves’ orbitopathy, thyrotoxic crisis, large goitre–> compression sx, AF, HF
What does a thyroglossal cyst move with?
Swallowing and tongue protrusion
Epidemiology of Still’s disease? Sx?
Bimodal distribution 15-25 and 35-46 y/o
Arthralgia, elevated serum ferritin, salmon-pink MP rash, pyrexia in later afternoon/ early evening accomp by worsened sx and rash, lymphadenopathy
Criteria and tx for Still’s disease?
Yamaguchi disease
NSAIDs for at least 1 week–> steroids for sx not prognosis
Methotrexate, IL-1 or anti-TNF therapy
What is Prinzmetal angina caused by? Decubitus angina caused by what?
CA spasm
Lying flat
Diet and exercise changes for CVD?
Total fat= <30% calories- mono and polyunsaturated- saturated<7% calories
Reduced sugar, wholegrain options, 5/day F&V, 2/week fish, 4/week legumes, seeds and nuts
Aerobic activity 150 mins/week mod activity/ 75 mins vigorous, strength 2 days/ week
How often do people have a health check between 40-74 y/o? What is used to calc primary prev CVD meds for 25-84 year olds?
Every 5 years
Q-risk3 (lifetime risk)
Do not do a Q-risk score(10-years) in who? Also assess what?
People with CVD, high risk- T1DM/ eGFR<6, has familial hypercholesterolaemia, aged 85 or above
HbA1C and kidney function
What is Q-risk underestimated in?
Those tx for HIV, w/serious mental health issues, taking drugs cause dyslipidaemia- some APs, immunosuppressants and corticosteroids, AI conditions- SLE, taking antihypertensive/ lipid mod therapy/ recently given up smoking
Factors in Q-risk score?
Age, sex, ethnicity, postcode, smoking/ diabetes/ angina or MI 1st degree relative<60/ CKD stage 3,4 or 5/ AF/ on BP tx/ have migraines/ RA/ SLE/ severe mental illness/ on atypical APs/ regular steroids/ ix or tx for ED status
Cholesterol/ HDL ratio
Systolic BP, SD of at least 2 most recent sys BP readings, BMI
Advice for Q-risk<10%?
Advise on lifestyle factors- smoking, HTN, abnormal lipids/ weight loss if overweight or obese- assess about sleep apnoea/ alcohol
Review co-morbidities
Tx for Q-risk>10%? How do they function?
Before= assess for familial lipid disorder, exclude secondary causes- excess alcohol, uncontrolled diabetes, hypothyroidism, liver disease and nephrotic syndrome
Discuss lifestyle mod- alcohol, BP, BMI, smoking, diabetes control/ optimise other RFs and co-morbidities
Offer statin e.g. atorvastatin 20mg, also CKD & T1DM for >10 years/ or are >40 y/o/ aged above 85 y/o
Inhibit HMG CoA reductase
Bloods before starting primary prev lipid therapy CVD?
When should lipids and LFTs be checked when starting statins? When should statins not be stopped with raised transaminases? When to repeat HbA1c?
Initial lipid profile(non-fasting)- total chol, HDL-C, non-HDL-C & triglycerides, TSH & renal function, LFTs, HbA1C, U&Es, CK
3m and 12m- aim for reduction in non-HDL of >40%, then review annually- consider low/ medium intensity statin vs high intensity
<3 times upper limit
at 3m
When to measure CK before starting statins?
If persistent generalised, unexplained muscle pain- if>5 times upper limit- repeat after 7 days, if remains>5- do NOT start statin, <5= start at lower dose
Action ezetimibe (w/ bempedoic acid)? Evolocumab and alirocumab? Max number statins before specialist advice?
Inhibits absorption of cholesterol/ ACL inhibitor- lowers LDL cholesterol
PCSK9 inhibitors-MABs lower cholesterol as SC injection every 2-4w
3
4 As for secondary prevention following CV event?
Antiplatelet meds, atorvastatin, atenolol/ alt Beta blocker, ACE-i titrated to max dose/ BACAS- Beta blocker, ACE-i, clop, aspirin, statin- 80mg
DAP therapy- aspirin 75mg daily continued & clop/ tic for 12m before stopping
High-risk emboli= warfarin 3-6m
Lipid profile consists of what? 3 situations when measured?
Total cholesterol, HDL- good, non-HDL including LDL- BAD, total cholesterol: HDL ratio, triglycerides
1) Recent CV event
2) Monitoring- high lipids/ CV event
3) Screening- 40-74 y/o every 5y, used as part of Q-risk 3/ has tendon xanthoma, xanthelasma or corneal arcus
When should lipid profile not be performed? Results in severe hyperlipidaemia?
Within 6w any acute illness/ injury
Total cholesterol >7.5mmol/L (hypercholesterolaemia) and/or
Non-HDL-C >5.9 mmol/L (hypercholesterolaemia) and/or
Triglycerides >4.5mmol/L (hypertriglyceridaemia)
Inheritance of familial hypercholesterolaemia? Criteria for making Ix? 3 important features?
AD- hetero or homozygous–> extremely high cholesterol above 7.5mmol/L in an adult/>9 in people aged over 30 y/o
Simon Broome criteria
Family hx of prem CVD, very high cholesterol, tendon xanthomata
Ix if familial hypercholesterolaemia is suspected? Tx?
2 x LDL measurements, assessed for signs, exclude secondary high cholesterol, SBC used to make Ix, specialist referral confirm Ix and initiate cascade testing
Lifestyle advice, high intensity lipid-mod therapy- reduce LDL>50% from baseline, consider aspirin and anti-HTN, follow-up
Homozygous/ in children= specialist tx
Target cholesterol levels?
Total cholesterol: should be 5mmol/L or less
HDL-C: should be >1 mmol/L in men and >1.2 mmol/L in women
Total cholesterol to HDL ratio: should be <6
Scoring and ix stable angina?
1= central, tight radiation to arms, jaws and neck
2= prec by exertion
3= relieved by rest
3/3= typical
2/3= atypical
1/3= non-anginal pain
ECG- ST depression, T-wave inversion, exercise ECG/ stress ECHO- monitor how long, ST dep= late-stage ischaemia, CT angio= GOLD, invasive= in cath lab
CT scan calcium scoring
SPECT/ myoview
Cardiac catheterisation, bloods- FBC, U&Es, TFTs, lipids, HbA1c, anaemia, CXR
Tx stable angina?
Modify RFs, pharm:
Aspirin, statins, GTN
BB/CCB- diltiazem or verapamil(avoid in HF w/ reduced EF,) switch, combine, 3rd= isosorbide mononitrate, ivabradine, nicorandil, ranolazine
PCI- stenting= brachial/ femoral artery, CABG= saphenous vein, internal thor/ mammary artery, radial artery
Secondary prevention- 4 As
Other things causing a raised troponin? Additional bloods & Ix?
CKD, sepsis, myocarditis, aortic dissection, PE
FBC, U&Es, LFTs, lipid profile and glucose, CXR, Echo- LV function
ECG
Trop= rise within 3-12h peak@24-48h and return to baseline by 5-14 days- above 30ng/L
CK-MB= rise within 3-12h onset pain
Myoglobin= rises within 1-4h onset pain
Pathological Q waves typically appear how many hours after onset sx? 5 types MI?
6> 25% QRS height and wider than ONE small square
1= spontaneous w/ ischaemic due to primary coronary event
2= secondary to ischaemia due to increased O2 demand/ decreased supply
3,4,5= sudden cardiac death related to PCI and CABG
Murmur in MI? ECG in STEMI & NSTEMI?
4th heart sound + pansystolic murmur
ST elevation at least two contiguous limb leads of >1mm or (1 small square)/ >2mm in 2 or more chest leads/ new LBBB
Subsequent Q waves
ST depression >0.5mm in >2 contiguous leads= ischaemia/ T wave inversion- other than V1 and III
Features of digoxin toxicity? Tx?
N&V, anorexia, diarrhoea
SVT and slow ventricular response, frequent PVCs- ventricular bigeminy and trigeminy, sinus bradycardia, slow AF, any AV block type, VT, downsloping ST depression- ‘reverse tick,’ slight PR interval prolongation, biphasic/ flattened and shortened QT interval
Stop digoxin, administer digifab
Troponin how long after MI pain? If not elevated? Also what within 3-12 hours and within 1-4h?
6 hours, another 3 hours- peak at 24 and 48 hours
CK-MB
Myoglobin
What are Q waves?
Any negative deflection that precedes an R wave
Tx for low risk GRACE score <3%? Tx for low and intermediate/ high >3%
Consider conservative without angiography
Offer aspirin + P2Y12 inhibitor- ticagrelor unless high bleeding risk–> clop or aspirin alone
Assess left ventricular function- consider assessing for unstable angina
Cardiac rehab and secondary prevention
Tx for intermediate/ higher-risk GRACE score >3%?
Offer immediate angiography if clinical condition unstable
Consider angiography with within 72 hours if no CI such as comorbidity or active bleeding
Prasugrel or ticagrelor with aspirin- pras only when PCI intended + systemic unfrac hep if having PCI
Reduced ejection fraction in heart failure? Mid-range? Preserved?
In systolic HF? Diastolic?
<40%, 40-49%, >50%
<40%
>50%
NY heart association classification?
I= no limitation on activity
II= comfortable at rest, but sx with ordinary activities
III= sx with any activity
IV= sx at rest
Tx for chronic heart failure? Other?
ABAL: ACE-i/ ARB, Beta-blocker- atenolol, aldosterone antagonist- not controlled with A and B/ REF, Loop diuretics e.g. furosemide or bumetanide
CCB and other- hydralazine with a nitrate
Digoxin
Ivabradine
SGLT2 inhibitor e.g. dapagliflozin
Sacubitril with valsartan
Procedural tx for HF?
ICD- previous vent tachy/ VF
CRT- severe with EF< 35% involves biventricular pacemakers with leads in RA, RV and LV
Severe= heart transplant
SODIUM tx for acute LVF?
Sit up
Oxygen<95%
Diuretics, GTN if systolic BP above 90mmHg
IV fluids should be stopped
Underlying causes identify and tx e.g. MI
Monitor fluid balance- daily weights reduce by 0.5kg/day
Diamorphine- consider CPAP
Tx for PEF HF? REF? Both?
Manage co-morbidities, offer cardiac rehab programme unless condition unstable
Offer ACE-i and BB- consider hydralazine and nitrate if intolerant of ACE-i and ARB,
MRA if sx continue + cardiac rehab programme
Offer annual influenza and one-off pneumococcal vaccine
Consider one of what if sx of HF continue?
Replace ACE-i with sacubitril valsartan if EF<35%
Add ivabradine for HR>75–> sinus rhythm
Add hydralazine w/nitrate if Afro-Caribbean
HF w/ sinus rhythm= digoxin
Bifascicular block commonly presents as what on ECG?
RBBB with LAD (LAFB is more susceptible to ischaemia)
What is adenosine CI in?
ASTHMA
Normal QT interval? QTc? Normal QRS complex width?
Men= 350-450ms
Women= 360-460
<430ms in males and <450ms in females
80-100ms, >120= abnormal
Indications for LTOT in COPD?
PaO2<7.3kPa on 2 readings more than 3w apart and are non-smokers
OR PaO2 of 7.3-8kPa alongside: nocturnal hypoxia, polycythaemia, peripheral oedema and pulmonary hypertension
LTOT can be also described for patients with terminal illness
2nd step of COPD management if FEV1>50% and persistent exacerbations?
LABA or LAMA
LABA AND ICS/ LAMA
Sx blue bloaters vs pink puffers?
Pink(emphysema)= near normal Pa02 and normal or low PaCO2- SOB NOT cyanosed, quiet chest, may progress to type 1 respiratory failure
Blue bloaters(chronic bronchitis)- polcythaemia, peripheral oedema, rhonchi and wheezing (low PaO2 and high PaCO2,) cyanosed but not SOB, may develop cor pulmonale
What is TCLO low in? High in?
Severe emphysema, fibrosing alveolitis, anaemia, pulmonary HTN, idiopathic pulmonary fibrosis, COPD
Pulmonary haemorrhage- more RBCs available due to bleeding
How long before spirometry should SABAs be stopped? LABAs? How is reversibility then tested?
6 hours
12 hours
400mcg salbutamol administered and spiro repeated after 15 minutes
FEV1, FVC and ratio in obstructive vs restrictive disease?
Ob= FEV1<80%, reduced FVC to lesser extent and FEV1<FVC<0.7, reduced peak flow
Restrictive= reduced FEV1 and FVC <80%, but ratio normal(>0.7,) normal PEFR
Causes of hypoxia(<PaO2)?
V/Q mismatch, hypoventilation, abnormal diffusion, R–>L cardiac shunts- V/Q= commonest
What is KCO (gas transfer coefficient) low in? High in?
Emphysema and ILD/ alveolar haemorrhage
S&S of COPD?
SOB, wheeze, exercise intolerance, chronic/ recurrent cough, regular sputum production
Tachypnoea, use of accessory muscles in respiration, hyperinflation, reduced CS distance<3cm, reduced CE, resonant percussion, quiet breath sounds, cyanosis, cor pulmonale
Ix COPD? Comps?
Info on condition & RFs, smoking cessation, pneumo and in vaccination, pulm rehab, tx comorbidities, self-management plan
FBC, CXR, ECG, ABG, lung function tests- spiro, DLCO, trial steroids- look for >15% in FEV1, 30mg pred/24h PO for 2 weeks
Acute exacerbations +/- infection, polycythaemia, resp failure, cor pulmonale, pneumothorax, lung carcinoma
Tx COPD?
General= smoking cessation, encourage exercise, tx poor nutrition/ obesity, inf and pneu vaccination, pulm rehab, NIPPV, PRN SABA or SAMA, review meds and inhaler technique/ adherence
Mild/mod= inhaled LAMA or LABA
Severe= LABA + CS e.g. Symbicort- bud + formeterol or tiotropium
Remain Sx: tiotropium and ICS + LABA, refer to specialist, home nebs, theophylline
Pulm HTN- assess need for LTOT, diuretics for oedema
Tx for advanced COPD? Indications for surgery?
Pulm rehab, LTOT if PaO2<7.3kPa
Recurrent pneumothoraces, isolated bullous disease; lung volume surgery
NIV if high CO2 on LTOT
Air travel risky if FEV1<50% or PaO2<6.7kPa
Assess home support and tx depresison
Indications for specialist referral for COPD? Pulm rehab referral?
Uncertain Ix/ suspected severe COPD/ rapid decline in FEV1, onset cor pulmonale, bullous lung disease, assessment for oral CSs, neb therapy or LTOT, <10 pack years smoking or COPD<40 y/o, sx disprop to lung function, frequent infections, suspected bronchiectasis
Functionally disabled, recent hospitalisation for acute exacerbation
Increased risk of what with ICS? Monitor for what? When is theophylline considered? Mucolytic therapy?
Pneumonia
Osteoporosis
After trial of short-acting and long-acting bronchodilators or can’t use inhaled therapy- monitor plasma levels and interactions
Stable COPD develops chronic cough productive of sputum- continue if improvement in sx
When should prophylactic macrolide ABx therapy in COPD be considered?
More than 3 exacerbations needing steroid therapy and at least one exacerbation needing hospital admission in previous
Azithromycin 500mg 3x week minimum 6-12 months
Do what before commencing proph ABx in COPD? After starting? Severe disease despited ICS and non-pharm?
ECG-QTC int, LFTs, counsel on SEs, arrange microbiological assessment sputum for NTM, consider CT scan
SEs= 250mg x3/ week
LFTs after 1 month and then every 6 months, ECG after 1m- stop if QTc prolonged
Follow up at 6m and 12m
Oral PDE4-i
4 stages of COPD?
1=>80% FEV1
2=50-79%
3= 30-49%
4=<30%
Pre flight resp assess in COPD?
Sig resp sxs, severe COPD, bullous lung disease, comorbid conditions worsened by hypoxia, discharged within 6w, recent pneumothorax, risk of/ previous VTE, pre-existing need for oxygen, CPAP or ventilator support(CI>4L needed)
Assess= walk test and or hypoxic challenge test
Sx of acute exacerbation of COPD? Severe?
Worsening SOB, cough, wheeze, fever without obvious source, URTI in past 5 days, increased RR/ pulse 20% above baseline
Marked SOB, tachypnoea, pursed-lip breathing and/or use accessory muscles at rest, new-onset cyanosis or peripheral oedema, acute confusion/ drowsiness, marked reduction in ADLs
When to arrange hospital admission for person with acute ex of COPD?
Severe SOB, inability to cope at home, poor/ det condition, rapid onset sx, acute confusion or impaired consciousness, cyanosis, worsening peripheral oedema, new arrhythmia, failure to respond to initial tx, receiving LTOT, changes on CXR, O2<90% on pulse ox- give 2-3l/min Venturi 24% or 28% 1-2l/min target sats 88-92%
Tx person with COPD not needing admission?
Increase doses/ freq SABAs, if fatigued- use nebuliser, consider ICS for increase SOB- 30mg oral pred for 5 days, consider need for AB- based on sx severity, risk comps, previous sputum culture, risk antimicrobial resistance & current ABx prophylaxis
Follow-up of exacerbation COPD?
Assess residual/ changed sx- consider need for further Ix, optimise non-pharm and pharm, use of meds, consider need for referral to specialist/ for pulm rehab
Offer short course oral steroids and AB keep at home if: ex in last year and remain at risk, understand when and how to take, know when to seek help
Review self-management plan
Factors ass w/ increased risk mortality in people with COPD? Tx?
Freq and severity exacerbations
Hosp during ex
Poor lung function on spiro
Low BMI
CMBs
Ensure has ACP, optimise sx- SOB, cough, secretions, pain, insomnia, depression, anxiety, discuss admission to hospice, family/ carer support
Sx? Signs on examination in during asthma attack?
Dyspnoea, cough- may be nocturnal, chest tightness, diurnal variation, sx may worsen following exercise, weather changes or following use of NSAIDs/ Beta blockers
Reduced chest expansion, prolonged expiratory time, bilateral expiratory polyphonic wheezes, tachypnoea, hyperinflated chest, hyperresonance on chest percussion, decreased air entry
Ix asthma?
RCP3 Qs- recent nocturnal waking/ usual asthma symptoms in day/ interference with ADLs
FeNO testing, spirometry- obstructive, BDR>12% or more of FEV1 and increase in volume of 200ml or more(children just 12%,) PEF variability>20% on >/=3d for 2w diagnostic lower in mornings, bronchial challenge testing with histamine or methacholine(PC20 value of 8mg/ml or less)
Asthma control test: 25= well controlled, 20-24= on target, <20= off target
Lung function- PEFR on waking, prior to taking BD and before bed after BD, spirometry, CO test= normal asthma
Exercise
CS trial
ENO
Blood and sputum tests- eosinophilia- sputum= more specific, raised total IgE
CXR
Ix asthma?
Presence of more than one variable sx wheeze, cough, SOB and chest tightness
Personal/ family hx of other atopic conditions- atopic eczema/ dermatitis and/ or allergic rhinitis(previous skin prick tests)
Results FeNO testing>40ppb adults/ 35 ppb in children
Tx chronic asthma?
Smoking cessation, avoidance factors, review inhaler technique, teach PEF X2/ day, emergency advice, written action plan–> relaxed breathing(Papworth)
Ask specifically about what during asthma history?
Precipitants- cold air, exercise, emotion , allergens- house dust mite, pollen fur/ infection, smoking, pollution, NSAIDs, beta-blockers
Diurnal variation
Exercise tolerance
Disturbed sleep- nights/ week
Acid reflux-tx improves spirometry
Other atopic disease- eczema, hayfever, allergy or family hx
Home- pets, carpet, feather pillows or duvet, floor cushions/ soft furnishings
Job- PEF at work (paint-sprayers, food processors, welders, and animal handlers) and home
Days per week off school or school
Monitoring asthma? Uncontrolled asthma?
At least annually
Adherence, inhaler technique, review if tx needs changing, ask about occupational asthma- refer to OT if needed, questionnaire
Spiro or PEF
3 or more days week w/ sx or 3 or more days a week with required use of SABA for relief or 1 or more nights week with awakening
When should inhaler technique be reviewed?
At every consultation relating to asthma attack, when deterioration in asthma control, when inhaler device changed, at every annual review, if person asks
People on long-term steroids or needing frequent courses offer what?
Monitoring of BP, urine or blood sugar, cholesterol, BMD, vision- cataracts or glaucoma
If meds adjusted- review response in 4-8 w
Hx for acute asthma attack?
Usual and recent tx, previous acute episodes and severity best PEFR, admitted to ICU
note agitation, consciousness, signs exhaustion- cyanosis, use accessory muscles
Examine chest- RR, pulse, BP, best of 3 PEFR, pulse oximetry
Features of moderate acute asthma attack? Acute severe? Life-threatening?
PEFR>50-75% best / predicted and normal speech, no features acute severe or life-threatening
PEFR 33-50%, RR at least 25, inability to complete sentence in one breath, accessory muscle use, O2 at least 92%, pulse>110bpm
PEFR<33%, O2<92% or altered consciousness or exhaustion or cardiac arrhythmia or hypotension/ cyanosis/ poor resp effort/ silent chest/ confusion(WARN ICU if severe or life-threatening)
Ix in acute asthma?
ABG- T2RF= life-threatening, tachypnoeic= resp alkalosis(low PaCO2 and high PaO2)
Falling RR= sign of patient fatigue, PaCO2 to normal= URGENT ESCALATION
Bloods- FBC, CRP
CXR- exclude
Tx for acute asthma?
Ensure patent airway(AE)
O2 if SATS below 94%- target 94-98%
Salb/ ipratropium nebs- O2 driven(every 20-30 minutes if intermittent or over 30-60 minutes if continuous)
(If not available- 4 puffs metered-dose inhaler with large-volume spacer–> 2 puffs every 2 minutes up to 10 puffs, repeat every 10-20 minutes if needed)
Ipra if life-threatening or severe/ poor resp to salb
Oral pred/ IV hydrocortisone
Monitor PEFR and oxygen, ECG- arrhythmias
IV MgSO4 if severe
IV aminophylline if severe and inadequate BD response from nebs–> ICU(no improvement)- invasive ventilation
Tx acute asthma not in hosp? Follow-up?
Salb large vol spacer- 4 puffs, then 2 puffs every 2 mins up to 10 puffs, repeat every 10-20 minutes
Short course oral pred
Return to SABA up to QDS once sx gone
Monitor PEFR
Within 48 hours and 2 days discharge- sx, PEFR, inhaler technique, consider increasing ICS dose, address RFs, lifestyle, recognising poor control, keep oral CSs at home
Consider referral to resp physician if person has what?
2 asthma attacks within 12 months
3 e.g. of ABGs in context?
Normal PaO2 on high-flow oxygen
Normal PaCO2 in hypoxic asthmatic patient- NEED ITU intervention
Very low PaO2 in someone who looks well, not SOB and normal O2 SATS
In someone receiving oxygen therapy, what should their PaO2 be in relation to their inspired conc?
10kPa less than % inspired conc e.g. 40%- PaO2 of 30kPa
Simple face masks can deliver a maximum FiO2 of approximately what at a flow rate of 15L/min- NEVER LESS THAN 5L/min? Reservoir masks e.g. non-rebreather? Venturi masks?
40-60%
60-90% at 10-15L/min
24, 28, 35, 40 and 60%(24 and 28% for those at risk of CO2 retention)
Normal and abnormal PaO2 and PaCO2 levels?
11-15, <10= hypoxaemic, <8= severely hypoxaemic- RF
4.6-6.4kPa, <6= normocapnic, >6kPa= hypercapnic(T2RF)
Causes of type 1 and type 2 RF?
Type 1= V/Q mismatch- PE most commonly, pulm oedema
Type 2= hypoventilation- COPD, pneumonia, rib fractures, obesity, GBS, MND, opiates
High HCO3- means what on ABG?
Low HCO3-? CO2 and HCO3- in mixed acidosis/ alkalosis? Causes?
Metabolic alkalosis/ comp respiratory acidosis
Metabolic acidosis or comp respiratory alkalosis
Move in opposite directions
Cardiac arrest, multi-organ failure= acidosis
Liver cirrhosis in addition to diuretic use, HG, excessive ventilation in COPD= alkalosis
Causes of resp acidosis? Resp alkalosis? Normal anion gap met acidosis? High anion met acidosis? Met alkalosis?
Resp depression, GBS, asthma COPD, iatrogenic
Anxiety, pain, hypoxia, PE, pneumothorax, PE, iatrogenic
GI, renal tubular disease, Addison’s disease
DKA, lactic acidosis, aspirin overdose, renal failure
GI loss, renal loss H+, iatrogenic
Anion gap formula? Normal value?
Na+- (Cl- + HCO3-)
4-12 mmol/L
How can changes in CO2 be compensated? HCO3-?
By increasing/ decreasing levels HCO3-
increasing/ decreasing levels CO2
What can a VBG be used to comment on and not?
To exclude resp acidosis and and T2RF, determining response–> treatment, resp function in comb with pulse ox
Oxygen levels- ABG needed
Tx for pneumonia?
ABC- O2 if SATS<88%, 24-28% if COPD/ hypercapnia- maintain between 94-98%
Tx hypotension/ shock- consider IV fluid
ABx- WITHIN 4 HOURS
Paracetamol/ NSAID
CPAP if still hypoxic, hypercapnic= intubation
Discuss with ICU if rising PaCO2 or remains hypoxic
ABx for CAP? Atypical?
Mild= amoxicillin/ clar/ doxy
Moderate= amox + clar/ doxy(amox + clar if IV)
Severe= co-amox or cephalosporin + clarithromycin
Add fluclo +/- rif if staph suspected; vanc if MRSA suspected
If legionella pneumophilia suspected? Chlamydophila species? Pneumocystis jiroveci? Necrotising/ other features PVL–> s.aureus? Pseudomonas- CF & bronchiectasis?
Levofloxacin and clari/ rifampicin if severe- HYPONATRAEMIA AND LYMPHOPENIA COMMON
Tetracycline- doxy/ lymecycline
High dose co-trimoxazole- DRY COUGH, EXERCISE-INDUCED DESATS & ABSENCE CHEST SIGNS
IV linezolid, IV clindamycin, IV rifampicin
IV ceftazidime w/ gent/ tobramycin- consider dual therapy minimise resistance
Tx for HAP? Aspiration? Neutropenic?
IV aminoglycoside e.g. gentamicin(Hartford protocol)-risk of oto & nephrotoxicity once-daily dosing + antipseudomonal penicillin e.g. ticarcillin/ piperacillin with tazobactam
(Ceftazidime or Tazocin)
IV ceph + metro
Aminogly + antipseudomonal/ 3rd gen caph
Consider antifungals after 48h
CXR findings in s.pneumoniae, aureus and legionella? S.aureus? Klebsiella? Tx?
Multi-lobar, multiple abscesses, upper lobe cavity- EXCLUDE TB
Cefotaxime/ imipenem
Ix pneumonia?
Bloods: FBC- WBCs for severity, ESR & CRP, U&Es- severity, LFTs, pulse ox and ABG if O2 <94%
HIV test, sputum culture and sens +/- Gram stain, blood culture, serology- viruses and atypical
Comps of pneumonia? When would someone with CAP have a CXR 6 weeks after?
Resp failure, hypotension, parapneumonic effusion and empyema, pleural effusion, septicaemia, brain abscess, myocarditis, cholestatic jaundice, pericarditisƒ
S&S persist despite tx, higher risk malignancy- >50 y/o and smokes
Indications of empyema? Ix? Tx? ABx?
Ongoing fever, failure of fever/ WBC/CRP to settle, pain deep inspiration, signs pleural collection
Pleural tap–> pH<7.2, low glucose, fluid- yellow and turbid
Chest drain
Co-amoxiclav, pip-taz, meropenem- anaerobic
CXR for lung abscess? Seen in who? Organisms? Tx?
Cavity formation
Aspiration- alcoholics, oesophageal obstruction, inadequate tx CAP, TB, foreign body, septic emboli- staph
S.milleri, Klebsiella, GRAM-VE bacteria
Prolonged ABx up to 6w- surgical drainage may be required
Idiopathic interstitial pneumonia group non-infective causes pneumonia including what? Comp of what?
Cryptogenic organising pneumonia- form bronchiolitis as comp of RA or amiodarone therapy
Discharge advice if in past 24h pneumonia patients have had 2 or more of what?
NOT DISCHARGE- temp>37.5 degrees, RR>24, HR>100, sys BP<90, O2<90% on RA, abnormal mental status, inability eat without assistance
Resolution pneumonia sx?
Fever= 1w
Chest pain & sputum= 4w
Cough & SOB= 6w
Most resolve except fatigue- 3m
6m= back to normal
S&S of TB?
FEVER- gradual onset and low-graded
Dyspnoea, initial dry cough–> productive> 3 months
Night sweats
Weight loss
Pleurisy/ chest pain/ SOB
Pleural effusion/ consolidation, pulm collapse from compression lobar bronchus
Anorexia
Can be hoarse voice
Sx of extrapulmonary TB?
swollen lymph nodes +/- discharge
Pericarditis
Pain/ swollen joints, Potts disease- spinal
Abdo- ascites, abdo LNs, ileal malabsorption
Epididymitis, LUTs, haematuria
CNS= raised ICP sx, low grade meningitis, random CN palsies
Skin- lupus vulgaris, erythema nodosum
Eyes(retinal/ ocular)- blurred vision and light sensitivity
Ix Latent TB? Active TB? Active non-resp TB?
Mantoux/ tuberculin test 48-72 hours response–> type 4 HS reaction- +ve(immunity) - consider interferon-gamma testing- use ESAT-60 and CFP10 dis between M.tub between BCG vaccine or environmental mycobacteria(indicate exposure but not active)
MILIARY/ IMMUNOSUPPRESSED WON’T TEST
If CXR suggests- take sputum samples>/= 3 samples- MC&S for AFB resist acid on Ziehl-Neelsen staining/ bronchoscopy and lavage if not possible/ pleural fluid or lung biopsy
Culture- up to 6 weeks with Lowenstein-Jensen agar, lquid media= rapid results within 1-3 weeks
Sputum, pleura and pleural fluid, early morning urine samples for dipstick, microscopy and mycobacteria culture, pus, ascites, peri, bone marrow/ CSF samples & LP for non-resp, TB culture by micro, ECHO, CT- chest/ CNS/ bones & joints
CXR- patchy/ nodular shadows in upper zones with loss volume and fibrosis w or w/o cavitation, consol, mediastinal/ hilar lymphadenopathy
PCR(NAAT,) histology= caseating granulomata
Tx active TB? Do what before and after tx? Tx latent TB?Check what? Reduce rif dose by 50% in what situation? Monitor what for ethambutol?
NOTIFY PHE & contact tracing- all household members, close contacts, most work colleagues, isolate until 2 weeks after starting tx
Rx before culture results
Fully sens TB= 6m tx, CNS= 12m(R&I, P&E during 1st 2m):
First 8 weeks= pyrazinamide- 2.5g 3 times a week
Ethambutol 30mg x3 times/ week/ streptomycin
Rifampicin 600-900mg x3 times a week for 6 months
Isoniazid= 15mg/ kg 3 times/ week max 900mg for 6m
GIVEN IN DOTS- direct observed therapy
Consider steroids for meningeal/ pericardial TB
3m isoniazid and rifampicin OR 6m isoniazid
Colour vision and visual acuity
If pre-tx creatinine clearance 10-50ml/min, U&Esp
Monitoring and SEs of TB drugs?
Sputum samples- M & C at monthly intervals
R= hepatitis, red urine, drug inter- the pill
I= hepatitis, neuropathy
P= hepatitis, arthralgia/ gout & rash
E= optic neuritis- COLOUR VISION
Common regime for resistant TB? Extensively drug-resistant TB?
Levo + bedaquiline + linezolid
At least 5 of fluoroquinolone, bedaquoline, linezolid and additional
New alternative= 26-week regimen of bedaquiline, pretomanid and linezolid
TB comps?
Haemoptysis, pneumothorax, bronchiectasis, pulm destruction, fistula, tracheobronchial stenosis, malignancy, chronic pulm aspergillosis
TB effusions and empyema
Miliary TB
Septic shock
How is TB screened for? In who? BCG vaccine?
Mantoux and IGRAs- active/ +ve–> CXR, sputum stain and culture, people starting immunosuppressant treatment e.g. anti-TNF- infliximab- should be screened
Recent exposures, healthcare workers, homeless shelters and prisons, increased risk reactivation- HIV, travellers from high-incidence countries
Live from m.bovis- children in high-risk region, healthcare
Features of mycoplasma pneumoniae? Ix? Comps? Tx?
Flu-like sx followed by cough
CXR= reticular nodular shadowing/ patchy consolidation often of 1 lower lobe and worse than signs suggest
PCR sputum or serology
Erythema multiforme, SJS, meningoencephalitis or myelitis, GBS
Clarithromycin or doxycycline or cipro
Predominant pathogens in acute sinusitis? Tx? Comps?
S.pneumoniae, h.influenzae & Moraxella catarrhalis, rhinoviruses
Facial pain, nasal discharge, nasal obstruction
Analgesics, decongestants, intranasal corticosteroids and saline irrigation, ABx- fail to improved after 7-10 days- phenoxy or co-amoxiclav if systemically unwell, sx more serious, high-risk comps
Orbital cellulitis, subperiosteal formation and intracranial extension –> meningitis or brain abscesses
Most common cause epiglottitis? Sx? Tx?
Hib
Severe sore throat and odynophagia- painful swallowing + drooling, muffled voice, stridor, resp distress, high-grade fever, tripod/ sniffing position- DON’T EXAMINE THROAT
Lateral neck radiograph= THUMB SIGN only if stable, flexible fiberoptic laryngoscopy- only if stable, blood cultures and throat swabs
Urgent endotracheal intubation, tracheostomy
IV ceftazidime, supportive, close monitoring, vaccination in children
Most PE clots from which veins? rarer causes?
Pelvic and abdominal veins- but femoral and occasionally axillary thrombosis
Right vent thrombus- post MI, septic emboli, fat embolism- long bone fracture, air embolism, amniotic fluid embolism, neoplastic cells, parasites, foreign material during IV drug misuse
Other causes of PE? Sx?
Immobility
Recent surgery
Long-haul travel
Pregnancy
Hormone therapy with oestrogen (e.g., combined oral contraceptive pill or hormone replacement therapy)
Malignancy
Polycythaemia (raised haemoglobin)
Systemic lupus erythematosus
Thrombophilia
SOB, tachypnoea, pleuritic chest pain, haemoptysis, dizziness, syncope, pyrexia, cyanosis, past hx or family hx
Gallop rhythm, raised JVP, loud P2, right vent heave, pleural rub, AF, DVT
Ix PE?
FBC, U&E baseline clotting, D-dimers, ABG–> reduced PaO2 and PaCO2
CXR- often normal, decreased vascular markings, small pleural effusion, wedge-shaped area infarction, atelectasis, pulm oligaemia
ECG- sinus tachy, RAD, RBBB, AF, “SIQIIITIII,” RV strain
ABG- T1RF
Two-level Wells score unless HD unstable, pregnant or has given birth within 6 weeks
Serum D-dimer- rules out
CTPA- interim anticoagulation–> V/Q scan- also if RENAL IMPAIRMENT/ CONTRAST ALLERGY/ AT RISK FROM RADIATION
Tx of PE?
Immediate admission if pregnant/ HD unstable- cardiac arrest, obstructive shock, sys BP<90, eng-organ hypoperfusion, persistent hypotension/given birth within the past 6 weeks
Wells score>4 immediate CTPA/ interim anticoagulation–>V/Q scan
<4= D-dimer with results within 4 hours- if not–> anticoagulation, -ve= stop anticoag + consider alt
+ve–> CTPA/ interim anticoag
Features in Wells score for PE?
Clinical S& S of DVT
PE is number 1 diagnosis/ equally likely
HR>100
Immobilisation at least 3 days OR surgery in previous 4 weeks
Previous Ix PE/ DVT
Haemoptysis
Malignancy w/ tx within 6m or palliative
Follow-up after PE confirmed and AC started?
Adequate monitoring, info booklet, alert card, verbal and written info on AC treatment, Ix for unprovoked, hereditary thrombophilia testing where appropriate
Ix for unprovoked= FBC, U&Es, LFTs, APTT, PT, physical exam
If planned to stop AC- consider AP antibodies, hereditary thrombophilia for 1st degree relative with DVT/PE
If clinical suspicion is low for PE, consider using what to determine further Ix? Use of score?
PERC:
Age>50, HR>/=100, O2 sat on room air<95%, unilateral leg swelling, haemoptysis, recent surgery/ trauma, prior PE/ DVT, hormone use
All absent to rule out PE
Options for interim anticoagulation in PE? blood tests?
Apixaban or rivaroxaban/ LMWH for at least 5 days followed by dabigatran or edoxaban
LMWH with vit K ant(warfarin) at least 5 days
FBC, U&Es, LFTs, PT and APTT- don’t wait for results to tx
Tx for PE?
Oxygen if hypoxic 10-15L/min
Morphine 5-10mg IV w/ anti-emetic if pain/ distressed
LMWH unless CI e.g. active bleeding/ existing AC w/ DOAC/ warfarin
Anti-embolic stocking unless CI e.g. PAD
HD= immediate thrombolysis + cont infusion fibrinolytic unfrac heparin/ LMWH e.g. alteplase, streptokinase- IV/ catheter-directed OR embolectomy- less common
IVC filters- repeat despite adequate AC
Score for considering OP tx in PE?
PESI: age, sex, hx cancer/ HF/ chronic lung disease, HR>/=110, sys BP<100, RR>30, temp<36, altered mental status, O2<90%
AC following PE Ix?
Apixaban or rivaroxaban
Unsuitable= LMWH–> dabigatran or edoxaban/ LMWH–> VKA e.g. warfarin at least 5 days until INR 2
Renal impair<15ml/min= LMWH, unfrac heparin/ LMWH–> VKA
APS= LMWH–> VKA, target INR= 2-3
Pregnancy= LMWH
Length AC in PE? Score for assessing risk of bleeding on AC?
3 months- provoked
Unprovoked/ recurrent/ irreversible cause e.g. thrombophilia= 6m
3-6m in active cancer, then review
HASBLED (mainly AF)- HTN>160mmHg, renal disease, liver disease, stroke hx, prior major bleeding/ predis–> bleeding, labile INR, age>65, med predis–> bleeding, alcohol use>/=8 drinks/ week
Give what in PE if BP<90mmHg? Still reduced after 500ml? Still low? Still<90 after 30-60 min standard tx? If BP>90 mmHg?
Colloid infusion+ ICU input
Dobutamine- aim for BP>90 mmHg
IV noradrenaline infusion
Consider thrombolysis- unless already given
Warfarin loading regimen e.g. 5-10mg PO- confirm Ix
Comps of PE?
Acute RVF, cardiogenic shock, arrhythmias-SVT/VT, resp failure, infarction & lung necrosis, pleural effusion, pneumothoax
CTEPH= pulm HTN + right HF eventually
Legionella pneumophilia features? Ix? Tx?
Flu-like, dyspnoea and dry cough, anorexia, D&V, hepatitis, renal failure, confusion and coma
CXR= bi-basal consolidation
Bloods= lymphopenia, hyponatraemia, deranged LFTs, urinalysis may show haematuria
Legionella urine antigen/ culture
Fluoroquin(cipro) for 2-3 weeks/ clari
Chlamydophila pneumoniae features? Ix? Tx?
Biphasic- pharyngitis, hoarsenss, otitis, followed by pneumonia
Chlam complement fixation test, PCR invasive samples
Tx= doxy/ clari
Chlamydophila psittaci features? Ix? Tx?
Causes psittacosis- from infected birds
Headache, fever, dry cough, lethargy, arthralgia, anorexia, D&V
Meningo-encephalitis, infective endocarditis, hepatitis, nephritis, rash, splenomegaly
Chlam serology
Doxy/ clari
Pneumocystis pneumonia features? Ix? Tx?
Pneumonia in immunosuppressed- dry cough, ex dyspnoea, reduced PaO2, fever, bilateral creps
CXR- may be normal or show bil perihilar interstitial shadowing
Visual organism in induced sputum, bronch lavage/ lung biopsy
High dose co-trimoxazole/ pentamidine for 2-3w
Steroids in severe hypoxaemia
Prophylaxis if CD4<200x10^6/ after first attack
Mnemonic for causes upper lobe fibrosis?
CHARTS= coal workers’ pneumoconiosis, histiocytosis, ankylosing spondylitis/ allergic bronchopulmonary aspergillosis, radiation, tuberculosis, silicosis/ sarcoidosis
Drugs causing secondary pulmonary fibrosis? Conditions?
Nitrofurantoin, bleomycin, amiodarone- also causes grey/ blue skin, sulfasalazine, busulfan, cyclophosphamide, methotrexate
ALAT deficiency, RA, SLE, systemic sclerosis, sarcoidosis
2 medications licensed for idiopathic pulm fibrosis?
Pirfenidone
Nintedanib- inhibits tyrosine kinase
Drugs that cause secondary pulmonary fibrosis? Conditions?
Amiodarone, cyclophosphamide, methotrexate, nitrofurantoin
A1AT deficiency, RA, SLE, systemic sclerosis, sarcoidosis
EXPLAIN mnemonic for causes of pulmonary fibrosis?
Exogenous drugs- sulfonylureas or insulin
Pituitary insufficiency
Liver failure
Addison’s disease
Islet cell tumours- insulinomas
Non-pancreatic neoplasms
What can you not get above with hernias?
A hernia or an infantile hydrocele due to a patent processus vaginalis- is irreducible, testis is impalpable and has no cough impulse
RILE mnemonic for murmurs?
Right-sided= best on inspiration
Left-sided= best on expiration
Causes of bronchiectasis?
Idiopathic, pneumonia, whooping cough, TB, A1AT deficiency, connective- rheumatoid arthritis, CF, yellow nail syndrome, primary ciliary dyskinesia, allergic BP aspergillosis (CAPT Kangaroo has Mounier-Kuhn)
Most common organisms in bronchiectasis?
H.influenzae, pseudomonas, Klebsiella, s.pneumoniae
A1AT deficiency is caused by what?
Lack of protease inhibitor normally produced by the liver
Ch 14- autosomal recessive fashion(SERPINA1 gene)
Alleles classified by their electrophoretic mobility- M for normal, S for slow and Z for very slow(most common)
Normal= PiMM, heterozygous= PiMZ
Normal A1AT levels in homozygous PiSS and PiZZ? Ass w/ A1AT?
50% and 10%- manifest disease= usually PiZZ genotype, PIMZ= asymptomatic, S only symptomatic with Z(PISZ)
Asthma, pancreatitis, aneurysms, including intracranial aneurysms
Apical vs basal fibrosis mnemonic?
TEARS IN THE SKY- TB, extrinsic allergic alveolitis, AS/ allergic bronchopulmonary aspergillosis, radiation, silicosis/ sarcoidosis/ berylliosis/ pneumoconiosis- coal worker’s
CRABS ON THE FLOOR- cryptogenic fibrosing alveolitis (IPF,) rheumatoid arthritis/ systemic sclerosis, asbestosis/ aspiration/ A1AT deficiency, busulfan/bleomycin/ bronchiectasis, scleroderma
Staging of ABPA? Major and minor criteria?
1= acute, II= remission, III= recurrent exacerbation, IV= steroid-dependent asthma, V= pulmonary fibrosis
Major= asthma, pulmonary opacities, central bronchiectasis, blood eosinophilia, elevated IgG or IgE against A. fumigatus, IgE>1000IU/ ml
Minor= fungal elements in sputum, expectoration of brown plugs/ flecks, delayed skin reactivity to fungal antigens
What may be seen in the sputum of people with bronchial asthma and ABPA?
Charcot-Leyden crystals
Light’s criteria for pleural fluid interpretation? If though transudative, but Light’s suggest exudate what done?
Pleural fluid: serum protein>0.5
Fluid: serum LDH>0.6
Fluid LDH> 2/3 upper limit normal serum value
Serum- pleural fluid protein gradient
Pleural fluid LDH>1000 IU/L? Low pleural glucose <3.4mmol/L? <1.6?
Empyema, malignancy or rheumatoid effusion
Empyema, rheumatoid pleuritis ass w/ TB, malignancy and oesophageal rupture
Empyema and rheumatoid disease
Low pleural pH <7.3? High amylase above 110 IU/L?
Same pathologies causing low pleural fluid glucose levels
Pancreatitis, malignancy or ruptured oesophagus
WBCs in transudative or exudates? Lymphocytosis? Neutrophils?
Exudates>50,000 cells/ microL
Trans<1000 cells/ microL
TB, sarcoidosis or malignancy
Empyema or PE
Triglyceride and cholesterol levels in chylothorax and pseudochylothoax diagnoses?
Tri>1.24mmol/L, chol<5.18 mmol/L
Tri<0.56mmol/L, chol>5.18
Causes of resp acidosis and alkalosis?
COPD, life-threatening asthma, opiates overdose, benzos, NM disease, obesity hypoventilation syndrome
PE, anxiety–> hyperventilation, CNS disorders- stroke, SAH, encephalitis, altitude, pregnancy, salicylate poisoning
Diagnostic criteria for OHS? Tx? Ass w what?
BMI>/= 30kg/ m^2, daytime PaCO2>45mmHg, ass sleep-breathing disorder, absence of other known causes of hypoventilation
Return to normal body weight, severe= bariatric, assisted ventilation supp by O2
CHF, pulm HTN, cor pulmonale, angina
Ix for OHS?
ABGs- daytime hypercapnia and hypoxaemia, serum HCO3- exclude in low-risk, nocturnal oximetry for sleep apnoea, CXR, ECHO- RVH, ECG- RBBB, pulm function- flow volume loop (exp volume by spirometry against flow rate–> sawtooth pattern,) FVC + exp reserve volume reduced and airways resistance increased
Overnight polysomnography- hypovent, hypoxia and hypercapnia during sleep, especially in children and adolescents, FBC & TFTs- anaemia and mxyoedema
Features indicating urgent CXR within 2 weeks aged 40 and over for suspected lung cancer/ mesothelioma?
Persistent or recurrent chest infection, finger clubbing, SC lymphadenopathy or persistent cervical lymphadenopathy, chest signs cons, thrombocytosis
CXR recommended to patients over 40 y/o who have never smoked with two or more of what sx (one or more if they have ever smoked/ had asbestos exposure)
Cough, SOB, chest pain, fatigue, weight loss, appetite loss
Ix for lung cancer?
Staging CT, PET-CT, bronchoscopy with endobronchial ultrasound(EBUS,) histological diagnosis needs biopsy by bronchoscopy or percutaneous biopsy through skin
Cytology from sputum and pleural fluid
FBC
MRI= spread to brain or bones
Sites of met spread from lung cancer?
Liver, bone, adrenal glands, brain(more common to spread TO lung)
Breast, bowel, kidney- MOST COMMONLY, bladder
TNM class of lung cancer?
T1<3cm, T2>3cm, T3= chest wall, diaphragm and pericardium, T4= mediastinum, heart, great vessels, trachea, oesophagus, vertebra, carina, malignant effusion, mets in same lobe
N1= hilar nodes, N2= same side mediastinal nodes or subcarinal, N3= contralateral mediastinum/ supraclavicular
M1a= tumour same side, M1b= tumour elsewhere
What is pulm HTN defined as?
mPAP above 25mmHg as measured at right heart catheterisation and secondary right ventricular failure
5 groups of causes of pulmonary hypertension?
Idiopathic/ CTD e.g. SLE
Left heart failure- MI/ systemic HTN
Chronic lung disease- COPD/ pulm fibrosis
Pulmonary vascular disease- PE
Miscellaneous- sarcoidosis, glycogen storage disease and haematological disorders
Gene involved in Goodpasture’s syndrome? Antibodies?
HLA-DRB1
Anti-GBM vs alpha-3 chain of type IV collagen
Auto-antibodies in Wegener’s granulomatosis (granulomatosis with polyangiitis)? Drugs? Nasal carriage of what?
PR3-ANCA(cANCA,) A1AT, HLA-DP, raised ESR & CRP
Propylthiouracil, hydralazine, sulfasalazine, phenytoin and allopurinol
Silica dust, mercury
S.aureus
Presentation of GPA?
Fever, malaise, arthralgias and weight loss–> rhinosinusitis, cough, dyspnoea, hearing loss, purpura, urinary sediment or neurological dysfunction
Upper(90%)= sinusitis, nasal crusting, subglottic stenosis, otitis media, hearing loss, ear pain
Dyspnoea, cough, pleuritis, haemoptysis, pulm infiltrates
Micro haematuria, urinary sediment, pauci-immune RPGN–> CKD
60%= scleritis/ episcleritis, orbital mass, 50%= cutaneous skin lesions, 15%= mononeuritis multiplex, peripheral sensorimotor polyneuropathy, cranial neuropathy
Sx of Churg- Strauss syndrome/ eosinophilic granulomatosis with polyangiitis?
Asthma, pneumonitis, haemoptysis
Allergic rhinitis, paransal sinusitis, nasal polyposis
HF, myocarditis and MI
Leukocytoclastic angiitis, livedo reticularis, urticardia
GN, HTN, advanced CKD
Peripheral neuropathy
ANCA autoantibodies in CSS?
p-ANCA, elevated CRP & ESR, eosinophilia and anaemia on FBC, elevated serum creatinineSus
Suspect atelectasis in dyspnoea and hypoxaemia how long after surgery? Also?
72 hours
Pyrexia in first 48 hours–> chest physio and breathing exercises
5 groups of pulmonary hypertension?
Idiopathic/ CTD e.g. SLE
Left heart failure
Chronic lung disease- COPD/ pulm fibrosis
Pulmonary vasc- PE
Misc- sarcoidosis, haem disorders, glycogen storage
Levine scale for murmurs?
Grade I= very fine- may only be heard by an expert, not heard in all positions, no thrill
II= soft, heart in all positions- no thrill
III= moderately loud, no thrill
IV= loud and associated with palpable thrill
V= very loud with thrill, heard with stethoscope partly off chest
VI= loudest with thrill, heard with stetho entirely off chest (just above precordium)
SE of cyclophosphamide?
Haemorrhagic cystitis
Mnemonic for causes erythema nodosum?
NO/DOSOUM- no cause, drugs- antibiotics, oral contraceptives, sarcoidosis/ Lofgren’s syndrome, UC/ Crohn’s/ Behcet’s, micro- TB/ viral/ bacterial/ psittacosis/ parasitic
Naegele’s rule?
Add 1 year and 7 days to first day of LMP and then subtract 3 months
Tx for mild-moderate acne?
12-weeks of topical adapalene with topical benzoyl peroxide(0.1 or 0.3% with 2.5%)
Topical retinoin with topical clindamycin (0.025% with 1% clindamycin)
Topical BP + clindamycin (3 or 5% with 1% clindamycin)
Mono= topical benzoyl peroxide
Once or twice a week–> daily if tolerated
Moderate- severe acne?
12w of topical ada w/ topical BP ON
Topical retinoin with topical clindamycin ON
Ada with topical benzoyl peroxide ON w/ oral lymecycline 408mg/ oral doxy
Topical azelaic acid BD with oral lym 408mg/ oral doxy 100mg OD
Topical benzoyl peroxide
(Trimeth or oral macro instead of lymecycline or oral doxy)
Last-line option acne? Most effective contraception for acne?
Oral retinoids- isotretinoin (pregnant only 1 month after)
Co-cyprindiol (Dianette)- discontinue 3 months after controlled, also spiro- CI IN PREGNANCY TOO
Refer who to on-call derm team within 24 hours? To consultant led team?
Acne fulminans
Ix uncertainty, acne conglobata, nodulo-cystic acne
Consider if mild-moderate not responded to x2 completed courses tx/ not responses to previous tx including oral AB, acne w/ scarring/ w/ pigmentary changes, causing psych distress
Follow-up acne patients when? Taking oral isotretinoin?
12 weeks- review ABx at 3-monthly intervals- stop ASAP
Review after 1 week- monitor for suicidal ideation, sexual function, dry skin & lips, photosensitivity–> sunlight, rarely= SJS & TEN
STOP FOR 1 MONTH AT LEAST BEFORE BECOMING PREGNANT
Surgical sieve?
VITAMIN DEF
Ix for acne rosacea?
At least one of phymatous changes, persistent erythema/ two of:
Major= flushing/ transient erythema, papules and pustules, telangiectasia, ocular
(Minor= skin and/ or stinging sensation, skin dryness, oedema)
Tx for rosacea? Refer to dermatologist? Oph?
Persistent erythema= topical brimonidine
Topical ivermectin for mild-moderate papules/ pustules
Oral doxy for moderate- to-severe papules/ pustules depending on CIs
Persistent erythema or papules/ pustules not responded to optimal management in primary care, severe telangiectasia
Keratitis/ anterior uveitis
4x things for examining skin?
1) Inspect- general, site & number lesions- pattern distribution and configuration
2) Describe: SCAM- size/ shape, colour, ass secondary change, morphology/ margin
If pigmented: ABCDE- asymmetry, irregular border, two or more colours within lesion/ pink/ grey/ white, diameter>6mm, E- quick growing or rapid appearance changes
3) Palpate- surface, consistency, mobility, tenderness, temperature, tenderness, edge- induration?, bleeding?
4) Systematic- nails, scalp, hair and mucous membranes, general examination
OR LOOK, FEEL, MOVE, REGIONAL LYMPHATIC DRAINAGE, SPECIAL TESTS- peripheral pulses, light touch & pressure sensation, evidence bony involvement, additional examination from PC
Tx for eczema?
Emollients, consider topical steroids for red, inflamed skin- lowest potency and amount of topical corticosteroid
Persistent severe itch or urticaria= 1 month trial non-sedating antihistamine
Affecting sleep= short course sedating antihistamine
Severe extensive eczema= short course oral CSs
Weeping, crusting/ pustules w/ fever or malaise= consider 2 bacterial infection
Thin vs thick greasy emollients for eczema?
E45, Diprobase, Oilatum, Aveeno, Cetraben, Epaderm
50:50, hydromol, diprobase, cetraben, epaderm ointments
Steroid ladder for eczema(ONLY INFLAMED AREAS)? Severe eczema? 2nd line tx?
Hydrocortisone 0.5, 1 and 2.5%
Eumovate- clobetasone butyrate 0.05%
Betnovate- betamethasone 0.1%
Very potent- Dermovate- clobetasol proprionate 0.05%
Ciclosporin, azathioprine, phototherapy UVA, antihistamines e.g. chlorphenamine
Oral corticosteroids e.g. 30mg pred for 1 week
Topical calcineurin inhibitors- less SE, more useful for sensitive areas e.g. tacrolimus or pimecrolimus–> burning/ stinging
When should corticosteroids be continued for? Delicate areas skin? Review emollients? Topical CSs? Non-sedating antihistamines?
48 hours after flare controlled
5 days max
Annually
3-6 monthly, 3 months
Refer within 2w to derm for eczema? Routine?
If severe and not responded to optimum topical tx after 1 week
Ix uncertain, adverse reaction–> emollients, facial eczema not responding, contact allergic dermatitis suspected, social/ psych issues
Tx for infected eczema?
Flucloxacillin/ clarithromycin/ localised= fusidic acid
Not respond–> refer within 2 weeks
Amount and freq emollient eczema?
250-500g/ week child
500-750g/ week for adult
LAMBSKIN for exacerbating factors for psoriasis? Drugs causing mnemonic?
Lithium/ UVA exposure, alcohol, meds- chloroquine & derivatives, steroid withdrawal, M, stress/ smoking, infection with Group A strep, N
Relieving= sunlight
BALI: beta blockers, anti-malarials, lithium, indomethacin- NSAIDs
Tx for psoriasis?
Emollients
Topical CSs- potent no longer than 8 weeks at time
Vit D analogues e.g. calcipotriol/ Dovobet
Coal tar
Short-contact dithranol
CV review every 5y, advice reducing VTE risk- if severe
Derm referral for psoriasis?
Uncertainty, extensive>10%, mod-severe, resistant in primary care, not tolerated, severe nail disease, psych effects
Specialist treatments
Referral to rheumatologist for psoriasis? Severity tool? QOL tool? Rules of 9 for body surface area?
3/more out of 5 on PEST tool
PGA- 6 points
DLQI/ CDLQI
Arm-9%, head-9%, neck- 1%, leg- 18%, anterior trunk- 18%, posterior trunk- 18%
Lund and Browder chart
Types of psoriasis?
Pustular, erythrodermic, chronic plaque, scalp, facial, flexural, guttate, nail
Review psoriasis after how many weeks?
4 weeks, at least annually if using multiple courses potent topical corticosteroids
CV risk every 5 years, advice reduce risk VTE
Specialist tx for psoriasis? Advice?
Skin biopsy
Calcineurin inhibitors- tacrolimus and pimecrolimus- flexural/ facial psoriasis
UVB phototherapy- mild-moderate/ guttate
Severe= methotrexate, ciclosporin, acitretin, apremilast- severe plaque/ nail disease/ high-impact sites (phototherapy ineffective/CI/rapid relapse within 3 months)
Contraception, effects during conception and pregnancy, vaccines= CI, regular influenza and pneumococcal jabs
Anti-TNF for mod-severe plaque- target IL-17 and IL-23 (after phototherapy when conventional failed/ not tolerated/ CI)
Tx for flexural psoriasis? Guttate? Palmoplantar?
Topical mild-mod corticosteroids- short course
Top vit D analogue
Topical mild-mod CSs, UVB, coal tar
Emollients, salicylic acid, potent topical CSs, UVA, oral retinoid alongside phototherapy, anti-TNF only once systemic FAILED- IV inflix/ etan/ adalimumab
What is the Parkland formula for calculating fluid requirements in burns?
Total body surface area % x body weight (kg) x 4 ml
Mnemonic for multiple myeloma?
CRABBI: calcium- high/ renal- light chain deposition, amyloidosis, nephrocalcinosis, nephrolithiasis/ anaemia/ bleeding/ bones- pathological fractures/ infection
Also: carpal tunnel, neuropathy, hyperviscosity
Major and minor criteria for diagnosing multiple myeloma?(one minor and major/ three minor)
Plasmacytoma, 30% plasma cells in bone marrow sample, elevated levels of M protein in blood or urine
10-30% plasma in bone marrow sample, minor elevations in level M protein in blood or urine, low levels antibodies in blood
What is group and save and crossmatching for?
Blood loss is not anticipated but blood may be required if greater blood loss is expected- DONE BEFORE XMATCH
Mix patient with donor blood to see if any immune reaction takes place- if none, donor blood can be issued
Done if blood loss anticipated
BOTH TAKE 40 MINUTES
What is Wallace’s Rule of Nine?
Head & neck, each arm, each anterior part of leg, each posterior part of leg, anterior chest, posterior chest, anterior abdomen, posterior abdomen
What are the thresholds and targets for Hb g/L in patients without and with ACS? Rate in non-urgent?
Without= 70g/L- target= 70-90
With ACS= 80g/L- target= 80-100g/L
STORED AT 4 DEGREES PRIOR TO TRANSFUSION
90-120 minutes- 3 hours with HF, urgent= STAT
Common causes of an itch with a rash? With no rash?
urticari, atopic eczema, psoriasis, scabies
Renal failure, jaundice, iron deficiency, lymphoma- Hodgkin’s, polycythaemia, pregnancy, drugs, diabetes, cholestasis, ageing
Fitzpatrick scale for skin?
1= never tans, always burns
2= usually tans, always burns
3= always tans, sometimes burns
4= always tans, rarely burns- olive skin
5= sunburn and tanning after extreme UV exposure
6= black skin, never tans/ burns
Causes of DIC? Blood picture?
Sepsis, trauma, obstetric, malignancy
Low platelets, fibrinogen, high PT & APTT, high fibrinogen deg products, schistocytes
Possible cause of pityriasis rosea? Versicolor?
HHV-6 or HHV-7
Gold, ACE-i, penicillamine, biologics
BCG, hep B & pneumococcal vaccine
Malassezia fungi
Ix and tx of pityriasis versicolor?
Wood lamp exam–> yellow-green fluorescence
Dermoscopy microscopy of skin scrapings- hyphae and yeast cells that resemble spag and meatballs
Dermoscopy= pallor- background faint pigment network
Fungal culture
Skin biopsy- fungal elements within outer cells of stratum corneum
Topical antifungal shampoo- selenium sulfide(not in pregnancy or breastfeeding,) ketoconazole/ econazole, oral if extensive/ topical ineffective
Small areas= imidazole cream
Terbinafine gel
(Refer pregnant/ breastfeeding–> derm)
Resolve within 2-3 months
Is relapse of pityriasis versicolor common?
Yes- usually when warm weather, regular use topical tx minimises risk- ket shampoo OD for max 3 days prior to exposure
Sx of pityriasis alba?
1-20 patches/ thin plaques on face on cheeks/ chin, may appear on neck, shoulders, upper arms
0.5-5cm diameter, slightly scaly pink patch/ plaque–> hypopigment patch/ plaque with fine surface scale–> post-inflam hypopigment macule without scale–> resolution
May have well-demarcated or/ poorly defined edges
Minimal/ absent itch
Hypopigment noticeable in summer
Dryness more in winter
Ix and tx of pityriasis alba?
Wood lamp- hypopig doesn’t enhance, no fluorescence, mycology scrapings= negative
Skin biopsy= rarely needed
No tx- maybe moisturiser, mild topical steroid, calcineurin inhibitors
USE SUNSCREEN, usually clears after one year
Cause and presentation of lichen planus(6 Ps)?
T-cell mediated AI disorder- attack unknown protein within skin and mucosal keratinocytes
Genetics, physical & emotional stress, injury–> skin, herpes zoster, hep C, contact, drugs- gold, quinine, quinidine, others–> lichenoid rash, vit D deficiency
10%= nails, 50%= oral- W>M
Pruritic- not painful, purple- except palms and soles= yellowish- brown, polygonal, planar, papules and plaques- interspersed with Wickham striae
Often wrists, lower back and ankles, also genitals
Ix and tx lichen planus?
Clinically- skin biopsy often recommended(lichenoid tissue reaction affecting epidermis), patch testing for oral those affecting gums & amalgam fillings
Avoid soaps and shower gels, use emollients regularly, sedating antihistamines
MOST RESOLVE WITHIN COUPLE YEARS
Drugs causing lichenoid eruption? Fixed drug eruption?
Absent Wickham’s striae, usually 2m before, affects trunk, ACE-i, BBx, nifedipine, diuretics- thiazide, NSAIDs, anticonvulsants, TB meds, antifungals, hydroxychloroquine, gold, allopurinol, tetracyclines
Quinine
MOST RESOLVE BY 12M SPONT
Paracetamol, tetracyclines, sulfonamides, aspirin
Types lichen planus?
Planopilaris, nail, oral, cutaneous, pigmentosus, actinicus- sunlight, lichenoid drug eruption, bullous & pemphigoides
Ix and tx or vitiligo?
Wood’s lamp= enhances white patches
Dermoscopy= white glow
Skin biopsy sometimes
Blood tests- other autoimmune e.g. TFTs, ANA and B12 levels
Loose fitting clothing, cosmetic camouflage, sun protection, topical CSs, calcineurin inhibitors
Topical vitamin D derivatives
Ruxolitinib cream- JK1 and JK2 inhibitor, topical tacrolimus, phototherapy- UVB twice weekly for 3-4 months
ABPI values indicating arterial disease? Features and tx venous ulcers?
Below 0.9, >1.3
Diabetes, RA, vasculitis, SCD, malignancy, drugs- nicorandil, corticosteroids, NSAIDs, radiotherapy, hydroxycarbamide, varicose veins, DVT
Gaiter area- ankle–> mid calf, chronic venous changes, after minor injury larger than arterial, more superficial than arterial, irregular gently sloping border, more likely to bleed, less painful than arterial, pain relieved by elevation and worse on lowering, pulses present
Normal ABPI, Doppler exclude arterial disease- every 6-12 months
Clean and dress wound, high compression 4 layered bandage, leg elevation, ABx for infection, analgesia, support stockings for life
Pentoxifylline improves healing- NOT LICENSED
Regular walking, avoiding leg trauma, emollient frequently
No healing after 2 weeks comp therapy= specialist referral
Recurrent ulcer= refer for superficial venous surgery
Comps venous ulcers?
Allergic contact dermatitis, infection- osteomyelitis, sepsis, nec fas, chronic pain, malignant transformation= Marjolin’s ulcer, sinus formation and fistula
In hx- ASK ABOUT LATEX ALLERGY
Sx and Ix of arterial ulcers?
Feet, heels or toes, from diabetes, smoking, high blood fat and cholesterol, renal failure, obesity, RA, clotting and circulation disorders, other arterial disease
Typically punched out out appearance, painful- particularly at night or when the legs are at rest and elevated, may be areas of gangrene, cold with no palpable pulses, smaller than venous ulcers, well defined borders, less likely to bleed, NO OEDEMA
Low ABPI measurements<0.9, severe=<0.5
Bloods- FBC, CRP, HbA1C, CRP, charcoal swab- infection, skin biopsy in suspected skin cancer- 2 week wait referral
CRT, Buerger test, Doppler- transcutaneous oximetry<20mmHg= severe insufficiency
