OSCE nuggets Flashcards
What is third HS heard in
HF
Young athletes
When is gallop rythm heard
HF on history of HTN
LVH vs HF on ECG and CXR
LVH- tall r waves and normal on X-ray cos heart grows in
HF- cardiomégalie and normal ECG
BMI levels
Overweight -25 30 Obese- 30 35 Severe obesity 35 40 Morbid obesity 40 50 Severe morbid 50+
How does obesity levels change with ethnicity
Over 23 is overweight in South Asians
What are you gonna do if BP over 140 diastolic
Check multiple times and and examine patient for signs of HTN
On examination what would be signs of HTN
Carotid bruits
S4
Fundoscopy
Heave
What is seen in grade 1 HTN fundoscopy
Silver wiring
What is silver wiring
Line in artery coming off the disc
What is grade 2 HTN fundoscopy finding
AV nipping
What is AV nipping
Crossing between artery and vein
What is grade 3 HTN of fundoscopy
Flame haemorrhages
Cotten wool spots showing ischaemia
What is grade 4 HTN fundoscopy finding
Papilloedema
What are secondary causes of HTN
Acromegaly Nephritis Renal artery stenosis Coarctation of aorta Cushing Cons Phaeos
What is primary HTN called
Essential HTN
Why do FBC HTN
Polycythaemia
Why do U&Es HTN
Low K is Conns or Cushing
See if kidney function affected in nephritis or renal artery stenosis
ECG finding HTN
LVH
What to look for urinalysis HTN
Nephritis
Investigations would do for HTN
FBC U&Es Glucose Lipids ECG Urinalysis
Most important investigation for secondary HTN investigations
U&Es
If suspected Renal artery causing HTN what is first line investigation for this
MR Angio as can see aortic coarctation too
What are 3 steps to diabetic retinopathy
Background
Pre-proliferative
Proliferative
What are signs of background retinopathy
Hard exudates
Microaneurysms
Blot haemorrhages
What are signs of pre proliferative diabetic retinopathy
Cotton wool spots
What are signs of proliferative retinopathy
New blood vessels formed due to ischaemia
What is maculopathy
When macula is damaged by retinopathy
What are signs of maculopathy
Hard exudates over macula
Antibiotics used in appendicitis
Cefoxamine and metronidazole
Who does appendicular mass occur in
People who wait to present
What are appendix perfs more common in
When faecolith involved- children
What in any abdo pain in young women is first line
Pregnancy
What does a positive psoas sign suggest about appendix position
Retrocaecal
What does a positive copes sign suggest about appendix position
Near to obturator externus
What non bowel symptoms are common in diverticulitis
Urinary ones
Especially when fistula- brown urine
What surgical procedure is done in diverticulitis
Hartmanns
What is a hartmanns procedure
Form colostomy bag leaving anorectal stump- once inflammation has died down will do promary anastomosis
Why cant you do primary anastomosis in diverticulitis
Oedema will mean when close the bowel there will be holes
What is first line investigation for diverticular disease
Barium swallow through
OPeration done in severe diverticular disease
Primary anastomosis
Complications of diverticular disease
Perf Diverticulitis Peri-colic abscess LBO Faecal peritonitis Fistulas
Risk factors to ask about in hernia history
Constipation
Chronic cough
Heavy lifting
Hernia presentation
Lump in groin
Groin pain
Scrotal swelling
Vomiting
Who does femoral hernias occur in
Elder females
Who does inguinal hernias occur in
Younger males
What do inguinal hernias contain
Bowel
What do femoral hernias contain
Omentum
In what position do hernias often reduce
Supinated
Signs of strangulated hernias
Tender Red Colicky pain Distension Vomiting
Difference in management of femoral and inguinal hernias
Will do surgery much more often in femoral as risk of strangulation
Which drugs cause pancreatitis
Thiazides
Azathioprine
Signs on examination of pancreatitis
Epigastric tenderness
Reduced bowel sounds
Fever
Shock
What does a normal Ca in glasgow score suggest about pancreatitis cause
Hypercalcaemia
What does very low Ca suggest about prognosis
Not good
How long after eating does chronic pancreatitis pain present
15-30mins
What is often new diagnosis in chronic pancreatitis
T2DM
1st line investigation for chronic pancreatitis
CT abdo- see calcified pancreas
Management of sigmoid volvulus
Rigid sigmoidoscope decompression
What is the other name for watershed zone
Griffiths
If ischaemia at griffiths point what is most likely cause of
Hypovolaemia ( water shed zone is griffiths point)
Which areas are susceptible to ischaemic colitis
Sudeks point
Griffiths point
Right colon
Where is sudeks point
Rectosigmoid junction
What are most likely causes of ischaemic colitis
Hypoperfusion
What are most likely causes of acute mesenteric ischaemia
VTE
Managment of ischaemic colitis vs mesenteric ischaemia
Mesenteric immediate surgery
Ischaemic conservative- fluids and bowel rest
What is presentation of mesenteric ischaemia
Vomiting
Diarrorhoea
Sudden onset diffuse pain
Risk factors mesenteric ischaemia
AF
Cocaine
Smoking
Triad for mesenteric ischaemia
Sudden diffuse pain
Normal exam
Shock signs
Investigations for acute mesenteric ischaemia
ECG
ABG
AXR
CT
Signs seen on imaging mesenteric ischaemia
Perforated
Megacolon
Dilated
Managment of occlusive mesenteric ischaemia no gangrene
Thrombectomy
Thrombolysis
Management of non-occlusive mesenteric ischaemia with no gangrene
Fluid resus
Presentation of ischaemic colitis
Post prandial gut pain history
PR bleeding
Weigjht loss
Causes of non occlusive ischaemia in bowels
SEPSIS
Shock
Trauma
Complication of iscahemic colitis
Ileus
Management of iscahemic colitis causing ileus
Drip and suck
Management of ischaemic colitis
IV fluids
Diet lifestyle management in diabetes
Low sugars and complex carbs
Snack less regularly
After metformin what are 3 drugs can choose from
Sulphonylureas
Gliptins
SGLT2i
How does metformin work
Reduces liver production of glucose and improves sensitisation to insulin
Pros of metformin
Shown to easily reduce Hb1ac
Improves reduced CVA events, life expectancy and cancer risk
Cons of metformin
Diarrorhoea
Metabolic acidosis risk
Symptoms for metformin acidosis
stomach pain, nausea, irregular heart rate, anxiety, hypotension (low blood pressure), rapid heart rate.
How do sulphonylureas work
Increase insulin production at level of pancreas
How can metformin does be delivered to help with diarrorhoea
Titre up slowly
What impact does sulphonylureas have on weight
Makes you gain weight
What is main risk of sulphonylureas
Can have hypoglycaemic episode
Who isnt sulphonylureas appropriate for
Overweight people
People who drive regularly or are truck drivers as risk of hypo
Cons of sulphonylureas
Weight gain
No benefit longer term in terms of mortality
Risk of hypos
What do gliptins do
GLP 1 enzyme inhibitor thus increases insulin production
Benefits of gliptins
Help reduce appetitie and lose weight
Good at lowering Hb1ac
Cons of gliptin
Risk of pancreatitis
Can have diarrorhoea
How do SGL2Ti work
Block a channel in kidney allowing glucose to pass out
Side effects of SGL2Ti
Polyuria and polydipsia
Genital infections
Positives of SGL2Ti
Especially helpful for kidney and heart failure patients- improved mortality
Help lose weight
Names of sulphonylureas
Glibenclamide
Glipizide
Names of gliptins
Vildagliptin
Saxagliptin
Names of SGLT2i
empagliflozin
If troponin and ECG neg what is next investigation
Exercise tolerance test
Gastro causes of chest pain
Oesophagitis
Gastritis
Oesophageal spasm
What is major risk factor for boerhaves perforation
Recent endoscopy
How high can JVP go
Up to ear can even appear pulsatile
Causes of tricuspid regurg
RV dilation
Leaflet damage- RF, endocarditis
What infection can commonly lead to pericarditis
TB
Rfs for pericarditis
TB
Recent URTI infection
CTD
What questions ascertains in syncope if LOC
Can you remember
What does sinus mean in reference to rythm
Present P waves
Causes of sinus tachycardia
Hypovolaemia Sepsis Pain Caffeine PE Endo- thyrotoxicosis, phaeochromocytoma
How to determine if AVRT or AVNRT
Return to normal rate and rythm
Amir sam causes of Afib
Thyrotoxicosis Alcohol Heart: - pericarditis - muscle. cardiomyopathy, IHD - Valvular Lung - PE - cancer - pneumonia
Causes of VT
Electrolyte abnormalities
Ischaemia
Long QT
Management of SVT haem stable
Valsalva and vagal manouevres
Adenosine
Treat cause
Management of SVT haem unstable
DC cardioversion
What can cause fixed splitting of S2
Atrial septal defect
If patient is hypothermic needing defib what must do
Warm up
Management of haem stable VT
IV amiodarone
Treat underlying cause
ICD
How to work out if LVH
Add deep S in V1 to tall R in V5/6 and if greater than 35 small squares
What scores are used to work out if anticoagulate in Afib
CHAD VASC
HASBLED
How to work out if long QT
Draw 2 lines between R waves and work out midpoint
If t wave here or further then long QT
Which type of stroke will normally lead to collapse
Haemorrhagic
Why do we feel carotid pulses
Hypovolaemia will be weak
Slow rising pulse for aortic stenosis
What does carotid feel like in aortic stenosis
Like a thrill
Slow rising
Weak
What is pulsus tardus and parvus seen in
Aortic stenosis
What is bifid carotid pulse seen in
Aortic regurg
What is the anion gap
Sodium and potassium - chloride and bicarbonate however chloride and bicarrbonate dont account for all of the negative ions so the anion gap is all those left that allow electroneutrality
What is a normal anion gap
Should be small
What is an abnormal anion gap
Very high- due to extra anions normally due to dissociated acid part
What causes a high anion gap
Lactate Uraemia Ketones Toxins KULT
What does hypoalbuminaemia indicate about liver disease
Chronic
What does isolated elevated PT suggest about liver disease
Acute liver disease
Causes of hyperkalaemia
Addisons Renal failure ACE Spironolactone Rhabdomyolysis Metabolic acidosis
Main ECG findings of hyperkalaemia
Bradycardia Absent or small p waves Long PR Broad QRS Tented T waves
Management of hyperkalaemia
ECG Calcium Gluconate 10% 10ml Salbutamol nebs.10mg Insulin 5-10 units \+ Glucose 50% 50mmol Regular VBGs
Symptoms of hypokalaemia
Weakness
Arrythmia
Hypokalaemia
Causes of hypokalaemia
Vomiting Diarrorhoea Loop diuretics Thiazide diuretics Conns Cushing
Arrythmia hypokalaemia can lead to
Torsades de pointes
What does RAAS do to k and na
Excretes K
Reabsorb Na
Keys to managment of hypo Na and K
Do it slowly
Na fast leads to central pontine myelinolysis
K is an irritant to veins so either cheset drain or slowly in cannula
Mild hyponatraemia presentation
Confusion
Severe hyponatraemia presentation
Vomiting
Seizures
Death
What causes ADH release
Low volume at carotid sinus
Low Na concentration
Why does ADH release cause hyponatraemia
It only retains water not Na like aldosterone as acts on collecting duct
Hypovolaemia signs on examination
Dry membranes Reduced skin turgor Postural hypotension HR up Reduced urine output Confused
What happens to urine sodium in hypovolaemia
Its low
Signs on examination of hypervolaemia
JVP up
Bibasal creps
Peripheral oedema
Why do you get hyponatraemia in hypovolaemia
Lose sodium and fluid however ADH only fixes water so volume goes up but sodium remains the same
Why do you get hyponatreamia in hypothyroidism
Reduced thyroxine reduces CO thus reducing apparent volume causing ADH release
How does addisons lead to hypovolaemic then euvolaemic hyponatraemia
Aldosterone production is reduced causing sodium loss and so also water loss leading to hypovolaemia. Then as reudced volume ADH increase water up to euvolaemic
Why dont you become hypervolaemic in SIADH
Initially you release too much ADH causing retention of water however this hypervolaemia triggers ANP and BNP release which gets rid of water and sodium
Causes of SIADH
CNS pathology such as meningitis, enchepahlitis and SAH
Surgery
Drugs- SSRIs, TCAs, opiates, PPIs, carbamezapines
Lung pathology
Investigation for euvolaemic hyponatraemia
Short SynACThen
TFTs
Urine osmolaltiy
Causes of hypernatraemia
Diabetes insipidus
Conns
Cushings
What is defined as HTN
BP over 140/90mmHg
If in OSCE take BP what do you offer to do
Take in both arms and if is difference of over 15 then recheck in the arm with highest BP
If you notice that BP is over 140/90 on first go what do you do
Ideally take 3 readings and take the lower of last 2
Once a clinic reading of 140/90 is made what is next step
Offer ambulatory BP measurement
What are 3 cut offs for ABPM
If under 135/85 then not hypertensive
If over 150/95 then stage 2 HTN
If over 135/85 then stage 1 HTN
What does stage 1 HTN mean for treatment plan
If under the age of 80 and has one of these then treat;
- established CVD
- renal disease
- diabetes
- organ damage
- 10 year risk of CVA over 10%
Way to remember HTN stage 1 reasons for treatment
CORD 10
What does it mean for stage 2 HTN
Treat all patients regardless of age
What is metformin contraindicated in
Renal failure due to lactica acidosis risk
What would be suspected in MI at young age
HOCM
Long QT
Familial hypercholesterolaemia
What can cause elevated lipids non lifestyle
Liver failure
Renal problems
Hypothyroidism
High glucose
Management plan for hypercholesterolaemia
Lifestyle
Statin
Ezetimibe
Bezafibrate
SEs of statins
Headache
Proximal myopathy
Flatulence
Tired
What is problem of nifedipine in malignant HTN management
Done too quickly- want to manage slowly down in around 24hrs
What is target BP for diabetics
130:80
What offer if BP less than 140:90
To check every 5 years maybe less if close to target
What must be measured when giving apixaban
Renal function
Investigations for stable angina
Bedside - ECG - Obs- BP to see if hypertensive Bloods - FBC - troponin - lipid profile - glucose or hba1c Imaging - ETT with ECG - ETT with echo - stress echo - cardac CT angiography - invasive coronary angiography
Management plan for stable angina
Lifestyle advice - lipid, diabetes and HTN management Aspirin 75mg or clopidogrel or both GTN spray for when in pain First line anti anginal of either CCB or beta blocker depending on SEs of patietns choice Then both if tolerated Second line ivabradine or long acting nitrate Third line PCI with stent or CABG
Why is FBC important in stable angina
Anaemia can exacerbate symptoms
In cardiac CT angio and invasive coronary angio what is defined as coronary obstruction
Stenosis of 50-70%
Management plan for acute UAP
Aspirin and clopidogrel
Nitrates- if not toleralted morphine
Fondaparinaux
Sent for ETT/stress echo then potential PCI
Investigations for UAP
Bedside - obs - ECG Bloods - troponin - FBC - U&Es - LFTSs - lipids - glucose/Hba1c Investigations - stress echo - echo - ETT - myoview of heart - cardiac CT angio - invasive angio with potential PCI
Why are LFTs important in ACS
Check clotting for anticoagulation
Why are U&Es important ACS
Baseline
Why do an Echo UAP
See if any regional wall abnormaliites
Check LVF
What is seen in myocardial perfusion scan of heart UAP
Unmatched perfusion between rest and stress
Long term management of UAP
Continue on aspirin for life and clopidogrel for one year
Statin
Beta blockers or verapmil or carvedilol (mainly beta blocker)
ACEi/ARB
Spironolactone
DM/HTN management
What is verapamil MOA
CCB
What class of drug is clopidogrel
P2Y12 inhibitor
What are 2 P2Y12 inhibitors
Clopidogrel
Ticagrelor
What is MOA of flecainide
Sodium channel blocker
What are 2 examples of ARBs
Losartan
Candesartan
MOA of thiazides
Inhibits Na/Cl channel DCT
2 examples of thiazide diuretics
Bendroflumethazide
Indapamide
MOA of spironolactone
Aldosterone inhibitor
What does ARB stand for
Angiotensin 2 receptor blocker
MOA of digoxin
Reduces HR and also improves contractility
Management plan of Type B aortic dissection
If no end organ ischaemia
- beta blockade using labetalol
- aiming for HR under 60 and systolic under 120 so if beta blockade fails use vasodilator therapy
- first line vasodilator therapy is nitropusside
- second line diltiazem
If end organ failure open surgery or endovascular graft
BP managemet in any aortic dissection
Beta blockade using labetalol
Aim for HR under 60 and sys under 120
If beta blockade fails use 1st line nitropusside, 2nd line diltiazem
Investigations ordered for aortic dissection
Bedside - BP in both arms - ECG Bloods - FBC - U&Es - LFTs - G&S - troponin - VBG Imaging - CXR - CT angio - echo
What can be seen aortic dissection on ECG
St depression or ST elevation
CXR findings aortic dissection
Widened mediastinum with blunted aortic knuckle
Can get pleural effusion
Risk factors for pericarditis
TB CTD Recent MI URTI- viral Cancer Uraemia
Where can pericarditis pain also be
Trapezius ridge
O/E constrictive pericarditis
Pericardial friction rub
Raised JVP
HF signs possible
Management plan for pericarditis
NSAIDS(aspirin or ibuprofen) with PPI!
Colchicine
Exercise restriction
Second line steroids if unresponsive
Investigations for pericarditis and findings
ECG- widespread concave ST elevation Throat swab Bloods - FBC- lymphocytosis - U&Es- uraemia is cause - troponin Echo- pericardial effusion or helps distinguish from MI and pericardial thickening helps distinguish from restrictive cardiomyopathy Pericardiocentesis helps identify cause
Examples of target organ failure in HTN
LVH
Retinopathy
Increased albumin to creatinine ratio
CKD
In stage 2 HTN when is a statin given
If q risk over 10%
What is as significant contraindications for CCB
HF
What is main side effect of thiazides
Sexual dysfunction
Complications of pneumothorax
Bronchopleural fistula
Recurrent pneumothoraces are common- 20% chance of repeat
Management of recurrent pneumothoraces
PLeuroidesis using sclerosants like tetracycline
Diffuse abdo pain with nausea and vomiting
Obstruction
Mesenteric ischaemia
How does acute mesenteric ischaemia present
Acute diffuse abdo pain
Nausea and vomiting
Haematochezia
Complains of post prandial pain
What is small meal syndrome
When due to chronic mesenteric ischaemia you start eating smaller meals due to pain caused by eating larger ones
Risk factors for liver abscess
intrahepatic processes/surgery DM Biliary disease GI infection Recent travel
Difference in pain of SBO vs LBO
SBO pain higher up due to somatic supply
LBO lower and spasms last for longer
What is PT in obstructive causes of jaundice
High as reduced absorption of VIT K
US finding of cholangiocarcinoma
Mass
Dilated bile ducts
What are 2 cancer markers raised in cholangiocarcinoma
CA19-9
CEA
Ratio of CA19-9>40xCEA
What non cancerous disease is CEA raised in
IBD
Why isnt measuring CEA to screen adenocarcinoma in UC a good idea
Also elevated in UC
Why do U&Es plus LTFs in sarcoidosis
Can get liver and renal involvement
Management of diverticular disease
Improved diet and hydration
If bacterial overgrowth suggested give abx
If symptoms persist for a while can consider surgery
Management plan for diverticulitis
Analgesia
Fluids
Abx
Consider surgery if perforation, abscess, fistula or excessive bleeding
What should be done if excessive bleeding that cant be stopped in acute diverticulitis
Consider transfusions
CT angio or isotope labelled red blood cell nuclear scan
Complications of diverticulitis
Abscess Fistula Perforation Sepsis Excessive bleeding
Investigatons for acute diverticulitis
Bloods FBC- neutrophillia, CRP up, anaemia U&Es for baseline Blood cultures G&S CT eCXR or AXR to look for pneumoperitoneum
What is seen on CT diverticulitis
Abscess
Fistula
Thickened bowel walls
Outpouchings inflammed
What can be done for patients who have regular COPD exacerbations
Arithomycin thrice weekly
Who does constipation cause confusion in
The elderly especially post op
What causes ischaemic colitis in younger people
Cocaine use
What happens to Hba1c in hereditary spherocytosis
It decreases and is so underestimated
What causes PSM heard loudest at left sternal edge lower down and with louder P2
VSD
If variceal haemorrhage is uncontrolled with terlipressin what must be done prior to endoscopy
Insertion of sengstaken blakemore tube
If patient has atelectasis what is best immediate management
Sit patient up
Then refer for chet physio
What can cause ischaemic hepatitis
Sepsis leading to hypoperfusion
Clot
What artery most commonly affects the trigeminal nerve in TN
Superior cerebellar artery
What can be secondary causes of cluster headaches
Pituitary adenoma or hypothalamic dysregulation
Pathophysiology of cluster headaches
hypothalamic activation with secondary trigeminal and autonomic activation
What can trigger a cluster headache
Alcohol
Stress
Sleep
Volatile smells
Investigations for cluster headache
ESR to rule out GCA
MRI to rule out secondary pituitary or hypothalamic cause
Pituitary function tests can rule out secondary cause
What is seen on head CT of extradural
Lemon shaped bleed
Midline shift and cerebral oedema
What is alternative cause of extradural and how would be investigated
AV malformation
CT angio
Major criteria for rheumatic fever
JONES pnemonic Arthritis Carditis Nodules sub cut Erytherma marginatum Sydenhams chorea
Minor criteria for rheumatic fever
Raised CRP
Raised ESR
Fever over 38.5
Prolonged PR
Investigations for rheumatic fever
Bloods -ESR -CRP -WCC ECG - can show elongated PR Echo - valve damage PCR or throat culture for strep Anti-streptolysin titres
How does erythema marginatum appear
Ring like appearance on torso and legs
What is management of gallstones
If symptomatic give NSAIDS like diclofenac and offered laparoscopic cholecystectomy
If asymptomatic from being found incidentally dont offer cholecystectomy unless signs of porcelain gall bladder, high risk of GB cancer and chronic risk like SCD
When would you offer cholecystectomy in asymptomatic biliary colic
Signs of porcelain GB
High risk of GB cancer
Chronic risk from diseases like SCD
What are main complications of biliary colic
Cholecystitis Cholangitis Pancreatitis Mirrizi syndrome Gallstone ileus
Investigations ordered for bilairy colic
Bloods - FBC looking for WCC - CRP as inflammation - LFTs see if liver function deranged - amylase - lipid profile Imaging - US showing gallstones, dilated ducts and sludge - MRCP and CT also showing this Only really would do this if stones unidentifiable or signs of complications
What is most common viral cause of subacute thyroiditis
Cocksackie virus
Investigations for subacute thyroiditis
Bloods
- ESR and CRP up
- TFTs depends on the stage of disease
- antithyroid peroxidase abs can be present
Imaging
- scintigraphy will show global reduced uptake
- FNA will show granulomas and WCC infiltration
How long cant you drive for following a first unprovoked seizure
6 months
O/E idiopathic pulmonary fibrosis
Clubbing
Fine late inspiratory crackles
What should be ruled out in initial idiopathic pulmonary fibrosis screen
RA
Myositis
What is positive BPPV finding
Delayed onset torsional unilateral nystagmus
What is podagra
Gout
What are smudge/smear cells
Remnants of cells
RFs for saccular aneurysms
Marfans
Ehlers
PCKD
NF1
What is lupus vernio seen in
Sarcoid
What are risk factors for burkitts lymphoma
Immunosuppression- HIV
EBV
Investigations for SIADH
TFTs
Short Synacten to rule out these as causes of euvolaemic hyponatraemia
What is difference in pupil between anterior uveitis and closed angle glaucoma
Dilated in glaucoma
Constricted in anterior uveitis
what is finding of CSF in GBS
High protein
Albumin cytological dissociation
What indicates severity of mitral stenosis
Length of murmur
How to diagnose zollinger ellison syndrome
Fasting gastrin level
How is nephrogenic diabetes insipidus treated
Thiazide diuretics
How is cranial diabetes insipidus treated
Intranasal desmopressin
What virus predisposes to MS
EBV
What 2 lifestyle changes will help improve BP
Lose weight
Eat less salt
What cardiac abnormailities are seen in carcinoid syndrome
Pulmonary stenosis
Tricuspid insufficiency
O/E myocarditis
HF signs
Sinus tachycardia
Arrythmias common
Investigations for myoarditis
Bloods - WCC up - CK MB up - troponin very up ECG - non specific ST elevation and depression - some T wave inversion CXR - bibasal crackles if in HF Echo - global dyskinesia - LV dilation Endomyocardial biopsy - infiltration and necrosis
Management plan for bronchiectasis
All patients - improve diet and exercise - physio Some patients - inhaled bronchodilator - mucolytic (hypertonic saline)
What is example of mucolytic used in bronchiectasis
Hypertonic saline
What is done for patients with bronchiectasis who have over 3 exacerbations a year
Inhaled abx
When are patients with bronchiectasis given inhaled abx
If have over 3 exacerbations a year
What causes systolic HF
Arrythmia
Cardiomyopathy
MI
What causes diastolic HF
Constrictive pericarditis
Valve regurg
HTN
Why in stroke do you stop anticoagulants
Is risk of haemorrhagic transformation
Immediate treatment for stroke
Aspirin 300mg and stop anticoags
Anticoagulation for stroke first 2 weeks
Aspirin 300mg and stop anticoags
Anticoagulation for stroke after first 2 weeks
Stop aspirin
Clopidogrel 75mg OD
Specialist consideration for anticoags depending on cause etc
What is given to someone just before going to PCI regardless of if NSTEMI or STEMI
Unfractionated heparin
Immediate antplatelet therapy in ACS
Aspirin 300mg
Clopidogrel 300mg or ticagrelor 180mg
Long term ACS dual antiplatelet
Aspirin 75mg for life
Clopidogrel 75mg or ticagrelor 90mg BD
What is only long term ACS antiplatelet take BD
Ticagrelor
What is myelodysplasia
A precancerous state where mutations leads to bone marrow production of immature cells in all myeloid strains leading to pancytopenia
What does myelodysplasia lead to in 1/3 of cases
AML
What happens initially in myelofibrosis
Produce loads of every cell but bone marrow then decompensates leading to fibrous deposits
Causes of TTP
Cancer
Pregnancy
Idiopathic
What are nerve comlpications of amyloid
Carpal tunnel
Neuropathies
What causes dry eyes in sarcoid
Keratoconjunctivitis sicca
What is skin change seen in amyloid
Purpuric rash
What is main difference between PBC and PSC
PBC only affects intrahepatic bile ducts
What is condition linked to polyarteritis nodosa
Hep B- most sufferers will have Hep B
What is rosary sign seen in
Polyarteritis nodosa
What is rosary sign
Aneurysms formation polyarteritis nodosa
What is pathergy test used for
Behcets
What happens in pathergy test
Skin prick made into skin and in behcets get small red lump
What are 3 types of amyloid
AL- myeloma
AA- inflammatory conditions
ATTR- elderly and familial
What does Amyloid ATTR stand for
Amyloid trans thyretin
What is only vasculitis that causes cavitating lesion
Wegners
What is common to all COPD categories
FEV1/FVC ratio less than 0.7
COPD categories are based on what
Percentage of expected FEV1
COPD categories
Mild above 80% expected FEV1
Moderate 50-80% expected FEV1
Severe 30-50% of expected FEV1
Very severe less than 30% of expected FEV1
What are main complications of COPD
Cor pulmonale
Pneumothorax
Recurrent infection leading to exacerbations
Polycythaemia vera
What are 3 treatmetns known to improve mortality in COPD
Stop smoking
Lung reduction surgery
Long term O2
4 factors that determine if COPD patient goes down asthma pathway
Raised eosinophil count
Diurnal variation of PEF greater than 20%
FEV1 variation in time
Diagnosis of asthma or atopy
Simple COPD management
Stop smoking
Annual flu vaccine
Pneumococcal vaccination
Drug management COPD
SABA or SAMA
If asthmatic LABA and ICS
If not LABA and LAMA
Finally LABA, LAMA, ICS
Further long term management of COPD
Lung reduction surgery
Long term O2 if meet criteria 1 of either
- terminally ill
- PaO2 less than 7.3
- PaO2 7.3-8 with pulmonary HTN, PCV or nocturnal hypoxaemia
What is difference in hydrocrotisone dose between asthma and COPD infective exacerbation
100mg in asthma
200mg in COPD
How does Hep C present typically
Asymptomatically- most people will be able to clear but sometimes can progress to cirrhosis
What is main risk factor for progression of Hep C to cirrhosis
Alcohol intake
Hep C
Most common cause of CKD
Diabetes
What antibiotic should be avoided in pregnancy
Trimethoprin
Which is more common FAP or HNPCC
HNPCC
What is target Hba1c for T1DM
48
What does ST elevation alone in AVR and widespread ST depression imply
Left main or LAD ischaemia
What is definition of TIA based on now
The definition of a TIA is now tissue-based, not time-based: a transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischaemia, without acute infarction
General management of atypical pneumonia
Amoxicillin and clarithomycin
If want to DCcardiovert someone in AF who has been symptomatic for longer than 48 hours what are 2 options
TEE to look for clots if clear can do it
Anticoagulate for 3 weeks
Metabolic compications of DM
DKA
HHS
Hypoglycaemia
Cavitating lesion causes
Wegners SqCC Klebsiella TB Staph aureus Mycetoma Rheumatoid arthritis
Cause of bleed if malaena and recurrent nose bleeds
Hereditary telengiectasia
Cancer causes of parasthesia
Myeloma
Paraneoplastic syndrome
Hereditary causes of parasthesia
Hereditary sensory motor neuropathy
Common symptom of MS often overlooked by clinicians
Fatigue
What is L’hermites sign most commonly seen in
MS from transverse myelitis
Which countries are MS sufferers normally seen in
Scandinavia
How can you tell if a lesion in MS is new or old
Gadolinium contrast will show what lesions are new as acute inflammation leads to increased uptake
Which types of people does MG most commonly occur in
Women under 40
Men over 60
What happens to reflexes in MG
Normal
What mainly happens to thymus in MG
Majority of time get thymic hyperplasia but can sometimes get thymomas
What is picks disease
A type of frontotemporal dementia
How is diagnosis of MND made
Clincal but other diagnoses must be excluded
Differential diagnoses to rule out in MND
B12 deficiency MS Cervical myelopathy HIV Metastatic brain cancer
Investigations done in MND work up
Bloods- B12, HIV and lyme disease serology
CT/MRI
EMG finding of MND
Fasiculations and fibrillations
Main wasting sites of MND
Thenar
Tongue
Sign on examination of MND causing dysphagia
Tongue wasting
What is typical initial presentation of ALS
Foot drop
Clumsy weak hand
Signs on examination of initial ALS
Some wasting
Mix of initial UMN and LMN
Proportions of types of MND
ALS- 60%
Bulbar- 30%
Progressive lateral sclerosis- 5%
Progressive muscular atropy-5%
4 types of MS
Relapsing remitting
Primary progressive
Secondary progressive
Clinically isolated syndrome
What is presentation of bulbar MND
Dysarthria and dysphagia
Signs on examination of bulbar MND
Dysarthria
Brisk jaw jerk
Tongue fasiculations and wasting
What is difference in prognosis between bulbar MND and ALS
Bulbar much worse
What MND gives pure UMN onset
Primary lateral sclerosis
What MND gives purely LMN onset
Progressive muscular atrophy
What does pseudobulbar MND mean
Purely UMN findings
What is difference between pseudobulbar and bulbar MND
Pseudobulbar is purely UMN whereas bulbar is a mix
What are UMN bulbar signs
Exaggerated gag reflex
Brisk jaw jerk
Spastic tongue
What are LMN bulbar signs
Tongue wasting
Tongue fasicullations and fibrillations
Absent jaw jerk and gag reflex
Main risk factors for parkinsons
Male
Age
Living in countryside
Fhx
What rigidity is seen on examination on parkinsons
Initially is lead pipe but with tremor superimposed becomes cog wheel
What comes under umbrella of parkinsonism
Parkinsons disease
Drug induced parkinsons
Atypical parkinsons diseases
What drugs can causes drug induced parkinsonism
Anti-epileptics
Anti-emetics
Anti-psychotics
What are some atypical parkinsons diseases
Multi infarct parkinsons
Parkinsons diseae dementia
What is main difference between parkinsons disease dementia and LBD
With LBD motor and cognitive sx come on at same time
In parkinons disease dementia the cognitive decline comes on way after
What is main pathognomic symptom for parkinsons disease dementia
Visuospatial disturbances
What is best test for parkinsons
Responsiveness to L dopa
What does lead pipe rigidity mean on examination
Increased smooth hypertonia in both directions
Hypomimia sign on face
Blinking
What is needed for parkinsons diagnosis
3 of triad
2 is just parkinsonims
What are 2 degenerations of parkinsons
Progressive supranuclear palsy
Multiple system atropy
Defining features of progressive supranuclear palsy
Dysarthria
Instability
Fail to look downwards
Defining features of multiple system atrophy
Early autonomic features- incontinence, orthostatic hypotension
What is degeneration of parkinsons that leads to autonomic symptoms
Multiple system atrophy
What is degeneration of parkinsons that leads to postural instability and impaired gaze
Progressive supranuclear palsy
What are features that distinguish parkinsons from parkinsonism
Asymmetrical features
Response to L dopa
No atypical features
No history of parkinsonism assocaited drugs
Common drugs causing parkinsonism
Haloperidol
Metoclopramide
Risperidone
What is defining feature on imaging of pseudogout
Chondrocalcinosis
What is main cause of renal artery stenosis in younger women
Fibromuscular dysplasia
What is normal appearance of arthrocentesis
Cloudy yellow
What is appearance of arthrocentesis in septic arthritis
Turbid grey
What is appearance of crystal arthritis on arthrocentesis
Cloudy yellow
What is appearance of crystal arthritis on arthrocentestis
Cloudy yellow
Dementia differentials
Alzheimers LBD PDD Frontotemporal dementia Depression Syphillis Hydrocephalus
What typically comes first in alzheimers
Amnesia
What is later progression of alzheimers
Language problems Failure to recognise people Poor calculation Loss of executive thinking Poor with names
What is episodic memory
Remembering specific dates and days you did something
What part of brain is affected in episodic memory loss
Hippocampus
On MRI of brain what is seen in huntingtons
Atrophy of medial temporal lobe mainly
Whole brain atrophy
What is needed to definitively diagnose dementia
Brain biopsy
What is seen on biopsy of dementia brain
Amyloid deposits
Fibrillatory tangles
Loss of synapses and neurones
What are fibrillatory tangles
Hyperphosphate tau proteins
Investigations for dementia
Clinical diagnosis using various mental tests
LP will show high tau protein and low amyloid
CT/MRI in later disease progression will show atrophy
Cognitive tests that can be done assess dementia
MOCA
MMSE
Addenbrookes cognitive assessment
Features of vascular dementia
Focal neurology Stepwise decline Emotional and personality changes Stepwise decline Cardiovascular rfx
Imaging finding of vascular dementia
Multiple hypodense lesions showing haemosederin deposites
What is picks disease a type of
Frontotemporal dementia
What are features of frontotemporal dementia
Poor hygiene
Loss of inhibition
Personality changes
Which ages does picks disease tend to affect
Younger than other dementias- 40-60
What is different about brain biopsy finding of picks disease to alzheimers
Picks is purely tau proteins
What is athetosis
Writhing movements of hands
Presentation of huntingtons
Chorea Athetosis Ataxia Dysphagia Cognitive symptoms
What is disease course progression of huntingtons
To begin with twitching of hands then get full motor symptoms
Later on progresses to cognitive dysfunction
Cognitive dysfunctioning of huntingtons
Poor concentration
Depression
Dementia
Personality changes- aggression
What is inheritance of huntingtons
Autosomal dominant
What is mutation in huntingtons
CAG repeat in HTT gene
What is early MRI finding of huntingtons
Basal gangial atrophy
Mainly striatum
What is late MRI finding of huntingtons
Global brain atrophy
What are investigations for huntingtons
Genetic testing for HTT
MRI showing striatal atrophy
In which disease cant you stick out tongue
Huntingtons
How does alcoholism lead to wernickes
Alcoholics have poor diet
Alcohol impairs ability to absorb B1
Investigations done for wernickes
Bloods - B1 and albumin as marker of liver disease
ECG
CT scan
Neuropsycology
Differences between werkickes and korsakoffs
W patient is confused but in korsakoffs alert
Signs of W are cerebellar whereas K is confabulation and amnesia
W reversible whereas korsakoffs irreversible
W acute but K chronic
3 mechanisms leading to iscahemic stroke
Thrombous
AF
Watershed stroke
What are watershed strokes
In hypotension reduced blood flow to areas on borders between artery territories
What HAS BLED score would contraindicate against CHAD VASC
HASBLED of 3
What in history would suggest haemorrhagic stroke
Headache
Meningism
Nausea and vomiting
LOC
Causes of haemorrhagic stroke
HTN
Microaneurysms
AV malformations
Vasculitis
In stroke what are eye abnormalities at in each territory for ACA, MCA and PCA
ACA- homonymous hemianopia
MCA- quadrantopias
PCA- macula sparing homonymous hemianopia
What are eye deficits in MCA strokes
Quadrantopias
What are eye deficits in PCA strokes
Macula sparing homonymous hemianopias
Visual agnosia
Where is damage in visual agnosia
Occipital lobe
Where are strokes in LOC or reduced consciousness
Posterior CA
MCA stroke symptoms
Contralateral hemiparesis upper limb/face > lower limb Contralateral hemisensory loss Apraxia Aphasia Quadrantopias
What is apraxia
Disorder of skilled movement
Where is stroke in pure motor loss
Internal capsule
Patient comes into A&E with suspected stroke what do
A-E make sure hydrated, saturated
Send for CT scan non contrast
Take bloods
ECG is possible
What bloods are ordered in stroke
Glucose FBC- thrombophlia, polycythaemia U&Es- electrolyte imbalances could be cause of sx LFTs- clotting and INR Cardiac enzymes
Is aspirin given before or after alteplase
After
Management of stroke when on ward
A-E
Swallow screen
GCS monitoring
DVT prophylaxis
Subsequent tests for stroke
Doppler
Echo
MR angiography
What does secondary prevention of stroke depends on
Whether stroke AF in origin or not
If AF anticoagulate based on chadvasc and hasbled
If not clopidogrel for life after 2 weeks
What is done to assess risk of stroke progression in TIA
ABCD2
What are criteria for carotid endarterectomy
Over 70% stenosed
50-69% stenosed and symptomatic
Fully recovered from stroke
Complications of stroke
Aspiration pneumonia Cerebral oedema (↑ ICP) Immobility Depression DVT Seizures Death
Management of haemorrhagic stroke
ITU place and refer to neurosurgery
BP and ICP management
Causes of reflex syncope
Carotid sinus hypersensitivity
Vasovagal
Situational
Define epilepsy, seizure and convulsion
Seizure- abnormal paroxysmal discharge of cerebral neurones
Convulsion- motor seizure
Epilepsy- increased tendancy to have unprovoked seizures
What are triggers for epilepsy
Poor sleep Alcohol Increased flashing lights Stress Poor adherance to medications
Feelings of epilepsy before seizure
Deja vu
Flashing lights
Strange smells
Feeling in the gut
What happens during epileptic seizure
Lasts for less than 3 mins
Incontinence
Tongue biting
Convulsions
What happens after seizure
Slow time to recover
Confused
Weakness in arm
What happens in focal parietal seizure
Sensory loss or tingling in body
What happens in focal frontal seizure
Spasms
Todds paresis after
Involuntary actions
Jacksonian march
What happens in jacksonian march
Spasms spread from distal to proximal muscles
Investigations for epilepsy
EEG
Bloods
CT
Bloods ordered after seizure
Glucose
FBC to look if infection as cause
U&Es as can cause seizure
Main problems of epilepsy drugs
Weight gain
Depression
Management of focal epilepsy
First line carbamezapine
Second line lmaotrigine
Management of generalised epilepsy
Sodium valproate is first line
Second line carbamezapine
Which antiepileptic should be strictly avoided in pregnancy
Sodium valproate
Complications of epilepsy
SUDEP (sudden death in epilepsy)
Behavioural problems
Fractures (from seizures)
Complications from drugs
First line management of status elipticus
ABC- secure airway
THEN LORAZEPAM
What antibody can be found in GBS
Anti ganglioside
Investigations for GBS
Spirometry to check FVC
LP- high protein, albumincytological dissociation
Nerve conduction studies showing decreased velocity
What is pathophysiology of normal pressure hydrocephalus
Increase in size of ventricles without increase in CSF volume
What can cause non communicating/obstructive hydrocephalus
Stenosis of cerebral aqueduct
Lesions of posterior fossa
Wha causes white matter damage in hydrocephalus
Seapage out through ventricle walls
What are sunset eyes seen in
Hydrocephalus
What are sunset eyes
Eyes permenantly looking downwards
What are investigations for hydrocephalus
CT/MRI
Intraventricular drain
Where is lesion in radiculopathy, CES and spinal chord compression
CES- below L2 over cauda equina
Spinal chord compression- above cauda euina in spinal chord
Radiculopathy the spinal nerve root is affected
Causes of spinal chord compression
Pagets Osteoporosis Steroid use Cancer Osteoarthritis Intervertebral disease Trauma
What are signs below and at level of chord compression
LMN at site
UMN below
Investigations for chord compression
Bloods- FBC, U&Es, LFTs, calcium, ESR, immunoglobulins
MRI
Urinalysis for bence jones proteins
What causes dissociative seizures
Hx of abuse, psychological or emotional precipitants
What are features of dissociative seizures
NO biological correlate
Prolonged duration
Hx of abuse, psychological or emotional precipitants
How does a radiculopathy present
Sensory loss in a dermatome
Pain and numbness in that area
Weakness in those muscles supplied
Where is weakness in sciatica
The calfs
Where is pain in sciatica
Back of thigh and buttock
What is nerve affected in sciatica
Lumbosacral
Causes of radiculpathies
Degenerative disc disease Spondylolisthesis Osteoarthritis Cancer Abscess
What is spondylolisthesis
Forward protrusion of vertebral disc impinging on nerve
How is sciatica diagnosed
Clinically using straight leg test
What is done in straight leg test
Someone flexes the hip with straight leg and if pain of sciatica is replicated then is positive- lesagues sign
What is a positive lesagues sign
Pain replicated on passive flexion of straight hip
What is a positive lesague test indicative of
Sciatica
Investigations for sciatica
Straight leg test
MRI/CT to visualise the cause
What happens to liver in acute phase of drinking alcohol
Steatosis with no symptoms
What tends to cause alcoholic hepatitis
Not necessarily binge drinking but after drinking heavily for a substantial amount of time
How does mild alcoholic hepatitis present
N&V
Anorexia
Weight loss
Sign on examination of mild alcoholic hepatitis
Hepatomegaly
Presentation of severe alcoholic hepatitis
Jaundice
Fever
Ascites
Signs on examination of severe alcoholic hepatitis
Jaundice
Bruising
Ascites
RUQ tenderness
Investigations for alcoholic hepatitis
Bloods
- FBC macrocytic anaemia, WCC up
- LFTs AST, ALT and GGT all up mainly AST and GGT
- Clotting PT very high
Liver USS rule out cancer, clots and see if cirrhosis
Biopsy will show mallory denk bodies and ballooning
What are mallory denk bodies a sign of
Liver inflammation not specific to any condition
What is management in hospital of alcoholic hepatitis
Mainly supportive Fluids and hydration Feeding enterally with vitamins etc Alcohol abstinence Treat complications- ascites, SBP, alcohol withdrawal
Longer term management of alcoholic hepatitis
Lose weight
Stop smoking and drinking
Refer to therapy groups to help with this
Management of alcoholic hepatitis if severe in hospital
Can give steroids
What are 3 parts to progression of NAFLD
Steatosis
NASH
Cirrhosis
What are rfs for NAFLD
Hyperlipidaemia
HTN
Diabetes
Obesity
Management of NAFLD
Exercise
Improve diet
RF management- statin for cholesterol, metformin for DM, HTN drugs
Investigations for NAFLSD
LFTs- high ALT and AST
Measure Hba1c and cholesterol
What can be sign on examination of insulin resistance
Acanthosis nigricans
Why cant metfromin be given in liver failure
Risk of metabolic acidosis
How do hep a and e present
Acutely with jaundice
What is presentation of Hep A
Prodrome of fever, malaise and vomiting
Then get jaundice, RUQ pain, dark urine and pale stools
What is only hepatic cause of jaundice that gives you pale stools
hep A
Transmission of Hep A
Faeco oral-
Gay sex
Contaminated water
Management of Hep A and E
Supportive
Avoid alcohol and
Management of acute Hep B
Supportive as 90% of people will self recover
Management of acute Hep C
Antiviral- sofosbuvir or ledipasvir
Same for chronic
Management of chronic Hep C
Antiviral- sofosbuvir or ledipasvir
Same for acute
What is role of anti virals in chronic Hep B
Suppress viral replication but isnt curative
Management of Hep B if compensated liver disease
If liver working well then give peg interferon
Management of Hep B if decompensated liver disease
Tenofovir or entecavir
Management of Hep D superimposed on Hep B
Tenofovir and peg interferon
How can Hep E affect pregnant women differently
Strong chance will progress to liver failure
How does Hep E affect immunocompromised individuals differently
More likely to become chronic
Difference on serology of Hep D chronic vs acute
Acute IgM HepD RNA Chronic IgG HepD RNA Will always be RNA no matter if acute or not
What is main difference between transmission of Hep B vs C
Hep B more likely to be form sex
Hep C more likely to be from poor medical products
What is Hep C serology findings infection vs cleared
Firstly do HCV IgG- present in all forms
Then check for HCV RNA
If cleared will be absent
If acute or chronic will have
Serology findings of chronic Hep C
HCV IgG
HCV RNA positive for over 6 months
Serology findings of cleared Hep C infection
HCV IgG
RNA negative
Serology findings of acute Hep C infection
HCV IgG
RNA positive for less than 6 months
Secondary causes of haemochromatosis
Iron overload from transfusions
Causes of haemochromatosis
Hereditary haemochromatosis
Iron overload
What can haemochromatosis progress to
CIrrhosis
Cancer
What is differnce between macronodular and micronodular cirrhosis
Size of nodules
<3cm is micro
>3cm is macro
What tends to be difference in cause of micro and macro nodular cirrhosis
Macro is viral
Micro alcohol
Common causes of liver cirrhosis
Alcohol Hep B/C NASH Haemochromatosis Autoimmune hepatitis PSC and PBC
Definition of NAFLD
Fatty damage to liver having not drank the alcohol to cause damage such damage
Define liver cirrhosis
Replacement of healthy liver tissue with fibrosis and nodules of regenerating hepatocytes
Long term management of liver cirrhosis
Avoid hepatotoxic drugs
Work out MELD score
6 monthly USS
Endoscopy on diagnosis and 3 yearly one to look for varcies
What is MELD score
Model for end stage liver disease
4 main complications of liver cirrhosis
Ascites
SBP
Encephalopathy
Varices
Management of ascites
Ascitic tap and sample Sodium and fluid restrict Spironolactone and or furosemide Therapeutic paracentesis Albumin supplementation
Management of SBP
Broad spectrum Abx- cefuroxamine and metronidazole
Most common cause of SBP
E coli
Management of encephalopathy (4 points)
Lactulose and phosphate enemas Protein restrict short term Treat cause (infection, GI bleed) Avoid sedation
What are common tirggers for encephalopathy
Infection
GI bleed
High protein diet
Primary prevention of oesophageal varices if small if picked up on endoscopy
Non selective beta blocker- pindolol or propanolol
Acute management of oesophageal varices
ABCDE
IV access- fluids or blood if Hb beloe 70
Terlipressin and abx
If this doesnt work sengstaken blakemore tube
After resus and haemoodynamically stable do endoscopic band ligation
Primary prevention of oesophageal varices if large if picked up on endoscopy
Endoscopic band ligation
Secondary prevention of oesophageal varices
Pindolol or propanolol started after 2-5 days
If propanolol or endoscopic band ligation fails do TIPS
Definition of liver failure
Dysfunction of liver leading to jaundice, encephalopathy and coagulopathy
How is liver failure classified
Based on onset of encephalopathy following jaundice
Hyperacute- within 7 days
Acute- 1-4 weeks
Subacute- 4-12 weeks
What is most common cause of acute liver failure
Paracetamol
Investigations for liver failure acute
Viral serology
Paracetamol mesurements
Management of liver failure
Treat cause ie paracetamol OD
Suportive
Treat complications
Transplant ideally
RUQ pain that radiates to shoulder with jaundice
Liver abscess
RUQ pain with jaundice, travel history and diarrorhoea
Entamoeba histolytica abscess
Most common cause of liver abscess in child
S.aureus
Most common cause of liver abscess in adults
E coli
What is major risk factor for hydatid cyst
Contact with sheep
What organism causes hydatid cyst
Tapework echinoccus granulosis
4 causes of liver cyst/abscess according to amir sam
Pyogenic
Amoebic abscess
Hydatid cyst
TB
What is blood finding for hydatid cyst
Eosinophilia
Serology positive
Aspiration finding for amoebic abscess in liver
Anchovy sauce with necrotic hepatocytes and trophozoites
What is a trophozoite
Early stage of life parasite
How is amoebic abscess best diagnosed
Stool sample
How is hydatid cyst best diagnosed
Stool sample
What is cholelithisasis vs biliary colic
Cholelithiasis is gallstones in the gall bladder whereas biliary colic is with this with pain
Management of biliary colic vs cholelithiasis vs cholecystitis
Bilairy colic- analgesia and elective cholecystectomy
Cholelithiasis- no management
Cholecystitis- clear fluids, fluid resus, analgesia, IV abx, lap chole within a week
What is difference between asymptomatic stone in CBD, stone in CBD with pain and cholangitis
Asymptomatic stone in CBD- choledocholithiasis
Painful stone in CBD- biliary colic
Painful stone in CBD with infection- cholangitis
Management of choledocholitiasis
ERCP and lap chole
Management of biliary colic in CBD
Analgesia
ERCP
Lap chole
Managemnet of biliary colic in CBD vs cystic duct
Have to do ERCP if in common bilde duct
When is percutaneous cholecystostomy only indicated in acute cholecystitis
If complicated ie empyema
Complications of choledocholithiasis
Pancreatitis
Asceding cholangitis
Obstructive jaundice
Complications of cholecystitis long term
Porcelain gall bladder
Increased GB cancer risk
What is florid duct lesion on histology seen in
PBC
What is concentric onion skin fibrosis seen in
PSC
Risk factors for pancreatic cancer
Obesity T2DM Chronic pancreatitis Smoking MEN
Signs on examination of pancreatic cancer
Corvoursiers law Trousseas sign Hepatomegaly if met Scleral icterus Cachexia
Gold standard for diagnosing pancreatic cancer
ERCP with biopsy
Most common source of mets to liver
Oesophagus Bowel Breast Pancreas Stomach
Risk factors for primary liver cancer
Viral hepatitis, Hep C and B most common Alcoholic cirrhosis PSC and PBC Haemochromatosis AIH NAFLD
Symptoms of liver cancer
Anorexia RUQ pain Weight loss Malaise Jaundice
Investigations for liver cancer
Bloods- LFTS, AFP
CT
Biopsy
Gold standard for liver cancer
Biopsy
Risk factors for cholangiocarcinoma
PSC
Cirrhosis
Worms
Stroke territory if cant name an item they can see in front of them
Posterior- visual agnosia
What is abx given in variceal bleed management
Tazocin
Why is tazocin given in variceal bleed
Portal HTN increases risk of SBP
What causes palpable kidneys
PCKD
Cancer
Hydronephrosis
Causes of suprapubic mass
Bladder cancer
Bladder retention
Causes of pain in suprapubic
Bladder cancer
Urinary retention
Torsion
RIF in elderly
Caecal- volvulus, cancer
Aorta
Diarrhoea in young person
IBD Gastroenteritis Coeliac Hyperthyroid IBS
What causes pain on eating 4 things
Chronic mesenteric ischaemia
GORD
Peptic ulcers
Gallstones
What endocarditis causing organism is associated with colorectal cancer
Strep bovis
First sign of hyperkalaemia on ECG
Tented T waves
Blood abnormalities in hypothyroidism
Macrocytic non megaloblastic anaemia
Risk factors for endocarditis
Damaged valves Artifical valves IVDU Dental stuff Immunocompromised
Difference between pulmonary HTN and Cor pulmonale
Pulmonary HTN- heart hypertrophies due to having to work harder
In cor pulmonale there is failure of RH and so dilates
How much post bronchodilator change must there be in asthma
Over 12 %
Mouth ulcers differentials
SLE Behcets Crohns Coeliac Anaemia
Pathophysiological causes of anal fissure
Hard stools tearing mucosal lining of distal anal canal
Poor blood supply
Risk factors for anal fissure
Constipation
(anything that causes constipation like opiates)
Pregnancy
How do you examine an anal fissure
You cant do DRE- mainly clinical diagnosis
Must be under anaesthetic
First line management of anal fissure
Manage constipation- more fibre and water
Sitz baths
Topical GTN or diltiazem
How long do anal fissure normally take to heal
6-8 weeks
Management of anal fissures if persist
Botulinim injection
Surgical sphincterectomy
What is a sitz bath
Use warm water on buttocks
What causes frequent abscesses around the anus
Anal fistula
What are rfx for anal fistula
Crohns
Trauma
Radiation
Clogged anal glands
How do anal fistulas present
Frequent anal abscesses
Pain and abscesses around the anus
Bloody foul smelling drainage inuinderwear
What presents with pus in underwear thats foul smelling
Anal fistula
How does an anal fistula appear on examination
Opening of skin around the anus
Swelling
What is an anal fistula
Connection between anal canal and skin surrounding the anus
How do you examine an anal fistula
Rectoscope
If doesnt work consider MRI or examination under anaesthetic
How to manage anal fistulas
Fistulotomy
Seton
Risk factors for anal abscesses
Crohns
Anal fistulas
Constipation
How do anal abscesses present
Perianal pain not related to defaecation
Perianal swelling and tenderness
LOOK OUT for fever and tachycardia if shock
Diagnosis for anal abscess
Visualise abscess or EUA then MRI if internal pelvic abscess
Management of anal abscess
Surgical drainage of abscess
Fistulotomy
IF SYSTEMIC give ABX
What are 2 types of anal haemorrhoid
Internal or external
Depends if above or below the dentate line
What is boundary between internal and external haemorrhoids
Dentate line
What are rfx for haemorrhoids
Constipation
Pregnancy
SOL in pelvis
Presentation of haemorrhoids
Painlesss bleeding with defacation
Can be painful and cause discomfort
Anal pruritus
Palpable mass
How to diagnose a haemorrhoid
Anoscope
Can consider colonoscopy to rule out other diagnoses and FBC
Conservative management of haemorrhoids
Lifestyle- fibre and water
Discourage straining
What is management of grade 1 haemorrhoids
Topical corticosteroids to alleviate itching
What is management of grade 2 haemorrhoids
Rubber band ligation
What is management of grade 3 haemorrhoids
Rubber band ligation
What is management of grade 4 haemorrhoids
Surgical haemorrhoidectomy
Complication of haemorrhoids
Thrombosed haemorrhoid
How to manage thrombosed haemorrhoid
Conservative - stool softeners, ice packs, warm baths, analgesia
If very severe or early on in presentation can consider excision
How does a thrombosed haemorrhoid present
Significant pain and tender lump
How does a thrombosed haemorrhoid appear on examination
Purple
Oedematous
Sub cut mass
What causes pilonidal sinus
Caused by forceful insertion of hairs into skin of natal cleft
Rfx for pilonidal sinus
Young males
Stiff hair
Hirsutism
Presentaion of pilonidal sinus
Pain when sitting down
Swelling
Discharge that can be offensive and stains underwear
Investigation for pilonidal sinus
Clinincal diagnosis
How to manage pilonidal sinus if symptomatic
Surgical management to excise it
Antibiotics
Laser hair removal
Local hygiene advice
Management of asymptomatic pilonidal sinus
Laser hair removal and local hygiene advice
What is lynch syndrome
HNPCC
Rfx for colonic cancer
Age Obesity UC Acromegaly Poor fibre intake HNPCC FAP
Signs on examinatin of colon cancer
Koilonychia Cachexia Lymphadenopathy Mass Ascites
How old do you have to be to be investigated urgently for IDA
60
What imaging is used for colon cancer
Colonoscopy with biopsy
Double contrast barium enema
CTAP for staging
What imaging is apple core sign seen on
Double contrast barium swallow
Risk factors for crohns
FHx
Smoking
OCP
High sugar diet
What condition is seen frequnetly in the ashkenazi jews
Crohns
Where can pain be in crohns
RIF and periumbilical
Signs on examination of crohns
Oral ulcers RIF tenderness Fistulae Abscesses Erythema nodosum, pyoderma gangrenosum Episcleritis
CT findings of crohns
Bowel wall thickening
Skip lesions
Barium findings of crohns
Rose thorn ulcers
String sign of kantor
What do rose thorn ulcers refer to
Deep ulcerations
What does string sign of kantor suggest
Fibrosis and strictures
What is seen on colonoscopy of crohns
Ulcers
Cobblestoning
How is crohns confirmed
Histology
How is crohns treated in relapse
IV steroids and azathioprine/mercatopurine/methotrexate
What further therapy can be given to crohns patients to induce remission
Biologics- adalimumab or infliximab
What is severe management stricture in crohns management
Surgery
What is further adjunct management of crohns
Nutritional management
Perianal disease mx
Smoking cessation
How are extra intestinal manifestatoins of crohns and UC managed
MDT
Maintaining remission in crohns
Infliximab
Azathioprine or any other immunomodulator
What immunomodulators are given in crohns
Azathioprine
Mercatopurine
Methotrexate
Risk factors for UC
FHx
HLAB27
Not smoking
Examination finding of UC
Skin
Episcleritis
Anaemia
DRE see blood
Investigations for UC bloods
FBC -anaemia
LFTs- PSC and albumin
CRP and ESR
pANCA
Histology signs of UC
Crypt abscesses
Goblet cell depletion
Mucosal ulceration
What is seen on UC plain AXR
Severe dilation of large bowel
Leadpipe
Thumbprinting
Ank Spond
What is a double contrast barium swallow
Use negative and psoitive contrasts to increase sensitivity
Double contrast barium swallow findings UC
Thickened haustra
Leadpiping
Treatment of aute UC
Oral betclamethasone
Mesalazine
Maintaining remission UC
Azathioprine
Infliximab
Niche ciclosporin and vedolizumab
How to cure UC
Total colectomy
4 comlications of UC
Toxic megacolon PSC Adenocarcinoma Strictures Obstruction and perforation
Histology finding of coeliac
Subvillous atropy
Crypt hyperplasia
Lymphocyte infiltrates
RFs coeliac
T1DM
Autoimmune thyroid
FHx
IgA deficiency
Management of coeliac
Gluten free diet
Vitamin supplements
Investigations for IBS
Exclude coeliac, IBD
Bloods- anaemia, CRP
TTG, IgA
FIT and calprotectin
Main difference between IBS and coeliac
Pain relieved by defacation in IBS
What is R in CURB 65
30
What are absent a waves seen in
A fib
What is preferred as method of cardioversion in early AF treatment
Electrical
What can PSM heard best at left sternal edge be
VSD
Tricuspid regurg
In acute COPD what comes first ABG or peak flow
ABG
When is only time permitted to DC cardiovert earlier than 3 weeks AF
TTE
What is fleischner sign seen in
PE on CXR
Will show enlarged pulmonary arteries
What is atelectasis to percussion
Dull
In DVT what is normally the most major risk factor
Smoking
If a young person is in dilated cardiomyopathy HF what think of as cause
Myocarditis
What type of heparin is given in acute limb ischaemia
UFH
What is most common site for ablation in atrial flutter
Tricuspid valve isthmus
What is main difference in treatment of atrial flutter vs AF
Atrial flutter responds much better to DC cardioversion, is quite poor to chemical
What are 2 types of V tach
Monomorphic
Polymorphic
What is only type of polymorphic v tach need to know
Torsades des pointes
What ACS gives you permenant ST elevation that isnt STEMI
Prinzmetal angina
What is screening method for abdominal aorta
One off surveillance for all men over 65
Then depending on size plan from there is determined
What does susceptible mean with regards to serology
Never any exposure
What gives granulocytes with absent granulation and hyposegmented nuclei
Myelodysplasia
What are 2 tpyes of bladder cancer
Transitional
Squamous
What to think of as differentials for lower abdo pain
Diverticular pain Cancer Constipation UC Pseudomembranous
What are causes of viral meningitis
HSV
Polio
Cocksackie
What type of pericarditis are steroids containdicated in
Viral
What does rheumatic fever cause in heart
Endocarditis
Which drugs shouldnt be given in HF with reduced EF
CCBs
Common arrythmia causing acute HF
Palpitations
Acute HF causes
MI
Atrial flutter or any arrythmia
What typically is type of gangrene in gut
Wet
What causes dry vs wet gangrene
Dry typically arterial
Wet typically venous insufficiency
If cardiac arrest is witnessed by someone how many shocks are given
3
Causes of dilated cardiomyopathy
Myocarditis
Alcohol
Haemochromatosis
Sarcoid
Why would sarcoid cause chest pain
Dilated cardiomyopathy
What WELLS score suggests DVT likely or not
2 or more
What do if WELLS score 2 or more
US of leg within 4 hours
If not available do D-dimer and anticoagulate with US within 24 hours
What do if WELLS score 1
Do dimer with result in 1 hour
If WELLS score 1 and d dimer positive what do
Same as if WELLS was 2
What counts as high grace score risk
3% or above
What does GRACE score do
Work out 6 month mortality
What is difference between primary and secondary dose statin
Primary is 20mg
Secondary is 80mg
What is done if 80mg statin not tolerated
Lower dose or switch to different drug
Before doing CTPA what is one investigation must do
CXR
What is difference in kussmals sign between cardiac tamponade and constrictive pericarditis
Kussmals positive in constrictive pericarditis
Negative in tamponade
Which lung cancer is assocaited with gynaecomastia
Adenocarcinoma
Leg pain on walking differentials
Ischaemia
Buergers disease
Spinal canal stenosis
Vertigo lasting around an hour
Vestibular migraine
TIA
MS
Vestibular neuronitis
Vertigo lasting a few seconds
Menieres
BPPV
Vestibular neuronitis
