Other Flashcards
0Where does L5 provide sensation to? What happens if it is damaged?
Big toe sensation and dorsum of the foot
If damaged causes foot drop and a positive sciatic nerve stretch test
Ix of pancreatitis?
Raised serum lipase, amylase and pain is diagnostic. Lipase is the most sensitive and specific test
Only US to confirm cause
How much must CK be elevated by to diagnose Rhabdomyolysis?
> 5 times the upper limit of normal
It may be elevated less than this due to other causes e.g. dehydration/hypovolaemia
What is the most common cause of protozoal diarrhoea in the UK? Who is it commonly seen in and how do you test for it?
Cryptosporidium = most common
Seen in the immunocompromised and young children
It is diagnosed on the Ziehl-Neelsen stain (shows red cysts)
Which way does the tongue deviate in hypoglossal nerve injuries?
TOWARDS the damaged side
Sx of Acute angle closure glaucoma?
Severe pain (ocular or a headache), reduced visual acuity, Sx worse in the dark (i.e. on mydriasis), semi-dilated non-reactive pupil, hard red eye, halos around lights, dull/hazy cornea and nausea/vomiting/abdo pain
Ix and Definitive Mx of Acute angle closure glaucoma?
Ix = measure IOP
Definitive Mx = laser peripheral iridotomy
What can B12 deficiency cause if uncorrected?
Sub acute combined degeneration of the spinal cord
Name the non-sedating antihistamines?
Cetirizine, Fexofenadine, Loratadine and Acrivastine
What signs may be seen on fundoscopy in hypertensive retinopathy?
Silver/copper wiring = walls of the arterioles become thickened and sclerosed
Arteriovenous nipping = arterioles compress the veins where they cross
Describe Bowen’s disease?
Red scaly slow growing patches on sun exposed sites. Is a precursor to squamous cell carcinoma
Mx = TOP 5-flurouracil
What is the initial Mx of hyperthyroidism?
Propranolol
This will control symptoms whilst a definitive Mx is started
How will arterial ulcers appear?
Deep and punched out ulcers, they are painful with a low ABPI measurement.
Feet will be cold with no peripheral foot pulses
When should you stop metformin before giving contrast?
48 hours before, this reduced the risk of lactic acidosis
How do you calculate serum osmolality?
2x(Na+) + glucose +urea
What is the transfusion threshold?
Hb <70g/L if no ACS
Hb <80g/L if ACS
What is the role of a fluid challenge?
Should be done in patients for whom you think fluids will be beneficial but you are not sure if they will tolerate them
Mx MRSA?
Vancomycin
Describe central retinal artery occlusion?
Sudden painless unilateral vision loss, RAPD and a pale retina with a cherry red spot
How can you manage peripheral neuropathy in renal impairment?
Amitriptyline, Pregabalin or Gabapentin
Duloxetine should not be used if the eGFR <30
What are the endoscopic findings in coeliac’s disease?
Crypt hyperplasia, villous atrophy, increased intraepithelial lymphocytes and lamina propria infiltration with lymphocytes
True or false, mesothelioma causes pleural effusion?
True - and it more commonly affects the right lung than the left
What should you measure in erectile dysfunciton?
Free testosterone level between 9am-11am. If this is abnormal/borderline measure FSH, LH and prolactin levels
Risk factors and Mx of erectile dysfunciton?
Risk factors = any risk factors for cardiovascular disease, alcohol use, SSRIs and beta blockers
Mx = PDE-5 inhibitors e.g. sildenafil
What is Choledocholithiasis?
Gall stones in the CBD. Can cause obstructive jaundice
Drug causes of hyperkalaemia?
K+ sparring diuretics, ACEis, ARBs, ciclosporin and heparin. Beta blockers can contribute if there is renal failure
How do you interpret the results of AAA screening?
<3cm = no further action
3-4.4 cm = rescan every 12 months
4.5-5.4 cm = rescan every 3 months
>=5.5cm or symptomatic or rapidly growing (>1cm/year) = 2WW to vascular surgeons
Mx of oral candidiasis secondary to steroid inhaler?
Give anti-fungal oral suspension and use a large volume spacer
How can we biochemically differentiate between sarcoidosis and TB?
Sarcoidosis causes hypercalcaemia, TB does not
Who should conduct the initial Ix for pressure sores in the community?
District nurses
Mx of needlestick injury?
Encourage the wound to bleed (hold it under running water), wash the wound, cover it with a dressing and contact occupational health
COPD Mx if not steroid responsive?
1st line = SABA (e.g. salbutamol) or SAMA (e.g. ipratropium)
2nd line = LABA (e.g. salmeterol), LAMA (e.g. tiotropium) and SABA (if on SAMA switch to SABA)
3rd line = LAMA, LABA, SABA and ICS (e.g. beclometasone)
COPD Mx if steroid responsive?
1st line = SABA (e.g. salbutamol) or SAMA (e.g. ipratropium)
2nd line = LABA (e.g. tiotropium), ICS (e.g. beclometasone) and SABA or SAMA
3rd line = LAMA + LABA + ICS + SABA (if on SAMA switch to SABA)
Signs that COPD may be steroid responsive?
Previous asthma/atopy, raised eosinophils, variation in FEV1 or PEFR with diurnal variation
Describe BCC?
The most common cancer in the western world
Lesions are slow growing and occur at sun exposed sites. They start off flesh coloured but may ulcerate
If you suspect make a routine referral to derm (metastases are rare)
Describe Squamous cell carcinoma?
Usually occur at sun exposed sites, they are rapidly expanding painless ulcerated nodules which may have a cauliflower like appearance and show areas of bleeding.
If <20mm diameter excise with 4mm margins, if >20mm diameter excise with 6mm margins.
Metastases are rare
How do we screen for malnutrition?
Malnutrition Universal Screen Tool (MUST)
What should you do with any abrupt onset headache?
Consider immediate referral to hospital
Ix of Granulomatosis with Polyangitis?
cANCA positive, CXR may show cavitating lesions, renal biopsy may show epithelial crescents in the Bowman’s capsule. Red cell casts may be seen on urinalysis (this is haematuria)
Mx of Granulomatosis with Polyangitis?
Steroids and cyclophosphamide
What do you characteristically see in disseminated miliary TB?
Millet seeds on CXR
Name the TB drugs and their side effects?
Rifampicin (6/12) = red/orange discolouration of the urine/tears, reduced the efficacy of the contraceptive pill
Isoniazid (6/12) = peripheral neuropathy (give pyridoxine aka vit B6)
Pyrazinamide (2/12) = hyperuricaemia leading to gout
Ethambutol (2/12) = colour blindness and reduced visual acuity
What is the bone profile like in bony metastases?
Calcium and ALP are high. PTH is low (due to high calcium) and so phosphate will also be high
What is the bone profile like in primary hyperparathyroidism?
Calcium is high and phosphate is low.
PTH will either be high or inappropriately normal (given the high calcium). ALP may be high
What is Zolpidem?
A sedative hypnotic used in the Mx of insomnia, it may cause dizziness
Describe Scurvy?
Vitamin C (aka ascorbic acid) deficiency. Causes easy bruising, bleeding/receding gums (gingivitis) and poor wound healing
A patient has low testosterone and low LH and FSH, what may be the cause of his erectile dysfunction?
Hypogonadotropic hypogonadism. May be caused by pituitary or hypothalamus pathology
What is seen in acute mitral regurgitation secondary to MI? What is the cause?
Systolic murmur heard at the apex with hypotension and pulmonary oedema
Occurs due to rupture of the papillary muscles.
What type of visual field defect does acromegaly cause?
An upper (superior) bitemporal visual field defect due to inferior compression of optic chiasm by the pituitary gland
Obesity Mx?
1st line = diet and exercise
2nd line = Orlistat (pancreatic lipase inhibitor) or liraglutide/semaglutide (GLP-1 inhibitor - also used in T2DM)
3rd line = Bariatric surgery
Name 3 diseases strep pneumonia most commonly causes?
Pneumonia (most common cause), Meningitis (second most common cause, after N. meningitidis) and Otitis media
How do you Mx bladder issues in MS?
USS of the bladder
If significant residual volume = intermittent self-catheterisation
If no significant residual volume = anticholinergics
Mx MS relapse?
5 days oral/IV high dose steroids (e.g. methylprednisolone)
Why is C.diff hard to destroy?
Due to its spore formation
Mx of post-operative ileus?
Make NBM, insert NG tube, monitor/correct electrolyte imbalances, early mobilisation and reduce opioid analgesia
How does Bendroflumethiazide affect electrolytes?
Causes low K+ and Na+ and hypochloraemic alkalosis
What structure is affected 1st in Alzheimer’s? Where is it located?
The hippocampus is affected first, it is buried in the temporal lobe
Describe CHA2DS2-VASc?
CHF - 1 point
HTN - 1 point
Age >= 75 - 2 points, 65-74 - 1 point
DM - 1 point
Stroke/TIA/VTE - 2 points
Vascular disease (CVD or PVD) - 1 point
Sex - Female - 1 point
0 = no management required
1 = anticoagulate if male
>= 2 = anticoagulate
Which artery is most commonly affected in bleeding secondary to peptic ulcer disease?
The gastroduodenal artery
Describe Lymphogranuloma Venereum?
Caused by chlamydia
Sx = small painless pustule leading to an ulcer, painful inguinal lymphadenopathy and proctocolitis (pain on defecation)
Mx = doxycyline
Ix and Mx of DI?
Ix = raised plasma osmolality, decreased urine osmolality. Do a water deprivation test
Mx = nephrogenic DI give thiazide like diuretics and low sodium diet
craniogenic DI give desmopressin
What is the normal LH:FSH? What is the LH:FSH in PCOS?
LH:FSH = 1:1 normally
In PCOS LH:FSH = 2:1
What is silicosis?
Upper-zone fibrosing lung disease leading to egg shell calcification of the hilar lymph nodes
Seen in those who worked in mining, slate and potteries
What is central retinal vein occlusion?
Sudden painless vision loss which will lead to retinal haemorrhages.
If haemorrhages are more localised on fundoscopy this may be branch retinal vein occlusion
How can we differentiate between gastric and duodenal ulcers?
Gastric ulcers are worse after eating
Duodenal ulcers are worse when hungry and better after eating - they are more common
Haloperidol is absolutely contraindicated in PD. How can we manage agitation/acute confusional state in these patients?
Manage agitation with lorazepam
In an emergency acute confusional state can be managed with quetiapine or clozapine (other antipsychotics are also contraindicated in PD)
Mx of tricyclic antidepressant OD?
IV bicarbonate
When can BiPAP be useful in COPD exacerbation?
When there is type 2 respiratory failure with a pH of 7.25-7.35 when medical management has failed
What is a case control study?
Compares the history of a group of people with a condition to the history of a group of people without it - is retrospective
What is a cohort study?
Follows a group of people to track the presence of risk factors and outcomes over time - may be prospective (the condition of interest has not yet happened but there are clear outcomes and risk factors defined) or retrospective (the illness has already occurred and the histories are looked at to find risk factors)
What is a cross-sectional study?
Assesses the prevalence of an outcome in a broad population at 1 specific time
What is a case-report study?
Takes a detailed history of a small number of individuals or a specific group
Gout Mx?
Acute = Colchicine or NSAID, if already taking allopurinol this should be continued
Chronic prevention = Allopurinol, cover with colchicine or and NSAID when starting/if not tolerated
Most common cause of Osteomyelitis?
Staph Aureus unless they have sickle cell - then Salmonella
What are supraventricular premature beats?
A cause of arrhythmias and palpitations in otherwise healthy individuals
1st line Mx of agitation in palliative care?
Haloperidol
Ix of PSC?
ERCP (is more sensitive than MRCP) may be p-ANCA positive
PSC vs PBC?
PSC = UC associated, is pANCA positive
PBC = seen in middle aged women, is AMA (M2) positive (highly specific) and associated with raised IgM
What should you consider if the plasma osmolality is decreased and the urine osmolality is >400?
Psychogenic Polydipsia
What options are available to treat STEMI?
PCI or thrombolysis
What medications should everyone receive on discharge after MI?
ACEi, Beta blocker, Statin and dual antiplatelet therapy
Name 5 cardiac enzymes raised in cardiac damage e.g. MI?
Troponin T, Troponin I, CK-MB, LDH and myoglobin (is the first to rise)
What ECG abnormalities may persist after a STEMI?
Pathological Q waves, inverted T waves
Can you drive after MI?
Yes but not for 4 weeks - no need to inform the DVLA
Apart from exercise name some possible triggers of angina?
Anger/excitement, cold weather, lying down, vivid dreams
Apart from chest pain/heaviness name some symptoms seen in angina?
SOB, sweating and feeling light headed/dizzy
What bloods may you request on diagnosing angina?
FBC - exclude anaemia, TFTs - exclude thyrotoxicosis, U&Es - exclude renal disease/if considering ACEi, Lipid profile - exclude hypercholesterolaemia, FPG/OGTT - exclude diabetes,
How does aspirin work?
Cyclooxygenase 1 and 2 inhibitor which reduces the ability of platelets to aggregate by blocking thromboxane A2 formation
Give 5 signs of pulmonary oedema?
Tachycardia, Tachypnoea, Raised JVP, Cyanosis, Dyspnoea and coarse crepitations on auscultation
Mx of acute pulmonary oedema?
Oxygen, IV furosemide, IV morphine, GTN
What is a capture beat on ECG?
A normal QRS seen between VT complexes
How does salbutamol work?
Causes relaxation of the airway smooth muscles by activating beta 2 receptors in the respiratory tract
Mx of COPD exacerbation?
Oxygen (targets 88-92% until pCO2 is confirmed as normal), Salbutamol/ipratropium nebulisers, steroids, consider IV theophylline and NIV and chest physio
What tests would you do when seeing a ?CAP in hospital?
CXR, sputum cultures, ABG, urinary antigen testing
Why are 4 antibiotics used in TB?
To combat multi-drug resistance
What can cause erythema nodosum?
TB, sarcoidosis, idiopathic, Crohn’s/UC, strep infection, oral contraceptives and chlamydia
Causes of reduced chest expansion?
Symmetrical = pulmonary fibrosis
Asymmetrical = pneumothorax, pneumonia and pleural effusion
Abnormal findings in percussion and their causes?
Dullness = tumour, lung collapse, consolidation
Stony dullness = pleural effusion
Hyper-resonance = pneumothorax
Causes of increased and decreased vocal resonance?
Increased = consolidation, tumour or collapse
Decreased = pleural effusion or pneumothorax
Name some abnormal findings on auscultation of the lungs and their causes?
Bronchial breathing = consolidation
Quiet breath sounds = pleural effusion or pneumothorax
Wheeze = asthma, COPD or bronchiectasis
Stridor = foreign body inhalation and subglottic stenosis
Coarse crackles = pneumonia, bronchiectasis and pulmonary oedema
Fine end-inspiratory crackles = pulmonary fibrosis
Causes of CKD?
DM, HTN, Chronic Glomerulonephritis, Chronic Pyelonephritis, Polycystic Kidney Disease
When should you start ACEis in CKD?
If there is DM and ACR >3
If there is HTN and ACR >30
If there is ACR >70
Signs of chronic kidney disease?
Pallor, flapping tremor, HTN, peripheral oedema, bruising/purpura, proximal myopathy
Complications of peritoneal dialysis?
Local infection at catheter site, peritonitis, sclerosing peritonitis and failure
When is transplant rejection classed as chronic?
If it occurs after 6 months
What is the action of PTH?
Increases calcium and phosphate resorption from the bones. Increases activation of vitamin D which increases calcium and phosphate absorption from the gut. Increases reabsorption of calcium at the kidneys and increases phosphate excretion at the kidneys
Where is vitamin D activated?
First the liver and then the kidneys
What is it called when the bones are damaged secondary to CKD (and hyperparathyroidism)
CKD Mineral Bone Disease aka Renal Osteodystrophy
Name some pre-renal, renal and post-renal causes of AKI?
Pre-renal = Hypovolaemia, renal artery stenosis and sepsis
Renal = Glomerulonephritis, acute tubular necrosis, acute interstitial nephritis, rhabdomyolysis, tumour lysis syndrome and nephrotoxic drugs/contrast
Post-renal = kidney stones, BPH and prostate/bladder cancer compressing the ureter
When is haemodialysis indicated in AKI?
Treatment resistant hyperkalaemia, pulmonary oedema, metabolic acidosis an uraemic encephalopathy/pericarditis
How does rhabdomyolysis cause AKI?
Myoglobin becomes stuck in the tubules leading to acute tubular necrosis
What is seen on urinary microscopy in AKI caused by rhabdomyolysis?
Urinary myoglobin
Causes of rhabdomyolysis?
Statins, long lie, excessive exercise, crush injuries, burns, seizures, neuroleptic malignant syndrome, heroin and MDMA
What are the 4 most common causes of pneumonia?
Strep. Pneumoniae (most common), Haemophilus Influenzae, Mycoplasma Pneumoniae, Staph Aureus (common after influenza infection)
X-ray changes in RA?
Early = loss of joint space, juxta-articular osteoporosis/osteopenia, soft tissue swelling
Late = periarticular erosions and subluxation
Extra-articular manifestations of RA?
Pulmonary fibrosis, bronchiolitis obliterans, pleural effusions, Sjogren’s syndrome, scleritis/episcleritis, anaemia, rheumatoid nodules, carpel tunnel syndrome
What is Felty’s syndrome?
RA, Neutropenia and splenomegaly
How do NSAIDs treat rheumatological issues?
They are COX inhibitors, this reduces prostaglandin secretion thereby reducing inflammation
What is it called when there are calcium phosphate crystals seen in the joint space on XR?
Chondrocalcinosis. If seen this is pathognomic of pseudo-gout
Which joints are most commonly affected in pseudogout?
Knee (most common), shoulders, wrists and hips
Which conditions pre-dispose to Pseudogout?
Hemochromatosis, Hyperparathyroidism, Acromegaly, Wilson’s disease, increasing age, low magnesium and low phosphate
What is seen on examination in a OA joint?
Swelling and tenderness, crepitus, reduced ROM, muscle wasting, may be bony deformity (e.g. Heberden’s/Bouchard’s nodes or fixed flexion deformities)
Name some features of Acromegaly?
Coarse facial appearance, spade like hands, increased shoe size, large tongue, protrusion of the mandible, increased interdental space, excessive sweating and oily skin, pituitary tumour Sx and galactorrhoea
Name 4 important complications of acromegaly?
HTN, DM (GH is anti-insulin), Cardiomyopathy (CVD is the most common cause of death) and colorectal cancer
How does the OGTT help in diagnosing acromegaly?
Normally GH is suppressed with hyperglycaemia however in acromegaly it will not be suppressed
Which drug can cause hyper and hypo thryoidism?
Amiodarone
Signs of hypothyroidism?
Weight gain, lethargy, cold intolerance, dry skin, coarse hair/hair loss, loss of lateral aspect of the eyebrows, constipation, oedema, hyporeflexia, menorrhagia and carpal tunnel syndrome
Which anatomical structure represents the site at which the thyroid gland originated before embryological descent?
The foramen caecum
Signs of Hyperthyroidism (not specific to Grave’s)
Anxiety/irritability, sweating, heat intolerance, tachycardia, weight loss, fatigue, diarrhoea, sexual dysfunction, menorrhagia, palmar erythema and warm peripheries
What hormones are secreted by the posterior pituitary?
Vasopressin and Oxytocin
What are the autonomic Sx of hypoglycaemia - occur when BM is <3.3?
Sweating, shaking, anxiety, hunger and nausea
What are the neuroglycopenic Sx of hypoglycaemia (when BM is <2.8)?
Weakness, vision changes, confusion, dizziness, convulsion and coma
Causes of hypoglycaemia in non diabetics?
Insulinoma, liver failure, Addison’s disease, alcohol excess
What signs do you see commonly in lymphoma?
Lymphadenopathy, and hepatosplenomegaly
How do you stage Hodgkin’s Lymphoma?
Ann-Arbor staging
Signs of iron deficiency anaemia?
Pallor, Tachypnoea, Tachycardia, Ejection systolic murmur, Hair loss, Koilonychia, Atrophic glossitis, Angular stomatitis
Mx of Sickle cell anaemia?
Hydroxycarbamide (aka Hydroxyurea), Penicillin V and ensure vaccines are UTD
Name some precipitants for thrombotic crises in sickle cell?
Infection, dehydration, cold weather and deoxygenation (e.g. high altitude)
What is multiple myeloma?
Malignant clonal proliferation of beta lymphocytic plasma cells
What is seen on serum electrophoresis, peripheral blood film and in the urine in myeloma?
Serum electrophoresis = raised IgA and IgG
Peripheral blood film = Roleaux formations
Urine = Bence Jones Proteins
Name some complications of myeloma?
Infection, Pain, AKI, Anaemia, Hypercalcaemia, Peripheral neuropathy, Spinal cord compression and hyperviscosity
What are the causes of massive splenomegaly?
Myelofibrosis, CML, Malaria
How can we tell between chronic and acute leukaemia on blood film?
In acute leukaemia there are only immature white blood cells (blast cells)
In chronic leukaemia there are white cells at all stages of maturation (including mature)
What is the 1st line Mx of CML?
Imatinib - a tyrosine kinase inhibitor
What monitoring should you do in myasthenia crisis
Do serial FVC measurements and negative inspiratory force measurements
Sx of haemachromatosis
Fatigue, erectile dysfunction, arthralgia, bronze pigmentation of the skin, liver disease, DM, dilated cardiomyopathy and arthritis
Ix of hereditary haemachromatosis
Raised transferrin saturation (most useful), raised ferritin, low TIBC, Hypogonadotrophic hypogonadism.
Also test family for HFE mutation (it is autosomal recessive)
Mx of haemachromatosis?
Venessaction 1st line
Desferrioxamine 2nd line
Sx of Wilson’s disease
Hepatitis, Cirrhosis, basal ganglia degeneration, psychiatric problems, asterixis, chorea, dementia, kayser-fleisher rings, blue nails, haemolysis and renal tubular acidosis
Ix of Wilson’s disease?
Decrease serum caeruloplasmin, decreased serum copper, 24 hour urinary copper excretion is increased
It is AR
Mx of Wilson’s disease
Penicillamine
1st line Mx prolactinoma
Carbergoline or Bromocriptine
1st line Ix of a neck lump?
USS of the neck
What drug class is dipyrimadole?
Antiplatlet
Mx SVCO
IV Dexamethasone, Insert endovascular stent if there is stridor
Most common cause of cellulitis?
Strep pyogenes
If there is an isolated unexpected rise in potassium?
Repeat the sample as it may be haemolysed
What nerve lesion causes foot drop
Common peroneal nerve
Mx biliary colic
Elective laproscopic cholecystectomy
What should you give if major bleeding on warfarin?
IV vitamin K and prothrombin complex, only use fresh frozen plasma if there is not PTC available
How do you manage venous ulcers?
Compression stockings
Where does ovarian cancer commonly metastasise to?
The pelvic/para-aortic lymph nodes
What are the blood tests like in DIC?
Low platelets, low fibrinogen, high PT, high APTT, high fibrinogen degradation products
Schistocytes are seen
What will water deprivation tests show in nephrogenic DI?
After water deprivation (8 hours) urine osmolality = low
After ADH is given urine osmolality = low
There is also hypernatremia
What will water deprivation tests show in cranial DI?
After water deprivation (8 hours) urine osmolality = low
After ADH is given urine osmolality = high
There is also hypernatremia
What will water deprivation tests show in psychogenic polydypsia?
After water deprivation (8 hours) urine osmolality = high
After ADH is given urine osmolality = high
Where is pain felt in De Quervian’s tenosynovitis? Which test do you investigate it with? Mx?
Over the radial aspect of the wrist
Ix = Finkelstein’s test
Mx = Analgesia, splinting and steroid injections
How should you manage DM drugs if you are undergoing a morning surgery?
Take metformin or DDP 4 inhibitors (-gliptins) as normal
Omit sulfonylureas (e.g. gliclazide), GLP-1 analogues (-tides) and SGLT-2 inhibitors (-flozins)
What can cocaine cause?
Coronary artery spasm (leading to ischaemia or infarction). It can also cause seizures
What is fibrocystic disease?
Aka fibroadenosis
It causes cyclical breast pain and lumpy breasts in middle aged women
Which joints are most commonly affected in RA?
The hands and feet
Where are epidydimal cysts found?
Above and behind the testes
What should you do with a patient presenting with an unprovoked DVT?
Offer CT abdo pelvis to identify possible malignancies
True or false, both ESR and CRP are often elevated in PMR?
True! Elevated ESR is associated with a worse prognosis
What can be seen histologically in Crohn’s disease?
Granulomas, transmural inflammation, lymphocytic infiltration
Which part of the bowel is most commonly affected in Crohn’s?
The terminal ileum
Name some extra-intestinal symptoms of Crohn’s?
Aphthous mouth ulcers, erythema nodosum, conjunctivitis/episcleritis, enteropathic arthritis, metabolic bone disease
Complications of Crohn’s long term?
Colorectal cancer, perianal abscess/fistulas, perforated bowel, SBO, malnutrition
Ix of oesophageal varices and peptic ulcers?
Oesophagogastroduodenoscopy
Name a portosystemic anastomoses and the symptom it causes in portal vein hypertension?
Paraumbilical vein shunt leading to visible veins in the chest
How does the urea breath test work?
H.pylori produces urease which breaks down urea to ammonium and carbon dioxide, therefore increasing ammonium levels
Mx of H.pylori?
Amoxicillin + Clarithromycin OR Metronidazole + PPI
If pen allergic Clarithromycin AND Metronidazole + PPI
Ix of ?peptic ulcer perforation?
Erect chest XR - looking for pneumoperitoneum
What conditions may cause gastrin levels to be high in the body?
Gastrin secreting tumour of the duodenum or pancreas, seen in MEN 1 or Zollinger-Ellison Syndrome
What is the gold standard for investigating GORD?
24 hour Oesophageal pH monitoring
Name some causes of dysphagia?
Oesophageal CA, Oesophagitis, Achalasia, Pharyngeal pouch, MG, Oesophageal stricture
How does Nissen Fundoplication work? Name a side effect?
Helps to strengthen the gastro-oesophageal junction and sphincter. There is a risk that it can compress the GOJ leading to dysphagia
1st line Ix for obstructive jaundice (confirmed on blood tests)?
Abdo USS
What is the most common type of pancreatic cancer? How do you investigate?
adenocarcinoma - CT abdo
Name some complications of persistent jaundice?
Increased susceptibility to infection, pruritus, liver dysfunction, AKI and nutritional dysfunction
Describe Kernig’s sign
Pain on passive extension of the knee when the hips and knees are flexed to 90 degrees, is associated with meningitis
What is Brudzinski sign?
Severe neck stiffness which causes a patients hips and knees to flex when the neck is flexed
Which bones meet at the pterion?
Temporal, parietal, frontal and sphenoid bones
What shape is SAH, EDH and SDH on CT?
SAH = blood distributed in the basal cisterns and sulci, EDH = biconvex, SDH = crescent
RFs for an ischaemic stroke?
Cardiovascular disease, AF, TIA/previous stroke, carotid artery disease, HTN, DM, smoking, COCP, thrombophilia
Define hemiparesis and hemiplegia?
Hemiparesis = partial weakness of both limbs on 1 side
Hemiplegia = complete paralysis of both limbs on 1 side
When can you consider doing a carotid endarterectomy/stenting post stroke?
If there is carotid artery disease with >70% stenosis
Define epilepsy?
Intermittent abnormal electrical activity in the brain which manifests as seizures
Define aura?
Symptoms experienced at the start of a seizure which precede other seizure symptoms
Name some metabolic causes of seizure?
Hyponatraemia/Hypernatraemia, Hypocalcaemia, uraemia, low blood glucose and anoxia
What is it called when you lose vision in both peripheries?
Bitemporal hemianopia
Causes of a homonymous hemianopia?
Incongruous (uneven) defect? = lesion of the optic tract
Congruous (the same in both eyes) = lesion of the optic radiation or occipital cortex
Macula sparing = lesion of the occipital cortex
Why does the pain in appendicitis move?
Initially the visceral peritoneum is irritated, this has no somatic innervation so pain is referred to the periumbilical region. As it becomes more inflamed the appendix irritates the parietal peritoneum, this has somatic innervation so pain localises
What is a diverticulum?
An outpouching of the bowel mucosae through a whole in the muscular wall. Most commonly seen in the sigmoid colon
Define diverticulosis, diverticular disease and diverticulitis?
Diverticulosis = the presence of asymptomatic diverticula
Diverticular disease = symptomatic diverticula
Diverticulitis = infection and inflammation of the diverticula
Complications if diverticulitis?
Bowel perforation, bleeding, abscess, strictures and colovesical/colovaginal fistula
What is a hernia?
The protrusion of a structure through the wall of the cavity it is usually contained in
What causes indirect inguinal hernias?
A patent processus vaginalis
Define obstructed and strangulated hernias?
Obstructed = bowel contents can not pass through it
Strangulated = ischaemia of the bowel
Name some complications of hernia repair?
Reoccurrence, bladder/bowel damage and hydrocoele
Sx and Ix of haemarrhoids?
Sx = fresh red rectal bleeding, sore/itchy anus and feeling a lump around or inside the anus.
Ix = FBC, PR examination and proctoscopy
Mx of haemarrhoids?
TOP analgesics or steroids, increase the amount of fibre/fluid intake, rubber band ligation, infra-red coagulation, haemorrhoidal artery ligation and haemorrhoidectomy
Which blood vessels supply the bowel?
Foregut = coeliac artery
Midgut = superior mesenteric artery
Hindgut = inferior mesenteric artery
Ix of Acute Mesenteric Iscaemia? What is the aim of surgery?
Contrast CT or Ct angiogram
Metabolic acidosis, raised lactate, raised CRP and WCC
Surgery aims to remove necrotic bowel and remove or bypass the thrombus to reperfuse the bowel
How should you investigate ascites?
Do an Abdo USS to assess the liver, spleen, pancreas and lymph nodes. Then if it is painful (tense ascites) do an investigative ascitic tap or a therapeutic paracentessis
What will the LP be like in bacterial meningitis?
Raised opening pressure, increased WCC (mainly neutrophils), raised protein and low glucose
What will the LP be like in viral meningitis?
Normal opening pressure, mildly raised WCC (lymphocyte dominant), mildly raised protein and normal glucose
What may be seen in a contaminated urine sample?
Mixed growth (on culture) or epithelial cells (on microscopy)
On oesophageal biopsy you find columnar epithelium and goblet cell with paneth cells. What is this?
Barrett’s oesophagus (intestinal metaplasia)
What is para protein?
AKA Bence Jones Protein it is seen in the blood/urine in multiple myeloma
Sx, Ix and Mx of HSP?
Purpuric rash (on the buttocks and extensor surfaces of the legs), arthritis/arthralgia, abdo pain, proteinuria/haematuria
Ix = IgA deposits, protein/haematuria
M = supportive, monitor BP (to look for HTN) and do urine dip (to monitor renal status)
What is involved in a triple assessment of a breast lump?
Physical exam, imaging (mammogram or USS) and core biopsy
What are monoclonal IgG Kappa associated with?
Multiple Myeloma
Describe phaeochromocytoma?
Sx = Episodic headaches, HTN, palpitations, sweating and anxiety
Ix = 24 hour urinary metanephrines
Mx = phenoxybenzamine then propranolol then surgery
Sx of vestibular neuronitis?
Recurrent vertigo lasting hours-days, N+V, horizontal nystagmus and no hearing issues
Describe atelectasis?
Basal alveolar collapse post surgery. Causes dyspnoea and hypoxia less than 72 hours post surgery.
Mx = position the patient upright and give chest physio
Sx of a temporal focal seizure?
A rising epigastric sensation (aura) and automatisms
What is the Ix of choice for ?lung cancer?
CT scan
What does a low base excess imply?
A lower than normal base level
What should you do in those taking clozapine who become ill?
Do a FBC
1st line Mx of PBC?
Ursodeoxycholic acid
True or false, inflammation of the parotid glands can be seen in Sjogren’s Syndrome?
TRUE
Mx pericarditis?
NSAIDs and Colchicine
What is seen on Ix of ITP?
Isolated thrombocytopenia
Describe SBP?
Ascites, abdo pain and fever in those with existing liver disease.
Ix = Neutrophils >250 on paracentesis, grows E.coli
Mx = IV cefotaxime and prophylaxis ciprofloxacin/norfloxacin
When should you use rhythm control over rate control in AF Mx?
HF, 1st onset of AF or if there is an obvious reversible cause e.g. CAP
If AF >48 hours anticoagulate for at least 3 weeks before cardioversion
Describe the results of the treponemal and non-treponemal test?
TT positive and NTT positive = active syphilis
TT negative and NTT positive = false positive (e.g. due to HIV, TB, SLE or pregnancy)
TT positive and NTT negative = treated syphillis
How long should you treat with metformin before you can consider increasing the dose?
At least 1 week
Sx of acute haemolytic reaction?
Abdo pain, fever and wheeze following transfusion
Sx and Mx of Rheumatic Fever?
Sx = recent sore throat, rash, arthritis and murmur (mitral or aortic stenosis)
Mx = Pen V and NSAIDs
Describe Beta hCG?
It is secreted by the syncytiotrophoblast. It is detectable from day 8 and doubles every 48 hours before peaking at 8-10 weeks
What should you consider as the cause of bilateral carpel tunnel syndrome?
<50 = ?RA
>50 = ?Acromegaly
What are the causes of post-splenectomy sepsis?
NHS
Neisseria Meningitidis
H. influenzae
Strep. pneumoniae
Describe Autonomic hyperreflexia?
Seen in those with a spinal lesion at T6 or above
Constipation or urinary retention causes extreme HTN, flushing and sweating. This can lead to a haemorrhagic stroke
How do kidney stones appear on X-ray?
Urate and Xanthine stones are radiolucent
Cystine stones are semi-opaque
Miscarriage Mx?
Expectant for 7-14 days unless there is infection, increased risk of haemorrhage (late 1st trimester or coagulopathy) or previous trauma
Medical = vaginal misoprostol
Surgical or vacuum aspiration
True or false, severe iron deficiency anaemia can cause dysphagia?
True
Where are sebaceous cysts most commonly located?
On the scalp
Which antibodies are seen in anti-phospholipid syndrome?
Lupus anticoagulant and anti-cardinolipin antibodies
What diagnosis should you consider in a patient with diarrhoea, fatigue and osteomalacia?
Coeliac’s disease
What is Eisenmenger’s syndrome?
The reversal of a left to right shunt leading to cyanosis
What indicated beta thalassaemia trait as the cause of anaemia?
Microcytic anaemia with a very low MCV compared to Hb levels and normal iron
What is a Richter Hernia?
Strangulation of a hernia without the Sx of bowel obstruction
Ix = metabolic acidosis and an erythematous mass with signs of ischaemia and necrosis
What should you always prescribe when you prescribe a bisphosphonate?
Calcium supplements if the dietary intake is insufficient and vitamin D supplements
Mx of hypercalcaemia?
IV fluids unless calcium is >3 then give IV bisphosphonates
When should you never do an LP in ?meningitis?
Non-blanching petechial rash or Sx of raised ICP (e.g. papilloedema)
What scale is used in post-natal depression?
The Edinburgh scale
Which nerve root leads to foot drop if damaged?
L5
What is the Simmonds triad of Achilles tendon rupture?
Palpation of the Achilles tendon, perform a calf squeeze and observe for a normal angle of declination of the foot (one foot is more dorsiflexed than the other)
Which type of betablockers can cause peripheral vasoconstriction?
Non-cardioselective e.g. propranolol, carvedilol or labetalol
SEs of the contraceptive implant?
Irregular heavy bleeding (can be managed with the COCP), headache, nausea and breast pain
No increased of VTE or migraines
It can be inserted immediately post TOP
True or false, enzymes in the small intestine are more acidic than enzymes in the colon?
False, they are more alkaline!
List 5 causes of acute urinary retention?
BPH, UTI, constipation, anticholinergics/opioids, post-analgesia and calculi stuck in the urethra
What can occur after catheter insertion for urinary retention?
Post-obstruction diuresis. Ensure you monitor fluid output and correct losses
Causes of macroscopic haematuria?
BPH, renal calculi, UTI, nephritic syndrome and renal tract trauma/tumours
Risk factors for bladder cancer?
Smoking, exposure to alanine dyes, rubber manufacture and cyclophosphamides
Mx of bladder CA?
TURBT or radical cystectomy
Define sensitivity?
The ability of a test to correctly identify patients with a disease
Define specificity?
The ability of a test to correctly identify people without the disease
What factors must be true for a screening test to be made available to the public?
Test must be cost effective and acceptable to the population, the course of the disease being screened for must be known, there must be early symptoms of the disease which can be seen, there must be an effective treatment available to all with the disease
Ix of prostate cancer?
Multiparametric MRI
Ix of testicular torsion?
Urgent scrotal exploration. Timely identification and treatment is needed to prevent scrotal ischaemia and necrosis
Name 4 layers which are dissected in scrotal exploration?
Skin, Cremaster muscle, External/Internal spermatic fascia
What are the most common type of renal tumours in children vs adults?
Children = Nephroblastoma (Wilm’s tumour)
Adults = Renal cell carcinoma
What can happen to Hb in renal CA?
Some renal CA cause increase in EPO levels leading to a rise in Hb
RFs for RCC?
Smoking, obesity, increasing age, HTN, male and long term dialysis
Which bacteria is most likely to cause septic arthritis? Which should you consider if there is a metal prosthesis?
Most likely staph aureus, consider Staph. epidermis if there is a prostesis
RFs for septic arthritis?
Immunocompromise, intra-articular injections, RA, DM, penetrating injury
Which muscles allow shoulder abduction?
Supraspinatus for 1st 15 degrees then deltoid to 90 degrees then trapezius and serratus anterior
Which blood tests should you always do in trauma with a low BP?
FBC, U&Es, Coagulation screen/clotting profile and group and save/crossmatch
Mx of tension pneumothorax?
Needle decompression then insert a chest drain
What should you consider as a cause of dull percussion and tracheal deviation away in trauma? How would you manage?
Haemothorax, Mx = insert chest drain
Which three knee structures are often injured together?
ACL, MCL and medial meniscus
Where can a graft be taken from to repair ACL injruy?
Hamstring/Quadriceps tendon
What should you consider as the cause of an AKI in a hypovolaemic patient?
Pre-renal hypoperfusion of the kidney
What is seen in Acute Tubular Necrosis?
AKI with muddy brown casts on urinalysis
What is seen in asbestosis?
Lower lobe fibrosis associated with dyspnoea, clubbing and bilateral end inspiratory crackles
What should you suspect if there are multiple nodules on a CXR and weight loss?
?Metastatic CA
Sx of adhesive capsulitis?
Dull shoulder pain which often disturbs sleep which is followed by stiffness and loss of shoulder mobility. It is commonly seen in those with DM
Can COPD cause weight loss? How do you Ix COPD
Yes!
Ix = spirometry
How raised is amylase in pancreatitis?
Typically >3x upper limit of normal
Reversal of hypoglycaemia in an unconscious patient?
IV 20% glucose
When does neutropenic sepsis often occur after chemotherapy? What should you do if you suspect it?
7-14 days after chemotherapy
If you suspect it give immediate ABx (do NOT wait for WBC count)
What should you do if serum creatinine has increased but by <30%?
No need to change medications, instead repeat renal function at 2-4 weeks
Ix of any acute abdomen post-surgery?
Contrast CT abdomen
When should you give oxygen in STEMI?
If sats fall below 94%
Ix of renal colic?
Non-contrast CT KUB
What should you do in ?septic arthritis if the gram stain is negative?
Still give IV Abx whilst you await culture results
Mx RA flares?
PO/IM steroids
Which drugs should you consider starting if metformin is contraindicated in T2DM?
Pioglitazone, Sulfonylurea, DPP-4 inhibitor or SGLT-2 inhibitor
What should you do if a patient has a large PE but is high risk of haemorrhage?
Give IV unfractionated heparin
Can you give indapamide for BP management when the creatinine clearance is <30?
No, thiazide like diuretics are ineffective when creatinine clearance is <30
Consider furosemide instead
True or false, you must always have focal neurological signs to have cerebral metastases?
FALSE
They can cause raised ICP Sx without focal neurology
What is classes as pre-diabetes?
HbA1c 42-47
FPG 6.1-6.9
Refer these patients to a diabetes prevention programme
Mx of short duration lower back pain in an otherwise healthy individual?
No Mx required, continue usual activities
Sx of an Addisonian crisis?
Reduced consciousness, hypoglycaemia, hyponatraemia, hyperkalaemia, hypotension
It is often preceded by weight loss and lethargy
Ix of ?norovirus?
Stool PCR
Coagulation profile in DIC?
Low platelets, low fibrinogen, high PT, high APTT, high fibrinogen degradation products
What is Meckel’s diverticulum?
Abdo pain which may mimic appendicitis, massive painless GI bleeding in children and bowel obstruction
SBO Mx?
NG tube insertion and IV fluids
What is classed as a moderate UC flare?
4-6 loose stools per day with minimal systemic upset.
Less than this is a mild flare up
True or false, ciprofloxacin lowers the seizure threshold?
True
Pyoderma gangrenosum is associated with IBD, what skin manifestations can it cause?
Very painful skin ulceration - especially on the legs
What metabolic abnormality is caused by vomiting?
Metabolic alkalosis with low potassium
Mx of SVT in a shocked patient?
Synchronised D/C cardioversion
Which TB drug can cause lupus? Which antibody is drug induced lupus associated with?
Isoniazid
Anti-histone antibody
Mx of PMS?
Conservative measures (e.g. frequent small meals which are rich in carbohydrates)
COCP
SSRIs if severe
What does down’s syndrome cause on the quadruple test?
Low alpha fetoprotein, low unconjugated oestradiol, high beta HCG and high inhibin A
What are electrical alternans?
QRS complexes which have amplitudes which alternate between each beat.
Seen in pericarditis
What does the Barthel index measure?
The degree of assistance which is required by an individual
What should you offer to all women who have had a previous child with illness secondary to group B strep?
Intrapartum IV Benzylpenicillin
What should you do with a perforated TM?
Advise the patient to keep it dry and review in 6-8 weeks
What is the gold standard investigation for a perianal fistula in Crohn’s?
MRI of the pelvis
Which antibodies are seen in sjogren’s syndrome?
Anti-Ro and ANA
What should you do if a patient has been on a bisphosphonate for more than 5 years?
Repeat DEXA and FRAX sore and reassess risk
When is chronic urinary retention classed as high pressure?
If there is impaired renal function or bilateral hydronephrosis
What should you ALWYAS consider in a patient with a RUQ mass and painless jaundice?
Pancreatic cancer
True or false, CBD stones can cause epigastric pain which radiates to the back?
TRUE
What is PSC a risk factor for?
Cholangiocarcinoma
What is an important complication of chronic Chagas disease?
Cardiomyopathy
What are the missed pill rules from the COCP e.g. microgynon?
If 1 pill is missed no EC is required, take last pill asap
If 2 or more pills missed take the last pill and use barrier methods for 7 days. If week 1 take EC, if week 2/3 no EC required but if week 3 omit pill free interval
Which lung function test can be reduced in recurrent PEs and why?
Reduced TLCO as oxygen is not able to diffuse efficiently from alveoli to capillaries
Which type of diuretics can be associated with digoxin toxicity?
Thiazide diuretics
Ix menorrhagia?
TVUS
Can calcium be raised in secondary hyperparathyroidism?
NO, never
If it is raised and there is a low/normal phosphate you should suspect tertiary hyperparathyroidism
What are bullae?
Air spaces in the lungs. Large emphysematous bullae may imitate pneumothorax
Large blisters of the skin share the same name
Mx athletes foot?
TOP miconazole
Mx OE in diabetics?
Ciprofloxacin to cover pseudomonas
When should you give acetylcysteine without waiting for paracetamol plasma concentration in paracetamol OD?
When a patient presents with an OD 8-24 hours ago where they have taken >150mg/kg
SVT Mx if haemodynamically stable?
Adenosine IV 6mg, then 12mg then 18mg, then DC cardioversion.
If asthmatic give verapamil
Which antibodies can be used as part of follow up in thyroid cancer?
Thyroglobulin
What is raised in medullary thyroid cancer?
Calcitonin
Which type of MND has the worst prognosis?
Progressive bulbar palsy
Imaging in ?TIA?
Diffusion weighted MRI
What is the strongest risk factor for anal cancer?
HPV infection
Mx of perthe’s disease in children under 6?
Observation only
Which muscle initiates arm abduction at the shoulder?
Supraspinatus
What medication should you use in MI if cocaine is the cause?
Diazepam
Ix of carotid artery stenosis?
Duplex USS
Which electrolyte abnormality can precipitate digoxin toxicity?
Hypokalaemia
Define orthostatic hypotension?
A drop in BP of >20 systolic or >10 diastolic within 3 mins of standing
Prophylaxis of VTE in pregnancy?
MUST be LMWH
Most common cause of tonsillitis?
Strep Pyogenes
Name 2 side effects of bendroflumethiazide?
Can cause ED and affect glucose tolerance
How should you monitor the Mx of hemochromatosis?
With transferrin saturation and serum ferritin
What should you do if the expectant Mx of miscarriage fails after 14 days?
If haemodynamically stable offer misoprostol medical Mx
If unstable offer surgical Mx
What is seen in CT in diverticulitis?
Mural thickening of the colon with pericolic fat stranding the sigmoid colon
Should you mix adrenaline in to the lidocaine when applying local anaesthetics to the digits?
NO
It can cause ischaemia
What is suxamethonium apnoea?
An AD condition which leads to prolonged muscle paralysis requiring ITU admission
Posterior inferior cerebellar stroke signs?
Cerebellar signs, contralateral sensory loss and ipsilateral horners syndrome
1st line Mx impetigo?
1% TOP hydrogen peroxide
Define PPH?
Blood loss of more than 500mls of blood after vaginal delivery
If it occurs within 24 hours it is primary, secondary is 24 hours to 6 weeks
From when should you start doing smears every 5 years?
From 50
What are Cullen’s and Grey-Turner’s sign?
Cullen’s = Periumbilical discolouration
Grey-Turner’s = flank discolouration
What is lichen planus?
Polygonal flat-topped papule lesions that are purple and pruritic. Seen on flexural surfaces and oral involvement is common
Most common cause of discitis?
Staph Aureus
What is the difference between ALS and PLS?
ALS = UMN and LMN signs
PLS = UMN signs only
1st line Mx of T1DM?
Basal bolus using twice daily insulin
1st line Mx of spasticity in MS?
Baclofen and Gabapentin
Sudden painless vision loss with dark spots in the vision in a diabetic should raise suspicion of what?
Vitreous haemorrhage
Ix Mallory-Weiss Tear vs Boerhaave?
Mallory-Weiss = endoscopy
Boerhaave = CT contrast swallow
A PEFR below what % is considered life threatening?
<33% predicted
Describe intermittent claudication?
Cramping leg pain on exercise relived by rest
Mx = exercise training, atorvastatin 80mg, aspirin/clopidogrel. Consider angioplasty and stenting, endarterectomy or bypass surgery
Describe Critical Limb Ischaemia?
Burning pain which is worse at night and relieved by hanging the leg over the bed.
6Ps = Pain, Pallor, Pulseless, Paraesthesia, Paralysis and Perishingly cold
Mx = urgent vascular referal for angioplasty and stenting, endarterectomy or bypass surgery
Describe acute limb ischaemia?
Rapid onset of ischaemia of a limb due to thrombus or emboli
Mx = urgent vascular referral for angioplasty and stenting, endarterectomy or bypass surgery
What is leriche syndrome?
Thigh/buttock claudication, male impotence and absent leg pulses seen due to atherosclerosis of the distal aorta/common iliac arteries
What is an arterial aneurysm?
A weakness in the muscular wall leading to abnormal dilation of >150% of the original diameter
True if there is an abnormal dilation of a blood vessel
False if there is a collection of blood around the vessel which communicates with the lumen
Define number needed to screen?
The number of people needed to screen for a condition to prevent one excess death or morbidity
Causes of AAA?
Connective tissue disorder e.g. Marfan’s or Ehlers Danlos, Syphilis, HTN or atheroma degeneration
Complications of AAA repair?
DVT/PE, MI, limb ischaemia due to distal thrombus, bleeding and death
Disadvantages of using endovascular repair for AAA?
Long term follow up is require, not all aneurysms are suitable and there is a high rate of re-intervention
Ix of a ruptured AAA if the patient is stable vs unstable?
Stable = CT abdo with contrast
Unstable, = FBC, G&S, U&Es and send to surgery
What is a cholesterol embolism?
Occurs after repair of (ruptured) AAA, atheromatous debris is shed and lodges in distal vessels often leading to ischaemia of the feet/toes
Name the layers of a blood vessel?
Tunica externa (adventitia), tunica media, tunica intima and endothelium
What cells are commonly seen in an aneurysmal wall?
Fibroblasts, macrophages and lymphocytes
Name 2 complications of heparin infusions?
Can cause heparin induced thrombocytopenia, increases the bleeding risk elsewhere in the body
Mx of acute limb ischaemia before surgery can be done?
Analgesia, oxygen, heparin infusion and IV fluids
Define incidence?
The number of cases seen in a given population in a specific period of time
What causes amaurosis fugax?
Central retinal artery occlusion
Name some risks of carotid endartectomy?
Dislodging of the atheroma/clot leading to stroke/MI, wound haematoma and death. Also a risk of damage to the hypoglossal or vagus nerve if open surgery
Where does epistaxis most commonly occur?
Little’s area
What is the medical term for pain on swallowing?
Odonophagia
Which lymph node is most commonly inflamed in tonsilitis?
Jugulodigastric lymph node
Name some differentials for tonsillitis?
Infectious mononucleosis, tonsillar cancer, peritonsillar abscess or parapharyngeal abcess
Why is Penicillin V prescribe over Amoxicillin in tonsillitis?
Amoxicillin can cause maculopapular rash if the diagnosis is actually infecious mononucleosis
RFs for oesophageal cancer?
GORD, Barrett’s oesophagus, smoking, obesity, alcohol and achlasia
Why is left recurrent laryngeal palsy more common than right? Sx?
It has a longer course
Sx = hoarse voice, quiet voice, vocal fatigue, SOB and cough
Which laryngeal muscle is not supplied by the recurrent laryngeal nerve? What supplies it?
Cricothyroid, supplied by superior laryngeal nerve
Name some causes of unilateral facial weakness?
Stroke, TIA, Bell’s palsy, Ramsay Hunt Syndrome, Parotid glad swelling/tumour, Acoustic Neuroma, Trauma, GBS
Name the branches of the facial nerve?
Temporal, Zygomatic, Buccal, Marginal Mandibular, Cervical
Name some complications of Bells Palsy?
Ongoing facial weakness, corneal damage/abrasions and altered taste
Ix of C.diffe?
Stool microscopy and culture, Stool C.diff toxin testing (antigen shows exposure only)
How is C.diffe spread?
Direct contact via person-to-person spread or from environmental contamination
What should you always do first in hypercalcaemia?
ECG to exclude arrythmias (causes a shortened QT)
What are the 2 most common causes of hypercalcaemia?
Primary hyperparathyroidism
Malignancy (e.g. PTHrP from squamous cell lung cancer, bony mets or melanoma)
Mx of hypercalcaemia?
IV NaCl 0.9%
If this does not work IV bisphosphonate
How can we tell between Testicular Torsion and Epididymo-orchitis?
Torsion = testicle is retracted and lies transversely, cord is most tender, absent cremasteric reflex and Phren’s sign negative
EO = erythema/warmth, the whole testicle is tender with scrotal involvement and Phren’s sign positive
Ix of Neisseria Gonorrhoea and Chlamydia Trachomatis in males?
NAAT from first catch urine sample (1st line) or urethral swab
Why does peritonsillar abscess cause trismus?
Pus causes the pterygoid muscle to spasm
Mx of peritonsillar abscess?
IV NaCl, Analgesia, Penicillin + Metronidazole IV and Needle aspiration
Mx of CAP requiring hospital admission?
Co-amoxiclav and a macrolide e.g. clarithromycin IV
Which blood result can help you decide the urgency of CAP treatment?
Lactate
Name some indications for considering ITU in CAP?
Severe pneumonia (CURB65 >= 3) and serious co-morbidities
Respiratory or metabolic acidosis
Hypotension
Progressive hypercapnia and hypoxia indicating respiratory failure
Exhaustion, drowsiness or LOC
Septic Shock
Which treatments should you initiate early in Pyelonephritis?
IV NaCl 0.9%, IV Abx, oxygen if needed
Imaging which can be done in pyelonephritis?
Abdominal USS or Non-contrast CT KUB
What classifies as transudate and exudate pleural effusion? What is the most common cause of each?
Transudate = <30g/L - Heart Failure
Exudate = >30g/L - Pneumonia
What is seen in a complete miscarriage?
Vaginal bleeding, products of conception completely expelled and a closed cervical os (but may be open if caught early)
Signs of hypokalaemia?
Muscle weakness/Tetany/cramps, Lethargy, Constipation/hypoactive bowel sounds, hypotension, high urine output, irregular pulse, hypotonia
Sx of Hyperkalaemia?
Muscle weakness, low urine output, respiratory failure, palpitations, muscle twitching/cramps, nausea/vomiting
Imaging in possible lymphoma?
Whole body CT scan for staging
Mx lymphoma?
Chemotherapy, radiotherapy and stem cell transplant
What should you mix drugs with when putting them in a syringe driver?
Water unless granisetron, ketamine, ketorolac, octreotide or ondansetron - mix these with 0.9% NaCl
What does the double effect doctrine say?
It is sometimes acceptable to cause harm as a side effect of bringing a good result so long as the side effect was not the intended outcome
Which 2 drug classes should be avoided in the last few weeks of pregnancy and why?
NSAIDs due to increased risk of prolonged pulmonary hypertension and inter-utero closure of the PDA
Opioids due to risk of respiratory depression and withdrawal
Describe eczema?
Symmetrical flexural scaly erythematous areas with signs of excoriation, linchenification and crust/weeping if infected
Mx eczema?
Emollients, topical steroids, oral steroids, methotrexate/ciclosporin/azathioprine and phototherapy
Name the types of psoriasis?
Plaque psoriasis (most common), flexural psoriasis (skin is smooth), guttate psoriasis (due to strep infection) and pustular psoriasis (on palms and soles)
Name some common sites for psoriasis to be found?
Elbows, knees, scalp and sacrum
Describe Pemphigus Vulgaris?
Autoimmune disorder (or drug induced) typically seen in Ashkenazi-Jewish population.
Sx = mucosal ulceration, painful non-itchy skin blistering. Nikolsky’s sign = spread of the bullae when pressure is applied to the skin
Ix = biopsy bulla and screen for autoantibodies
Mx = steroids and immunosppression
What are the types of malignant melanoma?
Superficial spreading, nodular, lentigo maligna and acral lentiginous
RFs for malignant melanoma?
Fair skin (Fitzpatrick Type 1), sunburn or radiotherapy treatment, UVB exposure, family history
Name 3 sites melanoma can occur at other than the skin?
CNS, GI tract and Choroid of the eye
Appearance of SCC vs BCC?
SCC = rapidly expanding painless ulcerated nodules which can have a cauliflower like appearance and bleed
BCC = slow growing pearly flesh coloured papule with telangiectasia which may ulcerate leaving a central crater
What are the 2 main broad causes of conjunctivitis?
Allergy and infection
Name the common causes of a red eye?
Acute angle closure glaucoma, anterior uveitis, scleritis, conjunctivitis, subconjunctival haemorrhage and endophthalmitis
What should you consider as the cause if there is conjunctivitis in a new born?
Chlamydia Trachomatis
Name the fundoscopy findings in non-proliferative diabetic retinopathy?
Microaneurysms, blot haemorrhages, hard exudates, cotton wool spots
Mx proliferative diabetic retinopathy?
Panretinal laser photocoagulation
What should you suspect if there is reduced visual acuity in a patient with diabetic retinopathy?
Maculopathy
Apart from diabetic retinopathy what eye conditions are diabetic patients at increased risk of?
Vitreous haemorrhage, retinal detachment, cataract and glaucoma
What is seen at the different stages of hypertensive retinopathy
I = arteriolar narrowing and silver/copper wiring
II = arteriovenous nipping
III = cotton wool exudates and flame/blot haemorrhages
IV = papilloedema
Causes of sudden painless vision loss?
Central retinal artery/vein occlusion, retinal detachment, vitreous haemorrhage, TIA/stroke and ischaemic optic neuropathy
RFs for cataracts?
Increasing age, DM, long term steroids, radiation exposure, trauma, smoking and alcohol XS
Sx of cataracts?
Loss of the red reflex and clouded lens. Reduced vision and colour vision with glare/halos around lights
Complications of cataract surgery?
Early = posterior capsule rupture/endothalamitis
Late = posterior capsule opacification
We measure intraocular pressure with a tonometer, what is the upper limit of normal? What may you see on fundoscopy?
=< 21mmHg
Examine the optic disc, you may see optic disc cupping, pallor and notching or bayonetting of vessels
What is gonioscopy?
Measures the anterior chamber angle to look at the drainage of the aqueous humour to differentiate open and closure angle glaucoma
Mx open angle glaucoma?
1st line = prostaglandin analogue eye drop
2nd line = carbonic anhydrase inhibitor, beta blocker or sympathomimetic eye drop
RFs for glaucoma?
Increasing age, family history, myopia (short sightedness), black ethnic origin
