PACEs Flashcards

Question

**Neuro** **Ascending** Dorsal Columns Spinothalamic Cell bodies for both? Spinocerebellar **Descending** Pyramidal - Corticospinal Extrapyrimadal - rubropsinal, tectospinal, vestibulospinal

Answer 1

**Dorsal Columns** - Fine touch, proprioception, vibration **Spinothalamic** - Anterior- crude touch, pressrure lateral - pain temperature **Cell Bodies -** DRG **Spinocerebellar** - subconscious somatosensory pathway (posterior, cuneo, rostral, anterior **descending** **Pyramidal** (voluntary) - Corticospinal, corticobulbar (contralateral UMN for hypoglossal and for facial nerve below eyes. Bicortical representation for facial nerve above eyes) **Extrapyrimadal** (involuntary, automatic control) - rubropsinal (hand movements), tectospinal (head in relation to vestibular stimulus), vestibulospinal (posture and balance) , reticulospinal (control of tone)

Answer 2

UMN - points away from lesion LMN - point towards the lesion

Answer 3

**4 midline structures beginning with M (**i) motor tract (corticospinal), medial leminiscus, MLF, motor nuclei) **4 structures to the side beginning with S (**spinocerebellar, spinothalamic, sensory trigeminal nucleus, sympathetic pathway) **4 CNs in medulla (9, 10, 11, 12), pons (5, 6, 7, 8), and above the pons (1, 2, 3, 4,)** Remember 7 and earlier CNs ahve ipsilateral innervaton **4 midline motor nuclei divine into 12 (but not 1 or 2), 3, 4, 6, 12** (5, 7, 9 and 11 are lateral brainstem structures)

Answer 4

Eye receives light input --\> pre-tectal nucleus --\> then to **both ipsilateral** (direct) and **contralateral** (consneusal) edinger-westphal nuclei --\> occulomotorn nerve fibres carry AP to the ciliary ganglion which is **SNS** and causes contraction of sphincter pupillae

Answer 5

**Motor** Usually **distal** weakness If **root** involvement - **proximal** weakness (GBS, Botulinum, polio) Mononeuropathy (single nerve - usually mechanical cause) Mononeuritis Multiplex (multiple nerves - DM and vasculitis) **Diabetic neuoropathy** All modalities effected, absent reflexes. starts at feet and works its ay up

Answer 6

**UMN (primary motor cortex to anterior horn cell)** - Spasticity (hypertonia), Pyramidal pattern of weakness (Extensors in UL, flexors in LL), hyperreflexia, upgoing plantars, no wasting **LMN (Anterior horn cells to NMJ)** -flaccid (hypotonia), hyporeflexia, downgoing plantars, wasting, fasciculations **Motor** Symmetrical, reflexes may still be present, no sensory disturbance, fatiguability (MG) **Cerebellar Signs** Dysdiadochokineisa, Dysmetria, Ataxia, Nystagmus, Intention Tremor, Staccato speech, hypotonia **Causes of cerebellar pathology** **Paraneoplastic**, **Alcohol**, **Sclerosis** (MS), **Tumour** (CPA), **Rare** (MSA, Friedrich's, AT), **Iatrogenic** (phenytoin), **Endo** (hypothyroidism), **Stroke** (vertebrobasilar **Dissociative sensory loss** Suggest of cervical lesion (syringomyelia) - **ST-** loss of pain and temp but no loss of **DCLM -**proprioception or vibration **Wallenberg's** PICA/ AICA insult DANVAH - Dysphagia, Ataxia (IL), Nystagmus (IL), Vertigo, Anasthesia (IL facial numbness, CL pain loss), Horner's **Neuropathy -** EMG can help with diagnosis distinguish between axonal loss/ demyelination

Answer 7

**CPA Syndrome** causes - VSchwann, Meningioma, Mets, AStrocytoma Sx - CN 5,6,7,8 (IL), DANISH **Beck's Syndrome -** Anterior Spinal Artery Syndrome (AAA repair). Lesions effect- Corticospinal tract, Spinothalamic Tract but not DCLM (this is not in anterior spinal artery distribution) **Spasticity (clasp knife) -** Extremity is weak, resistance is greater in flexion than extension. Velocity dependent (faster the more spastic) **Rigidity -** equal resistance throughout and in all planes of movement, **Cord Lesion -** LMN + pain at level, UMN below, Look for reflex, sensory and motor level **Spinal stenosis -** aching pain in buttocks, parasthaesia/numbness, relieved by leaning forwards, worse on walking up hills, **spinal claudication. negative SLR (cf disc prolapse)** **neuropathy vs myopathy - Neuropathy** = distal weakness, **Myopathy** = proximal weakness, **rest pain/tenderness** = inflammatory myopathy, **firm muscles** = pseudohypertrophy in muscular dystrophies, **fasciculatons** = anterior horn/root disease, **Fatiguabuility** = MG/LEMS

Answer 8

**Cererbral** - VINIT N= any SOL I = usually demyelination **Cord** - V= beck;s , I = MS, transverse myelitis, Devic's. Trauma **Anterior Horn -** I= Polio, I= GBS, progressive muscular atrophy **Roots/ Plexus -** Compression - Sponydlosis, Cauda equina, Carcinoma. Inflammation - Neuritis, Parsonage turner radiation **Nerve -** Mononeuropathy - Compression/.trauma Polyneuropahty - GBS, CMT, CIDP **NMJ -** MG, LEMS, Botulism **Muscle -** Dystrophies (proximal, symettrical loss), Myositis, Disuse (RA), Toxins - Steroids, electrolytes, Endo - hypothyroidism

Answer 9

ALS (Anterior horn and PMC) Friedrich's Ataxia (ataxia, cardiomyopathy, absent reflexes, DM, **FRATAXIN)** SACD (B12) Taboparesis (syphyllis)

Answer 10

Cord - Syringomyelia Anterior Horn- MND , Polio Roots - Spondylosis, Neurofibroma Plexus - Compression - rib, pancoast's. Trauma -Klumpke's Nerves - Compressive, Mononeuritis- DM, Generalised - CMT Muscles - Disuse (RA), Myotonic Dystrophy, Volkman ischaemic contracture

Answer 11

Positive = Vestibular (CPA, labyrinthitis) or proprioceptive (DCML - SACD. Peripheral nerves - Senosry neuropathy - Alcohol, DM, uraemia, b12) Negative = cerebellar (infarct, aclohol etc. etc.)

Answer 12

**Postural Hypotension** **Salt** (Hypovolaemia, addison's), **Toxins** - hypotension inducing, TCas, Anti psychotics, L DOPA. **Autonomic** neuropathy - DM, GBS, Parkinson's, **Dialysis,** **Unwell,** **Pooling (venous)** **VERTIGO** I- inf,injury M - menieres's, peri lymph B- BPV A- minoglycosides, furosemia L- ymph A- rterial N- erve C- entral E - pilepsy **Conductive hearing loss** W - wax,FB, I- infection, cholesteatoma D- Drum perf, Extra - otosclerosis, Neoplasia (NPC), Injury - barotrauma, Granulomatous- Wegener's, Sarcoid **SNHL** Developmental (alports, waaardenberg, NIE, TORCH), degenerative , infection (meningitis, measles, mumps), vascular (stroke, ischaemia of internal auditory artery), inflammatory (vasculitis, sarcoidosis), neoplastic (CPA), injury , toxins (gent, frus, aspirin)

Answer 13

**Tremor**- Regular, Rhythmic osccilation RAPID -Resting (4-6, worse with distraction), Action/postural (6-12, worse with outstretched hand. Either Benign essential tremor or caused by **sympathetic excess**), intention (worse at end stage of movement, cerebellar), Dystonic (variable) **Myoclonus** - sudden involuntary jerk **Dystonia -** prolonged muscular contraction **Chorea -** non-rhythmic, purposeless, jerky, flitting movements (huntinton's, RF, L- DOPA, WIlson's) **Athetosis -** slow, sinous, writhing movements (CP, kernicterus) **hemiballismus -** large aplitude flinging chorea, (STN lesion) **Tardive Syndromes: (anti dopaminergics)** **Dyskinesia - lip smacking etc., Dystonia (prolonged muscular contraction), Akathisia (restlessness)**

Answer 14

**Global -** ALl domains of speech effected **Wernicke's -** Limited comprehension (temporal) **Brocha's -** Comprehend well but can't express (look frstrated) (parietal) **Conductive -** Can't repat things (angulate) **Anomic aphasia -** struggle with nouns and verbs

Answer 15

**Epilepsy -** Tendency to recurrenty spontaneous , intermittent, abnormal electrical actiity in part of the brain manifesting as seizures **Multiple Sclerosis -** Chronic inflammatory condition of CNS involving demyelination white matter plaques that are disseminated in space and time **Spondylosis -** Degenerative process due to trauma and aging. Can cause - **myelopathy** (central - UMN) **radiculopathy (**lateral - LMN) **Spinal Stenosis -** Generalised narrowing of the spinal canal. Degenerative osteoarthritic process **Polyneuropathy -** Generalised symmetrical and widely distributed disorders of peripheral and cranial nerves. Distal weakness and senosry loss in a glove and stocking distribution **muscular Dystrophy -** Group of conditions causes progressive degeneration and weakness of specific muscle groups. (effect proteins involved in muscle function i.e. dystrophin) **Syrinx -** fluid filled tubular cavity in the central canal of spinal cord

Answer 16

**Proving someone has parkinson's? -** Glabellar tap (blinking doesn't disappear), **Synkinesis -** tone (tremor) can be worsened on distraction **Signs -** Tremor, BRadykinesia (slow initiation of movement), Rigidity, Festenating gait, Postural instability, micrographia, mask like face, dementia, autonomic instability, loss of arm swing,, monotonous voice, sleep disorders (insomnia, EDS, rem sleep disorder), depression **Causes -** Parkinson's Disease, Parkinson's Plus (**PSP** - postural inst, vertical gaze palsy, dementia, **MSA -** autonomic, cerebellar, **CBD** - aphasia, apraxia, akinetic regidity, alien limb, **LBD -** fluctuating cognition, visual hallucinations ), Iatrogenic (Neuroleptics, Metoclopramide), Infection (syphillis, HIV, CJD), Trauma (dementia Puglistica), Genetic (wilson's) **Pathology in PD -** Loss of Da Neurones in pars compacta of SN. beta amyloid plaques. NFT. Braak staging **ix in PD -** largely clinical UK Parkinsons Society Brain Bank Diagnostic Criteria, Structural imaging MRI to rule out Park + Syndromes, DaT Scan **Mx of PD -** **MDT approach** - Nurse, Neurologist, OT, PT, depression, disability (unified parkinsone disease rating scale) L DOPA (w/ Dopa Decarb Inh. Lose response in \<5 years). MOAi, Do Analog, COMT inhib, DBS, SSRIs (depression), Apomorphine - Rapidly acting dopamine agonist. SC rescue pen

Answer 17

Hyper - salivation, hydrosis Constipation urinary - frequency , urgency, nocturia Erectile dysfunction Postural hypotension

Answer 18

HLA DRB1 associated condition. Chronic inflammatory condition of the CNS characterised by demyelinated white matter plaques desseminated in space and time **DDx -** MS, Devic, Sarcoid, SOL **Pathology -** CD4 mediated destruction of of oligodendrocytes --\> demyelination. Later in disease process formation of islands of T Cells which secrete cytokines that lead to a diffuse atrophic process. **Subtypes -** Relapsing remitting, Primary progressive, Secondary progressive, Progressive relapsing **Signs/ Symptoms -** lhermitte's sign, Uhthoff's phenomenon, parasthaesia, redued vibration sense, optic neuritis, INO, RAPD, diplopia, ataxia, cerebellar signs, spastic paresis, GI - swallowing disorder, constipation, erectile dysfunction, urinary retention/incontinence, **McDonald Criteria** **Ix** - LP (IgG oligoclonal bands), MRI (gad enhancing, T2 hyperintense plaque), Anti-AQP4/NMO (Devic Syndrome), Anti-MBP, Delayed evoked potentials **Mx -** MDT - Nurse, Nueorlogy, PT, OT, Disability assessment Acute attack - high dose methylpred DMARDs - Flinglimod, Glatiremer Acetate, PEG-Ifn, Natalazumab (Anti\_VLA a4), Alemtuzumab (Anti- CD52) Sx mx - Spasticity - baclofen, dantrolene. Urinary symptoms - oxybutynin, Depresion - SSRIs, Fatigue - midafonil + amantadine, Pain -amitryptilline, ED - Sildenafil, Tremor - clonazepam

Answer 19

**pathology** - Degeneraive condition efecting spine. Osteophyte formation may also in volve lumbar disc prolapse. Can involve myelopathy or radiculopathy Conservative - rest, analgesia, physio Medical - Transforminal steroid joint injection Surgical - Discectomy/ Laminectomy **Spinal canal stenosis** Conservative - corsets, analgesia, physio medical -analgesics, epidural injections Surgical- decompresson

Answer 20

Polyneuropathy - Generalised symmetrical and widely distributed disorders of peripheral and cranial nerves. Distal weakness and senosry loss in a glove and stocking distribution **Features senosry:** Glove and stocking distribution (length dependent), loss of reflexes, Charcot's joints, painful neuropathie in alcoholic/diabetic, proprioceptive loss (B12 - large fiber loss), loss of pain/temperature sensation ( painful dysthesia) **Features motor:** Weakness, clumsiness, LMN signs, CN - diplopia, dysarthria, dysphagia, Resipiratory invovlement **Features Autonomic:** Horner's, Anhydrosis, Postural instability, Urinary retention, constipation, gastroparesis, ED/ Ejaculatory failure Tests - Standing/sitting BP, ECG \>10bpm variation with respiration **Main causes:** **Sensory -** Etoh, B12, DM, Paraproteinaemias (CRF, Cancer), Vasculitis **Motor -** GBS, Pb, CMT, Botulinism, Paraneoplastic **Autonomic Neuropathy -** DM, HIV, SLE, GBS/LEMS **GBS (anti ganglioside antibodies, raised protein on LP) ( Ix - Cjej, Mycplas, CMV)** - AIDP (demyelinating) , ADAM (axonal loss) , Miller Fisher (opthalmaplegia, ataxia, areflexia) - Ascending flaccid paralysis. Proximal \> distal. LMN signs **Mx -** Supprotive (autonomic - inotropes, respiratory, VTE proph) , Rx infection, IVIG/ PLEX, Novel SC IVIG for CIDP **Metabolic ( mostly axonal - reduced amplitute EMG)** - Uraemic, DM, Hypothyroid, B1 deficiency, B12 deficiecny **Inflammatory Causes** - GBS, CIDP, Sarcoidosis **Inherited Causes** - CMT - HSMN1 (demyelinating) + 2 (PMP22) - Friedrich's Ataxia (sensory) (FRATAXIN) - Refsum's Syndrome **vasculitis** - small vessel vasculitidies (PAN, Cryoglobulinaemia, RA, Wegener's) **Drugs** - Vincristine, Isoniazide, Phenytoin, Alcohol **Infection** - Leprosy, Syphyllis, Lyme, HIV, **Toxic** - Lead, **Other** - amyloid, paraproteinaemias

Answer 21

Def - Group of inherited motor neuropathies involving demyelination of axons. No sensory or occular involvement Associated with SOD1, C9ORF mutations and FTLD Types - Progressive Muscular Atrophy (best), Progressive Bulbar Palsy (worst), Primary Latertal Sclerosis, Amyotrophic Lateral Sclerosis Ix - MRI - exclude plaques/ cord lesions LP - exclude inflammation EMG - reduced velocity **Revised El Escorial Diagnostic Criteria** **Features**- mixed UMN/LMN Bulbar involvement indicated bad prognosis FTLD **mx - MDT approach** Nurse, neurologist, PT, OT, orthoptist Symptomatic treatment - dysphagia (NG, PEG), Resp fail (NIV), Spasticity (bacl, botul), Drooling (amitrypt) Riluzole - Glutamate antagonist. Improve life expectancy \>3ms **Bulbar Palsy -** MND, GBS, MG, CPMyelinoly. **Psuedobulbar -** Stroke, MS, MND, CPMyelin. **Myotonic Dystrophy** **Def-** AD Cl Channelopathy --\> causes tonic muscle spasms (percussion myotonia) - Expressionless faces, Ptsosis ,dysarthria, Dysphagia, **slow relaxation of hand , wasting wekaness of distal muscles,** cataracts, cardiomyoptahy, dm Rx - phenytoin for myotonia, avoid GA Acquired myopathies - usually related to systemic disease (Cushing, Hypothyroid, hyper/hypocalcaemia) Inclusion body myositis (dysphagia, distal + prox muscles), Dermatomyositis, polymyositis

Answer 22

**Marfan's** - Arachnodact, arm spain \>height, Downward lens dislocation, high arched palate Cx - Ruptured AA, pneumothorax, hernias Mx - Bbs slow dilation of aortic root, Regular reveiw with ortho, ophth, cardio5 **Parkinson's -** Gait, glabellar tap, synkinesis- tone/tremor worse with distraction **Myasthaenia -** ptosis and eye drooping on upward gaze, voice tires counting to 50, fatiguability (test strength, chicken flap, re-test strength), hold breath count down (used to evaluate acute disease severity), myasthenic snarl, Tensilon test (edrophonium - power will improve. Only small improvement in LEMS). EMG - decreased response to train of impulses. **Drugs worsening MG -** Beta blockers, lithium, macrolide, tetracyclines **Myotonic Dystrophy -** percussion myotonia, can't stop you from blowing out there cheeks **NF1 - CAFE NOIR** Cafe au lait, ax freck, neurofibroma, retinal hamartoma, neoplasm, orthopaedic, reduced IQ, renal (RAS) **TS** Adenoma Sebaceum, Subgunfual Fibroma, Retinal hamartoma, Ash leaf depigmented patch, Shagreen patch - Epilepsy, developmnetal delay, lyphangiomyomas - lung, liver kidney, rhabdomyoma - heart, glioma- brain **Behcet's** Skin pathergy needle prick test (develop ulcer at site of needle) **Sjogren's** Schirmer's Tear Test **Acromegaly** Hands - boggy sweaty, spade like, thenar wasting, thenar wasting Face - prominent supraorbital ridge, cuti verticis gyrata, prognathis, macroglossia, widely spaced teeth Proximal weakness GTT, IGF1, Glucose, MRI, Visual fields **Thyroid** Active vs inactive - **Active signs**: Sweaty hands, Tichycardia, AF, Lid Lag, Brisk reflexes, Tremor Grave's - Pretibial, Opthalmoplegia, Exopthalmus, THyroid acropachy **HHT (OWD syndrome. AD )** Typical oromucocutaneous telangiectasia --\> epistaxis 5 AV malformations in viscera, Pulmonary HTN GI polyps

Answer 23

**Brown- Sequard** 1. Ipsilateral spast paresis inferiot to lesion, 2. ips lat. loss of proprioception and vibration. 3. contralateral loss of pain and temp **Friedrich's Ataxia (+cerebellar signs) / SACD (B12)** - ST tracts spared 1. Bilateral spastic paresis 2. Bilateral loss of proprioception and vibration sensation 3. Bilateral limb ataxia **Anterior SPinal artery Occlusion** 1. Bilateral spastic paresis 2. Bilateral loss of pain and temperature sensation **Syringomyelia (arnold ch mal, masses, spina bif, 2o - trauma, myelitis etc.)** 1. **Flacid** paresis (typically affecting the intrinsic hand muscles) (ventral horns not Corticospinal tract), UMN signs in legs 2. Loss of pain and temperature sensation **dissociated sensory loss -** absent pain/tem preserved touch, propr, vibration. **Horner's syndrome** **Tabes Dorsalis (neurosyphillis)** 1. Loss of proprioception and vibration sensation **intrinsic cord disease** Painless Early sphincter/erectile dysfunction Bilateral motor and sensory distrbance below lesion

Answer 24

**Lumbar Plexus** - I Twice get laid on fridays (T12- L4) Ilioinguinal, Iliohypogastric, Genitofemoral, lateral cutaneous nerve of thigh, obturator femoral **Sacral Plexus ( descend near psoas and exit via the greater/infeior sciatic foramen or obturator foramen) - Main branches- some irish sailors pestor polly** Superior gluteal, inferior gluteal, sciatic, posterir cutaneous nerve of thigh, pudendal nerve **Brachial Plexus** - MARMU (C4-T1) Musculocut, axillary, radial, median ulnar, **Subclavian Artery** - Indeed very tired individuals sip, strong cofee served daily done at last Internal thoracic, vertebral, thyrocervical, inferior thyroid, superficial cervical, supra scapular, costocervical, superior intercostal, deep cervical, dorsal scapular, axillary **external carotid artery -** Some anatomists like fucking others prefer s and m Superior thyroid, ascending pharyngeal, lingual, facial, occipital , posterior aurcular, maxillary, superficial temporal **Facial Nerve** - two zulus buggered my cat temporal, zygomatic, bucallis, mandibular, cervical **Orbital fissure -** live frankly to see absolutely no insult Lacrimal ,frontal, trochlea, Superior CN III, abducens ,Nasociliary, Inferior CN III

Answer 25

**Deep Inguinal ring -** oval shaped opening in the transersalis fascia **Inguinal Canal** - Floor - inguinal ligament, lacunar ligament medially. Roof - Arching fibres of internal oblique and transversus abdominus Anteriorly - External oblique aponeurosis (and internal oblique). Superficial ring allows exits here Posteriorly - Conjoint tendon medially and fascia transversalis. Deep ring permits entry through the fascia transversalis here) **Femoral ring** - Beginning if femoral canal. Anterior - inguinal ligament Posterior - pectinal ligmanet Medially - lacunar ligament Laterally - Femoral vein **Borders of femoral canal** - Continuous with the femoral ring so same borders Contains lymph node of cloquet + other lymphatic structures **Femoral Triangle -** Superiorly - Inguinal ligament Sartorius - Medially Adductor Longus - Laterally **Hesselbach's triangle - Defect through which direct inguinal hernias often occurs** Inferiorly - Inguinal ligament Medially - Lateral border of rectus abdominus Lateraly - Inferior epigastric artery / vein **Inferior Lumbar Triangle** Inferiorly - Iliac Crest Postero-Medially - Latissumus Dorsi Antero-Laterally - External Oblique **Superior Lumbar Triangle** Superiorly - 12th rib Medially - Quadratus Lumborum Laterally - Internal Oblique Roof - External Oblique Floor - Transveralis fascia **Borders of the adductor canal** Anterio-medial - Sartorius Antero-lateral - Vastus Medialis Posterior - Adductor longus+ Magnus **Anterior neck triangle -** Midline Medial border SCM, Mandible **Posterior neck triangle** lateral border of SCM clavicel trapezius

Answer 26

(Postero - ) Lateral - Sural nerve L5/S1 Medial - Saphenous nerve / L4 Sole of the foot - largely branches of tibial nerve, small lateral area supplied by sural nerve, small medial area supplied by the saphenous nerve (at the foot arch)

Answer 27

FBC, Haematinics, ESR, CRP, Us and Es, Serum Urate, Bone profile Autoimmune - ANA, RhF, Anti - CCP, Anti DsDNA Urine Chlamydia PCR Blood Culture HLA - DR4/ DR1 **Imaging:** **CXR -** RA, SLE, Sarcoid, TB, Vasculitis (wegener's) **US/MRI -** tenosynovitis, enthesitis, Septic arthritis/ osteomyelitis **LOSS -** OA **LESS (O) -** RA **Normal joint space, periarticular erosions, soft tissue swellings -** Gout **chondrocalcinosis -** Pseudogout

Answer 28

**L2** - Hip flexion and adduction **L3 -** Knee extension, Hip adduction, Knee jerk reflex **L4 -** Foot inversion and dorsiflexion, Knee extension, Knee jerk **L5 -** Hallux dorsiflexion, Foot inversion, Foot dorsiflexion, Knee flexion, Hip extension, Hip abduction **S1 -** Foot eversion, Foot and toe plantar flexion, Knee flexion, Ankle jerk

Answer 29

Ix - Only if red flags. FBC, CRP, ESR, Bone Profile, Serum electrophoresis, Urine dip for bence jones, PSA, U&Es Imaging - MRI is most detailed Mx- Conservative: Max 2d bed rest Keep active, how to lift/stoop PT Psychosocial issues re. chronic pain and disability. Warmth Medical: Analgesia: paracetamol +/- NSAIDs +/- codeine Muscle relaxant: low dose diazepam ST Facet joint injectoins Surgical: Decompression Prolapse surgery e.g. microdiscectomy

Answer 30

**OA -** chronic degenerative condition where there is a progressive loss of hyaline cartilage **RA -** Chronic systemic inflammatory disease characterised by a systemic , deforming, peripheral polyarthritis **Trinucleotide repeat's** - Huntingtin's, Freidrich's ataxia (no anticipation), Fragile X, Myotonic Dystrophy **Gout** - is an inflammatory, erosive joint disorder characterised by the presence of monosodium5 urate crystals within the joint space. **Pseudogout -** an inflammatory, erosive joint disorder characterised by the presence of calcium pyrophopshate crystals within the joint space. **Seronegative arthropathies -** Inflammatory arthropathies effecting spine and peripheral joints in the absence of RhF and associated with HLA- B27 **Ank Spond -** Chronic disease of unknown aetiology associated with spondylosing, inflammation and thickening of the spinal joints alongside systemic manifestations **Relapsing Polychondirits -** Is a rare, relapsing autoimmune disorder causing inflammatory destruction of cartilage (ear, nose larynx) **Behcet;s -** is an autoimmune connective tissue disease leading to a small vessel vasculitis, mucositis as well as occular and other systemic manfiestations (cardiac neuro) **Raynaud's -** Peripheral digit ischaemia precipitated by cold or emotion **Polymyositis Dermatomyositis -** Acquired autoimmune condition leading to inflammation of the striated muscles and skin with some other systemic involvement **SLE -** Multisystem autoimmune disorder where various antibodies form immune complexes, which deposit in various organs **Wegener's -** Granulomatosis With polyangitis. Necrotising Granulomatous inflammatiion and small vessel vasculitis with a prediliction for skin, kidneys and respiratory tract

Answer 31

**OA** **Conservative:** Reduce weight Alter activities: increase rest, reduce sport Physio: muscle strengthening Walking aids, supportive footwear, home mods **Medical:** Analgesia: Paracetamol and or topical NSAIDs e.g. topical diclofenac (rather than oral NSAIDs) If insufficient control consider addition of opioid analgesics e.g. tramodol. NB antiplatelet, coRx with PPI if NSAIDs Joint injection: LA and steorids **Surgical:** Arthroscopic washout: esp knee, remove foreign bodies and trim cartilage Arthroplasty: replacement or excision Osteotomy: small area of bone cut out Arthrodesis: last resort of pain management. Novel techniques: microfracture-\> fibro-cartilage formation Autologous chondrocyte implantation **RA** Conservative: Physio, OT, PT Medical: Methotrexate +DMARD (initally oral steroids). 2 failed DMARDS --\> biologics. Infliximab, Adalamimumab, Etanercept, Rituximab Mx of CV risk Surgical - prosthesis , ulna stylectomy **Paget's** Cons - hearing aids, OT, PT, surveillance for malignancy, HF Medical- bisphosphonates, Mx of high output HF

Answer 32

**Features of RA - ANTI CCP Or RF** **Arthritis** (swan neck, boutonnieres, Z thumb, ulnar deviation, dorsal subluxation of ulnar stylid), **nodules**, **tenosynovitis** (de quervians - EPL/APL and atlanto - axial subluxation), **Immune** (AIHA, Vasculitis, Amyloid), **cardiac** (IHD, pericarditis), **Carpal tunnel**, **Pulmonary** - nodules, lower zone fibrosis, effusion, **Ophthalmic** - Sjogren's, Conjuctivitis, keratitis, scleritis, epislcleritis, **Raynaud's**, **Felty's** \>1 hr morning stiffness, exercise helps **SLE - SOAP BRAIN MD** Anti DsDNA, Anti Smith, Anti -ro, Anti - LA, ANA. Complement - C3 C4 Serositis (pleuritis, pericarditis) , Arthritis, Oral Ulcers, Peripheral Neuropathy Blood Involement, renal involvement, ANA, Immune (AIHA, vasculitis, , Neurology (seizures, psychosis), Malar Rash, Discoid Rash Monitoring - ESR, DsDNA, C3/C4 Nb Rashes are photosensitive **APLS--\> Anticardiolipin. Lupus ANticoagulant** **CLOTT -\>** Clotting abnormality - long APTT, Livedo reticularis, Obstetric problems, Thrombocytopenia, Thrombosis - Venous and arterial **Anyklosing Spondylitits - Anylosis of SI joints, Ossification of the spinous ligaments, spondylitis of the vertebrae, fusion of the anterior and posterior spinal segments. Squaring of the vertebral bodies. Ankylosis of costovertebral joints.** HLAB27 Kyphosis, Restrictive spirometry pattern Apical fibrosis, Anterior Uveitis, AV Node Block, Aortic Regurgitation, Amyloidosis, apical fibrosis, achilles tendonitis

Answer 33

Three: Infra patellar Pre patellar Supra patellar - but you only milk the supra patellar when you do tap and sweep. This is hte only one that communicates with the capsule **Baker's Cyst -** fluid accumulation in the semi-membranous bursa

Answer 34

Semitendinosis + gracilis - wrapped together to increase tensile strength pinned into the medial tibia plateau

Answer 35

Inspect- scar, size, any previous scars, skin changes, any signs of steal phenomona, ask about any hand pain, needle marks should be well spaced in a rope ladder like fashion Palpate - hum and a thrill (vein) Comment on how far the trhill is palpable from the fistula site --\> if the thrill is not palpable proximally can indicate thrombosis -\> if thrill is not palpable proximally but the fistula is pulsatile --\> then that is a sign of proximal thrombosis --\> look for evidence of multiple central venous scars --\> central venous scarring = higher risk of throbosis

Answer 36

Central - Vertical nystagmus Peripheral - Horizontal nystagmus

Answer 37

Subunglual Hyperkeratosis Pitting onycholysis

Answer 38

**Environmental Causes** Pneumoconiosis - Silicosis, Asbestosis **Drug Causes** Nitro, Metho, Amiod, Sulfasalaz, Bleomycin **Hypersensitivity Causes** EAA- Malt worker, Farm worker, Bird fancier **Infectious Causes** TB, Viral, Aspergillos **Systemic Causes** Sarcoid, Sclerosis, Dermatomyositis, SLE, RA, Ankylosing spondylitis **Idiopathic Pulmonary Fibrosis** **Apical** - ABPA, Pneumoconiosis -silicosis, coal. EAA, Negative seroarthropathy - Ank spond, TB **Basal** - Sarcoid. Toxins - . -Asbestosis. Idiopathic. Rheumatoid - sjogren, SLE, scleroderma

Answer 39

**General** MDT: physician, GP, physio, dietician, specialist nurse **Chest**: PT: postural drainage, forced expiratory techniques Abx: acute infections and prophylaxis Mucolytis: DNAse Bronchodilators Vaccinations **GI**: Pancreatic enzyme replacement: Creon ADEK supplements Insulin Ursodeoxycholic acid for impaired hepatic function to stimulate bile secretion **Advanced lung disease:** O2 Diuretics NIV Heart/lung transplant **Other**: Rx of complications e.g. DM Fertility and genetic counselling DEXA osteoporosis screen

Answer 40

Gottron's papules Shawl sign - mac pac rash on back Mechanic's hands Heliotropic rash Nailford erythema Subcut calcification Retinopathy Poly - Pulmonary HTN Derm - Pulmonary fibrosis

Answer 41

Occular - ant uveitis, conjunctiitis, iritis, episcleritis Lungs - BHL, PF Cardio - restricitve cardiomyopathy Neuro - neurosarcoidosis Renal - sarcoidosis Cutaneous - Lupus pernio, Granuloma, ERythema nodosum Joint - polyarthralgia Other - parotitid, lacrimal, submand gland enlargement

Answer 42

Clubbing - boggy nail bed, loss of concave angle with nailbed, drumstick nail, Increased cruvature in transverse/longitudinal planes Resp - Carcinoma, Fibrosis, Suppartive lung diseases Cardiac - Infective endocarditis, Cyanotic Heart Disease, Atrial Myxoma GI - Cirrhosis, GI Lymphoma, IBD, Coeliac Other - Sarcoid, Thyroid acropachy, familial, Unilateral - upper limb AVM/ aneurysm

Answer 43

**Consolidation -** Reduced expansion, increase TVF, ?dull percussion, Bronchial breathing, Reduced air entry, crackles **Bronchiectasis -** Coarse inspiratory crackles that change when patient coughs, purulent sputum, clubbing, wheeze + systemic signs for other disease (splenomegaly in Immunodefieicnt causes / Situs inversus in Kartagener's) **ILD -** Dyspnoea, dry cough, restrictive spirometry, clubbing, reduced chest expansion, fine inspiratory crackles, reduced air entry, **Pleural effusion -** Dyspnoea, pleuritic chest pain, dull percussion, reduced breath sounds, reduced TVF, tracheal deviation.

Answer 44

**Pneumonia** - An infective or inflammatory process leading to consolidation of part or parts of the lung **Emyema** - Pus in the pleural space **Bronchiectasis -** chronic respiratory condition in which there is dilatation of the bronchioles leading to accumulation of mucus, secretion and microbes --\> airway damage and infection **Cystic Fibrosis -** AR condition affecting CTFR gene leading to reduced luminal Cl secretion / Na resorption and Reduced NaCl resorption in sweat (hence sweat test salty), Faecal elastase, Neonatal immunoreactive trypsinogen - Pancreas, GI, Male genital tract, sinus, Lung **Aspergillosis/ Mycetoma -** Collection of fungus within a pre-existing cavity **Extrinsic Allergic Alveolitis -** Can be either an acute or chronic hypersensitivity reaction to various environmental allergens (aspergillus clavatus, farmer's lung, pidgeon fancier's lung) . Acute - T3HS . Chronic - Granuloma and fibrosis **Sarcoidosis -** Multisystem granulomatous disease of unknown cause **Pulmonary HTN -** PA Pressure \>25 mmHg **Cor Pulmonale -** RHF due to chronic PHTN **Asthma -** episodic, reversible airway obstruction due to bronchiole hypersensitivity to allergens **Pneumothorax -** accumulation of air in pleural space with secondary lung collapse

Answer 45

**Light's Criteria -** Used when pleural fluid pH between 7.25-7.35 LDH \>20 Fluid:Serum LDH Ratio: \>0.6 Fluid:serum protein ratio: \>0.5 Gravity: \>1.016 = Exudate **rTransudate** - HF, LF, RF, Dressler Syndrome, trauma, asbestos, yellow nail **Exudate** - Empyema, infection, malignancy, PE, TB, RA, SLE, Lymphoma, oesophageal rupture ( raised amylase) **Visible on X ray -** \>250 ml **Empyema -** Wide angle with chest wall, asymmetrical/unilateral, bi convex angle with the wall (whereas effusions or concave (sloping) ) **Tap** - percuss upper border and then go one to two intercostal spaces below. Infiltrate with LA down to pleura Larger catheter for haemothorax. **Send for -** MC&S, Biochem, Cytology, Immunology

Answer 46

**Primary -** Idiopathic , CF, PCD (Kartag.) Young's syndrome, Yellow Nail syndrome, \ **Secondary -** **Post infectious:** Pneumonia, TB, ABPA, UC Bronchial obstruction: Malginancy, FB, Immunodeficiency - Brutons, CVID, IGa def **Sputum: MC&s, Bloods - Search for underlying cause,** **CXR -** Tram lining, Signet rings, increased bronchovascular markings , **Spirometry** - obstructive, **HRCT - dilated thickened airways, pooling of mucus** **CF - Sweat test** **Abdo exam -** situs inversus **Mx -** Conser - Chest physio, clerance techniques, stop smoking Med - Bronchodilators, Mucolytics - carbocysteine, Ab prophylaxis, vacccinations. CF - Dornase alfa, ABPA - steroids Exacerbations - cipro Surg - Localised disease

Answer 47

**Transudative** Increased caillary hydrostatic pressure - **CCF**, **Overload**, RF Reduced oncotic pressure - Hypoalbuminaemia, Beri Beri, **Nephrotic** **Syndrome**, **Cirrhosis**, **Protein** **losing** **states** Raised interstitial pressure - Reduced lymph drainage **Exudative** Increased capillary permeability - **ARDS**

Answer 48

T1: PaO2 \<8 kPa / Pa CO2 \<6 kPa T2 : PaO2 \<8 kPa/ PaCo2 \>6kPa **V/Q Mismatch** - PE,PHT, Eisenmonger/ R-L Shunt, Asthma, Pneumothorax, Atelactasis **Reduced Diffusion -** Fibrosis, Fluid, Low Hb, Hbopathy, pneumonia, infarction **Alveolar Hypoventilation** - Obstructive (asthma, COPD, Bronchiectasis, FB) Restrictive (NMD, Bone Disease, Overweight, OSA, Fibrosis, Fluid) **Chronic Hypoxia -** Polycythaemia, PHT, Cor Pulmonale

Answer 49

**SCLC and NSCLC** (**SCC**, LCLC, Adenocarcinoma, Mesothelioma, hamartoma, adenoma 5) **SCC - most common** **SCC** - centrally located Locally invasive, metastasizes late via Lns PTHrP Mx- chemotherapy, palliation: RT- obstruction, mets; SVCO - stenting, dex radio; pleural drainage **Adeno -** peripherally located Metastasizes distantly and early **LCLC -** Central/peripheral poor prognosis EGFR-TK Mutations = legibility for biological treatment (cetuximab, erlotinib) Mx- i) surgery ii) curative radiotherapy iii) palliative/ chemo raiotherapy **SCLC -** central metastasize early chemotherapy sensitive arise from APUD cells **Complications:** **Local -** SVCO, Lobar collapse, recurrent pneumonias, AF, phrenic nerve palsy, recurrent laryngeal nerve palsy, Horner's **Paraneoplastic -** PTHrp, ACTH, SIADH, Cerebellar (Anti-Yo). Carcinoid, Dermato/polymyositis **Metastatic -** Hepatic, Neurological , Adrenal, Bone **Ix** Bloods: FBC, U+E, Ca, LFTs (treatment fitness) Cytology: sputum, pleural fluid **imaging** CXR Contrast-enhanced volumetric CT: staging Consider CT brain PET-CT: exclude distant mets Radionucleotide bone scan **Biopsy:** Percutaneous FNA: peripheral lesions and LNS Bronchoscopy Endoscopic bronchial US biopsy: mediastinal LNs Mediastinoscopy **TNM:** **LCLC :** **Tx (cells on BAL) Tis (CIS) T0 nothing** **T1 - \<3 cm, peripheral** **T2 - \>3 cm, \>2 cm from carina, pleural involvement** **T3 - \<2 cm from carina , chest wall or diaphram involement** **T4 - Mediastinal / malignant effusion** **N0, N1 - peribronchial/ipsilateral hilar, N2 ipsilateral mediastinum, N3 - C/L hilum or supraclavicular** **Mx- MDT - resp, radiology, nurse, palliative, surgeons** 5

Answer 50

Multisystem granulomatous disease of unknown cause HLA DRB1 + HLA DQB1 associated **GRANULOMAS** **General** (lymph, hepatosplenomegaly) , **Resp** - otitis, sinusitis, BHL, basal fibrosis, **Arthritis**, **Neurological** (meningitis, CN palsies), **Urine** (DI, nephrocalcinosis) **Hormone** deficiency, **Ophthalmological** - iritis, scleritis, episcleritis. **Myocardial** - Restrictive cardiomyopathy, pericardial effusion, **Abdo**, **Skin** - lupus pernio, erythema nodosum **Ix** Bloods - FBC, UEs, Bone profile, Serum ACE, CXR, CT, MRI Spirometry - restrictive TIssue biopsy -non caseating granuloma **Mx -** NSAIDs, rest, steroids, DMARDs **EAA** hypersensitivity reaction to environmental allergens (T3HS)--\> chronic exposure can lead to granuloma and obliterative bronchiolitis. Malt workers, Farmers lung, Bird Fanciers, **Ix -** **Bloods -** Raised inflammatory markers, FBC - neutrophilia, serum precipitants **CXR -** Upper lobe reticulonodular shadowing, honecyombing **Spirometry -** restrictive, reduced transfer factor **BAL -** raised inflammatory cells (lymphocytes and mast cells) **Mx -** avoid precipitant. steroids **IPF** **Complications -** PHT, Corpulmonale, T2RF, Lung Ca **Ix - CRP, ANA, RF** ABG - T2RF CXR- Reticulonodular, honeycomb shadowing (LZ) **HRCT -** most sensitive **Spirometry-** Restrictive **Biopsy, BAL (immune cells), radioisotope scanning for disease activity** **Mx** - Supportive - Palliation, O2 therapy Antifibrinolytics - Perfinidone, Nintedanib Lung Tx 5

Answer 51

Pul HTN - Pa pressure **\>25 mmHg** Causes- Left Heart disease (PS, MR, LVH, LVF) , parenchymal disease (COPD, PF, Brohcniectasis etc.) , pulmonary arterial disease (primary, systemic - Limited scleroderma, Polymyositis, SLE wegener's. PE. Portal HTN), hypoventilation (NM, OSA, thoracic cage abnormalities) **Ix** - ECG (p pulmonale - peaked p wave due to R atrial enlargement, RVH, RAD) FBC, Autoimmune (ANCA, centromere, jo1), LFT, X Ray, Echo, **Catheterisation** (right heart) **Cor pulmonale - RHF due to chronic PHTN** Signs: L parasternal heave Loud P2 + S3 PR, TR murmurs pulsatile hepatomegaly Systemic oedema + pul oedema **Ix** ECG - P pulmonale, RVH CXR - RA enlargement, enlarged pulmonary arteries Echo - RVH, TR, Raised PA pressure **Right heard catheterisation** **Rx (for both)** Conservative Medical - LTOT, Sildenafil, Bosentan, CCB Rx heartfailure - ACE-i (afterload), Diuretic (preload) Heart lung Tx

Answer 52

Asthma - Chronic reversible airway obstruction due to bronchiole hypersensitvity Hx - Diurnal variation, atopy, triggers- environment, pets, cold, exercise, drugs, stress, seasonal. Home, smoking, impact on QOL **Ix** PEFR, Obs, ECG FBC , Raised IgE, , eosinophils Spirometry - reversible obstruction with B2 agonist. \>15% improvement / 400 ml. FENO - Increased iNOS compared to normal people PEFR diary - Diurnal variation considered significcant = 20% Atopy - skin prick testing etc. **Mx** TAME - technique, avoidance - allergence , monitor, educate Bagonist, ICS, LTRA, THeophylline, omalizumab **Hx if acute** - Any ITU visits? Elicit precipitent, Best PEFR - compared to current PEFR, current medication **D/c -** 5 day oral course of steroids, follow up with GP then with resp clinic **PEFR** 50-75% = moderate 50-33% = severe (RR \>25, HR 110, trouble comp. sentences) \<33% = life threatening (PaO2 \< 8, CO2 normal or high, silent chest, exhaustion, cyanosis, SpO2 \<90%) ---\> manage intensively with constant monitoring. SABA, SAMA, GC, IV SABA, MG, methylxanthines

Answer 53

Irreversible airway disease caused by emphysema and chronic bronchitis. **FEV1/FVC ratio \<0.7**. **FEV \<0.8**. **Reduced transfer factor** No/little reversibility with bronchodilator **Chronic bronchitis**: cough and sputum production on most days for 3m of 2 successive years **Emphysema** - histological destruction of alveoli with more dead space and thickened alveolar membranes **Signs** Pursed lip breathing, Intercostal recessions, prolonged expiratory phase to breathing, wheeze, reduced air entry, cor pulmonale (loud P2, raised JVP, S3, L PS heave) Hyper expansion - reduce CS distance, loss of cardiac dullness, displaced liver edge **Pink Puffers** Emphysema, Increased alveolar ventilation. ABG usually normal but can have T1RF. bEtter prognosis Appear breathless but not cyanosed **Blue boaters** Chronic bronchitis. Obstructive airway disease. T2Rf. Reduced alveolar ventilation --\> appear cyanosed but not breathless (as rely on CO2 drive) Cor pulmonale Cx - exacerbations, Cor pulmonale, polycythaemia, pneumothorax, lung cancer **ix** **MRC breathlessness score (1-5)** **1. unaccustomed breathlessness --\> 3. walks slowly -----\> 5. too breathless to leave house** SPOT X Bloods - Polycythaemia, ABG, A1AT? CXR - hyperexpansion, bullae, bronchovascular markings, ECG - RA enlargement --\> P pulmonale, RVH, RAD SPirometry: FEV1/FVC \< 0.7, FEV1 \<0.8, Reduced TF, Raised TLC, Raised RV. Echo - PHT **BODE index, Golds criteria** **Mild - FEV1 \>80** **Mod - FEV1 80- 50** **severe - FEV1 50-30** **very severe -** **FEV1 \<30** **Mx** Cons - Stop smoking, pul rehab, nutrition, Vaccines, rescue packs, reviews Mx - carbocysteine, SABA, SAMA, LABA, LAMA, ICS (FEV1 \<50), theophylline LTOT - PaO2 \<7.3 x 2. PaO2 \<8.0 + polycythaemia, PHT, cor pulmonale, nocturnal hypoxaemia Home rescue kits - Doxy +pred Sx - lung reduction, recurrent pneumotharaces Hx gain info about - smoking status, current meds, exercise status, previous exacerbations Ix - PEFR, OBS, History, MC&S, ABG FBC, UE, Gluc, LFT, CRP, CXR - consolidation? Infect? pneumothorax? HRCT- Emphysematous changes --\> if apices then smoking/ If bases then A1AT ECG Mx - 24% venturi to start. If PaCO2 redues then can increase O2. SABA, SAMA, 200mg GC / pred 40mg, Theophylline, Doxy **If pH \<7.35 and RR \> 30 = BiPAP** **Invasive ventilation? If pH \<7.26**

Answer 54

**Towards** - Pneumonectomy - COllapse - Hypoplasia (fibrosis) **No movement** **-**consolidation - oedema, - mesothelioma **Away** - Mass - effusion - diaphragmatic hernia - consolidation (pneumothorax)

Answer 55

**Resp Alkalosis -** Anxiety related hyperventilation, PE, salicylate poisoning **Resp Acidosis -** Asthma, COPD, Pneumonia, Fibrosis,

Answer 56

Pleural thickening Pleural Plaque Asbestosis (Pneumoconiosis Lower Zone) Mesothelioma (pleural effusions, bloody tap) Lung cancer

Answer 57

\<60 bpm **DIVISIONSS - Drugs** (beta blockers, digoxin, non-dipyrimadole ccbs, amiodarone) , **Ischaemia** (inferior due to AVN involvement), **Vagal** **hypotonia** (Athletes, syncope,)5, **Infection**, **Sick** **sinus** syndrome, **Infiltration (**cardiomyopathy, sarcoid, amyloid, HH, dystrophies), **Os** (hypothyroid, hypokalaemia hypothermia), **Neuro (raised ICP)**, **septal** defect (primum)5, **Surgery**/catheterisation **Types - Sinus** **AV Block - 1, 2, 3, - Narrow QRS** **Ventricular tachycardia - Broad QRS** Junctional, atrial escape rhythms occur when the rate of electricla conduction is less than the intrinsic rate of the secondary pacing cells. **Mx** - only treat if **rate \<40 /** **symptomatic** **Atropine** 1.2mg IV Isoprenaline Transvenous pacing but can use transcutaenous as interim (needed for Mobitz II, Complete heart block, Ventricular rhythm rates, Ventricular pauses \>3 s ) **SVT** - \>100 bpm \<120 ms QRS **Causes**- Atrial - fib, flut, Sinus tachy, AVRT, AVNRT **Mx -** Stable - Vagal, Adenosine 6 12 12 (verapamil, dig, amiod alternative) Unstable - DC cardioversion (time with r wave). then amiodarone 300 mg over 60 minutes. 900 mg over 23 hours. If **irregularly** **irrefular** SVT - **AF**. **\<48 hour from onset** then - Amiodarone, Fleicanide, --\> digoxin for rhythm control. **\> 48 hour from onset** -\> Rate control with metoprolol/ digoxin consider anticoagulation **IF AF with WPW ---\> avoid** CCB, Adenosine, beta blockers ---\> lead to VF Amiodarone or DIgoxin **instead** **prophylaxis** SVT - Beta blockers AVRT- Fleicanide AVNRT - Verapamil VT - Amiodarone, ICD **Braod complex tachy** **Causes -** IM QVICK - Ischaemic, myocarditis, Long QT, Valve problems, Iatrogenic - digoxin, Cardiomyopathy, hypo**kalaemia, magnesaemia O2** 5 \>120 ms QRS \> 100 BPM Irregularly irrefular --\> AF w/ BBB **treat as AF** Could be --\> **SVT with BBB, VT, TdP** **Pulseless -** CPR **unstable - DC Cardioversion + Amiodarone 300mg over 60 minuts. 900mg over 24 hours** **stable -** **Irregular** Flecanide/ amiodarone (AF with BBB) **Regular** amiodarone/lignocaine (VW I) and correct undelying precipitants **TDP -** IV MgSO4

Answer 58

AF - LA pathology leads to loss of refractoriness. Recurrent microre-entrant rhythms 300-600 bpm. Causes - **PIRATES** P- PE, Pneumonia, I- ischaemia, idiopathic, infection, R- rhematic valve disease, A- anaemia, age, alcohol, T- toxins (alochol, cafeeine, tyroixne) , E levated BP, Sleep apnoae, surgery sepsis **Signs** - irreg irreg pulse, thready pulse, absent a wave , LVF, pulse deficit (HS vs pulse discrepancy) **Ix - Find cause if possible (Bloods, TTE, CXR)** ECG **Mx Acuet AF - \<48 hours** **Unstable** - DC cardiovert **Stable** -i) Control rate with - BB, CCB, / Digox, amiodarone ii) Anticoagulate iii) Cardiovert - Electrical, Chemical (i) fleicanide (CI if structural heart disease) ii) amiodarone) **Mx Paroxysmal - recurrent AF lasting \<7 days** i) anticoagulate ii) pill in pocket - fleicanide amiodarone iii) Prophylaxis - BBs, VWI - amiodarone, sotalol **Mx persistent AF - \>7 days and recurs desipite cardioversion** **Rhyhtm control if -** young, symptomatic, CCF, first presentation, treated precipitatn. **need to be pre anticoagulatd for 3 weeks, and then electrical/chemical cardioversion --\> anticoagulate for 4 weeks after** **Otherwise:** I) anticoagulate ii) maintenance - beta blocker or amiodarone iii) rate control \<90 bpm. BB CCB DIgoxin or amiodarone **Other options for persistent af - MAZE, pacing, ablation of AVN** **permanent af \>1 year** Rate control rate control \<90 bpm. BB CCB DIgoxin or amiodarone **Atrial FLutter (L/R Re-entrant rhythm (macro) )** **Similar approach to AF** But. AMiodarone to achieve sinus then sotalol/amiodarone to maintain sinus **Definitive -** cavotrisupid isthmus ablation

Answer 59

**Complications -** Death passing PRAED street Death, pump failure, pericarditis, arrhythmias, ventricular aneurysm, dressler snydrome, papillary muscle rupture, septal rupture, free wall rupture, dyskinetic movements, embolism **Myomalacia cordis --\>** Pap muscle rupture, free wall rupture, septal rupture5 **Inferior MI - bradyarrhyhtmia, Aortic dissection**

Answer 60

Congenital Accessory conducting pathway between atria and ventricles. Causes **AVRT** ECG Signs - Short PR - wide QRS Type A - RAD with left accessory **dominant r wave in v1** Type B- LAD with right accessory Associations - HOCM, MVR, Ebstein's anamoly, thyrotoxicosis, secundum ASD Rx - radiofrequency ablation, Medical - Amiodarone, Fleicanide, sotalol (avoid in AF) **Long QT** Men \>430 ms women \>450 ms Causes - Primary - LQTS 1 + 2 , Romano ward, Jervel and lange neilsen syndrome Secondary - hypokalaemia,calcaemia mg, hypothermia, myocarditis , K blocking drugs - Amiodarone, Anti psychotics, Anti depressants, Anti histamines, Macrolides Rx - becareful with drug prescribing Beta blockers ( not stoalol ) **CoA** Signs - HTN, RF delay, notching of ribs on x ray, mid systolic click (best over back) Turner's, Bicuspi aortic valave, berry aneurysm, NF **HOCM - AD condition** ECG- LV Strain, AF, progressive TWI Echo - MR SAM ASH - MR, Systol anterior motion ofanterior mitral valve leaflet, Asymmetrical hypertrophy

Answer 61

PREDICTION **Primary**, **Renal** (RAS, CRF, PKD. GN ), **Endo** -Liddle's, acromegaly phaeo, Hyperthyr, Cush, Conn's, **Drugs -** cocaine, NSAIDs, OCP, **I -** increased viscosity, **Coarctation**, **Toxaemia** of pregnancy, **ICP**, **Overload,** **Neurogenic -** DAI **End organ damage** - CANER --\> Cardiac, Aortic, Neuro, Eye, Renal **STAGES** (Clinic/ ABPM) 1. 140/90 / 135/85 2. 160/100 / 150/95 3. 180 / 110 **Rx.** **Only Rx stage 1 IF \<80 + End organ damage, CKD, DM, CV Risk \>20%** **\<55 / DM / CKD --\> ACEi** **\>55 / afrocaribean --\> CCB** A + C A + C + D A + C +D + other (sprionoalctone, a blocker, b blocker, more diuretics) **HF - medications improving mortality** B Blockers (carvedilol, bisoprolol) ACE - i Ald Antagonist Hydralazine w/ nitrates 1. B Blocker + ACEi 2. Ald Antag, ARB, hydr w/ nitrate 3. Dig / ivabradine / cardiac resync. Sx - Diuretics, Inhalers Vaccinations - IFV, PVC

Answer 62

**Prizmental** - CAS. Occurs at rest. *CCB / Long NItrate* **Decubitus -** Occurs when lying down **Sydrome X -** angina pain + ST elevation on exercise but no evidence of atherosclerosis. ? small vessel disease **CAD Risk Stratification** 10-29 % - Ct Ca Scoring 30-60 - myocardial perfusion scan 60 - 90 - coronary angiography **Aspirin + statin + GTN** **Beta blocker / non dipyrimadole CCB** **Next BB + D CCB** **then Long acting nitrate, ranozaline, ivabradine (Ifunny K+ channels --\> rate limiting ) , nicorandil** PCI - Refractory sx despite medical therapy Unsutiable fo CABG Cx - MI, Death, re-stenosis CABG - LMS disease - triple vessel idsease - refractory angina - unsuccessful angioplasty Cx - MI, Stroke, Pericardial tamponade, AF, stenosis of graft

Answer 63

Cardiogenic shock - inadequite tissue perfusion due to cardiac dysfunction MI HEART - MI, Hyperkalaemia, Endocarditis, Aortic Dissection, Rhyhthm disturbance, tamponade, tension pneumo, massive PE **HOCM - Left ventricular ouflow tract obstruction from asymmetrical hypertrophy** Beta myosin **Echo -** MR SAM ASH - MR, Systolic anterior movement of valve leaflet, Asymmetrical hypertrophy **Mx - Med -** -ve inotropes (BBs, Verapamil) **Sx -** septal myomectomy Rx any arrhythmias associated **Thyrotoxicosis -** The clinical effects of elevated T4 (usually due to gland hyperfunction)

Answer 64

**Signs** - **Sounds:** Early Diastolic Murmur, Soft absent S2, S3, Heard in aortic and triscupid area. Austin flint - Rumbling MDM heard Left 3 IC parasternal Collapsing pulse, Corrigan's sign, Quinke's sign, de musset's sign - head nodding, Traube's - pistol shot femorals, Wide PP, **Signs of severe disease -** Wide PP, LVF, S3, Collapsing pulse5 **Causes** - **CTD** - Marfan's, Ehler's Danlos **Rheumatic** Valve disease **Congenital** valve disease - Bicuspid aorta Root **dilatation** - idiopathic, Hypertensiin, vasculitis - behcet's takayasu **Autoimmune** - ank spond, RA **Acute** : Aortic Dissection, Infective endocarditis **Ix** **ECG** - LVH **CXR** - Cardiomegaly and dilated aorta **Echo** - LVEF, aortic valve structure, end systolic dimension Jet width \>65% of outflow tract= ssevere **Catch -** Assess LVF, assess severity, root size **Mx -** **Medical -** Reduce preload - Diuretics Reduce afterload - ACE-i, CCB **Surgical -** aortic valve replacement or repair

Answer 65

**Mitral Stenosis** **Signs -** Pulse- AF, low volume **Sounds** Low pitched rumbling Mid diastolic murmur heard best at apex and radiates to axilla. Loud S1 Tapping apex, Pulmonary oedema ---\> PHT PHT- Loud P2, PR , TR (large v wave) , Left Parasternal heave Raised JVP, oedema, ascites AF (absent a waves) malar flush **Severity -** RVF (pulsatile hepatomegaly, oedema) mitral facies **Causes -** Rheumatic heart disease, prosthetic valve, congenital heart disase **Ix** NB people come symptomatic when valve orifice \<2 cm2 ECG - AF, RV Strain - ST depression , TWI in V1-V2, RAD, P Mitrale (bifid) CXR - LA enlargement, mitral valve calcification, pulmonary oedema Echo - Valve orifice (severe \<1cm2), Pressure graident \>10 mmHg, RVH, PHTN (PA systolic pressure \>50 mmHg) 5 **Cx -** PHTN/ RVF Emboli **LA enlargement** RLN palsy - ortner's syndrome Compression - oesophagus, trachea **Mx -** Vaccinations Reduce pre-load with diuretics - no point reducing afterload **Sx -** Percutaneous valvuloplast Valve repair Valve replacement

Answer 66

**Dilation** - Overload. AR, MR, HF, VSD/ASD **Hypertrophy -** Heart works harder to push blood out. HOCM, HTN , AS, CoA **Restrictive cardiomyopathy miSSHAPEN -** Post MI, Sarcoidosis, systemic sclerosis , HH, amyloidisois, primary endomyocardial fibrosis, Eosophinilic endocarditis, Neoplasia - carcinoid TR+ PS Dx is with catheterisation **Dilated cardiomyopathy** - Dystrophy - myotonic, GSD , Inarction/infection, Late pregnancy, Autoimmune - SLE, Toxins - Et, doxirubicin, DXT, Endo - hypothyroidism

Answer 67

**Signs** Hands - Terry's Nails, Leukonychia, Palmar Flush, Dupuyten's, Clubbing, Asterixis, Excoriations (cholestatic), Scleral icterus, Macroglossia (defficiency), Raised JVP, Spider Naevi, Gynaecomastia, Ascites, Hepatomegaly, Splenomegaly, Testicular atrophy, DIstended abdominal veins, Portal HTN - Ascites, Splenomegaly, visible veins **Obstructive -** Excoriations, pale stools, dark urine Urine dip - absent urobilinogen, raised bilirubin

Answer 68

**Cushing's** - Iatrogenic, **Cushing's disease** (pit. adenoma), Toxic ADenoma, ADrenal hyperplasia, Ectopic ACTH **(primary) ACTH** **Independent** (suppressed ACTH, don't suppress on dex supression test )--- Adrenal Adenoma. (+virilisation), iatrogenic steroids, Adrenal Hyperplasia, **(secondary) ACTH** **dependent (raised ACTH)** -- Cushing's disease, ectopic ACTH secretion, Features - Catabolic - osteoporosis, proximal myopathy, straie, brusiing. GC effects - DM obesity. MC effects- Hypernatraemia, Hypokalaemia, HTN **Ix - High Dose** Dexamaethasone suppression test --\> If cortisol suppresses = ACTH dependent causes. (won't suppress ectopic ACTH) **Rx -** Metyrapone, ketaconazole Transphenoidal excision, adrenalectomy **Paget's** - disorder of increased boen metablosim leading to the formation of haphazard and poorly structured bone. Signs - SKull involement (bossing, x ray signs), SNHL, conductive deafness, signs of HF (due to lots of AV shunting), Pathological Fx Mx - Bisphosphonates **Hyperadlosteronism** - hypokalaemia, weakness, HTN/ MC XS High AR Ratio . Primary - Conn's ADenoma, **Adrenal hyerplasia** Normal AR Ratio. Secondary - RAS, Diuretics, CCF, Hepatic failure, Nephrotic Syndroe 5 Rx - Hyerplasia - Anatagonist - Spironalactone/ eplenerone Adenoma- adrenalectomy **Addison's - lack of GC. primary adrenal insufficeincy** Hyperkalaemia, hyponatraemia, hypoglycaemia, postural hypotension , hyperpigmentation, vitiligo **Primary Causes-** Autoimmune, TB Metastatic cancer- Lung, Breast Haemorrhage- waterhouse freidrichso n syndrome Congenital - CAH **Secondary -** Hypothal, pit failure **Ix** **Bloods -** Hyperkalaemia, Hypoglycaemia, Reduce Ca, Anaemia **Specific:** Reduced 9 am cortisol Short and Long synacthen - if short is nrmal (200nmol/l rise) then not addison's 21 hydroxylase Ab +VE Plasma Renin:alodsterone CXR - TB AXR - adrenal calcification **Rx -** hydrocortisone + fludrocortisone Sydrome - **AIPE1 -** Candidiasis, Addison's, hypoparathyroidism **AIPE2 -** ADdison's, Thyroid disease, T1DM **Ix Phaeo -** VMA, Metanephrines, Catecholamines Abdo CT/MRI Rx - alpha blcok (phenoxybenzamine) then beta block Adrenalecomty Radiolabelled MIBG MIBG scan - nuclear scan that finds catecholamine secreting tissue **Hypopituitarism** Causes - Hypothalamic (kallmann's, Tumour, infection inflammation), pituitary stalk (adenoma, surgery, trauma), pituitary (Vascular - apoplexy, sheehan's. Adenoma. Failure. Surgery. Infiltration - HH, amyloid).

Answer 69

Pronator drift- suggests UMN pathology Clonus - flex knee slightly, sign of very brisk reflexes

Answer 70

**Signs** - **Pan systolic** murmur loudest in apical region with radiation to the axilla. S3 heart sound. Quiet **A1** Displaced apex. AF, HTN, Pulm oedema, peripheral oedema. Inaudible S2 (as the murmur is pansystolic) RVH - left parasternal heave, Loud P2 (if PHTN, P2 comes after A2 so if there is a crescendo nature of the Second heart sound the nconsider PHTN ) Severe - LVF, Large LV, AF **Cause**- Idiopathic (due to mitral valve prolapse), **Annular** **calcification**, Infective endocarditis, Rheumatic fever. CTD - Marfan's, ehler's danlos. **IHD** - Papillary muscle rupture, poor ventricualr function leading to dilation of the left ventricle (AR, AS, HTN) DIlated cardiomyopathy **Mitral valve prolapse -** barlow syndrome (v common). **Myxomatous degeneration,** post MI, CTD - Marfan, ehler danlos, turner's **Ix -** ECG - LV Strain, AF, p mitrale (LA enlargement) CXR - Cardiomegaly, mitral valve calcificaiton, pul oedema Echo - Jet width \>0.6 cm, pulmonary flow reversal in systole, regurgitant volume \>60 ml , Card Cath - Assess coronaries, assess pressure, assess PHTN **Mx -** Medical - Reduce preload (Diuretics) and afterload ( ACE-I , CCB) Anti coagulate - esp if in AF ( consider rate control) Surgical - MVReplacement or repair (severe symptoms, Severe LV impairment) **TR** **Causes** - Infective endocarditis, RV dilation (late in RHF), rheumatic fever Malignant - carcinoid syndrome Congenital - ebstein's anomaly **Signs** - PSM, LLSE (tricuspid area) louder on inspiration. raised JVP, giant v waves, RV heave Ascites, oedema, pulsatile hepatomegaly , jaundice **Ix - LFTs!** ECG - RV strain ( V1-V2) CXR - RVH, distended pulmonary vein, Echo - Assess regurgitant volume, valve orifice, residual volume, **Mx:** REduce proload - diuretics Reduce afterload - ACEi, CCBs, Digoxin (also negatively chronotropic so reduced metabolic demand) Sx **TS-** Rheumatic fever **Signs -** End diastolic murmur, LLSE louder on inspiration. Large A wave oedema ascites **Mx -** reduce preload - diuretics Sx - repair/ replae **PR -** **Pulmonary HTN** **MS** - Graham steele murmur Rheumatic fever, IE **CTD** - marfon, Ehler's danlos **Signs -** Decrescendo Early diastolic murmur louder at the ULSE on inspiration that odesn't radiate to the carotids. RVH, Ascites, oedema **Pulmonary Stenosis :** Causes - **Rheumatic**, **Congenital** - turner's fallots, Malignancy - **Carcinoid** **Signs -** ESM louder at ULSE not radiating to carotids (may radiate to left shoulder) . Large a wave. RV heave, Ascietes, Oedema **Ix -** ECG (RV Strain - V1-V2), p pulmonale, RAD, RBBB CXR - prominent pulmonary arterioles due to post stenotic dilatation Echo - Jet folume, valve gradient, jet velocity, Cath - right atrial/ventricular pressures **Mx - valvuloplasty, valvotomy**

Answer 71

Path - Example of molecular mimicry--\> Ab cross reactivity with cardiac constituents (myocytes) Aschoff Bodies /Antikschow myocytes **Jones Criteria ( 2 major , 1 major 2 minor)** J- oints, O - myocarditis, pericarditis, epicardities, N - Nodules, E - erythema marginatum, S- sydenham's corea Minor - Fever, ESR/ CRP, arthralgia, prolonged PR Evidence of GAS - Throat culture, rapid antigen test, ASOT, scarlet fever recently **Mx -** Benpen, analgaesia, prednisolone - for heart block , Haloperidol/ BZD for chorea

Answer 72

**PBC** - pruritis, pigmentation, bones - osteoporisi/malacia, big organs (HSM), Cirrhosis, cholesterol - xanthelasma, steatorrhoea AMA Associations - Thyroid, Rheumatalogical, coeliac, Rx - Itch- cholestyramine, diarrhoea - codeine, LFTs - urseodeoxycholic acid, transplant **Liver transplant** Indications - HCC, Advanced cirrhosis Complications - acute rejection, sepsis, hepatic artery thrombosis, CMV, chronic rejection,

Answer 73

Any cause of pericarditis Viral - Coxsackie Bacterial - pneumonia, TB Fungi Metabolic - uraemic, hypothyroidism Drug - phenytoin, isoniazid, hydralazine **plus** Aortic dissection, trauma, warfarin **ASD - Pulmonary ESM (blood moves from left to right) , RF, Raised JPV, PHT- TR/PR** **Cx - eisenmonger's syndrome, paradoxical emboli** **VSD - causes - congenital or post MI** **Murmur** - pan systolic murmur heard best over LLSE, PHT TOF - Overriding aorta, RVH, PS, VSD ASsociated with Di George

Answer 74

**Diabeteic** (microangiopathy --\> occlusion = ischaemia + neovascularisation. microaneurysm = rupture = blot haemorrhage. Vascular lekage = exudate) Annual screening with fundus photgraphy Fluoroscein angiography **Mild** - Micro aneurysm **Mod** - Microenurysms, dot haemorrahges, cotton wool spots, IRMAs **Severe** - Intra retinvl microvascular abnormalities, itnra rateinal haemorrhages, venous beading, micro aneurysms, **PDR** - Neovascularisation **Rx -** Glycaemic control, pan retianl photocoagulation, maculopathy photocoagulation **Keith wagener** I - Silver wiring (arteriolar constrilction) 2 - AV Nipping 3 - Cotton wool spots + flame shapped haemorrhages 4- papillodoema **Macula** - contains teh fovea - high density of cone cells - Pigmented area of retina responsible for cetnral vision

Answer 75

**IBS -** **Abdominal discomfort relieved by passing stools** Alternating bowel habits - constipated loose passage of mucus made worse by eating **Red flags --\>** Rectal bleeding, symptoms occuring at night, wieght loss, late adult onset, FH bowel/ovarian cancer

Answer 76

**Ustekinumab -** IL12/IL23 inhibitor **Vedolizumab** - alpha 4 beta 7 integrin inhibitor. Prevents lymphocyte migration

Answer 77

**Diabetic** Both ischaemic and neuropathic: **Ischaemia:** Critical toes Absent pulses Ulcers: painful, punched-out, foot margins, pressure points **Neuropathy:** Loss of protective sensation Deformity: Charcot's joints, pes cavus, claw toes Injury or infection over pressure points Ulcers: painless, punched out, metatarsal heads, calcaneum **Arterial** - Trophic nail changes, loss of hair, reduced CRT - painful punched out ulcers at pressure points (between toes, heel, base of metatarsals) , dry looking, scabbed **venous** - haemosiddherin deposition, lipdermatosclerosis, atrophe blanche, venous eczema, - Gaiter area (medial malleolus) - Less painful than arterial, shallow, slough, wet looking

Answer 78

Exogenous drugs, Pituitary insufficiency, liver failure, addison's, islet cell trumour/immune - insulin receptor antibodies, non pancreatic neoplasms Ix : 72 h fast with monitoring of - ketones, c peptide, glucose, insulin Hyperinsulinaemic hypoglycaemia, w/ ketones - Insulin, Secretagogues, Insulinoma Hypoinsulinaemic hypoglycaemia n/ketones - non pancreatic neoplasm, insulin r antibodies Hypoinsulinaemic hypogylacemic /wketones - addison's, alocohol, pit insuff

Answer 79

Causes - graves, toxic multinodular goitre (plummer syndrome - Autonomous nodule develops o background of of goitre ---\> due to id deficiency), toxic adenoma, thyroiditis (de quervains, hashimotos, lymphocytic), Drugs (amiodarone) **Signs** - hand: tremor, sweaty, fast irregular pulse, palmar erythema, thyroid acropachy - face: hiar loss, lid lag, lid retraction, loss of outer third of eyebrow, exopthalmus, complex opthalmoplegia, - neck - goitre, LNs (malignancy), - Chest - retrosternal goitre, apical heave, - leg- pretibial myxoedema, brisk reflexes **Ix -** Addison's, Vitiligo, T1DM **IX** ECG - tachy, AF. general ischeamic signs CXR - ?ret goitre, Cardiomegaly (high output HF FBC, U&E, LFT, CRP, ESR, **TFT,** Anti - TSH, Anti - TPO (can soemtimes be raised), ANti - TG (more of a tumour marker) Isotope scanning - diffuse uptake (reduced in thyroiditis) **Rx** Symptomatic - beta/alpha block Anti thyroid - carbimazole / PTU ( both prevent idodinistation of TG residues but PTU also prevents peripheral T4 --\> T3 conversion) Block and replace with thyroid Radio-iodine Thyroidectomy

Answer 80

**Symptoms -** lethargy, cold intolerance, weight gain, hoarse voice, dry skin, depression, constipation, menorrhagia **Signs -** slow relaxing reflexes, bradycardia, dry skin, puffy face, goitre, myopathy, Ascites, myxodoemaa - SC swelling **Causes -** Primary - autoimmune hypothyroidism (anti-TPO, Anti-TSH), Hashimoto's thyroiditis, subacute thyroiditis, reidel's yhyroiditis, iodine deficiency.Sick euthyroid syndrome, Radio exposure, Drugs - carbimazole , amiodarone, lithium Secondary- Pituitary failure, pituitary apoplexy Associations of atrophic thyroiditis -\> pernicious anaemia, vitiligo and other endocrine abnormalities Ix - ECG FBC (macro/normocytic anaemia), TFTs,. TG+ Chol, SIADH, Raised CK? TPO TSH Raised Prolactin

Answer 81

**Thyroid** Incision - collar Indications - Relapsing hyperthyroid, pressure, cosmetic, carcinoma Cx Early - haemmorhage, RLN injury, laryngeal oedema, hypoparathyroidism, toxic storm Late - hypothyroid, keloid scar, recurrent hyperthyroidism **Renal Tx** Incisions - traditional rutherford morris hockey shaped Cx - Immediate - damage to structures, reactive harmorrhage Early - ATN of graft, vascular thrombosis, urine leakage, UTI Late - GvHD, chronic graft rejection, infections related to immuno suppression

Answer 82

Cardiac - Long QT GI - Pancreatitis, constipation Orthopaedic - osteitis fibrosa cystica ( loss of phaangeal tuft), brown's tumour (fluffy pop corn calcification looks like giant cell tumour but is reversible) DEXA - osteoporosis **Rx -** increase fluid intake, avoid thiazides / try frusemide Bisphosphonates Sx - excise adenoma ( RLN palsy, Hypoparathyroidism) **Presentation of hypocalcaemia** SPASMODIC Spasms (chvostek, trosseau), perioral anasthaesia, anxiety, seizures, increased muscle tone, Orientation, dermatitis, impetigo herpetiformis, Cardiac - QTc)

Answer 83

**peutz jehgers** Mucocutaneous freckles, Gi Hamartomas, Pancreatic endocrine tumours, Increased risk of cancers **Von Hippel Lindau (mutated VHL gene on chromsome 3)** Renal cysts, RCC, Haemangioblastomas, Phaeos, Pancreatic endocrine tumours

Answer 84

**Constipation** OPENED IT - Obstruction (adhesions, hernia, post-op ileus), Pain (anal fissure, proctalgia fugax), Endocrine (, hypothyroidism, hypocalcaemia), Neuro (parkinson's, MS, Myelopathy chagas, MND), Edlerly, Diet/Dehydration, IBS, Toxins ( opiates, IroN) **Cx of PUD** **perforation -** peritonitis. **haemorrhage-** haematemesis, IDA. **Gastric outflow obstruction** - vomiting, obstruction. **Malignancy**- Increased risk of h pylori. **Cx of UGI surgery** SARS BDW - Stump leakage, reflux, Abdominal fullness, stricture. - Blind loop syndrome , dumping syndrome, weight loss **haematemesis** VINTAGE - Varices, Inflammation (oesophagitis, PUD), Neoplastic, Trauma(MW, Boerrhaves, OGD), Angiodysplasia, HHT, de liefuoy lesions, general Bleeding diathesis, epistaxis **PR bleed -** DRIPING arse - Diverticulae, Rectal - haemorrhoids, fissure, , Infection, Polyps, Infalammation (IBD), Neoplastic, Gastric bleed, Angiodysplasia DLF, varices,

Answer 85

**GORD** **LA classification** I. Muc tear \<5mm confine tu muc folds. II. Muc tear \>5mm confined to muc folds. III. tears briding muc folds \<75% circumference IV. \>75% **Hepatic encephalopathy** West haven criteria **Drug incuded liver failure** kings college criteira (acidosis, PT, Creatinine, encephalopathy, bilirubin)

Answer 86

**Nissns fundoplication** - For GORD Wrap Fundus around LOS and correct and diaphragmatic defects. **Cx.** Inability to belch, dysphagia/ reflux

Answer 87

**Pre Hepatic -** HA, Malaria, thalassaemia, Red Cell defects, Pseudo - rifampicin, **Hepatic** **unconjugated -** **Reduced conjugation -** Crigler Najjar (UDP GT absence), Gilbert's (UDP GT deficiency), Hypothyroidism **Reduced BR uptake -** CCF, contrast media **Conjugated -** Rotary, Dubin JOhnson, **Hepatocyte dysfunction** - Congenital - HH, Wilson 's. AI- AIH, Infection - HAV, HBV, HCV, CMV, EMV. Toxins. Neoplasia - HCC, METS, Budd chiari **Post hepatic - Obstruction** (gall stones, malignancy), PBC, PSC, cholangiocarcinoma **Drugs -** OCP, tetracyclines, sulphonylureas, co ampxiclav, flucoxaxlin, sulfonylureas

Answer 88

Dilated, Unresponsive to light - CNIII surgical palsy Tonically dilated, reacts slowly to light with more definite accomodation response - Holmes Adie pupil Pupil appears to constrict less when direct test than when consensual testing - marcus gunn pupil Bilaterally small pupils that dont react to light but do accomodate - argyll robertson pupil

Answer 89

**Endovascular** Using contrast - RFs for contrast nephropathy - Renal impairment, Elderly, dehydrated, cardiac disease, concurrent nephrotoxic drug use

Answer 90

**Upper GI Bleed** Rockall/ Blatchford scoring (urea, hb, SBP, melaena, syncope, hepatic disease, cardiac failure ) **Bleeding on warfarin** Major bleed - IV Vit K, Prothrombin CC Minor bleed INR \>8 = Iv vit k INR 5-8 = IV Vit k No bleeding INR \>8 = oral vit k INR 5-8 = omit few doses INR \<5 = reduce dose

Answer 91

B - pegIFN + NRTI ( lamivudine , tenofovir) C - pegIFN + ribavarin + sofusbuvir (proteosome inhibitor)

Answer 92

**HH** - AR HFE Chr 6 Myocardial - dilated, Endocrine - pancreas, pituitary, hypogonadism, A- rthritis chrondocalcinosis, L - cirrhosis, S - skin Pearl's prussion blue stain **A1AT** - AR Chr 14 A1At usually produced in liver ---\> neutrophil elastases in lung have free reign and cause emphysema Cirrhosis too Periodic acid schiff stain +ve globules **Wilson's** (impaired incorporatioin of Cu into caeruloplasmin / biliary excretion causing it to accumulate in other organs) CLANKAH - Cornea- Liver, Arthritis - cho ndrocalcinosis, osteoporosis, Neurological - parkinsonism, ataxia, psychaitric, Kidney - Fanconi, abortions, HA CF **Coeliac -** DQ2 DQ8 GLIAD - GI malabsorption (flatulence, steatorrhoea, hypoalbuminaemia, Vitamins), Lymphoma, Immune associations (IgA, T1DM, PBC), Anaemia (Micro/macro, hyposplenism), Dermatological **Alport-'s** X linked Haematuria,proteinuria. SNHL deafness, Lens dislocation. retinal flecks.

Answer 93

**Pancreatic** - **Adenocarcinoma(head\>body\>tail)** (neuroendocrine malignancy - MEN1) RF- Smoking, inflammation, etoh, diabetes, high fat diet Rx - Whipple's + chemo if curative. Mx replace vitamins, enzymes, Palliative - (open or ERCP) stent CBD, Palliative bypass, chemo **Staging** -**EUS - Goldstandard** **CT/MRI , CXR, laparoscopy** **CHolangiocarcinoma** CA 199 Rfs - PSC, UC,

Answer 94

SACD MND Friedrich's ataxia MS (if severe sensory involvement) pellagra

Answer 95

Glomerulus - endothelium, basement membrane and epithelium Negatively charge - anions can't pass Na resorption - controlled by aldosterone (triggered by macula densa response to hypotension and low osmolality) Water resorption - controlled by ADH (triggered by JGA response to hypotension and high osmolality) PCT - Bicarb (carbonic anyhdrase), Glucose, AA, Sodium resorption here **(CA inhibitors --\> metabolic acidosis)** Ascending tubule - Triple transporter **(loop diuretics --\>** metabolic alkalosis, hypocalcaemia) Descending tubule - NaCl DCT - eNaC channel (aldosterone,) ( **thiazide** - reudce renal stones, hypercalcaemia) (**amiloride) (ald antagonist)** CT - eNaC (adlosterone) **(amiloride)(ald antagonist)** Distal collecting tubule- AQP2 (ADH) (**SIADH**- vaptan, demeclocycline. **DI - desmopressin,** ) Hormones- EPO, 1 alpha hydrox

Answer 96

Renal - PCKD, Trauma, Infection, neoplasm, GN/TIN Extra- renal - trauma (stones, cather), infections, neoplasm, bleeding diathesis, Drugs- nsaid, frusemen, cipro, cephalosporin, cyclophosphamide, Asymptomatic --\> alport's, thin basement membrane, iga nephropathy **Proteinuria** - Common - DM, Minimal change, membranous , amyloidosis, SLE Other- HTN, ATN. TIN, UTI,

Answer 97

10 ml 10 % ca gluconate 100ml 20% glucose and 10u insulin salbutamol 5mg neb Calcium resonium 15g po Haemofiltration Dialysis: AEIOU Acidosis, Electrolytes (hyperkalaemia), Intoxcation (SLIME - Saliclyates, Lithium Isopranolol, magnesium laxatives, Ethylene glycol), Overload, Uraemia

Answer 98

Classification I \>90 II 89-60 III 59-45 IV 44-30 V \<29 Causes: **DM, HTN,** SLE, RAS, GN, PKD, Drugs, Myeloma, **Ix -** Urine Dip, CXR FBC, UE, LFT, Autoantibodies for SLE etc., Complement levels, Bone profile US Renal biopsy Cx - CVD, Bone, Oedema, HTN, Hyperkalaemia, Uraemia (Fibrosis, encephalopathy, neuropathy), Anaemia, Restless Legs **Bone Disease** \< 1a hydroxylation, Phosphate retention --\> increased PTH, Acidotic bone buffering OP, Omal, Osteitis fibrosa cystica (brown tumours - fluffy popcorn, pseudofractures, periosteal bone resorption) . pepper pot skull, rugger jersey spine **Mx** Treat reversible causes + stop nephrotoxic drugs + Na fluid and phosphate restriction CV- Statin, aspirin HTN - ACE i / ARB Frusemide, Alfacalcidol + ca + phosphate binders. EPO cautiously as too high --\> thrombosis

Answer 99

Contraindications - infection, cancer, other severe co morbidity Types - live heart beating donor, cadaveric, brain death **Immunosuppresion - IL 2 R antagonists -** Daclizumab+ basiliximab. **CD52 -** Alemtuzumab **Maintenance -** pred, purine antag - MMF/ AZT, Calcienurin - Tac, ciclosporin

Answer 100

**Large kidneys:** PCKD Amyloidosis Malignancy Obstructive hyronephrosis Hypertrophic diabetic nephropathy Hypertrophy due to contralateral renal failure/agenesis/RAS **Malignancy:** **Direct -** RCC, urological tract (obstruction), Renal infiltration, **Indirect -** Calcium mediated - Nephrocalcinosis, Toxic chemo, Tumour lysis **myeloma - ATN due to light chains. Nephrcalcinosis due to hypercalcaemia**

Answer 101

**Gastro** - DRE, Stool Culture +/ Faecal CAloportectin, Obs, hernial orifices, external genitalia **Resp -** Sputum culture, Peak flow, Obs (including Temp), X Ray, ECG, Spirometry **Cardio -** ECG, Obs, Standing and seated blood pressure, Weigh them (if HF), Eye exam (IE,), Urine Dip (microscopic haematuria) **UL Neuro -** LL Nuero, CN Exam, Nerve conduction studies, Assess anal tone, Cerebellar exam **LL Neuro -** UL Neuro, CN Exam, Nerve conduction studies, Anal tone **CN - Reflexes - corneal, gag, jaw jerk.** UL Neuro, LL Neuro, Cerebellar, Fundoscopy, Comprehernsive visual field testing, Audiometry **Thyroid -** ECG, CV Exam, CN Exam **Knee (remmber clarke's and simmond's tests) -** Hip Exam, Foot Exam, Neurovascular exam of the distal limb, orthoganol x rays, joint aspiration **Hip -**Knee exam, Spine exam, neurovascular exam of the distal limb, orthoganol x rays, joint aspiration **Shoulder -** C spine exam, elbow exam, neurovascular exam of the distal limb, Imaging **Breast -** Spine exam, Abdominal Exam, Resp Exam, Imaging - to assess mets, Referal for triple assessment **Arterial -** ABPI, Arterial doppler (mild disease = biphasic, severe disease = monophasic) , ECG, CV Exam, Neurological exam of hte lower limb, walk test **Venous -** ABPI, Venous Doppler, Arterial exam, Abdominal/ pelvic exam **Hands -** UL Neurological exam, Vascular exam, Imaging, Joint aspiration ( big effusion ? septic ?reactive)

Answer 102

**Hepatomegaly -** Cirrhosis, Cardiac failure, Cancer (mets, Primary) Infective - abscess (eneterococcus, ameobiasis, hydatid), HAV, HBV, HCV, Infiltrative - Wilson's, HH, A1AT, **Splenomegaly -** Haematological - SCD, Heriedatry spherocytosis, CML, MF Infection - EBV, Malaria, Kala Azar (leshmaniasis) Liver - portal hypertension **hepatosplenomegaly-** CML, Portal hypertension, Myelofibosis, Kala Azar, Malaria, Gauchers (LSD)

Answer 103

Causes **(GET SMASHED)** **Signs** - Jaundice, Echymycoses (grey turner's, cullen's) , hypovolaemia, hypovolaemia, ileus, cholestasis, sentinal loop **Glasgow** criteria - PANCREAS. Pao2 \<8, Age 55 , Neutrophilia, Calcium low, renal function . \>16 urea , Enzymes: LDH/ AST elevated, Albumin \<32, S ugar \>10 1 = mild. 2 = moderate. 3 = severe CRP \>150 48 hours later is a marker of poor prognosis **Cx** - hypovolaemia, ARDS, DIC, BM Pancreatic - necrosis, pseudocyst (walled off fluid collection in the lesser sac) , haemorrhage, infection, thrombosis (GDA, splenic artery), fistula formation **ix - Balthazar severity score CT. CXR - ARDS , ERCP (if gallstones the cause)** **Bloods** **mx -** Manage complications - ARDS- ventilatory support. Hypovolaemia, DIC etc, neep anticoagulation Drip and suck, NBM Consider TPN CVP5 Some give prophylaxtic Imipenem due to risk of infection in pancreatic necrosis Surgical - Debridement of necrosis, Pseudocyst/ abscess drainage **Chronic pancreatitis** - AGITS - Alcohol, Genetic - CF, HH, Inflammation (IgG4 related), hypertryglyceridaemia, Structural obstruction Cx - DM, Osteoporosis, Malabsorption of vitamins/ nutritents, Malignancy, psuedocyst, splenic vein thrombosis Ix - bloods, stools - reduced faecal elastase, USS - psuedocyst, AXR/ CT- calcifiactiosn **mx -** Conservative - lifestyle, diet Medical - supplementation - CREON, ADEK vitamins, Octreotide (somatostatin analogue reduce secretions), treat DM Sx - Whipples, pancreaticojejunostomy, Endoscopic stenting

Answer 104

5 Fs - female, fat, fair, forty, fertile Amirands triangle, cholestasis, bilary sepsis Gall stone types - pigment, cholesterol, mixes Complications of gallstones - Biliary Colic, Acute cholecystitis, Ascending cholangitis, Gallstone ileus, Gall bladder empyema, Mucocele, porcelaine gall bladder, pancreatitis, Mirizzi syndrome Ix - Bloods, Obs, Urine US (dilated ducts \>6mm, visualise stone) --\> MRCP if no stone visualised ERCP --\> dilated ducts and to rx (sphincterotomy) **Mx** **Avoid morphiene (sphinter of oddi spasm)but give analgesics.** **Fluids, NBM if planning urgent surgery** **Abx - cef and met** **Biliary Colic -- Elective chole 6 -12 weeks** **Acute cholecystitis - Lap chole 1 week later** **Gall bladder empyema/ lap chole - percutaneous cholecystotomy** **All of these are +/- t tube insertion or sphinter of oddi resection to release gallstones**

Answer 105

Gallstones, Mirizzi syndrome Malignancy Other : **Porta hepatis - LNs** **Cholestasis -** Drugs, pregnancy **inflammatory -** PBC, pSC **ix** **Us --\> MRCP/ ERCP** **percutaneous** **transpehatic cholecystography -** contrast study

Answer 106

**Immediate** - Damage to structures (perforation, bleeding) - Primary/ Reactive haemorrhage - Oropharyngeal trauma **Early** - Secondary Haemorrhage **-** Ileus - Infection - VTE - Urinary retention (Drug related - opioids, antimuscharincs, Pain related, psychogenic. Neuropathy, Hernia/ anorectal surgery) - Basal atelectasis (mucus plugging and distal collapse. RFs - Smoking, anaesthetic, pain -\> reduced coughing), pneumonia - Antibitoic associated colitis - Wound infection, dehiscence (Jenkin's rule - 4 times length of wound, 1 cm bites , 1 cm apart) - Anastamotic Leak - High output stoma **Late** - Failure of operation - Scarring 5- Neuropathy **Inguinal Repair** **Early** -Haematoma/Seroma formation, Infection, Urinary retention, intra abdo injury **Late** Recurrence, ischaemic orchitis, chronic groin paion **Appendicectomy** **Early** Abscess formation, fallopian tube trauma, need to perfrom right hemicolectomy **Colonic** **Early** - Intra abdominal Damage, Intraabdominal Collections (Interloop, Paracolic, Pelvic, morrison's space), Enterocutaneous fistulae, Ileus, AAC, Anastomotic leak **Late** Adhesions, Incisional hernia **Anorectal** Urinary retention, Anal incontinence, fissure, anal stenosis, sexual dysfunction **Small bowel surgery** Fistulae, adhesions, short gut syndrome, malabsorption **Splenectomy** Gastric dilation, thrombocytosis, increased predisposition to infection particularly with encapsulated organisms **Arterial** Pseudoaneurysm formation, emboli, graft failure/thrombosis, anastomatic leak (endoleak for EV procedures), graft infection, compartment syndrome **Aortic surgery** Renal ischaemia, occlusion of spinal arteries (artery of adamkewitz), gut ischaemia, trash foot, aorto-enteric fistulae **Breast** Haematoma/seroma formation, lymph damage --\> lymphoedema, skin necrosis, flap failure/necrosis (TRAM, LD Flap) **Urological** Sperm granuloma, Uroma, Sepsis, Retrograde ejaculation, **Prostatectomy** TUR syndrome, retrograde ejaculation, sexual dysfunction, urinary incontinence, prostatis **Thyroidectomy** Haematoma formation, RLN damage, Hypoglossal nerve damage, Tracheal compression Hypoparathyroidism **Fracture repair** malunion, infection, fat emboli, compartment syndrome, AVN **Hip replacement** VTE, neurovascular structure damage (SGN/ SN), Infection, aseptic loosening, dislocation, leg length disrepancy **Cardiothoracic** Mediastinitis, empyema, **Abscess Collection sites-** Pelvic, Subphrenic, Paracolic, Interloop, Morrison's space, Lesser sac **Causes of ileus -** Bowel handling, Electrolyte abnormalities, Anaesthesia, Pancreatitis, Ogilvie's syndrome

Answer 107

**Diverticulum -** outpouching of a tubular structure . **True-** composed of complete wall (meckel's). **False -** composed of mucosa (pharyngeal, colonic) **Hernia -** protrusion of a viscus through its cavity into an abnormal position **Fistula** - abnormal connection between two epithelial surface (exception is AV fistula in which case the connection is between two endothelial surfaces) **sinus** - epithelial lined blind ending tract that often contains granulation tissue **Meckel's Diverticulum** - True diverticulum of the vitello-intestinal duct remnant often containing ectopic pancreatic or gastric tissue. 2 foot from the ileocaecal valve on antimesenteric border. **intessuseption -** portion of intestine is invaginated into its own lumen **Mesenteric adenitis -** painful large lymphadenopathy in the abdomen following URTi infection **Aneurysm -** abnormal dilatation of an artery \>50% its normal diameter **True -** involving all layers of the vessel wall (fusiform- ballooning on all sides, saccular - balooning on one aspect) **False -** collection of blood around a vessel wall that communicates with the lumen **Dissection** - Vessel dilatation caused by splaying apart the media to form a channel in the vessel wall **Ulcer -** interruption in the continuity of an epithelial serface **Varicose Vein -** Dilated tortuous veins of the superficial venous system **lymphodoema-** Collection of interstitial fluid due to block or absence of draining lymph ducts **Dermatome -** area of skin supplied by a spinal segment **myotome -** Group of muscles supplid by a spinal segment **Stoma-** bringing of lumen or visceral contents onto the skin **Ganglion -** multilocular cystic swelling which may communicate with joint capsule or tendons --\> due to degenerative changes **Baker's Cyst-** Fluid filled collection within the tendon sheath of the semimembranosous muscle that as a result of degeneration now communicates with the joint capsule

Answer 108

Raised IAP causes mucosa to herniate through muscularis propria at weak points in the bowel wall - perforating arteries). **Sx -** altered bowel habit relieved by defectaion, nausea, flatulence Diverticulitis = inflammation of diverticulae due to faecolith causing obstruction of diverticulae. **ix -** CT, Gastrograffin enema, (erect CXR, AXR). **Flexi Sig.** **Colonscopy (not in acute)** **Rx -** increase fibre, reduce straining, mebeverine from cramping Sx - for unremitting symptoms **Grading - Hinchey** I-IV I. para colonic abscess. II. Large abscess . III purulent peritonitis IV faecal peritonitis **Mx . 1-2 hinchey** Home, bowel rest, fluids only ?antibiotics Hospital --\> NBM, Fluids, Analgesics (avoid nsaids and opioids), Cef& Met . **Cx -** perforation, haemorrhage (mesenteric angiography), strictures, peritonitis, abscess (CT / US guided drainage), fistulae (enterocolic, colovaginal, colovesicular) **Sx** - If -\> Perforation, large haemorrhag,e Obstruction **Hartmann's**5

Answer 109

Types - simple (one obstructed point), closed loop (two obstructed points - volvulus), strangulated ( comprised vasc supply) **SBO -** Adhesions, hernia **LBO -** Malignancy, strictures, volvulus **Mechanical. non mechanical causes of bO** Non mechanical - paralytic ileus ( peritonitis, pancreatitis, suergery, electrolyte imbalance, pseudo obstruction) Mechanical - Intraluminal (Intessusception, Food bolus, gall stone ileus ) , intramural (stricture, malignancy, atresia, 5hypertrophied peyers patch, polyp, extraluminal (ladd's bands, retroperitoneal fibrosis, urinary retentio,

Answer 110

Littre - containing meckel's diverticulum Amyands - appendix herniating through inguinal canal Sliding - hernia where bowel makes up part of the hernai sac Maydl - Double loop herniates Richter - only part of the bowel is in the herniating sac. usually the anti mesenteric border of involved bowel Spigellian - hernia between the semilunaris and the lateral rectus sheeth Pantaloon - simultaneous direct and indirect hernia **Herniatomy** - Excision of sac **Herniorapphy -** Suture repair of hernial defect **hernioplasty -** meh repair of hernial defect

Answer 111

**Otitis Externa** - Tenderness - tragal, Itch, Watery discharge - Causes - Moisutre, itching, absence of wax, hearing aids - ORganisms - bacterial - pseudomonas, staph, fungal Rx - topical acetic acid, analgesics, topical abx +/e topical steroid Cx - cholesteatoma, malignant otitis externa, OM of temporal bone, cerebral abascess, Eczematous -b etamethasone **Malignant OE -** Leads to skull osteomyelitis Need to be managed in hopsital with IV abx +/- debridement **Acute OM** - Bulging red TM membrane - Mx - Analgesics, delayed abx prescription 5 Cx - **intratemporal cx** - Choleteatoma, Osteomyelitis, Drum perf, ,, mastoiditis, CNVII palsy5 **Intra cranial cx-** Meningitis, encephalitis, subdural sbcess Intracranial abscess **OME** - effusion after symptom regression Mx - Grommets if persistent hearing loss (glue ear) **Chronic OM** - \>3m effusion / \>6m effusion if Unilateral5 **Chronic suppartive OM** - discharge, hearing loss and evidence of drum perforation Mx - aural toilet, steroid/abx ear drops Cx - cholesteatoma **Cholesteatom** - Locally destructive expansion of squamous epithelial tissue in middle ear Cx - Deafnese due to ossicle destruction, meningitis, cerebral abscess **Otosclerosis** AD disorder causing fixation of the stapes at the oval window **Menieres** Destructive condition due to endolymph formation in the inner ear Mx - acute attacks- cyclziine, beta histine LT management --\> saccus decompression, gentamicin instillation **BPV** Displacement of otoliths in semicircular canals **Epiglottitis** Mx - call senior A-E. 1:1000 adrenaline nebulised Steroids - budesonide nebs + IV dex O2 - intubation/ cric **Little's area (kiesselbach's plexus)** Anteriorinferior part of nasal septum Four arteries anastamose to form plexus - atnerior posterior ethmoidal arteries, spheopalatine artery, greater palatine artery, septal branch of superior labial artery **Conductive hearing loss** - anywhere from TM to round window Causes - TM perf, Ossicle defects, External canal obstruction, Inadequate ventilation of eustachian tube **SNHL** - cochlea, cochlear nerve or brain **pinna haematoma** - blunt trauma leading to subperichondrial haematoma - ischaemic necrosis of cartilage ---\> fibrosis ---\> cauliflwoer ear Mx - aspiration and packed. **Exostoses -** Smooth , symmetrical bony narrowing of external canals . Due to cold expsoure **bacterial sinusitis -** pseudomonas, haemophilus, morexalla Ix - Nasoendoscopy **perf Tymp Membrane** keep dry, most will heal in a matter of weeks. Sometimes tympanoplasty is needed

Answer 112

**Third nerve palsy** Ptosis, Ophthalmolplegia + (blown pupil) Causes: Ischaemia- GCA, Atherosclerosis, DM, Vasculitis Vascular - PComm Inflammatory- MF syndrome, post viral Neoplastic - astrocytoma , meningioma Congenital causes- midbrain agenesis, Stroke - Brainstem (weber syndrome) **Sixth -** eye drifts medially Causes - Vasculopathic (DM), Tumour, Raised ICP **Fourth -** Nasally and upward deviated (SO usually depresses and intorts the eye) Causes - vasculopathic, Raised ICP, Trauma **Cataracts** **- Age related, DM, Steroids** **Congenital - myotonic dytrophy** **Acquired - trauma, wilson's disease, galactosaemia**

Answer 113

Proptosis (superior tarsal muscle), Anyhdrosis, Meiosis (small pupil), Enopthalmus (pseudo), Loss of ciliospinal reflex (dilation on pain) Symapthetic defect **Central -** Stroke (PICA), Multiple Sclerois **Pre Ganglionics -** Pancoast Tumour, **Post ganglionic -** Carotid artery dissection, carotid aneurysm,

Answer 114

**Holmes adie pupil-** Tonically Dilated, Dont react to light, Sluggish reaction to accomodation **Argyll Robertson Pupil -** Small pupils, dont react to light, react to accomodaiton **OA:** Central scotoma, pale optic disc, reduced acuity (MS + Glaucoma) CAC VISION **Congenital** - Didmoad, Leber's optic, HMSN, RP. **ALcohol**/ smoking amblyopia, ethambutol, lea, **Compression** of ON - paget's, Glauoma, **Vascular** - Stroke, DM, GCA, Anterior Ischaemic Optic Neuropaty (posterior ciliary artery atherosclerosis/ vasculitis) 5, **Inflammatory** - MS, DEvic's **Sarcoid**, **Infection -** Herpes ZOster, Syphillis, **Oedema -** papilloedema, **Neoplasm** **Causes of optic neuritis:** Devics + MS, DM, Drugs - ethambutol, chloraphenicol Vitamin, Infection - lyme, zoster **eye chambers** Anterior( aqueous drainage, cornea to iris) , Posterior (, aqeuous production, iris to lens), Virreous (lens to retina)

Answer 115

Tonsillectomy - Recurrent disabling tonsillitis., Quinsy, Suspected malignancy Method - Cold steel, Cautery 5 Cx - haemmorhage, tonsillar gag may damage teeth, TMJ, pharyngeal wall

Answer 116

**Entrapment of CNVII in the facial canal (oedematous) likely due to viral pathology** Ix - Serology - VZV, Lyme MRI - SOL, Stroke, MS LP **mx -** protect eye, high dose steroids, valaciclovir if ?ramsay hunt) 5 Cx - **Synkinesis -** blinking --\> upturning of mouth. eating --\> tears **Ramsay hunt** Reactivation of VZV in the geniculate nuclues of CNVII

Answer 117

**Computed Optic Tomography** - Visualisation of the retina **Tonometry -** measures the IOP **Gonioscopy -** lets you see the angels

Answer 118

**Under first rib:** Subclavian --\> Axillary **Teres major border;** Axillary ---\> Brachial **Axillary artery aneurysm, Cervical rib**

Answer 119

**Superficial and deep veins in the arm (brachial vein example of deep --\> paired with arteries)** Cephalic (lateral) Basilar (medial) Median cubital vein --\> connects the two in the antecubital fossa Cephalic continues superficially Basilar continues deep **Brachial**

Answer 120

Femoral artery continuoation of EIA becoming the femoral artery under the inguinal ligament In femoral triange ---\> profunda femoral branch (has three branches of its own --\> Lateral and medial (femoral neck fracture) circumflex arteries. perforating branch COntinues as the superficial femoral artery in the adductor canal (Vastus medialis, Sartorius, Adductur longus) Becomes the popliteal artery after leaving the adductor canal ---\> popliteal fossa **Popliteal artery then ---\>** bifurcates after the popliteal fossa into the **anterior (becomes the dorsalis pedis) and posterior tibial arteries--\> Posterior tibial artery has a branch called the common peroneal artery** **Other arteries in the leg ---\>** Obturator rtery, superior and inferior gluteaal arteries

Answer 121

**Deep** Dorsal arches --\> anterior tibial vein Plantar arches ---\> posterior and peroneal vein anterior tibial vein, posterior tibial and peroneal vein ---\> popliteal vein (enters thigh as femoral vein through adductor canal) profunda femoral vein joins the femoral vein ---\> become the external iliac vein underneath the inguinal ligament **Superficial** - Medial --\> long saphenous vein joins the femoral vein at the SFJ Laterally --\> short saphenous vein joins the popliteal vein at the SPJ in popliteal fossa **sfj - 2.5 cm infeiror and lateral to the pubic tubercle**

Answer 122

**CLI -** is ankle artery pressure \<50 mmHg + either gangrene/ulceration or rest pain **acute limb ischaemia -** onset in less than 14 days **i)thrombosis** (previous plaque ruptured. angioplasty--\>reconstruction--\> thrombolysis --\> amputation ) **ii)** **embolic** - AF, valve disease, long bone fractures) , graft/stent occlusion, trauma, aortic dissection) ---\> embolectomy(fogarty)\>thrombolysis\>bypass\>amputation **acute on chronic -** worsening of symptoms and signs within 14 days **Chronic limb ischaemia signs -** Punched out ulcers (painful), Trophic nail changes, skin - cold, white, atrophic, hair loss, venous guttering, muscle atrophy **Critical Limb Ischaemia - Fontaine 3/4** Rest pain (especially at night) Ulceration/gangrene **Buerger's angle cut offs - \>90 normal ,** 20-30 ischaemia, \<20 severe ischaemia Fontaine- I (asymptomatic \>0.8), II (intermittent claudication 0.8-.5)), III(rest pain 0.5-0.3), IV (Ulceration/Gangrene \<0.3) **Mx:** * *Cons** - **Exercise**, stop smoking, lose weight, foot care, eat well * *Med** - **Clopidogrel**, **Statin**, Peripheral vasodilators, ACEi used for CV risk(but with caution as patients might have concurrent RAS) **Surg** - Need good proximal supply and distal run off for success. Often undergo deep fasciotomies **Endovascular** - Angioplasty, Stenting **Surgical** - Anatomical bypass (aorto bi fem, fem pop, fem distal) , extra anaatomical bypass (axillo fem/ bi fem, fem fem crossover), endartrectomy , amputation **Cx -** Compartment syndrome, ARDS, Acidosis, Shock, chronic pain syndrome **leriche syndroem -** buttock claudication, absent femoral pulses, erectile dysfunction (aorto-iliac disease)

Answer 123

Aneurysm - Abnromal **Dilatation** of a vessel **wall** \>**50**% its normal diameter **True** - Dilatation involves **all** **layers** of the vessel wall **False** - collection of blood around a vessel wall that **communicates** with the **lumen** **Fusiform** - ballooning involves **all** **sides** of the vessel -AAA **Saccular** - ballooning confined to **one** **aspect** of the vessel - berry aneurysm **Casues** **Congenital** - APKD, marfans, Ehler's Dahnlos **Acquired** (TIA)- Trauma, Inflammatory- takayasu's, HSP, Kawasaki's, **Infective**: mycotic (IE), Syphylitic , Atherosclerosis **Cx -** Rupture, Embolisation distally, thrombosis, pressuer symptoms (nutcracker syndrome - Renal vein compression between SMA and aorta, berry aenurysm in brain), Fistulat

Answer 124

**Dilation of the abdominal aorta \>3 cm** - 30% involve iliacs, 10% involve the renals Ix - US used to screen, **CT/MRI is gold standard** to elucidate the involvement, **Angiography** - to check for renal involement **Screening (once at age of 65)** \<4 cm yearly monitoring. 4-5.5 6 monthly monitoring treatment threshold is at \>5.5 cm **Indications for surgical intervention** Back pain, \>5.5 cm , Expanding \>1 cm year, Complications (emboli) **Repair** **Both EVAR and Open have similar 5 year mortality figures but EVAR has immediately better mortality. EVAR found to not be suitable for medically unfit patients either.** EVAR - Bi femoral access. Need a 1.2 cm distal neck from the renals for stent fixation. (landing zone) Open - need good operative fitness Rupture - emergency . fluids but keep SBP\< 100 mm/Hg (rush to theatre). Clamp aorta and dacron graft

Answer 125

DIlatation of the thoracic aorta due to a breach of the media causing the formation of a channel **causes** - Congenital - marfan's, ehler's dahnloss Acquired - HTN and atherosclerosis **classification -** **Stanford** **A - ascending aorta ( need aortic root replacement )** **B - descending - distal to left subclavaian vein (medical management initially but endovasular options can be considered -- TEVAR)** Ix ECG Stable - CT/MRI angio Unstable - TTE/ TOE

Answer 126

**Tissue necrosis from poor blood supply** Wet - Infection + death Dry - just death Pre - tissue on brink of gangrene Gas gangrene - clostridium perfringens ( benpen + metro) Synergistic - Anaerobes or Aerobes --\>progress to necrotising Meleney's - form of synergistic gangrene common after abdominal srugery (benpen + clida) Fourniere's gangreent - type of synergistic gangrene after perineal surgery (benpen + clinda)

Answer 127

Varicose veins - dilated and tortuous veins of sueprficial venous system caused by valve failure **Causes** - Primary - prolonged standing, congenital valve incompetence, valve agenesis, overweight, pregnancy, OCP, FH Secondary - Valve destruction: DVT, THrombophlebitis, Obstruction - DVT, Foetus, pelvic mass. Constipation, AVM, Cyclists, KTS **Signs -** venous eczema, lipodermatosclerosis, atrophic blanche, haemosiddherosis, venous starring, oedema, ulcers. Calf perforators **-** medial leg = **cockett's,** medial thigh = **hunter's** **Boyd.** **Ix -** Duplex ultrasonography. Pre-op bloods **CEAP classification -** clinical signs, etiology, anatomy, patho **Sx -** bleeding, ulceration, pain, thrombopheleitis, severe impact on QOL **Sx types** **Consevative managements -** weight loss, reduce straining avoid standing for long periods, graduated compression stockings , skin care **Sx:** **Interventional** (small below knee varicose veins)- radifrequency ablation, infrared ablation, sclerotherapy Compression bandage **Srugical** (bad symptoms, or major perforator/sfj incompetenece)- SFJ ligation, SSJ ligation, perforator ligation, venous stripping **cx** Haemoatoma, wound sepsis, nerve damage, DVT, Thrombophlebitis, recurrence!!5

Answer 128

Venous engorgement Loss of venous pulsation Blurring of the optic disc margins Exudates Elevation of the optic disc Hyperaemia disc **Normal IOP:** 10 -21 mmHg **Cataract -** Majority - DM, Age related, UV light Systemic - GCs, Hypocalcaemia, Myotonic Dystrophy, Wilson's, Down's Ocular - Trauma, uveitis, topical steroids

Answer 129

Bone healing : Reactive (haemorrhage) , Reparative(cartilage and woven bone --\>calus -\> lamellar bone ) Remodelling (remodelling due to mechanical forces) **Wolff's law -** bone will remodel in accordance to the load it is placed under **Describing fractures -** Pattern of fracture, Intra/extra articular, Angulation, displacement, Deformity, soft tissues, Eponymous names Rsuscitation, reduction, restriction, rehabilitation **6 As -** Analgesics, Asess (NV status, soft tissue damage etc.), Anti sepsis, ALignment, Anti tetanus, anti biotics, Open Fracture can be complicated by gas gangrene **Classification - gustillo and anderson** **I- \<1 cm,II \> 1cm, III\> 1cm + extensive soft tissue / high trauma injury** Reduction: **Manipulation, Traction, ORIF** External fixation: Pins applied away from site of injury Monoplanaer, Multiplaner ( hex fix) --\> for open fractures, burns, tissue loss Internal fixation: Plates, pins/ screws, K wires, IM rods Cx of fractures: General: Tissue damage: haemorrhage, shock, compartment syndrome (if compartment pressure \> Capillary pressure = ischaemia), rhabdomyolysis Surgery - anaesthesia related, damage to teeth, basal atelectasis, aspiration Prolonged bed rest - deconditioning, chest infection, uti, DVT/PE, pressure sores, dicreased mineralised bone **immediate -\>** Neurovascular damage, visceral damage **Early -\>** compartment syndrome, Fat embolism, Infection **Late -** Malunion (5Is - infection, ischaemia, increased interfragmentary strain, interposition of tissue, intercurrent disease), growth interruption, CPRS (1= no nerve damage -\> symptoms affect neighbouring area, 2= associated nerve damage) **Seddon** - Neuropraxia (temporary interruption), Axonotmesis (disruption ofn erve axon --\> tissue framework is preserved) , Neurotmesis (tissue framework not preserved **Ortho injury nerve damage** Shoulder dislocation - Axillary Humerus shaft - radius Supracondylar fracture - Ulnae nerve Hip dislocation - Posterior (sciatic) Fibula - common peroneal **Ottawaw ankle criteria** - Assesses the need for an x ray after ankle injury Pain in malleolar zone + -\> swelling, inability to walk 4 steps, bony tenderness in latera/ medial malleolus

Answer 130

Colles' - transverse fracture of radius, 1 inch proximal to radio-carpal joint, dorsal displacement and angulation (fall onto extended outstratched hand) Smiths' - Volar angulation of distal radius fragment. (falling backwards onto the palm of an outstretched hand/ falling with wrists flexed) Bennett's - intra articular fracture of first carpo metacarpal joint. (impact on flexed metacarpal, caused by fist fights) Monteggia's - dislocation of proximal radioulnar joint in assocation with ulna fracture (outstretched hand with forced pronation) Galeazzi - radial shaft fracture with dislocation of distal radioulnar joint Pott's - bimallelar ankle fracture (forced foot eversion) Barton's - distal radius fracture with radiocarpal dislocation (extended pronated wrist) Jone's - fifth metatarsal fracture Dancer's (pseudo-jones) - fifth meta tarsal fracture Lisfranc's - disuption of lisfranc ligament (tarsal metatarsal joint. widening of first and second metatarsal space/ midfoot dislocation)

Answer 131

Inspection - Of the shoulder neck and chest of the arm - looking for previous scars, signs of thrombophelbitis, signs of wasting of the hand Fistula - extent, lateral (radiocepahlic or brachiocephalic) , Medial (radiobasilic) Palpate - Capillar refil time, VEnous hum, arterial thrill. If its pulsatile --\> then that is a indicator of proximal thrombosis Auscultate - the vein for a venous hum Extra ppitns - can also use dacron --\> which can be needled immediately whereas autologous can only be needled -6-8 weeks after creation

Answer 132

**Supraspinatous, Teres minor, Infraspinatous - greater tuberosity** **Subscapularis - lesser tuberosity** **Supraspinatus - abduct** **Teres minor/infraspinatous - externally rotate** **Subscapularis - Internally rotate** **Innervation -** Supraspinatous + Infraspinatus - Suprascapular nerve Teres Minor - axillary nerve Subscapularis - upper and lower subscapular nerve

Answer 133

Shenton's Line - Medial edge of femoral neck and inferor edge of superior pubic ramus Intracapsular - subcapital, transcervical, basicervical Extra capsular- intertrochanteric, subtrochanteric, reverse oblique, Blood supply ot femoral head - **lateral circumflex (branceh of profunda femoral)** , medial circumflex, obturator artery Capsule - attaches superiorly to the acetabulum and inferiorly to the intertrochanteric line **intracpasular NOF class:** Garden classification I-II (undisplaced) III some cortical contact remains IV - complete displacement **surgical management** **Intracapsular** 1-2 : ORIF cancellous screws 3-4: Young ORIF with screws5, 55-75 (THR) \>75 (Hemiarthroplasty: Mobilises cemented thimpsons. non-mobiliser - uncemented auston moore) **Extracapsu.ar** -ORIF with DHS Cx - AVN, Malunion, Infection, OA, Damage to neurovascular structures (SGN, SN)

Answer 134

Barrett's, Smoking, Alcohol, DM, Achalasia, Nitrosamine dyes Spreads to LNs and locally invasive **RFs for GORD -** Smoking, Alcohol. Obesity, Pregnancy, Iatrogenic - heller's myotomy for achalasia, Drugs - CCBs, Anti-cholinergic, **Cx of GORD --\>** Barrett's, aspiration, asthma, oeophagitis, benign strictures **Rfs for PUD -** H Pylori infection, Smoking, alcohol, NSAIDs/Steroids, Cushings ulcers, Curlings ulcers **cx of pud -** perforation -usually anterior duodenal first part, haemorrhage -posterior duodenal first part, malignant transformation, Gastric outflow obstruction, **Gastric cancer - adenocarcinomas . H Pylori - \> Maltoma** Rfs - H pylori, Smoking, EToh, high dieteary ntirates, gastritis, Borrmann Classification system --\> Polyopoid fungating---\> ulcerating ---\> linitis plastica (IV) **Mx - Conservative /palliative -** Chemo, analgesics etc. etc. nurses **invasive pallaitive -** endoscopic stenting, by pass procedures, ostomies to allow feedings **Curative -** Endoscopic resection, Gastrectomy (roux en y), Bilroth procedures

Answer 135

Tibial - Schatzker Hip - Garden Supracondylar extension - Garton Ankle- Weber classification

Answer 136

**Arthroscopy** - allows examination of the knee Can be used for meniscal tear resection/reparation **Reparation of ACL** i) autologous using the semiteninosis + gracilisi, twisted to form a rope like structure. Slight reduction in speed but very strong. Held using screws ii) can use patellar tendon **patho of OA:** Loss of articular cartilage-- \> exposed bony surfaces come into contact --\> leads to sclerosis/osteophyte formation/ fibrosis **Surgical OA :** Arthroscopy + joint washout Ralignment osteotomy - redistributed the load Arthroplasty - replacement Arthrodesis - fusion Novel techniques - cartilage repair, microfractures

Answer 137

FAP - APC Mutations. (Gardner example of FAP +) HNPCC - (Lynch 1 + Lynch 2 - involves extra GP cancer) DNMA mismatch repair. Cowdwn - PTEN mutation. Pigmented polyps Peutz Jahgers - Mucocutaneous freckling + GI polyposis **HNPCC is most common**

Answer 138

**Duke's** A - mucosa B - Bowel wall C - LN metastases D - Distant metastases **TNM** Tis - lamina propria, T0 T1 - Submucosa T2 - Musclaris popria T3 - Pericolorectal tissues (invasian through bowel) T4 - Intraabdominal involvement - visceral peritoneum, other organs N0 , N1 - \<4 nodes N2- \>4 nodes M0, M1 - distant mets **Oesophageal - TNM** T0 , Tis (lamina propria), T1 - submucosa. T2- muscularis propria. T3 - into the serosa. T4 - through the serosa N0 . N1 \<4 LNs , N2 \>4 Lns M0. M1 - distant mets

Answer 139

**Histological** CD (TH1/TH17) - skip lesionss, granuloma, fibromas, transmural inflamamtion of bowel wall. strictures and fistulae (enterocolic, enterovesicular, enterovaginal, perianal) UC (TH2) - contiguous inflammation imited to the mucosa +pseudopolyps. Crypt abscesses. Rectal - colon +/- bacwash ileitis. no strictures **Extra intestinal** Eye - Uveities (UC), scleritis, episcleritis (CD) joints - arthritis Skin - Nodosum, Gangrenosum, apthous ulcers, clubbing, GI - PSC, cholangiocarcinoma, hyposplenism, galllstones (crohn's) Features of malabsorption (particularly with crohn's ) - Angular stomatitis, pallor, macroglossia, peripheral neuropathy Colonoscopic classificcaiton system - baron scoring (UC) Truelove and witts criteria **Imaging in UC -** LEad piping , thumb printing, no skip lesions **Imaging in crohn's** - cobblestoning, string sign of kantor, rose thorn ulcers **MX (emergency - UC 5ASA/ Pred. Emergency - CD- IV Hydrocortisone/ PR if rectal. ) Antibiotics sometimes given also** **Rescue therapy - if things arent working metronidazole +/- infliximab** **UC** Inducing remission - 5ASA (second line steroid) Maintaing remission - 5ASA (second line methotrexate/azathiaprine and then third line is ant TNF then fourht is ustekinuman / vedolizumab) Sx - If **elective** can do panproctocolectomy with end ileostomy/ileoanal pouch formation Total colectomy with Ileo-rectal anastamosis if **emergency** colectomy/ subtotal colectomy + end ileostomy +/- mucous fistula for distal stump--\> completion proctetomy / ileonal pouch formation later on **CD** Inducing remission - oral pred (oral budenoside/sulfasalazine. Add ons azathiaproine, methotrexate. Biologics ) Perianal disease --\> Metronidazole + normal suppresion regimen Surgery/ seton suture insertion Maintaining remission - AZT, MTX, Infliximab etc.

Answer 140

**Resection** - TME + \>12 LN need to be excised following vasc supply **High** anterior resection / low anterior resection - \>6 cm from anal vergem \> 2 m for sphincter complex/anorectal ring **APR** - When malignancy is 6cm from anal verge / \<2 cm from the sphincter complex/ anorectal ring **Minimal** **resection** - Carcinoma in situ/ T1 T3/T4 are given adjuvant chemo radiotherapy/brachytherapy **Dentate line -** line demarcating the transition point between squamsous and columnar epithelium in the anorectal canal. posterior 1/3 anterior 2/3

Answer 141

**pouch** - poorly functioning pouch, pouchitis, anastamotic dehiscence **pouch in crohn's - bad idea** as they have a high chance of fistula formation. so for severe perianal/rectal crohn's best to do a proctectomy and fashion an end colostomy. **Ileal resections -** crohn's . poor enterohepatic bile salt recycling so these may need to be replaced. --\> cholestyramine **laparasocopy -** Bowel **perforation** due to verre's needles/ trochar insertion, **Hamerrohage** due to iliac artery/epigastric artery peforations, need to **convert** to **laparotomy**, srugical **emphysema** Later - **adhesions**,

Answer 142

**Carpal tunnel** - WRIST - **Water**: (hypothyroidism,. oedema, pregnancy) **Radial** fracture. **Inflammation**: (RA, gout). **Soft** tissue (acromegaly, amyloidosis, lipomas. **T- oxic** (DM, EtOH0 Mx - conservative: splinting, wieght loss, Mx - steroid injections, Sx - decompression

Answer 143

**Refeeding syndrome -** life threatening metabolic complication of feeding after prolonged starvation - Principal problem is phosphate ---\> Less phosphate stores anyway and then when they eat --\> increase insulin which causes intracellular phosphate shift ---\> hypophosphataamia KPMG all reduced **Enteral delivery -** NG/ND/NJ tubes - \<4 weeks. PEG/RIG feeding

Answer 144

Anterior, anterolateral, lateral, arthroscopy, posterior

Answer 145

Skin, campers fascia , Scarpers fascia, EO, IO, TA TF, Pre peritoneal fat, peritoneum

Answer 146

Causes - congenital - PPV Acquired - Raised IAP (constipation, occupation) obesity, previous surgery. , CTD - marfans, ehler's dhanlos Indirect - PPV DIrect- Hessebechs triangle (Inguinal ligament, lateral border of rectus sheath, inferior epigastric vessels) **inferior epigastric vessels ( coem from the EIA)** If hernial sac emerges laterally to these vessels = indirect (outside of hesselbeach's triangle) If hernial sac emerges medially to these vessels = direct (within hesselbach's triangle) **Structure of inguinal canal** Floor - inguinal ligament Roof - arching fibres of the transversus abdominus and the internal oblique Anterior - aponeurosis of the external oblique and internal oblique Posterior - transversalis fascia and conjoint tendon Deep ring - Transveralis fascia Superficial ring - external oblique **Mx** Most are managed surgicaly but Conservative - reduce IAP (reduce coughin) lose wieght Surgical - tension free mesh (lichtenstein repair0 Totally extraperitoneal hernia repair Transabdominal pre peritoneal hernia repair

Answer 147

**Herniation through femoral canal** Arise inferior and lateral to the pubic tubercle Femoral ring borders - Psoterior - pectineal ligament anterior - inguinal ligament Medial - lacunar ligament laterally - femoral vein **mx** emergency surgery - if urgent then mcevedy longituindal inguinal incision (high repair) Lockwood low infra inguinal incision (herniotomy and herniorapphy -plication of inguinal and pectineal ligament) **Paraumbilical hernia** - Acquired hernia just above or below umbilicus that needs repair due to high risk of strangulation - Mayo mesh repair 5 **Epigastric hernia** - pea shaped swelling just above the umbilicus that is prone to strangulating - mesh repair

Answer 148

Disrupted and Dilated anal cushions Due to chornic straining and coughing / portal hypertension Mx - Consverative - increased fibre / reduced straining Mx - stool softerners Sx - interventional - phenol/almond injection sclerotherapy cryotherapy Barons banding Surgically - haemorrhoidectomy Haemorrhoid artery ligation **Anal fissure** Tear in the squamous epithelium of lower anal canal Due to - tonic internal anal sphincter (+crohn's) Conservative - fibre intake, toileting habits Mx - stool softeners TOpical GTN DIltaizem Sx - Botulinum injection Lateral sphincterotomy **Pilonidal sinus** Sx - Either removal of sinus Removal of natal cleft

Answer 149

**Types of LB malignancy** - Adenocarcinoma - Carcinoid tumour - GIST **Types of Small bowel malginancy** - Adenocarcinoma - GIST - Carcinoid tumour - lymphoma

Answer 150

**Ileal Conduit -** Ureters are diverted to a portion of the ileum which is brought to the surface as a stoma

Answer 151

**Midline + bilateral groin scars -** Aorto bifemoral bypass **Axillary + unilateral/bilateral knee scar -** Axillo popliteal **groin + leg scar -** fem distal **Groin scars x 2 -** fem fem cross over. EVAR/ TEVAR