PASS MED Flashcards
A 27-year-old female presents with weakness of both hands. On examination you note wasting and weakness of the small muscles of the hands and loss of pain and temperature sensation over the trunk and arms. Vibration sense is intact.
What is the most likely diagnosis?
Syringomyelia - yringomyelia is a condition whereby fluid filled cavities develop within the spinal cord. Pressure can increase resulting in compression of the spinal cord tracts. The syrinx can extend to and damage the anterior horn cells, thereby resulting in lower motor neurone features. The spinothalamic tract axons decussate to the other side of the spinal cord via the anterior white commissure, and they are particularly susceptible to damage from the syrinx. Pain and temperature sensation are lost due to spinothalamic tract damage, and one side may be affected more than the other. Classically, the sensation loss is experienced in a shawl-like distribution over the arms, shoulders and upper body. Light touch, vibration and proprioception may also be affected as the syrinx enlarges into the dorsal columns.
Complications of aneurysmal SAH:
Re-bleeding
happens in around 10% of cases and most common in the first 12 hours
if rebleeding is suspected (e.g. sudden worsening of neurological symptoms) then a repeat CT should be arranged
associated with a high mortality (up to 70%)
Vasospasm (also termed delayed cerebral ischaemia), typically 7-14 days after onset
Hyponatraemia (most typically due to syndrome inappropriate anti-diuretic hormone (SIADH))
Seizures
Hydrocephalus
Death
window for thrombolysis stroke
A combination of thrombolysis AND thrombectomy is recommend for patients with an acute ischaemic stroke who present within 4.5 hours
NICE have also made recommendations to use a modified Rankin score of less than 3 and a National Institutes of Health Stroke Scale (NIHSS) score of more than 5 when considering the selection of patients for mechanical thrombectomy.
Contraindications to thrombolysis:
Absolute
- Previous intracranial haemorrhage
- Seizure at onset of stroke
- Intracranial neoplasm
- Suspected subarachnoid haemorrhage
- Stroke or traumatic brain injury in preceding 3 months
- Lumbar puncture in preceding 7 days
- Gastrointestinal haemorrhage in preceding 3 weeks
- Active bleeding
- Pregnancy
- Oesophageal varices
- Uncontrolled hypertension >200/120mmHg
relative
Concurrent anticoagulation (INR >1.7)
- Haemorrhagic diathesis
- Active diabetic haemorrhagic retinopathy
- Suspected intracardiac thrombus
- Major surgery / trauma in the preceding 2 weeks
A 68-year-old gentleman was diagnosed with glaucoma and commenced on treatment. He returned in one month for review, his eye pressures had improved but he complains his eyelashes have increased in length. What medicine is likely to have caused his eyelashes to grow in length?
Lantanprost - treatment for glaucoma
preferred antiplatelet for secondary prevention following stroke
Clopidogrel is the preferred antiplatelet for secondary prevention following stroke
In baby (neonate) feeding intolerance, abdominal distension and bloody stools, which can quickly progress to abdominal discolouration, perforation and peritonitis. Xray - pneumatosis intestinalis (intramural gas)
Necrotising enterocolitis
Bone protection for patients who are going to take long-term steroids
should start immediately= start vitamin D and calcium supplements
tetanus vaccination - unsure history - management?
Patients with an uncertain tetanus vaccination history should be given a booster vaccine + immunoglobulin, unless the wound is very minor and < 6 hours old
Infective exacerbation of COPD antibiotics
Infective exacerbation of COPD: first-line antibiotics are amoxicillin or clarithromycin or doxycycline
Laryngomalacia
Congenital abnormality of the larynx.
Infants typical present at 4 weeks of age with:
stridor
Bacterial endocarditis - causative organism
he vast majority of cases of bacterial endocarditis are caused by gram positive cocci.
Common causes:
Streptococcus viridans
Staphylococcus aureus (in intravenous drugs uses or prosthetic valves)
Staphylococcus epidermidis (in prosthetic valves)
HBA1c diagnostic of diabetes.
A HbA1c of 48mmol/mol is diagnostic of diabetes.
Over 58 = 2nd medication
A 17-year-old male presents to the Ear Nose and Throat clinic to discuss the results from the fine needle aspirate taken from a smooth, fluctuant, non-tender, non-translucent mass located anterior to his left sternocleidomastoid muscle. It does not move on tongue protrusion. The aspirate reveals an acellular fluid with cholesterol crystals.
A branchial cyst is typically a benign, lateral, unilateral neck mass
VTE post warfarin length
Venous thromoboembolism - length of warfarin treatment
provoked (e.g. recent surgery): 3 months
unprovoked: 6 months
Pyloric stenosis
Pyloric stenosis typically presents in the second to fourth weeks of life with vomiting, although rarely may present later at up to four months. It is caused by hypertrophy of the circular muscles of the pylorus.
Epidemiology incidence of 4 per 1,000 live births 4 times more common in males 10-15% of infants have a positive family history first-borns are more commonly affected
Features
‘projectile’ vomiting, typically 30 minutes after a feed
constipation and dehydration may also be present
a palpable mass may be present in the upper abdomen
hypochloraemic, hypokalaemic alkalosis due to persistent vomiting
Diagnosis is most commonly made by ultrasound.
Management is with Ramstedt pyloromyotomy.
Myocardial infarction: secondary prevention
NICE produced guidelines on the management of patients following a myocardial infarction (MI) in 2013. Some key points are listed below
All patients should be offered the following drugs:
dual antiplatelet therapy (aspirin plus a second antiplatelet agent)
ACE inhibitor
beta-blocker
statin
Parotid gland mass - Benign pleomorphic adenoma or benign mixed tumor
Most common parotid neoplasm (80%)
Proliferation of epithelial and myoepithelial cells of the ducts and an increase in stromal components
Slow growing, lobular, and not well encapsulated
Recurrence rate of 1-5% with appropriate excision (parotidectomy)
Recurrence possibly secondary to capsular disruption during surgery
Malignant degeneration occurring in 2-10% of adenomas observed for long periods, with carcinoma ex-pleomorphic adenoma occurring most frequently as adenocarcinoma
Paranoid gland mass
Second most common benign parotid tumor (5%)
Most common bilateral benign neoplasm of the parotid
Marked male as compared to female predominance
Occurs later in life (sixth and seventh decades)
Presents as a lymphocytic infiltrate and cystic epithelial proliferation
May represent heterotopic salivary gland epithelial tissue trapped within intraparotid lymph nodes
Incidence of bilaterality and multicentricity of 10%
Malignant transformation rare (almost unheard of)
COPD management
General management
>smoking cessation advice: including offering nicotine replacement therapy, varenicline or bupropion
annual influenza vaccination
one-off pneumococcal vaccination
pulmonary rehabilitation to all people who view themselves as functionally disabled by COPD (usually Medical Research Council [MRC] grade 3 and above)
synchronised DC cardioversion indications
Unstable atrial fibrillation, atrial flutter, atrial tachycardia, and supraventricular tachycardias
Klebsiella pneumonia
Features of Klebsiella pneumonia more common in alcoholic and diabetics may occur following aspiration 'red-currant jelly' sputum often affects upper lobes
Progressive multifocal leukoencephalopathy
Caused by JC or BK virus
superior vena cava obstruction presentation?
Features dyspnoea is the most common symptom swelling of the face, neck and arms - conjunctival and periorbital oedema may be seen headache: often worse in the mornings visual disturbance pulseless jugular venous distension
superior vena Cava obstruction causes and management
Causes
common malignancies: small cell lung cancer, lymphoma
other malignancies: metastatic seminoma, Kaposi’s sarcoma, breast cancer
aortic aneurysm
mediastinal fibrosis
goitre
SVC thrombosis
Management
general: dexamethasone, balloon venoplasty, stenting
small cell: chemotherapy + radiotherapy
non-small cell: radiotherapy
ECG: hypokalaemia
ECG features of hypokalaemia U waves small or absent T waves (occasionally inversion) prolong PR interval ST depression long QT
Palliative care prescribing: pain
when starting treatment, offer patients with advanced and progressive disease regular oral modified-release (MR) or oral immediate-release morphine (depending on patient preference), with oral immediate-release morphine for breakthrough pain
oral modified-release morphine should be used in preference to transdermal patches
laxatives should be prescribed for all patients initiating strong opioids
patients should be advised that nausea is often transient. If it persists then an antiemetic should be offered
drowsiness is usually transient - if it does not settle then adjustment of the dose should be considered
Palliative care prescribing: pain SIGN
the breakthrough dose of morphine is one-sixth the daily dose of morphine
all patients who receive opioids should be prescribed a laxative
opioids should be used with caution in patients with chronic kidney disease
oxycodone is preferred to morphine in palliative patients with mild-moderate renal impairment
if renal impairment is more severe, alfentanil, buprenorphine and fentanyl are preferred
Palliative care prescribing: pain - increasing dose
When increasing the dose of opioids the next dose should be increased by 30-50%.
Conversion between opioids Codine -> morphine = tramadol -> morphine Morphine -> oxy Oral morphine -> Subcutaneous morphine Oral morphine -> Subcutaneous dimorphine Oral oxycodone ->Subcutaneous dimorphine
Codine -> morphine = Divide by 10
tramadol -> morphne = Divide by 10
Morphine -> oxy = Divide by 1.5-2
Oral morphine -> Subcutaneous morphine = divide by 2
Oral morphine -> Subcutaneous dimorphine = divide by 3
Oral oxycodone ->Subcutaneous dimorphine = divide by 1.5
Small bowel bacterial overgrowth syndrome
Diagnosis
Management
Diagnosis
hydrogen breath test
small bowel aspiration and culture: this is used less often as invasive and results are often difficult to reproduce
clinicians may sometimes give a course of antibiotics as a diagnostic trial
Management
correction of underlying disorder
antibiotic therapy: rifaximin is now the treatment of choice due to relatively low resistance. Co-amoxiclav or metronidazole are also effective in the majority of patients.
Undescended testes
A congenital undescended testis is one that has failed to reach the bottom of the scrotum by 3 months of age
consider age - may watch and wait
Treatment
Orchidopexy at 6- 18 months of age. The operation usually consists of inguinal exploration, mobilisation of the testis and implantation into a dartos pouch.
Intra-abdominal testis should be evaluated laparoscopically and mobilised. Whether this is a single stage or two stage procedure depends upon the exact location.
After the age of 2 years in untreated individuals the Sertoli cells will degrade and those presenting late in teenage years may be better served by orchidectomy than to try and salvage a non functioning testis with an increased risk of malignancy.
epigastric ulcers
Features
epigastric pain
nausea
duodenal ulcers -more common than gastric ulcers
epigastric pain when hungry, relieved by eating
gastric ulcers- epigastric pain worsened by eating
non-invasive ventilation indications
Non-invasive ventilation - key indications
COPD with respiratory acidosis pH 7.25-7.35*
type II respiratory failure secondary to chest wall deformity, neuromuscular disease or obstructive sleep apnoea
cardiogenic pulmonary oedema unresponsive to CPAP
weaning from tracheal intubation
Keratoacanthoma
Features - said to look like a volcano or crater
initially a smooth dome-shaped papule
rapidly grows to become a crater centrally-filled with keratin
Spontaneous regression of keratoacanthoma within 3 months is common, often resulting in a scar. Such lesions should however be urgently excised as it is difficult clinically to exclude squamous cell carcinoma. Removal also may prevent scarring.
Osteoporosis: assessing risk
They advise that all women aged >= 65 years and all men aged >= 75 years should be assessed. Younger patients should be assessed in the presence of risk factors, such as:
previous fragility fracture
current use or frequent recent use of oral or systemic glucocorticoid
history of falls
family history of hip fracture
other causes of secondary osteoporosis
low body mass index (BMI) (less than 18.5 kg/m²)
smoking
alcohol intake of more than 14 units per week for women and more than 14 units per week for men.
Use FRAX
neuroleptic malignant syndrome management
Management
stop antipsychotic
patients should be transferred to a medical ward if they are on a psychiatric ward and often they are nursed in intensive care units
IV fluids to prevent renal failure
dantrolene may be useful in selected cases
thought to work by decreasing excitation-contraction coupling in skeletal muscle by binding to the ryanodine receptor, and decreasing the release of calcium from the sarcoplasmic reticulum
bromocriptine, dopamine agonist, may also be used
Gastro-oesophageal reflux disease presentation
oesophagitis secondary to refluxed gastric contents
Gastro-oesophageal reflux disease: management
Endoscopically proven oesophagitis
full dose proton pump inhibitor (PPI) for 1-2 months
if response then low dose treatment as required
if no response then double-dose PPI for 1 month
Endoscopically negative reflux disease
full dose PPI for 1 month
if response then offer low dose treatment, possibly on an as-required basis, with a limited number of repeat prescriptions
if no response then H2RA or prokinetic for one month
otitis externa Features and management
Features
ear pain, itch, discharge
otoscopy: red, swollen, or eczematous canal
Give Topical combination steroid and antibiotic drops s
Swab
may need referral for micro-suction.
If a patient fails to respond to topical antibiotics then the patient should be referred to ENT.
Anterior uveitis presentation
Features
acute onset
ocular discomfort & pain (may increase with use)
pupil may be irregular and small
photophobia (often intense)
blurred vision
red eye
lacrimation
ciliary flush
hypopyon; describes pus and inflammatory cells in the anterior chamber, often resulting in a visible fluid level
visual acuity initially normal → impaired
Associated conditions ankylosing spondylitis reactive arthritis ulcerative colitis, Crohn's disease Behcet's disease sarcoidosis: bilateral disease may be seen
Anterior uveitis management
Management
urgent review by ophthalmology
cycloplegics (dilates the pupil which helps to relieve pain and photophobia) e.g. Atropine, cyclopentolate
steroid eye drops
Subacute thyroiditis
occur following viral infection and typically presents with hyperthyroidism.
There are typically 4 phases; phase 1 (lasts 3-6 weeks): hyperthyroidism, painful goitre, raised ESR phase 2 (1-3 weeks): euthyroid phase 3 (weeks - months): hypothyroidism phase 4: thyroid structure and function goes back to normal
Investigations
thyroid scintigraphy: globally reduced uptake of iodine-131
Management
usually self-limiting - most patients do not require treatment
thyroid pain may respond to aspirin or other NSAIDs
in more severe cases steroids are used, particularly if hypothyroidism develops
Pulsus paradoxus
greater than the normal (10 mmHg) fall in systolic blood pressure during inspiration → faint or absent pulse in inspiration
- severe asthma, cardiac tamponade
Slow-rising/plateau
aortic stenosis
Pulsus alternans
regular alternation of the force of the arterial pulse
severe LVF
Bisferiens pulse
‘double pulse’ - two systolic peaks
mixed aortic valve disease
‘Jerky’ pulse
hypertrophic obstructive cardiomyopathy*
Legionnaire’s disease
Legionella pneumophilia. It typically colonizes water tanks and hence questions may hint at air-conditioning systems or foreign holidays. Person-to-person transmission is not seen
Features flu-like symptoms including fever (present in > 95% of patients) dry cough relative bradycardia confusion lymphopaenia hyponatraemia deranged liver function tests pleural effusion: seen in around 30% of patients
iagnosis
urinary antigen
Management
treat with erythromycin/clarithromycin
Superficial spreading melanoma
70% of cases
Arms, legs, back and chest, young people
A growing moles
flat patch of pigmented skin which grows slowly, often taking months or years to be recognised. It can be recognised by an ABCDE approach (asymmetry, border irregularity, colour variation, diameter >6mm and evolving)
routine manintance fluids adult
NICE guidelines from 2013 state for routine maintenance fluids the water requirement is approximately 25-30 ml/kg/day.
Osteogenesis imperfecta
Features
Investigations
Overview
autosomal dominant
abnormality in type 1 collagen due to decreased synthesis of pro-alpha 1 or pro-alpha 2 collagen polypeptides
Features presents in childhood fractures following minor trauma blue sclera deafness secondary to otosclerosis dental imperfections are common
Investigations
adjusted calcium, phosphate, parathyroid hormone and ALP results are usually normal in osteogenesis imperfecta
Smudge or smear cells
CLL
Reed-Sternberg cells
Hodgkin’s lymphoma.
Rouleaux formation
multiple myeloma.
Auer rods
a feature of AML.
Pseudo Pelger-Huet cells
CML
Hypothermia on ECG
J Wave
reverse tick sign ECG
dioxin
PE management
the use of direct oral anticoagulants (DOACs) as first-line treatment for most people with VTE
the use of DOACs in patients with active cancer, as opposed to low-molecular weight heparin as was the previous recommendation
outpatient treatment in low-risk pulmonary embolism (PE) patients
routine cancer screening is no longer recommended following a VTE diagnosis
if neither apixaban or rivaroxaban are suitable then either LMWH followed by dabigatran or edoxaban OR LMWH followed by a vitamin K antagonist (VKA, i.e. warfarin)
if the patient has active cancer
previously LMWH was recommended
the new guidelines now recommend using a DOAC, unless this is contraindicated
Anticoag for at least three months if provoked
Thrombolysis
thrombolysis is now recommended as the first-line treatment for massive PE where there is circulatory failure (e.g. hypotension)
other invasive approaches should be considered where appropriate facilities exist
Toxic epidermal necrolysis
Drugs known to induce TEN phenytoin sulphonamides allopurinol penicillins carbamazepine NSAIDs
Pericarditis Features
Features
chest pain: may be pleuritic. Is often relieved by sitting forwards
other symptoms include non-productive cough, dyspnoea and flu-like symptoms
pericardial rub
tachypnoea
tachycardia
Pericarditis causes
Causes viral infections (Coxsackie) tuberculosis uraemia (causes 'fibrinous' pericarditis) trauma post-myocardial infarction, Dressler's syndrome connective tissue disease hypothyroidism malignancy
Pericarditis Investigations & Management
Investigations
ECG changes
the changes in pericarditis are often global/widespread, as opposed to the ‘territories’ seen in ischaemic events
‘saddle-shaped’ ST elevation
PR depression: most specific ECG marker for pericarditis
all patients with suspected acute pericarditis should have transthoracic echocardiography
Management
treat the underlying cause
a combination of NSAIDs and colchicine is now generally used for first-line for patients with acute idiopathic or viral pericarditis
Type 1 RTA
distal)
inability to generate acid urine (secrete H+) in distal tubule
causes hypokalaemia
complications include nephrocalcinosis and renal stones
causes include idiopathic, rheumatoid arthritis, SLE, Sjogren’s, amphotericin B toxicity, analgesic nephropathy
absolute contraindication to the use of regional anaesthesia such as spinal, epidural or plexus block?
Therapeutic anticoagulation is an absolute contraindication to the use of regional anaesthesia due to the risk of bleeding and the severity of a hematoma within the rigid space of the central nervous system.
Ankylosing spondylitis
Features
typically a young man who presents with lower back pain and stiffness of insidious onset
stiffness is usually worse in the morning and improves with exercise
the patient may experience pain at night which improves on getting up
Clinical examination
reduced lateral flexion
reduced forward flexion - Schober’s test - a line is drawn 10 cm above and 5 cm below the back dimples (dimples of Venus). The distance between the two lines should increase by more than 5 cm when the patient bends as far forward as possible
reduced chest expansion
lithium toxciity precipitated by
Toxicity may be precipitated by:
dehydration
renal failure
drugs: diuretics (especially thiazides), ACE inhibitors/angiotensin II receptor blockers, NSAIDs and metronidazole.
Diclofenac NSAID - contraindications
Diclofenac is now contraindicated with any form of cardiovascular disease
Degenerative cervical myelopathy
DCM symptoms can include any combination of [1]:
Pain (affecting the neck, upper or lower limbs)
Loss of motor function (loss of digital dexterity, preventing simple tasks such as holding a fork or doing up their shirt buttons, arm or leg weakness/stiffness leading to impaired gait and imbalance
Loss of sensory function causing numbness
Loss of autonomic function (urinary or faecal incontinence and/or impotence) - these can occur and do not necessarily suggest cauda equina syndrome in the absence of other hallmarks of that condition
Hoffman’s sign: is a reflex test to assess for cervical myelopathy. It is performed by gently flicking one finger on a patient’s hand. A positive test results in reflex twitching of the other fingers on the same hand in response to the flick.
(GOLD Standard - MRI of cervical spine if cervical suspected )
primary hyperparathyroidism
features
Features - ‘bones, stones, abdominal groans and psychic moans’
polydipsia, polyuria
peptic ulceration/constipation/pancreatitis
bone pain/fracture
renal stones
depression
hypertension
primary hyperparathyroidism
investigations
Investigations
raised calcium, low phosphate
PTH may be raised or (inappropriately, given the raised calcium) normal
technetium-MIBI subtraction scan
pepperpot skull is a characteristic X-ray finding of hyperparathyroidism
Treatment
the definitive management is total parathyroidectomy
conservative management may be offered if the calcium level is less than 0.25 mmol/L above the upper limit of normal AND the patient is > 50 years AND there is no evidence of end-organ damage
calcimimetic agents such as cinacalcet are sometimes used in patients who are unsuitable for surgery
Ottawa Rules with for ankle x-rays
The Ottawa Rules with for ankle x-rays have a sensitivity approaching 100%
An ankle x-ray is required only if there is any pain in the malleolar zone and any one of the following findings:
bony tenderness at the lateral malleolar zone (from the tip of the lateral malleolus to include the lower 6 cm of posterior border of the fibular)
bony tenderness at the medial malleolar zone (from the tip of the medial malleolus to the lower 6 cm of the posterior border of the tibia)
inability to walk four weight bearing steps immediately after the injury and in the emergency department
New York Heart Association (NYHA) classification
NYHA Class I
no symptoms
no limitation: ordinary physical exercise does not cause undue fatigue, dyspnoea or palpitations
NYHA Class II
mild symptoms
slight limitation of physical activity: comfortable at rest but ordinary activity results in fatigue, palpitations or dyspnoea
NYHA Class III
moderate symptoms
marked limitation of physical activity: comfortable at rest but less than ordinary activity results in symptoms
NYHA Class IV
severe symptoms
unable to carry out any physical activity without discomfort: symptoms of heart failure are present even at rest with increased discomfort with any physical activity
DDX breathing difficulty in children
Infection (ie croup, URTI) If stridor present - Larynomalcia, asthma Allergy Cardiac (malformation in young children)
croup
presentation
Parainfluenza viruses
Features stridor barking cough (worse at night) fever coryzal symptoms
croup
when to admit
CKS suggest admitting any child with moderate or severe croup. Other features which should prompt admission include:
< 6 months of age
known upper airway abnormalities (e.g. Laryngomalacia, Down’s syndrome)
uncertainty about diagnosis (important differentials include acute epiglottitis, bacterial tracheitis, peritonsillar abscess and foreign body inhalation)
croup investigations
the vast majority of children are diagnosed clinically
however, if a chest x-ray is done:
a posterior-anterior view will show subglottic narrowing, commonly called the ‘steeple sign’
in contrast, a lateral view in acute epiglottis will show swelling of the epiglottis - the ‘thumb sign’
croup management
Management
CKS recommend giving a single dose of oral dexamethasone (0.15mg/kg) to all children regardless of severity
prednisolone is an alternative if dexamethasone is not available
Emergency treatment
high-flow oxygen
nebulised adrenaline
Acute epiglottitis
Haemophilus influenzae type B.
Prompt recognition and treatment is essential as airway obstruction may develop. Epiglottitis generally occurs in children between the ages of 2 and 6 years. The incidence of epiglottitis has decreased since the introduction of the Hib vaccine
Features rapid onset unwell, toxic child stridor drooling of saliva
Acute epiglottitis
management
Management
immediate senior involvement, including those able to provide emergency airway support (e.g. anaesthetics, ENT)
endotracheal intubation may be necessary to protect the airway
if suspected do NOT examine the throat due to the risk of acute airway obstruction
the diagnosis is made by direct visualisation but this should only be done by senior staff who are able to intubate if necessary
oxygen
intravenous antibiotics
Parainfluenza virus
croup
Rhinovirus
cold
Streptococcus pneumoniae
he most common cause of community-acquired pneumonia
Haemophilus influenzae
Community-acquired pneumonia
Most common cause of bronchiectasis exacerbations
Acute epiglottitis
Staphylococcus aureus
Pneumonia, particularly following influenza
Mycoplasma pneumoniae
Atypical pneumonia
Flu-like symptoms classically precede a dry cough. Complications include haemolytic anaemia and erythema multiforme
Pneumocystis jiroveci
Common cause of pneumonia in HIV patients. Typically patients have few chest signs and develop exertional dyspnoea
Mycobacterium tuberculosis
Causes tuberculosis. A wide range of presentations from asymptomatic to disseminated disease are possible. Cough, night sweats and weight loss may be seen
Wheeze questions
- Infection - systemic illness
- Associated symptoms
-Associated with excersies
Associated with environment (pet, dust, smoking, mould, damp,
_ Imms
Ddx Cyanosis
- Illness and infection
- cardiac (TOF, ebsteins, tricuspid atresia, transposition)
Medications (quinones)
Resp - choanal atresia, Pierre Robin Sequence, airway hemangioma, vascular rings/slings, cystic hygroma, and micrognathia
Blood related disorders - Polycythemia, Methemoglobinemia
pansystolic murmur at his lower left sternal edge and a loud P2.
Ventricular septal defect
typical features of heart failure in child
breathlessness, difficulty feeding, poor growth at an early age
VSD presentation
associations
classically a pan-systolic murmur which is louder in smaller defects
chromosomal disorders (e.g. Down’s syndrome, Edward’s syndrome, Patau syndrome) and single gene disorders such as Non-congenital causes include post myocardial infarction
VSD complications
Complications aortic regurgitation* infective endocarditis Eisenmenger's complex right heart failure pulmonary hypertension: pregnancy is contraindicated in women with pulmonary hypertension as it carries a 30-50% risk of mortality
ostium secundum
stium secundum (70% of ASDs)
associated with Holt-Oram syndrome (tri-phalangeal thumbs)
ECG: RBBB with RAD
Ostium primum
present earlier than ostium secundum defects
associated with abnormal AV valves
ECG: RBBB with LAD, prolonged PR interval
Coarctation of the aorta presentation
infancy: heart failure
adult: hypertension
radio-femoral delay
mid systolic murmur, maximal over back
apical click from the aortic valve
notching of the inferior border of the ribs (due to collateral vessels) is not seen in young children
Coarctation of the aorta associations
Associations Turner's syndrome bicuspid aortic valve berry aneurysms neurofibromatosis
hypertrophic obstructive cardiomyopathy associated pulse
bisferiens pulse (double pulse).
Aortic stenosis management
VR if symptomatic, otherwise cut-off is gradient of 40 mmHg
Features of severe aortic stenosis
narrow pulse pressure slow rising pulse delayed ESM soft/absent S2 S4 thrill duration of murmur left ventricular hypertrophy or failure
Aortic regurgitation features
ifficulty breathing at night, occasional palpitations and tight chest pain. On examination, he has a collapsing pulse and a laterally shifted apex beat
murmur = early diastolic
Abdominal pain ddx in children
- infection (Gastroenteritis)
-Constipation
_ Appendcitis
Merkles adentisi - Hernia
Intussception
Allergery
Hischsprung
IBS
coalic
-
Attention Deficit Hyperactivity Disorder presentaion
- inattentiveness
hyperactivity and impulsiveness
associated mood or behaviour disorders
Attention Deficit Hyperactivity Disorder management
watch and wait
(CAMHS ref needed)
Drug therapy should be seen as a last resort and is only available to those aged 5 years or more
Methylphenidate is first line in children
f there is inadequate response, switch to lisdexamfetamine;
Methylphenidate side effects
ide-effects include abdominal pain, nausea and dyspepsia. In children, weight and height should be monitored every 6 months
Features Bronchiolitis
eatures
coryzal symptoms (including mild fever) precede:
dry cough
increasing breathlessness
wheezing, fine inspiratory crackles (not always present)
feeding difficulties associated with increasing dyspnoea are often the reason for hospital admission
Bronchiolitis - NICE recommend immediate referral (usually by 999 ambulance) if they have any of the following:
apnoea (observed or reported)
child looks seriously unwell to a healthcare professional
severe respiratory distress, for example grunting, marked chest recession, or a respiratory rate of over 70 breaths/minute
central cyanosis
persistent oxygen saturation of less than 92% when breathing air.
Bronchiolitis- management
Management is largely supportive
humidified oxygen is given via a head box and is typically recommended if the oxygen saturations are persistently < 92%
nasogastric feeding may be needed if children cannot take enough fluid/feed by mouth
suction is sometimes used for excessive upper airway secretions
causes Cerebral palsy
Causes
antenatal (80%): e.g. cerebral malformation and congenital infection (rubella, toxoplasmosis, CMV)
intrapartum (10%): birth asphyxia/trauma
postnatal (10%): intraventricular haemorrhage, meningitis, head-trauma
presentations Cerebral palsy
Possible manifestations include: abnormal tone early infancy delayed motor milestones abnormal gait feeding difficultie.
Cerebral palsy
Management
as with any child with a chronic condition a multidisciplinary approach is needed
treatments for spasticity include oral diazepam, oral and intrathecal baclofen, botulinum toxin type A, orthopaedic surgery and selective dorsal rhizotomy
anticonvulsants, analgesia as required
Exanthems
eruptive skin rashes associated with a fever or other constitutional symptoms
Causes of maculopapular eruptions
Measles (rubeola) Rubella Erythema infectiosum (slapped cheek) Exanthum subitum (roseola) Lyme disease Pityriasis Drug-related eruptions Erythema multiforme
Causes of diffuse erythema with desquamation
Scarlet fever
Toxic shock syndrome
Staphylococcal scaled skin syndrome
Kawasaki disease
Measles rash
erythematous maculopapular rash beginning on the head, with a cephalocaudad progression.
Blue-white Kopliks spots occurring on the buccal mucosa opposite the second molar and lasting around 1-2 day
Measles management
Measles is a notifiable illness and notification is required based on clinical suspicion.
Children diagnosed with measles should be kept off school until 5 days after the appearance of the rash.
The treatment of measles is largely symptomatic and the majority of children will recover uneventfully.
Meckel’s diverticulum
presentation
Presentation (usually asymptomatic)
abdominal pain mimicking appendicitis
rectal bleeding
Meckel’s diverticulum is the most common cause of painless massive GI bleeding requiring a transfusion in children between the ages of 1 and 2 years
intestinal obstruction
secondary to an omphalomesenteric band (most commonly), volvulus and intussusception
Anaphylaxis presentation
Anaphylaxis may be defined as a severe, life-threatening, generalised or systemic hypersensitivity reaction.
Common identified causes of anaphylaxis:
food (e.g. nuts) - the most common cause in children
drugs
venom (e.g. wasp sting)
Anaphylaxis management
Adrenaline is by far the most important drug in anaphylaxis and should be given as soon as possible.
also give Hydrocortisone and Chlorphenamine
Adrenaline can be repeated every 5 minutes if necessary. The best site for IM injection is the anterolateral aspect of the middle third of the thigh.
Management following stabilisation:
patients who have had emergency treatment for anaphylaxis should be observed for 6–12 hours from the onset of symptoms, as it is known that biphasic reactions can occur in up to 20% of patients
sometimes it can be difficult to establish whether a patient had a true episode of anaphylaxis. Serum tryptase levels are sometimes taken in such patients as they remain elevated for up to 12 hours following an acute episode of anaphylaxis.v
Anaphylaxis test after episode to confirm
serum tryptase levels rise following an acute episode
Acute exacerbations of COPD features
Features
increase in dyspnoea, cough, wheeze
there may be an increase in sputum suggestive of an infective cause
patients may be hypoxic and in some cases have acute confusion
The most common bacterial organisms that cause infective exacerbations of COPD are:
Haemophilus influenzae (most common cause)
Streptococcus pneumoniae
Moraxella catarrhalis
Infective exacerbations of COPD managements
NICE guidelines from 2010 recommend the following:
increase frequency of bronchodilator use and consider giving via a nebuliser
give prednisolone 30 mg daily for 5 days
it is common practice for all patients with an exacerbation of COPD to receive antibiotics. NICE do not support this approach. They recommend giving oral antibiotics ‘if sputum is purulent or there are clinical signs of pneumonia’
the BNF recommends one of the following oral antibiotics first-line: amoxicillin or clarithromycin or doxycycline.
pneumonia causes
bacterial pneumonia is by far the most common type of pneumonia
Streptococcus pneumoniae = most common
Haemophilus influenzae = COPD
Staphylococcus aureus = occurs in patient following influenza infection
Klebsiella pneumoniae = alcoholics
Pneumonia Bloods
Bloods
full blood count: would usually show a neutrophilia in bacterial infections
urea and electrolytes: check for dehydration (remember the ‘U’ for urea in CURB-65, see below) and also other changes seen with some atypical pneumonias
CRP: raised in response to infection
Pneumonia management
Patients with pneumonia require the following:
antibiotics: to treat the underlying infection
supportive care: for example oxygen therapy if the patients is hypoxaemic, intravenous fluids if the patient is hypotensive or shows signs of dehydration
CURB- 65 score
Pneumonia - Discharge criteria and advice post-discharge
Discharge criteria and advice post-discharge
NICE recommend that patients are not routinely discharged if in the past 24 hours they have had 2 or more of the following findings: temperature higher than 37.5°C respiratory rate 24 breaths per minute or more heart rate over 100 beats per minute systolic blood pressure 90 mmHg or less oxygen saturation under 90% on room air abnormal mental status inability to eat without assistance.
They also recommend delaying discharge if the temperature is higher than 37.5°C.
Pneumothorax risk factors
Risk factors
pre-existing lung disease: COPD, asthma, cystic fibrosis, lung cancer, Pneumocystis pneumonia
connective tissue disease: Marfan’s syndrome, rheumatoid arthritis
ventilation, including non-invasive ventilation
catamenial pneumothorax is the cause of 3-6% of spontaneous pneumothoraces occurring in menstruating women. It is thought to be caused by endometriosis within the thorax
Pneumothorax symptoms
Symptoms tend to come on suddenly. Features include: dyspnoea chest pain: often pleuritic sweating tachypnoea tachycardia
Primary pneumothorax
management
Recommendations include:
if the rim of air is < 2cm and the patient is not short of breath then discharge should be considered
otherwise, aspiration should be attempted
if this fails (defined as > 2 cm or still short of breath) then a chest drain should be inserted
patients should be advised to avoid smoking to reduce the risk of further episodes - the lifetime risk of developing a pneumothorax in healthy smoking men is around 10% compared with around 0.1% in non-smoking men
Secondary pneumothorax management
Recommendations include:
if the patient is > 50 years old and the rim of air is > 2cm and/or the patient is short of breath then a chest drain should be inserted.
otherwise aspiration should be attempted if the rim of air is between 1-2cm. If aspiration fails (i.e. pneumothorax is still greater then 1cm) a chest drain should be inserted. All patients should be admitted for at least 24 hours
if the pneumothorax is less the 1cm then the BTS guidelines suggest giving oxygen and admitting for 24 hours
regarding scuba diving, the BTS guidelines state: ‘Diving should be permanently avoided unless the patient has undergone bilateral surgical pleurectomy and has normal lung function and chest CT scan postoperatively.’
triad of PE
and clinical signs
pleuritic chest pain, dyspnoea and haemoptysis.
The relative frequency of common clinical signs is shown below:
Tachypnea (respiratory rate >20/min) - 96%
Crackles - 58%
Tachycardia (heart rate >100/min) - 44%
Fever (temperature >37.8°C) - 43%
PE suspected
If a PE is suspected a 2-level PE Wells score should be performed:
linical probability simplified scores
PE likely - more than 4 points
PE unlikely - 4 points or less
If a PE is ‘likely’ (more than 4 points) arrange an immediate computed tomography pulmonary angiogram (CTPA). If there is a delay in getting the CTPA then interim therapeutic anticoagulation should be given until the scan is performed.
interim therapeutic anticoagulation used to mean giving low-molecular weight heparin
NICE updated their guidance in 2020. They now recommend using an anticoagulant that can be continued if the result is positive.
this means normally a direct oral anticoagulant (DOAC) such as apixaban or rivaroxaban
test in PE
CTPA is now the recommended initial lung-imaging modality for non-massive PE. Advantages compared to V/Q scans include speed, easier to perform out-of-hours, a reduced need for further imaging and the possibility of providing an alternative diagnosis if PE is excluded
if the CTPA is negative then patients do not need further investigations or treatment for PE
V/Q scanning may be used initially if appropriate facilities exist, the chest x-ray is normal, and there is no significant symptomatic concurrent cardiopulmonary disease. V/Q scanning is also the investigation of choice if there is renal impairment (doesn’t require the use of contrast unlike CTPA)
Pulmonary embolism and renal impairment →
V/Q scan is the investigation of choice
Massive PE + hypotension
- thrombolyse
bloods PE
Pulmonary embolism causes hyperventilation, causing a drop in arterial carbonic dioxide partial pressure and thus alkalosis.
Features of pulmonary oedema on a chest x-ray may include:
Features of pulmonary oedema on a chest x-ray may include:
interstitial oedema
bat’s wing appearance
upper lobe diversion (increased blood flow to the superior parts of the lung)
Kerley B lines
pleural effusion
cardiomegaly may be seen if there is cardiogenic cause
Tricuspid regurgitation signs
Pan systolic mumur
JVP increase
Hepatomegaly
Heave
Tricuspid regurgitation causes
Right V INFARCT
Pulmonary hypertension
Rheumatic heart disease
Infective endo
Ébstekns
NSTEMI
All patients should receive
aspirin 300mg
nitrates or morphine to relieve chest pain if required
Clopidogrel
optic neuritis causes
Causes
multiple sclerosis
diabetes
syphilis
optic neuritis features
Features
unilateral decrease in visual acuity over hours or days
poor discrimination of colours, ‘red desaturation’
pain worse on eye movement
relative afferent pupillary defect
central scotoma
optic neuritis management
Management
high-dose steroids
recovery usually takes 4-6 weeks
Prognosis
MRI: if > 3 white-matter lesions, 5-year risk of developing multiple sclerosis is c. 50%
abdo signs
A number of eponymous abdominal signs are noted. These include:
Rovsings sign- appendicitis
Boas sign -cholecystitis
Murphys sign- cholecystitis
Cullens sign- pancreatitis (other intraabdominal haemorrhage)
Grey-Turners sign- pancreatitis (or other retroperitoneal haemorrhage)
BV causes and treatment
Bacterial vaginosis (BV) describes an overgrowth of predominately anaerobic organisms such as Gardnerella vaginalis
Features
vaginal discharge: ‘fishy’, offensive
asymptomatic in 50%
Amsel’s criteria for diagnosis of BV - 3 of the following 4 points should be present
thin, white homogenous discharge
clue cells on microscopy: stippled vaginal epithelial cells
vaginal pH > 4.5
positive whiff test (addition of potassium hydroxide results in fishy odour)
Management oral metronidazole for 5-7 days 70-80% initial cure rate relapse rate > 50% within 3 months the BNF suggests topical metronidazole or topical clindamycin as alternatives.
BV in pregnancy
Bacterial vaginosis in pregnancy
results in an increased risk of preterm labour, low birth weight and chorioamnionitis, late miscarriage
it was previously taught that oral metronidazole should be avoided in the first trimester and topical clindamycin used instead. Recent guidelines however recommend that oral metronidazole is used throughout pregnancy. The BNF still advises against the use of high dose metronidazole regimes
hypocalcaemia causes
auses
vitamin D deficiency (osteomalacia)
chronic kidney disease
hypoparathyroidism (e.g. post thyroid/parathyroid surgery)
pseudohypoparathyroidism (target cells insensitive to PTH)
rhabdomyolysis (initial stages)
magnesium deficiency (due to end organ PTH resistance)
massive blood transfusion
acute pancreatitis
hypocalcaemia Management
Management
acute management of severe hypocalcaemia is with intravenous replacement. The preferred method is with intravenous calcium gluconate, 10ml of 10% solution over 10 minutes
intravenous calcium chloride is more likely to cause local irritation
ECG monitoring is recommended
further management depends on the underlying cause
Bells palsy presentation
Features
lower motor neuron facial nerve palsy - forehead affected*
patients may also notice post-auricular pain (may precede paralysis), altered taste, dry eyes, hyperacusis
Bells palsy management
prednisolone 1mg/kg for 10 days should be prescribed for patients within 72 hours of onset of Bell’s palsy. Adding in aciclovir gives no additional benefit
eye care is important - prescription of artificial tears and eye lubricants should be considered
large fluid volumes risk
hyperchloraemic acidosis
stroke post coag
Aspirin 300 mg daily for 2 weeks should be given immediately after an ischaemic stroke is confirmed by brain imaging. Following this, clopidogrel 75 mg daily should be given long-term -if it can be tolerated and is not contraindicated.
If clopidogrel is contraindicated or not tolerated, then the patient should be given modified-release dipyridamole alongside low dose aspirin.
Age-related macular degeneration presentation
Patients typically present with a subacute onset of visual loss with:
a reduction in visual acuity, particularly for near field objects
difficulties in dark adaptation with an overall deterioration in vision at night
fluctuations in visual disturbance which may vary significantly from day to day
they may also suffer from photopsia, (a perception of flickering or flashing lights), and glare around objects
Age-related macular degeneration treatment
zinc with anti-oxidant vitamins A,C and E reduced progression of the disease by around one third.
anti-VEGF agents (wet) - instituted within the first two months of diagnosis of wet ARMD if possible.
Laser photocoagulation does slow progression of ARMD where there is new vessel formation, although there is a risk of acute visual loss after treatment, which may be increased in patients with sub-foveal ARMD. For this reason anti-VEGF therapies are usually preferred.
Central retinal vein occlusion presentation
Features
sudden, painless reduction or loss of visual acuity, usually unilaterally
severe retinal haemorrhages are usually seen on fundoscopy
Herpes simplex keratitis presentation
Features red, painful eye photophobia epiphora visual acuity may be decreased fluorescein staining may show an epithelial ulcer
Herpes simplex keratitis management
Management
immediate referral to an ophthalmologist
topical aciclovir
Rentral retinal artery occlusion
causes sudden unilateral visual loss
due to thromboembolism (from atherosclerosis) or arteritis (e.g. temporal arteritis)
features include afferent pupillary defect, ‘cherry red’ spot on a pale retina
retinal detachment presentaition
Peripheral curtain over vision + spider webs + flashing lights in vision
(painless loss of vision)
amaurosis fugax
Painless, transient monocular blindness together with the description of a ‘black curtain coming down’
Tunnel vision is the concentric diminution of the visual fields
Causes
Causes papilloedema glaucoma retinitis pigmentosa choroidoretinitis optic atrophy secondary to tabes dorsalis hysteria
Acute angle closure glaucoma is associated with ?
hypermetropia,
primary open-angle glaucoma is associated with
myopia
Acyanotic heart disease
most common causes (blood contains oxygen)
ventricular septal defects (VSD) - most common, accounts for 30% atrial septal defect (ASD) patent ductus arteriosus (PDA) coarctation of the aorta aortic valve stenosis
