Passmed Flashcards
If a patient with AF has a stroke or TIA, the anticoagulant of choice should be?
Warfarin or a direct thrombin or factor Xa inhibitor
What can cause gingival hyperplasia?
Phenytoin, ciclosporin, calcium channel blockers and AML
Hypokalaemia on an ECG?
Prolonged PR interval, inverted T waves, and prominent U waves
What may be seen on the full blood count as a long-term result of COPD?
Polycythaemia; inc. conc of haematocrit
Holmes ADIe pupil
DIlated pupil, females, absent leg reflexes
What is the purpose of studies where they focus on testing patients with the condition for which the drug is intended to treat?
The purpose of phase 2 studies is to assess the efficacy of drugs or devices
What is the most appropriate initial investigation to confirm a diagnosis of ankylosing spondylitis?
Plain radiography of pelvis: sacro-ilitis
What’s first-line for knee osteoarthritis?
Topical NSAIDs e.g. diclofenac
If renin is high then is it primary or secondary aldosteronism?
Secondary e.g. renal artery stenosis
A blood film shows crescent-shaped red blood cells and schistocytes.
Sickle cell
Bg of sickle cell.
Acutely painful right arm
Vomiting
Can’t eat or drink.
Apyrexial.
Anaemic, normal platelets.
DDx?
Thrombotic crises in sickle cell can be precipitated by infection, dehydration or deoxygenation
In X-linked recessive conditions, if there is an affected male then can he pass the condition onto a son?
No, but daughters may be carriers
How to calculate likelihood ratio for a positive test result?
Sensitivity / (1 - specificity)
Pt has first VTE and diagnosed with antiphospholipid syndrome. What’s the most appropriate long-term anticoagulation strategy?
Lifelong warfarin.
High-risk paracetamol overdose because of what factors?
Chronic alcohol, HIV, anorexia, P450 inducers
Proteinuric CKD and no diabetes. what drug to give?
Dapagliflozin (SGLT2 inhibitors) even if not diabetic
Ptosis + dilated pupil =
CNIII palsy
Ptosis + constricted pupil =
Horner’s
Persistent ST elevation in precordial leads after MI. Bibasal crackles, S3 and S4.
Left ventricular aneurysm
Post MI - 2 days - mitral regurgitation, hypotensive, pulmonary oedema.
Papillary muscle rupture.
Post MI - 24 hrs - Chest pain worse on lying flat
Pericarditis
What is brugada syndrome?
Genetic mutation
ST elevation in some leads, inverted T waves
Documented VF episode
Sudden cardiac death in relative
Nocturnal agonal breathing
Tear drop poikilocytes on blood film indicate:
Myelofibrosis
Abdominal pain + ascites + tender hepatomegaly =?
Budd-Chiari syndrome
Renal impairment, resp symptoms, joint pain, systemic features:
ANCA associated vasculitis
When to give platelet transfusion:
Bleeding + 29 platelet count
Give (under 30)
When to give platelet transfusion:
Not bleeding + 11 platelet count
No (under 10)
Ciclosporin side effects:
Everything increased - fluid, BP, K+, hairy, gums, glucose
What anaesthetic should be used in caution with a pneumothorax?
Nitrous oxide
SIADH treatment?
Fluid restriction
SACD presentation:
Distal sensory loss
Tingling
Absent ankle jerks
Extensor plantars
Romberg’s positive
Widened QRS?
> 100ms –> inc. risk seizures
160ms –> inc. risk ventricular arrhythmias
Secondary prevention for MI?
ACEi + beta-blocker + statin + aspirin + ticagrelor
Animal bite abx?
Co-amoxiclav
Photosensitivity, macular rash, heliotrope rash, Gottron’s papules, Raynaud’s
Diagnosis and antibody?
Dermatomyositis is associated with the anti-Jo-1 antibody
Hartmann’s is what
Sigmoid colectomy + formation of end colostomy
Which meds should be avoided in myasthenia gravis?
Beta-blockers
High pulmonary capillary wedge pressure means:
Backlog into the veins –> cardiac failure
TRALI vs ARDS
TRALI is ARDS within 6 hours of transfusion
A patient presents with numbness and tingling along the ulnar border of his wrist and forearm. On examination you also note weak flexion of all the digits including the thumb.
C8 radiculopathy
AF + QRS 130ms
AF with bundle branch block
Post MI - 1 week - acute heart failure, cardiac tamponade
Left ventricular free wall rupture
MMSE score of below 26 indicates?
Cognitive impairment –> complete blood screen
If G6PD deficiency, which antibiotic is contraindicated?
Ciprofloxacin
Highly specific test for SLE?
Anti-dsDNA
Management of Perthes’ disease
Reassurance and follow-up
HIV, neuro symptoms, multiple brain lesions with ring enhancement
Toxoplasmosis
Rheumatoid arthritis, splenomegaly, low WCC
Felty’s syndrome
What is a type II error?
Failure to reject the null hypothesis (that there is no difference between mindfulness and no intervention) when it is false.
Lithium toxicity can be precipitated by…
Dehydration
Renal failure
Diuretics
ACEi/ARBs
NSAIDs
Metronidazole
20M with acute swelling and tense knee joint. No other features and no signs of injury, plain X-R show no fracture.
Likely explanation?
Haemophilia A or B
First line for neuropathic pain?
amitriptyline, duloxetine, gabapentin or pregabalin
Pincer grip?
12 months
Corneal abrasion management?
Topical antibiotics should be given to prevent secondary bacterial infection
A patient develops acute heart failure 5 days after a myocardial infarction. A new pan-systolic murmur is noted on examination
Ventricular septal defect
Switching from fluoxetine to another SSRI
withdraw then leave a gap of 4-7 days (as it has a long half-life) before starting a low dose of the alternative SSRI
Stereotypical features of Legionella
flu-like symptoms and a dry cough, relative bradycardia and confusion. Blood tests may show hyponatraemia
Acute heart failure not responding to treatment. What should we consider?
Consider CPAP
ADPKD is a risk factor for SAH or bacterial meningitis?
SAH
What is the most common presentation of ALS?
Asymmetric limb weakness
First-line treatment for most patients with a pituitary tumour causing acromegaly
Trans-sphenoidal surgery
Increased risk of placental abruption is associated with
increasing maternal age, multiparity and maternal trauma
potential complication of panretinal photocoagulation
A decrease in night vision
Horner’s syndrome
miosis + ptosis + enophthalmos +/- anhydrosis
Notching of the inferior border of the ribs indicates what condition?
Notching of the inferior border of the ribs is present in around 70% of adults with coarctation of the aorta
What is management ofintracapsular (subcapital) and displaced hip injury?
Total hip replacement
What is management ofextracapsular (trochanteric or subtrochanteric) hip injury?
- intertrochanteric → dynamic hip screw
- subtrochanteric → intramedullary nail
What is management ofintracapsular (subcapital) and NOT displaced hip injury?
internal fixation (cannulated hip screw) (fit)
- hemiarthroplasty (unfit)
Pregnancy-induced HTN does not happen before what gestational age?
20 weeks
Patients with NHPCC (Lynch syndrome) are at a high risk of developing which cancers:
Inherited colon cancer (mostly proximal)
Endometrial cancer
Which inheritance pattern has no male-to-male transmission?
X-linked recessive or dominant
Which type of inheritance is not typically seen in every generation of an affected family?
Autosomal recessive
Which inheritance pattern causes all offspring to be carriers if one affected and one unaffected reproduce?
Autosomal recessive
Acute graft rejection
within months, is usually asymptomatic and is picked up by a rising creatinine, pyuria and proteinuria
Monteggia fracture
A Monteggia fracture involves dislocation of the proximal radioulnar joint in association with an ulnar fracture
Loss of corneal reflex with vertigo, tinnitus and unilateral sensorineural hearing loss
Acoustic neuroma
Conductive hearing loss in the affected ear. Disturbance in balance and vertigo.
Cholesteatoma
Acute vertigo, prolonged in the first few days and then eases.
Viral labyrinthitis
Tinnitus, vertigo and sensorineural hearing loss. Relapsing and remitting vertigo.
Meniere’s disease
Progressive, bilateral conductive hearing loss.
Otosclerosis
What is a normal anion gap?
10-18 mmol
What kind of anion gap does diarrhoea cause?
Normal anion gap (loss of bicarbs but inc. Cl- in the kidney compensates)
What kind of anion gap does DKA cause?
Raised anion gap (accumulation of ketotic acid)
What kind of anion gap does renal failure cause?
Raised anion gap (accumulation of uric acid)
What kind of anion gap does salicylate poisoning cause?
Raised anion gap (accumulation of salicylic acid)
What kind of anion gap does septic shock cause?
Raised anion gap (accumulation of lactic acid)
Which drugs can cause pancreatitis?
Azathioprine
Mesalazine
Didanosine
Bendroflumethiazide
Furosemide
Pentamidine
Steroids
Sodium valproate
Contralateral hemiparesis and sensory loss, lower extremity > upper
Anterior cerebral artery
Contralateral hemiparesis and sensory loss, upper extremity > lower
Contralateral homonymous hemianopia
Aphasia
Middle cerebral artery
Contralateral homonymous hemianopia with macular sparing
Visual agnosia
Posterior cerebral artery
Ipsilateral CN III palsy
Contralateral weakness of upper and lower extremity
Weber’s syndrome (branches of the posterior cerebral artery that supply the midbrain)
Ipsilateral: facial pain and temperature loss, cranial nerve palsy e.g. Horner’s
Contralateral: limb/torso pain and temperature loss
Ataxia, nystagmus
Posterior inferior cerebellar artery (lateral medullary syndrome, Wallenberg syndrome)
Symptoms are similar to Wallenberg’s (see above), but:
Ipsilateral: facial paralysis and deafness
Anterior inferior cerebellar artery (lateral pontine syndrome)
Sudden, painless vision loss in one eye that lasts seconds to minutes, often described as a “shade” or “curtain” descending over the visual field.
Amaurosis fugax due to retinal/ophthalmic artery
‘Locked-in’ syndrome
Basilar artery
This condition presents with either isolated hemiparesis, hemisensory loss or hemiparesis with limb ataxia
PMHx HTN
Lacunar stroke
Impairment of vertical gaze (down gaze worse than up gaze - patients may complain of difficulty reading or descending stairs)
Parkinsonism
Falls
Slurring of speech
Cognitive impairment
PSP
What’s long-term prevention for cluster headaches?
Verapamil
Wet, wacky, wobbly
i.e. urinary incontinence, dementia, gait disturbance
Normal pressure hydrocephalus
Combo of UMN + LMN
Limb-onset or bulbar-onset
ALS
PLS is upper or lower?
Upper
PMA is upper or lower?
Lower
Normal power on resisted movements of shoulder and hip
Morning stiffness
Severe tiredness
Shoulder and hip muscle pain
Polymyalgia rheumatica
Multiple myeloma without metastasis bone profile results?
High calcium
Normal phosphate
Normal ALP
All invasive diarrhoeas are treated with ciprofloxacin, except __ which is treated with ___
Campylobacter treated with clarithromycin
Slow growing, painless, mobile lump in parotid gland of older female
Pleomorphic adenoma
Otitis externa in diabetics. What Mx?
Ciprofloxacin to cover Pseudomonas
MEN type I
3Ps
Parathyroid (95%): hyperparathyroidism due to parathyroid hyperplasia
Pituitary (70%)
Pancreas (50%): e.g. insulinoma, gastrinoma (leading to recurrent peptic ulceration)
Also: adrenal and thyroid
MEN1 gene
Most common presentation = hypercalcaemia
MEN type IIa
Medullary thyroid cancer (70%)
2 P’s
Parathyroid (60%)
Phaeochromocytoma
RET oncogene
MEN type IIb
Medullary thyroid cancer
1 P
Phaeochromocytoma
Marfanoid body habitus
Neuromas
Cutaneous features
depigmented ‘ash-leaf’ spots which fluoresce under UV light
roughened patches of skin over lumbar spine (Shagreen patches)
adenoma sebaceum (angiofibromas): butterfly distribution over nose
fibromata beneath nails (subungual fibromata)
cafe-au-lait spots* may be seen
Neurological features
developmental delay
epilepsy (infantile spasms or partial)
intellectual impairment
Also
retinal hamartomas: dense white areas on retina (phakomata)
rhabdomyomas of the heart
gliomatous changes can occur in the brain lesions
polycystic kidneys, renal angiomyolipomata
lymphangioleiomyomatosis: multiple lung cysts
Tuberous sclerosis
Cafe-au-lait spots (>= 6, 15 mm in diameter)
Axillary/groin freckles
Peripheral neurofibromas
Iris hamatomas (Lisch nodules) in > 90%
Scoliosis
Pheochromocytomas
Neurofibromatosis I
Bilateral vestibular schwannomas
Multiple intracranial schwannomas, meningiomas and ependymomas
Neurofibromatosis II
What investigation is most useful in investigating multiple myeloma?
Serum protein electrophoresis
Tetracycline side effects
Photosensitivity
Discolouration of teeth in children and during pregnancy
Hepatotoxicity
Renal impairment
What is an important cause of visual impairment in babies born before 32 weeks gestation?
Retinopathy of prematurity
Chronic insomnia diagnostic criteria
may be diagnosed after three months, if a person has trouble falling asleep or staying asleep at least three nights per week
AKI diagnostic criteria in adults
↑ creatinine > 26µmol/L in 48 hours
↑ creatinine > 50% in 7 days
↓ urine output < 0.5ml/kg/hr for more than 6 hours
Tender, purple/red raised lesions with a pale centre. These lesions occur as a result of immune complex deposition.
Osler nodes
Patients typically present with hard, painless nodules at the DIP joints. These nodes can be bilateral and may lead to decreased range of motion and functional impairment over time.
Heberdens nodes
17M
Soft, fluctuant swelling on the dorsal aspect of the hand, it is most obvious on making a fist.
Ganglion
Non-functioning pituitary tumours present with…?
hypopituitarism and pressure effects
Marfan’s syndrome is caused by a mutation in what?
Fibrillin-1
Types of nephrotic syndromes
Focal segmental glomerulosclerosis
Minimal change disease
Membranous nephropathy
Diabetic nephropathy
Major bleeding (e.g. variceal haemorrhage, intracranial haemorrhage)
Stop warfarin
Give intravenous vitamin K 5mg
Prothrombin complex concentrate - if not available then FFP*
INR > 8.0
Minor bleeding
Stop warfarin
Give intravenous vitamin K 1-3mg
Repeat dose of vitamin K if INR still too high after 24 hours
Restart warfarin when INR < 5.0
INR > 8.0
No bleeding
Stop warfarin
Give vitamin K 1-5mg by mouth, using the intravenous preparation orally
Repeat dose of vitamin K if INR still too high after 24 hours
Restart when INR < 5.0
INR 5.0-8.0
Minor bleeding
Stop warfarin
Give intravenous vitamin K 1-3mg
Restart when INR < 5.0
INR 5.0-8.0
No bleeding
Withhold 1 or 2 doses of warfarin
Reduce subsequent maintenance dose
Posterior Mi presents with what on ECG
Tall R waves V1-V2
Types of nephritic syndrome?
IgA nephropathy
Membranoproliferative glomerulonephritis
Rapidly progressive glomerulonephritis
Transudative causes of pleural effusions?
Transudate (< 30g/L protein)
heart failure (most common transudate cause)
hypoalbuminaemia
liver disease
nephrotic syndrome
malabsorption
hypothyroidism
Meigs’ syndrome
Exudative causes of pleural effusions?
Exudate (> 30g/L protein)
infection
pneumonia (most common exudate cause),
tuberculosis
subphrenic abscess
connective tissue disease
rheumatoid arthritis
systemic lupus erythematosus
neoplasia
lung cancer
mesothelioma
metastases
pancreatitis
pulmonary embolism
Dressler’s syndrome
yellow nail syndrome
Acute pancreatitis can cause what kind of mineral imbalance?
Hypocalcaemia
Which two drugs together may cause bone marrow suppression and severe or fatal pancytopaenia?
Methotrexate and trimethoprim
CN I
Olfactory
CN II
Optic
CN III
Oculomotor
CN IV
Trochlear
CN V
Trigeminal
CN VI
Abducens
CN VII
Facial
CN VIII
Vestibulocochlear
CN IX
Glossopharyngeal
CN X
Vagus
CN XI
Accessory
CN XII
Hypoglossal
Function of CN I
Smell
Function of CN II
Vision
Function of CN III
Eye movement and blinking
Function of CN IV
Superior oblique muscle –>
Up and down and back and forth eye movements
Function of CN V
Facial sensations, muscles of mastication
Function of CN VI
Lateral rectus muscle –>
Eye movements
Function of CN VII
Expression and sense of taste
Function of CN VIII
Hearing and balance
Function of CN IX
Taste and swallowing
Function of CN X
Heart rate and digestion
Function of CN XI
Neck and shoulder movement
Function of CN XII
Tongue movement
First line for primary biliary cholangitis?
Ursodeoxycholic acid
Management of bilateral adrenocortical hyperplasia
Primary hyperaldosteronism: Spironolactone
All patients with PAD should take what?
Clopidogrel and atorvastatin
Rheumatoid arthritis x-ray changes
loss of joint space
juxta-articular osteoporosis
soft-tissue swelling
periarticular erosions
subluxation
Heberden’s nodes and Bouchard’s nodes for what?
Osteoarthritis
First-line management in patients with hypercalcaemia
IV fluid
If known COPD pt has a normal CO2 on ABG, what’s their target O2 sat?
90-94%
Paracetamol poisoning Mx?
activated charcoal if ingested < 1 hour ago
N-acetylcysteine (NAC)
liver transplantation
Salicylate poisoning Mx?
Urinary alkalinization with IV bicarbonate
haemodialysis
Opioid/opiates poisoning Mx?
Naloxone
Benzodiazepine poisoning Mx?
Flumazenil
The majority of overdoses are managed with supportive care only due to the risk of seizures with flumazenil. It is generally only used with severe or iatrogenic overdoses.
Tricyclic antidepressants overdose Mx?
IV bicarbonate may reduce the risk of seizures and arrhythmias in severe toxicity
arrhythmias: class 1a (e.g. Quinidine) and class Ic antiarrhythmics (e.g. Flecainide) are contraindicated as they prolong depolarisation. Class III drugs such as amiodarone should also be avoided as they prolong the QT interval. Response to lignocaine is variable and it should be emphasized that correction of acidosis is the first line in management of tricyclic induced arrhythmias
dialysis is ineffective in removing tricyclics
Lithium poisoning Mx?
mild-moderate toxicity may respond to volume resuscitation with normal saline
haemodialysis may be needed in severe toxicity
sodium bicarbonate is sometimes used but there is limited evidence to support this. By increasing the alkalinity of the urine it promotes lithium excretion
Warfarin poisoning Mx?
Vitamin K, prothrombin complex
Heparin poisoning Mx?
Protamine sulphate
Beta-blockers overdose Mx?
if bradycardic then atropine
in resistant cases glucagon may be used
Ethylene glycol overdose Mx?
ethanol has been used for many years
works by competing with ethylene glycol for the enzyme alcohol dehydrogenase
this limits the formation of toxic metabolites (e.g. Glycoaldehyde and glycolic acid) which are responsible for the haemodynamic/metabolic features of poisoning
fomepizole, an inhibitor of alcohol dehydrogenase, is now used first-line in preference to ethanol
haemodialysis also has a role in refractory cases
Methanol poisoning Mx?
fomepizole or ethanol
haemodialysis
Organophosphate insecticides poisoning Mx?
atropine
the role of pralidoxime is still unclear - meta-analyses to date have failed to show any clear benefit
Digoxin poisoning Mx?
Digoxin-specific antibody fragments
Iron overdose Mx?
Desferrioxamine
Lead poisoning Mx?
Dimercaprol, calcium edetate
Carbon monoxide poisoning Mx?
Management
100% oxygen
hyperbaric oxygen
Cyanide poisoning Mx?
Hydroxocobalamin; also combination of amyl nitrite, sodium nitrite, and sodium thiosulfate
Scarlet fever school exclusion?
24 hours after starting Abx
Whooping cough school exclusion?
2 days after starting Abx
or 21 days after Sx onset if no Abx
Measles school exclusion?
4 days after rash
Rubella school exclusion?
5 days after rash
Chickenpox school exclusion?
Until lesions crusted over
Mumps school exclusion?
5 days from onset of swollen glands
D+V school exclusion?
Until settled for 48hrs
Impetigo school exclusion?
Until lesions are crusted and healed, or 48 hours after commencing antibiotic treatment
Scabies school exclusion?
Until treated
Influenza school exclusion?
Until recovered
Which drugs are contraindicated in aortic stenosis?
Nitrates
Abdominal pain, diarrhoea and flushing triad is?
Carcinoid syndrome
Likelihood ratio of a positive test result
Sensitivity/(1-Specificity)
Likelihood ratio of a negative test result
(1-Sensitivity)/Specificity
Over-replacement with thyroxine causes what
Osteoporosis
- Raynaud’s may be the first sign
- Scleroderma affects face and distal limbs predominately
- Associated with anti-centromere antibodies
- A subtype of it is CREST syndrome.
- Anti-centromere antibodies
Limited cutaneous systemic sclerosis
Scleroderma affects trunk and proximal limbs predominately
associated with anti scl-70 antibodies
the most common cause of death is now respiratory involvement, which is seen in around 80%: interstitial lung disease (ILD) and pulmonary arterial hypertension (PAH)
other complications include renal disease and hypertension
patients with renal disease should be started on an ACE inhibitor - captopril is typically used due to its rapid onset and short half-life, allowing for dose titration
ACE inhibitors target the underlying mechanism by reducing efferent arteriolar vasoconstriction and limiting renin-angiotensin system activation
poor prognosis
Anti-Scl-70 antibodies
Diffuse cutaneous systemic sclerosis
tightening and fibrosis of skin
may be manifest as plaques (morphoea) or linear
Scleroderma without organ involvement
CREST syndrome stands for…
Calcinosis, Raynaud’s phenomenon, oEsophageal dysmotility, Sclerodactyly, Telangiectasia
After an initial negative result when testing for HIV in an asymptomatic patient, offer a repeat test at…
12 weeks
AML is characterised by…?
Neutropaenia and thrombocytopaenia
Guttate psoriasis Mx?
Reassurance + topical treatment if lesions are symptomatic
- asthma
- blood eosinophilia (e.g. > 10%)
- paranasal sinusitis
- mononeuritis multiplex
- renal involvement occurs in around 20%
- pANCA positive in 60%
Eosinophilic granulomatosis with polyangiitis
What is the most common cause of traveller’s diarrhoea? (non-bloody)
E. coli
If you are waiting for a phaeochromocytoma surgery, what medical management do you give first?
Phenoxybenzamine
What’s the RRR equation?
(Treatment rate - Control rate) / Control rate
Pain at rest in leg for greater than 2 weeks, often at night, not helped by analgesia
Critical limb ischaemia
Premenstrual syndrome Mx?
Drospirenone-containing COC taken continuously
RBC transfusion threshold for patients with ACS is what
80
Which meds can cause SJS?
* Carbamezapine
* Lamotrigine
* Allopurinol
* Sulfonamide
* Phenobarbital
* Phenytoin
* Salicylates
* Sertraline
* Imidazole antifungal agents
* Nevirapine
What should we give a lady with a fibroids who is waiting for surgery?
GnRH agonist e.g. Goserelin
If UTI + catheter, no symptoms, what Mx?
NOTHING; DON’T DO ANYTHING.
Which cranial nerves are affected in vestibular schwannomas?
V, VII, VIII
PID + RUQ pain =
Fitz-Hugh-Curtis Syndrome
Type I SH fracture
Fracture through physis (x-r may be normal)
Transverse
Type II SH Fracture
Physis and metaphysis
—/
Type III SH Fracture
Physis, epiphysis, include joint
|—
Type IV SH Fracture
Physis, metaphysis, epiphysis
|
Initial Mx for Graves’ disease?
Propanolol
Rovsings sign in…
Appendicitis
Boas sign in…
Cholecystitis
Murphy’s sign in…
Cholecystitis
Cullens sign in…
Pancreatitis
Grey-Turners sign in…
Pancreatitis
Cardiac tamponade triad
Elevated JVP, hypotension, muffled heart sounds
CT within an hour indications?
- GCS <13 now
- <15 after
- Vomiting > 1
- Skull fracture
- Seizures
CT within 8 hours
- > = 65
- Anticoagulants
- Dangerous mechanism of injury
Tell me pneumothorax guidelines
–
What do you not give in a variceal bleed?
PPIs
In patients with nephrotic syndrome, you give prednisolone and furosemide. What next?
Prophylactic LMWH e.g. enoxaparin due to inc. risk of VTE
What are the contraindications for suxamethonium?
- Penetrating eye injuries
- Acute glaucoma
Because it inc. IOP
