Passmed General Medical Mushkies Flashcards
1
Q
How can you classify the causes of pleural effusion?
A
Transudate (<30g/L protein) and exudate (>30g/L protein)
2
Q
What are the transudative causes of pleural effusion?
A
- Heart failure (most common transudate cause)
- Hypoalbuminaemia (liver disease, nephrotic syndrome, malabsorption)
- Hypothyroidism
- Meigs’ syndrome
3
Q
What are the exudative causes of pleural effusion?
A
- Infection: pneumonia (most common exudate cause), TB, subphrenic abscess
- Connective tissue disease: RA, SLE
- Neoplasia: lung cancer, mesothelioma, metastases
- Pancreatitis
- Pulmonary embolism
- Dressler’s syndrome
- Yellow nail syndrome
4
Q
What disease are bite and blister cells a feature of?
A
G6PDD
5
Q
What drugs cause haemolysis in G6PDD?
A
Antimalarials e.g. primaquine
Ciprofloxacin
Sulph groups (sulphonamides, sulfonylureas, sulphasalazine)
6
Q
What investigation do you do for phaeochromocytomas?
A
24hr urinary collection of catecholamines
7
Q
What are 3 syndromes that phaeochromocytomas are associated with?
A
- MEN II
- NF
- vHL
8
Q
What is the definitive management of phaeochromocytomas, and how does one prepare pts for it?
A
- Surgery is definitive treatment
2. Give alpha blocker (e.g. phenoxybenzamine) before giving a beta blocker (e.g. propranolol)
9
Q
How do you treat ascites secondary to liver cirrhosis?
A
Spironolactone, with furosemide only being used as an adjuvant if needed
10
Q
What is TIPS and what can it be used to treat?
A
Transjugular intrahepatic portosystemic shunt
Used to treat portal HTN, life threatening oesophageal varices, and ascites
11
Q
What are some features of granulomatosis with polyangiitis (GPA, a.k.a Wegener’s Granulomatosis)
A
- Upper respiratory tract (epistaxis, sinusitis, nasal crusting)
- Lower respiratory tract (dyspnoea, haemoptysis)
- Glomerulonephritis = rapidly progressive, pauci-immune
- Saddle shaped nose deformity
12
Q
What Ab is the marker for GPA?
A
cANCA
13
Q
What is the management for GPA?
A
Steroids
Cyclophosphamide
Plasma exchange
14
Q
What is achalasia?
A
Failure of oesophageal peristalsis and of relaxation of lower oesophageal sphincter (LOS) due to degenerative loss of ganglia from Auerbach’s plexus
15
Q
What are the investigations for achalasia?
A
- Manometry
- Barium swallow = birds beak
- CXR = wide mediastinum, fluid level
16
Q
What are the treatment options for achalasia?
A
- Intra-sphincteric injection of botulinum toxin
- Heller cardiomyotomy
- Balloon dilatation
- Drugs have limited effect
17
Q
What is HBPM?
A
Home blood pressure monitoring
18
Q
What is the PEP for Hep A?
A
HNIG (human normal immunoglobulin) or Hep A vaccine
19
Q
What is the PEP for Hep B?
A
- HBsAg positive source: if the person exposed is a known responder to HBV vaccine then a booster dose should be given. If they are in the process of being vaccinated or are a non-responder they need to have hepatitis B immune globulin (HBIG) and the vaccine
- Unknown source: for known responders the green book advises considering a booster dose of HBV vaccine. For known non-responders HBIG + vaccine should be given whilst those in the process of being vaccinated should have an accelerated course of HBV vaccine
20
Q
What is the PEP for Hep C?
A
Monthly PCR - if seroconversion then interferon +/- ribavirin
21
Q
What is PEP for HIV?
A
- A combination of oral antiretrovirals (e.g. Tenofovir, emtricitabine, lopinavir and ritonavir) as soon as possible (i.e. Within 1-2 hours, but may be started up to 72 hours following exposure) for 4 weeks
- serological testing at 12 weeks following completion of post-exposure prophylaxis
- reduces risk of transmission by 80%
22
Q
What is the transmission rate after a needlestick injury for HIV?
A
0.3%
23
Q
What is the transmission rate after a needlestick injury for Hep B?
A
20-30%
24
Q
What is the transmission rate after a needlestick injury for Hep C?
A
0.5-2%
25
What medication can worsen gout?
Thiazides
26
What is the STOPP-START Criteria (Gallagher et al., 2008)?
Outlines medications that we should consider withdrawing in the elderly
27
What is the BP target for pts <80y/o?
<140/90
28
What is the BP target for pts >80y/o?
<150/90
29
if a patient has progressive dysphagia what should you be thinking of?
Oesophageal carcinoma
30
What nerve can an oesophageal carcinoma damage?
Laryngeal nerve, leading to hoarsening of voice
31
How do pts with achalasia present?
Trouble with swallowing both solids and liquids equally
32
What do patients with oesophageal spasm typically present with?
Pain when swallowing
33
How does bulbar palsy present?
Symptoms of weakness, such as drooling, weak and wasted tongue, dysphonia and problems articulating.
34
Where are the majority of oesophageal carcinomas?
The middle third of the oesophagus
35
What is the most standard surgical procedure for management of oesophageal carcinoma?
Ivor- Lewis type oesophagectomy
36
What causes internuclear ophthalmoplegia?
A lesion of the medial longitudinal fasciculus (MLF), a tract that allows conjugate eye movement and connects the connects the IIIrd, IVth and VIth cranial nuclei
37
What are the signs of internuclear ophthalmoplegia?
Impairment of adduction of the ipsilateral eye. The contralateral eye abducts, however with nystagmus.
38
What are 2 causes of internuclear ophthalmoplegia?
MS and vascular disease
39
What would cause a metabolic ketoacidosis with a low or normal blood glucose?
Alcohol
40
What are the 3 stages of presentation of Churg-Strauss (eGPA)?
1. Allergy with many patients having a history of asthma or allergic rhinitis. This inflammation of the nasal passages can lead to the development of nasal polyps.
2. The second phase is eosinophilia
3. Vasculitis itself which affects small and medium-sized blood vessels and therefore resulting in damage to many organs
41
What are the 4Hs of the reversible causes of cardiac arrest?
1. Hypoxia
2. Hypovolaemia
3. Hyperkalaemia, hypokalaemia, hypoglycaemia, hypocalcaemia, acidaemia and other metabolic disorders
4. Hypothermia
42
What are the 4Ts of the reversible causes of cardiac arrest?
1. Thrombosis (coronary or pulmonary)
2. Tension pneumothorax
3. Tamponade – cardiac
4. Toxins
43
What is the treatment for Bell's palsy?
1. Prednisolone 1mg/kg for 10 days w/in 72hrs
| 2. Lubricating eye drops
44
What is the definition for Bell's palsy?
An acute, unilateral, idiopathic, facial nerve paralysis
45
Who is Bell's palsy more common in?
Pregnant women
46
How can you classify the causes of SIADH?
MINDO
Malignancy = SCLC, pancreas, prostate
Infection = TB, pneumonia
Neurological = stroke, subarachnoid haemorrhage, subdural haemorrhage, meningitis/encephalitis/abscess
Drugs = sulfonylureas, SSRIs, TCAs, carbamazepine
Other = PEEP, porphyria
47
What type of tumour accounts for 5% of intracranial tumours and 90% of cerebellopontine angle tumours?
Vestibular schwannomas (acoustic neuromas)
48
In what condition do you see bilateral vestibular schwannomas?
NF2
49
What is the investigation of choice for acoustic neuromas?
MRI cerebellopontine angle
50
What is the anatomical basis for how vestibular schwannomas present?
CN 5, 7, 8
1. cranial nerve VIII: vertigo, unilateral sensorineural hearing loss, unilateral tinnitus
2. cranial nerve V: absent corneal reflex
3. cranial nerve VII: facial palsy
51
What is the management for vestibular schwannomas?
Surgery
Radiotherapy
Observation
52
What could be the cause for unexplained petechiae and hepatosplenomegaly?
Leukaemia, and thus needs immediate assessment
53
What is a granuloma?
A collection of epithelialioid histiocytes
54
What is the 1st line test for pts with with suspected chronic HF?
NT-proBNP -->
1. If levels are 'high' (>2000) arrange specialist assessment (including transthoracic echocardiography) within 2 weeks
2. If levels are 'raised' (400-2000) arrange specialist assessment (including transthoracic echocardiography) echocardiogram within 6 weeks
55
What are some factors that can raise BNP levels?
1. Cardiac = LVH, RVH, ischaemia, hypertrophy
2. Resp = COPD
3. Renal = CKD
4. Hepatic = CLD
5. DM, old age, sepsis
56
What are some factors that can lower BNP levels?
1. Anti-hypertensives = ACEi, ARBs, BBs, Aldosterone antagonists, diuretics (i.e. all of them)
2. Obesity
57
What are 3 adverse effects of statins?
1. Myopathy (myalgia, myositis, rhabdomyolysis and asymptomatic raised creatine kinase)
2. Liver impairment
3. Intraceberal haemorrhage in pts who have previously had a stroke
58
How should pts be monitored whilst on statins?
Checking LFTs at baseline, 3 months and 12 months. Treatment should be discontinued if serum transaminase concentrations rise to and persist at 3 times the upper limit of the reference range
59
Which statins are more likely to cause myopathy?
Lipophilic statins such as simvastatin and atorvastatin
60
What are 2 contraindications to taking statins?
1. Pregnancy
| 2. Macrolides (statins should be stopped until course is finished)
61
What are the indications for starting a statin?
1. All people with established cardiovascular disease (stroke, TIA, ischaemic heart disease, peripheral arterial disease)
2. Anyone with a 10-year cardiovascular risk >= 10%
3. Patients with type 2 diabetes mellitus should now be assessed using QRISK2 like other patients are, to determine whether they should be started on statins
4. Patients with type 1 diabetes mellitus who were diagnosed more than 10 years ago OR are aged over 40 OR have established nephropathy
62
When should statins be taken?
Statins should be taken at night as this is when the majority of cholesterol synthesis takes place. This is especially true for simvastatin which has a shorter half-life than other statins.
63
What are the statin doses for the prevention of cardiovascular disease?
Atorvastatin 20mg OD for primary prevention
| Atorvastatin 80mg OD for secondary prevention
64
What are 5 sinister features of a headache which require further imaging (CT)?
1. Vomiting more than once with no other cause.
2. New neurological deficit (motor or sensory).
3. Reduction in GCS
4. Valsalva (associated with coughing or sneezing) or positional headaches.
5. Progressive headache with a fever.
65
What can a pt with parkinsons who is NBM be given?
Dopamine agonist patch as rescue medication to prevent acute dystonia
66
What can be given to manage drooling in patients with parkinsons disease:
Glycopyrronium bromide
67
What are 6 parkinsons medications?
1. L-DOPA
2. Dopamine receptor agonists
3. MAO-B inhibitors
4. Amantadine
5. COMT inhibitors
6. Anti-muscarinics
68
What is L-DOPA usually combined with?
A decarboxylase inhibitor (e.g. carbidopa or benserazide) to prevent peripheral metabolism of levodopa to dopamine
69
What is an example of a MAO-B inhibitor and how does it work?
1. Selegine
| 2. Inhibits the breakdown of dopamine secreted by the dopaminergic neurons
70
What is the MOA of amantadine?
Mechanism is not fully understood, probably increases dopamine release and inhibits its uptake at dopaminergic synapses
71
What is an example of a COMT inhibitor and how does it work?
1. Entacapone, tolcapone
| 2. COMT is an enzyme involved in the breakdown of dopamine, and hence may be used as an adjunct to levodopa therapy
72
How can anti-muscarinics help in Parkinsons disease? What is an example?
1. Help tremor and rigidity, and are used more to treat drug-induced parkinsonism
2. E.g. procyclidine
73
What are some indications for haemodialysis?
1. Pulmonary oedema
2. Refractory hyperkalaemia
3. Metabolic acidosis
4. Uraemia
74
How does one officially diagnose AKI?
1. A rise in serum creatinine of 26 micromol/litre or greater within 48 hours
2. A 50% or greater rise in serum creatinine known or presumed to have occurred within the past 7 days
3. A fall in urine output to less than 0.5 ml/kg/hour for more than 6 hours in adults and more than
75
What are 5 drugs that should be stopped during AKI as it may worsen renal function?
1. ACEi
2. ARBs
3. Diuretics
4. NSAIDs
5. Aminoglycosides
76
What is the loss of the left heard border a classic sign of?
Left lingula consolidation
77
What are 6 causes of white shadowing on CXRs?
1. Consolidation
2. Pleural effusion
3. Collapse
4. Pneumonectomy
5. Specific lesions e.g. tumours
6. Fluid e.g. pulmonary oedema
78
Trachea pulled towards white-out?
1. Pneumonectomy
2. Complete lung collapse e.g. endobronchial intubation
3. Pulmonary hypoplasia
79
Trachea central with white-out?
1. Consolidation
2. Pulmonary oedema (usually bilateral)
3. Mesothelioma
80
Trachea pulled away from white-out?
1. Pleural effusion
2. Diaphragmatic hernia
3. Large thoracic mass
81
4 features of acute moderate asthma?
1. PEFR 50-75% best or predicted
2. Speech normal
3. RR < 25 / min
4. Pulse < 110 bpm
82
4 features of acute severe asthma?
1. PEFR 33 - 50% best or predicted
2. Can't complete sentences
3. RR > 25/min
4. Pulse > 110 bpm
83
5 features of acute life threatening asthma?
1. PEFR < 33% best or predicted
2. Oxygen sats < 92%
3. Silent chest, cyanosis or feeble respiratory effort
4. Bradycardia, dysrhythmia or hypotension
5. Exhaustion, confusion or coma
84
Pt presents with acute asthma attack that is managed with salbutamol nebs, what should you discharge her on?
1. Prednisolone 40mg OD 5d (w/ stat dose now)
| 2. Beclametasone inhaler 200mcg BD
85
What causes hypopigmentation and loss of sensation?
Leprosy
86
What is leprosy?
A granulomatous disease primarily affecting the peripheral nerves and skin, caused by Mycobacterium leprae
87
What determines the type of leprosy a patient will develop?
The degree of cell mediated immunity
88
If a patient has a low degree of cell mediated immunity, what kind of leprosy will they develop?
Lepromatous leprosy ('multibacillary'), characterised by extensive skin involvement and symmetrical nerve involvement
89
If a patient has a high degree of cell mediated immunity, what kind of leprosy will they develop?
Tuberculoid leprosy ('paucibacillary'), characterised by limited skin disease and asymmetric nerve involvement
90
What is the management for leprosy?
WHO-recommended triple therapy: rifampicin, dapsone and clofazimine
91
What is a CLO test?
Campylobacter-like organism test a.k.a. rapid urease test, is a rapid diagnostic test for Helicobacter pylori
92
What test is indicated for H.pylori detection post eradication therapy?
Urea breath test
93
What investigation still yields a positive result after H.pylori eradication therapy?
H. pylori serology
94
What 6 tests can be performed for H.pylori?
1. Urea breath test
2. Rapid urease test (CLO test)
3. Serum antibody test
4. Gastric biopsy
5. Culture of gastric biopsy
6. Stool antigen test
95
When can you not perform a urea breath test for H.pylori?
Within 4 wks of treatment with an antibiotic or within 2 weeks of an antisecretory drug (PPI)
96
What are 4 contraindications to lung cancer surgery?
1. SVC obstruction
2. FEV < 1.5
3. Malignant pleural effusion
4. Vocal cord paralysis
97
What is Wellen's syndrome?
Deep arrowhead T wave inversion (biphasic T waves) in the anterior leads (esp V2 and V3) = precursor to a ruptured lesion in the LAD
98
What may cause shortening of the QTc interval?
Hypercalcaemia
99
What 3 presentations are included as part of ACS?
STEMI
NSTEMI
Unstable angina
100
What are 3 non-modifiable risk factors for MI?
Age
Male
FHx
101
What are 5 modifiable risk factors for MI?
```
Smoking
DM
HTN
Hypercholesterolaemia
Obesity
```
102
What artery supplies the anterior leads (V1-V4)?
LAD
103
What artery supplies the inferior leads (II, III, aVF)
RCA
104
What artery supplies the lateral leads (I, V5, V6)
LCX
105
What medications should you give a pt during a ACS?
Morphine
Metoclopramide
Aspirin
Clopidogrel
106
What are the 5 post-STEMI prescriptions? (secondary prevention)
1. Atorvastatin 80mg
2. Aspirin 75mg
3. Clopidogrel 75mg
4. ACEi (less risk of HF) e.g. ramipril
5. BB (less risk of ventricular arrhythmia and HF) e.g. bisoprolol
107
What are the 2 main causes of ACS?
1. Plaque rupture = 95%
| 2. Embolism = 5%
108
When should you give oxygen during an ACS?
If Sats <94%
109
What scoring system can be used to risk stratify pts during an NSTEMI?
GRACE score
110
What are 2 drugs than cause a nephrogenic diabetes insipidus?
Lithium and demeclocycline
111
What are the causes of cranial Diabetes Insipidus?
1. Idiopathic
2. Post head injury
3. Pituitary surgery
4. Craniopharyngioma
5. Histiocytosis
6. DIDMOAD
7. Haemochromatosis
112
What is DIDMOAD?
The association of cranial DI, DM, Optic Atrophy and Deafness (a.k.a. Wolfram's syndrome)
113
What are the causes of nephrogenic Diabetes Insipidus?
1. Genetic = AQP2 mutation
2. E- = hypercalcaemia, hypokalaemia
3. Drugs = lithium, demeclocycline
4. Tubulo-interstitial disease = obstruction, sickle cell, pyelonephritis
114
How can you treat cranial DI?
Desmopressin
115
How can you treat nephrogenic DI?
Thiazides, low salt/protein diet
116
What is the U&E picture for a pt with rhabdomyolysis?
1. AKI with disproportionately raised creatinine
2. Raised CK
3. Hypocalcaemia (myoglobin binds calcium)
4. High phosphate (released from myocytes)
5. Hyperkalaemia
6. Metabolic acidosis
117
What is the management for rhabdomyolysis?
1. IV fluids to maintain good urine output
| 2. Urinary alkalinisation is sometime used
118
What should pts with frequent exacerbations of COPD be given at home?
A home supply of prednisolone and an antibiotic (ask pt to contact you if they are required to use them)
119
What are the general management strategies for COPD?
1. Smoking cessation advice: including offering nicotine replacement therapy, varenicline or bupropion
2. Annual influenza vaccination
3. One-off pneumococcal vaccination
4. Pulmonary rehabilitation to all people who view themselves as functionally disabled by COPD (MRC grade 3 and above)
120
What is the first line treatment for COPD?
1. SABA or SAMA
2. for patients who remain breathless or have exacerbations despite using short-acting bronchodilators the next step is determined by whether the patient has 'asthmatic features/features suggesting steroid responsiveness'
121
What are the NICE criteria to determine whether a patient has asthmatic/steroid responsive features in COPD?
1. Previous asthma/atopy
2. High eosinophil count
3. FEV1 variation over time
4. Diurnal peak flow variation (at least 20%)
122
If pt doesnt have asthmatic features/features suggesting steroid responsiveness, what is 2nd line treatment for COPD?
Add LABA + LAMA
123
If pt has sthmatic features/features suggesting steroid responsiveness, what is the 2nd line treatment for COPD?
1. LABA + inhaled corticosteroid (ICS)
| 2. if patients remain breathless or have exacerbations offer triple therapy i.e. LAMA + LABA + ICS
124
What are 3 factors which may improve survival in pts with stable COPD?
1. Smoking cessation
2. LTOT if fit criteria
3. Lung volume reduction surgery in selected patients
125
What is required to diagnose tumour lysis syndrome?
A positive laboratory TLS and a positive clinical TLS (The Cairo-Bishop scoring system)
126
What are the criteria for a positive laboratory TLS?
2 or more of the below within 7 days of chemotherapy or 3 days before:
1. uric acid > 475umol/l or 25% increase
2. potassium > 6 mmol/l or 25% increase
3. phosphate > 1.125mmol/l or 25% increase
4. calcium < 1.75mmol/l or 25% decrease
127
What are the criteria for a positive clinical TLS?
1. Increased creatinine (1.5x upper limit of normal)
2. Cardiac arrhythmia/SCD
3. Seizure
128
What should pts at high risk of TLS be given?
IV allopurinol or IV rasburicase
129
What is the stereotypical history for mycoplasmia pneumonia?
Worsening flu-like symptoms and a dry cough, with erythema multiforme on examination
130
What kind of haemolytic anaemia do you get with a mycoplasma pneumonia?
Cold AIHA
131
How is mycoplasma pneumonia diagnosed?
Serology
132
How is legionella pneumonia diagnosed?
Urinary antigens
133
What neuro conditions can you get due to mycoplasma?
Encephalitis and GBS
134
What heart conditions can you get due to mycoplasma?
Pericarditis/myocarditis
135
What is the gold standard investigation for diagnosis of degenerative cervical myelopathy?
MRI cervical spine
136
What are some symptoms of degenerative cervical myelopathy?
1. Pain (neck, upper/lower limbs)
2. Loss of motor function
3. Loss of sensation
4. Loss of autonomic function (faecal/urinary incompetence and impotence)
5. Hoffman's sign
137
What is Hoffman's sign?
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.
138
What may an MRI C-spine show in degenerative cervical myelopathy?
Disc degeneration and ligament hypertrophy, with accompanying cord signal change
139
What is the only effective treatment for degenerative cervical myelopathy?
Decompressive surgery
140
What are the 3 components of hyperkalaemia management?
1. Stabilisation of the cardiac membrane
2. Short-term shift in potassium from extracellular to intracellular fluid compartment
3. Removal of potassium from the body
141
What drug is given for stabilisation of the cardiac membrane?
IV calcium gluconate
142
What is given for short-term shift in potassium from extracellular to intracellular fluid compartment?
1. Combined insulin/dextrose infusion
| 2. Nebulised salbutamol
143
What is given for removal of potassium from the body?
1. Calcium resonium
2. Loop diuretics
3. Dialysis
144
Why are calcium resonium enemas more effective than oral potassium?
As potassium is secreted by the rectum
145
What is the most likely cause of right sided tenderness on a PR exam?
Appendicitis
146
What may you see on FBC with appendicitis?
A neutrophil-predominant leucocytosis
147
What is a dermatological complication of warfarin?
Skin necrosis. 3F:1M, typically occurs within 10 days of warfarin administration
148
How does skin necrosis with warfarin present?
A large red patch progressing to purpura/ecchymosis with an INR still in the therapeutic range
149
What is the MOA of warfarin?
Vitamin K epoxide reductase inhibitor, prevents the reduction of Vitamin K to its active hydroquinone form, which in turn acts as a cofator in the carboxylation of clotting factor 2,7,9,10 and Protein C
150
What are 3 indications for warfarin?
1. VTE
2. AF
3. Mechanical heart valves
151
What is the target INR when giving warfarin for VTE?
2.5, if recurrent 3.5
152
What is the target INR when giving warfarin for AF?
2.5
153
What is the target INR when giving warfarin for mechanical heart valves?
Depends on type of valve and location, mitral valves generally require a higher INR than aortic valves
154
What are 4 side effects of warfarin?
1. Haemorrhage
2. Teratogenic
3. Skin necrosis
4. Purple toes
155
What are some factors that may potentiate warfarin?
1. Liver disease
2. P450 enzyme inhibitors e.g. amiodarone, ciprofloxacin
3. Cranberry juice
4. Drugs that displace warfarin from plasma albumin e.g. NSAIDs
5. Inhibit plt function e.g. NSAIDs
156
What kind of virus is parvovirus B19?
DNA virus
157
What is the MOA of sulfnylureas?
Bind to an ATP-dependent K+(KATP) channel on the cell membrane of pancreatic beta cell. They increase pancreatic insulin secretion and hence are only effective if functional B-cells are present
158
What are 3 side effects of sulfonylureas?
Hypoglycaemic episodes
Weight gain
Peripheral neuropathy
159
What causes Wilson's disease?
A defect in the ATP7B gene located on chromosome 13, leading to increased copper absorption from the small intestine and decreased hepatic copper excretion.
160
When does Wilson's disease present?
10-25 years old
161
How does Wilson's typically present?
```
Liver = hepatitis/cirrhosis
Neurological = basal ganglia degeneration, speech, behavioural and psychiatric problems
```
162
How is Wilson's diagnosed?
1. Reduced serum caerulopasmin
2. Reduced serum copper (as 95% of plasma copper is carried by caeruloplasmin)
3. Increased 24hr urinary copper excretion
163
How is Wilson's diagnosed?
1. Penicillamine (chelates copper)
| 2. Trientine hydrochloride (another chelating agent for the future)
164
What can precipitate renal failure in pts with multiple myeloma and should therefore be avoided?
NSAIDS
165
What are the X-ray findings of the skull in multiple myeloma?
'Rain-drop' skull
166
What causes hypercalcaemia in myeloma?
Increased osteoclastic bone resorption causes by local cytokines (IL1, TNF) released by myeloma cells
167
Where do cancers below the pectinate line spread to?
The superficial inguinal nodes
168
Where do cancers above the pectinate line spread to?
Internal iliac lymph nodes
169
What do the pararectal lymph nodes drain?
Upper part of the rectum and parts of the colon
170
What lymph nodes do the testes and the ovaries drain to?
Para-aortic lymph nodes
171
What drains into the superficial inguinal lymph nodes?
1. Anal canal below pectinate line
2. Perineum
3. Skin of the thigh
4. Penis
5. Scrotum
6. Vagin
172
What drains into the deep inguinanl lymph nodes?
Glans penis
173
What drains into the para-aortic lymph nodes?
1. Testes, ovaries
2. Kidneys
3. Adrenal gland
174
What drains into the axillary lymph nodes?
1. Lateral breast
| 2. Upper limb
175
What drains into the internal iliac lymph nodes?
1. Anal canal above the pectinate line
2. Lower part of the rectum
3. Pelvic structures, including cervix and inferior part of uterus
176
What drains into the superior mesenteric lymph nodes?
The duodenum and jejenum
177
What drains into the inferior mesenteric lymph nodes?
The descending colon, sigmoid colon and upper part of the rectum
178
What drains into the coeliac lymph nodes?
Stomach
179
When do you refer pts for a 2wk lung cancer appointment?
1. CXR with findings that suggest lung cancer
| 2. >40y/o with unexplained haemoptysis
180
What is the first line treatment for treating agitation and confusion in a palliative setting?
Oral Haloperidol
181
What is the best treatment for treating agitation and confusion in the terminal phase of an illness?
Subcutaneous midazolam
182
What is the finding on ABG for an Addisonian crisis?
A hyponatraemic, hyperkalaemic metabolic acidosis
183
Why can an Addisonian crisis occur during and after pregnancy?
Due to immune-regulatory changes
184
What are 3 situations where an Addisonian crisis is common?
1. Sepsis/surgery causing an acute exacerbation of chronic insufficiency (Addison's, Hypopituitarism)
2. Adrenal haemorrhage (Waterhouse-Friderichsen syndrome due to fulminant meningococcaemia)
3. Steroid withdrawal
185
What is the management of an Addisonian crisis?
1. Hydrocortisone 100mg IM/IV (continue 6hrly until pt stable)
2. 1L 0.9% saline infused over 30-60mins/with dextrose if hypoglycaemic
186
What is a pharyngeal pouch?
A posteromedial herniation between thyropharyngeus and cricopharyngeus muscles
187
How can you classify the causes of dysphagia?
1. Extramural
2. Mural
3. Intramural
4. Neurological
188
What are the extramural causes of dysphagia?
1. Mediastinal masses
| 2. Cervical spondylosis
189
What are the mural causes of dysphagia?
1. Achalasia
2. Oesophageal spasm
3. Hypertensive lower oesophageal sphincter
190
What are the intramural causes of dysphagia?
1. Tumours
2. Strictures
3. Infection (candidiasis)
3. Oesophageal web
4. Schatzki rings
191
What are some neurological causes of dysphagia?
1. CVA
2. Parkinsons
3. MS
4. Brainstem pathology
5. Myasthenia gravis
192
Why might an SGLT2 inhibitor cause worsening of thrush?
Prevents the reabsorption of glucose from the proximal renal tubule, resulting in more glucose being secreted in the urine
193
What is an example of an SGLT2 inhibitor?
Empagliflozin
194
What are 3 important adverse effects of SGLT2 inhibitors?
1. Urinary and genital infection
2. Normoglycaemic ketoacodisis
3. Risk of lower limb amputation
195
How does rhabdomyolysis cause AKI?
Myoglobin causes tubular cell necrosis
196
What is the most common cause of secondary hyperparathyroidism?
CKD
197
What is an obese, young female with headaches/blurred vision (and papilloedema) most likely to have?
Idiopathic intracranial hypertension
198
What is the management of idiopathic intracranial hypertension?
1. Weight loss
2. Diuretics e.g. acetozolamide
3. Repeated LP
4. Surgery = optic nerve sheath decompression and fenestration to prevent damage to the optic nerve
5. Surgery = VP/lumboperitoneal shunt
199
What are the differentials for hypertension with low potassium?
1. Conn's
2. Cushing's
3. RAS
4. Liddle's
200
How do you differentiate between the causes of hypertension with low potassium?
Check renin and aldosterone levels
1. High A + Low R = Cushings and Conns
2. High A + High R = RAS
3. Low A + Low R = Liddle's
201
What is Liddle's syndrome?
Rare hereditary disorder due to increased activity of ENaC, causing hypernatraemia, hypokalaemia and hypertension (and thus also a metabolic alkalosis)
202
What organism causes Lyme disease?
Borrelia Burgdorferi
203
What are the features of Lyme disease?
1. Systemic = fever, arthralgia
2. Cardiovascular = heart block, myositis
3. Neuro = facial nerve palsy, meningitis
4. Derm = erythema chronicum migrans
204
What is the first line test for diagnosis of Lyme disease?
ELISA for Borrelia Burgdorferi
205
What is the management for Lyme disease?
1. Doxycycline if early disease
2. Amoxicllin if doxy c/i (e.g. pregnancy)
3. Ceftriaxone if disseminated disease
206
What is the Jarisch-Herxeimher reaction?
A reaction to endotoxin-like products (e.g. lipoproteins) being released by the death of microorganisms during antibiotic treatment.
207
What infections when treated most commonly lead to a Jarisch-Herxeimher reaction?
1. Syphilis
2. Spirochetes = Lyme, Leptospirosis
3. Tropical = Q fever, bartonella, trypanosomiasis
208
What is the CHA2DS2-VASc scoring system used for?
Used to determine the need to anticoagulate a patient in atrial fibrillation
209
ABCD2 score?
Prognostic score for risk stratifying patients who've had a suspected TIA
210
NYHA score?
Heart failure severity scale
211
DAS28 score?
Measure of disease activity in rheumatoid arthritis
212
Child-Pugh classification?
A scoring system used to assess the severity of liver cirrhosis
213
Wells score?
Helps estimate the risk of a patient having a deep vein thrombosis
214
MMSE?
Mini-mental state examination - used to assess cognitive impairment
215
HAD scale?
Hospital Anxiety and Depression (HAD) scale - assesses severity of anxiety and depression symptoms
216
PHQ-9?
Patient Health Questionnaire - assesses severity of depression symptoms
217
GAD-7?
Used as a screening tool and severity measure for generalised anxiety disorder
218
SCOFF?
Questionnaire used to detect eating disorders and aid treatment
219
What are 3 alcohol screening tools?
AUDIT, CAGE and FAST
220
CURB-65?
Used to assess the prognosis of a patient with pneumonia
221
Epworth Sleepiness Scale?
Used in the assessment of suspected obstructive sleep apnoea
222
IPSS?
International prostate symptom score
223
Gleason score?
Indicates prognosis in prostate cancer
224
Waterlow score?
Assesses the risk of a patient developing a pressure sore
225
FRAX?
Risk assessment tool developed by WHO which calculates a patients 10-year risk of developing an osteoporosis related fracture
226
Ranson criteria?
Acute pancreatitis
227
MUST
Malnutrition
228
What are the two categories for results of a Wells score?
1. DVT likely = 2 points or more
| 2. DVT unlikely = 1 point or less
229
What investigations are indicated if Wells score shows DVT likely?
1. A proximal leg vein ultrasound scan should be carried out within 4 hours and, if the result is negative, a D-dimer test
2. If a proximal leg vein ultrasound scan cannot be carried out within 4 hours a D-dimer test should be performed and low-molecular weight heparin administered whilst waiting for the proximal leg vein ultrasound scan (which should be performed within 24 hours)
230
What investigations are indicated if Wells score shows DVT unlikely?
1. Perform a D-dimer test and if it is positive arrange:
2. A proximal leg vein ultrasound scan within 4 hours
3. If a proximal leg vein ultrasound scan cannot be carried out within 4 hours low-molecular weight heparin should be administered whilst waiting for the proximal leg vein ultrasound scan (which should be performed within 24 hours)
231
What is the management of a DVT?
1. Low molecular weight heparin (LMWH) or fondaparinux should be given initially after a DVT is diagnosed.
2. Warfarin should be given within 24 hours of the diagnosis
3. LMWH or fondaparinux should be continued for at least 5 days or until the international normalised ratio (INR) is 2.0 or above for at least 24 hours, whichever is longer
4. Warfarin should be continued for at least 3 months. At 3 months, NICE advise that clinicians should 'assess the risks and benefits of extending treatment'
5. NICE add 'consider extending warfarin beyond 3 months (usually 6 months) for patients with unprovoked proximal DVT if their risk of VTE recurrence is high and there is no additional risk of major bleeding'
232
How can you classify the different types of stroke?
The Oxford Stroke classification (a.k.a. Bamford stroke classification). It classifies strokes based on the initial symptoms
233
Which criteria should be assessed as part of the Bamford stroke classification?
1. Unilateral hemiparesis and/or hemisensory loss of the face, arm and leg
2. Homonymous hemianopia
3. High cognitive dysfunction e.g. dysphasia
234
What are the 4 possible classifications of stroke as per the Bamford stroke classification system?
1. TACS = total anterior circulation stroke (15%)
2. PACS = partial anterior circulation stroke (25%)
3. LACS = lacunar stroke (25%)
4. POCS = posterior circulation stroke (25%)
235
What causes a TACS and which bamford criteria are present?
1. Involves middle and anterior cerebral arteries
| 2. All 3 criteria present
236
What causes a PACS and which bamford criteria are present?
1. Involves smaller arteries or anterior circulation e.g. upper or lower division of middle cerebral artery
2. 2 criteria present
237
What causes a LACS and which bamford criteria are present?
1. Involves perforating arteries around the internal capsule, thalamus and basal ganglia
2. Presents with 1 of the following
a. unilateral weakness (and/or sensory deficit) of face and arm, arm and leg or all three.
b. pure sensory stroke.
c. ataxic hemiparesis
238
What causes a POCS and which bamford criteria are present?
1. Involves vertebrobasilar arteries
2. Presents with 1 of the following
a. cerebellar or brainstem syndromes
b. loss of consciousness
c. isolated homonymous hemianopia
239
What causes lateral medullary syndrome and what is it also known as?
Blockage of posterior inferior cerebellar artery, and a.k.a. Wallenberg's syndrome
240
What are the features of lateral medullary syndrome?
1. Ipsilateral: ataxia, nystagmus, dysphagia, facial numbness, cranial nerve palsy e.g. Horner's
2. Contralateral limb sensory loss
241
What is Weber's syndrome?
A midbrain stroke syndrome that involves fascicles of the oculomotor nerve resulting in an ipsilateral CN III palsy and contralateral hemiplegia or hemiparesis
242
What is titubation?
Head tremor
243
What is the most common cause of titubation?
Benign essential tremor
244
What are 3 features of benign essential tremor?
1. Postural tremor
2. Improved by alcohol and rest
3. Most common cause of titubation
245
What is the management of benign essential tremor?
1. Propranolol is 1st line
| 2. Primidone is sometimes used
246
What causes haemolytic uraemic syndrome?
E. coli 0157
247
What is the triad of HUS?
MAHA
Thrombocytopenia
AKI
248
What are the types of Hodgkin's lymphoma?
1. Classical HL
| 2. Nodular lymphocyte-predominant HL
249
What are the types of Classical HL?
1. Nodular sclerosing
2. Mixed cellularity
3. Lymphocyte-rich
4. Lymphocyte-depleted
250
What implies poor prognosis in Hodgkin's lymphoma?
B symptoms
1. Weight loss >10% in last 6m
2. Fever >38C
3. Night sweats
251
What is the best way to assess response to Hep C treatment?
Viral load
252
What kind of virus is Hep C?
RNA flavivirus
253
What is the incubation period of Hep C?
6-9 weeks
254
What is the investigation of choice to diagnose acute Hep C infection?
HCV RNA
255
What is the prognosis of Hep C?
Around 15-45% will clear the virus after an acute infection, and hence the majority (55-85%) will develop chronic Hep C§
256
What is the definition for chronic Hep C?
The persistence of HCV RNA in the blood for 6m
257
What are some complications of Hep C?
1. Rheum = arthralgia, arthritis
2. Eye = sjogrens
3. Hepatic = cirrhosis, HCC
4. Type II cryoglobulinaemia
5. PCT
6. Membranoproliferative glomerulonephritis
258
What is the aim of Hep C treatment?
A sustained virologic response (SVR) defined as undetectable serum HCV RNA 6m after the end of therapy
259
What is the treatment of Hep C?
A combination of protease inhibitors +/- ribavarin
260
What are complications of ribavarin?
1. Haemolytic anaemia
2. Cough
3. Teratogenic (women cant become pregnant within 6m)
261
What is the treatment of genital warts?
1. Multiple non-keratinised warts = topical podophyllum
| 2. Solitary, keratinised warts = cryotherapy
262
What are genital warts also called and what are they caused by?
Condylomata accuminata
| HPV 6&11
263
What is a contraindication to triptans?
A history of (or risk factors for) ischaemic heart disease or cerebrovascular disease
264
What are 4 first line treatments for neuropathic pain?
1. Amitryptiline
2. Gabapentin
3. Pregabalin
4. Duloxetine
265
What is neuropathic pain?
Pain which arises following damage or disruption of the nervous system
266
What are 4 causes of neuropathic pain?
1. Diabetic neuropathy
2. Post-herpetic neuralgia
3. Trigeminal neuralgia
4. Prolapsed intervertebral disc
267
What may be used for localised neuropathic pain?
Topical capsaicin
268
What is vitamin C also known as?
Ascorbic acid
269
What are 4 functions of Vitamin C?
1. Antioxidant
2. Cofactor for collagen synthesis
3. Facilitates iron absorption
4. Cofactor for NA synthesis
270
What are some features of Vitamin C deficiency?
1. Gingivitis, loose teeth
2. Poor wound healing
3. Bleeding from gums, haematuria, epistaxis
4. General malaise
271
What are 5HT3 antagonists used for and what are some examples?
Anti-emetics used mainly in the management of chemo-related nausea, they mainly act in the CTZ area of the medulla oblongata
E.g. ondansetron and granisetron
272
Which drugs have been shown to improve mortality in pts with chronic HF and what trials proved this?
1. ACEi (SAVE, SOLVD, CONSENSUS)
2. Spironolactone (RALES)
3. BBs (CIBIS)
4. Hydralazine w/ nitrates (VHEFT-1)
273
What other options are available for tx of chronic HF once triple therapy has failed?
CRT, digoxin, and Entresto
274
Renal transplant + infection?
CMV
275
What percentage of renal transplant pts have a significant infection w/in the first 12m of having a renal transplant?
50%
276
What is the appearance of CMV-infected cells>
'Owl's eye' appearance due to intranuclear inclusion bodies
277
What causes red man syndrome?
Rapid IV infusion of vancomycin leading to redness, pruritis and a burning sensation predominantly in the upper body. Due to vancomycin-related activation of mast cells with release of histamine
278
What is the management of red man syndrome?
Cessation of vancomycin infusion, and when symptoms have resolved, recommencement at a slower rate
279
What are some adverse effects of vancomycin?
1. Nephrotoxicity
2. Ototoxicity
3. Thrombophlebitis
4. Red man syndrome
280
What is the HbA1c target in T2DM?
1. Lifestyle = 48mmol/mol (6.5%)
2. Lifestyle + metformin = 48mmol/mol (6.5%)
3. Lifestyle + any drug which might cause hypo = 53mmol/mol (7.0%)
281
How often should HbA1c levels be checked in T2DM?
Every 3-6m until stable, then 6 monthly
