PassMed Learning Flashcards
mx painful raynaud’s phenomenon
nifedipine
also stop smoking and keep hands warm
menorrhagia first line mx if not conceiving
mirena / IUS
diagnosing CKD
Chronic kidney disease is only diagnosed in this situation if supporting tests such as urinalysis or renal ultrasound are abnormal
c diff common trigger abx
clindamycin, cephalosporins, penicillins and fluoroquinolones (floxacins)
first line angina attack prevention
beta blocker or cal channel blocker depending on what already on
primary hyperparathyroidism
raised calcium, low phosphate
PTH may be raised or (inappropriately, given the raised calcium) normal!
bone protection decisions
Start alendronate in patients >= 75 years following a fragility fracture, without waiting for a DEXA scan
Bone pain, tenderness and proximal myopathy (→ waddling gait)
low calc, low phos, high ALP , low vit D
osteomalacia
metaclopramide
high prolactin and galactorrhoea
inducers of CYP450
PCBRAS
P – Phenytoin
C – Carbamazepine
B – Barbituates
R – Rifampicin
A – Alcohol (chronic use)
S – Sulphonylureas
CYP450 inhibitors
ODEVICES
O – Omperazole
D – Disulfiram
E – Erythromycin
V – Valproate
I – Isoniazid
C – Cimetidine + Ciprofloxacin
E – Ethanol (Acutely)
S – Sulphonamides
cavitating pneumonia alc diab
Klebsiella most commonly causes a cavitating pneumonia in the upper lobes, mainly in diabetics and alcoholics
posterior vitreous detachement
Flashes of light (photopsia) - in the peripheral field of vision
Floaters, often on the temporal side of the central vision
retinal detachement
Dense shadow that starts peripherally progresses towards the central vision
A veil or curtain over the field of vision
Straight lines appear curved
Central visual loss
managing DVT
If a 2-level DVT Wells score is ≥ 2 points then arrange a proximal leg vein ultrasound scan within 4 hours
if can’t do quickly enough, cover with DOAC
if scan negative, do D dimer - rpt scan in 1 week if positive
if D dimer +ve with score <2, do scan in 4 hrs with Tx dose cover
GCS motor
Motor response
- Obeys commands
- Localises to pain
- Withdraws from pain
- Abnormal flexion to pain (decorticate posture)
- Extending to pain
- None
GCS verbal
Verbal response
- Orientated
- Confused
- Words
- Sounds
- None
GCS eyes
Eye opening
4. Spontaneous
3. To speech
2. To pain
1. None
back pain red flags
Thoracic pain
Age <20 or >55 years
Non-mechanical pain
Pain worse when supine
Night pain
Weight loss
Pain associated with systemic illness
Presence of neurological signs
Past medical history of cancer or HIV
Immunosuppression or steroid use
IV drug use
Structural deformity
back pain inv if red flag
Patients with red flags should have blood tests for FBC, ESR, Calcium, Phosphate, Alkaline phosphatase and PSA if appropriate. X-ray imaging should also be arrange
pain /sx often relieved by sitting down or leaning forward
Spinal stenosis
red-eye associated with slight watering and mild photophobia. He reports no pain or tenderness and vision is not affected
episcleritis
supplementary mx if cocaine induced ACS
IV benzodiazepine
emergency contraception levonorgestrel
must be taken within 72 hours of unprotected sexual intercourse (UPSI)*
single dose of levonorgestrel 1.5mg (a progesterone)
the dose should be doubled for those with a BMI >26 or weight over 70kg
hormonal contraception can be started immediately after using
emergency contraception ulipristal ellaone
30mg oral dose taken as soon as possible, no later than 120 hours after intercourse
use barrier contraception for 5 days post
can’t breastfeed til a week later, caution in asthma
copper IUD emergency contraception
must be inserted within 5 days of UPSI, or
if a woman presents after more than 5 days then an IUD may be fitted up to 5 days after the likely ovulation date
subacromial impingement
Subacromial impingement often presents with a painful arc of abduction
if muscle weakness and injury hx more likely rotator cuff tear
paracetamol OD when to give NAC
if blood level >100 mg/L at 4 hours or > 15 mg/L at 15 hours
or if total taken is > 150mg/kg
or if staggered overdose/unsure on details
NB Paracetamol levels prior to 4 hours post-ingestion are inaccurate and therefore should not be used to assess the need for treatment.
treat antifreeze poisoning
Fomepizole
treat salicylate or TCA overdose
IV bicarb
what to treat first if deficiency in b12/folate
In patients with both vitamin B12 and folate deficiencies, the vitamin B12 deficiency must be treated first to avoid subacute combined degeneration of spinal cord
what infective process may mimick appendicitis
Campylobacter jejuni infection may cause marked right iliac fossa pain mimicking appendicitis
TIA aspirin decision making
give aspirin 300 mg immediately, unless:
1. the patient has a bleeding disorder or is taking an anticoagulant (needs immediate admission for imaging to exclude a haemorrhage)
2. the patient is already taking low-dose aspirin regularly: continue the current dose of aspirin until reviewed by a specialist
3. Aspirin is contraindicated: discuss management urgently with the specialist team
mx of TIA from GP setting
Specialist review
if the patient has had more than 1 TIA (‘crescendo TIA’) or has a suspected cardioembolic source or severe carotid stenosis:
discuss the need for admission or observation urgently with a stroke specialist
If the patient has had a suspected TIA in the last 7 days:
arrange urgent assessment (within 24 hours) by a specialist stroke physician
if the patient has had a suspected TIA which occurred more than a week previously:
refer for specialist assessment as soon as possible within 7 days
differentiate hashimoto’s vs de quervain’s
Subacute thyroiditis can be distinguished from Hashimoto’s as a cause of hypothyroid or hyperthyroid vs graves (initial phase) by tenderness of the thyroid gland
when to excise fibroadenoma
if >3cm
mx mild flare UC
If a mild-moderate flare of ulcerative colitis does not respond to topical or oral aminosalicylates then oral corticosteroids are added
classify severity UC flare
mild: < 4 stools/day, only a small amount of blood
moderate: 4-6 stools/day, varying amounts of blood, no systemic upset
severe: >6 bloody stools per day + features of systemic upset (pyrexia, tachycardia, anaemia, raised inflammatory markers)
mx mild mod severe UC flares
mild/mod:
1. recetal mesalazine
2. oral mesalazine
3. oral steroids
severe:
1. admit, IV steroids
2. if after 72 hours there has been no improvement, consider adding intravenous ciclosporin to intravenous corticosteroids or consider surgery
manage acute flare RA already on mx
Intramuscular steroids such as methylprednisolone are used to manage the acute flares of rheumatoid arthritis
frequency cervical ca screening
Routine recall is every 3 years for patients aged 25-49 years old, and every 5 years for patients aged 50-64 years old.
mx spont pneumothorax
If a secondary pneumothorax > 2cm and/or the patient is short of breath then patient should be treated with chest drain (not aspiration) as first-line
whenn to PCI NSTEMI pt
if GRACE score > 3%
COPD abx prophylaxis
NICE guidelines recommend prescribing azithromycin for patients with COPD who have had >3 exacerbations requiring steroid therapy and at least one exacerbation requiring hospital admission in the previous year.
stroke mx
can thrombolyse within 4.5 hrs
if below 6 hrs do thrombectomy too
exclude haemmorhagic first on CT
NB For thrombectomy in acute ischaemic stroke, an extended target time of 6-24 hours may be considered if there is the potential to salvage brain tissue
diabetics who conceive need to take
Patients with diabetes (type 1 and 2) should take aspirin 75mg daily from 12 weeks gestation to reduce the risk of pre-eclampsia. They are also at higher risk of neural tube defects, therefore should take the higher dose of folic acid, 5mg daily, whilst trying to conceive until 12 weeks gestation.
acute closed angle glauc
acute closed-angle glaucoma presents with a fixed dilated pupil with conjunctival injection
ant uveitis
Anterior uveitis is characterised by symptoms of a painful red eye with photophobia. Visual loss is more variable and can include reduced visual acuity, blurred vision, or reduced peripheral fields
CONSTRICTED PUPIL
first line for rosacea
ivermectin gel
add oral doxy if bad later
avoid what drug with ssris
triptan - inc risk serotonin syndrome
post TIA drug regimes
post high dose aspirin should be on 75mg clopi + a statin long term
only do endartectomy if narrowing>50%
post partum when contraception
3 weeks post
cotard syndrome
Cotard syndrome is characterised by a person believing they are dead or non-existent
othello syndrome
Othello syndrome is a delusional belief that a patients partner is committing infidelity despite no evidence of this
de clerembault syndrome
De Clerambault syndrome (otherwise known as erotomania), is where a patient believes that a person of a higher social or professional standing is in love with them
ekbom syndrome
Ekbom syndrome is also known as delusional parasitosis and is the belief that they are infected with parasites or have ‘bugs’ under their skin.
capgras syndrome
Capgras delusion is the belief that friends or family members have been replaced by an identical looking imposter.
mx whooping cough
Whooping cough - azithromycin or clarithromycin if the onset of cough is within the previous 21 days
COPD symptoms not controlled with SABA/SAMA
NO asthmatic features:
add LABA+LAMA
ASTHMATIC FEATURES:
add LABA+ICS
in both cases if on SAMA at first switch the SAMA to a SABA
light’s criteria for pleural effusion
Light’s Criteria for exudative effusion requires one of more of the following:
Pleural fluid protein / Serum protein >0.5
Pleural fluid LDH / Serum LDH >0.6
Pleural fluid LDH > 2/3 * Serum LDH upper limit of normal
Glucose is not used in Light’s Criteria.
abx lowers seizure threshold
Ciprofloxacin lowers the seizure threshold
abx can prolong qt interval
erythromycin
abx can cause cholestasis
Flucloxacillin can cause cholestasis.
Knee locking and giving-way are common features of
meniscal lesions
other bloods for rhabdo except CK
An elderly patient with a raised CK after a long lie should also have their urine checked for myoglobins, and their blood checked for calcium and phosphate
cervical screening interpretation of results
negative HPV - continue normal interval for screening
positive HPV- examine cytology
if normal -> return to normal screening recall
if abnormal -> colposcopy
If the sample is ‘inadequate’
repeat the sample in 3 months
if two consecutive inadequate samples then → colposcopy
mx graves
Propranolol should be used in new cases of Graves’ disease to help control symptoms
as well as carbimazole
Genital wart treatment
multiple, non-keratinised warts: topical podophyllum
solitary, keratinised warts: cryotherapy
mx angina adding ccb
already taking beta blocker
ADD a longer-acting dihydropyridine calcium channel blocker (e.g. amlodipine, modified-release nifedipine)
remember that beta-blockers should not be prescribed concurrently with verapamil or diltiazemq(risk of complete heart block)
reduced foetal movements post 28 weeks inv
If after 28/40 weeks there are reduced fetal movements and no heart is detected with handheld Doppler then an immediate ultrasound should be offered
if heart rate detected then do CTG 20 mins monitoring
differentiate beta thal trait vs alpha thal trait
disproporionate microcytic anaemia with RAISED hbA2 = beta thal trait
if A2 not raised then alpha thal trait
thalassaemia blood film = Microcytic, hypochromic erythrocytes with basophilic stippling and occasional target cells
secondary dysmenorrhoea
Secondary dysmenorrhoea typically develops many years after the menarche and is the result of an underlying pathology. In contrast to primary dysmenorrhoea the pain usually starts 3-4 days before the onset of the period. Causes include:
endometriosis
adenomyosis
pelvic inflammatory disease
intrauterine devices*
fibroids
Clinical Knowledge Summaries recommend referring all patients with secondary dysmenorrhoea to gynaecology for investigation.
mx ramsay hunt syndrome
Oral aciclovir for 7 days and oral prednisolone for 5 days
IgG is
long term immunity
IgM is current active infection!
first line inv MS
MRI brain and spine with contrast
Witnessed cardiac arrest while on a monitor -
up to three successive shocks before CPR
inv stroke
Non-contrast CT head scan is the first line radiological investigation for suspected stroke
exacerbating factors psoriasis
The following factors may exacerbate psoriasis:
trauma
alcohol
drugs: beta blockers, lithium, antimalarials (chloroquine and hydroxychloroquine), NSAIDs and ACE inhibitors, infliximab
withdrawal of systemic steroids
bishop score interpret
A score above 8 indicates that spontaneous labour is likely whereas a lower score suggests that induction may be needed.
5 or less likely will need induction
methods of inducing labour
NICE guidelines
firstly membrane sweep
if the Bishop score is ≤ 6
vaginal prostaglandins or oral misoprostol
if the Bishop score is > 6
amniotomy and an intravenous oxytocin infusion
red flag child dev pre 12 months
Hand preference before 12 months is abnormal - it could be an indicator of cerebral palsy
TCA overdose symptoms incl ecg
ECG shows sinus tachycardia with a widened QRS and prolonged QT interval classically seen in TCA toxicity
.
the typical symptoms of TCA toxicity: acute onset tachycardia, sweating, and a fluctuating GCS.
bradycardia and signs of shock mx
Patients with bradycardia and signs of shock require 500micrograms of atropine (repeated up to max 3mg)
epistaxis mx
- standard first aid measures
- if can see bleeding point - silver nitrate cautery
- if can’t -anterior packing
- if all fails and can’t find bleeding point - sphenopalatine ligation in theatre
all pt need naseptin mid term post initial mx
TIA mx
TIA in the last 7 days:
arrange urgent assessment (within 24 hours) by a specialist stroke physician
suspected TIA which occurred more than a week previously:
refer for specialist assessment as soon as possible within 7 days
all get aspirin 300 unless risk of bleeding due to pmh
dx asthma
Adults with suspected asthma should have both a FeNO test and spirometry with reversibility
risk with over replacement of thyroxine
Over-replacement with thyroxine increases the risk for osteoporosis
acute limb ischaemia mx
The initial management of acute limb ischaemia includes analgesia, IV heparin and vascular review
then surg or angioplasty
when can you start hormonal contraception post levonergestrol
Hormonal contraception can be started immediately after using levonorgestrel (Levonelle) for emergency contraception
keloid scar prevention if starting
refer for intralesional triamcinolone.
AI hepatitis
combination of deranged LFTs combined with secondary amenorrhoea in a young female strongly suggest autoimmune hepatitis
NSTEMI medical mx choice
NSTEMI (managed conservatively) antiplatelet choice
aspirin, plus either:
ticagrelor, if not high bleeding risk
clopidogrel, if high bleeding risk
common reflexes
Ankle S1-S2
Knee L3-L4
Biceps C5-C6
Triceps C7-C8
GCS mnemonic
Eyes closed 1
Y pain Y 2
Ear splitting noise 3
Spontaneous 4
Voiceless 1
Obscure 2
Inappropriate 3
Confused 4
Easy 5
Motionless 1
Overly extended 2
Totally flexed 3
I will withdraw 4
Ow, that hurt! 5
Natural 6
allergic conjunctivitis
Allergic conjunctivitis may occur alone but is often seen in the context of hay fever
Features
Bilateral symptoms conjunctival erythema, conjunctival swelling (chemosis)
Itch is prominent
the eyelids may also be swollen
May be a history of atopy
May be seasonal (due to pollen) or perennial (due to dust mite, washing powder or other allergens)
Management of allergic conjunctivitis
first-line: topical or systemic antihistamines
second-line: topical mast-cell stabilisers, e.g. Sodium cromoglicate and nedocromil
UKMEC 4 conditions COCP
more than 35 years old and smoking more than 15 cigarettes/day
migraine with aura
history of thromboembolic disease or thrombogenic mutation
history of stroke or ischaemic heart disease
breast feeding < 6 weeks post-partum
uncontrolled hypertension
current breast cancer
major surgery with prolonged immobilisation
positive antiphospholipid antibodies (e.g. in SLE)
tumours markers raised bHCG and AFP
A raised alpha-feto protein level excludes a seminoma
common tumour markers
CA 125 Ovarian cancer
CA 19-9 Pancreatic cancer
CA 15-3 Breast cancer
(PSA) Prostatic carcinoma
(AFP) Hepatocellular carcinoma, teratoma
(CEA) Colorectal cancer
S-100 Melanoma, schwannomas
Bombesin Small cell lung ca, gastric , neuroblastoma
asthma adult stepwise mx
- SABA
- SABA + low dose ICS
- SABA + low dose ICS + LTRA
- SABA + low dose ICS + LTRA + LABA
- SABA + MART + LTRA
- SABA + MART (more steroid) + LTRA
- specialist input
A 5-month-old girl is seen in the paediatric urology clinic with recurrent urinary tract infections. She has had a renal ultrasound that showed dilatation of the ureters.dx/inv etc
Micturating cystography is the correct answer. 25% of children <6 years of age with a urinary tract infection (UTI) have vesicoureteral reflux (VUR)
DMSA looks for renal scarring
transplant rejection
hyperacute - pre existing ABO/HLA antibodies, type II hypersensitivity reaction ( hours after, pain / fever)
acute <6 months - HLA mismatch, cytotoxic T cells
chronic >6 months - mixture of ab/cytotoxic or recurrence of previous disease
postpartum contraception
Post-partum, women only require contraception 21 days from giving birth
mirena coil + HRT
can use mirena as the progesterone component of HRT if one already in situ
keratoderma blenorrhagica
Assoc reactive arthritis
Soles of feet
Angina but got asthma what to add instead of bb
For a patient with symptomatic stable angina on a calcium channel blocker but with a contraindication to a beta-blocker, the next line treatment should be long-acting nitrate, ivabradine, nicorandil
Suspected TIA and on anticoag
If a patient is on warfarin/a DOAC/ or has a bleeding disorder and they are suspected of having a TIA, they should be admitted immediately for imaging to exclude a haemorrhage
normal values fasting OGTT
Fasting glucose Normal <5.6 mmol/L
2-hour post glucose challenge Normal <7.8mmol/L
no blast cells means what
The absence of blast cells indicates this is not acute leukaemia.
involuntary pouting of the mouth on antipsychotic
tardive dyskinesia
had a stroke had undx AF
If a patient with AF has a stroke or TIA, the anticoagulant of choice should be warfarin or a DOAC
Osteochondritis dissecans
would typically cause locking and swelling of the joint as well as tenderness.
Patellofemoral pain syndrome, previously known as chondromalacia patellae,
would classically cause anterior knee pain worsened by going up or down stairs.
runner, knee pain, not red or swollen
full ROM, pain over the lateral epicondyle of the femur, particularly with the knee at 30 degrees of flexion.
iliotibial band syndrome
anterior uveitis mx
Anterior uveitis is most likely to be treated with a steroid + cycloplegic (mydriatic) drops
convert codeine to morphine dose
Oral codeine to morphine (divide by 10)
ectopic preg algorithm
Expectant management
Size <35mm, HCG <1000, no heartbeat, unruptured, well pt
medical mx - size >35mm, HCG <5000, no heartbeat, unruptured
surgical - 35mm +, heartbeat, HCG 5000+, sympto
