Passmed Year 3 Flashcards
What do parietal cells secrete?
Gastrin
Symptoms of brucellosis and key risk factors
Symptoms: Fluctuating fever, sweats, myalgia, arthralgia
Key risk factors: Animal contact, unpasteurised cheese
Symptoms of echinococcosis and key risk factors
Symptoms: Liver cysts (or other cysts)
Key risk factor: Contact with sheep
What body system does Cryptococcus neoformans infect?
CNS
Symptom and epidemiology of enterobius vermicularis
Anal itching in children or contacts
Malaria symptoms
Flu-like illness after 2 weeks. If untreated can cause respiratory distress, acidosis, raised ICP and organ failure
Typical symptoms of candida skin infection
Red itchy rash in axilla or groin
Typical symptoms of herpes skin infections
Localised blistering and vesicles
What can patients with eczema get if they get a herpes skin infection?
Eczema herpeticum
Scabies treatment
Permethrin cream (treat all household contacts)
Arterial supply of the bladder
Superior and Inferior vesical arteries (branches of internal iliac)
Venous supply of the bladder
Vesicoprostatic / vesicouterine plexus (drain into internal iliac)
Lymphatic drainage of bladder
External and internal inguinal nodes
Bladder innervation
Sympathetic: hypogastric plexus
Parasympathetic: pelvic splanchnic nerves
Treatment for mild psoriasis
Topical corticosteroids
MOA of dipyridamole
Anti-platelet
Score used to assess severity of acute pancreatitis
Glasgow score (score >3 indicates ICU / HDU referral)
Artery that supplies posterior stomach
Splenic artery
Can CPAP be considered in acute heart failure?
Yes if not responding to treatment
Contraindication of metoclopramide
Parkinson’s
Mediator and examples of type I hypersensitivity reaction
IgE mediated
Anaphylaxis
Atopy e.g. asthma / hayfever
Mediator and examples of type II hypersensitivity reaction
Cell mediated
Goodpastures
Pernicious anaemia
Pemphigus
Mediator and examples of type III hypersensitivity reaction
Immune complex mediated
SLE
Post-streptococcal glomerulonephritis
Mediator and examples of type IV hypersensitivity reaction
T cell mediated (delayed)
Scabies
MS
Allergic contact dermatitis
Mediator and examples of type V hypersensitivity reaction
Antibodies act as agonists / antagonists
Grave’s disease
Myasthenia gravis
Two types of osteomyelitis
Haematogenous (spread via blood)
Non-haematogenous (from adjacent soft tissue / trauma)
Risk factors for osteomyeltis
Haematogenous: children, sickle cell, IVDU, immune suppression, infective endocarditis
Non-haematogenous: ulcers, pressure sores, diabetes, peripheral arterial disease, surgery
Most common organism in osteomyelitis
Staph aureus
Most common organism in children with sickle cell and osteomyelitis
Salmonella
Investigation of osteomyelitis
MRI
MOA of cetuximab
Monoclonal antibody against epidermal growth factor receptor
Indications for cetuximab
Metastatic colorectal / head and neck cancer
Most common organism causing spontaneous bacterial pertonitis
E. coli
Symptoms of spontaneous bacterial peritonitis
Abdo pain, fever, ascites
Diagnosis of spontaneous bacterial peritonitis
Paracentesis - raised neutrophils and culture and organism
Management of spontaneous bacterial peritonitis
IV abx
Indications for abx prophylaxis against spontaneous bacterial peritonitis
Ascites and either previous spontaneous bacterial peritonitis or high protein on paracentesis or a high Child-Pugh score (>9)
Typical presentation of patient with taenia solium infection
Latin American patient with seizures and brain cysts on imaging
Symptoms of Lyme disease
Fever, arthralgia, headache, bullseye rash
What electrolyte imbalance can hypomagnesaemia cause?
Hypocalcaemia (unresponsive to treatment with calcium and vitamin D supplements)
Main cells that mediate organ rejection
Cytotoxic T cells
Symptoms of erysipelas
Elevated, well defined, painful rash
Risk factors for erysipelas
Reduced immunity, older age
Microorganism responsible for erysipelas
Strep pyogenes
Typical rash in ringworm
Red, circular, scaly, itchy rash
Organism that causes ringworm
Trichophyton rubrum
What is erysipelas?
Superficial, limited cellulitis
Treatment of erysipelas
Abx eg flucloxacillin
What should be co-prescribed with methotrexate?
Folic acid 5mg once per week (taken on a different day to the methotrexate)
What is Budd-Chiari syndrome?
Hepatic vein thrombosis
Risk factors for Budd-Chiari syndrome
polycythaemia
thrombophilia (e.g. protein C resistance / deficiency, antithrombin III deficiency)
pregnancy
combined oral contraceptive pill
Symptoms of Budd-Chiari syndrome
Abdo pain (sudden onset and severe)
Ascites
Tender hepatomegaly
Jaundice
Investigations of Budd-Chiari syndrome
Ultrasound with doppler flow
Surgical procedure in pyloric stenosis
Ramstedt’s pyloromyotomy
Surgical procedure in achalasia
Heller’s cardiomyotomy
Surgery to remove head of pancreas and duodenum
Whipple’s procedure
What is achalasia?
Failure of peristalsis and lower oesophageal relaxation
Symptoms of achalasia
dysphagia of BOTH liquids and solids
typically variation in severity of symptoms
heartburn
regurgitation of food (may lead to cough, aspiration pneumonia etc)
malignant change in small number of patients
Investigation of achalsia
oesophageal manometry (excessive LOS tone which doesn't relax on swallowing, considered the most important diagnostic test) barium swallow (shows grossly expanded oesophagus, fluid level, 'bird's beak' appearance) chest x-ray (wide mediastinum, fluid level)
First line treatment in achalasia
Balloon dilation
Most common type of renal cancer
Renal cell carcinoma
Key complications of acute pancreatitis
Peripancreatic fluid collections Pseudocysts Pancreatic necrosis Abscess Haemorrhage
What nerve supplies the medial leg and foot?
Saphenous nerve
What nerve supplies the lateral leg and foot?
Sural nerve
What nerve supplies the dorsum of the foot?
Superficial peroneal nerve
Inheritance of alpha-1 antitrypsin deficiency
Recessive / codominant
Pathophysiology of alpha - antitrypsin deficiency
Reduces the breakdown of neutrophil elastase, which leads to emphysema
Symptoms of alpha-1 antitrypsin deficiency
Emphysema / COPD symptoms (breathlessness, cough, frequent infections)
May have liver symptoms e.g. cholestasis, cirrhosis, carcinoma
Investigation of alpha-1 antitrypsin deficiency
A1AT concentrations
spirometry: obstructive picture
Management of alpha-1 antitrypsin deficiency
no smoking
supportive: bronchodilators, physiotherapy
intravenous alpha1-antitrypsin protein concentrates
surgery: lung volume reduction surgery, lung transplantation
What does an ABG typically show in salicylate overdose?
salicylate overdose leads to a mixed respiratory alkalosis and metabolic acidosis. Early stimulation of the respiratory centre leads to a respiratory alkalosis whilst later the direct acid effects of salicylates (combined with acute renal failure) may lead to an acidosis
What muscle flexes the proximal interphalangeal joints?
Flexor digitorum superficialis
What muscle flexes the diatal interphalangeal joints?
Flexor digitorum profundus
Monitoring of Barratt’s oesophagus
for patients with metaplasia endoscopy is recommended every 3-5 years
Management of Barratt’s oesophagus
endoscopic surveillance with biopsies
high-dose proton pump inhibitor
If dysplasia of any grade is identified, endoscopic intervention is offered (options include endoscopic mucosal resection or radiofrequency ablation)
Blood supply to thyroid
Superior and inferior thyroid arteries
Venous drainage of thyroid
Superior, middle and inferior thyroid veins
Symptoms of strongyloides infection
Abdo pain, diarrhoea, papulovesicular lesions on the soles of his feet and an urticarial rash
How is strongyloides infection acquired?
Via soil
Symptoms of chlonorchis sinensis
abdominal pain, nausea, jaundice
Risk factor for chlonorchis sinensis
Undercooked fish
Risk factor for taenia solium
Undercooked pork
What system does taenia solium infect?
CNS
Symptoms of congenital ventricular septal defect
failure to thrive
features of heart failure (hepatomegaly, tachypnoea, tachycardia, pallor)
classically a pan-systolic murmur which is louder in smaller defects
Management of congenital ventricular septal defect
Small VSDs which are asymptomatic often close spontaneously are simply require monitoring
Moderate to large VSDs usually result in a degree of heart failure in the first few months so need nutritional support, medication for heart failure (e.g. diuretics), surgical closure of the defect
Complications of a ventricular septal defect
Aortic regurgitation
Infective endocarditis
Right sided hypertrophy and failure
Pulmonary hypertension
Indications for antibiotics in otitis media
Symptoms lasting more than 4 days or not improving
Systemically unwell but not requiring admission
Immunocompromise or high risk of complications secondary to significant heart, lung, kidney, liver, or neuromuscular disease
Younger than 2 years with bilateral otitis media
Otitis media with perforation and/or discharge in the canal
Complications of otitis media
perforation of the tympanic membrane hearing loss labyrinthitis mastoiditis meningitis brain abscess facial nerve paralysis
Stanford classification of aortic dissection
Type A: Ascending aorta (2/3 of cases)
Type B: Descending aorta (1/3 of cases)
Management of aortic dissection
Type A (ascending aorta): surgical management, but blood pressure should be controlled to a target systolic of 100-120 mmHg whilst awaiting intervention Type B (descending aorta): conservative management (bed rest, reduce blood pressure with IV labetalol)
Complications of aortic dissection
aortic incompetence/regurgitation
MI
stroke
renal failure
Actions of biceps brachii
Elbow flexion
Supination
Symptoms of an ovarian cyst
Asymptomatic
Pelvic pain
Bloating
Heavy periods
Management of inguinal hernias
Usually surgical mesh repair, even if asymptomatic
MOA of syntocinon
Synthetic oxytocin
Use of ergometrine
Can be used instead of oxytocin in the third stage of labour
Drugs used in medical abortion
Mifepristone and misoprostol
Most common type of testicular cancers
Germ cell tumours (e.g. seminomas)
Risk factors for testicular cancer
male aged 20-30 infertility (increases risk by a factor of 3) cryptorchidism family history Klinefelter's syndrome mumps orchitis
Symptoms of testicular cancer
a painless lump is the most common presenting symptom
hydrocele
pain (uncommon)
gynaecomastia
Testicular cancer tumour markers
AFP (60%)
LDH (40%)
hCG (20%)
Diagnosis of testicular cancer
Ultrasound first line
Treatment of testicular cancer
orchidectomy
chemotherapy and radiotherapy may be given depending on staging and tumour type
Prognosis of testicular cancer
Good
What is the qSOFA score used for?
Predicting increased mortality in sepsis
What makes up the qSOFA score?
Resp rate >22
BP <100
Altered mental state
Symptoms of vitamin B3 deficiency
Dermatitis, dementia, diarrhoea
Symptoms of vitamin B2 deficiency
Angular stomatitis, keratitis, glossitis
Symptoms of vitamin B6 deficiency
anaemia, neuropathy, irritability and abdominal discomfort.
Symptoms of B12 deficiency
Anaemia and neurological symptoms
First line in neuropathic pain
Amitriptyline OR pregabalin
Second line in neuropathic pain
Amitriptyline AND pregabalin
First line in neuropathic pain in diabetes
Duloxetine
Metformin ADRs
Gastrointestinal upsets are common (nausea, anorexia, diarrhoea), intolerable in 20%
reduced vitamin B12 absorption - rarely a clinical problem
lactic acidosis with severe liver disease or renal failure
Metformin contraindications
chronic kidney disease: review if eGFR <45 and stop if eGFR < 30
Recent MI / sepsis / stroke / AKI
iodine-containing x-ray contrast media (day of and two days after procedure due to risk of renal impairment
alcohol abuse is a relative contraindication
Dose of adrenaline in anaphylaxis in adults
500 micrograms (0.5ml 1 in 1,000) IM. Repeat every 5 minutes if necessary
Dose of adrenaline in anaphylaxis in children age 6-12
300 micrograms (0.3ml 1 in 1,000) IM. Repeat every 5 minutes if necessary
Dose of adrenaline in anaphylaxis in children under 6
150 micrograms (0.15ml 1 in 1,000) IM. Repeat every 5 minutes if necessary
Blood test that can be done to determine if someone has had an anaphylactic reaction
Serum tryptase
Indication for letrozole
Breast cancer in postmenopausal women
MOA of tamoxifen
Oestrogen receptor blocker
What is Ebstein’s anomaly and what is the key risk factor?
Ebstein’s anomaly is a congenital heart defect characterised by low insertion of the tricuspid valve resulting in a large atrium and small ventricle. It is sometimes referred to as ‘atrialisation’ of the right ventricle.
Ebstein’s anomaly may be caused by exposure to lithium in-utero (e.g. maternal mood disorder)
What is Wilson’s disease
Accumulation of copper
Symptoms of Wilson’s disease
liver: hepatitis, cirrhosis neurological e.g. speech / behaviour problems Kayser-Fleischer rings renal tubular acidosis haemolysis blue nails
ECG in hypokalaemia
U waves small or absent T waves (occasionally inversion) prolong PR interval ST depression long QT
Causative organism for pneumonia in multiple otherwise fit patients who have developed pneumonia after air condition exposure.
Legionella
Most common causative agent of pneumonia in people with COPD
Haemophilus influenzae
Most common causative agent of pneumonia in alcoholoics
Klebsiella pneumoniae
Most common causative agent of pneumonia in patients with HIV
Pneumocystis jiroveci
Most common causative agent of pneumonia
Streptococcus pneumoniae
Pancreatic cancer symptoms
classically painless jaundice
pale stools, dark urine, and pruritus
cholestatic liver function tests
anorexia
weight loss
epigastric pain (and often atypical back pain)
loss of exocrine function (e.g. steatorrhoea)
loss of endocrine function (e.g. diabetes mellitus)
Imaging tests in pancreatic cancer
ultrasound has a sensitivity of around 60-90%
high-resolution CT scanning is the investigation of choice if the diagnosis is suspected
Management of pancreatic cancer
less than 20% are suitable for surgery at diagnosis
Whipple’s resection (pancreaticoduodenectomy) is performed for resectable lesions in the head of pancreas with adjuvant chemotherapy
ERCP with stenting is often used for palliation
What is Rovsing’s sign and what does it indicate?
more pain in RIF than LIF when palpating LIF
appendicitis
Blood supply to prostate
Inferior vesical artery
Venous drainage of prostate
Prostatic venous plexus
Lymphatic drainage of prostate
Internal iliac nodes
Hyperaldosteronism investigation
plasma aldosterone/renin ratio is the first-line investigation (high aldosterone and low renin due to negative feedback)
following this a high-resolution CT abdomen
if the CT is normal adrenal venous sampling (AVS) can be used to distinguish between unilateral adenoma and bilateral hyperplasia
Treatment of hyperaldosteronism
adrenal adenoma (Conn's syndrome): surgery bilateral adrenocortical hyperplasia: aldosterone antagonist e.g. spironolactone
What is Conn’s syndrome?
Adrenal adenoma leading to hyperaldosteronism
Screening for PCKD
Ultrasound in relatives
Diagnosis of oesophageal cancer
Endoscopy first line
Then CT for staging
Management of oesophageal cancer
Surgery usually
May have adjuvant chemo
Oesophageal cancer adenocarcinoma vs squamous cells cancer
Adenocarcinoma more common in developed countries, squamous cell in developing
Adenocarcinoma more common in lower 1/3, squamous cell in upper 2/3
Adenocarcinoma key risk factors GORD and Barratts, squamous cell are smoking and alcohol
Causes of jaundice in first 24 hours of life
rhesus haemolytic disease
ABO haemolytic disease
hereditary spherocytosis
glucose-6-phosphodehydrogenase
Causes of neonatal prolonged jaundice (after 14 days)
biliary atresia hypothyroidism galactosaemia urinary tract infection breast milk jaundice congenital infections
Treatment of carpal tunnel syndrome
corticosteroid injection wrist splints at night surgical decompression (flexor retinaculum division)
What nerve is compressed in cubital tunnel syndrome?
Ulnar
Cubital tunnel syndrome symptoms
Tingling and numbness of the 4th and 5th finger which starts off intermittent and then becomes constant.
Patients may also develop weakness and muscle wasting
Pain worse on leaning on the affected elbow
Often a history of osteoarthritis or prior trauma
Cubital tunnel syndrome management
Avoid aggravating activity
Physiotherapy
Steroid injections
Surgery in resistant cases
Diet encouraged in kidney disease
Low protein
Low phosphate
Low sodium
Low potassium
What causes hepatic encephalopathy?
Raised ammonia
Grading of hepatic encephalopathy
Grade I: Irritability
Grade II: Confusion, inappropriate behaviour
Grade III: Incoherent, restless
Grade IV: Coma
Treatment of hepatic encephalopathy
Lactulose (promotes ammonia excretion)
Rifaximin (prophylaxis by modulating gut bacteria to reduce ammonia production)
Thyroid cancer management
total thyroidectomy
followed by radioiodine (I-131) to kill residual cells
yearly thyroglobulin levels to detect early recurrent disease
Aetiology of ventricular septal defect
Congenital VSDs are often association with chromosomal disorders (e.g. Down’s syndrome, Edward’s syndrome, Patau syndrome, cri-du-chat syndrome)
Congenital infections
Acquired causes (e.g. post-myocardial infarction)
Symptoms of rheumatic fever
Evidence of recent streptococcal infection (swab or antigen test for group A strep) Erythema marginatum Polyarthritis Carditis and valvulitis Raised ESR or CRP Pyrexia
Management of rheumatic fever
Antibiotics (oral penicillin V)
Anti-inflammatories: NSAIDs are first-line
Treatment of any complications that develop e.g. heart failure
Common CNS complication of HIV
Toxoplasmosis lesions (symptoms of headache, confusion, drowsiness)
Lymphoma lesions (symptoms of headache, confusion, drowsiness)
TB
Encephalitis
Meningitis (often caused by Cryptococcus)
Progressive multifocal leukoencephalopathy (symptoms of behavioural changes, speech, motor, visual impairment)
AIDS dementia complex
Toxoplasmosis symptoms
Headache, confusion, drowsiness
Imaging in toxoplasmosis
Multiple ring enhancing lesions on CT
CNS lymphoma symptoms
Headache, confusion, drowsiness
CNS lymphoma imaging
Single / multiple lesions that show solid enhancement
Toxoplasmosis treatment
Medical (sulfadiazine and pyrimethamine)
CNS lymphoma management
Steroids
Chemo
May also have radiotherapy
Small tumours may consider surgery
What does CNS TB look like on imaging?
Single ring enhancing lesion on CT
What is Progressive multifocal leukoencephalopathy (PML)
Widespread demyelination of CNS tissue in lesions
Imaging of Progressive multifocal leukoencephalopathy (PML)
CT: single or multiple lesions, no mass effect, don’t usually enhance. MRI is better - high-signal demyelinating white matter lesions are seen
Imaging in AIDS dementia complex
Cortical and subcortical atrophy seen on CT
First line antibiotic in pregnant women with a UTI
Nitrofurantoin
Zone of the adrenal gland where cortisol is produced
Zona fasciculata
What is carcinoid syndrome?
When a tumour secretes hormones e.g. serotonin
Symptoms of carcinoid syndrome
Diarrhoea, flushing, SOB, itching, others
Most common site of carcinoid tumours
GI tract, though they often have liver mets
Diagnosis of carcinoid syndrome
CT
Octreoscan (binds to increased somatostatin receptors)
Urine 5HIAA
Niacin deficiency seen on bloods
Treatment of carcinoid syndrome
Reduce alcohol and stress (reduces hormone release)
Somatostatin analogue e.g. octreotide to reduce hormone release
Surgery on tumour
Treatment of testicular torsion
Treatment is with surgical exploration. If a torted testis is identified then both testis should be fixed as the condition of bell clapper testis is often bilateral.
Does hydrocele trans illuminate?
Yes
Investigation of hydrocele
USS to exclude tumour
Causes of normal anion gap acidosis
Gastrointestinal base loss e.g. diarrhoea Renal tubular acidosis Drugs: e.g. acetazolamide Ammonium chloride injection Addison's disease
Causes of raised anion gap acidosis
Lactate: shock, hypoxia
Ketones: diabetic ketoacidosis, alcohol
Urate: renal failure
Acid poisoning: salicylates, methanol
Which muscle is responsible for causing flexion of the distal interphalangeal joint?
Flexor digitorum profundus
Symptoms of opioid overdose
Tachycardia Constricted pupils Psychotic symptoms Cardiac arrest Seizures
What type of drug is heroin?
Opioid
Management of opioid overdose
Naloxone
Management of benzodiazepine overdose
Supportive care
flumazenil
Management of amphetamine / cocaine overdose
Benzodiazepine
Use of disulfirazem
Chronic alcohol use
Causes unpleasant symptoms with alcohol do discourage alcohol intake
Treatment of salicylate poisining
urinary alkalinization with IV bicarbonate
haemodialysis
Management of lithium overdose
Fluids
Dialysis if severe
Reversal of warfarin
Vitamin K, prothrombin complex
Reversal of heparin
Protamine
Management of ethylene glycol (antifreeze) overdose
Fomepizole now first line
Ethanol
Dialysis if severe
Management of methanol poisoning
Fomepizole or Ethanol
Dialysis if severe
Management of digoxin overdose
Digoxin-specific antibody fragments
Management of carbon monoxide poisinging
High flow / hyperbaric O2
Investigation of choice for bowel ischaemia
CT
Symptoms of chronic mesenteric ischaemia
Colickly, intermittent abdominal pain occurs
Definition of ischaemic colitis
acute but transient compromise in the blood flow to the large bowel
Management of ischaemic colitis
- usually supportive
- surgery may be required in a minority of cases if conservative measures fail. Indications would include generalised peritonitis, perforation or ongoing haemorrhage
Management of Raynauds
all patients with suspected secondary Raynaud's phenomenon should be referred to secondary care (as it is associated with may underlying conditions) first-line: calcium channel blockers e.g. nifedipine IV prostacyclin (epoprostenol) infusions: effects may last several weeks/months
Definition of malignant otitis externa
Uncommon type of otitis externa that is found in immunocompromised individuals (90% cases found in diabetics) most commonly caused by Pseudomonas aeruginosa
Symptoms of malignant otitis externa
Diabetes (90%) or immunosuppression (illness or treatment-related)
Severe, unrelenting, deep-seated otalgia
Temporal headaches
Purulent otorrhea
Treatment of malignant otitis externa
non-resolving otitis externa with worsening pain should be referred urgently to ENT
Intravenous antibiotics that cover pseudomonal infections
Nerve damaged in claw hand
Ulnar
Lifestyle modifications in gout
Weight loss
avoid food high in purines e.g. Liver, kidneys, seafood, oily fish (mackerel, sardines) and yeast products
Reduce alcohol and avoid in an acute attack
vitamin C
Cholesteatoma risk factors
Adolescents
Cleft lip
Cholesteatoma symptoms
foul-smelling, non-resolving discharge
hearing loss
tympanic membrane crusting on otoscopy
What is cholesteatoma
Cholesteatoma is a non-cancerous growth of squamous epithelium in the ear
Management of cholesteatoma
ENT referral for surgical removal
Symptoms of granulomatosis with polyangiitis
upper respiratory tract: epistaxis, sinusitis, nasal crusting
lower respiratory tract: dyspnoea, haemoptysis
rapidly progressive glomerulonephritis
Investigations in granulomatosis with polyangiitis
cANCA positive in > 90%, pANCA positive in 25%
chest x-ray: wide variety of presentations, including cavitating lesions
renal biopsy: epithelial crescents in Bowman’s capsule
Management of granulomatosis with polyangiitis
steroids
cyclophosphamide (90% response)
plasma exchange
Cause of S3 heart sound
considered normal if < 30 years old
heard in left ventricular failure (e.g. dilated cardiomyopathy), constrictive pericarditis and mitral regurgitation
Causes of S4 heart sound
aortic stenosis, HOCM, hypertension
Risk factors for bladder cancer
age 50-80
male
smoking
schistosomiasis
Most common bladder cancer
Transitional cell carcinoma
Bladder cancer symptoms
Haematuria (painless)
Bladder cancer diagnosis
Cystoscopy and biopsy
MRI / CT for staging
Management of bladder cancer
Trans urethral resection (low grade)
Intravesical chemo
Surgery
Radiotherapy
Virus that causes hand foot and mouth disease
Coxsackie A
Advice to patients with shingles
Loose fitting clothing, creams and cool ice packs as symptom relief
Contagious until lesions crusted over
Pain management in shingles
paracetamol and NSAIDs are first-line
if not responding then use of neuropathic agents (e.g. amitriptyline) can be considered
oral corticosteroids if the pain is severe and not responding
Complications of shingles
Post-herpetic neuralgia
Ramsay Hunt syndrome
Risk factors for pericarditis
viral infections (Coxsackie) tuberculosis uraemia (causes 'fibrinous' pericarditis) trauma post-myocardial infarction, Dressler's syndrome connective tissue disease hypothyroidism malignancy
Key investigations in pericarditis
ECG and echo
Inheritance of Fabry disease
X-linked recessive
Symptoms of Fabry disease
burning pain/paraesthesia in childhood angiokeratomas lens opacities proteinuria early cardiovascular disease
Management of idiopathic pulmonary hypertension
Test response to vasodilators. If effective use these
If ineffective use other medications. Consider heart-lung transplant if severe
Risk factors for idiopathic pulmonary hypertension
Female
30s - 50s
Genetic in 10%
Symptoms of idiopathic pulmonary hypertension
progressive exertional dyspnoea is the classical presentation
other possible features include exertional syncope, exertional chest pain and peripheral oedema
cyanosis
right ventricular heave, raised JVP, tricuspid regurgitation
Diagnosis of heart failure
Take BNP.
If high, echo within 2 weeks
If raised, echo within 6 weeks
Pathogen causing bronchiolitis
RSV
Pathogen causing croup
Parainfluenza virus
Congenital syphilis symptoms
blunted upper incisor teeth (Hutchinson’s teeth), ‘mulberry’ molars
rhagades (linear scars at the angle of the mouth)
keratitis
saber shins
saddle nose
deafness
Symptoms of bubonic plague
Headache, fever, weakness, painful lymph nodes 3-7 days after rodent exposure
Treatment of bubonic plague
Abx
Causative organism in bubonic plague
Yersinia pestis
Symptoms of cat scratch disease
Enlarged lymph nodes after cat scratch exposure
Causative organism in cat scratch disease
Bartonella henselae
Pathophysiology of rheumatic fever
follows an immunological reaction to recent (2-6 weeks ago) Streptococcus pyogenes infection.
Dilated cardiomyopathy symptoms
right ventricular failure, dyspnoea, pulmonary oedema, and atrial fibrillation.
Restrictive cardiomyopathy symptoms
right heart failure signs predominate: raised JVP, hepatomegaly, oedema, ascites.
Atrial myxoma symptoms
dizziness, fainting and palpitations, due to obstruction of the conductive pathway.
Murmur associated with hypertrophic cardiomyopathy
Ejection systolic
Is there a vaccine for Hep A?
Yes
Typhoid symptoms
headache, fever, arthralgia bradycardia abdo pain or distension constipation rose spots on trunk
Typhoid complications
osteomyelitis (especially in sickle cell disease) GI bleed/perforation meningitis cholecystitis chronic carriage (1%)
Antibody associated with Sjogrens
Anti-La
Symptoms of lithium overdose
coarse tremor (a fine tremor is seen in therapeutic levels) hyperreflexia acute confusion polyuria seizure coma
Nerve at risk of damage in inguinal hernia repair surgery
Ilioinguinal
How to distinguish vestibular neuritis form labyrinthitis
vestibular neuritis: only the vestibular nerve is involved, hence there is no hearing impairment
Labyrinthitis: both the vestibular nerve and the labyrinth are involved, usually resulting in both vertigo and hearing impairment.
Age group most commonly affected by labyrinthitis
Middle age
Symptoms of labyrinthitis
acute onset of:
vertigo (not triggered by movement but exacerbated by movement)
nausea and vomiting
sensorineural hearing loss (unilateral or bilateral with varying severity)
tinnitus
preceding or concurrent symptoms of upper respiratory tract infection
spontaneous unidirectional horizontal nystagmus towards the unaffected side
gait disturbance (may fall towards the affected side)
Management of labyrinthitis
episodes are usually self-limiting
prochlorperazine or antihistamines may help reduce the sensation of dizziness
Treatment for contact dermatitis
Topical steroid
Symptoms of reactive arthritis
Conjunctivitis, urethritis and arthritis
Typical age and gender of reactive arthritis
Young males
What joint are most commonly affected in reactive arthritis?
Lower limbs
Symptoms of scleroderma / systemic sclerosis
Raynaud phenomenon, skin thickening, calcinosis and telangectasia.
Medication used in variceal bleeding
Terlipressin
Prophylactic abx if they have cirrhosis
Typical patients with intususseption
Boys more than twice as likely as girls
6-18 months
Symptoms of intususseption
paroxysmal abdominal colic pain (characteristically draw their knees up and turn pale)
vomiting
bloodstained stool - ‘red-currant jelly’ - is a late sign
sausage-shaped mass in the right upper quadrant
Key investigation in intususseption
USS
Management of intususseption
the majority of children can be treated with reduction by air insufflation under radiological control
if this fails, or the child has signs of peritonitis, surgery is performed
Endocrine effects of renal cell carcinoma
endocrine effects: may secrete erythropoietin (polycythaemia), parathyroid hormone (hypercalcaemia), renin, ACTH
Renal cell cancer management
Total / partial nephrectomy if localised
Chemo / biological therapy if higher grade
Most common thyroid cancer
Papillary
Prognosis in papillary thyroid cancer
Good
Typical demographic of papillary thyroid cancer
Young females
Management of papillary / follicular thyroid cancer
total thyroidectomy
followed by radioiodine (I-131) to kill residual cells
yearly thyroglobulin levels to detect early recurrent disease
Hypokalaemia ECG
U waves small or absent T waves (occasionally inversion) prolong PR interval ST depression long QT
Most common causative agent of empyema
Strep pneumoniae
Symptoms of pemphigus vulgaris
Mouth ulcers
Skin blisters - flaccid, easily ruptured vesicles and bullae, typically painful but not itchy, may develop months after the initial mucosal symptoms
Treatment of pemphigus vulgaris
Steroids
Immunosuppressants
Symptoms of extrinsic allergic alveolitis
acute (occurs 4-8 hrs after exposure): dyspnoea, dry cough, fever
chronic (occurs weeks-months after exposure): lethargy, dyspnoea, productive cough, anorexia and weight loss
Investigation of extrinsic allergic alveolitis
imaging: upper/mid-zone fibrosis
bronchoalveolar lavage: lymphocytosis
serologic assays for specific IgG antibodies
blood: NO eosinophilia
Management of extrinsic allergic alveolitis
Avoid precipitant
Oral steroids
What is megaloblastic macrocytic anaemia?
RBCs not fully formed
Symptoms of vitamin B12 deficiency
macrocytic anaemia
sore tongue and mouth
neurological symptoms
the dorsal column is usually affected first (joint position, vibration) prior to distal paraesthesia
neuropsychiatric symptoms: e.g. mood disturbances
Treatment of B12 deficiency without neurological deficit
IM cobalamin 3 times per week for 2 weeks then 3 monthly
Treatment for B12 deficiency with folate deficiency
Treat B12 deficiency first
Symptoms of B6 deficiency
Peripheral neuropathy
Sideroblastic anaemia Convulsions
Indication for pentoxifylline
Venous ulcer
Definition of gastroschisis
Gastroschisis describes a congenital defect in the anterior abdominal wall just lateral to the umbilical cord
Management of gastroschisis
vaginal delivery may be attempted
newborns should go to theatre as soon as possible after delivery, e.g. within 4 hours
Definition of exomphalos
abdominal contents protrude through the anterior abdominal wall but are covered in an amniotic sac formed by amniotic membrane and peritoneum
Management of exomphalos
Caesarian section
Staged repair where first a shell is formed around exposed bowel then a later operation returns it to the abdominal cavity
What is anti phospholipid syndrome?
an autoimmune, hypercoagulable state
Complications of anti phospholipid syndrome
miscarriage, stillbirth, preterm delivery, or severe preeclampsia
In rare cases, APS leads to rapid organ failure due to generalised thrombosis; this is termed ‘catastrophic antiphospholipid syndrome’ (CAPS) and is associated with a high risk of death.
Diagnosis of anti phospholipid syndrome
one clinical event, i.e. thrombosis or pregnancy complication, and two positive blood tests spaced at least 3 months apart. These antibodies are: lupus anticoagulant, anti-cardiolipin and anti-β2-glycoprotein
What is primary anti phospholipid syndrome
Primary antiphospholipid syndrome occurs in the absence of any other related disease
What is secondary anti phospholipid syndrome
Secondary antiphospholipid syndrome occurs with other autoimmune diseases, such as systemic lupus erythematosus (SLE)
Management of anti phospholipid syndrome
Heparin
Symptoms of anti thrombin deficiency
Hypercoagulability
Aetiology of anti thrombin deficiency
Autosomal dominant
Symptoms of alpha-1 anti trypsin deficiency
lungs: panacinar emphysema, most marked in lower lobes
liver: cirrhosis and hepatocellular carcinoma in adults, cholestasis in children
Lymphatic drainage of anal canal below pectinate line
Superficial inguinal nodes
Lymphatic drainage of perineum, scrotum and vagina
Superficial inguinal nodes
Lymphatic drainage of testes
Para-aortic lymph nodes
Lymphatic drainage of ovaries
Para-aortic lymph nodes
Lymphatic drainage of kidneys and adrenal glands
Para-aortic nodes
Lymphatic drainage of anal canal above pectinate line
Internal iliac lymph nodes
Lymphatic drainage of lower rectum
Internal iliac lymph nodes
Lymphatic drainage of many pelvic structures
Internal iliac lymph nodes
Lymphatic drainage of duodenum
Superior mesenteric nodes
Lymphatic drainage of jejunum
Superior mesenteric nodes
Lymphatic drainage of colon
Inferior mesenteric nodes
Lymphatic drainage of upper rectum
Inferior mesenteric nodes
Lymphatic drainage of stomach
Coeliac nodes
Most common renal stones
Calcium oxalate
Risk factors for calcium oxalate stones
High calcium is the key risk factor
Can be idiopathic
Other causes include antifreeze ingestion, vitamin C abuse, hypocitraturia and malabsorption (e.g. Crohn disease)
Appearance of calcium oxalate stones on imaging
Radio-opaque
Risk factor for uric acid stones
High cell turnover e.g. malignancy
Appearance of uric acid stones on imaging
Radio lucent
Risk factor for calcium phosphate stones
Renal tubular acidosis
Appearance of calcium phosphate stones on imaging
Radio opaque
Risk factor for struvite stones
Certain infections
Appearance of struvite stones on imaging
Radio opaque
Which lymphoma is associated with Reed-Sternberg cells?
Hodgkin lymphoma
Which lymphoma is associated with alcohol pain
Hodgkin lymphoma
Blood tests in Hodgkin lymphoma
Anaemia, eosinophilia, raised LDH
Aetiology of maple syrup urine disease
Autosomal recessive
Management of maple syrup urine disease
restricting leucine, isoleucine and valine in the diet
Complications of maple syrup urine disease
Ketoacidosis, neurological defects
Causes of massive splenomegaly
Myelofibrosis Chronic myeloid leukaemia Visceral leishmaniasis (kala-azar) Malaria Gaucher's syndrome
Causes of non-massive splenomegaly
Any causes of massive splenomegaly plus…
Portal hypertension e.g. secondary to cirrhosis
Lymphoproliferative disease e.g. CLL, Hodgkin’s
Haemolytic anaemia
Infection: hepatitis, glandular fever
Infective endocarditis
Sickle-cell*, thalassaemia
Rheumatoid arthritis (Felty’s syndrome)
APTT in haemophilia
Raised
PT in haemophilia
Normal
APTT in von Willebrand disease
Raised
PT in von Willebrand disease
Normal
APTT in vitamin K deficiency
Raised
PT in vitamin K deficiency
Raised
Echo findings in atrial myxoma
pedunculated heterogeneous mass typically attached to the fossa ovalis region of the interatrial septum
Symptoms of atrial myxoma
systemic: dyspnoea, fatigue, weight loss, pyrexia of unknown origin, clubbing
emboli
atrial fibrillation
What does interferon-gamma release assay test for?
Latent TB
Why is irradiated blood useful?
It has fewer immune cells left so reduces risk of graft vs host disease
Indications for irradiated blood products
Low immunity eg neonates or transplant patients
What is graft vs host disease?
Immune cells in transplanted tissue begins to attack the host tissue
Criteria for medical miscarriage
Foetal size less than 35mm
Low foetal heartbeat
hCG less than 1500
What is courvousier’s sign?
a palpable gallbladder in the presence of painless jaundice is unlikely to be gallstones
Pancreatic or gall bladder malignancy is more likely
Main risk factor for cholangiocarcinoma
PSC
Symptoms of cholangiocarcinoma
Persistent biliary colic symptoms Anorexia and weight loss Jaundice Painless RUQ mass Periumbilical / supraclavicular lymphadenopathy
Management of TACO
Stop transfusion
O2
Diuretics
Symptoms of TRALI
Hypoxia, pulmonary infiltrates on chest x-ray, fever, hypotension
Management of TRALI
Stop the transfusion
Oxygen and supportive care
Symptoms of acute haemolytic transfusion reaction
fever, abdominal and chest pain, agitation and hypotension within a few minutes of transfusion
Management of acute haemolytic transfusion reaction
Stop transfusion
Fluid resuscitation
Supportive management
Murmur in HOCM
ejection systolic murmur that increases with Valsalva manoeuvre and decreases on squatting
May have mitral regurgitation
ECG in HOCM
left ventricular hypertrophy
non-specific ST segment and T-wave abnormalities, progressive T wave inversion may be seen
deep Q waves
Who should be screened for risk of osteoporosis?
Women over 65
Men over 75
Younger adults if there are other risk factors
Scoring systems to estimate 10-year risk of fragility fractures
FRAX
Qfracture
First line in maturity onset diabetes of the young
Sulfonylurea
Pathophysiology of maturity onset diabetes of the young
Genetic defect reduces insulin secretion
Pathophysiology of rheumatoid heart fever
antibodies to the bacteria causing a pharyngeal infection react with the cardiac myocyte antigen resulting in valve destruction
Organism responsible for rheumatic heart fever
Strep pyogenes
Diagnosis of rheumatic fever
Evidence of recent streptococcal infection (throat swab / antigens / antibodies)
2 major criteria (erythema marginatum, polyarthritis, carditis and valvulitis, SC nodules)
Or 1 major and 2 minor criteria (raised ESR or CRP, pyrexia, arthralgia, prolonged PR interval)
Management of rheumatic fever
Antibiotics (oral penicillin V)
Anti inflammatory (NSAIDS first line)
Treatment of cardiac complications
Causes of disseminated intravascular coagulation
Infection Malignancy Trauma e.g. major surgery, burns, shock, dissecting aortic aneurysm Liver disease Obstetric complications
Blood test results in disseminated intravascular coagulation
Prolonged clotting time
Decreased fibrinogen
Low platelets
Increased fibrinogen breakdown products
Symptoms of congenital adrenal hyperplasia
Depends on the exact type but typically consists of genital ambiguity, precocious puberty and hypertension
What age group is intraventricular haemorrhage associated with?
Neonates
Treatment of intraventricular haemorrhage
Supportive. Shunting if there’s hydrocephalus and raised ICP
Pathophysiology of paroxysmal nocturnal haemoglobinuria
Intravascular haemolysis leads to hemolytic anemia, dark urine in the morning, pancytopenia, and venous thrombosis
Management of paroxysmal nocturnal haemoglobinuria
Replacement of blood products,anticoagulants, stem cell transplant
What is Chvostek’s sign?
the facial twitch obtained by tapping the distribution of the facial nerve in front of the tragus. It is caused by mechanical irritability of peripheral nerves. It is indicative of hypocalcemia and is the most reliable test for hypocalcemia.
Blood tests in hypoparathyroidism
Low PTH, low calcium, high phosphate
Symptoms of hypocalcaemia
tetany: muscle twitching, cramping and spasm
perioral paraesthesia
Trousseau’s sign: carpal spasm if the brachial artery occluded by inflating the blood pressure cuff and maintaining pressure above systolic
Chvostek’s sign: tapping over parotid causes facial muscles to twitch
if chronic: depression, cataracts
ECG: prolonged QT interval
What is trousseau’s sign and what does it suggest?
carpal spasm if the brachial artery occluded by inflating the blood pressure cuff and maintaining pressure above systolic
Hypocalcaemia
What is pseudohypoparathyroidism?
Insensitivity to PTH
Blood tests in pseudohypoparathyroisism
Low Ca
High phosphate
High PTH
What is the S4 heart sounds caused by?
atrial contraction forces blood into a noncompliant left ventricle
Causes of S4 heart sounds
HOCM, HTN, aortic stenosis
Treatment of dengue fever
Symptom control eg fluids and analgesia
Symptoms of dengue fever
causes headache (often retro-orbital) fever myalgia pleuritic pain facial flushing (dengue) maculopapular rash
Features of excess acetylcholine
Salivation Lacrimation Urination Defecation/diarrhoea cardiovascular: hypotension, bradycardia
Symptoms of congenital rubella
Sensorineural deafness
Congenital cataracts
Congenital heart disease (e.g. patent ductus arteriosus)
Glaucoma
Symptoms of congenital toxoplasmosis
Cerebral calcification
Chorioretinitis
Hydrocephalus
Arterial supply of parotid gland
Branch of external carotid
Venous drainage of parotid gland
Retromandibular vein
Lymphatic drainage of parotid gland
Deep cervical nodes
What artery does the inferior rectal artery branch off?
Inferior mesenteric
Causes of minimal change disease
Idiopathic
Drugs
Lymphoma
EBV
Biopsy results in minimal change disease
electron microscopy shows fusion of podocytes and effacement of foot processes
Prognosis in minimal change disease
Good, though relapse is common
What movement is difficult in winged scapula?
Shoulder abduction
Lymphatic drainage of ovaries
Para-aortic lymph nodes
Lymphatic drainage of uterus
Mostly iliac lymph nodes
Some inguinal or para-aortic lymph nodes
Lymphatic drainage of cervix
Internal and external iliac nodes and presacral nodes
Symptoms of pernicious anaemia
Symptoms of anaemia
Neurological features (eg peripheral neuropathy, spinal cord degeneration and neuropsychiatric symptoms)
Mild jaundice
What is a hypertrophic scar?
A scar with excess collagen leading to nodules within the wound boundary
Complications of hypertrophic scars
Contractures
What is a keloid scar?
A scar with excess collagen that extends beyond the wound edge
Organism most common in infective endocarditis following dental infection
Strep viridans eg strep mitis
What cancer is Rb gene associated with?
Retinoblastoma
What is cushings disease?
Pituitary daemons leads to excess ACTH and excess cortisol
Most common cause of endogenous excess of cortisol
Pituitary adenoma
Management of fistulae
They will often heal on their own so conservative measures such as skin protection and nutritional support are the main management
What drug is used to treat iron overload in haemochromatisis?
Desferrioxamine
Symptoms of CML
anaemia: lethargy
weight loss and sweating are common
splenomegaly may be marked → abdo discomfort
an increase in granulocytes at different stages of maturation +/- thrombocytosis
decreased leukocyte alkaline phosphatase
may undergo blast transformation (AML in 80%, ALL in 20%)
Early X-ray finding in ankylosing spondylitis
Sacroiliitis
Arterial supply of rectum
Superior rectal artery
Venous drainage of rectum
Superior rectal vein
Lymphatic drainage of rectum
Mesorectal lymph nodes (superior to dentate line)
Internal iliac and then para-aortic nodes
Inguinal nodes (inferior to dentate line)
Symptoms of congenital CMV
fever, jaundice, hepatosplenomegaly, growth retardation, hearing loss
What is factor V Leiden?
Inherited condition that increases risk of clots
CLL complications
anaemia
hypogammaglobulinaemia leading to recurrent infections
warm autoimmune haemolytic anaemia in 10-15% of patients
transformation to high-grade lymphoma (Richter’s transformation)
What is hirschprung’s disease?
Failure of neural crest cells to migrate to Auerbach’s and Meissner’s plexus means part of the bowel isn’t innervated
Symptoms of Hirschprung’s disease
neonatal period e.g. failure or delay to pass meconium
older children: constipation, abdominal distension
Investigation of Hirschprung’s disease
abdominal x-ray
rectal biopsy: gold standard for diagnosis
Management of Hirschprung’s disease
initially: rectal washouts/bowel irrigation
definitive management: surgery to affected segment of the colon
What is horseshoe kidney?
The kidneys are fused at their inferior pole causing there to be just one long kidney that it located more inferiorly
Trigger finger symptoms
Pain
Stiffness
Locking on flexion that causes difficulty with extension
Risk factors for dupytrens contracture
Older Male Family history manual labour phenytoin treatment alcoholic liver disease diabetes mellitus trauma to the hand
Symptoms of dupuytren’s contracture
Fixed flexion of palm, particularly of the 4th and 5th finger
May develop nodules on the affected fingers
Management of Dupuytren’s contracture
consider surgical treatment of Dupuytren’s contracture when the metacarpophalangeal joints cannot be straightened and thus the hand cannot be placed flat on the table
What is Gardners syndrome a variant of?
FAP
Symptoms of acute graft vs host disease
Painful maculopapular rash (often neck, palms and soles), which may progress to erythroderma or a toxic epidermal necrolysis-like syndrome
Jaundice
Watery or bloody diarrhoea
Persistent nausea and vomiting
Symptoms of chronic graft vs host disease
Skin: Many manifestations including poikiloderma, scleroderma, vitiligo, lichen planus
Eye: Often keratoconjunctivitis sicca, also corneal ulcers, scleritis
GI: Dysphagia, odynophagia, oral ulceration, ileus. Oral lichenous changes are a characteristic early sign (2)
Lung: my present as obstructive or restrictive pattern lung disease
Management of graft vs host disease
Steroids first line
Other immunosuppressants second line
What is Eisenmengers syndrome?
Left-to-right shunt is reversed due to pulmonary hypertension
Symptoms of venous sinus thrombosis
Headache
Seizures
Aetiology of Ehlers Danlos syndrome
Autosomal dominant
Symptoms and complications of Ehlers Danlos syndrome
elastic, fragile skin
joint hypermobility: recurrent joint dislocation
easy bruising
aortic regurgitation, mitral valve prolapse and aortic dissection
subarachnoid haemorrhage (due to Berry aneurism rupture)
angioid retinal streaks
Most common site of ectopic testes
Superficial inguinal pouch
Management of undescended testes
Place in the scrotum at 1 year of age (before this point they may descend spontaneously)
Testicular examination in testicular torsion
Enlarged and tender testis
What is an ectopic testis?
Testis laying outside the path of normal descent
What muscles does the axillary nerve innervate
Deltoid abs teres minor
What clotting factor is deficient in haemophilia A?
VIII
What clotting factor is deficient in haemophilia B?
IX
What does APTT represent?
Intrinsic and common pathways
What does prothrombin time represent?
Extrinsic and common pathways
What does bleeding time represent?
Platelet function
Blood test results in haemophilia (APTT, PT, Bleeding time)
Prolonged APTT
Normal PT and bleeding time
HPV strains associated with genital warts
6 and 11
What is Zollinger Ellison syndrome?
Zollinger-Ellison syndrome is condition characterised by excessive levels of gastrin, usually from a gastrin secreting tumour usually of the duodenum or pancreas.
Symptoms of zollinger ellison syndrome
multiple gastroduodenal ulcers
diarrhoea
malabsorption
What is the best test to diagnose Zollinger Ellison syndrome?
Fasting gastrin levels
What is a cholesteatoma?
A non cancerous growth of squamous epithelium in the ear
What is myringitis?
Condition associated with otitis externa whereby cysts form on the tympanic membrane
Management and complications of cholesteatoma
ENT referral for consideration of surgical removal.
Complications include erosion of the ossicles
Management of intususseption
the majority of children can be treated with reduction by air insufflation under radiological control, which is now widely used first-line compared to the traditional barium enema
if this fails, or the child has signs of peritonitis, surgery is performed
Symptoms of intususseption
paroxysmal abdominal colic pain
during paroxysm the infant will characteristically draw their knees up and turn pale
vomiting
bloodstained stool - ‘red-currant jelly’ - is a late sign
sausage-shaped mass in the right upper quadrant
Which part of the cochlea does the stapes articulate with?
Oval window
What is a smiths fracture?
Fracture of the distal radius, distal fragment is displaced volarly
What is a Colles fracture?
Fracture of the distal radius, distal fragment is displaced posteriorly
What is a monteggia fracture?
Fracture of the proximal third of the ulna. The proximal head of the radius becomes dislocated
What is a Galeazzi fracture?
Fracture of the distal third of the radius The distal radioulnar joint becomes dislocated
Symptoms of graft vs host disease
cholestasis and subsequent jaundice, a widespread rash and diarrhoea in many cases. It tends to occur during the year following transplant.
What is hyper acute transplant rejection and what timescale does it occur in?
Type 2 hypersensitivity reaction due to preformed antibodies against ABO or HLA antigens within minutes to hours
What is acute graft failure and what timescale does it occur within?
T cell mediated rejection due to ABO incompatibility within 6 months
What is chronic graft failure and what timescale does it occur in?
T cell and antibody mediated mechanisms causing organ fibrosis after more than 6 months
Management of acute graft failure
May be reversible with steroids and immunosuppressants
What system is affected by schistosomiasis?
Urinary
Calcium levels in primary hypercalcaemia
High
Phosphate levels in primary hypercalcaemia
Low
PTH levels in primary hypercalcaemia
Normal or raised
Calcium in secondary hyperparathyroidism
Low or normal
Phosphate in secondary hyperparathyroidism
Low or normal
PTH in secondary hyperparathyroidism
High
PTH in hypercalcaemia secondary to hyperthyroidism or malignancy
Low
Venous drainage of adrenals
Left: left renal vein
Right: IVC
Lymphatic drainage of tip of tongue
Sub mental nodes
Venous drainage of mid tongue
Submandibular nodes
Calcium in pagets
Normal
Phosphate in pagets
Normal
PTH in pagets
Normal
ALP in pagets
High
Lymphatic drainage of upper limb
Axillary nodes
What is “hungry bone syndrome”?
A rare complication of hyperparathyroidism surgery whereby the reduced PTH causes hypocalcaemia as the bones were used to high PTH levels
Where is McBurney’s point?
1/3 of the way along a line drawn from the Anterior Superior Iliac Spine to the Umbilicus
What is McBurney’s point?
The point where most pain is elicited by pressure in acute appendicitis
What is osteopetrosis?
rare disorder of defective osteoclast function resulting in failure of normal bone resorption, which results in dense, thick bones that are prone to fracture
Definition of acute graft vs host disease
Is classically defined as onset within 100 days of transplantation
Usually affects the skin (>80%), liver (50%), and gastrointestinal tract (50%)
Symptoms of acute graft vs host disease
Painful maculopapular rash (often neck, palms and soles), which may progress to erythroderma or a toxic epidermal necrolysis-like syndrome
Jaundice
Watery or bloody diarrhoea
Persistent nausea and vomiting
Can also present as a culture-negative fever
Definition of chronic graft vs host disease
Classically occurs after 100 days following transplantation
Has a more varied clinical picture: often lung and eye involvement in addition to skin and GI, although any organ system may be involved
Symptoms of chronic graft vs host disease
Skin: Many manifestations including poikiloderma, scleroderma, vitiligo, lichen planus
Eye: Often keratoconjunctivitis sicca, also corneal ulcers, scleritis
GI: Dysphagia, odynophagia, oral ulceration, ileus. Oral lichenous changes are a characteristic early sign (2)
Lung: my present as obstructive or restrictive pattern lung disease
Treatment of graft vs host disease
Steroids first line
Other immunosuppressants if steroids ineffective
B12 deficiency symptoms
Macrocytic anaemia
Sore tongue and mouth
Neurological symptoms
Neuropsychological symptoms eg mood disturbance
Phaeochromocytoma symptoms
Flushing, headache, palpitations, resistant hypertension
Nerve affected if there is hip abduction, foot drop and loss of sensation over the sole of the foot
L5
Nerve affected if there is reduced sensation over the inguinal area and reduced power in hip flexion
L1
Nerve affected if there is reduced sensation on the anterior thigh and reduced hip flexion
L2
Nerve affected if there is reduced sensation over the distal thigh and reduced hip flexion and knee extension
L3
Nerve affected if there is no sensation over the medial lower leg and reduced knee extension and reduced dorsiflexion
L4
Nerve affected if there is no sensation in posterolateral leg and lateral foot and reduced plantar flexion
S1
Effect of PTH on phosphate
Reduces serum phosphate
Complications of PVI
Tamponade, stroke, pulmonary vein stenosis
Features of opioid misuse
Rinorrhoea, track marks, pinpoint pupils, drowsiness, watery eyes, yawning
Causes of avascular necrosis
Long term steroids
Chemotherapy
Alcohol excess
Trauma
Symptoms of avascular necrosis
Initially asymptomatic
Investigation of avascular necrosis
X-ray may be normal initially
MRI investigation of choice
Management of avascular necrosis
May need joint replacement
When to give anti-D to Rh -ve mother
Delivery of Rh +ve infant Termination of pregnancy Miscarriage Antepartum haemorrhage Amniocentesis, CVS or foetal blood sampling Abdo trauma
Where is McBurney’s point?
2/3 of the way from the umbilicus to the ASIS
Treatment for urge incontinence
Bladder retraining
Second line is bladder stabilising drugs eg oxybutynin
Treatment for stress incontinence
Pelvic floor muscle retraining
Second line is surgery or duloxetine
Incontinence risk factors
advancing age previous pregnancy and childbirth high body mass index hysterectomy family history
What is overflow incontinence
due to bladder outlet obstruction, e.g. due to prostate enlargement
Incontinence investigation
bladder diaries should be completed for a minimum of 3 days
vaginal examination to exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles (‘Kegel’ exercises)
urine dipstick and culture
urodynamic studies
Most common type of ovarian tumour
Serous
