Passmedicine Flashcards
1
Q
What are the cut off changes to know if you need to switch anti-HTNs with regards to creatinine and potassium when starting an ACE-inhibitor?
A
You are allowed a rise in creatinine up to 30%
Potassium is allowed to rise to 5.5 mmol/L
2
Q
Generally speaking, most patients with chronic renal failure will have bilaterally small kidneys, however which 4 causes of CRF are the exception to this rule?
A
- Diabetic nephropathy
- PKD
- HIV-associated nephropathy
- Amyloidosis
3
Q
What is the FEV1/FVC of healthy lungs?
A
70-80%
4
Q
If the FEV1/FVC is <70% what does this imply?
A
Obstructive rather than restrictive cause
5
Q
List some obstructive causes of lung disease (3)
A
COPD (Emphysema and Chronic bronchitis)
Asthma
Bronchiectasis
6
Q
List some restrictive causes of lung disease (4)
A
Pulmonary fibrosis
Sarcoidosis
Pneumonia
Pulmonary oedema
7
Q
What is total gas transfer (TLCO)?
A
Overall measure of gas transfer for the lungs from the alveoli into the capillaries
8
Q
When would you expect to find a raised TLCO and why? (6)
A
- Asthma
- Left-to-right cardiac shunt
- Pulmonary haemorrhage (Wegener’s, Good pastures)
- Polycythaemia
- Hyperkinetic states
- Male gender, exercise
This is because in these two - the problem is not in the alveoli/gas exchange, so the lungs compensate by improving gas exchange hence increasing TLCO
9
Q
Give examples of conditions which cause a low TLCO (7)
A
- Pulmonary fibrosis
- Pulmonary oedema
- Emphysema
- Pneumonia
- Pulmonary embolus
- Anaemia
- Low cardiac output
10
Q
In which patient is adenosine contraindicated for?
A
Asthma
11
Q
Why is adenosine contraindicated in asthma?
A
Due to the risk of bronchospasm
12
Q
What is the criteria for typical vs atypical angina?
A
Typical: all three of the symptoms:
- constricting discomfort in the front of the chest, or in the neck, shoulders, jaw or arms
- precipitated by exertion
- relieved by rest or GTN in about 5 mins
Atypical - 2 out of the 3
13
Q
List the 1st, 2nd and 3rd line investigations for pts in whom stable angina cannot be excluded by clinical assessment alone
A
1st line: CT coronary angio
2nd line: Non-invasive functional imaging (e.g. stress echo, CMR)
3rd line: invasive coronary angiography
14
Q
In all 3 types of renal tubular acidosis, what would the blood gas show?
A
Hyperchloraemic metabolic acidosis with normal anion gap
15
Q
What is the pathology in Renal tubular acidosis type 1?
A
The kidney’s are unable to secrete H+ into the distal tubule - therefore unable to excrete hydrogen ions
16
Q
Which renal tubular acidosis types cause hypokalaemia.?
A
RTA type 1 and RTA type 2 - there is a loss of K+ ions
17
Q
What are the complications of RTA type 1?
A
nephrocalcinosis and renal stones
18
Q
What are the causes of RTA type 1? (4)
A
- Idiopathic
- Rheumatoid arthritis
- SLE
- Sjogren’s
19
Q
Which part of the nephron is affected in RTA type 1?
A
Distal convoluted tubule
20
Q
Which part of the nephron is affected in RTA type 2?
A
Proximal convoluted tubule
21
Q
What is the pathology in RTA type 2?
A
decreased bicarbonate reabsorption in proximal tubule
22
Q
What are the complications of RTA type 2?
A
Osteomalacia
23
Q
What are the causes of RTA type 2?
A
- Idiopathic
- Fanconi’s syndrome
- Wilson’s disease
- Cystinosis
- Carbonic anhydrase inhibitors (topiramate)
24
Q
In which type of renal tubular acidosis is potassium high?
A
RTA type 4
25
What is the pathology in RTA type 4?
reduction in aldosterone leads to reduction in proximal tubular ammonium excretion
26
What are the causes of RTA type 4?
Hypoaldosteronism (e.g. Addisons), Diabetes
27
What vaccinations do COPD patient require?
Annual flu vaccine
| One-off Pneumococcal vaccine
28
If a patient presents with dyspepsia - What features/symptoms would warrant urgent referral for upper gastrointestinal endoscopy? (7)
1. Anorexia
2. Weight loss
3. Anaemia
4. Dysphagia
5. Melaena
6. Haematemesis
7. Recent progression of symptoms
29
What are the different liver patient categories e.g. chronic liver disease .... (5)
1. Chronic liver disease
2. Liver cell failure
3. Portal hypertension
4. Encephalopathy
5. Cholestasis
30
What are the signs of chronic stable liver disease? 6
1. Spider naevi >5
2. clubbing
3. Palmer erythema
4. Dupytren's contracture
5. Gynaecomastia
6. Testicular atrophy
31
Where are spider naevi present?
In the chest, not the abdomen (SVC distribution)
32
What happens when you press down on a spider naevi?
the whole thing goes pale and then flushes from the inside and goes red again
33
What are the signs of portal hypertension? 4
1. Splenomegaly
2. Ascites
3. Dilated veins on the abdomen (caput medusae)
4. Haemtemesis/melaena
34
What are the signs of liver cell failure? 5
1. Jaundice
2. Leuconychia (low protein)
3. Bruising (clotting/fibrinogen)
4. Ascites
5. Encephalopathy (flapping tremor caused by nitrogen)
35
What happens when you squeeze the blood out of the caput medusae vein by pushing on it?
The Blood fills the vein again from the umbilicus outwards
36
What is the other cause of distended abdominal veins on the abdomen?
Inferior vena cava obstruction
37
How can you differentiate between IVC obstruction and caput mudusae from portal hypertension?
Look at the vein below the umbillicus and press down on it - the blood should re-fill towards the umbillicus wherease in caput medusae the blood would refill away from the umbilicus
38
What are 5 causes of ascites?
1. Portal hypertension /
2. portal thrombosis
3. IVC obstruction
4. Budd chiari syndrome (hepatic vein obstruction)
5. Ovarian malignancy
39
What are the features of Cholestasis?
1. Excoriations (scratch marks)
2. Pale stools
3. Dark urine (negative for urobilinogen)
4. Jaundice
5. Xanthelasmata
6. If they have PBC then anti-mitochrondrial antibodies may be positive
40
On palpation how can you differentiate between a spleen and the left kidney? (5)
1. Spleen has a notch
2. You cannot get above the spleen, but you can for the kidney
3. Spleen = dull to percussion (but kidney is resonant due to overlying bowel
4. Kidney is ballotable
5. Spleen moves to RIF
Kidney mores down when the pt inhales
41
When you ballot the kidney which hand should remain still?
The top hand
42
What are the causes of erythema nodosum?
1. Sarcoidosis
2. Strep infection
3. IBD
4. TB
43
Erythema multiforme (looks like targets)- which age groups tend to get them?
Children and young adults
44
What is the most common cause of erythema multiforme?
7-14 days after Herpes simplex
45
What are the other causes of erythema multiforme?
Mycoplasma
Strep
TB
Sulphonylurea
46
What is another name for really severe erythema multiforme?
Stevens- Johnson-Syndrome (this is erythema multiforme with mucosal ulceration and you get liver failure
47
What is erythema ab igne and what is it caused by?
It is brown patchy discolouration caused by chronic heat e.g. from repeated use of a hot water bottle
(No treatment is needed)
48
What is erythema margniatum associated with?
Acute rheumatic fever
49
What is erythema chronicium migrans associated with?
Lyme disease
50
What are the stages of diabetic retinopathy?
1. Background
2. Pre-proliferative
3. Proliferative
51
What are the features of background diabetic retinopathy?
1. Venodilation
2. Microaneurysms
3. Hard exudates (protein and lipid deposits)
52
What are the features of pre-proliferative diabetic retinopathy?
1. Cotton wool spots (soft exudate) - these are ischaemic events
53
What are the features of proliferative diabetic retinopathy?
New vessel growth
54
If cotton wool spots are present what treatment is needed?
Laser
55
What are the 4 grades of hypertensive retinopathy?
Grade 1. Silver wiring and arteriolar narrowing
Grade 2. AV nipping
Grade 3. Flame shaped haemorrhages and cotton wool spots
Grade 4. Papilloedema
56
What is AV nipping?
When the artery crosses the vein, the vein gets narrower
57
If someone has a positive Romberg's sign what does this tell you and what would you then want to check?
Romberg's sign (stand with feet together and eyes closed - if they fall then it is positive)
It tells you they are very visually dependent when they walk and so you would want to check proprioception
58
What nerves are being tested when you ask someone to stand on their heels?
L4 and L5
59
What nerves are tested when you ask someone to stand on their toes?
S1 and S2
60
What is the gait like in an UMN lesion?
They will drag their feet and circumduct their legs (bilaterally)
61
What condition will cause positive Trendenlenburg sign?
Trendenlenburg sign - when you try and pick up you leg off the ground, the hip for that leg sinks so when these patients walk they waddling leaning their whole body weight from side to side)
myopathy - weakness in the gluteal muscles
62
What is the difference between cerebellar ataxic gait vs sensory ataxic gait?
Both are broad based
| the difference is that in sensory they will stamp as they are not aware of where the floor is/how hard they are stepping
63
If there is a sensory ataxic gait and they are stamping, what sign might you want to check for?
Romberg's
64
If it was a motor and sensory peripheral neuropathy then what might you notice on the gait?
Foot drop + broad-based gait w/ stamping
65
At the start of the neuro exam - what is it really important to ask the patient and why?
If they have any pain or numbness or tingling
(when you get to the examination you need to work from the numb area towards the normal area)
if they have a lot of pain, then you work from the normal area towards the area with pain because you dont want to plunge straight into the painful bit
66
What may Charcot's joints be a sign of on inspection?
Peripheral neuropathy - if the sensation in the feet is down and they repeatedly crash their feet they can get Charcot's joint
67
Is Spasticity UMN or LMN?
UMN
68
What is the descriptive term for spasticity?
Clasp knife
69
What are the features of spasticity?
Velocity dependent
Directional (given away by posture) - e.g. pushing the fingers is in is fine but then you try and open the fingers out it is much more difficult
70
What are the two types of rigidity in Parkinsons?
Lead pipe rigidity
| Cog wheel rigidity
71
What is lead pipe rigidity?
When rigidity is smooth and consistent throughout
72
What is cog wheel rigidity?
If the rigidity is jerky then it is cog wheel which is thought to be rigidity superimposed onto an underlying tremor
73
Which nerve root does the triceps reflex test?
C7
74
Which nerve root does the biceps reflex test?
C5
75
Which nerve root does the brachioradialis reflex test?
C6
76
Which nerve root does the knee/patellar reflex test?
L3 and L4
77
Which nerve root does the ankle/achilles reflex test?
S1 and S2
78
When is a reflex considered absent?
when it is absent with reinforcement
79
If the lesion is below L1 why will it always be lower motor neurone?
Because the spinal cord stops at T12/L1
80
What are the causes of predominantly hypertriglyceridaemia?
```
Alcohol
Diabetes type 1 and 2
Obesity
Drugs: Thiazide diuretics, non-selective beta blockers, unopposed oestrogen
Liver disease
Chronic renal failure
```
81
What are the causes of predominantly hypercholesterolaemia?
Nephrotic syndrome
Cholestasis
Hypothyroidism
82
What is the sensory role of the median nerve?
Thumb
Index finger
Middle finger
83
What is the motor role of the median nerve?
```
LOAF muscles
Lateral lumbricals,
Opponens pollicis,
Abductor pollicis brevis
Flexor policis brevis
```
84
What is Leishmania spread by?
Sandfly
85
Name the 3 different types of Leishmania
Cutaneous
Mucocutaneous
Visceral
86
What are the buzz words for Strep pneumonia cause of pneumonia?
Lobar
| rusty coloured sputum
87
What are the buzz words for Haemophiulus influenzae cause of pneumonia?
COPD
| Bronchiectasis
88
What are the buzz words for Klebsiella cause of pneumonia?
Alcoholic
| red-currant jelly sputum
89
What are the buzz words for Staph aureus cause of pneumonia?
Post- influenza infection
90
What are the buzz words for Mycoplasma pneumoniae cause of pneumonia?
Atypical
Dry
Autoimmune haemolytic anaemia
Hyponatraemia
91
What are the buzz words for Pneumocystis jiroveci (PCP) cause of pneumonia?
Exertional desaturation
HIV
dry cough
92
What are the buzz words for Legionella pneumophilia cause of pneumonia?
Atypical
Air conditioning
Hyponatraemia
lymphopaenia
93
What type of organism is Pneumocytis jirovecii?
Fungus
94
Which of organisms cause cavitating in pnuemonia?(2)
Klebsiella
| Staph aureus
95
What is the gold standard investigation for Bronchiectasis?
High resolution CT (signet ring- the airway is larger than the artery next to it)
96
How long do patients with bronchiectasis and infective exacerbation need antibiotics for compared to pneumonia?
Bronchiectasis - 14 day course of Abx
| Pneumonia - 5 days if mild, 7-10 days if more severe
97
What are the features of a moderate asthma attack? (4)
1. PEFR 50-75% best or predicted
2. Speech normal
3. RR < 25 / min
4. Pulse < 110 bpm
98
What are the features of a severe asthma attack? (4)
1. PEFR 33-50% best or predicted
2. Can't speak in full sentences
3. RR > 25/ min
4. Pulse >110 bpm
99
What are the features of life-threatening asthma attack? (5)
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
NOte: normal CO2 indicates life threatening also
100
CXR is not routinely done in an asthma attack, but when would you get one?
1. Life threatening
2. Not responding to treatment
3. Suspected pneumothorax
101
In acute asthma attack, what is the criteria for admission to hospital?
1. Life threatening
2. Severe that is not responding to initial treatment
3. Pregnancy
4. Previous near fatal asthma attack
5. Asthma attack despite being on oral corticosteroids
6. Presentation at night time
102
Describe the criteria of how to administer SABA e.g. salbutamol or terbutaline in asthma attack
Modterate - give SABA via pressurised Metered dose inhaler
| Severe - give nebulised SABA
103
Which patients in asthma attack should be given corticosteroid and what prescription?
```
All patients
Prednisolone
40-50mg
Oral
for 5 days (or until they recover)
```
104
Whilst the patient is on oral corticosteroid for asthma attack what is the advice regarding their normal asthma managment?
Continue as normal
| even the inhaled corticosteroid can be taken whilst they are on oral prednisolone
105
Which patients in asthma attack receive ipratropium bromide?
1. Severe or Life-threatening asthma
| 2. Non-responders to SABA and corticosteroids
106
Which asthma attack patients may receive mag sulf?
Severe or life threatening attacks
107
When might you consider aminophylline in asthma attack?
after consultation with a senior staff member
108
If asthma attack patients fail to respond, what could they receive in ITU?
Intubation and ventilation
| ECMO - extracorporeal membrane oxygenation
109
What is the criteria for discharging a patient following an asthma attack? (3)
1. They have been stable on their discharge medication (i.e. no nebulisers or oxygen) for 12–24 hours
2. Inhaler technique checked and recorded
3. PEF >75% of best or predicted
110
Which antibiotics can be used first line in COPD acute exacerbations?
Amoxicillin
Clarithromycin
Doxycycline
111
What is the corticosteroid prescription given in acute COPD exacerbation?
Prednisolone
30mg
Oral
for 5 days
112
How do you differentiate between acute bronchitis and pneumonia?
History
Sputum, wheeze, breathlessness may be absent in acute bronchitis whereas at least one tends to be present in pneumonia
Examination: No other focal chest signs (dullness to percussion, crepitations, bronchial breathing) in acute bronchitis other than wheeze.
Systemic features (malaise, myalgia, and fever) may be absent in acute bronchitis, whereas they tend to be present in pneumonia.
113
What are the contraindications to lung cancer surgery?
SVC obstruction, FEV < 1.5, MALIGNANT pleural effusion, and vocal cord paralysis
114
How is asthma diagnosed in patients >17 yo?
1. Find out if the symptoms are better away from work/home - if yes then refer to specialist
2. Spirometry with bronchodilator reversibility (BDR) testing - ALL PATIENTS
3. FeNO (fractional exhaled nitric oxide) - ALL PATIENTS
115
How is asthma diagnosed in patients aged 5-16 yo?
1. Spirometry with bronchodilator reversibility testing - ALL PATIENTS
2. FeNO testing - ONLY if spirometry showed normal/obstructive picture with negative Bronchodilator reversibility (BDR) test
116
How is asthma diagnosed in patients <5 yo?
Based on clinical judgment - usually it would be viral induced wheeze at that age
117
What is considered positive FeNO?
adults > or = to 40 ppb
| children > or = 35 ppb
118
What is considered positive BDR test?
adults:
1. improvement of FEV1 by 12% or more and
2. an increase in volume of 200ml or more
children:
1. improvement of FEV1 by 12% or more
119
What are the doses of low, moderate and high dose ICS in adults?
< or = 400 micrograms (mcg) = low dose
400 - 800 micrograms (mcg) = moderate
>800 micrograms (mcg) = high
120
How often should you consider stepping down asthma treatment?
Every 2-3 months
121
IF you decide to reduce the dose of ICS, by how much is advised in each step down?
25-50% at a time
122
When diagnosing COPD, when should spirometry be carried out?
Post-bronchodilator - FEV1/FVC ratio needs to be <70% even after the bronchodilator
123
In COPD diagnosis, what is the role of FBC?
To exclude secondary polycythaemia
124
What are the stages of COPD severity?
```
FEV1 (of predicted):
Mild >80 % (need symptoms to diagnose)
Moderate 50-79%
Severe 30 -49%
Very severe <30%
```
125
If a patient is on LTOT for COPD how long much supplementary oxygen should they be breathing per day?
15 hours
126
Which COPD patients should be assessed for LTOT?
1. Very severe COPD (consider assessment if Severe)
2. Cyanosis
3. Polycythaemia
4. Raised JVP
5. Peripheral oedema
6. Oxygen sats < or = 92% on air
127
What does the assessment for LTOT in COPD patients consist of?
ABG on 2 occasions at least 3 weeks apart
128
In which COPD patients do you then offer LTOT to?
1. If O2 is <7.3kPa
2. Is O2 is between 7.3 -8 kPa and they have one of the following
- peripheral oedema
- pulmonary HTN
- secondary polycythaemia
129
Who should LTOT not be offered to?
Those who continue to smoke despite the smoking cessation support
130
What vaccinations do COPD patients need?
1. annual influenza
| 2. one-off pneumococcal
131
Outline the 2-level Wells score of Pulmonary embolism
1. Clinical signs and symptoms of DVT (minimum of leg swelling and pain with palpation of the deep veins) = 3 points
2. Alternative diagnosis less likely than PE = 3 points
3. Tachycardia > 100bpm = 1.5 points
4. Immobilisation for 3 days / surgery in the last 4 weeks = 1.5 points
5. Previous DVT/PE = 1.5 points
6. Haemoptysis = 1 point
7. Malignancy (on Rx, Rx in the last 6 months, palliative) = 1 point
132
What is the interpretation of the 2 -level Wells score for PE?
< or = 4 points - PE unlikely
| > 4 points - PE likely
133
If PE is likely according to Wells score, what do you do?
Arrange an immediate CTPA (if unable to occur soon then start anticoagulation)
134
If CTPA for PE is negative what do you do?
Proximal leg vein US if DVT is suspected
135
If PE is unlikely according to Wells score what do you do?
Arrange a D-dimer test (if it cannot be attained within 4 hours then start anticoagulation)
136
If the D- dimer for PE is positive, what do you do?
Arrange an immediate CTPA
137
If the D- dimer for PE is nagative, what do you do?
PE is unlikely, consider other diagnosis
138
If a patient has renal failure, which is used CTPA or V/Q scan in ?PE and why?
V/Q scan as you avoid the contrast which is used in CTPA
139
What are the ECG findings of PE?
S1Q3T3
S1 = Large S wave in lead 1
Q3 = Large Q wave in lead 3
T3 = T wave inversion in lead 3
RBBB
Right axis deviation
Sinus tachycardia
140
In ?PE, which patients should have a CXR?
All patients - important to exclude other pathology
141
What are the 8 criteria in the Pulmonary Embolism rule out criteria (PERC)?
1. Age > or = 50
2. Heart rate > or = to 100 bpm
3. Oxygen < or = to 94%
4. Previous PE or DVT
5. Recent trauma or surgery in the last 4 weeks
6. Haemoptysis
7. Unilateral leg swelling
8. Oestrogen use (COPC or contraceptives)
142
When should PERC be used?
When there is a low pre-test probability of PE but you want to be sure
143
How is PERC interpreted?
Negative means all 8 are negative - meaning less than 2% chance of PE
(if positive then do 2 level Wells score)
144
In PE how long should patients be anticoagulated for?
A minimum of 3 months
145
If a patient is unstable how do you investigate for PE?
CTPA
| But if not able to get an urgent CTPA, you can get a bedside echo instead (RV dysfunction)
146
What is the management of PE in an unstable patient?
if PE found on CTPA/ RV dysfunction detected on echo
then pt needs URGENT REPERFUSION
1. UFH 10,000 Units IV - bolus
2. UFH continuous infusion
3. Consider if they need fluid resus (if SBP <90mmHg)
4. +/- vasoactive agents e.g. Noradrenaline if fluid resus is not successful
5. Consider if they need Oxygen
6. Whilst Heparin is still running, do pharmacological thrombolysis to break down the clot:
- Alteplase, Streptokinase, Urokinase (all IV)
7. Later on switch to anticoagulant (DOAC, LMWH, VKA)
147
What is the management of PE in a stable patient?
Confirmed or suspected PE - start DOAC (apixaban or rivaroxaban)
148
If a patient is unsuitable for Apixaban or Rivaroxaban, what are the alternatives?
1. LMWH (5 days) + Dabigatran or Edoxaban, then after 5 day just the DOAC
2. LMWH (5 days or until INR is > or = 2) + VKA then VKA alone
149
What 4 features might suggest COPD may be responsive to steroid (ICS)?
1. Previous diagnosis of asthma or atopy
2. Higher blood eosinophil count
3. Substantial variation in FEV1 over time (>400ml)
4. Substantial diurnal variation in PEFR (>20%)
150
When treating PE, you can risk stratify them using PESI (PE severity index) - which PESI classes are low vs intermediate?
PESI classes I and II = low
| PESI classes III and IV = intermediate
151
If PESI is low risk - how do you manage them?
Rx at home- with oral anticoag
Safety net them about bleeding risk
Follow up in 1 week
152
Within the PESI intermediate group there are 2 groups intermediate-low and intermediate-high - how do you differentiate between the two groups?
Intermediate - low has either:
RV dysfunction on Echo
OR
Cardiac markers increased (e.g. BNP, trop)
Both simply indicate strain on the heart
Intermediate high has BOTH:
RV dysfunction on echo AND raised cardiac markers
153
How do you manage intermediate patients?
Any intermediate patient will need to be admitted but if intermediate-high they will need close monitoring as they are at risk of being unstable
154
How do you manage high risk?
Unstable management:
Unfractionate Heparin
+
Thrombolysis
155
How do you define a provoke PE?
If the PE was preceded by a transient and major clinical RF in the last 3 months
156
Which needs a longer course of anticoagulation provoked or unprovoked?
Unprovoked as they might have an underlying clotting disorder etc - we dont know why they had the PE
157
In provoked PE, how long do you anticoagulate?
AT LEAST 3 months
| except in cancer it is 3-6 months
158
What is the cut off aspirate pH for knowing an NG tube is safe to use?
<5.5
159
If the aspirate pH is >5.5 on NG tube, what should you do?
CXR to confirm the position
160
If the CO2 is normal on ABG of a COPD patient, what should the o2 sats targets be?
94-98% (instead of 88-92%)
161
What are the two important investigations to get in pneumothorax?
CXR
| Bloods - Clotting profile
162
Why is clotting profile so important in Pneumothorax?
You need to know the bleeding risk before inserting a chest drain
Chest drain has a high bleeding risk and you can cause a haemothorax if clotting is derranged
163
What are the 3 categories for causes of pneumothorax?
1. Cystic causes e.g. Bullae in COPD, emphysema - if they rupture you get interruption of the pleural space
2. Parenchymal necrosis - Massive PE, severe pneumonia/TB can also cause death of lung tissue and if this area is near the pleura you can interrupt the pleura and cause air to enter
3. Iatrogenic/traumatic causes: Percutaneous biopsies, chest drains (e.g. for pleural effusion), Rib fractures
164
How should the CXR for a ?pneumothorax be taken and why
In full expiration (not inspiration) - it allows the space between the two pleura to be as wide as possible
165
In primary pneumothorax, which ones need percutaneous aspiration?
If they are symptomatic e.g. SOB
or
If the rim is >2cm
166
Where is the insertion point for percutaneous aspiration in pneumothorax?
Mid-axillary line, 5th intercostal space
167
How can you tell if percutaneous aspiration has been successful in pneumothorax?
Seeing the rim decrease on repeat CXR (<2cm) and the patient is no longer SOB
If this is the case you can discharge the patient after some observation
168
What do you do if percutaneous aspiration has not been successful in pneumothorax?
Admit and do a chest drain
169
What is another name for chest drain?
Thoracotomy tube
170
What are the surgical options for a patient in which the chest drain has bene unsuccessful?
1. Open thoracotomy
| 2. Video assisted thoracoscopic surgery (VATS)
171
What is the management of primary pneumothorax with a rim <2cm and no SOB?
Discharge home after a period of observation
172
What is the management of secondary pneumothorax with a rim <1cm (small)?
High flow oxygen
| Admit and observe
173
What is the management of secondary pneumothorax with a rim 1-2cm (moderate)?
1. Percutaneous aspiration
If successful then High flow oxygen, admit and observe
If unsuccessful then Chest drain and admit
If chest drain then unsuccessful --> surgical options
174
What is the management of secondary pneumothorax with a rim >2cm (moderate) or SOB?
Proceed straight to chest drain - no percutaneous aspiration
If unsuccessful then surgical options
175
Can you do percutaneous aspiration twice?
NO!! go straight for chest drain
176
What is the difference between empyema and abscess?
Abscess is pus in a new cavity
| Empyema literally means 'bag of pus' but it is specifically in an already existing cavity such as the pleural space
177
What is the management of Tension Pneumothorax (non-traumatic)?
1. Peri-arrest call
2. Immediate decompression using large bore cannula + high flow o2
3. Chest drain + admit
178
Where do you insert the large bore cannula for immediate decompression in Tension Pneumothorax (non-traumatic)?
2nd ICS in MCL
179
What should the advice be after a pneumothorax?
STOP SMOKING (it is a major RF)
No diving
No flying <1wk after CXR resolution
180
What is the safety triangle for insertion of a chest drain?
1. Axilla (superior boundary)
2. Lateral edge of the pectoralis major (medial boundary)
3. 5th intercostal space (inferior boundary) and
4. anterior border or latissimus dorsi (lateral boundary)
(even though "triangle" it has 4 sides)
181
What diagnosis is important to consider following acute deterioration after ventilating a patient?
Tension pneumothorax
182
Which pts should be referred for 2ww for lung cancer?
1. CXR findings suggest lung cancer
| 2. >40yo with unexplained haemoptysis
183
Which pts should be offered an urgent CXR (within 2wks) for ?lung cancer?
Age >40 (with 2 or more of the following if never smoked or 1 or more of the following if they have ever smoked):
1. cough
2. SOB
3. chest pain
4. fatigue
5. weight loss
6. appetite loss
184
Which pts should you consider doing an urgent CXR for ?lung cancer?
Age >40 and any 1 of the following:
1. persistent or recurrent chest infection
2. finger clubbing
3. supraclavicular lymphadenopathy or persistent cervical lymphadenopathy
4. chest signs consistent with lung cancer
5. thrombocytosis
185
In pleural effusion - what protein level differentiates between transudate and exudate?
30g/L
i.e. >30g/L protein level = exudate
<30 g/L protein level = transudate
186
Between what fluid protein level would you use Light''s criteria in pleural effusion?
25 -35g/L (this is a grey zone where you cannot be certain so Lights criteria is useful
187
What is Light's criteria for pleural effusion?
If any of the following apply then it is exudate:
fluid protein : serum protein >0.5
fluid LDH : serum LDH > 0.6
fluid LDH > two-thirds the ULN of serum LDH
188
What is the transfusion threshold for patients with ACS?
Hb 80g/L
189
What is the transfusion threshold in the general patient population?
Hb 70g/L
190
In pleural effusion what are the differentials for exudate?
Malignancy (lung cancer, mets, mesothelioma, lymphoma), infection (TB, pneumonia), inflammatory (SLE, Rheumatoid arthritis), Pulmonary infarct, pulmonary embolism
191
In pleural effusion, what is the pathophysiology of exudate?
Increased microvascular permeability
192
In pleural effusion what is the pathophysiology of transudate?
Increased hydrostatic pressure
| Reduced osmotic pressure
193
What are the differentials for transudate in pleural effusion?
```
Heart failure
Liver failure (cirrhosis)
Nephrotic syndrome
Meig's syndrome
Trauma
Hypoalbuminaemia
```
194
What perianal features do you find in Crohn's disease?
Skin tags
| ulcers
195
What the risk factors for Crohn's?
FH
| Smoking
196
What are the extra GI manifestations for Crohn's disease?
Skin - pyoderman gangrenosum, erythema nodosum
Eyes - uveitis, episcleritis
Joints - arthritis
197
What is the most common extra GI manifestation of Crohn's?
episcleritis
198
What bloods do you want to do to investigate Crohn's?
```
FBC (anaemia)
CRP (good marker of disease activity)
Ferritin
B12, Folate, Vitamin D (important as the malabsorption from the gut may lead to deficiency)
LFTs (albumin)
```
199
What stool investigations do you want to do for ?Crohn's?
Stool MC&S - to exclude infection e.g. ?c.diff
| Faecal calprotectin
200
What is faecal calprotectin?
It is an inflammatory marker for inflammation in the gut - but is not specific
- it is a good rule out - because fi negative then it means NO Inflammation and IBD is unlikely
201
If faecal caprotectin is raised in the work up to IBD, what IVx comes next?
Colonoscopy + histology
202
Why is b12 always replaced before folate?
if folate is replaced first it can lead to subacute combined degeneration of the spinal cord
203
When might you use imaging in diagnosis of Crohn's and what imaging options are there?
If colonoscopy doesn't detect anything
| Barium enema of small bowel, MRI, capsule endoscopy
204
What else can imagine be useful for in Crohn's disease?
Complications
205
List the imaging used in the complications of Crohn's?
```
Pelvic MRI (perianal disease)
CT Abdo + Pelvis (abscesses, fistulae, obstruction)
AXR (dilation/obstruction)
```
206
Describe the treatment ladder for inducing remission in Crohn's disease
1. Glucocorticoids (oral, topical, IV)
2. 5-ASA (you stop the steroids)
3. Add on: Azathioprine/ Mercaptopurine/ Methotrexate (this will be commonly used in those with recurrent flares (2 or more in 12 months)
4. Biologic agents: Infliximab or Adalimumab
207
When might you be inclined to use topical 5-ASA as 1st line for inducing remission in Crohn's disease (rather than glucocorticoid)?
If the disease is limited to the perianal area
208
What does 5-ASA stand fo and Name 2 examples of 5-ASAs
Aminosalicylates
Mesalazine
Olsalazine
209
If you are going to give patients Azathioprine or Mercaptopurine, what is it important to measure before starting?
TPMT levels
210
Describe the treatment ladder for maintaining remission in Crohn's disease
1. STOP SMOKING - really important
2. Azathioprine or mercaptopurine
3. Methotrexate
5. 5-ASA (often given if the person has had operations for their Crohn's disease)
211
What % of people with Crohn's disease require surgery?
80%
212
In Crohn's what is the most common surgery performed and for what?
Ileocaecal resection for terminal ileum disease
213
Which complications of Crohn's might require surgery?
1. Strictures - ballon dilatations
2. Fistulae
3. Perforation
214
How much in advance before an upper GI endoscopy do PPIs need to be stopped?
2 weeks before
215
What is the triad of symptoms in Budd Chiari syndrome?
1. Sudden onset abdo pain
2. Ascites
3. Tender hepatomegaly (Can also get splenomegaly from the portal hypertension)
216
Where do you usually get abdo pain in UC?
Left lower quadrant, but can be elsewhere
217
Which extra-GI manifestation of IBD is more common in UC than Crohn's?
uveitis (instead of episcleritis)
218
What is the additional extra-GI manifestation that you see in UC but not in Crohn's?
PSC
219
In UC, you shouldn't see disease beyond which point?
The ileum (not beyond the ileocaecal vavle)
220
However, when might you see disease in UC beyond the ileum (from the ileocaecal valve)?
In backwash ileitis
221
Which imaging can be used to really help you distinguish between UC and Crohn's
Cross sectional imaging using CT/MRI/Small bowel US
222
Management of UC is based on which 2 factors?
The extent of the disease
| The severity of the disease
223
What are the different options for extent of the disease in UC?
proctitis (just the rectum), protosigmoiditis (involves the sigmoid), left sided UC (has gone all the way up)
224
What 3 things determine severity of UC?
Stool frequency
Blood in stool
Endoscopic appearance
225
Classify UC into mild, moderate and severe based on stool frequency
Mild - 1-2/day (more than normal)
Moderate - 3-4/day (more than normal)
Severe - >5/day (more than normal)
226
Classify UC into mild, moderate and severe based on blood in stool
Mild - Streaks of blood
Moderate - Obvious blood with stool most of the time
Severe - Blood without stool (just blood coming out)
227
Classify UC into mild, moderate and severe based on endoscopic appearance
Mild - Erythema, mild friability
Moderate - Marked erythema, loss of vascular patterns, erosions
Severe - Spontaneous bleeding, ulceration
228
Describe the mangement of mild-moderate ACTIVE UC disease
1. Topical 5-ASA
2. Add on oral 5-ASA (if incomplete response after 4 weeks)
3. Switch or add topical steroids (if incomplete response)
4. If that still doesn't work then oral steroids (jump straight to step 4 if severe UC)
5. Biological agents (infliximab) - only if incomplete response to oral steroids after 2 weeks
229
What is maintenance therapy in UC involving proctosigmoiditis?
Topical 5-ASA +/- oral 5 ASA
230
What is maintenance therapy for left sided UC?
oral ASA (As topical will not work for back enough)
231
In the maintenance of UC, at what point do you consider azathioprine/mercaptopurine?
If more than 2 flares per year
232
Describe the management of severe ACTIVE UC disease (this is not for an acute flare but someone who is systemically well but just has severe disease )
1. Consider for admission
2. Oral steroids
3. Biological agents (infliximab) - only if incomplete response to oral steroids after 2 weeks
233
In Crohn's disease where do you tend to get the abdominal pain?
Right iliac fossa
| remember: UC - left lower quadrant pain
234
Compare the complications in UC vs Crohn's
Crohn's: fistulae, abscesses, gallstones
| UC: there is a higher risk of Colorectal cancer, PSC
235
Why is gallstones more of a problem in Crohn's compared to UC?
The terminal ileum is involved with bile acid resorption, so if you have terminal ileum disease in Crohn's then more prone to gallstones
236
Compare the histology in UC vs Crohn's
Crohn's: inflammaiton all layers, increased goblet cells and granulomas
UC: inflammation limited to mucosa and submucosa, crypt abscesses
237
Compare the endoscopy findings in UC vs Crohn's
Crohn's : Deep ulcers, skip lesions, cobblestone mucosa
| UC: Superficial ulceration, pseudopolyps
238
Compare the barium study findings in UC vs Crohn's
Crohn's: kantor's sign (strictures), rose thorn mucosa (ulcers)
UC: loss of haustra, pseudopolyps, lead-pipe colon
239
What does a serum albumin ascites gradient (SAAG) help you distinguish between?
A peritoneal (<11) vs non-peritonial (>11) cause of ascites
240
List some non-peritoneal causes of ascites
Budd Chiari
Nephrotic syndrome
Liver cirrhosis
241
List some peritoneal causes of ascites
TB Peritonitis
| Peritoneal mesothelioma
242
Which is medication is used for ascites secondary to liver cirrhosis?
Spironolactone
243
Upon diagnosis of which two conditions should you also then screen for coeliac disease?
T1DM
autoimmune thyroid disease
(this is cause there is a link between these 2 and coeliac disease)
244
Which vaccine does Coeliac UK recommend for those with coeliac? (And state the regimen)
Pneumococcal vaccine upon diagnosis and a booster every 5 years
245
Why do coeliac patients receive a pneumococcal vaccine?
They are prone to overwhelming pneumococcal sepsis due to hyposplenism
246
Which bloods should those with coeliac disease have annually?
1. FBC
2. Ferritin
3. TFTs
4. LFTs
5. B12
6. Folate
247
What bloods should you take for someone with an acute flare of IBD?
```
FBC
CRP
U and E
LFTs
Additonal bloods:
Hep B, Hep C, HIV, VZV, TB screen
```
248
What is the reason for doing additional bloods such as Hep B and C and HIV screen for a pt having an acute flare of IBD?
In case they need to be started on a biologic agent
249
How do you initially manage an acute flare of IBD?
A-E approach
| NBM + IV fluids + IV hydrocortisone (100mg) + LMWH
250
If there is no improvement within 72 hours of initial management for acute flare of IBD, what is the next step?
```
IV infliximab
IV ciclosporin (UC)
```
251
During the management an acute flare of IBD, it is important to always consider the need for what?
Emergency surgery
252
What is the referral criteria for 2ww OGD ?
Any dysphagia
OR
>55 yo with ALARM symptoms
253
What are the alarm symptoms?
```
Anaemia
Loss of weight
Anorexia
Recent/progressive symptoms
Malaena/Haemoatemsis
Swallowing difficulty (dysphagia)
```
254
If someone presents with dyspepsia, what is the lifestyle advice?
Weight loss
Smoking cessation
Reduce alcohol
Review medications - NSAIDs and steroids
255
What is the medical management for dyspepsia?
Test for H. pyloria, whilst you are waiting start them on a 4 week trial of PPI
256
If a patient with dyspepsia has trialled the 4 weeks of PPI and their H.pyloria testing returned as negative, what is the next step?
Try a different medication
H2-receptor antagonist e.g. ranitidine
If that also doesn't work (i.e. optimal medical management has failed, then refer for endoscopy)
257
If you use H. pylori eradication therapy, in which patients would you do an H.pylori retest?
- Poor compliance
- Still symptomatic
- Hx of peptic ulcer disease
258
How long do you give H. pylori eradication therapy for?
7 days
259
What is the 2nd line H.pylori eradication therapy for someone who is not pen allergic?
PPI, metronidazole, clarithromycin
| note first line would have been PPI, amoxicillin, clarithromycin
260
What is 2nd line H. pylori eradication in someone who is pen allergic?
PPI, metronidazole, levofloxacin
261
What are the risk factors for GORD?
Smoking
Obesity
Alcohol
Male
262
If a patient has dyspepsia and is sent for ODG and it is found they have GORD (and hence oesophagitis on OGD) - what is the treatment?
Conservative : weight loss, stress reduction, alcohol reduction, sleep with head of bed raised
Medication: PPI for 8 weeks
263
What are the risk for peptic ulcer disease?
H. pylori
NSAIDs
Stress (physiological e.g. shock, sepsis, burns)
Zollinger-Ellison syndrome
264
How do you manage peptic ulcer disease?
Test for H.pylori, and if +ve then eradicatino therapy
| If -ve, full dose PPI for 4-8 weeks
265
HOw do you manage a peptic ulcer if it is associated with both NSAIDs and H.pylori?
2 months of full dose PPI before you then give eradiacation therapy
266
What is the follow up for peptic ulcer disease?
Repeat H.pylori testing in 6-8 weeks
| Repeat endoscopy in 6-8 weeks (only if it was gastric ulcer)
267
GI bleeding is more common with which type of peptic ulcer and why?
dudodenal ulcers as they can erode the gastroduodenal artery
268
What are the complications of peptic ulcer?
GI bleed
Perforation
Gastric outlet obstruction (if Stricture/ scarring/ pyloric stenosis/ duodenal stenosis from inflammation)
269
What are the RF for barrets oesophagus?
GORD
Smoking
Male
Obesity
270
What is the management of barrets oeseophagus?
Full dose PPI
| Endoscopic surveillance
271
How often is the endoscsopic surveillance in barrets oesophagus?
every 3-5 years
272
If dysplasia is detected within barrets oesophagus, what is the management?
endoscopic mucosal resection or radiofrequency ablation
273
How can you categorise Upper GI bleed?
Variceal vs non-variceal
274
What are the variceal upper GI bleeds?
Oesophageal varices
| Gastric varices
275
Non-variceal bleeds (5)
1. Mallory Weiss tear
2. Boerhaave's
3. Peptic ulcer disease
4. Malignancy
5. Angiodysplasia
276
What bloods do you want to take in an upper GI bleed?
```
FBC (anaemia)
U and E
LFTs
Clotting
VBG/ABG
G+S
Cross match
```
277
What is the risk assessment for upper GI bleed?
Glasgow Blatchford scale
278
How do you manage a non-variceal bleed?
Resuscitate then OGD in 24 hours
(fi severe bleed then OGD immediately after resus)
Do NOT give PPIs before endoscopy as it can affect what you see
279
If on OCG during Upper GI bleed, they detect a bleeding peptic ulcer what can they do?
1. adrenaline injection to the ulcer
2. sclerosant injections
3. endoclips
these are all during the endoscopy
280
If they have a bleeding peptic ulcer in Upper GI bleed what prescription of PPI would you give?
IV PPI for 72 hours
281
What is the treatment for variceal bleed?
Resus
Prophylactic antibiotics
Terlipressin
Urgent OGD
282
If varices are detected on OGD what can be done during the endoscopy?
```
Band ligation
(it is better for varices over sclerotherapy)
```
283
What is the triad of acute liver failure?
Jaundice
Encephalopathy
Coagulopathy
284
What are the causes of acute liver failure?
Infections - Hep A-B (esp A and B), EBV/CMV, leptospirosis
Toxins - Paracetamol, drug induced
Vascular - Budd chiari, veno-occlusive disease
Others - Wilson disease, autoimmune hepatitis, lymphoma
285
Where are platelets made?
By the liver
286
What imaging might you want to do if ?acute liver failrue?
Abdo USS - liver texture, vessel flow, splenic size
| CTAP (CT abdo pelvis) - liver texture and volume, vessel patency
287
What is the criteria for diagnosing acute kidney injury?
1. increase in Creatinine 26nanomol/L in 48 hours
2. increase in creatinine by more than 50% in 7 days
3. urine output <0.5/kg/hour for more than 6 hours
288
How does calcitonin reduce serum calcium levels?
It inhibits osteoclast activity
289
Why are the bones at risk of osteomalacia if a patient has a high phopshate?
PTH is released to reduce the phosphate but in the process PTH also breaks down bone
290
What 'standard' bloods do you want to request in acute liver failure and justify each
FBC - platelets (produced by liver- indicates function)
U and Es - hepatorenal syndrome (if severe)
LFTs - may help identify cause
ABG - pH and lactate (can indicate severity)
Clotting - synthetic function
Group and save - transfusions may be required
291
Which additional bloods do you want to check for helping to identify the cause of actue liver failure?
1. Paracetamol levels
2. Viral hepatitis serology
3. ANA/Anti-smooth muscle (autoimmune hepatitis)
4. Urinary copper, serum ceruloplasmin (Wilson's disease)
292
What is the King's College criteria can be used to determine need for liver transplant in acute liver failure due to PARACETAMOL OVERDOSE?
King's College criteria
ph <7.3
OR
INR >6.5 + creatinine >300 + grade 4 encephalopathy
293
What is the King's College criteria can be used to determine need for liver transplant in acute liver failure NOT due to PARACETAMOL OVERDOSE?
```
INR >6.5
OR
Any 3 of:
- Age <10, Age >40
- time from jaundice to encephalopathy >7
- INR >3.5
- Bilirubin >300
- non A or B viral hepatitis
- drug induced hepatitis
```
294
Where should patients with acute liver failure be treated?
in ITU
295
What is the treatment for acute liver failure caused by autoimmune hepatitis?
methyprednisolone
296
What is the treatment for acute liver failure caused by Budd Chiari syndrome?
Anticoagulation
297
What is the surveillance for those with cirrhosis (and hence an increased risk of HCC)?
Anyone with confirmed cirrhosis should have 6 monthly USS and AFP to screen for HCC
298
At diagnosis of cirrhosis why do patients need an OGD?
To check for oesophageal varices
299
If there are no oesophageal varices upon OGD (after diagnosis of cirrhosis) what is the surveillance?
OGDs every 3 years
300
If varices are detected on OGD (after cirrhosis diagnosis) but are not bleeding - what prophylaxis can you give?
Propranolol
301
Aside from HCC and oesophageal varices what is the other big complication of cirrhosis?
Ascites
302
What is first line treatment to ascites?
Diuretic - spironolactone
303
If ascites is refractory to diuretic treatment, what might you do next?
Therapeutic paracentesis (come in regularly to get ascitic drains)
304
What is a TIPSS procedure?
Transjugular Intrahepatic Portosystemic shunt (helps to divert blood away from the portal vein so that you can reduce the portal HTN
305
Give some examples of triggers for decompensated liver disease
Alcohol/drugs
Sepsis/Infection
GI bleed
Ischaemic injury
306
If in ascitic tap, the neutrophils are >250 what does this mean?
Spontaneous Bacterial peritonitis
307
What is the treatment for SBP?
IV antibiotics and Human Albumin Solution
308
What is the treatment for hepatic encephalopathy?
Lactuloase and
| Rifaximin
309
What does lactulose do, to help treat hepatic encephalopathy?
It promotes excretion of ammonia
310
What does Rifaximin do to help treat encephalopathy?
Decreases production of ammonia
311
What are the 3 stages of alcoholic liver disease?
Steatosis (fatty liver)
Alcoholic hepatitis (inflammation and necrosis)
Cirrhrosis
312
What is the management for alcoholic liver disease?
Alcohol abstinence +/- withdrawal management
Nutritional supplements: Thiamine/pabrinex
Steroids: for alcoholic hepatitis
313
Which hepatitis is always acute?
Hep A
314
What is the incubation time of Hep A?
2 weeks
315
Which hepatitis is dangerous in pregnant women?
Hep E
316
What is the treatment of Hep A and E?
supportive treatment, self- limiting
317
What makes Hep B different to the other Hep viruses?
It is a DNA virus - the others are RNA
318
Which part of Hep B serology is a marker of severity?
HBeAg
319
How long does anti HBc IgM remain high for?
6 months (remember the IgM is seen in the acute infection whilst the IgG is seen in the chronic infection)
320
What is the treatment for Hep B ?
Supportive - 90% of adults will clear it
321
When can Hep D infect someone and why?
It can either co-infect someone with Hep B simultaneously or it can superinfect an individual that already has Hep B
This is because it is an incomplete RNA virus
322
Which Hepatitis is curable?
Hep C - treated with antivirals based on the virus genotype
323
What investigations would you do for Hep C?
Hep C PCR
| Viral genotyping - dictates treatment
324
What is the main complication with Hep C?
HCC
325
Which HLA is autoimmune hep associated with?
HLA DR3
| HLA B8
326
What are the antibodies to look out for in autoimmune hepatitis?
ANA
anti- smooth muscle antibodies (SMA)
anti LKM antibodies
327
What is the treatment of autoimmune hepatitis?
1. Steroids
2. immunosuppressants e.g. azathioprine
3. live transplant if really bad
328
What do you need in order to see Kaiser Fleischer rings
A slit lamp
329
What will the copper IVx look like for Wilsons disease?
reduced serum caeruloplasmin
reduced serum copper
increased 24 hr urinary copper
330
Penicillamine used in the Rx of Wilsons disease does what?
copper chelating agent
331
Which antibodies for PBC?
AMA - main one
SMA
Raised IgM
332
What is the treatment of PBC?
itching - cholestyramine
Ursodeoxycholic acid - for bile salts
transplant
333
Which autoimmune condition is associated with cholangiocarcinoma
PSC
334
Which ANCA does PSC have?
p-ANCA
335
What might liver biopsy show in PSC?
onion-skinning - concentric circles around bile duct of fibrosis
336
Which UTIs are complicated?
Persistent infection
Rx failure
Recurrent infection
Atypical organism
337
What are upper urinary tract infection?
Ureter or kidney (pyelonephritis)
338
What is the time period to define catheter associate UTI?
symptoms within 48 hours
339
What is the eGFR cut off for CKD? and what other features help to diagnose CKD?
PERSISTENT eGFR <60
- urinary albumin:creatinine >3
- urine sediment abnormalities
- structural abnormalities
340
What are the first things you want to assess in AKI?
1. Assess the volume status - this will help indicate if they are pre-renal, renal or post-renal
2. Review the DH and stop any nephrotoxic drugs
341
What is the management for pre-renal AKI?
Fluid resus and treat the underlying cause
342
What is the management for renal AKI?
Investigate the cause (e.g. ANA, ANCA)
Refer to specialist
Consider dialysis
343
What is the management for post-renal AKI?
If they have a catheter, flush it and see if still draining - if not then put a new one
Catheterise the patient if they have post-renal without a catheter- this will relieve the urinary retention
344
What is the criteria for receiving dialysis in AKI?
Refractory pulmonary oedema
persistent hyperkalaemia
Metabolic acidosis
Uraemic complications e.g. pericarditis
345
What are the 3 main causes of CKD?
HTN
Diabetes
Glomerular disease
346
What pneumonic can be used to remember the complications of CKD?
CRF HEALS
347
What does CRF HEALS stand for?
Cardiovascular disease
Renal osteodystrophy
Fluid (oedema)
```
Hypertension
Electrolyte abnormalities
Anaemia
Leg restlessness
Sensory neuropathy
```
348
Which medications may be involved in the management of CKD?
```
Statin
Antiplatelet therapy
Vitamin D and calcium suppplements
Phosphate binders
Diuretics
EPO (if iron def)
```
349
What are the blood pressure targets in CKD?
<140/90
350
What are the BP targets in T2DM?
<140/90
351
What are the BP targets in T1DM?
<135/85
But if T1DM and albuminuria then <130/80
But if T1DM and 2 or more features of metabolic syndrome then <130/80
352
What foods should those with CKD avoid?
Those which are potassium and phosphate rich
353
Which foods have high potassium?
Bananas, oranges, potatoes and sweet potatoes
354
Which foods have high phosphate?
Chicken, turkey, seafood, dairy
355
What are the primary causes of nephrotic syndrome?
Minimal change disease
Focal segmental glomerulonephritis
Membranous glomerulonephritis
356
What are the secondary causes of nephrotic syndrome?
Diabetes
SLE
Amyloid
Hep B/C
357
What are the primary causes of nephritis syndrome
Membranoproliferative glomerulonephritis
| Rapidly proliferative glomerulonephritis (Crescentic)
358
What are the secondary causes of nephritis syndrome?
```
Post-streptococcal glomerulonephtritis
IgA nephropathy
Vasculitis
SLE
Good pasture's syndrome
```
359
What 3 things classify nephrotic syndrome
Proteinuria (>3g/24 hours)
Hypoalbuminaemia
Oedema
(Hyperlipidaemia)
360
What 3 things classify nephritis syndrome?
Hypertention
Haematuria
Oliguria /Proteinuria
361
What is the most severe glomerulonephritis with poor prognosis?
Rapidly progressive/proliferative
362
What is the difference between haemodialysis and haemfiltration?
Dialysis is vis diffusion
| Filtration is via convection
363
What is the triple therapy for maintenance of Renal replacement?
1. Calcineurin inhibitor e.g. Tacrolimus
2. Anti-metabolite e.g. azathioprirne
3. Prednisolone
(all are immunosuppressants)
364
What are the indications for renal replacement therapy in CKD?
eGFR <10
| symptomatic complications from the kidney disease
365
What is the acronym for causes of a normal anion gap? (expand it as well)
```
ABCD
Addisons
Bicarb loss
Chloride
Drugs
```
366
What are the features of L3 nerve root compression?
Sensory loss over anterior thigh
Weak quadriceps
Reduced knee reflex
Positive femoral stretch test
367
What are the features of L4 nerve root compression?
Sensory loss anterior aspect of knee
Weak quadriceps
Reduced knee reflex
Positive femoral stretch test
368
What are the features of L5 nerve root compression?
Sensory loss dorsum of foot
Weakness in foot and big toe dorsiflexion
Reflexes intact
Positive sciatic nerve stretch test
369
What are the features of S1 nerve root compression?
Sensory loss posterolateral aspect of leg and lateral aspect of foot
Weakness in plantar flexion of foot
Reduced ankle reflex
Positive sciatic nerve stretch test
370
What are the clinical signs of a fracture?
```
Pain
Swelling
Deformity
Crepitation
Adjacent structural damage: nerve, vessel, ligament, tendon
```
371
What are the five steps in describing a fracture?
1. Location i.e. which bone + which part of the bone
2. Pieces: Simple/multifragmentary
3. Pattern: Transverse/oblique/spiral
4. Displaced/undisplaced
5. Translated/Angulated
372
State the name of translation away from the midline and state the term for angulation away from the midline (coronal plane)
Lateral translation
| Valgus
373
State the name of translation toward the midline and state the term for angulation toward the midline (coronal plane)
Medial translation
| Varus
374
How would you describe translation and angulation in the sagittal plane i.e. the sideways plane
Anterior or posterior translation
| Dorsal or Volar angulation
375
What are the criteria for starting Ivabradine?
1. the patient is already on suitable therapy (ACE-inhibitor, beta-blocker + aldosterone antagonist), and
2. has a heart rate > 75/min, and
3. a left ventricular fraction < 35%
376
What is the gold standard IVx to diagnose aortic dissection?
CT Angio
377
If a patient with ?aortic dissection is unable to go for CT angio due to being unstable, what is the next best investigation?
Transoesophageal echo (TOE)
378
What is the most common type of aortic coarctation?
Post-ductal - this means that the narrowing is after ductus arteriosus and hence after the subclavian artery meaning the BP in the upper limbs is greater than that of the lower limbs
