Pastest Flashcards
What is pure red cell aplasia?
Unexplained anaemia and reticulocytopenia with a complete absence of red cell precursors in the bone marrow but with preservation of other cell lines.
It can occur spontaneously, or in association with autoimmune diseases, lymphoproliferative disorders or viral illnesses such as HIV, hepatitis and herpes.
Treatment is supportive, with immunosuppression.
Rarely the condition can occur where recombinant erythropoietin is administered and patients respond to withdrawal of erythropoietin.
What is the treatment of serotonin syndrome?
First line: Benzodiazepines,
Second line: Cyproheptadine
Haemodialysis does not directly treat but instead is a supportive measure to treat acute renal failure or to help remove excessive concentrations of myoglobin in rhabdomyolysis.
How do you investigate suspected gastinoma?
The best initial screen is a fasting gastrin level on 3 separate days, as the secretion of gastrin is pulsatile. Three samples in the normal range make gastrinoma unlikely.
This is usually followed by basal acid output estimation and a secretin stimulation test. After this, patients usually move on to imaging studies. In the absence of metastases, surgical resection is advised. Ocreotide, interferon and chemotherapy may be useful in non-surgically resectable lesions.
What antibodies are associated with diffuse systemic sclerosis?
Different auto-antibody patterns are associated with differing patterns of disease associated with systemic sclerosis. Anti-nuclear antibody (ANA) tests provide in approximately 95% of patients with SSc, and therefore a negative test should prompt consideration of other fibrosing illnesses.
Anti-RNA polymerase III antibodies are found in patients with diffuse disease, and are associated with rapidly progressive skin involvement as well as an increased risk for scleroderma renal crisis. These patients may also be at increased risk for cancer.
What are the most common findings on ECG for a hypothermia patient?
J-waves, prolonged QT interval and AV junctional rhythm.
J waves are highly sensitive and specific for hypothermia. Other causes of J-waves include hypercalcaemia and intracranial pathology likely SAH.
What are the features of Liddle syndrome?
Hypertension, Hypokalaemia, Alkalosis, Hyporeninaemic hypoaldosteronism and hypertension.
Autosomal dominant
What is the referral criteria for specialist transplant unit in paracetamol overdose?
Arterial pH <7.30
Grade III or IV hepatic encephalopathy
Coagulopathy with a PT >100 seconds
Acute renal impairment with a creatinine >300 micromol/l
-Studies have shown up to 80% mortality rate in this case
What is the treatment for mesothelioma?
Rarely suitable for surgical resection and is not responsive to chemotherapy.
Palliative radiotherapy after thoracoscopic pleurectomy may be indicated. Only pemetrexed and cisplatin as chemotherapy has demonstrated a positive response. The prognosis is extremely poor, with an average survival of 1-2 years from diagnosis.
What are the most effective agents in maintaining remission in Crohn’s disease?
Thiopurines (azathioprine and 6-mercaptopurine) are the most effective agents in maintaining remission in Crohn’d disease long term. They are thought to be particularly effective in patients with fistulating disease.
If not tolerated methotrexate could be used as an alternative.
ASA (5-Aminocalycilic acid) compounds such as balsalazide and sulphasalazine have a role in maintaining remission and are generally well tolerated but are not as effective as thiopurines.
Polymeric diet has most value in reducing the severity of acute flares and their frequency, rather than resolving fistulae.
Subacute meningitis (developing over weeks) is more associated with what organisms?
Tuberculous, cryptococcal, histoplasmal, partially treated bacterial, neoplastic or granulomatous infiltration of the meninges.
What features are assocaited with TB meningitis?
Subacute onset with confusion
Risk factors (homeless, incarceration, alcohol)
Involvement of the basal meninges (brainstem signs (e.g. cranial nerve palsy))
Associated secondary spinal meningitis,
High protein and very low glucose on CSF
Hyponatraemia secondary to SIADH.
What are the features of brown-sequard syndrome?
Loss of vibration and proprioception senses on the ipsilateral side.
Associated ipsilateral weakness, hypertonia, hyper-reflexia and extensor plantar reflex, with segmental anaesthesia at the level of the lesion.
Loss of pain and temperature on the contralateral side.
NOTE: complete syndrome picture is rare and many patients may only exhibit some features of the syndrome.
What is the most common papilloma virus subtype responsible for causing periungual squamous cell carcinoma?
HPV-16
Other high risk cancer HPV subtypes include 18, 31 and 45.
What are the primary cause of plantar warts?
HPV 4
HPV 2 is responsible for common and plantar warts.
How do you treat a suspected myxoedema crisis?
Treatment involves IV thyroxine (T3) and slow rewarming. It is also important to take serum for thyroid function and adrenal function. Coexisting hypoadrenalism is suggested by hyponatraemia, hyperkalaemia and raised urea. Patients may also be hypoglycaemia.
Treatment with hydrocortisone is recommended until Addison’s disease is excluded. It is important to provide hydrocortisone until Addison’s is excluded, as just giving thyroid hormone alone may precipitate an adrenal crisis.
When do NICE now recommend treatment in patients with Hep B?
Adults aged >30 years with Hepatitis B virus (HBV) DNA >2000 IU/ml and abnormal ALT (>30 IU/ml in men; >19 IU/ml in women) on two consecutive tests, three months apart.
Adults aged <30 years with the above but ALSO evidence of necro-inflammation or fibrosis on liver biopsy or a transient elastography score >6 kPa.
Adults who have HBV DNA > 20,000 IU/ml and abnormal ALT on two consecutive tests conducted 3 months apart, regardless of age or the extent of liver disease.
Patients without a liver biopsy with a transient elastography score > 11kPa
What is the treatment for patients with Hepatitis B who meet the criteria?
Pegylated interferon alfa-2a in patients with compensated liver disease for 48 weeks.
Entecavir and tenofovir are offered as second-line treatments where pegylated interferon therapy has failed or is not tolerated.
What is the treatment for Hepatitis C?
Pegylated interferon and ribavarin
However, NICE has recently recommended new antivirals for hepatitis C, eg sofosbuvir-velpatasvir (Epclusa) and patients are being selected on clinical need. Therefore, patients may elect to defer treatment with interferon-ribavarin due to its side-effect profile and opt to wait for the newer, better tolerated antivirals.
What is the treatment of glioblastoma multiforme post surgical resection?
Gold standard in fit patients is Radiotherapy 60 Gy in 30 fractions with concomitant temozolomide, followed by up to 6 cycles adjuvant temozolomide.
-Temozolomide is an alkylating agent with promotes guanine methylation; this, in turn, causes defective cell replication and triggers cancer death
-The phase III EORTC/NCIC CTG trial showed significant survival improvement in 18-70 year olds who recieved temozolomide and radiotherapy vs radiotherapy alone (2-year survival 26% vs 10%).
In geriatric (>70) patients it is radiotherapy 40 Gy in 15 fractions with concomitant temozolomide, followed by up to 12 cycles adjuvant temozolomide.
-Main concern about a radical course of radiotherapy is potential high incidence of neurotoxity and deterioration in quality of life.
-In addition, some trials have shown longer survival with a hypofractionated, shorter radiotherapy course in the geriatric population.
What is the treatment of glioblastoma multiforme post surgical resection?
Gold standard in fit patients is Radiotherapy 60 Gy in 30 fractions with concomitant temozolomide, followed by up to 6 cycles adjuvant temozolomide.
-Temozolomide is an alkylating agent with promotes guanine methylation; this, in turn, causes defective cell replication and triggers cancer death
-The phase III EORTC/NCIC CTG trial showed significant survival improvement in 18-70 year olds who recieved temozolomide and radiotherapy vs radiotherapy alone (2-year survival 26% vs 10%).
In geriatric (>70) patients it is radiotherapy 40 Gy in 15 fractions with concomitant temozolomide, followed by up to 12 cycles adjuvant temozolomide.
-Main concern about a radical course of radiotherapy is potential high incidence of neurotoxity and deterioration in quality of life.
-In addition, some trials have shown longer survival with a hypofractionated, shorter radiotherapy course in the geriatric population.
How commonly does genitourinary TB develop in those with pulmonary TB?
Genitourinary TB develops in approximately 5% of cases of pulmonary TB and is usually due to haematogenous spread to the renal cortex during the primary phase of infection. The cortical lesion may then ulcerate into the pelvis, ultimately involving the bladder, seminal vesicles and prostate. It tends to present between 20 and 40 years of age. Other clinical features include haematuria, urethral strictures, cold abscesses and chronic epidiymo-orchitis. Kidney disease may occur due to extensive destruction of the kidneys or by obstruction secondary to fibrosis.
What ECG changes would you see in dextrocardia (with normal lead placement)?
Inverted P-waves in lead I with a negative major QRS deflection. Upright P-waves with a positive QRS deflection are seen in lead aVR with mirror image findings in lead aVL, and an abnormal precordial progression of R wave from lead V1 to V6.
What percentage of patients with sarcoidosis will have neurological complications?
Around 5%.
These include cranial nerve palsies (from basal meningitis), optic neuritis, mononeuritis multiplex, myelopathy, seizures, granulomas causing mass effect and neuropsychiatric manifestations.
What is the treatment of cutaneous leprosy?
Dapsone, rifampicin and clofazimine
What is the pathogenesis of inclusion body myositis?
CD8 positive T cells and macrophages leading to muscle necrosis.
What is the treatment for Typhoid fever?
Options are ciprofloxacin, azithromycin and ceftriaxone
Sensitivity testing is important in this case as significant resistance to ciprofloxacin and azithromycin now exist.
Where sensitivity does exist to quinolones, these are an option for mild disease. In patients with more significant symptoms or resistance, IV ceftriaxone is the preferred option.
Patients are usually retested after 1 week following therapy to rule out chronic carriage or Salmonella
What is the criteria for discontinuing trastuzumab
If LVEF drops by 10% AND below 50%, treatment should be suspended and a repeat LVEF performed within 3 weeks.
If LVEF has not improved, or declined further trastuzumab should be discontinued unless benefits outweigh the risks. (these patients should be followed up by a cardiologist)
The her2 receptor is known to be protective against development of cardiomyopathy.
What gastric MALT lymphomas are less likely to respond to eradication therapy?
Response is less likely if cytogenetic abnormalities have been acquired (t11:18 being the most common), or if the muscularis mucosa has been invaded.
Maltomas (AKA marginal zone lymphomas) are often associated with chronic inflammation of which 4 types?
In the stomach secondary to chronic H. Pylori gastritis.
In the eyes secondary to Sjogren’s syndrome.
In the thyroid secondary to Hashimoto’s thyroiditis.
In the intestine secondary to Crohn’s or coeliac disease.
What is the diagnostic criteria for neurofibromatosis type 1?
Two or more of the following:
-6 or more cafe-au-lait macules > 5 mm (prepubertal) or > 15mm (post-pubertal)
-two or more neurofibromas of any type or one plexiform
-freaking in the axillary or inguinal regions
-optic glioma
-two or more Lisch nodules on the iris
-distinctive Osseous lesion typical of type 1 NF, e.g. sphenoid dysplasia, thickening of the long bone cortex with or without pseudo-arthrosis
-a first degree relative with type 1 NF
When should a lateral decubitus CXR be used in suspected pneumothorax?
If PA CXR is normal and a small pneumothorax is suspected, a lateral decubitus CXR provides added information in up to 14% of cases.
For patients in the lateral decubitus position, air rises to the non-dependent lateral location. Only 5ml of pleural air may be needed to detect pneumothorax in this position.
When do you add steroids in PCP?
BHIVA guidelines recommend addition of methylprednisolone to IV Co-trimoxazole when paO2 <9.3kPa or SpO2 <92% as this is an indicator of severe disease
What are the differentials for absent ankle reflexes and extensor (upgoing) plantars?
Syringimyelia
Friedreich’s ataxia
Motor neurone disease
Conus medularis lesion
Subacute degeneration of the cord
Taboparesis for of tertiary syphilis
Exercise electrocardiology is not useful in patients with what?
Conduction abnormalities
Resting ECG abnormalities such as ST-segment depression of > 1mm
Wolff-Parkinson-White syndrome
Those taking digitalis
Those with ventricular paced rhythm
