peer teaching Flashcards
What are the SE of L-dopa?
Postural hypotension on starting treatment
Confusion, hallucinations
L-dopa induced dyskinesias
On-off effect: fluctuations in motor performance between normal function
(on) and restricted mobility (off).
Shortening duration of action of each dose (i.e. end-dose deterioration where
dyskinesias become more prominent at the end of the duration of action)
What should be used in conjunction with L-dopa to reduce SE?
Dopa decarboxylase inhibitor (e.g. carbidopa or benserazide)
In terms on incontinence, what anti-muscaranics are best and worst for delirium?
oxybutnin worst, try use solifenacin or trospium instead as don’t cross BBB and cause delirium
1st line laxative in the elderly?
1st line: bulk forming laxative eg ispaghula (fibergel) UNLESS an opioid then do docusate (osmotic and stimulant laxative)
What is c.diff cause by and what is the mx?
C.diff caused by cephalosporins, ciprofloxacin, clindamycin, amoxicillin/co-amox
Mx: metronidazole for 10-14 days
What is the immediate vs long-term mx of a TIA?
Immediate Management Plan:
ABCDE assessment
Aspirin (300 mg daily) started immediately (with PPI if indicated).
Specialist assessment and investigation within 24 hours of onset of symptoms
Specialist assessment within 1 week if suspected TIA more than 1 week ago.
Long-Term Management Plan (secondary prevention):
Lifestyle modification
Clopidogrel 75mg daily
Statins, antihypertensives if necessary.
Warfarin/NOACs if AF, mitral stenosis, dilated cardiomyopathy, recent big septal MI.
What heart conditions can cause a CVA?
Atrial fibrillation MI causing mural thrombus Infective endocarditis Aortic or mitral valve disease Patent foramen ovalee
Describe the Oxford/ Bamford classification of strokes
- unilateral hemiparesis and/or hemisensory loss of the face, arm & leg
- homonymous hemianopia
- higher cognitive dysfunction e.g. dysphasia
Total anterior circulation infarcts (TACI, c. 15%)
involves middle and anterior cerebral arteries
all 3 of the above criteria are present
Partial anterior circulation infarcts (PACI, c. 25%)
involves smaller arteries of anterior circulation e.g. upper or lower division of middle cerebral artery
2 of the above criteria are present
Lacunar infarcts (LACI, c. 25%)
involves perforating arteries around the internal capsule, thalamus and basal ganglia
presents with 1 of the following:
1. unilateral weakness (and/or sensory deficit) of face and arm, arm and leg or all three.
2. pure sensory stroke.
3. ataxic hemiparesis
Posterior circulation infarcts (POCI, c. 25%) involves vertebrobasilar arteries presents with 1 of the following: 1. cerebellar or brainstem syndromes 2. loss of consciousness 3. isolated homonymous hemianopia
WHat are sx of hypercalcaemia?
Bone pain, fractures (hyperPTH or
malignancy)
Renal stones (renal colic); renal
impairment (renal calcinosis);
polyuria, polydipsia, dehydration
(nephrogenic diabetes insipidus)
Drowsiness, delirium, coma, muscle
weakness, impaired cognition,
depression
Nausea, vomiting, weight loss,
anorexia, constipation, abdominal
pain.
HTN, shortened QT, arrhythmias.
What are sx of hypocalcaemia?
Paraesthesia (usually fingers, toes
and around mouth).
Tetany.
Carpopedal spasm (wrist flexion and fingers drawn together).
Muscle cramps
Seizures.
Prolonged QT
Laryngospasm; bronchospasm
What MMSE score supports a diagnosis of dementia?
MMSE <25 supports dementia. 25-27 is borderline.
<10 severe; 10-20 moderate; 21-24 mild.
What other cognitive assessment tools may be used for dementia?
Addenbrookes cognitive examination-III (ACE-III)
Montreal cognitive assessment (MoCA)
Abbreviated mental test score (AMT)
6-Item cognitive impairment test (6CIT)
General practitioner assessment of cognition (GPCOG)
List 4 blood tests you would do to exclude treatable
causes of dementia.
Thyroid function tests
Syphilis serology (neurosyphilis)
Liver function tests (hepatic encephalopathy; alcoholism)
Vitamin B12, thiamine (B1) and folate levels
What is Donepezil and what types of dementia can it be
used to treat?
Donepezil is an acetylcholinesterase inhibitor; used only in
Alzheimer’s disease. (Others ACh-ase inhibitors: rivastigmine
and galantamine)
Alternative medication: memantine, a N-methyl-D-aspartate
(NMDA)-receptor antagonist which blocks glutamate. (Only in
moderate to severe Alzheimer’s)
What does the comprehensive geriatric assessment
entail?
1) Medical
Doctors, nurses, pharmacist,
dietician, speech & language
therapist
2) Mental Health
Doctors, nurses, psychologist, OT
3) Functional Capacity OT, PT, S&LT eg Activities of Daily Living Gait & Balance Activity/Exercise Status
4) Social & Environmental
OT, Social worker
What is important not to give in LBD?
neuroleptics should be avoided in Lewy body dementia as patients are extremely sensitive and may develop irreversible parkinsonism!!
When should alendronic acid be stopped?
After a 5year period for oral bisphosphonates (3years for IV zoledronate), treatment should be re-assessed for ongoing treatment, with an updated FRAX score and DEXA scan.
BUT If high risk continue, e.g. of high risks: Glucocorticoid therapy Age >75 Previous hip/vertebral fractures Further fractures on treatment High risk on FRAX scoring T score
what is second line after alendronic acid for OP?
risedronate or etidronate
Name the mechanism of action and adverse effects of alendronic acid
Bisphosphonates are analogues of pyrophosphate, a molecule which decreases demineralisation in bone. They inhibit osteoclasts by reducing recruitment and promoting apoptosis.
Adverse effects
oesophageal reactions: oesophagitis, oesophageal ulcers (especially alendronate)
osteonecrosis of the jaw
increased risk of atypical stress fractures of the proximal femoral shaft in patients taking alendronate
Describe the meaning of the T scores in OP
- 1 to +1 = healthy
- 2.5 to -1 = osteopenia
> -2.5 = osteoporosis
what is malnutrition?
BMI <18.5kg/m2
Unintentional weight loss >10% last 3-6mths
BMI <20kg/m2 AND unintentional weight loss >5% within last 3-6mths
Describe the physiological signs of refeeding syndrome
CVS: arrhythmia, HT, CHF
GI: abdo pain, constipation, vomiting, anorexia
MUSC: weakness, myalgias, rhabdomyolysis, osteomalacia
RESP: SOB, ventilator dependence, respiratory muscle weakness
NEURO: weakness, paraesthesia, ataxia
METABOLIC: infections, thrombocytopaenia, haemolysis, anaemia
hypophosphataemia; hypokalaemia; hypomagnesaemia
hyperglycaemia; thiamine deficiency (erthryocyte transketolase or thiamine level)
OTHER: ATN, Wernicke’s encephalopathy, liver failure
What can cause a rash in the EBV caused infection?
A maculopapular, pruritic rash develops in around 99% of patients who take amoxicillin whilst they have Infectious Mononucleosis (glandular fever)
What is pencillamine used for?
it is used as a copper
chelating agent in Wilson’s disease NOT a penicillin
What ix if used for monitoring progress in cancer?
a positron emission tomography (PET) scan. This uses a radioactive tracer to show
the areas of high uptake and therefore areas of active malignancy.
what sx count as the B sx of leukaemia B cancer?
unexplained fever, unexplained weight loss, and drenching sweats (particularly at
night)
RF for DDH?
Females are 6x more likely to have developmental dysplasia of the hip
(DDH). Breech birth, high birth weight, oligohydramnios, and prematurity are all risk factors.
What is the cheese effect and what antidepressants does it effect?
This is to avoid the ‘cheese effect’ of eating tyramine-rich foods with a Monoamine oxidase inhibitor
antidepressant, as it can lead to a build up of tyramine and hypertension. Phenelzine is an example of a
MAO inhibitor.
describe mx for acute mania vs acute bipolar depressive episode vs long ter mx of bipolar
The first line treatment for an acute manic or mixed episode in BAD is an atypical antipsychotic. For a
depressive episode it’s an atypical antipsychotic plus an SSRI, usually Olanzapine and Fluoxetine.
However, for long term maintenance, Lithium is the first line. Valproate, carbamazepine, Chlorpromazine can be
added in if this doesn’t work.
What kind of tremor is seen in lithium therapeutic levels vs OD? what are the other sx of lithium toxicity?
A fine tremor is generally regarded as a side effect of Lithium in the therapeutic range,
whereas a coarse tremor would develop if it was in the toxic range.
Ataxia, Seizure, Slurred speech, Vomiting
what is the first line drug for an alcohol detox?
Chlordiazepoxide
+ can also give thiamine (pabrinex) in detox
What is the ICD-10 classification of delirium?
- ) Impairment of consciousness and attention
- ) Global disturbance in cognition
- ) Psychomotor disturbance
- ) Disturbance of sleep-wake cycle
- ) Emotional disturbances
what ix results would you see for NMS?
Raised CK (creatine kinase) –> due to muscle rigidity
● Raised white cell count
● Deranged LFT’s
● Acute renal failure –> abnormal U&E’s
● Metabolic acidosis –> low pH, low HCO3
How do you tx PID in response to the coil?
Start antibiotics immediately
- Prescribe doxycycline, metronidazole, and IM ceftriaxone (broad-spectrum management)
- Leave in a recently inserted coil. If there is no response within 48hrs to the antibiotics,
remove the coil and prescribe any other necessary emergency contraceptives
What abx should be used for UTI in pregnancy ?
Nitrofurantoin should be avoided in the 3rd
trimester as there is a risk of haemolytic
anaemia in neonate with G6PD deficiency
Trimethoprim is a folate antagonist and so can cause neural tube defects if used in the 1st
trimester
cephalosporins and amoxicillin safe at any point in pregnancy
What is the first line drug tx for stress incontinence?
Duloxetine
What is the 1st, 2nd and 3rd line tx for endometriosis?
1st: NSAIDs
2nd: COCP
3rd: IUD
A 21 year old woman has acute onset of pain in her right iliac fossa pain. She has marked
tenderness upon palpation in this area, some voluntary guarding, but no rebound tenderness. She has
not vomited and denies feeling nauseous. Her temperature is 37.2°C, her pulse rate is 80 bpm, and her
blood pressure is 115/80 mmHg. Her pregnancy test is negative. An ultrasound scan shows a 7 cm
right-sided haemorrhagic ovarian cyst with no free fluid. Which is the single most appropriate initial
management?
needs to be
managed conservatively.
Most cysts presenting acutely will present with lower abdominal pain, but without signs of peritonism or
systemic upset. The absence of vomiting, peritonism, and a fever make torsion and appendicitis unlikely,
therefore no need to refer to the surgeons at this stage.
What is the mx of PROM?
antibiotics should be given for 10 days following premature preterm rupture
of membranes, or until the woman is in established labour, whichever is sooner.
1st line for chlamydia?
Chlamydia vs gonorrhoea?
1st line for candida?
-Doxycycline 100mg PO BD for 7 days
-gonorrhoea, unlike chlamdyia, classically causes ‘purulent’ vaginal
discharge, and doesn’t normally cause intermenstrual or post-coital bleeding
-Clotrimazole
What tests are used to diagnose syphilis?
Cardiolipin based tests (eg VDRL) and Specific treponemal antibody tests (TPHA)
is a migraine bilateral or unilateral?
uni
Which anti-psyotics cause parkinsonisms?
typical eg haloperidol
How do you diagnose orthosttic hypotension?
Drop in blood pressure of at least 20 systolic or 10 diastolic within 3 minutes of standing
aortic dissection vs MI presentation?
Aortic dissection and myocardial infarction share many common features (e.g. sudden severe central
chest pain, sites of radiation, sweaty appearance). However, aortic dissection is usually maximally
painful at the time of onset, whereas MI tends to build in intensity from the onset. Migration of the pain
caudally is also more suggestive of aortic dissection. A weak left-sided pulse suggests aortic dissection
(this occurs due to involvement of the subclavian artery). While hypertension can be a risk factor for MI,
it is the single biggest risk factor for aortic dissection (on examination, the patient may remain
hypertensive, or may become hypotensive due to blood loss).
What can be use dot reverse the effects of LMWH? What about DOACs?
Protamine can be used to reverse heparin. It is fully effective against unfractionated heparin, and
partially effective against LMWH.
Beriplex is used for most DOACs
After MONA how should a MI be treated once it reaches hospital?
Bisoprolol, clopidogrel, and LMWH
STEMIs presenting >12 hours from onset should be given streptokinase too.
What is the definitive test for the IBD
Ileocolonoscopy (taking biopsies from terminal ileum and affected colonic areas)
What blds may be seen in DKA?
hyperglycaemia, metabolic acidosis and ketonaemia
hyperkalaemia
mildly raised creatinine (sign dehdydration)
In what order does the rash of chickpox present as?
papules > vesicles > pustules > crusts
What psych med can cause agranulocytosis?
Clozapine, an atypical antipsychotic, carries a significant risk of agranulocytosis.
What med can be used in OCD apart from SSSRIs eg fluoxetine?
Clomipramine
When do clozapine blood tests takeplace?
Every week for 18 weeks
What is the most common type of vaginal cancer?
Secondary (metastatic) Vaginal cancer
Does nulli or high parity increase chance of placenta praevia?
increased parity
At what amniotic fluid index (AFI) would a pregnancy be diagnosed with polyhydramnios? what about olgio?
Polyhydramnios is usually diagnosed at an AFI of >24cm (or 2000ml+). Oligohydramnios is usually
diagnosed with an AFI of <5cm (or under 200ml)
A 23-year old lady attends her 20-week booking appointment and undertakes routine
asymptomatic bacteriuria screening, the result comes back positive for the presence of bacteriuria.
What are the most appropriate next steps?
Confirm presence of bacteriuria with second culture and then begin culture dependent
antibiotic
Mary is a 54 year old who presents with urine leakage when she runs. She has 3 vaginal deliveries,
with her youngest child she had retained placenta resulting in a hysterectomy. Her BMI is 28. She does
not experience leakage at night or just as she gets to the toilet. What is the most likely diagnosis?
stress incontinence
What is Mydriasis?
dilated pupil
are pupils dilated or constricted in horner’s syndrome?
constricted
Describe corticobasal vs PSP vs multi system atrophy?
Corticobasal degeneration and
progressive supranuclear palsy are Parkinson plus syndromes- corticobasal degeneration would have
alien hand syndrome (limbs moving on their own), apraxia and aphasia as well as Parkinsonism;
progressive supranuclear palsy would have supranuclear opthalmoplegia (can’t look down to begin with,
then progresses to inability to look left and right), pseudobulbar palsy (inability to control facial
movements), neck dystonia, balance issues with lots of falls, behavioural and cognitive impairment as
well as the Parkinsonism.
Multi-system atrophy causes autonomic symptoms as well as Parkinsonism e.g. postural
hypotension, erectile dysfunction or bladder disturbance.
What is the fluid choice in initial DKA mx?
Use 0.9% sodium chloride with 20 mmol potassium chloride in 500 ml (40 mmol per litre) until
blood glucose levels are less than 14 mmol/l
Describe feverpain score and its subsequent mx
fever past 24 hrs no cough or coryzal sx sx in last 3 days purulent tonsils severe tonsil inflamm
score is 2 you would consider a delayed prescription for antibiotics.
should be advised to use the prescription if there is no improvement in his symptoms in 3 to 5 days or if
his symptoms worsen.
If someone scores a FeverPAIN of 4 or 5 you would consider an immediate
antibiotic prescription or a back-up antibiotic prescription. Phenoxymethylpenicillin is often
prescribed for tonsillitis
what is Naevus flammeus
port wine stain - t it is due to a vascular malformation of the
capillaries in the dermis
Describe the 3 stages of disimpactation
A disimpaction regimen involves a
macrogol laxative (C) e.g. polyethylene glycol and electrolytes (Movicol Paediatric Plain). If this doesn’t
work, a stimulant laxative (E) e.g. senna can be added. If the macrogol laxative is not tolerated, an
osmotic laxative e.g. lactulose (D) can be used instead.
A 1-year old patient presents with a 2 day history of irritability and fever, with the parents
reporting a change in behaviour and reduced eating. After examination of the child you diagnose
them with bilateral acute otitis media. How would you manage this patient?
First line treatment for a patient under 2 years of age with bilateral acute otitis media is a 5-day
course of amoxicillin,
– Consideration of antibiotics if symptoms have not resolved by day 5 is applicable when there are no
indications for immediate antibiotic prescribing (e.g. AOM in only hearing ear, cochlear implant present,
AOM in both ears in children <2 and perforated TM)
What does a Wedge excision treat?
Meckel’s diverticulum –
A 30 year old woman with a history of depression asks her GP if she can stop her Fluoxetine as she
has been taking it for 2 months and is feeling much better now. What would the GP recommend?
If a patient has a good response to antidepressant therapy they should continue on treatment for at least
6 months after remission to reduce the risk of relapse
whhen are women tested for anemia in pregnancy?
Women are offered a blood test to screen for anaemia in their booking visit (8-12 weeks – ideally under
10 weeks) and at 28 weeks gestation.
when is cephalic version offered
37 weeks
What sections of the MHA to the police use
Section 136 allows a police office to section a person suspected of having a mental disorder in a public
place. They can be held for 72 hours and should be seen by a doctor or AMHP. Section 135 can be used to
section a person within their home and remove them to a place of safety. The other sections are less
clinically relevant.
A 70 year old gentleman called Jack presents to the GP complaining of headaches. They are right
sided and typically occur after he brushes his hair very specifically the right hand side of his forehead.
They are sharp pain and his forehead is delicate to touch. He recently had visual loss briefly describing
it like a curtain blocked his right eye vision. What first line treatment would you initiate?
Prednisolone
Concerns this may be Temporal arteritis with amaurosis fugax of the eye causing visual loss. Risk of total
visual loss therefore give high dose steroids urgently. Temporal artery biopsy is diagnostic. Also at risk of
aortic aneurysm in the condition would want to do a CTA.
e commonest cause of a convergent squin
A convergent squint is the commonest form of childhood quint. Hypermetropia or long sightedness
causes the image to focus behind the retina when the eye is at rest. excessive accommodation can bring
the image into focus but also causes a convergent squint in children. convex lenses can counteract the
refractory error and remove the squint in most cases.
tests for coeliacs
endoscopy NOT colonsocopy
add blds here:
What is the DSM-V criteria for ADHD?
make careless mistake, trouble paying attention, does not listen, fails instructions/ task follow through, disorganised, loses things, forgetful, easily distracted
fidgets, leaves seat, runs inapporpriately, loud, on the go, talks excessively, answers before questions completed, trouble waiting turn, interrupts others
<12 yrs, 2+ settings
What is the second line med in ADHD?
Lisdexamfetamine
What is seen on XR in NEC?
Dilated Bowel Loops
Bowel wall oedema
Pneumotitis Intestinalis: gas within the wall of the intestine
How is glue ear mx?
watch and wait, autoinflate (balloon nose), hearing aid and if bad grommets
WHat is speticaemia vs meningitis
septicaemia = positive blood cultures - therefore has the purpuric rash caused by bleeding into skin and mucus membranes meningitis = positive LP culture
What should be if a child has bilateral impabable testes?
Hormonal testing and karyotyping
What are the signs of lithium toxicity?
Signs of lithium toxicity include increasing diarrhoea, vomiting, anorexia, muscle weakness, lethargy,
dizziness, ataxia, lack of coordination, tinnitus, blurred vision, coarse tremor of the extremities and lower
jaw, muscle hyper-irritability, choreoathetoid movements, dysarthria, and drowsiness.
Severe lithium toxicity occurs at serum lithium concentrations of approximately 2 mmol/L and above.
Signs include, hyper-reflexia and hyperextension of limbs, syncope, toxic psychosis, seizures, polyuria,
renal failure, electrolyte imbalance, dehydration, circulatory failure, coma, and occasionally death.
How does disulfarim vs naltrexone work?
disulfarim = deterrent drug which results in an increase in serum acetaldehyde if alcohol is consumed –> unpleasane sx
(think disulfarim makes you want to DIe)
naltrexone = helps reduce cravings
What should be monitored in those who take lithium?
weight, urea and electrolytes (U&E), estimated glomerular filtration
rate (eGFR), calcium, and thyroid function tests (TFT)
When should someone be given Inpatient assisted withdrawal with chlordiazepoxide
Do AUDIT to assess whether they need it
They drink over 30 units of alcohol per day, have a score of more than 30 on the SADQ, have a history of epilepsy, or past experience of withdrawal-related seizures or delirium tremens during previous assisted withdrawal programmes, need concurrent withdrawal from alcohol
and benzodiazepines, regularly drink between 15 and 30 units of alcohol per day AND have significant
psychiatric or physical comorbidities (for example, chronic severe depression, psychosis, malnutrition,
congestive cardiac failure, unstable angina, chronic liver disease) or a significant learning disability or
cognitive impairment
What combination of drugs is most associated with serotnin syndrome?
the combination of a selective serotonin reuptake inhibitor (SSRI) such as fluoxetine with a mono-amine oxidase inhibitor (MAOI) such as phenelzine is most associated with serotonin syndrome
How is serotonin syndrome mx?
Cyproheptadine
What is the mx of preterm labour?
16-24 weeks - with a TVUS cervical length of <25mm and no previous preterm birth/trauma needs vaginal progesterone.
OR if the patient had a previous preterm birth or any cervical trauma cervical cerclage stitch
>24 weeks - TVUS <15mm tocolytic eg nifedipine + steroids
What to koplik spots look like?
red with white bit in middle
If someone present w depression what should be assessed first, physical causes or do a PHQ-9 test?
PHQ-9 test
what tests can be done for MG?
ice test or tensilon test
Which steroid do the sick day rules apply to?
hydrocortisone
When is oxygen given in a MI?
if sats are less than 94%
How does AF look on ECG?
irregularly irregular rhythm, and no distinct p waves
primary vs secondary vs tertiary prevention
In primary prevention, the intervention aims to remove or reduce a risk factor or introduce a protective factor (in this case folic acid) to prevent a disease before it has developed (in this case neural tube defects). Secondary prevention aims to intervene to prevent progression of a disease whilst it is asymptomatic or in the early stages (e.g. screening) or to prevent recurrence (e.g. after a myocardial infarction), whereas in tertiary prevention the disease is already established and the aim is to minimise disability and other negative effects of the disease and reduce complications.
define FTT
Weight falls across 1 or more weight centile spaces and birthweight was below the 9th centile or
Weight falls across 2 or more weight centile spaces and birthweight was between the 9th and 91st centiles or
Weight falls across 3 or more weight centile spaces and birthweight was above the 91st centile or
Current weight is below the 2nd centile for age, regardless of birthweight
NMS vs SS
NMS develops over days to weeks, whereas serotonin syndrome develops over 24 hours. NMS is more characterised by rigidity and bradyreflexia. Hyperreflexia and myoclonus are rare in NMS.
Leucocytosis, increased CK in NMS
What are RF for endometriosis
Risk factors for endometriosis include factors that would prolong the amount of bleeding a woman has in
her lifetime e.g. early menarche, late menopause, delayed childbearing, and nulliparity. Other risk factors
include family history, vaginal outflow obstruction, white ethnicity, low body mass index and
autoimmune disease.
What is the first line ix for menorrhagia?
FBC
Mirena is first line for management of menorrhagia and COCP is second line. For women who don’t want contraception, either tranexamic acid or mefenamic acid can be used.
Further investigations, such as a TVUS, are only indicated if there is suspected underlying pathology such as fibroids, polyps or adenomyosis
If you are unsure whetheter a pt has chlamydia or gonorrhoea, but want to treat before cultures, what should be the mx?
Azithromycin 1g stat can be used for both the treatment of gonorrhoea & chlamydia.
How can cauda equina be treated?
This is “high-dose Dex”, an easy and quick way of reducing malignant compression, because it reduces
the oedema around the tumour site, in this case reducing compression on the Cauda Equina
Then referred for surgical mx
What scan should be done for a pituitary tumour?
CT head is the best answer, they are quick and easily
available, helping us decide if this lady requires urgent admission or if she can wait a little longer.
What liver enzyme is elevated in alcoholic liver disease?
AST
