Peer teachings Flashcards
What type of hypersensitivity is SLE
3 and 2
Triad of lupus
Fever, joint pain, rash in woman of child bearing age
What is needed for SLE diagnosis
4/11 Malar rash Discoid rash Photosensitivity Mouth/nose ulcers Serositis (pleuritis/pericarditis) Polyarthritis Renal Neurological (siezures) Haematologic Antinuclear antibodies Other antibody (anti-smith, anti dsDNA, antiphospholipid)
What can pANCA differentiate
Crohns and UC. UC has it. Crohns doesnt.
Parkinsons genes
Normally not genetic but: PINK1, Parkin, alpha synuclein
What is present in the substantia nigra of those with parkinsons
Lewy bodies (eosinophilic with alpha synuclein)
Clinical features of parkinsons
Pill roll resting tremor, Cog wheel rigidity, Bradykinesia, Hypokinesia, Akinesia (from difficulty initiation movements), postural instability
What doesnt parkinsons cause
Weakness
How does the tremor differ between parkinsons and cerebellar disease
Parkinsons is resting, cerebellar is intention
Other dopaminergic dysfunction leads to
Depression, dementia, sleep disturbances, difficulty smelling.
Parkinsons treatment
Levodopa, Ropinirole (dopamine agonist). Selegiline (MAO-B inhibitor, early on), Entacapone (COMT inhibitor, later on). Deep brain stimulation.
What is the role of Th1
Helps macrophages produce an immune response. IL2, IFN gamma
What is the role of Th2
Helps B cells produce immunoglobulins. IL4,5,10
Requirements for Obstructive spirometry
Reduced FEV1 (<80% normal), Reduced FEV1:FVC ratio (<0.7), reduced peak flow
Requirements for restrictive spirometry
Reduced FVC and FEV1. Normal ratio and peak flow
Interstitial lung disease examples
Sarcoidosis, IPF, Asbestosis, Goodpastures, GPA (Wegeners granulomatosis)
Define asthma
Chronic respiratory condition associated with airway inflammation and hyperresponsiveness
3 pathophysiological changes in asthma
Airway inflammation, airway obstruction and bronchial hyperresponsiveness
Which drugs can make asthma worse
NSAIDs, Aspirin and beta blockers
What causes the second wave of inflammation in asthma
Leukotriene release from mast cells
Symptoms of asthma
Tachypnoea, wheeze, cough
Signs of asthma
Expiratory polyphonic wheeze, hyperinflation, cyanosis, use of accessory muscles, hyperresonant, reduced air entry
Investigations for asthma
FeNO (>40ppb), Spirometry (FEV1/FVC <0.7), bronchodilator reversibility (>12%/200ml), peak flow meter (diurnal variation)
1st line asthma
Short acting B2 agonist (salbutamol) as needed
2nd line asthma
Low dose inhaled corticosteroid (beclametasone)
3rd line asthma
Low dose ICS + LABA (salmeterol)
4th line asthma
+Leukotriene receptor antagonist (Montelukast) then pred
What is used for asthma monitoring
Peak flow and asthma control test
What is the asthma control test
Past 4 weeks How often has it affected your work How often were you SOB How often nocturnal waking How often use rescue inhaler
What does unable to complete sentences suggest
Acute asthma. Give high flow O2, salbutamol nebs and prednisolone. Do ABG and CXR. Can add MgSO4
Causes of acute asthma
Infections esp viral, pneumothorax, triggers
PEF for severity of acute asthma
Moderate = 50-75
Severe= 33-50/ cant complete sentence
Life threatening= below 33 or altered conscious
Define COPD
A common preventable and treatable disease characterised by persistent airflow limitation that is usually progressive and associated with an enhance chronic inflammatory response
What is CREST
Limited cutaneous systemic sclerosis. Calcinosis cutis Raynauds phenomenon oEsophageal dysmotility Sclerodactyly Telangiectasis
What causes wheeze
Air thorugh mucus
What cuases crackles
Alveoli opening
COPD signs
Exertional breathlessness, chornic cough, regular sputum production, wheeze, frequent winter bronchitis
What are signs of COPD
Use of accessory muscles, pursed lip breathing, barrel chest, tar staining on fingers, cyanosis, weight loss form prolonged hypoxaemia, wheeze and reduced breath sounds
COPD v Asthma histologically: cells
COPD neutrophils, CD8 T cells and many macrophages. Asthma mast cells, eosinophils, CD4 T cells and macrophages
COPD v Asthma histologically: mediators
Asthma: Histamine, IL-4, IL5, some ROS. COPD: IL8 TNFa, many ROS
COPD v Asthma histologically: effects
Asthma: all airways, little fibrosis, epithelial shedding. COPD: Peripheral airways, lung destruction, fibrosis and squamous metaplasia.
COPD v Asthma response to steroids
Asthma is very responsive, COPD isnt
What is the classification for airflow limitation
GOLD. FEV1% Predicted 1, mild= >80% 2, moderate= 50-79% 3, severe= 30-49% 4, very severe= <30%
COPD investigations
Spirometry and CXR to rule out pathology
What tool is used for COPD prognosis
BODE index. BMI, airflow Obstruction, Dyspnoea, Exercise capacity index
Non inhaler management of COPD
Smoking cessation and pulmonary rehabilitation. Physiotherapy and dornase alfa for sputum clearance. Influenza and pneumococcal vaccinations
Step one COPD
LAMA (Tiotropium bromide) with rescue SABA
Step two COPD FEV1 >50%
+ LABA (Salmeterol)
Step two COPD FEV1<50%
+LABA (Salmeterol) and ICS (hydrocortisone)
What PaO2 is needed to get oxygen therapy
PaO2<7.3kPa
What is the gene in alpha 1 antitrypsin deficiency
SERPINA 1
Management of acute asthma
Salbutmaol Nebs, Oxygen then prednisolone and IV hydrocortisone
Causes of COPD exacerbations
Community: Haemophilus influeza B, Strep Pneuominae Hospital: Psuedomonas Aeurginosa
Define pneuomothorax
Air in the pleural cavity resulting in collapse of the lung on the affected side.
What increases your risk of smoking
Marfans, tall young man smoker
Secondary causes of pneumothoarx
CF, COPD, Sarcoidosis
Catamenial pneumothorax
During menstruation
What is tension pneumothorax
1 way valve of air entering
Presentation of pneumothorax
Dyspnoea, pleuritic chest pain, hyperresonant on percussion + decreased breath sounds on affected side, reduced chest expansion
What are the additional signs of tension pneumothorax
Deviated trachea, mediastinal shift, hyperexpanded chest, tachypnoea and hypotension
Investigations of pneumothorax
CXR unless tension which is an emergency
Management of tension pneumothorax
100% O2, Large bore IV cannula 2nd intercostal space in mid clavicular line, chest drain
Management of non tension pneumothorax
observation if small, needle aspiration if bigger, chest drain tube if more severe
Define pleural effusion
Abnormal collection of fluid in the pleural space
Transudate pleural effusion
Changes in osmotic pressure, CCF Cirrhosis Nephrotic syndrome, low protein levels
Exudate pleural effusion
Inflammation/malignacy leads to increased vascular permeability. Sepsis, malignancy, TB, infections. high protein levels.
Pleural effusion signs and symptoms
Pleuritic chest pain, SOB, cough, reduced chest expansion and breath sounds, stony dull percussion.
Criteria for exudative pleural effusion
Lights criteria 2/3
Pleural effusion investigations
chest xray and diagnostic aspiration
Management of pleural effusion
Treat underlying cause, drain if symptomatic, pleuroectomy if mesothelioma
Define bronchiectasis
Thickening and permanent dilatation of the airways
Causes of bronchiectasis
HIV TB
SLE
CF, foreign body
Presentation of bronchiectasis
cough with purulent sputum, wheeze, recurrent infections, clubbing, bilateral coarse crackles
Investigations of bronchiectasis
Gold standard= CT chest. CXR= tram track sign, spirometry= obstruction defect, sputum culture
Management of bronchiectasis
Smoking cessation exercise, chest physiotherapy, mucoltics (dornase alfa), prophylactiic abx, pneumococcal and flu vaccination
CF inheritance pattern and gene and chromosome
Autosomal recessive, mutation in cystic fibrosis transmembrane conductance regulator chromosome 7
Pulmonary CF presentation
cough with purulent sputum, wheeze, recurrent infections, clubbing, bilateral coarse crackles
Extra pulmonary CF manifestations
Pancreas= steatorrhea, diabetes, pancreatitis
GI: Distal intestinal obstruction syndrome, cirrhosis
GU: Lack of vas deferens and amenorrhea
Respiratory complications of CF
Pneumothorax and respiratory failure
Diagnosis of CF
In the presence of symptoms, sweat test for children, CF gene test for adults and IRT test for babies
What is the heel prick test for CF in babies
immunoreactive tripsinogen
CF complications from malabsorption
Underweight, fat soluble vitamin deficiency, reduced bone mineral density, distal intestinal obstruction syndrome
Chronic complications of CF
Cirrhosis, infertility diabetes
Respiratory management of CF
Exercise, stop smoking, physio, mucolytics (dornase alfa), prophylactic abx (azithromycin), pneumococcal and flu vacinations
GI management of CF
ADEK supplementaion, pancreatic enzyme replacement therapy, ursodeoxycholic acid for liver disease
CF screening
All babies in UK, immunreactive trypsinogen and sweat test and genetic testing to confirm
Describe ARDS
Acute onset, bilateral infiltrates on XRay, small pulmonary wedge pressure. Caused by release of acute phase proteins and inflammatory mediators. Causing pulmonary oedema
Causes of ARDS
Pneumonia, gastric aspiration, smoke inhilation, trauma, DIC, Pancreatitis
Pulonary signs/symptoms of interstitial lung diseases
Dry cough, SOB, progressive dyspnoea on exertion, infective exacerbations, inspiratory crackles
Systemic signs/symptoms of interstitial lung diseases
Lasting tiredness, weight loss, clubbing
Sarcoid treatment
Prednisolone and methotrexate can try infliximab. SERUM ACE IS HIGH
Sarcoid signs penumonic
Skin - erythema nodosum
Arthritis- feet and hands
Resp- bilateral hilar lymphadenopathy and pulmonary infiltrates
Cardio- Heart block, VT, HF
Occular- uveitis
Intracranial- chronic meningitis, neuropathy, seizures
Derangement of liver and renal function
IPF treatment
Best supportive care, transplant, exacerbations (antibiotics, steroids, oxygen, ventilation)
Consequences of occupational lung disorders
Risk of unemployment, loss of earnings, chronic ill health
What type of hypersensitivity is extrinsic allergic alveolitis
3
Treatment for EAA
Avoid allergens, steroids, best supportive care
Ix for EAA
FBC (inflammatory markers and WBC), Antibody titre, CXR, Spirometry
Asbestosis
Blue is worse. Pleural plaques lead to pleural thickening and mesothelioma
Rheumatoid antibodies
antiCCP, antidsDNA, ANA
Bradford hill criteria of causality
Temporarlity, reversibility, exposure-response, strength of association, specificity, consistency, analogy, biological plausability
Granulomatosis with polyangitis (Wegeners) signs
Saddle nose deformtiy, rash, malaise, diarrhoea, weight loss, joint pain/swelling, nose bleeds
wegeners diagnosis
CXR= cavitating lung lesions FBC= anaemia U&E= ESR and CRP high Urine= blood and protein cANCA Biopsy
Treatment of wegeners
Severe= steroids, cyclophosamide, biologics
No organ damage= prednisolone, methotrexate
Microscopic polyangitis
Small vessel vasculitis like wegeners but pANCA. Fatigue, fever, breathlessness, wheeze, cough, haemoptysis
ANCA associated vasculitis treatment
Prednisolone, rituximab, cyclophosamide
Rheumatoid arthritis risk factors
Women, caucasian, rheumatiod factor, HLA DR4, Other autoimmune conditions, stress, smoking
Symptoms and signs of RA
Symmetrical inflamed joint, nodules, episcleritis, carpal tunnel, lymphadenopathy, anaemia, RA nodules and pleural effusions, pericarditis, amyloidosis
RA diagnosis
Aspirate joint, FBC (Anaemia), ESR/CRP (high), RF, antiCCP (cyclic citrullinated peptic), XRay
RA on Xray
Soft tissue swelling
joint space narrowing
periarticular erosions
RA treatment
Methotrexate and sulfasalazine. Pred injections an option
Methotrexate pharmacology
Inhibits dihydrofolate reductase which is needed for replication and DNA synthesis, coprescribe folic acid
Methotrexate side effects
Mucosal damage, GI upset, nausea, teratogenic
Goodpastures syndrome features
Pulmonary haemorrhage and rapidly progressive glomerulonephritis
What type of hypersensitivity reaction is goodpastures
Type two
What is the cause of goodpastures
antiglomerular basement membrane (anti-GBM) IgM form to T4 collagen
Symptoms of goodpastures
Cough, dyspnoea, crackles, increased JVP and haematuria
Investigations in goodpastures
Abnormal U&Es, urinalysis (high protein and haemturia), renal biopsy (crescentric GN), CXR (Patchy bilateral symmetrical consolidation)
Goodpastures treatment
Plasma exchange and steroids
Define PE
Embolic blockage of pulmonary artery, usually from DVT. Means lung tissue is ventilated but not perfused
Clinical presentation of PE
Sudden onset unexplained dyspnoea, pleuritic chest pain, cough, haemoptysis with previous leg pain/swelling
Diagnosis of PE
Gold= CT pulmonary angiogram. Risk assessment using Well’s Score. Bloods, baseline clotting, D-Dimer, ECG, ABG
Immediate management of PE
100% O2 and IV analgesia and enoxaparin
Define pneumonia
Inflammation of the lung parenchyma usually secondary to infection of the alveoli and surrounding tissue
Bacterial causes of penumonia
Strep Pneumonia (80%) H. Influenzae (COPD exacerbations) Klebsiella pneumoniae (alcoholics hobo)
Atypical causes of pneumonia
Mycoplasma pneumonia, legionella pneumophilia, chlamydophila pneumoniae, chlamydophila psittaci
Viral causes of pneumonia
Influenza virus A/B
Fungal causes of pneumonia
Pneumocystis jiroveci (HIV)
Signs and symptoms of pneumonia
Cough, SOB, fever, rigors, chest pain, tachycardia, low sats, crackles, reduced breath sounds
Diagnosis of pneumonia
Clinical examination, Bloods (high WCC, neutrophils and CRP), XRay (areas of opacification) Microbiology
How do you do microbiology for pneumonia
Sputum gram stain, culture and snesitivity
Urine serology: legionella antigen
Bronchoscopy/ bronchoalveolar lavange
Consequence of CURB 0-1 score
Outpatient amoxicillin
Consequences of CURB 2 score
Hospital admission. Amoxicillin and clarithromycin PO
Consequences fo CURB score over 3
Urgent admission, consider ITU, IV coamoxiclav and clarithromycin
Define TB
Chronic granulomatous infectious disease caused by mycobacterium tuberculosis
Risk factors for TB
Poverty/cramped conditions, poor hygiene, Immunosuppression, smokers, foreign travel
Clinical presentation of TB
Weight loss, night sweats, malaise, cough, haemoptysis, SOB, chest pain.
What is the test for latent TB
Mantoux test, injection of PPD
Diagnosis of TB
Sputum tst x3, . CXR opacities.
How long do you give TB drugs for
RIPE for 2 months, continue with R and I for 4 more
Pyrazinamide side effects
Arthralgia and hepatitis
Describe small cell tumours
15%. Highly associated with smoking. Neuroendocrine tumours. Rapid growth, highly malignant, poor prognosis
Which hormones are secreted by small cell lung cancers
5-HT, ACTH, ADH
Name three non small cel lung cancers in order of prevalence
Squamous cell, large cell, adenocarcinoma
Common sites of metastasis for bronchial carcinoma
Lymph, brain, bone
Symptoms of bronchial carcinoma
Cough with haemoptysis, weight loss, SOB, chest pain, Sx of mets (bone pain, seizures)
Do you get osteoporosis from inhaled corticosteroids
No
Diagnosis of bronchial carcinoma
CXR/ Chest CT and biopsy
Treatment of bronchial carcinoma
Surgery, chemo, radiotherapy
Define mesothelioma
Aggressive tumour of mesothelial cells which usually occurs in the pleura
Symptoms of mesothelioma
SOB, chest pain, weight loss, fatigue, signs of pleural effusion
Diagnosis of mesothelioma
CXR/ Chest CT and pleural biopsy
Treatment for mesothelioma
Surgery, chemo, radio
AIDS defining infections
Candidiasis oesophageal, mycobacterium TB, persistent herpes simplex, pneumocystis jirovecci penumonia, recurrant bacterial pneumonia
AIDS defining neoplasms
Kaposis carcinoma, NonHodkins lymphoma
Direct HIV effect conditions
HIV dementia
HIV associated wasting
Causes of acute breathlessness
Asthma, pneumonia, PE, pneumothorax, hyperventilation
CV causes of clubbing
Cyanotic congenital heart disease
Right to left defect
IE
GI causes of clubbing
IBD, PBC, Cirrhosis
Endo causes of clubbing
Acromegaly and graves acropachy
What do leads I, aVL, V5 and V6 represent
Lateral region, circumflex
What do leads II, III and aVF represent
Inferior, right coronary artery
What do leads V1-4 represent
Septal and anterior. LAD
Define ischaemic heart disease
Myocardial demand for oxygen/nutrients greater than delivery via coronary arteries
Causes of IHD from occlusion
Atherosclerosis, thrombosis, spasm, embolus, arteritis
Causes of IHD from reduced oxygen delivery
Anaemia and hypotension
Causes of IHD from increased oxygen requirements
Thyrotoxicosis, aortic stenosis
Non modifiable IHD risk factors
Age, male gender, family history
Modifiable IHD risk factors
Smoking, alcohol, poor diet, obesity, lack of exercise
Clinical IHD risk factors
Hyperlipidaemia, diabetes, hypertension
Psychosocial IHD risk factors
Work stress, lack of social support, depression
Define angina
Chest pain arising from the heart due to myocardial ischaemia
Describe the pain of angina
Heavy central (+retrosternal, radiates to arms and jaw), exertional with no clinical signs usually
Angina investigations
Exercise ECG showing ST depression, angiogram if uncertain or intervention likely
Acute management of angina
GTN spray, regular nitrates, beta blockers, CCB, revascularisation
Secondary prevention of angina
Lifestyle change, control risk factors, aspirin and a statin
How do you differentiate NSTEMI and unstable angina
Measure the serum troponin level at 12 hours. Will be positive in MI but not in unstable angina
Describe the pain in ACS
Severe central crushing, radiates to arms and jaw. Not relieved by nitrates or rest. Breathless, nausea, sweating, pale, sense of impending doom
Investigations for ACS
ECG, troponin, FBC
ECG changes in STEMI
Q waves, >1mm broad and 2mm deep, negative deflection at start of QRS, Normal in AVR and V1, ST elevation, T wave inversion
ECG changes in NSTEMI
No Q waves, deep ST depression, T wave inversion
Acute management of STEMI
ABCDE, MONA (Morphine, oxygen, nitrates, aspirin), Emergency PCI or thrombolysis
Which drugs are used for thrombolysis
Streptokinase or alteplase
Name two nitrates
Isosorbide mononitrate and glyceryl trinitrate
Long term management of ACS
Aspirin, beta blocker, statin, ACE inhibitor, optimise risk factors, no driving for 1 month
Early complications of MI
Arrythmias, sudden death, pericarditis, heart failure, cardiogenic shock, mitral regurgitation, VSD, cardiac dilatation
Late complications of MI
DVT, PE, Mural thrombus, cardiac aneurysm, Dressler syndrome
What is dressler syndroms
Post MI. Fever, chest pain, pericarditis
Causes of primary HTN
Idiopathic, genetic factors, fetal factors, obesity, alcohol,, salt intake, stress
Secondary causes of HTN
Renal, Endocrine (Conns, adrenal hyperplasia, phaeochromocytoma, cushings, acromegaly), coarctation, OCP, Steroids, NSAIDs, pregnancy
Stage 1 hypertension
Clinic 140/90, ambulatory 135/85
Stage 2 hypertension
clinic 160/100, ambulatory 150/95
Severe HTN
Clinic 180/110, Ambulatory 180/110
Diabetes HTN target
130/80
Investigations in HTN
Looking for end organ damage Urine dipstick for protein + blood Serum creatinine, electrolytes and eGFR 12 lead ECG (LVH or CHD signs) Echocardiography Fasting glucose, fasting serum total and HDL
Who do you treat in HTN
Over 80, stage1 +target organ damage or disease
Everyone with stage 2
Target BP under 80
140/90
Target BP over 80
150/90
Examples of ACE inhibitors
Rampiril, lisinopril, enalapril
Examples of Angiotensin II receptor antagonists
Losartan, candesartan
Examples of betablockers
Atenolol, bisoprolol
Examples of calcium channel blockers
Amlodipine, nifedipine
Examples of thiazide diuretics
Bendoflumethiazide
First line <55
Ramipril
First line Black or >55
Amlodipine
What to give instead of CCB if intolerant or high risk of heart failure
Bendroflumethiazide
Resistant hypertension
Consider adding low dose spironolactone or higher dose thiazide and refer
Define heart failure
The heart is unable to maintain sufficient cardiac output to provide a physiologically normal circulation
What two systems are involved in heart failure
RAAS and sympathetic
What is the sympathetic heart failure physiology
Reduced cardiac output, baroreceptor activation, tachycardia, cardiotoxicity, heart failure
What is the RAAS heart failure physiology
Reduced cardiac output, activated RAAS, vasoconstriction and sodium retention, increased peripheral resistance and increased venous pressure, heart failure
Left heart failure causes
IHD, cardiomyopathy, hypertension, aortic/mitral valve disease, arrythmias, congenital heart disease
Clinical features of left heart failure
Fatigue, SOBOE, Orthopnoea, Paroxysmal nocturnal dyspnoea, tachycardia, fine crackles at lung base
What is orthopnea
Shortness of breath which occurs when lying down
Right heart failure causes
Cor pulmonale, PE, pulmonary HTN, left to right shunts, tricuspid regurgitation
Clinical features of right heart failure
Fatigue, anorexia/nausea, GI upset, raised JVP, pitting oedema, ascites, pleural effusion, hepatomegaly
Investigations of heart failure
Chest XRay (ABCDE), ECG (for underlying cause), FBC, LFTs, U&Es, glucose, TFTs, Serum BNP (always high), Echocardiogram (ejection fraction below 0.45)
Signs of heart failure on XRay
Alveolar oedema Kerly B lines (interstitial oedema) Cardiomegaly Dilated upper lobe vessels pleural Effusion
Non drug treatment of heart failure
Education, lifestyle measures, optimise risk factors, correct aggravating features like anaemia, pneumococcal and influenza vaccines, driving unrestricted
Drugs for heart failure
ACE-i Bisoprolol Candesartan Digoxin Diuretics Spironolactone
Surgical treatment of heart failure
CABG, Valve replacement, pacemaker, heart transplant
Causes of congenital heart disease
Maternal factors -maternal rubella -foetal alcohol syndrome -maternal SLE Genetic -trisomy 21 -turners syndrome
Acyanotic congenital heart diseases with shunts
ASD, VSD, PDA
Acyanotic congenital heart diseases without shunts
Coarctation of the aorta, congenital aortic stenosis
Cyanotic congenital heart disease with shunts
Tetralogy of fallot, transposition of the great arteries
Cyanotic congenital heart disease without shunts
Severe pulmonary cyanosis
common consequences of congenital heart disease
Central cyanosis, congestive heart failure, pulmonary hypertension, polycythaemia, eisenmengers syndrome
Signs of ASD
Mid systolic ejection murmur in pulmonary area, fixed splitting of S2.
Symptoms of right heart overload
Dyspnoea, fatigue, exercise intolerance
Investigations for ASD
CXR- dilated pulmonary artery
ECG- right axis deviation
Echo- hypertrophy and dilation of right heart
Management for ASD
Conservative or surgery
Signs of VSD
Pansystolic murmur at left lower sternal edge, systolic thrill left parasternal heave
Consequence of small VSD
Loud murmur, asymptomatic
Consequences of a large VSD
Pulmonary hypertension, breathless, poor feeding
Investigations for VSD
CXR, ECG, Echo
Management of VSD
Conservative or surgery
What is patent ductus arteriosus
Bypass from the pulmonary artery to the aorta
Causes of PDA
90% isolated, 10% from maternal rubella
What is QRISK2
Used to calculate the risk of CVD event in the next ten years. Age, Sex, Ethnicity, Smoking, RA, Diabetes, CKD, AF, angina
Signs of PDA
Usually asymptomatic, continuous machinery murmur, pulmonary HTN
PDA management
Percutaneous devices, endocarditis prophylaxis
4 features of tetralogy of fallot
RV outflow obstruction
Large VSD
R ventricular hypertrophy
Overriding aorta
Tetralogy of fallot symptoms
Cyanosis, feeding difficulty, failure to thrive
Tetralogy of fallot signs
Clubbing, loud harsh ejection sysolic murmur at lower left sternal edge. Hyper cyanotic spells.
Investigations for tetralogy of fallot
CXR, ECG, Echo
Management of tetralogy of fallot
Initially medical, surgery at 6 months
Descibe coarctation of the aorta
Narrowing of the aorta at the ductus arteriosus.
Sever: collapse and heart failure
Mild: raised BP and mid-late systolic murmur
Symptoms of coarctation of the aorta
headaches, nose bleeds and claudication
Signs of coarctation of the aorta
Radio-femoral delay, BP higher in arm than leg. Poor peripheral pulses
Management of coarctation of the aorta
Surgery
Causes of aortic stenosis
Calcification
Congenital (bicuspid)
Rheumatic fever
Outflow obstruction- hypertrophic obstructive cardiomyopathy
Symptoms of aortic stenosis
exercise induced angina, syncope, breathlessness. Sudden death
Signs of aortic stenosis
Slow rising pulse, sustained apex beat, systolic thrill in aortic region
Aortic stenosis heart sounds
Ejection systolic murmur in aortic area, radiated to the carotid, soft second heart sound, fourth heart sound
Investigations for aortic stenosis
ECG - LV Hypertrophy (depressed ST, T wave invert)
Echo is diagnostic
Management of aortic stenosis
Conservative, valve replacement if severe/symptomatic
Acute causes of aortic regurgitation
Acute rheumatic fever, IE, aortic dissection
Chronic causes of aortic regurgitation
Rheumatic fever Marfans Syphilis Autoimmune Bicuspid aortic valve Severe hypertension
Symptoms of aortic regurg
Asymptomatic until LV fails
Palpitations
Angina/ dyspnoea
Signs of aortic regurgitation
Left ventricular failure
Quinckes sign (pulsating nailbeds)
de mussets sign (head nodding with heart beat)
waterhammer pulse
Pistol shot femoral (sharp bang on ausculation)
Aortic regurgitation heart sounds
Displaced hyperdynamic apex beat
Soft early diastolic murmur at left sternal edge
Accentuated when patient sits forward
Severe= austin flint murmur
Aortic regurgitation investigations
Chest XRay
ECG- LV hypertrophy
Echo
Management of aortic regurgitation
Mild= vasodilators and diuretics
Valve replacement
Causes of mitral stenosis
Rheumatic fever
Symptoms of mitral stenosis
Only in severe, breathlessness, paroxysmal nocturnal dyspnoea, haemoptysis, recurrant chest infections
Signs of mitral stenosis
Malar rash Small-volume pulse Atrial fibrillation Tapping apex beat Signs of RV failure
Mitral stenosis heart sounds
Loud first heart sound, opening snap, rumbling mid diastolic murmur at apex with patient on their left
Mitral stenosis investigations
Chest XR
ECG= bifid P WAVE
RV hypertrophy
Echo
Mitral stenosis management
Diuretics, digoxin, anticoagulation, valvotomy, replacement
Mitral regurgitation causes
Mitral valve prolapse Rheumatic fever Infective endocarditis IHD Cardiomyopathy SLE/Marfans/ Ehlers-Danlos
Symptoms of mitral regurg
Palpitations, dyspnoea, orthopnoea, fatigue, right heart failure
Signs of mitral regurg
Cardiac failure, laterally displaced apex, hyperdynamic, systolic thrill
Mitral regurg heart sounds
Soft first heart sound, loud pansystolic murmur at apex radiating to axilla, third heart sound
Mitral regurg investigations
Chest XR- left atrial and ventricular enlargement
Echo
Management of mitral regurg
Echo monitoring, endocarditis prophylaxis, valve replacement
Define pericarditis
Inflammation of the pericardium
Viral causes of pericarditis
Coxsackie B, echovirus (EBV, HIV)
Bacterial causes of pericarditis
Pneumococcal, staphylococci, gram-ve organisms, TB
Non infective causes of pericarditis
Dresslers syndrome, autoimmune (Rheumatic fever, SLE, RA)
Symptoms of pericarditis
Chest pain (worse on breathing and lying flat, relieved by sitting forward, may radiate to neck and shoulders) malaise
Signs of pericarditis
Fever, tachycardia, pericardial friction rub, dyspnoea
Investigations of pericarditis
Bloods, ECG, CXR, Echo
Bloods of pericarditis
Raised WCC, CRP/ESR, Blood cultures, cardiac enzymes
ECG of pericarditis
Widespread shaddle shaped ST elevation
Treatment of pericarditis
Treat cause, analgesia, NSAIDs, rest, manage complications ie pericardial effusion
Define cardiomyopathy
Disease of the myocardium that effects the mechanical or electrical function of the heart
Types of cardiomyopathy
Hypertrophic, dilated, restrictive, arrythmogenic
Define hypertrophic cardiomyopathy
Marked ventricular hypertrophy in the absence of abnormal loading conditions
What is teh effect of hypertrophic cardiomyopathy
Impaired diastolic filling, reduces stroke volume, most common cause of sudden death in young people. Most causes are familial and autosomal dominant
Symptoms of hypertrophic cardiomyopathy
Asymptomatic, breathless, angina syncope, sudden death
Signs of hypertrophic cardiomyopathy
Atrial and ventricular arrythmias, jerky carotid pulse, ejection systolic murmur, pansystolic murmur
Investigations of hypertrophic cardiomyopathy
ECG always abnormal
Echo shows ventricular hypertrophy
Genetic analysis
Management of hypertrophic cardiomyopathy
Amiodarone (reduces arrythmias and sudden death), if high risk then implantable cardioverter defibrillator. Beta blocker for symptoms
Define dilated cardiomyopathy
Dilated left ventricle which contracts poorly
Causes of dilated cardiomyopathy
Autosomal dominant familial disease Alcohol Post pregnancy Hypertension Valvular heart disease
Clinical features of dilated cardiomyopathy
SOB mainly, can present with embolism, arrythmia or proggressive heart failure
Dilated cardiomyopathy investigations
CXR (cardiac enlargement)
ECG
Echo
Management of dilated cardiomyopathy
Treat HF and AF, Implantable cardiac defibrilator, cardiac transplant
Define peripheral vascular disease
Disease which occurs when there is significant narrowing of the arteries distal to the arch of the aorta, most commonly due to atherosclerosis
Fontane classification for PVD
I asymptomatic
II intermittent claudication
III rest pain
IV necrosis/gangrene
Why is there fixed splitting of S2 in atrial septal defects
Because the pulmonary valve closes after the aortic
What has a boot shaped heart on XRay
Tetralogy of fallot
When is PCI contraindicated
When it is too late or they have already had it
Define intermittent claudication
Exertional discomfort mainly in the calf, relieved by rest
Define rest pain
Unremitting pain in the foot, stops patient from sleeping, relieved by dangling foot over the bed
Signs of PVD
Cold dry skin, diminshed pulses, ulceration
Investigations in PVD
Pulse, Ankle-Brachial pressure index, duplex ultrasound
ABPI results
1 or more= symptom free
0.9-0.5= intermittent claudication
<0.5= critical limb ischaemia
Management fo PVD
Aggressive risk factor management, statin, aspirin
The 6Ps of acute limb ischaemia
Pain Pallor Pulselss Paraesthesia Paralysis Perishingly cold
Causes of acute limb ischaemia
Can by embolic or thrombotic
Management of acute limb ischaemia
Heparin, if embolic long term warfarin, bypass graft
Define arrythmia
Abnormality of cardiac rhythm
Symptoms of. arrythmias
Asymptomatic, palpitations, dizziness, syncope, sudden death
What causes sinus arrythmia
Fluctuations in the autonomic tone results in changes in the sinus discharge rate
Extrinsic to heart causes of bradycardia
Drugs, hypothyroid, hypothermia, cholestatic jaundice, raised ICP
Intrinsic to heart causes of bradycardia
Ischaemia, infarction, fibrosis of atrium and sinus node
Treatment of bradycardia
Pacemaker if symptomatic
Causes of sinus bradycardia
Normal during sleep and athletes
Causes of neurally mediated bradycardia
Carotid sinus syndrome, vasovagal attacks
Common causes of heart block
Coronary artery disease, cardiomyopathy, fibrosis in conducting tissue
Causes of AV block
Block in the AV node or bundle of his
First degree AV block ECG
Delayed AV conduction, prolonged PR interval. No change in HR and no treatment needed
Second degree AV block cause
Some atrial impulses fail to reach the ventricle
Mobitz type 1 ECG
Progressive PR prolongation until fails to conduct
Mobitz type 2 ECG
Intermittent non conducted P waves without progressive prolongation of the PR interval
Third degree AV block
All atrial activity fails to conduct to the ventricles, atria and ventricles contact independently. No association between P waves and QRS on ECG
What is bundle branch block
Complete block of a bundle branch leads to abnormal conduction and widening of QRS >120ms
Right bundle branch block ECG
RBB no longer conducts impulse, spread of impulse from left to right. Secondary R wave in V1, slurred S wave in V6
Left bundle branch block ECG
Deep, wide S in V1, Secondary R wave in V6
What is sinus tachycardia
Physiological response to exercise or excitement. Occurs with fever, anaemia, HF, thyroid, PE, hypovolaeia and drugs
What is AV node reentrant tachycardia
The most common SVT, P waves arent visible or are seen directly before or after QRS. Narrow QRS complexes
What is Atrioventricular reciprocating tachycardia
Wolff-Parkinson-White syndrome, short PR interval, narrow QRS complexes
Supraventricular tachycardia symptoms
Rapid, regular palpitations, abrupt onset, sudeen termination. Dizziness, dyspnoea, central chest pain, syncope, aggravated by exercise, caffeine and alcohol
Treatment of unstable patient SVT
Emergency cardioversion, O2, electrolyte abnormalities corrected
Treatment of stable patient SVT
Vagal stimulation, adenosine, long term= ablation
Causes of atrial arrythmias
IHD, rheumatic disease, thyrotoxicosis, cardiomyopathy, pneumonia, ASD, pericarditis, alcohol use, cardiac surgery
Define atrial fibrillation
Uncoordinated rapid continous activation of the atria, leading to mechanically innefective contraction
What is the pulse like in atrial fibrillation
Irregularly irregular pulse
Presentation of atrial fibrillation
Asymptomatic, palpitations, reduced exercise tolerance, heart fialure, embolic events, irregularly irregular pulse
Investigations for AF
ECG: No P waves, irregular rapid QRS rhythm
Management of AF
Rate control -beta blockers or CCBs Rhythm control -if young, symptomatic or HF -electrical DC cardioversion then beta blockers -or with amiodarone
What score is used to determie the coagulation for AF
CHADS2VASc determines the risk of stroke
What does a score of 1 need
Aspirin
What does a score of 2 need
Warfarin
How do you calculate CHADS2VASc
Congestive heart failure Hypertension Age -65-74 -75=2 Diabetes mellitus Stroke of TIA=2 Vacular disease Sex female
Atrial flutter
Atrial rate of 300bpm and ventricular rate of 150bpm
Investigations of atrial flutter
Sawtooth F waves on ECG
Define aortic aneurysm
A permanent and irreversible dilation of a blood vessel by atleast 50% of normal
Risk factors for aortic aneurysm
Severe atherosclerotic damage, family history, smoking, male, increasing age, hypertension, COPD, hyperlipidaemia
Presentation of aortic aneurysm
Pain in back, abdomen, loin to groin. Pulsatile abdominal swelling. If ruptures then sever and sudden pain. Syncope, shock or collapse
Aortic aneurysm on examination
Pulsatile, expansible mass
Aortic anurysm investigations
Ultrasound, ct, mri angiography
Management of aortic aneurysm
Anti HTN, Statin, smoking cessation.
How does the size of aneurysm alter the treatment
Ultrasound and. surgery if big >5cm
Describe aortic dissection
Results from a tear in the intima, blood under high pressure seperates the aortic wall layers creating a false lumen. False lumen can obstruct the true lumen.
Risk factors for aortic dissection
Hypertension, smoking, hyperlipidaemia, aortic disease, bicuspid aortic valve, history of cardiac surgery
Inherited risks of aortic dissection
Marfans, Ehlers Danlos. Familial thoracic aneurysm type 1 and 2.
Aortic dissection presentation
Sudden tearing central pain which radiated to the back and moves as dissection progresses.
Investigation for aortic dissection
ECG, CXR, Imaging= CT, TOE, MRI
Management of aortic dissection
IV access, intensive care, aggressively control BP (<120sys with BB), blood, surgery
What do you call it when someone can speak but is making no sense
Expressive aphasia
Define transient ischaemic attack
Brief episode of neurological dysfunction due to temporary focal cerebral or retinal sichaemia without infarction, usually lasting seconds or minutes with complete recovery
Differential diagnosis of TIA
Hypoglycaemia Migraine aura Focal epilepsy Cerebral amyloid angiopathy Hyperventilation Retinal bleeds
Causes of tia
Atherothromboembolism (from carotid)
Cardioembolism- mural thrombus post MI or in AF, valve disease or prosthetic valve
Hyperviscosity- polycythaemia, sickle cell, myeloma
Vaculitis- SLE, syphilis, GCA
TIA anterior circulation
Amaurosis fugax, aphasia (brocas), hemiparesis or hemisensory loss
TIA posterior circulation
Diplopia, vertigo, vomiting, choking, dysarthria, ataxia, hemianopic visual loss, tetraparesis
What score is used for the risk of stroke within two days of TIA
ABCD2
How do you work out ABCD2 score
Age >60=1 BP >140/90=1 Clinical features, -unilateral weakness=2 -speech disturbance without weakness=1 Duration of symptoms ->60mins =2 - 10-59mins=1 Diabetes=1
Which ABCD2 score requires urgent investigation and. secondary prevention
> 4 or two recent TIAs
Investigations for TIA
Bloods, CXR, ECG and Echo, Carotid doppler and angiography, CT
Management of TIA
Control cardiovascular risk factors, antiplatelets, warfarin and carotid endarterectomy
How does clopidogrel work
It is a ADP receptor blocker
How does dipyridamole work
Increases cAMP and reduces thromboxane A2
Which antiplatelets would you use in TIA
Aspirin then Clopidogrel and dipyridamole together
Define stroke
A syndrome of rapid onset neurological defecit caused by focal, cerebral, spinal or retinal infaction. Tissue injury is confirmed by neuroimaging
Modifiable stroke risk factors
Hypertension, smoking, hyperlipidaemia, Diabetes mellitus, heart disease, increased alcohol, pill and hrt
Non modifiable stroke risk factors
Age, male, afrocarribean, previous vascular event, family history
Causes of ischaemic stroke
Thrombotic, large artery stenosis, small vessel disease, cardioembolic, hypoperfusion
Causes of haemorrhagic stroke
Intracerebral haemorrhage, subarachnoid haemorrhage. Other (arterial dissection, venous sinus thrombosis, vasculitis)
What classification is used for ischaemic stroke presentation
Bamford classification
What is the presentation of. an ischaemic stroke
Acute onset of negative symptoms indicating focal deficits in brain function such as weakness, sensory loss, dysphasia and visual loss
Anterior cerebral artery stroke symptoms
Leg weakness, sensory disturbance in legs, gait apraxia, incontinence, drowsiness, akinetic mutism
Middle cerebral artery stroke symptoms
Contralateral arm and leg weakness, contralateral sensory loss, hemianopia, aphasia or dysphasia, facial droop, neglect syndromes
Which ABCD2 score strongly predicts a stroke
> 6
Posterior cerebral artery symptoms
Contralateral homonymous hemianopia, cortical blindness, visual agnosia, prosopagnosia, anomic aphasia (colour naming and discrimination problems), unilateral headaches
Primary causes of intracerebral haemorrhage
Hypertensive- rupture of charcot bouchard aneurysms
Cerebral amyloid angiopathy
-lobar, recurrant, associated with alzheimers
Secondary causes of intracerebral haemorrhage
Tumour
Arterovenous malformations
Anticoagulants
Venous infarctions
Clinical features of intracerebral haemorrhage
Similar to ischaemic but more associated with severe headache and coma from raised intercranial pressure
Investigations in intracerebral haemorrhage
CT imaging
MRI and MR angiography for AVM or aneurysms
Management of ischaemic stroke
Frequent monitoring of GCS and signs
Reverse anticoagulation (vitamin K)
BP control
Where are berry aneurysms common
Between posterior communicating and ICA
Between anterior communicating and anterior cerebral
Consequence of posterior communicating aneurysm pressing on neighbouring structure
3rd nerve palsy
Causes of subarrachnoid haemorrhage
Berry aneurysm rupture, arteriovenous malformation
Clinical features of subarachnoid haemorrhage
Sudden severe thunderlap headache with lasts for housrs. Often associated with vomitting, HTN, neck stiffness or pain. Kernigs sign and budzinskis sign
What is kernigs sign and when is it present
Patient cant extend leg when hip flexed. SAH and meningitis
What is brudzinskis sign and when is it present
Neck pulled forward causes knee flexion. SAH and meningitis
Investigations of SAH
CT
If CT negative then 12 hours later do a LP if no CI and it will be Xanthochromic
Management of SAH
Urgent neurosurgery referral, regular CNS examination, hydration and antihypertensives, nimodipine for 3 weeks
Why is Nimodipine given in SAH
It is a CCB and reduces vasospasm
Cause of subdural haemorrhage
Rupture of bridging veins, caused by head injury and in the elderly, alcoholics and babies
Cause of extradural haemorrhage
Skull fracture tearing a branch of the middle meningeal artery
Time frame for subdural haematoma
Days weeks or months after
Time from for extradural haematoma
Lucid interval of hours or days
Presentation of subdural haematoma
Fluctuating conciousness, headache, personality change, unsteadiness, hemiparesis, focal sensory loss, seizures, unequal pupils
Extradural haematoma presentation
Low GCS as severe headache, vomitting, confusin, seizures, hemiparesis. Brisk reflexes, upgoing planter reflex. Coma, ipsilateral pupil dilation and irregular breathing
Subdural haematoma on CT
Crescent shaped with midline shift
Extradural haematoma on CT
Biconvex shape and midline shift
Treatment of subdural haematoma
Close attention, neurosurgery burr hole drill of craniotomy. Can resolve itself.
Treatment of extra dural haematoma
Neurosurgery, clot evacuation and ligation of bleeding vessel
What does it need to be to have thrombolysis
Clinical ischaemic stroke diagnosis
Assessed by experienced team
Within 4.5hours
What is alteplase
Tissue plasminogen activator used in thrombolysis
What can a space occupying lesion lead to
brain herniation and death
What is used to combat anticoagulants
Beriplex and Vitamin K
Beriplex is quicker
What are lacunar infarcts
Subcortical infarcts
What is a watershed infarct
Infarct at the border of arterial supplies caused by severe cerebral hypoperfusion
Why is extradural haemorrhage biconvex
As ararchnoid granulations restrict spread
Very painful eye movements. Bilateral internuclear opthalmoplegia
Multiple sclerosis
Define multiple sclerosis
Chronic autoimmune T cell mediated inflammation of the CNS. Plaques of demyleination occur thorughout the brain and spinal cord sporadically over years
Who gets MS
Women, 20-40, genetics, further from equator (VitD), can be triggered by viruses like EBV
Types of MS
Relapsing remitting
Secondary progressive
Primary progressive
Progressive relapsing
Describe relapsing remitting MS
Clearly defined disease relapses with full or partial recovery. Periods between disease relapses characterised by a lack of disease progression
Describe secondary progressive MS
Initial relapsing remitting pattern is followed by progressive disability allowing for occasional remission and relapses
Describe primary progressive MS
Disease progression from onset with occasional plateaus and temporary improvement allowed
Clinical presentation of MS
Optic neuritis, brainstem demyelination, spinal cord lesions
What are the symptoms of brainstem legions in MS
diplopia, vertigo, facial numbness/weakness, dyarthria and dysphasia. Bilateral internuclear opthalmoplegia
What are the symptoms of spinal cord lesions in MS
Thoracic or cervical lesions can lead to assymetric walking difficulty or numbness in limbs. Paraparesis develops over days or weeks.
Common symptoms in MS
Visual change Sensory symptoms Clumsy hand or limb Ataxia or unsteadiness Bladder hyperreflexia Neuropathic pain Fatigue Spascitiy Temperature sensitivity
What is uhthoff’s pnenomenon
Temperature sensitivity in MS
What is Lhermittes sign
Neck flexion leads to electric shock sensation
Late stage MS
Severe disability Spastic tetraparesis Optic atrophy Brainstem signs Urinary incontinence Pseudobulbar palsy Cognitive Impairment (often frontal lobe) Usually 15 years to needing walking aids and 25 to a wheelchair.
Diagnosis of MS
2 or more attacks disseminated in time and space, McDonald criteria
Investigations of MS
MRI brain + spinal cord
CSF= oligoclonal IgG bands
Blood tests to exclude other inflammatory disorders
Who can diagnose MS
Only consultants
Long term management of MS
No cure, education, MDT (physio, OT, counsellor), prevent infections with nonlive vaccinations
How to treat acute relapses of MS
Methylprednisolone
Disease modifying drug for MS
Beta interferon
Treatment for very aggressive RRMS
Immunomodulatory drugs- Natalizumab
Drug for spasticity
Baclofen or gabapentin
Drug for emotional lability
Amitriptyline
Drug for pain in MS
Amitriptyline
Drug for tremor in MS
Beta blockers or botulinum toxin A type
Urinary urgency/ frequency in MS treatment
Intermittent self catheterisation
Signs of meningism
Headache, neck stiffness, photophobia, Kernigs and Brudzinskis
Immediate signs of Bacterial meningitis
Fevers, rigors, severe headache, photophobia and vomitting
Signs of bacterial menigitis that appear within hours
Neck stiffness and positive Kernig’s sign
Signs of viral meningitis
Self limiting, headache, high fever
Causes of viral meningtis
Coxsackie, HSV, EBV, HIV mumps
Causes of bacterial meningitis in neonates
Ecoli, Group B strep, Listeria
Causes of bacterial meningitis in infants
Neisseria meningitidis, haemophilus influenzae, strep pneumoniae
Causes of bacterial meningitis in adults
Neisseria meningitidis, strep pneumonia
Causes of bacterial meningitis in the elderly
Strep pneumoniae, neisseria meningitidis, listeria
Investigations in meningtisi
Lunbar puncture, blood culture, nose and throat swabs, stool sample
What does non blanching petechial rash suggest
meningococcal septicaemia
Treatment for N.meningitidis in the community
IM Benzyl penicillin
Meningitis with no signs of sepsis or raised ICP treatment
Blood culture, lumbar puncture, IV dexamethasone. Then Ceftriaxone, fluids bloods
Meningitis with riased ICP management
Oxygen, blood culture, IV dexamethasone, delay LP. Give IV cefriaxone. CT imaging. Then bloods
Meningitis with severe sepsis or evolving rash managament
Oxygen, blood cultures, fluids. Delay LP. IV ceftriaxone, bloods
When wouldnt you lumbar puncture
Severe sepsis or rapidly evolving
Severe respiratory or cardiac compromise
Significant bleeding risk
Signs of raised ICP (need CT)
Migraines with aura diagnostic criteria
1 aura symtopm -visual, zigzags, spots -unilateral sensory, tingling, numbness -speech -motor weakness 2 out of -aura spreads gradually over >5mins or theres 2 aura symptoms -aura symptom lasts 5-60mins - an aura symptom is unilateral -headache follows aura within an hour
Migraine without aura criteria
>5 attacks lasting 4 to 72 hours 2 of -unilateral, pulsating, moderate/severe pain, aggravated by exercise 1 of -nausea/vomitting -photophobia and phonophobia
Triggers for Migraine
Sleep- too much or too little
Stress
Oestrogen for women
Eating- skipping meals and big meals, alcohol
Bright lights, loud noises, physical exercise
Mild migraine management
Aspirin + metoclopramide
Name an antiemetic
metoclopramide
Severe migraine management
Triptan + Paracetamol
Migraine preventative measures
Propanolol, acupuncture, amitriptyline
Describe tension headache
30mins to 7 days. Bilateral pressing mild/moderate pain. No associated symptoms. Take paracetamol
Describe cluster headache
15-180mins, unilateral retroorbital boring severe pain. With autonomic symptoms on the same side of the face. Take sumatriptan and 100% O2
Describe trigeminal neuralgia
Lasts seconds, unilateral electric severe pain with many triggers. No associated symptoms. Treat with carbamazepine
More than 50, jaw claudiaction, visual distrbance, tender and pulseless temporal arteries
Giant cell arteritis
Severe eye pain, red eyes, cloudy cornea, dilated and unresponsive pupil
Acute glaucoma
Headache worse on bending over
Sinusitis
Sudden onset thunderclap
Subarachnoid haemorrhage
Worse on lying down, exercise or valsalva
increased ICP
Fever fits and altered consciousness
Encephalitis
Define epilepsy
Paroxysmal event in which changes of behaviour, sensation or cognitive processes are caused by excessive hypersynchronous neural discharges in the brain
Are ischaemic or haemorrhagic strokes painful
Haemorrhagic
Temporal lobe seizure with awareness (simple partial)
Deja vu,, fear, olfactory, gustatory or auditory hallucinations
Ocipital lobe seizure with awareness (simple partial)
Visual phenomena such as zigzags
Frontal lobe seizure with awareness (simple partial)
Adversion seizures, jacksonian march
What is aura
A sensation percieved by a patient that preceds a condition affecting the brain
Temporal seizures with impaired awareness (complex partial)
Automatisms, auras, behaviour arrest, 1-2 minutes. Then post ictal confusion
Frontal seziures with impaired awareness (complex partial)
Complex movements like bicylce movement of legs, repeated words or phrases. Post ictal confusion
Gneralised absense seizure
loss of awareness and vacant expression for less than 10 seconds. Children
Myoclonic generalised seizure
Sudden, breif jerking of a limb face or trunk
Tonic generalised seizure
Body becomes stiff, can fall to the ground
Tonic clonic generalised seizure
Tonic phase (LOC increased tone) Clonic hase (synchronous jerking). Eyes open tongue biting. Postical confusion
Atonic generalised seizure
Sudden collapse with loss of muscle tone and consciousness
Epilepsy triggers
Sleep deprivation, missed doses, alcohol and recreational drug (withdrawal), exhaustion, intercurrent illness or metabolic disturbance
Which children and teenagers get epilepsy
Genetic, perinatal and congenital disorders
Which young adults get epilepsy
Trauma, drugs and alcohol
Which older adults get epilepsy
Vascular disease and neoplasms causing mass legions
Epilepsy investigations
Bloods, ECG, MRI, EEG, VIDEO telemetry DIAGNOSTIC
Management of focal seizures
Carbamazepine (lowers effectiveness of pill)
Management of general seizures
Sodium valproate (teratogenic)
How do you treat status epilepticus (seizure >5mins)
Airway, O2, IV access. Diazepam. Rectal in community, IV in hospital
Describe epilepsy
Aura, common from sleep, less than 2mins, rhythmical jerking, eyes open, tongue biting, incontinence, breathing stops, recovery slow
Describe non epileptic attack disorder
Aura, common in medical situations, more than 2 mins, thrashing movements, hip thrusting, respiration fast, eyes closed no tongue biting or incontince
Describe syncopy
Nausea, sweating, visual grey out, prolonged standing or on stnading. Less than 2 mins, occasional limb jerks, eyes closed no tonuge biting. Normal breathing, fast recovery
Ascending weakness, fasciculations, no sensory sphincter or eye loss, 50-70
MND
Define MND
Neurodegenerative condition caused by progressive loss of upper and lower motor neurones in the spinal cord, cranial nerve nuclei and motor cortex
Familial cause of MND
SOD1 gene mutation
Describe upper motor neurone legion
Weakness, increased reflexs, plantar and tone. No fasciculations or atrophy
Describe lower motor neurone lesions
Weakness atrophy fasciculation. Reduced reflexes, plantars, tone
What are the four clinical patterns of MND
Amyotrophic lateral sclerosis
Progressive muscular atrophy
Progressive bulbar palsy
Primary lateral sclerosis
Amyotrophic lateral sclerosis
UMN and LMN
Progressive muscular atrophy
LMN
Progressive bulbar palsy
CN 9-12
Primary lateral sclerosis
UMN
Over 40, stumbling spastic gait, footdrop, weak grip, weak shoulder abduction, aspiration pneumonia
MND
Diangosis of MND
Clinical
Electromyography confirms LMN
Brain/cord MRI for excluding other things
Diagnosis confirmed by steady progression over time
MND management
Specialist MDT. Non invasive ventilatory support and feeding (gastronomy. Riluzole
What drug is used in MND and what does it do
Riluzole, sodium channel blocker, inhibites glutatmate rlease
Define parkinsonism
Clinical syndrome characterised primarily by bradkinesia, rigidity, resting tremor and loss of postural reflexes
Describe the pathophysiology of parkinsons
Loss of dopaminergic neurones in the substantia nigra pars compacta and Lewy bodies leads to breakdown of the striatum pathway and decreased output tothe cortex
Describe spasticity
There is increased tone at the start of motion but this tops through the range of motion
3 cardinal features of parkinsons
Bradykinesia (button problems, micrographia, expressinoless face, dysphonia, dysdiadochokinesia) Resting tremor (unilateral pill rolling) Rigidity (paian, cog weel, stooped posture)
Characteristic gait of parkinsons
Slow to start walking, rapid short stride length, festination, reduced arm swing, impaired balance on turning
Not movement features of PD
Depression, phobias, anxiety, dementia, autonomic (constipation, increased urinary frequency. Not incontinence)
Parkinsons drugs to increase dopamine availability
Cocarledopa, levodopa and carbidopa(reduces SE from increased dopamine). These treat bradkyinesia and rigidity
Dopamine agonists used in parkinsons treatment
Ropinirole
Drugs which inhibit the enzymatic breakdown of dopamine in the treatment of parkinsons
Entacapone (COMT) Selegilene (MAO-B)
How do you treat the tremor in parkinsons
Anticholinergics- amantadine
Motor complications of late stage PD
Wearing off, on dyskinesias, off dyskinesias, freezing
Hyperkinetic movements, deranged liver function tests, kayser fleischer rings
Wilsons disease
Magnetic gait, incontience, dementia
Normal pressure hydrocephalus
Signs of cauda equina syndrome
Bilateral sciatica, bilateral flaccid leg weakness, saddle anaesthesia, bladder/bowel dysfunction, erectile dysfunction, areflexia
Causes of cauda equina syndrome
Herniated lumbar disc, lumbar spinal stenosis, inflammatory conditions, osteomyelitis, tumours/neoplasms, trauma
Diagnosis of cauda equina syndrome
MRI spine
Treatment of cauda equina syndrome
Surgical decompression by lumbar laminectomy
Describe the pathology of huntigntons
Autosomal dominant conditions. more than 39 repeats of the CAG triplet of the huntingtin gene. Striatum atrophy and depletion of GABA. Increased dopamine and increased movement
Clinical features of huntingtons
Irritability, depression, self neglect,behavioural problems
Chorea and rigidity
Dementia
How do you treat huntingtons
Chorea= sulpride Depression= SSRI Aggression= risperidone
What does anticipation in huntigntons mean
The symptoms get more severe and onset is earlier as the condition is passed from one generation to the next
Define myasthenia gravis
Autoimmune disease against nicotinic acetylcholine receptors in the neuromuscular junction
Presentation of myasthenia gravis
Painless, fatiguable muscle weakness particularly
-proximal limbs
-extra occular muscles
-bulbar and facial muscles
Worse at night, respiratory symptoms= cirsis
Stairs, chairs, hair
What is lambert eaton myasthenic syndrome
Paraneoplastic from small cell lung cancer. Defective Ach release but improves with exercise
Investigations for myasthenia gravis
Look for antiAChR and if negative look for antiMusk
Treatment for myasthenia gravis
Pyridostigmine (anticholinesterase), oral prednisolone
Define guillain barre syndrome
Acute inflammatory demyelinating ascending polyneuropathy affecting the peripheral nervous system following URT or GI infection
How do you treat guillain barre
IV immunoglobulin and enoxaparin
How does guillain barre present
Symmetrical ascending muscle weakness 1-3 weeks post infection
Carpal tunnel
Median nerve compression at the wrist. Tinnels or Phalens signs may be positive. Splinting and corticosteroid injections treatment
Clinical features of encephalitis
LOC, Confusion, seizures, headache and fever
Investigations of encephalitis
MRI, EEG, LP
Viral causes of Encephalitis
mumps, rabies, EBV
Define herpes zoster
Reactivation of varciella zoster virus in the dorsal root ganglia due to decreased immunity
Treatment of herpes zoster
Oral acyclovir. Post herpetic neuralgia=amitryptilline
Where do secondary brain tumours come from
Lungs, breast, melanoma, renal, GI
Glial cell tumours can be
Atrocytic or oligodendroliomas
Classification of astrocytomas
I Pilocytic
II premalginant
III anaplastic
IV diffuse glioblastoma multiforme
What causes the conversion to malginant
Isocitrate dehydrogenase 1
Presentation of brain tumours
Headache, papilloedema, seizures, progressive neurologicla deficit
Investigations of brain tumours
MRI/CT
Treatment of brain tumours
Debulking surgery, radiotherapy, chemo and dexamethasone
Define dementia
A syndrome caused by a number of brain disorders which causes memory loss, difficulty thhinking, problem solving or language and difficulties with activites of dailly living
Types of dementia
Alzheimers, vascular, lewy body, frontotemporal
What causes alzheimers
Accumulation of beta amyloid peptide causes progressive neuronal damage, neurofibrillary tangles, amyloid plaques and loss of ACH
5 Key features of alzheimers
Short term memory loss. Disintegration of personality and intellect Decline in language Decline in visuosptail skills Agnosia
Medication for alzheimers
Acetylcholinesterase inhibitors- donepezil
Antibiotics which cause C.dificle
Clindamycin, ciprofloxacin, coamoxiclav, cephalosporins
What is a mallory weiss tear
Linear tear in mucosa were the oesophagus meants the stomach
What does painless cholestatic jaundice suggest
Pancreatic cancer
What are varices
Distended veins from portal hypertension
What are the U+Es like in upper GI bleed
Only urea is raised and this is because of breakdown of blood
How do you treat mallory weiss tear
Minor=fluids
Major= banding
How do you treat varices
Banging and propanolol
Prehepatic cause of portal hypertension
Portal vein thrombosis
Hepatic cause of portal hypertension
Primary biliary cirrhosis, cirrhosis, buddchiari
Post hepatic cause of portal hypertension
Constrictive pericarditis, IVC obstruction
Causes of upper GI bleed
Mallory weiss tear, grastic and duodenal ulcer, varices
Causes of upper GI motility probelms
Achalasia and systemic sclerosis
How do you detect upper Gi motility problems
barium swallow
What are teh signs of limited systemic sclerosis
Calcinosis Raynauds phenomenon Esophageal dysfunction Sclerodactyly Telangiectasis
How do you detect systemic sclerosis
Anit nuclear antibodies
How do you treat upper GI motility disorders
Omeprazole, antacids and surgery
Define GORD
Excessive entry of gastric contents into the oesophagus through the gastrooesophageal junction
Risk factors for GORD
NSAIDs, large meals, hiatus hernia, obesity, prengancy, alcohol, coffee
Symptoms of GORD
Reflux, indigestion, heart urn, acid tast, bloatin, belching, discomfort, odynophagia
Diangosis of GORD
History and improvement with PPI
Managemtn of GORD
Weight loss, reduced alcohol, smoking cessation, avoid large or bedtime meals. Omeprazole and ranitidine (H2 antagnoist)
Define barrets oesophagus
Change in the lower oesophagus from squamous to columnar epithelium - metaplasia
Peptic ulcer disease investigation
H pylori testing and endoscopy only if over 55 or red flags
Treatment for PUD
Stop smoking, treat cause
- omeprazole, clarithromycin and amoxicillin
- stop NSAIDs
Wchich artery do posterior duodenal ulcers go into
Gastroduodenal artery
Which artery do gastric ulcers go into
Left gastric artery
What relieves pain in gastric
Vomitting, antacids and milk
What relieves pain in duodenal
Intake of food and anatacids and milk
Describe gastric ulcers
Occur in the stomach, epigastric pain 1-2hours after eating, cause haematemesis or melena, heart burn, chest discomfort and early satiety are ofetn seen. Can cause gastric carcinoma
Describe duodenal ulcers
Occurs in the duodenum, epigastric pain 2-5 hours after eating, cases melena or blood in stools. Pain may awaken patient during the night
Name 3 things H pylori can cause
Peptic ulcers, atopic gastritis, cancer
Investigations for H pylori
Endoscopy and biopsy for ulcers, C13 breath test
Dyspepsia features
Postprandal fullness, early satiation, epigastric burning
Causes of dyspepsia
GORD, IBS, PUD, lactose intolerance, anxiety or depression
Red flags in upper GI
Unexplain weight loss, anaemia, GI blood loss, dysphagia, upper abdo mass, persistent vomitting
early post prandial pain
GORD or gastritis
late post prandial pain
duodenal
Risk factors for oesophageal metaplasia
Obestiy, reflux, age
Risk factors for oesophageal squamous cell carinoma
Alcohol, smoking, east asia
Treatmetn of oesophagel cancer
Resection if fit, stent, chemo radio, palliative
Diangostic testing in oesophagel
Endoscopy, CT, PET
2 week wait for endoscopy if
Dysphagia or over 55 and upper abdo pain or reflux or dyspepsia
Non urgent endoscopy if
Haematemsis, over 55 with upper abso pain and anaemia, raised platelets, symptoms of GI cancer
Define coeliac disease
Systemic autoimmune disease trigerred by dietary gliadin
Describe the pathophysiology of coeliac disease
Autoimmune reaction, antiendomysial antibodies attack tissue transglutaminase enzyme which breaks down gluten
Risk factors for coeliac
HLA DQ2/8. T1D, AI addisons and gravves
Histoloical findings in the small intestine in coeliac
Increased lymphocytes in the epithelium and lamina propria, crypt hyperplasia, villous atrophy
Symptoms of coeliac disease
Abdo pain, bloating, diarrhoea, steatorrhea, weight loss
Signs of coeliac
dermatitis hepetiformis, anaemia, osteoporosis, failure to thrive
Where is iron absorbed
First part of the duodnum
Where is folate absorbed
jejunum
Where is B12 absorbed
Terminal ileum
What is dermatitis hepatiformis
Rash on the extenosr surfaces of the arms
Coeliac diagnosis
Tissue transglutaminase antibodies (IgA) (and endomysial antibodies. Bloods for serology, FBC and ferritin. Endoscopy and diagnosis is by small bowel biopsy
What would you see on a coeliac endoscopy
Atrophy and scalloping of mucosal folds, nodularity and mosaic pattern of mucosa
General symptoms of IBD
abdo pain, chronic diarrhoea (+- blood and mucous), weight loss
Describe UC
Continous inflammation that begins at the rectum to the ileocaecal valve. Cardinal symptom bloody diarrhoea. HLAB27
Describe crohns
Transmural and granulomatous inflammation from mouth to anus. Has skip legions. Mouth ulcers and perianal disease are classic. Smoking worsens symptoms
Investigations of IBD
Bloods: anaemia, FBC, increased CRP B12/Folate deficency, Stool MC&S, TFTs. Sigmoidoscopy Colonoscopy Diagnosed with biopsy
How do you differentiate IBD and IBS
IBD has increased faecal calprotectin
UCR v crohns histology
UC: not beyond submucosa, neutrophils migrate to form crypt abscesses, reduced goblet cells and mucin
Crohns: Non caseating granuloma, transmural inflammation, lymphocytic infiltration
UC v Crohns endoscopically
UC: uniform inflammation and pseudopolyps
Crohns: Skip lesions and cobblestone appearnace, commonly affects terminal ileum
UC v crohns long term complications
UC: haemorrhage, toxic megacolon, marked increase in colon cancer risk
Crohns: Fistula, abscess, obstruction, slight increased colon cancer risk
IBD extra intestinal manifestations
Erythema nodosum, pyoderma gangrenosum, irritis, conjunctivits, episcleritis, large joint arthrits, ank spond
How do you treat relapses of IBD
Prednisolone then mesalazine maintenance
What is mesalazine
5-aminosalicylic acid
Prophylactic treatment for severe IBD first and second line
Azathiopine then metronidazole
Diarrhoea which is winter, hospital outbreaks, selflimiting
Rotavirus
Undercooked meat
Campylobacter jejuni
Poor food hygeine
Staph aureus
Watery travellers diarhoea
Enterotoxigenic E Coli
Bloody diarrhoea
Eneterohaemorrhagic Ecoli (0157)
Parasitic causes fo diarrhoea
Giardia lamblia and schistosomiasis
Investigations for infective diarrhoea
Basic obs, bloods, U&Es stool sample
What do you do with the stool sample in infective diarrhoea
3 samples, 1 immmediately and 2 more 3 days apart. Culture, ova¶sites, serotyping/PCR
Mnagement of infective diarrhoea
Exclude from work, rehydration, anitemetic, analgesia, notify public health england (food,bloody or cholera)
Complication of infective diarrhoea
Haemolytic uraemic syndrome (microangiopathic, haemolytic anemia, thrombocytopenia, AKI)
Indirect inguinal hernia
Protrusion of abdo/pelvic contents thorugh the internal inguinal ring lateral to epigastric vessels
Direct inguinal hernia
Protrusion of abdo/pelvic contents thorugh the abdominal wall into the inguinal canal medial to epigastric vessels
Define appendicitis
Acute inflammation of the appendix usually caused by obstruction of the appendix (usually by faecolith)
Complications of appendicitis
Rupture and gangrene leading to peritonitis
Presentation of appendicitis
Generalised pain which moves to mcburneys point, diarrhoea, vomitting
Signs of appendicitis
Pyrexial,guarding and rebound tenderness in the right illiac fossa
Investiagtions of appendicitis
Diagnosis with abdo CT or USS, increased WCC, rule out ectopic
Mangement of appendicitis
Nil by mouth, IV fluids, Abx, laparoscopic appendectomy
Causes of small bowel obstruction
Post op adhesions, strangulated hernia volvulus (children)
Casues of large bowel obstruction
Malignancy, sigmoid/caecal volvulus
What is ileus
Bowel ceases to function and there is no peristalsis, caused by post op and opioids
What is volvuls
Complete twisting of a loop of intestina around its mesenteric attachment
How are bowel obstructions classified
Site, extent mecahnism pathology
Small bowel v large bowel presentation
Constipation early in SBO, LBO has faeculent vomitting and later contipation
Cardinal signs of bowel obstruction
N+V, colicky abdo ppain, abdo distension, contipation, tinkling bowel sounds, hyperresonant or absent bowel sounds
Ivestigation of obstruction
Bloods, erect CXR (exclude perforation) abdo XR (dilated bowel loops and kidney bean sign(volvolus)
Mangement of obstruction
IV fluis, analgesia, antiemetics and monitor then surgery
Define diverticulum
Outpouching of gut wall
Primary peritonitis
Spontaneous bacterial peritonitis, ascites, immunoompromised. Diagnose via ascitic tap. Broad spectrum Abx, dont need surgery
Secondary peritonitis
Appendicitis, ectopic pregnancy, bowel ischaemia, PUD
Bacteria for peritonitis
Ecoli or spneumoniae (children). Post dialysis gets Staph aureus
Signs of ascending cholangitis
Ecoli. Charcots triad
- RUQ pain
- Fever
- Jaundice
Acute cholecystits signs
RUQ pain, fever, raised inflammatory markers
Treatment of ascending cholangitis
Fluids, metronidazole, ERCP stenting, laparoscopic cholecystectomy
Typhoid antibiotic
Ciprofloxacin
Describe haemorrhoids
swolen veins, disrupted and dilated anal cushions. Band ligation. Get them in strainging pregancy, portal HTN and CCF. Fresh blood
Describe anal fissure
tear in skin around anal canal.Pain on defecation. Inspect. Hard faeces, IBD, anal cancer
Desribe anal fistula
Abnormal communication between anal canal and perianal skin. Crohns, Tb rectal carcinoma.
Pilondial sinus describe
Infected tract under skin between buttocks. Men sedentary obese. Hygeine
Functions of the liver
Glucose and fat metabolism, detoxification and excretion, protein synthesis, defense against infection
Screening for bowel cancer
Every 2 years 60-74. Faecal occult blood
Familial causes of bowel cancer
Familial adenomatous polyposis and hereditary nonpolyposis colorectal cancer(aggressive)
Risk factors for bowel cancer
Age 50, red meat low fibre, IBD, FHx, smoking alcohol and obesity
Red flag symptoms for bowel cancer
Abdominal pain, change in bowel habit, unexplained weight loss, chronic diarrhoea, Fe deficiency anaemia, rectal mass
Diagnosis of bowel cancer
Colonscopy and biopsy with histology
Staging of bowel cancer
TNM/ Dukes classification
Management of bowel cancer
Surgery, chemo, radio
Dukes A
Muscularis mucosae
Dukes B
Extension through the muscularis mucosa not lymph
Dukes C
Involvement of regional lymph nodes
Dukes D
Distant metastases
Causes of acute liver disease
Viral, drug, alcohol, congestion, obstruction
Causes of chronic liver disease
Alcohol, viral, autoimmune, metabolic
Presentation of acute liver disease
Malaise, nausea, anorexia, myalgia, abdo pain, bleeding, liver pain (=malignancy or obstruction). Ecephalopathy
Waht is hepatic encephalopathy
Liver flap, confusion, coma
Presentation of chronic liver failure
Ascites, oedema, haematemesis, malaise, anorexia, wasting, easy bruising, itching, hepatomegaly, abnormal LFTs, hypoglycaemia
Liver disease observations
Weight loss, scratching/itching, alcohol smell/withdrawal, encephalopathy
Liver disease hands
Clubbing, dupuytrens contracture, leuconychia, brusing, flapping tremor, palmar erythema
Liver disease face
Jaundice, spider naevi, parotid swelling, xanthelasma
Liver disease chest
Loss of body hair, spidernaevi, gynaecomastia
Liver disease abdomen
Ascites, caput medusae, hepatomegaly, spenomegaly, palpable gall bladder, hepatic bruit, tumour
Liver disease legs
Brusing oedema
Investigating chronic liver disease
Viral serology, immunology, biochemistry, Ultrasound scan
Initial test for alcoholic liver disease
Liver function tests. AST is higher than ALT, high MCV
Initial test for NASH
LFTs then confirm with liver biopsy
Initial test for chronic hep B
HBsAg
initial test for chronic hep C
HCV antibody
Initial test for primary biliary cirrhosis
Antimitochondrial antibody
Initial test for primary sclerosing cholangitis
Mangetic resonance cholagiopancreatography
Initial test for haemochromatosis
Transferrin and ferritin levels then confirm with HFE gene test
Initial test for wilsons disease
Caeruloplamin then confirm with 24hr urinary copper
Initial test for a1 antitrypsin
a1 antitrypsin level then confirm with genotype testing
Which serum liver enzymes are cholestatic
ALP and Gamma GT
Which serum live enzymes are hepatocellular
Asparate transaminase and alanine transaminase
What is ALP
Alkaline phosphatase produced by liver, bile duct and bone. If it is raised and GGT is not, it suggests a bone problem
When is ALT higher than AST
Chronic liver disease
When is AST raised higher than ALT
Cirrhosis and alocholic hepatitis
Which liver enzyme suggests and alcoholic cause
Aspartate transaminase
Causes of isolated rise in ALP
Bony mets, vitamin D defieincy, recent bone fracture, renal osteodystrophy
Causes of decompensation in chronic liver disease
New drugs, constipation, GI bleed, infetion, low sodium, pottasium or sugar, alcohol withdrawal
Consequences of liver dysfunction
Malnutrition, variceal bleeding, encephalopathy, ascites, infection, coagulopathy, endocrine changes, hypoglycaemia
How do you treat malnutrition
NG tube
how do you treat ascites
Fluid/salt restriction, diuretcs, paracentesis
Which haematology changes do you get from liver dysfunction
Vit K deficiency, impaired clotting factors, thrombocytopenia
Which endocrine changes do you get from liver failure
Gynaecomastia, impotence,, amenorrhea
Signs of alcoholic hepatitis
Mallory bodies and giant mitochondria
Stages of alcoholic liver disease
Fatty liver, hepatitis and cirrhosis
Describe steatosis
Acute reversible flat globules in the cytoplasm. FBC will be macrocytic if alcoholic
Describe hepatitis histopathology
Neutrophil infiltration, mallory bodies (hyalin aggregates), giant mitochondria
Symptoms of hepatitis
Jaundice, ascites, pain, hepatosplenomegaly
Tests for alcoholic hepatitis
Luecocytosis on FBC LFTs -ast/alt raised alk P raised prothrombin time longer Low albumin
Alcoholic cirrhosis histopathlogy
Mallory bodies, infiltration neutrophils
Symptoms of cirrhosis
Liver failure, portal hypertension, ascites, pain, varices, encephalopathy
Tests for cirrhosis
FBC= raised bilirubin adn leucocytosis U&E= low sodium, high creatitine LFT= deranged, long PT
Investigations for alcoholic liver disease
Blood tests, imaging, biopsy, ascitic tap
Management of ALD
Fatty liver=abstinence
Hepatitis= abstinence, supplements, steroids
Cirrhosis= manage complications
Alcohol withdrawal and managemtn
Tremors, hallucinations, agitation, delirium tremens. Give Chlorodiazepoxide
Treatment for alcohol dependence
Naltrexone and disulfiram
Describe paracetamol overdose.
Glutathione transferase runs out, you get reactive intermediats causing cellular necrosis. Very high ALT. Nausea and vomitting, needs Nacetylcysteine and acid base support
Autoimmune hepatitis
IgG, ANA, females. Good response to therapy.
Primary biliary cirrhosis
Chronic autoimmune granulomatous infiltration of interlobular bile ducts.. IgM, antimitochondrial antibodies. HCC
Treatment for primary biliary cirrhosis
Ursodeoxycholic acid
Primary sclerosing cholangitis
Primary sclerosing cholangitis, intrand extrahepatic bile ducts. Associated with UC. pANCA and ANA. Obliterative cholangitis and onion skin fibrosis
Haemochromatosis who gets it
Recessive, C282y. Hepcidin expression disrupted.
Symptoms of haemochromatosis
Iron deposition in liver heart, pancreas and joints leads to fibrosis. Tired Athralgia, grey skin, DVT, cirrhosis
Investigations for haemochromatosis
High ferritin, transferrin, serum iron. LFTs raised. Biopsy, genetic testing. Echo
Treatmetn of haemochromatosis
Venesection. Desferrioxamine iron chelator. tea, coffee, red wine
Pathophysiology of a1 antitrypsin
Recessive gene condition. Antitrpsin accumulation in liver and emphysema as protein defiency in blood
Investiagtions for a1antitrypin
Serum a1 antitrypsin low.
Biosy shows globules of alpha 1 antipsyin
Wilsons pathology
Copper toxicity. Decreased copper incorporation into caeruloplasmin and reuced copper excretion
Who gets wilsons
Autosomal recessive on 13
Symptoms of wilsons
Kayser Fleischer ring, grey skin, hypermobile joint. Depression, cirrhosis, tremor
Investigations of wilsons
Reduced serum copper, high urine copper 24hr, low serum caeruloplasmin. Do a liver biopsy. MRI basal ganglia. Genetinc testing
Treatment of wilsons
Penicillamine is a copper chelator
Screen family
No liver, chocolate, nuts, muschrooms, legumes
COPD and liver cirrhosis
Alpha 1 antitrypsin
Symptoms of hepatitis
General malaise, myalgia, GI upset, abdo pain
Hep A
Acute only, faecooral, travellers, foodhandlers, shellfish
Hep B
Blood bourne, needle stick, tattoos, sexual, vertical
Hep D
Needs HepB, bloody and bodily fluids. IVDU
Hep C
Blood and bodily fluids, IVDU, blood transfusions, needle stick, MSM
Hep E
Faecooral
Hep Vaccines
A100%
B inactivated HBsAg (HBV IgG post exposure)
D hepBvaccine
Complications of A and E hep
Fulminant hepatitis
Hep B C and D complications
Cirrhosis, HCC, Cholangiocarcinoma
Hep A and E treatment
Supportive
Hep B, C and D treatment
PEG IFN
HBsAg suggests
Acute or chronic infection. Infectious
antiHBs suggests
Recovered or has been vaccinated
antiHBc suggests
Have or recovered (proper infection)
Signs of cirrhosis
CLAPS Clubbing Leukonychia Ataxia Palmar erythema Scratch marks
General signs ofcirrhosis
Hepatomegaly, jaundice, ascites
Describe portal hypertension
Blockage leads to 10mmHg, collateral circulation occurs thorugh portosystemic shunt and dilation of gastro-oesophageal veins (varcies)
Transudate causes of ascites
Potal hypertension (cirrhosis)
BuddChiari
Cardiac failure
Exudate causes of acites
Pertioneal carcinoma Peritoneal TB Pancreatitis Nephrotic syndrome Lymphatic obstruction
Presenation of ascites
Abdominal distension, fullness in teh flanks, shifting dullness. Respiratory distress if tense ascites. Pleural effusion and oedema
Investigations for ascites
Aspiration. Albumin, Neutrophil (SBP?), MC&S, Cytology, amylase
Managemtn of ascites
Treat underlying cause, spironolactone
Paracentesis and albumin replacement
Transjugular intrahpeatic portosystemic shunt
Spontaneous bacterial peritonitis
Ecoli. Cefotaxime and metronidazole
Complications of gall stones
Biliary colic, ascending cholangitis and acute cholecystis
Define gall stones
Obstruction in cystic orcommon bile duct by a stone
Define ascending cholangitis
Infection of the biliary tree caused by obstruction of the common bile duct
Define acute cholecystitis
Obstruction of the neck of the gallbladder resulting in inflammation of the gall bladder
Signs of gall stones
Colicking RUQ pain after eating, can radiate to the right shoulder
Ascending cholangitis signs
Charcots triad: biliary colic, jaundice, fever (hypotension+confusion)
Acute cholecystitis signs
RUQ pain, fever and nausea, murphys sign
What is murphys sign
Pain on taking deeep breath when two fingers on RUQ
Diagnosis of gallstones
Abdominal ultrasound scan
Management of gallstones
Lithotripsy, ERCP, surgery
Describe prehepatic jaundice
Dark urine because of urobiliinogen and conjugated. Caused by Gilberts, haemolysis and malaria
Describe post hepatic jaundice
Dark urine (conjugated) and pale stool, gall stone or stricture
Describe heaptic jaundice
Hepatitis (all the types), ischaemia, neoplasm. Increased unconjugated
Difference between acute and chronic pancreatitis
Acute=reversible damage
Chronic=irreversible damage
Causes of acute pancreatitis
Gallstones Ethanol Trauma Steroid Mumps Autimmune Scorpion venom Hyperlipidaemia ERCP Drugs (azathioprine and sodium valproate)
Pancreatitis presentation
Severe epigastric pain that may radiate to the back, vomitting, cullens and grey turners
What is cullens sign
Perimubilical discolouration
What is grey turners sign
Flank discolouration
Pancreatitis investaigtion and diagnosis.
CT. Diagnosis= raised serum amylase X3 and serum lipase
Define polycythaemia
Increase in red blood cell, packed cell volume and haemoglobin concentrations
Causes of apparent polycythaemia
Beiing overweight, alcohol, diuretics, dehydration, stress
Describe primary polycythaemia
Polcythaemia vera, JAK2 mutation means the Bone marrow is increasedsensitivity to EPO so more RBC are produced. Peak in 60s
Causes of secondary absollute polycythaemia
Hypoxia, high altitude, abnormal RBC, tumours, renal artery stenosis
Symptoms of polycthaemia
Bleeding, bruising, fatigue, itchy skin
Signs of polycythaemia
Splenomegaly, hypertesnion, red skin, thrombocytosis
Polycythaemia puts you at risk of
Blood clots, MI, PE
Investigations of polycythaemia
History, FBC, blood film, genetic testing, U&Es, LFTs, serum EPO and red cell mass studies
Treatement of pvc
Venesection, hydroxycarbamide, interferon
Define pancytopenia
A reduction in RBC, WBC, and platelets
Causes of pancytopenia,
chemo, HIV, SLE, Malignancy
Diagnosis of pancytopenia
Bone marrow biopsy and FBC
How do you detect myeloblasts
Myeloperoxidase
How do you detect lymphoblasts
Tdt
Who gets AML
70s
Who gets AML
<p>70s</p>
Unique feauters of AML
Auer rods, Hepatosplenomegaly and gum hypertophy
Who gets ALL
3.5yo boys
What are ALL and AML linked to
Downs
Treatment of AML
Supportive, chemotherapy, bone marrow transplant
Unique presentation of ALL
Lymphadenopathy and testicular swelling
What are the symptoms of marrow failure
Fatigue, infection, bleeding and bruising
What should you give in ALL and AML to prevent tumour lysis syndrome
Allopurinol
What does Philadelphia chromosome cause
CML and ALL
Treatment of ALL
Supportive, chemotherapy and bone marrow transplant
Investigations in acute leukaemia
FBC, Blood film, BM biopsy, cytogenetics
Define CML
Uncontrolled proliferation of myeloid cells
Define AML
Neoplastic proliferation of blast cells derived from marrow myeloid elements
Define ALL
Malignancy of immature lymphoid cells
Who gets CML
40-60
What causes CML
Philadelphia chromosome causes increased tyrosine kinase activity
Presentation of CML
Constituional symptoms, massive splenomegaly, thrombocytosis
Investiagtions in CML
FBC, Blood Film, cytogenetics
Management of CML
Imatinib (tyrosine kinase inhibitor), hydroxycarbamide, bone marrow transplant
Define CLL
Accumulation of mature B cells which have escaped programmed cell death and undergone cell cycle arrest
Presentation of CLL
Enlarged rubbery non tender lymph nodes, constitutional symptoms, hepatosplenomegaly
Investigations of CLL
FBC and Rai staging
Treatment of CLL
Rituximab, radiotherapy, chemotherapy, stem cell transplant
Define myeloma
Malignant proliferation of clonal plasma cells
Who gets myeloma
60-70
Presentation of myeloma
Calcium, Renal impairment, Anaemia, Bone disease
Myeloma findings
Constitutional, amyloidosis, hyperviscosity, marrow infiltration, infection
Investigations in myeloma
FBC, blood film, U&E, urine electrophoresis, bone marrow biopsy, XRay skeletal survey
What are the findings on investigation in Myeloma
Marrow failure, roleaux formation, bence jones protein in urine and blood. Increased blasma cells in the bone marrow. Lytic lesions and pepperpot skull
Complications of myeloma
Hypercalcaemia, spinal cord compression, hyperviscosity, AKI
Treatment of myeloma
Analgesia and bisphosphonates, blood transfusion, IV immunoglobulin. Chemo, stem cell transplant
Painless, rubbery nodes which hurt with alcohol
Lymphoma
Define lymphoma
Malignancy of mature lymphocytes that arises in the lymphatic system
Define leukaemia
Malignancy of lymphocyte precursors that arises in the bone marrow
Presentation of lymphoma
Painless lymphadenopathy, systemic symptoms, compression syndromes
Investigations in lymphoma
Blood film, bone marrow and lymph node biopsy, immunophenotyping and cytogenetics
Staging of lymphoma
Bloods, CT chest/abdo./pelvis
Low grade non hodgkins
Follicular
High grade non hodgkins
Diffuse large b cell
Very high grade non hodgkins
burkitts
Define hodgkins lymphoma
Malignant proliferation of lymphocytes and reed stern berg cells present
Who gets hodgkins lymphoma
30s or 70s
Risk factors for hodgkins
EBV, SLE, post transplant, obesity
Staging of hodgkins lymhoma
Ann arbor
Presentation of hodgkins
Painless asymmetrical lymphadenopathy (pain on alcohol), systemic symptoms, anaemia, LDH raised and hepatosplenomegaly
Treatment of 1-2a HL
Short course chemo then radio
Treatment of 2b-4 HL
Combination chemo
Late effects of HL
Cancers, psychological issues
Late effects of HL chemo
Infertility, cardiomyopathy, lung damage, peripheral neuropathy
NHL presentation
Bowel obstruction, bone marrow crowding out, spinal cord compression
Risk factor for burkitts lymphoma
EBV
Risk factor for gastric MALT lymphoma
H pylori
Treatment of NHL
Conservative if follicular, chemo, radio, bone marrow transplant
Tumour lysis syndrome
Large tumour burden and aggressive cancers, release of cellular components overwhelms the kidneys
Signs of tumour lysis syndrome
Hyperkalaemia, hyperphosphotaemia, hyperuricaemia, hypercalcaemia. Results in AKI, Seizures, death
Treatment of tumour lysis syndrome
IV fluids, treat high pot
Features of febrile neutropenia
Fevers, rigors, hypotension
How to treat febrile neutropaenia
Broad spectrum ab (tazosin), and take blood cultures
Signs of malignant cord compression
Back pain, spastic paresis, sensory level
Treatment of spinal cord compression
Dexamethasone, urgent MRI, chemo or R/T surgery
Causes of hyperviscosity syndrome
Increased immunoglobulins (myeloma), increased blood cells (leukaemia), reduced deformability of RBC (sickle cell)
Presentation of hyperviscosity triad
Mucosal bleeding, visual change, neurological disturbance
Consequences of hyper viscosity
Congestive heart failure, MI, pulmonary oedema
4 species of malaria
P.vivax, ovale, malariae, facilparum
What effect does malaria have on cells
Haemolysis, RBC sequestration and cytokine release
Signs of malaria
Anaemia, thrombocytopenia, coma, convulsions, acidosis
Diagnosis of malaria
Serial thin and thick films
Other tests in malaria
FBC, Clotting, glucose, ABG, U&E, blood cultures
Prophylaxis for malaria
Malarone
Treatment for malaria
Chlorquine, primaquine
Which diseases give protection against malaria
Sickle cell and G6PD
Low Hb, high WCC, platelets normal
Autoimmune haemolysis
Infection following blood transfusion
Probably bacterial as platelets stored at room temperature
What is the effect of CKD on blood
Lack of EPO therefore anaemia
What is the effect of renal cell carcinoma on blood
Secondary polycthaemia
Types of haemoglobin
A2gamma2 switches to a2b2 at 6 months
Diagnositc tests for anaemia
WCC, platelet count, reticulocyte count, blood film, haematinics, bone marrow biopsy
Signs of iron deficiency anaemia
Koilonychia, angular cheilosis, atrophic glossitis, post cricoid webs
Causes of iron deficiency anaemia
Menorrhagia, GI bleeding, hookworm, coeliac
General signs of anaemia
Breathlessness, tachycardia, fatigue, pallor of mucous membranes, hyperdynamic circulation
Appearnace of microcytic anaemia RBC
Microcytic and hypochromic
Causes of microcytic anaemia
Iron deficiency, thalassaemia, sideroblastic anaemia, anaemia of chronic disease
Treatment of iron deficiency anaemia
Ferrous sulfate for 3 months and treat underlying cause
Causes of normocytic anaemia
Blood loss, chronic disease, bone marrow or renal failure. Pregnancy and hypothyroid
Iron deficiency anaemia in someone without an obvious cause
Do oesophagogastroduodenoscopy and colonoscopy for GI bleed and exclude malignancy
Causes of anaemia of chronic disease
Inflammation, malignancy, infection, renal failure, rheumatoid arthritis
Treatment for anaemia of chronic disease
Treat underlying cause and give EPO
Diagnosis of iron deficiency anemia
Low ferritin and serum iron. Total iron binding capacity high. Microcytic with anistocytosis and poikilocytosis. Do stool sample for ova and coeliac serology
Causes of sideroblastic anaemia
Congenita, cancer, antiTB drugs. Ring sideroblast appearance because of iron deposits. Ferritin increased
Describe pernicious anaemia
Antiparietal cell and intrinsic factor antibodies. Associated with other AI, Vitiligo and hyporthyroid
Diagnosis of pernicious
Low Hb, raised MCV, hypersegmented neutrophils on blood film. Megaloblasts on biopsy
Treatment of pernicious anaemia
IV hydroxycabalamin, oral folate
Sources of vitamin B12
Meat, fish, dairy
Causes of B12 deficiency
Dietary, malabsorption, congential metabolic errors
Causes of B12 malabsorption
Atrophic gastritis causing pernicious anaemia or short gut syndrome preventing uptake
Where is B12 absorbed
Terminal ileum
Where is folate found
Green vegetables
Where is folate absorbed
Duodenum/jejunum
Where is iron absorbed
First part of the duodenum
Causes of folate deficiency
Dietary, malabsorption, drugs
B12 deficiency features
Lemon tinged skin, beefy red tongue, demention, paraesthesia, peripheral neuropathy
Increased red cell distribution width
Coeliac. Both micro and macrocytic anaemia
Clinical features of haemolytic anaemia
Anaemia, jaundice, gall stones, hepatosplenomegaly
Signs of haemolytic anaemia
Anaemia. increased unconjugated bilirubin, increased urobilinogen, increased reticulocytes
Glucose 6 phosphate dehydrogenase deficiency
X linked, Africa and med, bite and blister cells
B thalassaemia
First year of life, skull bossing, hepatosplenomegaly, treat with transfusions and splenectomy. Target cells
Alpha thalassaemia
Cant do without. So die. Bart’s hydrops
Hereditary spherocytosis
Autosomal dominant, sherical red cells become trapped in spleen and undergo haemolysis
Result of thalassaemia
Unmatched chains clump together and cause haemolysis and anaemia
Result of vessel and platelet disorders
Purpura, bleeding, prolonged bleeding
Result of coagulation disorders
Delayed bleeding into joints and muscles
Causes of reduced platelet production
Bone marrow failure, aplastic anaemia
Casues of destruction of platelets
Immune thrombocytopenia and Disseminated intravascular coagulation
What makes foetal haemoglobin
Liver and spleen
What makes adult haemoglobin
Bone marrow
Describe sickle cell
Sickle cell haemoglobin is abnormal and polymerises when deoxygenated
How do you diagnose sickle cell
Hb electrophoresis
Symptoms of a sickle cell crisis
Acute chest, dactylitis, stroke, priapism
How do you treat sickle cell
Hydroxycarbamide
What causes an increased prothrombin time
Liver disease, warfarin, DIC
What causes and increased activated partial thromboplastin time
Haemophilia, heparin, DIC
What causes an increased thrombin time
Heparin and DIC
What causes increased D-Dimer
DVT and DIC
Signs of DIC
Purpura and brusing, bleeding from cannula sights. Shistocytes on blood film.
Casues of DIC
Trauma, malignancy, sepsis, birth
Treatment of DIC
Replace platelets and give fresh frozen plasma
Haemolytic uraemic syndrome
After EColi. Triad of AKI, haemolytic anaemia and low platelets
Immune thrombocytopenia
Antibodies against platelets in children two weeks after infections
Vitamin K deficiency
Low 2,7,9,10. Caused by anticoagulants, biliary obstruction. Causes increased PTT
Vonwillebrand disease
Factor 8 problem, increased PTT
Haemophilia A
X linked, factor 8 deficiency. Raised APTT. Treat with desmopressin and recombinant factor 8
Haemophilia B
Same but factor 9
Risk factors for DVT
Immobility, cancer, oestrogen, surgery, thrombophilia
Diagnosis of DVT
Wells score and D dimer then do ultrasound. If unprovoked look for malignancy.
Virchows triad of venous thrombosis
Stasis of blood
Thrombophilias
Clotting problem. Factor V leiden and antiphospholipid syndrome
Treatment fo DVT
LMWH and warfarin
How does LMWH work
Inactivates factor Xa and thrombin (IIa)
How does warfarin work
Vitamin K antagonist
How do DOACs work
Xa antagonist
How to prevent DVT
Early mobilisation, compression stockings, leg elevation, LMWH
Name a DOAC
apXaban
Long bleeding time but otherwise normal suggests
Von Willebrand disease
Anaemic male and nothing wrong suggests
Gastroenterology
What should you give someone who has gout if they have other things going on like AF and DM
Colchicine
Symptoms of OA
Pain on movement and at end of day
Signs of OA
Bony swelling: Heberdens (DIPJ), Bouchards (PIPJ)
Secondary causes of OA
Haemochromatosis, obesity, occupational
What causes OA
Abnormal stresses or abnormal cartilage lead to compromised cartilage and biophysical and biochemical changes lead to cartilage breakdown
Biophysical changes in OA
Collagen network fracture and proteoglycan unravelling
Biochemical changes in OA
Inhibitors are reduced and proteolytic enzymes are increased
OA on XRay
Loss of joint space
Non pharmacological management of OA
Weight loss, exercise, aids and devices
Pharmacological management of OA
Paracetamol then oral NSAID if needed and intrarticular pred
Surgical management of OA
Joint replacement
Should you give NSIADs to people on warfarin
No GI bleed risk
Should you give steroids to people with diabetes
No upsets diabetic control
Describe gout crystals
Monosodium urate crystals are needle shaped and negatively birefringent under polarised light
Describe pseudo gout crystals
Calcium pyrophosphate crystals which are rhomboid and positively birefringent under polarised light
What causes decreased uric acid secretion
Diuretics, CKD, lead
What causes increased production of uric acid
Leukaemia, cytotoxic drugs, severe psoriasis
How does gout present
Acute monoarthropathy with severe joint inflammation. Caused by hyperuricaemia resulting in monosodium urate crystal deposition
Where is gout most common
Metatarsophalangeal joint
Causes of gout
Hereditary, increased dietary purines, alcohol, diuretics, trauma, leukaemia, surgery, starvation
Associations of gout
CV disease, DM, CKD
Important differential of gout
Septic arthritis
Investigations in gout
Bloods: serum urate
Non pharmacological Mangement of acute gout
Protect rest, ice, elevate.
1st line acute gout
NSAID max dose (ibuprofen) w/ppi or colchicine
2nd line acute gout
Joint aspiration and intrarticular pred
3rd line gout
Short course oral pred or single IM pred
Prevention of gout 1st line
Allopurinol
Prevention of gout 2nd line
Febuxostat
How does allopurinol work
Xanthine oxidase inhibitor
Prevention of gout 3rd line
Consider colchicine to prevent acute attacks
Presentation of pseudogout
Acute monoarthropathy of larger joints. Can be provoked by trauma illness or surgery. Calcium pyrophosphate cystal arthritis
Risk factors for pseudogout
Old age, hyperparathyroidism, haemochromatosis, hypophosphataemia
Investigations of pseudogout
Polarised light microscopy of synovial fluid
Treatment of acute acute of pseudogout
Cool packs, rest aspirate, intrarticular steroids. NSAIDs or Colchicine
Treatment of chronic pseudogout
Methotrexate
RA initial management
Methotrexate + Sulfalasalzine + short course of pred
Definition of rheumatoid arthritis
Chronic systemic autoimmune inflammatory disease characterised by a symmetrical, deforming, peripheral arthritis
Define OA
Non inflammatory degenerative arthritis
Typical presentation of RA
Symmetrical, swollen, painful, stiff small joints of the hands and feet. Worse in the mornings. Slowly progressive, affects women more than men.
Investigations in RA
Bloods, XRay, Ultrasound
Blood in RA
Rheumatoid factor
XRay of RA
Periarticular erosions, soft tissue swelling, loss of joint space
Ultrasound of ra
Synovitis, bony erosion
Pathophysiology of RA
Synovitis, hypertrophy, T lymphocyte and macrophage proliferation, pannus, malnutrition from cytokine effect, thin cartilage and bone exposure
Early signs of RA
Inflammatory signs, swollen symmetrical MCP, PIP, wrist or MTP
Late signs of RA
Ulnar deviation
Extraarticular manifestations of RA
Vasculitis, pericarditis, raynaud’s, episcleritis, fibrosing alveolitis
Conservative management of RA
PT, OT, Podiatry, psychological support
RA 1st line
Methotrexate, sulfasalazine and short term pred
RA 2nd line
If combination not appropriate, just methotrexate
Long term MA management
Try and reduce DMARD dose, short term pred for flares. Consider bioligs
antiTNF alpha blocker
Infliximab, etanercept, adalimumab
Anti CD20 blocker
Rituximab
Tyrosine kinase inhibitor
Imatinib
Does RA or OA respond to steroids
RA better
Describe seronegative spondyloarthropathies
Test negative for Rheumatoid factor, HLAB27 antigen.
Which joints are involved in seronegative spondyloarthropathies
Inflammation of the sacroiliac joint and spine
SPINEACHE acronym for seronegative spondyloarthropathies
Sauasage digit (dactylitis)
Ank spond criteria
¾ in under 50
Ank Spond on XRay
Syndesmophytes, sacroiliitis
Ank Spond bloods
FBC, raised ESR and CRP, HLAB27
Management of Ank Spond
Exercise and manage CV risk. 1st line NSAIDs, consider bisphosphonates and pred injections
What are the three classic features of reactive arthritis
Urethritis, arthritis, conjunctivitis. Cant wee, cant see, cant climb a tree
Define reactive arthritis
Sterile large joint arthritis affect the lower limb typically 1-4 weeks after infection
Infections that cause reactive arthritis
Urethritis (chlamydia)
Other features of reactive arthritis other than reiters syndrome 3
Iritis, mouth ulcers, enthesitis
Reactive arthritis investigations
Bloods, culture stool/sexual health review, infectious serology.
Management of reactive arthritis
Splint, aspirate, NSAIDs, corticosteroids, antibiotics. If chronic methotrexate
Define psoriatic arthritis
Arthritis in patients with psoriasis or a family history of psoriasis.
Presentation of psoriatic arthritis
Joint swelling, pain, stiffness, tenderness of joints
Features of psoriatic
Dactylitis and onycholysis
Investigations for psoriatic
Bloods raised ESR and CRP
Management of psoriatic
NSAIDs, sulfasalazine, methotrexate
Triad of septic arthritis
Low grade fever, impaired ROM, painful large joint
Risks for septic arthritis
RA, DM, immunosuppression, IVDU, over 80
Investigations for septic arthritis
Urgent joint aspiration for MC&S, blood cultures
Management of septic arthritis 1st line
Flucoxacillin for 6weeks. Splint. If prosthetic then debride
If penicillin allergic and septic arthritis
Clindamycin
If gonococcal arthritis which antibiotic
Cefotaxime
Definition of septic arthritis
Infection of the surface fo cartilage
Definition of osteomylelitis
Infection of the bone that can include the periosteum, medullary cavity and cortical bone
Common causative agent of septic arthritis and osteomyelitis
Staph Aureus
Who gets septic arthritis
Old people
Who gets osteomyelitis
Children
Diagnosis of septic arthritis
Join aspiration
Diagnosis of osteomyelitis
Bone cultures
Management of osteomyelitis
Debridement and antibiotics
Define raynauds disease
Peripheral digital ischaemia due to vasospasm
Colour changes in raynauds
Normal to white to blue to red to normal
Triggers of raynauds
Cold and stress
Seconday raynauds causes
SLE, RA, occupational, beta blockers
Treatment of raynauds
Stop smoking, keep warm, nifedipine, sildenafil
Define systemic lupus erythematosus
Inflammatory multisystemic disease with antinuclear antibodies
What is the common presentation of lupus
Fatigue, malaise fever
SLE associations
Black, women, IBS
Criteria for lupus acronym
SOAP BRAIN MD
What does the lupus criteria stand for
Serositis
Diagnosis of lupus
Clinical, ESR high but CRP low. Skin or renal biopsy
Treatment of SLE
Avoid smoking and sunlight. NSAIDs for arthralgia and topical steroids for cutaneous.
Acute severe SLE flare
IV prednisolone and cyclophosmaide
Chronic managemtn of SLE
NSAIDs and hydroxychloroquine
Define sjorgens
Inflammatory autoimmune disorder with lymphocytic infiltration of exocrine glands
Symptoms of Sjorgens
Dry eyes, mouth, vagina. Fever, malaise, polyarthralgia
Diagnosis of Sjorgens
Schirmers test. Serology ANA, RF, AntiRo and AntiLa. Biopsy showing plasma and lymphocytes
Management of sjorgens
Synthetic tears and saliva, lubrication for vagina, NSAID
Complications of Sjorgens
Non HL
What symptoms do you get in all autoimmune conditions
Fatigue, malaise, polyarthralgia, myalgia
What is the presentation of dermatomyositis
Polymyositis and skin involvement. Heliotrope rash, macular rash, subcut calcifications and gottrons papule.
Define polymyositis
Inflammation and progressive necrosis of skeletal muscle fibres
Presentation of polymyositis
Difficulty squatting, climbing stairs, raising hands above head. Arthralgia, dysphonia, dysphagia, fever, raynauds
What causes polymyositis
Cytotoxic T cells
Diagnosis of polymyositis
Creatinine kinase and aldolase
Mangement of polymyositis
Oral prednisolone
Presentation of limited cutaneous systemic sclerosis
Calcinosis
What is the different presentation of diffuse cutaneous systemic sclerosis
Earlier organ fibrosis and diffuse cutaneous involvement
Diagnosis of limited cutaneous systemic sclerosis
Anti centrome ab
Diagnosis of diffuse cutaneous systemic sclerosis
AntiScl 70 and anti-RNA polymerase
Management of diffuse cutaneous systemic sclerosis
Control BP, monitor echo spirometry renal function
Complication of systemic sclerosis
Malnutrition
What causes systemic sclerosis
Collagen deposition
How do you diagnose PE
CT pulmonary angiogram
Antiphospholipid syndrome
Venous and arterial thrombosis. Phospholipid antibodies. Low dose aspirin treatment
Large cell vasculitis
Granulomatous disease. Giant cell arteritis and Takayasu arteritis
Medium vessel vasculitis
Polyarteritis nodosa and Kawasaki disease
What will you see on biopsy for GCA, polyarteritis nodosa, wegeners, churgg strauss
Granulomas
Consequences of vasculitis
Stroke, MI, fever headache
Signs of giant cell arteritis
Unilateral headache, scalp tenderness in temporal region, jaw cladication, amaurosis fugax, morning stiff ness
Diagnosis of giant cell arteritis
Clinical, bloods.
Management of giant cell arteritis
Immediate prednisolone
Define polymyositis
Inflammation of striated muscle
How would you differentiate polymyalgia rheumatica from polymyositis
PMR gets pain
Key deatures of polyarteritis nodosa
Medium arteries. Microaneurysms. HepB. Skin rash and punched out ulcers. No glomerulonephritis or ANCA
Diagnosis of polyarteritis nodosa
Renal angiography or biopsy
Management of polyarteritis nodosa
Prednisolone and cyclophosamide
Define granulomatosis with polyangiitis
Necrotising granulomatous vasculitis nmediated by neutrophils (cANCA)
Symptoms of GPA
Cough, sinusitis, haemoptysis, haematuria, ulcers, saddle nose deformity
Diagnosis of GPA
History, bloods, cANCA and PR3 ab test. Renal or lung biopsy showing granuloma
Treatment of acute GPA
Prednisolone and IV cyclophosamide
Maintenance of gpa
Azathioprine
Churg-Strauss syndrome
Asthma, eosinophilia and vasculitis. MPO ab, pANCA. Steroids. Then long term rituximab
Microscopic polyangiitis
Like wegeners but pANCA and no granuloma
Fibromyalgia treatment
CBT and tailored exercise programme
Define fibromyalgia
Chronic widespread pain and sensitivity to pressure at 11/18 tender points without inflammation (exclude DDx)
Yellow flags of fibromyalgia
Sickness behaviour (extended rest, social withdrawal, low participation in treatment, belief that pain and activities are harmful)
Investigations in back pain
Urgent MRI, FBC, U&E, LFT, ESR, CRP serum electrophoresis
Define multiple myeloma
Abnormal proliferation of a single clone plasma cell
Prognostic myeloma test
Serum Beta2 microglobulin
Osteosarcoma
Teenagers and children. Around knee. Chemo and surgery
Ewings sarcoma
5-20yo. Leg, pelvis, upper arm, ribs. Chemo and surgery
Chondrosarcoma
Malignant tumour of chondrocytes. 40-70, hip pelvis shoulder. Surgery
Secondarys to bone from
Breast, lung, thyroid, renal, prostate
Define osteoporosis
Progressive systemic skeleteal disease characterised by reduced bone mass and microarchitectural deterioration of bone tissue.
ACCESS for osteoporosis risk
Alcohol
What is a T score
Score compared to a gender matched individual at peak bone mass
-1 to -2.5
Osteopenia
< -2.5 osteoporosis
Osteoporosis
LESS THAN -2.5 AND FRACTURE
<p>Severe osteoporosis</p>
Management of osteoporosis
More exercise, less alcohol, vitamin D supplements. Bisphosphonates.
What does FRAX do
Fracture risk assessment tool. Evaluates the 10 year probability of bone fracture.
Name two loop diuretics
Furosemide and bumetanide
How do loop diuretics work
Act on NaK2Cl in the ascending limb
Adverse effects of loop diuretics
Dehydration, hypotension, hypokalaemia so metabolic alkalosis
Name two potassium sparing diuretics
Amiloride and spironolactone
How do potassium sparing diuretics work
Aldosterone antagonist so acts on ENaC in the DCT
Adverse effects of potassium sparing diuretics
GI upset, hyperkalaemia, metabolic acidosis, gynaecomastia
Name a thiazide diuretic
Bendroflumethiazide
How do thiazide diuretics work
Act on sodium chloride channels in the DCT, longer acting but not as potent as loop
Adverse effects of thiazide diuretics
Hypokalaemia, metabolic alkalosis, hypovolaemia, hyponatraemia, hyperglycaemia in diabetics
3 common sites where stones get stuck
Pelviureteric junction, pelvic brim, vesicoureteric junction
What are renal stones made up of
Calcium oxalate (75%), struvite, uric acid or cysteine. Caused by supersaturation of urine with salt/minerals
What are infection stones made up of
Magnesium ammonium phosphate
What causes cysteine stones
Cystinuria which is an autosomal recessive condition
How would describe colic
Waves of pain
If they have a catheter in and are confused what do you suspect
UTI
Renal colic pain presentation
Unilateral severe pain, starts in loin and moves to groin. Radiates to ipsilateral testis and labia. There can be periods of relief before it returns again.
What are the other symptoms of renal colic
Rigors, dysuria, haematuria, urinary retention, nausea and vomiting
Risk factors for stones
Anatomical abnormalities, FHx, hypertension, gout, hyperparathyroidism, immobile, dehydrated
Differentials for renal colic
Ruptured AAA, diverticulitis, appendicitis, pancreatitis, testicular torsion, pyelonephritis, MSK
Investigations for renal colic
Bloods inc calcium, phosphate urate. Urinalysis, MSU if positive. Non contrast computerised tomography kidney ureter bladder. NCCT KUB gold standard
Management of renal colic
Strong analgesic= diplofenac
Management of obstruction and infection
Ureteric stent
Prevention of renal stones
Drink plenty of water
Define AKI
An abrupt sustained rise in serum urea and creatinine due to a rapid decline in GFR leading to a failure to maintain, fluid, electrolyte and acid base homeostasis
3 criteria for AKI
Increase in creatinine of more than of 26micromol/L in 48hr
Risk factors for AKI
Age, CKD, cardiac failure, PVD, diabetes, drugs, sepsis, dehydration
Prerenal AKI causes
Hypoperfusion, hypotension, renal artery stenosis, drugs
Renal AKI causes
Acute tubular necrosis, AI, glomerulonephritis, vasculitis
Post renal causes of AKI
Urinary tract obstruction. Stones, malignancy, BPH
ACE-I and ARB effect on kidney
Results in dilated efferent arterioles, decreasing GFR
NSAIDs effect on kidney
Inhibits cyclooxygenase causing excess vasoconstriction of the afferent arterial
Aminoglycosides effect on the kidney
Acute tubular necrosis
Investigations of AKI
Full screen. Cr, U and E, LFT, clotting, glucose, urine dipstick, autoantibodies (antiGBM, ANCA), Renal USS. U and E is diagnostic
Management of AKI
Aim for euvolaemia, stop nephrotoxic drugs, treat cause, manage complications
How do you treat hyperkalaemia
Insulin/dextrose, salbutamol, calcium gluconate
Define CKD
GFR below 60mL/min/1.73m for more than 3 months, with or without evidence of kidney damage
Causes of CKD
Glomerular disease, hypertension, interstitial disease (myeloma, TB, schistosomiasis), PCKD, SLE, Vasculitis
CKD on USS
Bilaterally small kidneys
Presentation of CKD
Malaise, nocturia and polyuria, itching, NVD, oedema, bruising
What causes itching in CKD
High urea levels
Stage one CKD
GFR over 90, with evidence of kidney damage. Check for proteinuria and haematuria
Stage two CKD
60-89, kidney damage and slightly low GFR. Lower BP and give low protein diet
Stage three A and B CKD
30-45,45-60 moderate reduction in GFR. control BP low protein diet
Stage 4 CKD
15-29. Severely low GFR. Prepare for dialysis
Stage 5 CKD
<15 or dialysis. Kidney failure.
AKI v CKD: kidney size
Normal v small
AKI v CKD: anaemia
No v normochromic normocytic
AKI v CKD: diabetes
No v diabetes
AKI v CKD: BP
Low v high
AKI v CKD: time span
Rapid v slow
AKI v CKD: urine output
Oligouria v polyuria and nocturia then oligouria
AKI v CKD: CNS symptoms
None v In late disease
Nephrotic disease triad
Proteiunuria, hypoalbuminaemia, oedema. Also severe hyperlipidaemia as liver goes into overdrive from albumin loss
Causes of primary nephrotic
Minimal change disease, membranous nephropathy, focal segmental glomerulonephritis
Causes of secondary nephrotic
Diabetes, hepatitis, malignancy
Cause of nephrotic
Injury to podocyte foot processes
What happens in minimal change disease
Fusion of footprocesses of podocytes
Investigations of nephrotic
Urine dip (high protein), bloods (low albumin and biopsy in adults
Management of nephrotic
Steroids in children, diuretics, ACE-I for proteinuria. Treat cause
Complications of nephrotic
Infections, thromboembolism, hypercholesterolaemia
Nephritic syndrome 4 things
Haematuria (red cell clasts), proteinuria, hypertension, oligouria
Cause of nephritic
Immune response to podocytes so pores
Causes of nephritic
Spot streptococcal glomerulonephritis, IgA nephropathy, good pastures
What do red cell clasts indicate
Glomerular damage
How long after URTI does IgA nephropathy happen
Days
How long after URTI foes post strep glomerulonephritis happen
Weeks
What happens in IgA nephropathy
Abnormal IgA form and accumulate, IgG bind against. These immune complexes get trapped in the mesangium causing type 3 hypersensitivity
Why do you get a proinflammatory response in IgA nephropathy
Alternative complement system is activated by immune complexes
How do you diagnose IgA nephropathy
Mesangial proliferation
How do you prevent immune complexes
Prednisolone
Which bacteria cause post strep GN
Group A Beta haemolytic strep
How do you diagnose post strep GN
Biopsy shows enlarged glomerular basement membrane then EM shows humps
What hypersensitivity is post strep GN
3, immune complex. Then alternative complement.
Management of post strep GN
Supportive
Minimal change disease
Children, Cytokines damage podocytes making them flattened and lose their negative charge. Nephrotic syndrome. Selective proteinuria
Association of minimal change disease
Hodgkins lymphoma
Diagnosis of minimal change disease
Fused podocyte processes on EM
Treatment of minimal change disease
Prednisolone
Focal segmental glomerulonephritis
Hyalinosis leads to sclerosis. Diagnosed by afacement of podocytes on EM. Treat with prednisolone
What is used when the patient is steroid resistant
Ciclosporin
Membranous neuropathy
Immune complexes against basement membrane. Biopsy= thickened BM and C3 and IgG deposits. Treat with prednisolone
Causes of nephrotic
Minimal change disease, membranous neuropathy and focal segmental glomerulonephritis
Causes of nephritic
IgA nephropathy, post streptococcal glomerulonephritis, goodpastures
What are the features of nephrotic which nephritic doesn’t have
Oedema, hyperlipidaemia and hypoalbuminaemia
Autosomal dominant Polycystic kidney disease
PKD1 more common and more severe. PKD2 less common and less severe
Pathophysiology of ADPKD
Polycystin 1 and 2 mutations mean unregulated tubular and vascular growth in the kidneys and other organs
Other organ involvement of ADPKD
Liver= no affect on function
Presentation of ADPKD
Nocturia, loin pain, HTN, bilateral kidney enlargement. Haematuria following trauma. UTI, pyelonephritis, stones more common
Investigations of ADPKD
Ultrasound
Management of ADPKD
Counselling and support for family, monitor progression, treat HTN, UTI, Stones and colic. Dialysis when needed
What happens in retention
The kidneys are still producing urine but the bladder is unable to void
Causes of acute bladder retention
Bladder stone, BPH, Prostate cancer, MS, prolapsed disc at S2,3,4
Define BPH
Benign proliferation of musculofibrous/glandular tissue of the transitional zone of the prostate
Voiding LUTS
Hesitancy
Storage LUTS
Frequency
Investigations for BPH
DRE smooth and enlarged
Non medical prostatic hyperplasia treatment
Lower caffeine and alcohol, bladder training
What is needed for BPH
Dihydrotestosterone
1st line medical BPH
Alpha blockers, Tamsulosin
2nd line medical BPH
5alpha reductase inhibitors, finasteride
Surgical treatment of BPH
TURP, TUIP, Retropubic prostatectomy
Side effects of alpha blockers
Dizziness, postural hypertension, weight gain
Define prostate cancer
Malignant adenocarcinoma of the peripheral zone of the prostate
Symptoms of prostate cancer
LUTS, cancer symptoms, bone pains
Risk factors for prostate cancer
Family history, high levels of testosterone (obesity not a risk factor but more aggressive form)
Where does prostate met to
Adjacent structures, bone lung
Investigations of prostate cancer
DRE (hard and irregular), PSA, biopsy, TRUSS, imaging, bone scan
How does gleason grading work
20 biopsies. First part is most common, 2nd part the worst.
TNM: T for prostate 1
Non palpable
T2 prostate
Palpable and confined to prostate
T3 prostate
Palpable and through capsule
T4 prostate
Palpable and invades other structures
Prostate cancer localised treatment low rise
Active surveillance
Prostate cancer progression treatment
Radical prostatectomy and radiotherapy
Hormone treatment for prostate
LHRH agonist (goserelin) and antiandrogen
Metastatic prostate treatment
Surgical castration and palliative care
Side effects of hormone treatment
Osteoporosis, gynaecosmastia, sexual dysfunction
Renal cell carcinoma
Adenocarcinoma of the PCT, highly vascular
Where does renal cell carcinoma met to
Bone, liver lungs
Risk factors for renal cell carcinoma
Poor lifestyle, HTN, CKD, horseshoe kidney, haemodialysis
Signs of RCC
Abdo mass, haematuria, obstruction
Symptoms of RCC
Loin pain, cancer symptoms
Investiagtions of RCC
Bloods, urine, USS
Localised RCC treatment
Radical nephrectomy
Metastatic RCC treatment
Biologics
Symptoms of bladder cancer
Painless haematuria
3 types of bladder cancer
Transitional cell, squamous, adenocarcinoma
Risk factors for bladder cancer
Rubber, azo dyes, schistosomiasis(=squamous). Chronic cystitis, smoking, male
Bladder cancer diagnosis
Flexible cystoscopy, biopsy and CT urogram
Where does bladder cancer met to
Paraaortic and iliac lymph nodes
Management of T1 bladder cancer
Transurerthral resection of bladder tumour. And chemo
Management of T2-3 bladder cancer
Radical cystectomy
T4 bladder cancer management
Palliative chemo
Testicular pain causes
Torsion, sti=epididymoorchitis, renal colic referred pain
Testicular cancer types
Seminoma (germ cell) and non seminoma
Risk factors for testicular cancer
Undescended testes, infant hernia
Presentation of testicular cancer
Painless testicular lump, haematospermia
Testicular cancer diagnosis
Scrotal US, biopsy, serum tumour markers
Testicular cancer tumour markers
A-fetoprotein, B-human chorionic gonadotrophin, lactate dehydrogenase
Seminoma unique
Young. A-fetoprotein and B-HcG
Teratoma unique
B-HcG and LDH
Treatment of seminomas
Radical orchidectomy and radiotherapy
Treatment of no seminomas (teratoma)
Chemotherapy
Staging of testicular
1=no mets
Where can TCC occur
Bladder, renal pelvis, calyx, ureter, urethra
Wilms tumour
Childhood tumour, primitive renal tubules and mesenchymal cells. Abdo mass and haematuria in children.
Penile cancer
Irradiation or virus, ulceration and discharge. Give radiotherapy, iridum wired or amputate
Backpain, withdrawn, confused
Prostate with mets to bone
What makes testicular cancer more likely
Body of testes and cant separate
Epididymal cyst
Clear milk fluid, above and behind testes
Hydrocele
Can be transilluminated. Fluid in tunica vaginales, caused by patent process vaginales or secondary in older people to Tumour, trauma, infection. Aspirate and surgery if needed.
Varicocele
Dilated pampniform plexus, left more than right. Bag of worms. Ligate the gonadal vein
Haematocele
Blood in tunica vaginales from trauma, aspirate or surgery
Epidydmoorchitis
Sudden onset testicular pain, usually caused by STI
Why is varicocele more common on left
RCC invasion of left renal vein causes compression of left gonadal vein
What causes testicular torsion
Twisted spermatic cord cuts off blood supply to testes, causing ischaemia
Presentation of testicular torsion
Sudden onset testicular pain, inflamed and tender testical, unilateral, abdo pain, Nausea and vomiting
What to do for testicular torsion
Refer to urology ASAP, can do scrotal US. Surgery
Testicular lump
Cancer
Acute and tender lump
Testicular torsion
Definition of UTI
Pure growth of more than 10 5 organisms per ml of fresh MSU
Risk factors for UTI
Female, intercourse, pregnancy, menopause, UT obstructions, malformations, immunosuppression, catheterisation
What do you find on urine dipstick of UTI
Nitrites (bacteria convert nitrate to nitrites)
When is it hard to spot UTI
Dementia or children
Why do you get more UTI in diabetes
It weakens the immune system
Organisms in UTI
Escherichia coli
What is E Coli
Gram negative lactose fermenting
What is proteus mirabilis
Gram negative, swarming on cultures
What is klebsiella pneumonia
Gram negative
What is staphylococcus saprophyticus
Gram positive cocci, lactose fermenting, catalase positive, coagulase negative
What is enterococcus
Gram positive diplococci
What are upper UTI
Pyelonephritis and ureteritis
What are lower UTI
Cystitis, urethritis, prostatitis
What are signs and symptoms of UTI
Loin/abdo pain, offensive smelling urine, haematuria, fever
Investigations of UTI
GOLD= MC&S of MSU
Management of UTI
Abx, fluid intake, pain relief
How to prevent UTI
Hydrate, void before and after sex
Signs and symptoms of cystitis
Suprapubic pain, haematuria, dysuria, frequency, urgency
Uncomplicated UTI treatment
Trimethoprim or nitrofurantoin
Complicated UTI treatment
Cefalexin
Pyelonephritis signs and symptoms
High fever, loin pain, rigors, N and v
Uncomplicated pyelonephritis treatment
Ciprofloxacin or coamoxiclav
Complicated pyelonephritis treatment
Cefalexin
What do beta cells secrete
Insulin
What do alpha cells secrete
Glucagon
What do delta cells secrete
Somatostatin
Which hormones control glucose levels
Insulin, glucagon, cortisol and growth hormone
Actions of insulin
-stimulates glucose uptake by insulin dependent tissues
What should blood glucose always be between
3.5 and 8mmol
GLUT 1
Non insulin stimulated glucose uptake
GLUT 2
Low affinity transporter for Beta cells
GLUT 3
Non insulin stimulated glucose uptake into brain and placenta
GLUT 4
Insulin mediated glucose uptake in muscle and adipose tissue
Symptoms of hypoglycaemia
(<3) dizziness, confusion, hunger, convulsions, coma, sympathetic action (tachycardia, sweating, pallor)
Define diabetes mellitus
Syndrome of chronic hyperglycaemia due to relative insulin deficiency, resistance or both
Secondary causes of DM
Pancreatitis, cystic fibrosis, trauma, haemochromatosis, acromegaly, cushings
Diabetes Fasting plasma glucose
Over 7mmol/L
Prediabetes fasting plasma glucose
5.5-7mmol/L
Diabetes oral glucose tolerance test
11.1mmol/L
Prediabetes oral glucose tolerance test
7.8-11mmol/L
diabetes HBA1C concentration and percentage
47 or 6.4%
Prediabetes HBA1C concentration and percentage
42-27 or 6-6.4%
What test would you do if you suspect gestational diabetes
OGTT
If you are symptomatic how many positive results do you need
Just one
Define diabetes mellitus type one
Caused by insulin deficiency from autoimmune destruction of insulin secreting pancreatic beta cells
Which conditions is DMT1 associated with
Vitiligo, addisons, pernicious anaemia
Risk factors for DMT1
Polygenic,
If theres a thin old person with diabetes and rapid progression to insulin therapy what do they have
Latent autoimmune diabetes in adults (LADA)
What are the HLAs of DMT1
HLA DR3 DQ2 and HLA DR4 DQ8
Symptoms of DMT1
Polydipsia, polyuria, polyphagia, fatigue and weight loss. Diabetic ketoacidosis
Environmental influences of DMT1
Diet, enteroviruses, vitamin D deficiency, cleaner environment
Diagnosis of DMT1
Measure glycaemic control and find autoantibodies. Diabetic consequences like retinopathy is diagnostic
Treatment of DMT1
Dietary control and insulin therapy
Types of insulin therapy
Rapid, short, intermediate and long acting insulin
Define DMT2
Results from a combination of insulin resistance and less severe insulin deficiency
DMT2 pathology
Beta cell mass is greatly reduced, it isn’t a problem with binding. There is hypersecretion of insulin from a depleted cell mass due to higher demand. Amyloid deposition
Does DMT1 or DMT2 have a stronger genetic link
DMT2
Risk factors for DMT2
South Asian, African, FHx, male, obese central, lack of exercise, hyperlipidaemia, hypertension, alcohol, stress, urban environment
Acute presentation of DMT2
Polyuria, polydipsia, weight loss
Subacute presentation of DMT2
Lethargy, fatigue, visual blurring, pruritus vulvas
Complications of DMT2
Staph skin infections, retinopathy, polyneuropathy, erectile dysfuntion, arterial disease
Treatment of DMT2
Patient education, decrease alcohol, regular blood glucose measuring. Identify and manage long term complications
Drug treatment of DMT2
Statins and BP drugs
Metformin
Reduces gluconeogenesis by the liver and increases glucose sensitivity. It doesn’t cause hypoglycaemia or weight gain
Sulphonylureas
Gliclazide or tolbutamide (in elderly), act in beta cells to promote insulin secretion. Only works if beta cell mass, and causes weight gain and hypos
Microvascular DMT2 complications
Diabetic retinopathy, diabetic neuropathy, nephropathy
Macrovascular DMT2 complications
Increased risk fo CVD, IHD, MI and diabetic foot ulcers
Signs of diabetic retinopathy
Haemorrhages, abnormal growth of vessels, aneurysm, cotton wool spots
Who can get diabetic ketoacidosis
DMT1 mainly, DMT2 can but very rare
Circumstances of DKA
Previously undiagnosed diabetes, interruption of insulin therapy, stress of intercurrent illness
What causes DKA
Increased hepatic ketogenesis. Increased peripheral lipolysis means theres more FFA which are converted into acetyl CoA by the liver then into ketone bodies by the mitochondria. More ketone bodies mean more metabolic acidosis, and dehydration so impaired excretion.
Signs and symptoms of DKA
N,V Abdo pain. Polyuria, polydipsia, drowsiness, ketone smelling breath, Kussmaul breathing
Describe kussmaul breathing
Low deep, sighing inspiration and expiration
Diagnosis of DKA
Acidosis, ketonaemia, hyperglycaemia
Treatment of DKA
Saline
Cause of sudden CNS decline in DKA
Cerebral oedema
What is hyperosmolar, hyperglycaemic state
Hyperglycaemia and hyperosmolality. No ketosis or acidosis. Alteration of consciousness.
Features of HHS
Delerium, focal neurological signs, tremors, fasciculations. Give Saline and insulin
What test is used for acromegaly screening
IGF-1
What test is used for acromegaly diagnosis
Glucose tolerance test
What do C cells produce
Calcitonin
What is released from the hypothalamus that acts of the anterior pituitary for TSH release
Thyrotropin releasing hormone
What hormone is released by the anterior pituitary and acts on the thyroid
TSH- thyroid stimulating hormone
What is the role of thyroid peroxidase
It binds thyroglobulin and iodine, and also couples MIT and DIT to make T3 or T4
What is the role of thyroglobulin
Iodine binds to its tyrosine residues
Actions of thyroid hormone
Increases metabolic rate, beta adrenergic action on the heart and gut, CNS activation, bone demineralisation
What symptoms of hyperthyroid
Sweating
Signs of hyperthyroid
Tremor
Causes of hyperthyroidism
Graves
Who gets hyperthyroid
Women 20-40
Graves disease
Autoimmune with
Graves unique skin sign
Pretibial myoedema
Thyroid acropachy
Digital clubbing, swelling and new periosteal bone formation
Graves ophthalmology
Exopthalmos, opthalmoplegia, retroorbital inflammation and swelling of the extraorbital muscles
Hyperthyroid diagnosis
High T4 and T3 (more sensitive), thyroid peroxidase and thyroglobulin antibodies
Graves diagnosis
TSH receptor stimulating antibodies
Treatment of hyperthyroid
Propanolol for rapid symptom control
How does carbimazole work
Blocks thyroid hormone biosynthesis
Primary causes of hypothyroidism
Hashimotos thyroiditis
Secondary causes of hypothyroidism
Iodine deficiency, pituitary failure. Amiodarone
Hypo thyroid symptoms (everything a girl don’t want)
Weight gain
Signs of hypothyroid
Dry, brittle hair and nails. Bradycardia, macroglossia, hyporeflexia, hoarse voice, alopecia
Hashimotos thyroiditis
Lymphocytic infiltration and progressive destruction of the gland
Management of hypothyroid
Levothyroxine
Diagnosis of hypothyroid
Serum free T4 low
Hormones released by hypothalamus
GnRH, CRH, TRH, PRH, GHRH, ADH, Oxytocin
What does Gonadotrophin releasing hormone stimulate
FSH/LH release from the anterior pituitary which acts on the gonads
What does Corticotropin releasing hormone stimulate
ACTH release from the anterior pituitary which acts on the adrenal cortex
What does Thryotropin releasing hormone stimulate
TSH from the anterior pituitary which acts on the thyroid
What does prolactin releasing hormone stimulate
Porlactin release from the anterior pituitary which stimulates the mammary gland
What does Growth hormone releasing hormone stimulate
Growth hormone release from the anterior pituitary which stimulates the liver
What does antidiuretic hormone stimulate
Is released from the posterior pituitary and acts on the kidneys
What does oxytocin stimulate
Is released from the posterior pituitary and acts on the mammary gland
Explain the action of ADH
Acts on V2 receptors to cause the insertion of aquaporin 2 channels
ADH is increased by
Hypovolaemia, hypotension, anaemia, nicotine, adrenaline
ADH is decreased by
Hypertension, ethanol, alpha adrenergic stimuli
Define diabetes insipidus
ADH deficiency or insensitivity to its action
Clinical features of diabetes insipidus
Polyuria, nocturia, compensatory polydipsia, dehydration
Cranial causes of diabetes insipidus
Familial, tumours, infection, infiltrations, post surgical, trauma
Nephrogenic causes of diabetes insipidus
Renal disease, sickle cell disease, drugs
What can mask DI
Cortisol deficiency. So give cortisol and if still happening then its DI
What is clubbing
Loss of window between nail beds
Investigations of DI
Osmolality, U and E, 24hr urine volumes, waterdeprivation test
Diagnosis of diabetes insipidus
Water deprivation test (urine doesn’t concentrate) Low urine osmolality, hypernatraemia, high urine volume
Treatment of cranial DI
Demsmopressin which is an ADH analogue
Treatment of nephrogenic DI
Thiazide diuretics
What is SIADH
Inappropriate ADH secretion leads to retention of water and hyponatraemia
Clinical features of SIADH
Confusion, nausea, irritable (kinda like UTI), later fits and coma
Causes of SIADH
Tumour: SCLC, prostate
Investigations of SIADH
U and E, osmolality, urinalysis
Results of SIADH
Dilutional hyponatraemia, low plasma osmolality, urinary Na secretion
Treatment of SIADH
Restrict fluid intake
Functions of growth hormone
Decreases adipose tissue, increases bone growth and muscle mass
Cause of acromegaly/gigantism
Pituitary adenoma (MEN-1 or AIP gene)
Symptoms of acromegaly
Snoring, deep voice, increased sweating, reduced libido and arthralgia. Increased weight and size of hands and feet. Headache
Signs of acromegaly
Acathosis nigricans, big supraorbital ridge, interdental separation, macroglossia, prognathism. Spade like hands and feet, tight rings
Acromegaly screening
Increased IGF-1
Acromegaly diagnosis
Imparied glucose tolerance test (high glucose)
Acromegaly other investigations,
high calcium, bitemporal hemianopia, MRI for pituitary adenoma. Photos.
Treatment of acromegaly 1st line
Transsphenoidal surgery
Treatment of acromegaly 2nd line
Somatostatin analogue (IM ocreotide)
What does the hypothalamus produce in response to emotional and physical stresses
Corticotropin releasing hormone
What is conns and the cause
Excess aldosterone caused by solitary aldosterone producing adenoma
What is the result of conns
Increased sodium and water retention
How can conns present
Hypokalaemia: Hypertension, alkalosis, weakness, cramps
What is the diagnosis in Conns
U and E (low renin, high aldosterone), MRI
What is the treatment of Conns
Laparoscopic adrenalectomy and spironolactone
What is Cushings syndrome
Chronic glucocorticoid excess
What are the symptoms of cushings syndrome
Increased weight, mood changes, weakness, acne, recurrant achilles injury, gonadal dysfunction
Signs of cushings syndrome
Moon face, central obesity, buffalo neck hump, bruises, muscle atrophy, purple abdo striae
What are the causes of cushings
Pituitary adenoma (cushings disease), adrenal tumour, idiopathic. Taking glucorticoids (hydrocortisone)
What are the investigations in Cushings
Bloods= high plasma cortisol
How would you investigate a ACTH independent cause of cushings syndrome
CT adrenals
How would you investigate ACTH dependent cushings
High dose dexamethasone suppression test
If it is ACTH dependent and cortisol suppressed what do you do
MRI pituitary
If it is ACTH dependent and cortisol isn’t surpressed what do you do
CT chest and abdo
How do you treat iatrogenic cushings syndrome
Stop steroids
How do you treat cushings disease
Transsphenoidal surgery
How do you treat adrenal adenoma
Adrenalectomy
How do you treat adrenal carcinoma
Adrenalectomy and radiotherapy
How do you treat ectopic ACTH
Adrenalectomy and chemo
What is Addisons disease
Primary hypoadrenalism. Destruction of the entire adrenal cortex leads to mineralocorticoid, glucocorticoid and sex hormone deficiency
What are the causes of addisons
AI in Uk
Symptoms of addisons disease
Weight loss, anorexia, malaise, weakness, fever, depression, syncope, confusion, myalgia
Signs of addisons disease
Pigmentation, postural hypotension, general wasting, dehydration, alopecia
Why do you get hyperpigmentation in addisons
Negative feedback means theres increased ACTH which is a melatonin predisposer
Urgent addisons investigation
Blood sample cortisol and hydrocortisone
Controlled addisons investigation
ACTH stimulation test (impaired response)
What is the ACTH stimulation test
Measure plasma cortisol before and after IM Tetracosactide. synACTHen- ACTH analogue. Cortisol remains high 30 mins after
Treatment of acute addisons
Saline and hydrocortisone and glucose
Maintenance of addisons
Hydrocortisone (gluco-) and fludrocortisone (mineralo-). Wear steroid card
Secondary adrenal insufficiency
Iatrogenic, hypothalamic pituitary disease (no pigmentation and mineralocorticoids spared)
Actions of PTH
Increased renal uptake of calcium in exchange for phosphate in the PCT
Which hormones affect calcium metabolism
Vitamin D, parathyroid hormone and calcitonin
UV-B converts what into vitamin D3 (cholecalciferol)
7-dehydrocholesterol
The liver converts vitamin D3 into what
25 hydroxyvitamin D. Via Vtiamin D3 25 hydroxylase (using vitamin D3 from diet)
The kidney converse 25 hydroxyvitmain D into what
1,25-dihydroxy vitamin D (calcitriol) via 1 alpha hydroxylase
Vitamin D effects
Calcium and phosphate release from bone
What is primary hyperparathyroidism and its treatment
Raised/normal PTH in the presence of raised calcium. Surgery
What is secondary hyperparathyroidism
Physiological PTH increased secretion to compensate for prolonged hypocalcaemia
Causes of secondary hyperparathyroidism
Low Vitamin D, malabsorption, CKD, osteomalacia
What is tertiary hyperparathyroidism
Development of parathyroid hyperplasia following long standing secondary hyperparathyroidism
Treatment of tertiary hyperparathyroidism
Parathyroidectomy
Hypercalcaemia causes
Hyperparathyroidism, malignancy
Hypercalcaemia signs and symptoms
Bone pain, fractures, osteopenia
If there is high everything but low phosphate what does this suggest
Primary
What does just low calcium suggest
Secondary
What does everything high suggest
Tertiary
What is the investigation of hypercalcaemia
Serum calcium level, adjust for albumin
Treatment of hypercalcaemia
Calcium, treat underlying cause. Bisphosphonates
Causes of hypocalcaemia
Low serum albumin, low magnesium, malabsorption
Symptoms of hypocalcaemia
Ventricular arrhythmias
What is chovsteks sign
Tap on facial nerve leads to twitching
What is trousseaus sign
Inflating Bp above systolic leads to carpal flexion
How do you treat severe hypocalcaemia
Calcium gluconate, Cardiac monitoring. MgCl
Definition of hyperkalaemia
Serum potassium level above 5mmol/L
Causes of hyperkalaemia DREAD
Drugs
Hyperkalaemia ECG
Wide flat/absent P
Symptoms of hyperkalaemia
Fast irregular pulse, weakness, palpitations, dizziness, cardiac arrest
Treatment of mild hyperkalaemia
Dietary potassium restriction and restriction of hyperkalaemia causing drugs
Treatment of severe hyperkalaemia
Calcium gluconate
Desribe carcinoid tumours
Group of enterochromaffin cell tumours capable of producing serotonin
Where are carcinoid tumours common
Appendix, ileum, rectum, bronchioles and testes
What is carcinoid syndrome
Symptoms from when the tumour releases serotonin, kinins, histamine and prostaglandins into the circulation
Symptoms of carcinoid tumours
Flushing wheezing, watery diarrhoea, abdo pain, cardiac abnormalities
Diagnosis of carcinoid tumours
High level of 5-HIAA, liver US confirms
Treatment of carcinoid tumours
Ocreotide (somatostatin analogue) and surgery
Layers of the epidermis
Stratum corneum
Cells of the epidermis
Keratinocytes, melanocytes, Langerhans cells
What is the function of langherhans cells
Immunity
Cells of the dermis
Fibroplasts, sebaceous and sweat glands, hair follicles, Meissner and Pacinian corpuscles
What sense do meissners corpuscles conduct
Light touch
What sense do Pacinian corpuscles conduct
Coarse touch and vibration
Hypodermis
Subcutaneous fat
Functions of the skin
Sensation
Inflammatory skin diseases
Acne, psoarisis, eczema
Infections of the skin
Cellulitis and necrotizing fasciitis
Neoplasias of the skin
BCC, SCC, malignant melanoma
Ulcers of the skin
Venous, arterial, neuropathic
Describe acnes vulgaris
Inflammatory disease of the pilosebaceous follicles. Affecting face, chest and upper back
Steps in acne pathophysiology
Seborrhoea (high sebum production)
What is a papule
Small red bump
What is a pustule
White/yellow spots
What is a nodule
Large red painful bumps
What is a pseudocyst
Fluctuant nodules
What is the presentation of acne
Papules, pustules, nodules and pseudocysts
What suggest its mild acne
Open and close comedones predonminate
What suggests its moderate acne
Papules and pustules predominate
What suggests its severe acne
Nodules and cysts
What is the treatment of mild acne
Topical retinoid or benzoyl peroxide for first line. Azelaic acid if retinoids and Bp poorly tolerated. OCP as contraceptive
Name a topical retinoid
Tazarotene gel
What is the treatment for moderate acne
Same as above but. Clindamycin too
Severe acne treatment
Refer. Isotretinoin and laser treatment
Define eczema
Chronic itchy inflammatory condition. Papules and vesicles are present on an erythematous base. Commonly on face and flexure surfaces
Atopic eczema is seen with
Hay fever and asthma
What causes eczema
Fillagrin abnormalities cause poor barrier function and dry skin. Thinning of the stratum corneum. Allows antigen penetration and hyperreactivity
Triggers of atopic eczema
Soaps and detergents, house dust mites, extreme temperatures, pollen, food, stress
Eczema treatment
Avoid triggers, cut nails short.
Mild corticosteroid
Hydrocortisone
Calcineurin inhibitor
Tacrolimus
Moderately potent corticosteroid
Clobetasone butyrate
What classes as mild eczema
Areas of dry skin and infrequent scratching
What classes as moderate eczema
Areas of dry skin, frequent itching and redness
What classes as severe eczema
Widespread areas of dry skin, incessant itching and redness
What classes as infected eczema
Weeping, crusted or there are pustules
Treatment of severe eczema
Potent corticosteroid
Potent corticosteroid
Flucionide
Antihistamine
Chloramphenamine
Treatment of infected eczema
Topical antibiotic, if localised. Generalised then flucloxacillin
Define psoarisis
Chronic inflammatory skin disease due to hyperproliferation of keratinocytes and inflammatory cell infiltration
How would describe the lesions in psoarisis
Monomorphic erythematous plaques covered with silvery scales
What are the classic signs of psoarisis lesions
-epidermal hyperproliferation
What is the most common form of psoarisis
Chronic plaque psoarisis
Psoarisis but no scaling and older
Flexural psoarisis
Post streptococcal throat, oval plaques
Guttate psoarisis
Psoarisis, thickening of palms and soles
Palmoplantar psoarisis
Non skin changes in psoarisis
Nail pitting, discolouration and onycholysis
Precipiating factors in psoarisis
Trauma, lithium, stress, smoking, alcohol
Proarisis treatment
E45, hydrocortisone and Calcipotriol
What if psoarisis resistant
UV-B, Methotrexate and infliximab
Where are venous ulcers
Medial gaitor region
Where are arterial ulcers
Toes, heel and ankle
What are the edges of venous ulcers like
Sloping and gradual
What are the edges of arterial ulcers like
Punched out and well defined
What is the wound bed of venous ulcers like
Covered with slough
What is the wound bed of venous ulcers like
Covered with slough and necrotic tissue
What is the size of venous ulcers
Large
What is the size of arterial ulcers
Small
What is the exudate level of venous ulcers
High
What is the exudate level of arterial ulcers
Low
What is the pain like in venous ulcers
Minimal
What is the pain like in arterial ulcers
High
Arterial ulcer risk factors
Arterial disease, smoking, cholesterol, dm
What are the symptoms of arterial ulcers
Leg pain, worse when elevated
What are the signs of arterial ulcers
Cold skin, absent peripheral pulse, shiny pale skin, loss of hair
What are the investigations for arterial ulcers
ABPI below 0.8, doppler studies
What is the management of arterial ulcers
Vascular reconstruction, ibuprofen, clean and covered, don’t use compression bandages
What are the risk factors for venous ulcers
Varicose veins, DVT
What are the symptoms of venous ulcers
Pain is minimal, better when elevated
How would you describe a venous ulcer
Large, shallow, irregular, exudative
What are the signs of venous ulcer
Normal pulses, leg oedema, lipodermatosclerosis
What is the investigation for venous ulcer
ABPI normal
What is the management of venous ulcer
Compression bandage, antibiotics, ibuprofen
What is the risk factors for neuropathic ulcer
DM, Neuropathic disease
How would describe the ulcer in neuropathic ulcers
Found at pressure sites, variable size, might have vallus
Signs and symptoms of neuropathic ulcer
Warm skin and normal peripheral pulces, associated peripheral neuropathy
Management of neuropathic ulcer
Appropriate footwear, diabetic control podiatry
Define cellulitis
Bacterial infection of the subcutaneous tissue. Common on the lower leg or arm and may spread proximally
Define erysipelas
Bacterial infection of the upper dermis and superficial lymphatics, more common on the face and is sharply demarcated
Causative agents of cellulitis and erysipelas
Streptococcus pyogenes and staphylococcus aureus
Presentation of cellutitis and erysipelas
Tender confluent areas of inflamed skin, fever and malaise
Risk factors for cellulitis and erysipelas
Immunosuppresion, wounds, leg ulcers, trauma, atheltes foot, lymphoedema
Management of cellulitis and erysipelas
Flucloxacillin or clarithyromycin
Define necrotising fascitiits
Deep seated infection of the subcutaneous tissue that results indestruction of fascia and fat but initially spares skin
Presentation of necrotising fasciitis
Severe pain which is out of proportion with the degree of skin inflammation. Systemic upset
Cause of necrotizing fasciitis type 1 and 2
1:Mixture of aerobic and anaerobic following abdo surgery or diabetes
Treatment of type 2
IV benzylpenicillin and clindamycin
Treatment of type 1
Add metronidazole
Which is the most common skin cancer
Basal cell carcinoma
Describe basal cell carcinoma
Locally invasive, grows slowly, malignant neoplasm of epiderminal keratinocytes. Rarely mets
Risk factors for basal cell carcinoma
UV exposure, Skin type 1, ageing
Presentation of BCC (rodent ulcer)
Commonly on head and neck, has a pearly appearance with blood vessels
Management of BCC
Surgical excision, or radio. Normally completely cured but theres local tissue destruction
Describe squamous cell carcinoma
Locally invasive malignant tumour of squamous cells. More aggressive and likely to metastasise but still rare
Risk factors for squamous cell carcinoma
UV exposure
Describe the appearance of SCC
Scaly and crusty, Ill defined nodules, keratotic and may ulcerate
Management of SCC
Surgical excision and radiotherapy if unresectable
Define malignant melanoma
Invasive tumour of melanocytes
Risk factors for malignant melanoma
UV exposure
Signs of MM abcde
Assymetrical shape
Symptoms of MM
Bleeding. Itching
Presentation of MM
Scaly, cursty, ill defined, may ulcerate
Management of MM
Surgical excision, radio if cant. Chemo if metastatic
Name a non conventional therapy for psoarisis
Phototherapy
Onycholysis, pitting, thickening, subungal hyperkeratinosis
Psoarisis
Deep ulcerated base of skin cancer
SCC
Moderate acne 1st line if on back
Oral erythromycin
What type of hypersensitivity is contact dermatitis
Type IV
