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1
Q

What type of hypersensitivity is SLE

A

3 and 2

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2
Q

Triad of lupus

A

Fever, joint pain, rash in woman of child bearing age

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3
Q

What is needed for SLE diagnosis

A 
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)
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4
Q

What can pANCA differentiate

A

Crohns and UC. UC has it. Crohns doesnt.

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5
Q

Parkinsons genes

A

Normally not genetic but: PINK1, Parkin, alpha synuclein

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6
Q

What is present in the substantia nigra of those with parkinsons

A

Lewy bodies (eosinophilic with alpha synuclein)

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7
Q

Clinical features of parkinsons

A

Pill roll resting tremor, Cog wheel rigidity, Bradykinesia, Hypokinesia, Akinesia (from difficulty initiation movements), postural instability

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8
Q

What doesnt parkinsons cause

A

Weakness

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9
Q

How does the tremor differ between parkinsons and cerebellar disease

A

Parkinsons is resting, cerebellar is intention

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10
Q

Other dopaminergic dysfunction leads to

A

Depression, dementia, sleep disturbances, difficulty smelling.

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11
Q

Parkinsons treatment

A

Levodopa, Ropinirole (dopamine agonist). Selegiline (MAO-B inhibitor, early on), Entacapone (COMT inhibitor, later on). Deep brain stimulation.

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12
Q

What is the role of Th1

A

Helps macrophages produce an immune response. IL2, IFN gamma

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13
Q

What is the role of Th2

A

Helps B cells produce immunoglobulins. IL4,5,10

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14
Q

Requirements for Obstructive spirometry

A

Reduced FEV1 (<80% normal), Reduced FEV1:FVC ratio (<0.7), reduced peak flow

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15
Q

Requirements for restrictive spirometry

A

Reduced FVC and FEV1. Normal ratio and peak flow

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16
Q

Interstitial lung disease examples

A

Sarcoidosis, IPF, Asbestosis, Goodpastures, GPA (Wegeners granulomatosis)

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17
Q

Define asthma

A

Chronic respiratory condition associated with airway inflammation and hyperresponsiveness

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18
Q

3 pathophysiological changes in asthma

A

Airway inflammation, airway obstruction and bronchial hyperresponsiveness

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19
Q

Which drugs can make asthma worse

A

NSAIDs, Aspirin and beta blockers

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20
Q

What causes the second wave of inflammation in asthma

A

Leukotriene release from mast cells

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21
Q

Symptoms of asthma

A

Tachypnoea, wheeze, cough

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22
Q

Signs of asthma

A

Expiratory polyphonic wheeze, hyperinflation, cyanosis, use of accessory muscles, hyperresonant, reduced air entry

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23
Q

Investigations for asthma

A

FeNO (>40ppb), Spirometry (FEV1/FVC <0.7), bronchodilator reversibility (>12%/200ml), peak flow meter (diurnal variation)

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24
Q

1st line asthma

A

Short acting B2 agonist (salbutamol) as needed

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25
2nd line asthma
Low dose inhaled corticosteroid (beclametasone)
26
3rd line asthma
Low dose ICS + LABA (salmeterol)
27
4th line asthma
+Leukotriene receptor antagonist (Montelukast) then pred
28
What is used for asthma monitoring
Peak flow and asthma control test
29
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 ```
30
What does unable to complete sentences suggest
Acute asthma. Give high flow O2, salbutamol nebs and prednisolone. Do ABG and CXR. Can add MgSO4
31
Causes of acute asthma
Infections esp viral, pneumothorax, triggers
32
PEF for severity of acute asthma
Moderate = 50-75 Severe= 33-50/ cant complete sentence Life threatening= below 33 or altered conscious
33
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
34
What is CREST
``` Limited cutaneous systemic sclerosis. Calcinosis cutis Raynauds phenomenon oEsophageal dysmotility Sclerodactyly Telangiectasis ```
35
What causes wheeze
Air thorugh mucus
36
What cuases crackles
Alveoli opening
37
COPD signs
Exertional breathlessness, chornic cough, regular sputum production, wheeze, frequent winter bronchitis
38
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
39
COPD v Asthma histologically: cells
COPD neutrophils, CD8 T cells and many macrophages. Asthma mast cells, eosinophils, CD4 T cells and macrophages
40
COPD v Asthma histologically: mediators
Asthma: Histamine, IL-4, IL5, some ROS. COPD: IL8 TNFa, many ROS
41
COPD v Asthma histologically: effects
Asthma: all airways, little fibrosis, epithelial shedding. COPD: Peripheral airways, lung destruction, fibrosis and squamous metaplasia.
42
COPD v Asthma response to steroids
Asthma is very responsive, COPD isnt
43
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% ```
44
COPD investigations
Spirometry and CXR to rule out pathology
45
What tool is used for COPD prognosis
BODE index. BMI, airflow Obstruction, Dyspnoea, Exercise capacity index
46
Non inhaler management of COPD
Smoking cessation and pulmonary rehabilitation. Physiotherapy and dornase alfa for sputum clearance. Influenza and pneumococcal vaccinations
47
Step one COPD
LAMA (Tiotropium bromide) with rescue SABA
48
Step two COPD FEV1 >50%
+ LABA (Salmeterol)
49
Step two COPD FEV1<50%
+LABA (Salmeterol) and ICS (hydrocortisone)
50
What PaO2 is needed to get oxygen therapy
PaO2<7.3kPa
51
What is the gene in alpha 1 antitrypsin deficiency
SERPINA 1
52
Management of acute asthma
Salbutmaol Nebs, Oxygen then prednisolone and IV hydrocortisone
53
Causes of COPD exacerbations
Community: Haemophilus influeza B, Strep Pneuominae Hospital: Psuedomonas Aeurginosa
54
Define pneuomothorax
Air in the pleural cavity resulting in collapse of the lung on the affected side.
55
What increases your risk of smoking
Marfans, tall young man smoker
56
Secondary causes of pneumothoarx
CF, COPD, Sarcoidosis
57
Catamenial pneumothorax
During menstruation
58
What is tension pneumothorax
1 way valve of air entering
59
Presentation of pneumothorax
Dyspnoea, pleuritic chest pain, hyperresonant on percussion + decreased breath sounds on affected side, reduced chest expansion
60
What are the additional signs of tension pneumothorax
Deviated trachea, mediastinal shift, hyperexpanded chest, tachypnoea and hypotension
61
Investigations of pneumothorax
CXR unless tension which is an emergency
62
Management of tension pneumothorax
100% O2, Large bore IV cannula 2nd intercostal space in mid clavicular line, chest drain
63
Management of non tension pneumothorax
observation if small, needle aspiration if bigger, chest drain tube if more severe
64
Define pleural effusion
Abnormal collection of fluid in the pleural space
65
Transudate pleural effusion
Changes in osmotic pressure, CCF Cirrhosis Nephrotic syndrome, low protein levels
66
Exudate pleural effusion
Inflammation/malignacy leads to increased vascular permeability. Sepsis, malignancy, TB, infections. high protein levels.
67
Pleural effusion signs and symptoms
Pleuritic chest pain, SOB, cough, reduced chest expansion and breath sounds, stony dull percussion.
68
Criteria for exudative pleural effusion
Lights criteria 2/3
69
Pleural effusion investigations
chest xray and diagnostic aspiration
70
Management of pleural effusion
Treat underlying cause, drain if symptomatic, pleuroectomy if mesothelioma
71
Define bronchiectasis
Thickening and permanent dilatation of the airways
72
Causes of bronchiectasis
HIV TB SLE CF, foreign body
73
Presentation of bronchiectasis
cough with purulent sputum, wheeze, recurrent infections, clubbing, bilateral coarse crackles
74
Investigations of bronchiectasis
Gold standard= CT chest. CXR= tram track sign, spirometry= obstruction defect, sputum culture
75
Management of bronchiectasis
Smoking cessation exercise, chest physiotherapy, mucoltics (dornase alfa), prophylactiic abx, pneumococcal and flu vaccination
76
CF inheritance pattern and gene and chromosome
Autosomal recessive, mutation in cystic fibrosis transmembrane conductance regulator chromosome 7
77
Pulmonary CF presentation
cough with purulent sputum, wheeze, recurrent infections, clubbing, bilateral coarse crackles
78
Extra pulmonary CF manifestations
Pancreas= steatorrhea, diabetes, pancreatitis GI: Distal intestinal obstruction syndrome, cirrhosis GU: Lack of vas deferens and amenorrhea
79
Respiratory complications of CF
Pneumothorax and respiratory failure
80
Diagnosis of CF
In the presence of symptoms, sweat test for children, CF gene test for adults and IRT test for babies
81
What is the heel prick test for CF in babies
immunoreactive tripsinogen
82
CF complications from malabsorption
Underweight, fat soluble vitamin deficiency, reduced bone mineral density, distal intestinal obstruction syndrome
83
Chronic complications of CF
Cirrhosis, infertility diabetes
84
Respiratory management of CF
Exercise, stop smoking, physio, mucolytics (dornase alfa), prophylactic abx (azithromycin), pneumococcal and flu vacinations
85
GI management of CF
ADEK supplementaion, pancreatic enzyme replacement therapy, ursodeoxycholic acid for liver disease
86
CF screening
All babies in UK, immunreactive trypsinogen and sweat test and genetic testing to confirm
87
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
88
Causes of ARDS
Pneumonia, gastric aspiration, smoke inhilation, trauma, DIC, Pancreatitis
89
Pulonary signs/symptoms of interstitial lung diseases
Dry cough, SOB, progressive dyspnoea on exertion, infective exacerbations, inspiratory crackles
90
Systemic signs/symptoms of interstitial lung diseases
Lasting tiredness, weight loss, clubbing
91
Sarcoid treatment
Prednisolone and methotrexate can try infliximab. SERUM ACE IS HIGH
92
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
93
IPF treatment
Best supportive care, transplant, exacerbations (antibiotics, steroids, oxygen, ventilation)
94
Consequences of occupational lung disorders
Risk of unemployment, loss of earnings, chronic ill health
95
What type of hypersensitivity is extrinsic allergic alveolitis
3
96
Treatment for EAA
Avoid allergens, steroids, best supportive care
97
Ix for EAA
FBC (inflammatory markers and WBC), Antibody titre, CXR, Spirometry
98
Asbestosis
Blue is worse. Pleural plaques lead to pleural thickening and mesothelioma
99
Rheumatoid antibodies
antiCCP, antidsDNA, ANA
100
Bradford hill criteria of causality
Temporarlity, reversibility, exposure-response, strength of association, specificity, consistency, analogy, biological plausability
101
Granulomatosis with polyangitis (Wegeners) signs
Saddle nose deformtiy, rash, malaise, diarrhoea, weight loss, joint pain/swelling, nose bleeds
102
wegeners diagnosis
``` CXR= cavitating lung lesions FBC= anaemia U&E= ESR and CRP high Urine= blood and protein cANCA Biopsy ```
103
Treatment of wegeners
Severe= steroids, cyclophosamide, biologics | No organ damage= prednisolone, methotrexate
104
Microscopic polyangitis
Small vessel vasculitis like wegeners but pANCA. Fatigue, fever, breathlessness, wheeze, cough, haemoptysis
105
ANCA associated vasculitis treatment
Prednisolone, rituximab, cyclophosamide
106
Rheumatoid arthritis risk factors
Women, caucasian, rheumatiod factor, HLA DR4, Other autoimmune conditions, stress, smoking
107
Symptoms and signs of RA
Symmetrical inflamed joint, nodules, episcleritis, carpal tunnel, lymphadenopathy, anaemia, RA nodules and pleural effusions, pericarditis, amyloidosis
108
RA diagnosis
Aspirate joint, FBC (Anaemia), ESR/CRP (high), RF, antiCCP (cyclic citrullinated peptic), XRay
109
RA on Xray
Soft tissue swelling joint space narrowing periarticular erosions
110
RA treatment
Methotrexate and sulfasalazine. Pred injections an option
111
Methotrexate pharmacology
Inhibits dihydrofolate reductase which is needed for replication and DNA synthesis, coprescribe folic acid
112
Methotrexate side effects
Mucosal damage, GI upset, nausea, teratogenic
113
Goodpastures syndrome features
Pulmonary haemorrhage and rapidly progressive glomerulonephritis
114
What type of hypersensitivity reaction is goodpastures
Type two
115
What is the cause of goodpastures
antiglomerular basement membrane (anti-GBM) IgM form to T4 collagen
116
Symptoms of goodpastures
Cough, dyspnoea, crackles, increased JVP and haematuria
117
Investigations in goodpastures
Abnormal U&Es, urinalysis (high protein and haemturia), renal biopsy (crescentric GN), CXR (Patchy bilateral symmetrical consolidation)
118
Goodpastures treatment
Plasma exchange and steroids
119
Define PE
Embolic blockage of pulmonary artery, usually from DVT. Means lung tissue is ventilated but not perfused
120
Clinical presentation of PE
Sudden onset unexplained dyspnoea, pleuritic chest pain, cough, haemoptysis with previous leg pain/swelling
121
Diagnosis of PE
Gold= CT pulmonary angiogram. Risk assessment using Well's Score. Bloods, baseline clotting, D-Dimer, ECG, ABG
122
Immediate management of PE
100% O2 and IV analgesia and enoxaparin
123
Define pneumonia
Inflammation of the lung parenchyma usually secondary to infection of the alveoli and surrounding tissue
124
Bacterial causes of penumonia
``` Strep Pneumonia (80%) H. Influenzae (COPD exacerbations) Klebsiella pneumoniae (alcoholics hobo) ```
125
Atypical causes of pneumonia
Mycoplasma pneumonia, legionella pneumophilia, chlamydophila pneumoniae, chlamydophila psittaci
126
Viral causes of pneumonia
Influenza virus A/B
127
Fungal causes of pneumonia
Pneumocystis jiroveci (HIV)
128
Signs and symptoms of pneumonia
Cough, SOB, fever, rigors, chest pain, tachycardia, low sats, crackles, reduced breath sounds
129
Diagnosis of pneumonia
Clinical examination, Bloods (high WCC, neutrophils and CRP), XRay (areas of opacification) Microbiology
130
How do you do microbiology for pneumonia
Sputum gram stain, culture and snesitivity Urine serology: legionella antigen Bronchoscopy/ bronchoalveolar lavange
131
Consequence of CURB 0-1 score
Outpatient amoxicillin
132
Consequences of CURB 2 score
Hospital admission. Amoxicillin and clarithromycin PO
133
Consequences fo CURB score over 3
Urgent admission, consider ITU, IV coamoxiclav and clarithromycin
134
Define TB
Chronic granulomatous infectious disease caused by mycobacterium tuberculosis
135
Risk factors for TB
Poverty/cramped conditions, poor hygiene, Immunosuppression, smokers, foreign travel
137
Clinical presentation of TB
Weight loss, night sweats, malaise, cough, haemoptysis, SOB, chest pain.
137
What is the test for latent TB
Mantoux test, injection of PPD
138
Diagnosis of TB
Sputum tst x3, . CXR opacities.
139
How long do you give TB drugs for
RIPE for 2 months, continue with R and I for 4 more
140
Pyrazinamide side effects
Arthralgia and hepatitis
141
Describe small cell tumours
15%. Highly associated with smoking. Neuroendocrine tumours. Rapid growth, highly malignant, poor prognosis
142
Which hormones are secreted by small cell lung cancers
5-HT, ACTH, ADH
143
Name three non small cel lung cancers in order of prevalence
Squamous cell, large cell, adenocarcinoma
144
Common sites of metastasis for bronchial carcinoma
Lymph, brain, bone
145
Symptoms of bronchial carcinoma
Cough with haemoptysis, weight loss, SOB, chest pain, Sx of mets (bone pain, seizures)
146
Do you get osteoporosis from inhaled corticosteroids
No
147
Diagnosis of bronchial carcinoma
CXR/ Chest CT and biopsy
148
Treatment of bronchial carcinoma
Surgery, chemo, radiotherapy
149
Define mesothelioma
Aggressive tumour of mesothelial cells which usually occurs in the pleura
150
Symptoms of mesothelioma
SOB, chest pain, weight loss, fatigue, signs of pleural effusion
151
Diagnosis of mesothelioma
CXR/ Chest CT and pleural biopsy
152
Treatment for mesothelioma
Surgery, chemo, radio
153
AIDS defining infections
Candidiasis oesophageal, mycobacterium TB, persistent herpes simplex, pneumocystis jirovecci penumonia, recurrant bacterial pneumonia
154
AIDS defining neoplasms
Kaposis carcinoma, NonHodkins lymphoma
155
Direct HIV effect conditions
HIV dementia | HIV associated wasting
156
Causes of acute breathlessness
Asthma, pneumonia, PE, pneumothorax, hyperventilation
157
CV causes of clubbing
Cyanotic congenital heart disease Right to left defect IE
158
GI causes of clubbing
IBD, PBC, Cirrhosis
159
Endo causes of clubbing
Acromegaly and graves acropachy
160
What do leads I, aVL, V5 and V6 represent
Lateral region, circumflex
161
What do leads II, III and aVF represent
Inferior, right coronary artery
162
What do leads V1-4 represent
Septal and anterior. LAD
163
Define ischaemic heart disease
Myocardial demand for oxygen/nutrients greater than delivery via coronary arteries
164
Causes of IHD from occlusion
Atherosclerosis, thrombosis, spasm, embolus, arteritis
165
Causes of IHD from reduced oxygen delivery
Anaemia and hypotension
166
Causes of IHD from increased oxygen requirements
Thyrotoxicosis, aortic stenosis
167
Non modifiable IHD risk factors
Age, male gender, family history
168
Modifiable IHD risk factors
Smoking, alcohol, poor diet, obesity, lack of exercise
169
Clinical IHD risk factors
Hyperlipidaemia, diabetes, hypertension
170
Psychosocial IHD risk factors
Work stress, lack of social support, depression
171
Define angina
Chest pain arising from the heart due to myocardial ischaemia
172
Describe the pain of angina
Heavy central (+retrosternal, radiates to arms and jaw), exertional with no clinical signs usually
173
Angina investigations
Exercise ECG showing ST depression, angiogram if uncertain or intervention likely
174
Acute management of angina
GTN spray, regular nitrates, beta blockers, CCB, revascularisation
175
Secondary prevention of angina
Lifestyle change, control risk factors, aspirin and a statin
176
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
177
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
178
Investigations for ACS
ECG, troponin, FBC
179
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
180
ECG changes in NSTEMI
No Q waves, deep ST depression, T wave inversion
181
Acute management of STEMI
ABCDE, MONA (Morphine, oxygen, nitrates, aspirin), Emergency PCI or thrombolysis
182
Which drugs are used for thrombolysis
Streptokinase or alteplase
183
Name two nitrates
Isosorbide mononitrate and glyceryl trinitrate
184
Long term management of ACS
Aspirin, beta blocker, statin, ACE inhibitor, optimise risk factors, no driving for 1 month
185
Early complications of MI
Arrythmias, sudden death, pericarditis, heart failure, cardiogenic shock, mitral regurgitation, VSD, cardiac dilatation
186
Late complications of MI
DVT, PE, Mural thrombus, cardiac aneurysm, Dressler syndrome
187
What is dressler syndroms
Post MI. Fever, chest pain, pericarditis
188
Causes of primary HTN
Idiopathic, genetic factors, fetal factors, obesity, alcohol,, salt intake, stress
189
Secondary causes of HTN
Renal, Endocrine (Conns, adrenal hyperplasia, phaeochromocytoma, cushings, acromegaly), coarctation, OCP, Steroids, NSAIDs, pregnancy
190
Stage 1 hypertension
Clinic 140/90, ambulatory 135/85
191
Stage 2 hypertension
clinic 160/100, ambulatory 150/95
192
Severe HTN
Clinic 180/110, Ambulatory 180/110
193
Diabetes HTN target
130/80
194
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 ```
195
Who do you treat in HTN
Over 80, stage1 +target organ damage or disease | Everyone with stage 2
196
Target BP under 80
140/90
197
Target BP over 80
150/90
198
Examples of ACE inhibitors
Rampiril, lisinopril, enalapril
199
Examples of Angiotensin II receptor antagonists
Losartan, candesartan
200
Examples of betablockers
Atenolol, bisoprolol
201
Examples of calcium channel blockers
Amlodipine, nifedipine
202
Examples of thiazide diuretics
Bendoflumethiazide
203
First line <55
Ramipril
204
First line Black or >55
Amlodipine
205
What to give instead of CCB if intolerant or high risk of heart failure
Bendroflumethiazide
206
Resistant hypertension
Consider adding low dose spironolactone or higher dose thiazide and refer
207
Define heart failure
The heart is unable to maintain sufficient cardiac output to provide a physiologically normal circulation
208
What two systems are involved in heart failure
RAAS and sympathetic
209
What is the sympathetic heart failure physiology
Reduced cardiac output, baroreceptor activation, tachycardia, cardiotoxicity, heart failure
210
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
211
Left heart failure causes
IHD, cardiomyopathy, hypertension, aortic/mitral valve disease, arrythmias, congenital heart disease
212
Clinical features of left heart failure
Fatigue, SOBOE, Orthopnoea, Paroxysmal nocturnal dyspnoea, tachycardia, fine crackles at lung base
213
What is orthopnea
Shortness of breath which occurs when lying down
214
Right heart failure causes
Cor pulmonale, PE, pulmonary HTN, left to right shunts, tricuspid regurgitation
215
Clinical features of right heart failure
Fatigue, anorexia/nausea, GI upset, raised JVP, pitting oedema, ascites, pleural effusion, hepatomegaly
216
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)
217
Signs of heart failure on XRay
``` Alveolar oedema Kerly B lines (interstitial oedema) Cardiomegaly Dilated upper lobe vessels pleural Effusion ```
218
Non drug treatment of heart failure
Education, lifestyle measures, optimise risk factors, correct aggravating features like anaemia, pneumococcal and influenza vaccines, driving unrestricted
219
Drugs for heart failure
``` ACE-i Bisoprolol Candesartan Digoxin Diuretics Spironolactone ```
220
Surgical treatment of heart failure
CABG, Valve replacement, pacemaker, heart transplant
221
Causes of congenital heart disease
``` Maternal factors -maternal rubella -foetal alcohol syndrome -maternal SLE Genetic -trisomy 21 -turners syndrome ```
222
Acyanotic congenital heart diseases with shunts
ASD, VSD, PDA
223
Acyanotic congenital heart diseases without shunts
Coarctation of the aorta, congenital aortic stenosis
224
Cyanotic congenital heart disease with shunts
Tetralogy of fallot, transposition of the great arteries
225
Cyanotic congenital heart disease without shunts
Severe pulmonary cyanosis
226
common consequences of congenital heart disease
Central cyanosis, congestive heart failure, pulmonary hypertension, polycythaemia, eisenmengers syndrome
227
Signs of ASD
Mid systolic ejection murmur in pulmonary area, fixed splitting of S2.
228
Symptoms of right heart overload
Dyspnoea, fatigue, exercise intolerance
229
Investigations for ASD
CXR- dilated pulmonary artery ECG- right axis deviation Echo- hypertrophy and dilation of right heart
230
Management for ASD
Conservative or surgery
231
Signs of VSD
Pansystolic murmur at left lower sternal edge, systolic thrill left parasternal heave
232
Consequence of small VSD
Loud murmur, asymptomatic
233
Consequences of a large VSD
Pulmonary hypertension, breathless, poor feeding
234
Investigations for VSD
CXR, ECG, Echo
235
Management of VSD
Conservative or surgery
236
What is patent ductus arteriosus
Bypass from the pulmonary artery to the aorta
237
Causes of PDA
90% isolated, 10% from maternal rubella
238
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
239
Signs of PDA
Usually asymptomatic, continuous machinery murmur, pulmonary HTN
240
PDA management
Percutaneous devices, endocarditis prophylaxis
241
4 features of tetralogy of fallot
RV outflow obstruction Large VSD R ventricular hypertrophy Overriding aorta
242
Tetralogy of fallot symptoms
Cyanosis, feeding difficulty, failure to thrive
243
Tetralogy of fallot signs
Clubbing, loud harsh ejection sysolic murmur at lower left sternal edge. Hyper cyanotic spells.
244
Investigations for tetralogy of fallot
CXR, ECG, Echo
245
Management of tetralogy of fallot
Initially medical, surgery at 6 months
246
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
247
Symptoms of coarctation of the aorta
headaches, nose bleeds and claudication
248
Signs of coarctation of the aorta
Radio-femoral delay, BP higher in arm than leg. Poor peripheral pulses
249
Management of coarctation of the aorta
Surgery
250
Causes of aortic stenosis
Calcification Congenital (bicuspid) Rheumatic fever Outflow obstruction- hypertrophic obstructive cardiomyopathy
251
Symptoms of aortic stenosis
exercise induced angina, syncope, breathlessness. Sudden death
252
Signs of aortic stenosis
Slow rising pulse, sustained apex beat, systolic thrill in aortic region
253
Aortic stenosis heart sounds
Ejection systolic murmur in aortic area, radiated to the carotid, soft second heart sound, fourth heart sound
254
Investigations for aortic stenosis
ECG - LV Hypertrophy (depressed ST, T wave invert) | Echo is diagnostic
255
Management of aortic stenosis
Conservative, valve replacement if severe/symptomatic
256
Acute causes of aortic regurgitation
Acute rheumatic fever, IE, aortic dissection
257
Chronic causes of aortic regurgitation
``` Rheumatic fever Marfans Syphilis Autoimmune Bicuspid aortic valve Severe hypertension ```
258
Symptoms of aortic regurg
Asymptomatic until LV fails Palpitations Angina/ dyspnoea
259
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)
260
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
261
Aortic regurgitation investigations
Chest XRay ECG- LV hypertrophy Echo
262
Management of aortic regurgitation
Mild= vasodilators and diuretics | Valve replacement
263
Causes of mitral stenosis
Rheumatic fever
264
Symptoms of mitral stenosis
Only in severe, breathlessness, paroxysmal nocturnal dyspnoea, haemoptysis, recurrant chest infections
265
Signs of mitral stenosis
``` Malar rash Small-volume pulse Atrial fibrillation Tapping apex beat Signs of RV failure ```
266
Mitral stenosis heart sounds
Loud first heart sound, opening snap, rumbling mid diastolic murmur at apex with patient on their left
267
Mitral stenosis investigations
Chest XR ECG= bifid P WAVE RV hypertrophy Echo
268
Mitral stenosis management
Diuretics, digoxin, anticoagulation, valvotomy, replacement
269
Mitral regurgitation causes
``` Mitral valve prolapse Rheumatic fever Infective endocarditis IHD Cardiomyopathy SLE/Marfans/ Ehlers-Danlos ```
270
Symptoms of mitral regurg
Palpitations, dyspnoea, orthopnoea, fatigue, right heart failure
271
Signs of mitral regurg
Cardiac failure, laterally displaced apex, hyperdynamic, systolic thrill
272
Mitral regurg heart sounds
Soft first heart sound, loud pansystolic murmur at apex radiating to axilla, third heart sound
273
Mitral regurg investigations
Chest XR- left atrial and ventricular enlargement | Echo
274
Management of mitral regurg
Echo monitoring, endocarditis prophylaxis, valve replacement
275
Define pericarditis
Inflammation of the pericardium
276
Viral causes of pericarditis
Coxsackie B, echovirus (EBV, HIV)
277
Bacterial causes of pericarditis
Pneumococcal, staphylococci, gram-ve organisms, TB
278
Non infective causes of pericarditis
Dresslers syndrome, autoimmune (Rheumatic fever, SLE, RA)
279
Symptoms of pericarditis
Chest pain (worse on breathing and lying flat, relieved by sitting forward, may radiate to neck and shoulders) malaise
280
Signs of pericarditis
Fever, tachycardia, pericardial friction rub, dyspnoea
281
Investigations of pericarditis
Bloods, ECG, CXR, Echo
282
Bloods of pericarditis
Raised WCC, CRP/ESR, Blood cultures, cardiac enzymes
283
ECG of pericarditis
Widespread shaddle shaped ST elevation
284
Treatment of pericarditis
Treat cause, analgesia, NSAIDs, rest, manage complications ie pericardial effusion
285
Define cardiomyopathy
Disease of the myocardium that effects the mechanical or electrical function of the heart
286
Types of cardiomyopathy
Hypertrophic, dilated, restrictive, arrythmogenic
287
Define hypertrophic cardiomyopathy
Marked ventricular hypertrophy in the absence of abnormal loading conditions
288
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
289
Symptoms of hypertrophic cardiomyopathy
Asymptomatic, breathless, angina syncope, sudden death
290
Signs of hypertrophic cardiomyopathy
Atrial and ventricular arrythmias, jerky carotid pulse, ejection systolic murmur, pansystolic murmur
291
Investigations of hypertrophic cardiomyopathy
ECG always abnormal Echo shows ventricular hypertrophy Genetic analysis
292
Management of hypertrophic cardiomyopathy
Amiodarone (reduces arrythmias and sudden death), if high risk then implantable cardioverter defibrillator. Beta blocker for symptoms
293
Define dilated cardiomyopathy
Dilated left ventricle which contracts poorly
294
Causes of dilated cardiomyopathy
``` Autosomal dominant familial disease Alcohol Post pregnancy Hypertension Valvular heart disease ```
295
Clinical features of dilated cardiomyopathy
SOB mainly, can present with embolism, arrythmia or proggressive heart failure
296
Dilated cardiomyopathy investigations
CXR (cardiac enlargement) ECG Echo
297
Management of dilated cardiomyopathy
Treat HF and AF, Implantable cardiac defibrilator, cardiac transplant
298
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
299
Fontane classification for PVD
I asymptomatic II intermittent claudication III rest pain IV necrosis/gangrene
300
Why is there fixed splitting of S2 in atrial septal defects
Because the pulmonary valve closes after the aortic
301
What has a boot shaped heart on XRay
Tetralogy of fallot
302
When is PCI contraindicated
When it is too late or they have already had it
303
Define intermittent claudication
Exertional discomfort mainly in the calf, relieved by rest
304
Define rest pain
Unremitting pain in the foot, stops patient from sleeping, relieved by dangling foot over the bed
305
Signs of PVD
Cold dry skin, diminshed pulses, ulceration
306
Investigations in PVD
Pulse, Ankle-Brachial pressure index, duplex ultrasound
307
ABPI results
1 or more= symptom free 0.9-0.5= intermittent claudication <0.5= critical limb ischaemia
308
Management fo PVD
Aggressive risk factor management, statin, aspirin
309
The 6Ps of acute limb ischaemia
``` Pain Pallor Pulselss Paraesthesia Paralysis Perishingly cold ```
310
Causes of acute limb ischaemia
Can by embolic or thrombotic
311
Management of acute limb ischaemia
Heparin, if embolic long term warfarin, bypass graft
312
Define arrythmia
Abnormality of cardiac rhythm
313
Symptoms of. arrythmias
Asymptomatic, palpitations, dizziness, syncope, sudden death
314
What causes sinus arrythmia
Fluctuations in the autonomic tone results in changes in the sinus discharge rate
315
Extrinsic to heart causes of bradycardia
Drugs, hypothyroid, hypothermia, cholestatic jaundice, raised ICP
316
Intrinsic to heart causes of bradycardia
Ischaemia, infarction, fibrosis of atrium and sinus node
317
Treatment of bradycardia
Pacemaker if symptomatic
318
Causes of sinus bradycardia
Normal during sleep and athletes
319
Causes of neurally mediated bradycardia
Carotid sinus syndrome, vasovagal attacks
320
Common causes of heart block
Coronary artery disease, cardiomyopathy, fibrosis in conducting tissue
321
Causes of AV block
Block in the AV node or bundle of his
322
First degree AV block ECG
Delayed AV conduction, prolonged PR interval. No change in HR and no treatment needed
323
Second degree AV block cause
Some atrial impulses fail to reach the ventricle
324
Mobitz type 1 ECG
Progressive PR prolongation until fails to conduct
325
Mobitz type 2 ECG
Intermittent non conducted P waves without progressive prolongation of the PR interval
326
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
327
What is bundle branch block
Complete block of a bundle branch leads to abnormal conduction and widening of QRS >120ms
328
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
329
Left bundle branch block ECG
Deep, wide S in V1, Secondary R wave in V6
330
What is sinus tachycardia
Physiological response to exercise or excitement. Occurs with fever, anaemia, HF, thyroid, PE, hypovolaeia and drugs
331
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
332
What is Atrioventricular reciprocating tachycardia
Wolff-Parkinson-White syndrome, short PR interval, narrow QRS complexes
333
Supraventricular tachycardia symptoms
Rapid, regular palpitations, abrupt onset, sudeen termination. Dizziness, dyspnoea, central chest pain, syncope, aggravated by exercise, caffeine and alcohol
334
Treatment of unstable patient SVT
Emergency cardioversion, O2, electrolyte abnormalities corrected
335
Treatment of stable patient SVT
Vagal stimulation, adenosine, long term= ablation
336
Causes of atrial arrythmias
IHD, rheumatic disease, thyrotoxicosis, cardiomyopathy, pneumonia, ASD, pericarditis, alcohol use, cardiac surgery
337
Define atrial fibrillation
Uncoordinated rapid continous activation of the atria, leading to mechanically innefective contraction
338
What is the pulse like in atrial fibrillation
Irregularly irregular pulse
339
Presentation of atrial fibrillation
Asymptomatic, palpitations, reduced exercise tolerance, heart fialure, embolic events, irregularly irregular pulse
340
Investigations for AF
ECG: No P waves, irregular rapid QRS rhythm
341
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 ```
342
What score is used to determie the coagulation for AF
CHADS2VASc determines the risk of stroke
343
What does a score of 1 need
Aspirin
344
What does a score of 2 need
Warfarin
345
How do you calculate CHADS2VASc
``` Congestive heart failure Hypertension Age -65-74 -75=2 Diabetes mellitus Stroke of TIA=2 Vacular disease Sex female ```
346
Atrial flutter
Atrial rate of 300bpm and ventricular rate of 150bpm
347
Investigations of atrial flutter
Sawtooth F waves on ECG
348
Define aortic aneurysm
A permanent and irreversible dilation of a blood vessel by atleast 50% of normal
349
Risk factors for aortic aneurysm
Severe atherosclerotic damage, family history, smoking, male, increasing age, hypertension, COPD, hyperlipidaemia
350
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
351
Aortic aneurysm on examination
Pulsatile, expansible mass
352
Aortic anurysm investigations
Ultrasound, ct, mri angiography
353
Management of aortic aneurysm
Anti HTN, Statin, smoking cessation.
354
How does the size of aneurysm alter the treatment
Ultrasound and. surgery if big >5cm
355
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.
356
Risk factors for aortic dissection
Hypertension, smoking, hyperlipidaemia, aortic disease, bicuspid aortic valve, history of cardiac surgery
357
Inherited risks of aortic dissection
Marfans, Ehlers Danlos. Familial thoracic aneurysm type 1 and 2.
358
Aortic dissection presentation
Sudden tearing central pain which radiated to the back and moves as dissection progresses.
359
Investigation for aortic dissection
ECG, CXR, Imaging= CT, TOE, MRI
360
Management of aortic dissection
IV access, intensive care, aggressively control BP (<120sys with BB), blood, surgery
361
What do you call it when someone can speak but is making no sense
Expressive aphasia
362
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
363
Differential diagnosis of TIA
``` Hypoglycaemia Migraine aura Focal epilepsy Cerebral amyloid angiopathy Hyperventilation Retinal bleeds ```
364
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
365
TIA anterior circulation
Amaurosis fugax, aphasia (brocas), hemiparesis or hemisensory loss
366
TIA posterior circulation
Diplopia, vertigo, vomiting, choking, dysarthria, ataxia, hemianopic visual loss, tetraparesis
367
What score is used for the risk of stroke within two days of TIA
ABCD2
368
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 ```
369
Which ABCD2 score requires urgent investigation and. secondary prevention
>4 or two recent TIAs
370
Investigations for TIA
Bloods, CXR, ECG and Echo, Carotid doppler and angiography, CT
371
Management of TIA
Control cardiovascular risk factors, antiplatelets, warfarin and carotid endarterectomy
372
How does clopidogrel work
It is a ADP receptor blocker
373
How does dipyridamole work
Increases cAMP and reduces thromboxane A2
374
Which antiplatelets would you use in TIA
Aspirin then Clopidogrel and dipyridamole together
375
Define stroke
A syndrome of rapid onset neurological defecit caused by focal, cerebral, spinal or retinal infaction. Tissue injury is confirmed by neuroimaging
376
Modifiable stroke risk factors
Hypertension, smoking, hyperlipidaemia, Diabetes mellitus, heart disease, increased alcohol, pill and hrt
377
Non modifiable stroke risk factors
Age, male, afrocarribean, previous vascular event, family history
378
Causes of ischaemic stroke
Thrombotic, large artery stenosis, small vessel disease, cardioembolic, hypoperfusion
379
Causes of haemorrhagic stroke
Intracerebral haemorrhage, subarachnoid haemorrhage. Other (arterial dissection, venous sinus thrombosis, vasculitis)
380
What classification is used for ischaemic stroke presentation
Bamford classification
381
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
382
Anterior cerebral artery stroke symptoms
Leg weakness, sensory disturbance in legs, gait apraxia, incontinence, drowsiness, akinetic mutism
383
Middle cerebral artery stroke symptoms
Contralateral arm and leg weakness, contralateral sensory loss, hemianopia, aphasia or dysphasia, facial droop, neglect syndromes
384
Which ABCD2 score strongly predicts a stroke
>6
385
Posterior cerebral artery symptoms
Contralateral homonymous hemianopia, cortical blindness, visual agnosia, prosopagnosia, anomic aphasia (colour naming and discrimination problems), unilateral headaches
386
Primary causes of intracerebral haemorrhage
Hypertensive- rupture of charcot bouchard aneurysms Cerebral amyloid angiopathy -lobar, recurrant, associated with alzheimers
387
Secondary causes of intracerebral haemorrhage
Tumour Arterovenous malformations Anticoagulants Venous infarctions
388
Clinical features of intracerebral haemorrhage
Similar to ischaemic but more associated with severe headache and coma from raised intercranial pressure
389
Investigations in intracerebral haemorrhage
CT imaging | MRI and MR angiography for AVM or aneurysms
390
Management of ischaemic stroke
Frequent monitoring of GCS and signs Reverse anticoagulation (vitamin K) BP control
391
Where are berry aneurysms common
Between posterior communicating and ICA | Between anterior communicating and anterior cerebral
392
Consequence of posterior communicating aneurysm pressing on neighbouring structure
3rd nerve palsy
393
Causes of subarrachnoid haemorrhage
Berry aneurysm rupture, arteriovenous malformation
394
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
395
What is kernigs sign and when is it present
Patient cant extend leg when hip flexed. SAH and meningitis
396
What is brudzinskis sign and when is it present
Neck pulled forward causes knee flexion. SAH and meningitis
397
Investigations of SAH
CT | If CT negative then 12 hours later do a LP if no CI and it will be Xanthochromic
398
Management of SAH
Urgent neurosurgery referral, regular CNS examination, hydration and antihypertensives, nimodipine for 3 weeks
399
Why is Nimodipine given in SAH
It is a CCB and reduces vasospasm
400
Cause of subdural haemorrhage
Rupture of bridging veins, caused by head injury and in the elderly, alcoholics and babies
401
Cause of extradural haemorrhage
Skull fracture tearing a branch of the middle meningeal artery
402
Time frame for subdural haematoma
Days weeks or months after
403
Time from for extradural haematoma
Lucid interval of hours or days
404
Presentation of subdural haematoma
Fluctuating conciousness, headache, personality change, unsteadiness, hemiparesis, focal sensory loss, seizures, unequal pupils
405
Extradural haematoma presentation
Low GCS as severe headache, vomitting, confusin, seizures, hemiparesis. Brisk reflexes, upgoing planter reflex. Coma, ipsilateral pupil dilation and irregular breathing
406
Subdural haematoma on CT
Crescent shaped with midline shift
407
Extradural haematoma on CT
Biconvex shape and midline shift
408
Treatment of subdural haematoma
Close attention, neurosurgery burr hole drill of craniotomy. Can resolve itself.
409
Treatment of extra dural haematoma
Neurosurgery, clot evacuation and ligation of bleeding vessel
410
What does it need to be to have thrombolysis
Clinical ischaemic stroke diagnosis Assessed by experienced team Within 4.5hours
411
What is alteplase
Tissue plasminogen activator used in thrombolysis
412
What can a space occupying lesion lead to
brain herniation and death
413
What is used to combat anticoagulants
Beriplex and Vitamin K | Beriplex is quicker
414
What are lacunar infarcts
Subcortical infarcts
415
What is a watershed infarct
Infarct at the border of arterial supplies caused by severe cerebral hypoperfusion
416
Why is extradural haemorrhage biconvex
As ararchnoid granulations restrict spread
417
Very painful eye movements. Bilateral internuclear opthalmoplegia
Multiple sclerosis
418
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
419
Who gets MS
Women, 20-40, genetics, further from equator (VitD), can be triggered by viruses like EBV
420
Types of MS
Relapsing remitting Secondary progressive Primary progressive Progressive relapsing
421
Describe relapsing remitting MS
Clearly defined disease relapses with full or partial recovery. Periods between disease relapses characterised by a lack of disease progression
422
Describe secondary progressive MS
Initial relapsing remitting pattern is followed by progressive disability allowing for occasional remission and relapses
423
Describe primary progressive MS
Disease progression from onset with occasional plateaus and temporary improvement allowed
424
Clinical presentation of MS
Optic neuritis, brainstem demyelination, spinal cord lesions
425
What are the symptoms of brainstem legions in MS
diplopia, vertigo, facial numbness/weakness, dyarthria and dysphasia. Bilateral internuclear opthalmoplegia
426
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.
427
Common symptoms in MS
``` Visual change Sensory symptoms Clumsy hand or limb Ataxia or unsteadiness Bladder hyperreflexia Neuropathic pain Fatigue Spascitiy Temperature sensitivity ```
428
What is uhthoff's pnenomenon
Temperature sensitivity in MS
429
What is Lhermittes sign
Neck flexion leads to electric shock sensation
430
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. ```
431
Diagnosis of MS
2 or more attacks disseminated in time and space, McDonald criteria
432
Investigations of MS
MRI brain + spinal cord CSF= oligoclonal IgG bands Blood tests to exclude other inflammatory disorders
433
Who can diagnose MS
Only consultants
434
Long term management of MS
No cure, education, MDT (physio, OT, counsellor), prevent infections with nonlive vaccinations
435
How to treat acute relapses of MS
Methylprednisolone
436
Disease modifying drug for MS
Beta interferon
437
Treatment for very aggressive RRMS
Immunomodulatory drugs- Natalizumab
438
Drug for spasticity
Baclofen or gabapentin
439
Drug for emotional lability
Amitriptyline
440
Drug for pain in MS
Amitriptyline
441
Drug for tremor in MS
Beta blockers or botulinum toxin A type
442
Urinary urgency/ frequency in MS treatment
Intermittent self catheterisation
443
Signs of meningism
Headache, neck stiffness, photophobia, Kernigs and Brudzinskis
444
Immediate signs of Bacterial meningitis
Fevers, rigors, severe headache, photophobia and vomitting
445
Signs of bacterial menigitis that appear within hours
Neck stiffness and positive Kernig's sign
446
Signs of viral meningitis
Self limiting, headache, high fever
447
Causes of viral meningtis
Coxsackie, HSV, EBV, HIV mumps
448
Causes of bacterial meningitis in neonates
Ecoli, Group B strep, Listeria
449
Causes of bacterial meningitis in infants
Neisseria meningitidis, haemophilus influenzae, strep pneumoniae
450
Causes of bacterial meningitis in adults
Neisseria meningitidis, strep pneumonia
451
Causes of bacterial meningitis in the elderly
Strep pneumoniae, neisseria meningitidis, listeria
452
Investigations in meningtisi
Lunbar puncture, blood culture, nose and throat swabs, stool sample
453
What does non blanching petechial rash suggest
meningococcal septicaemia
454
Treatment for N.meningitidis in the community
IM Benzyl penicillin
455
Meningitis with no signs of sepsis or raised ICP treatment
Blood culture, lumbar puncture, IV dexamethasone. Then Ceftriaxone, fluids bloods
456
Meningitis with riased ICP management
Oxygen, blood culture, IV dexamethasone, delay LP. Give IV cefriaxone. CT imaging. Then bloods
457
Meningitis with severe sepsis or evolving rash managament
Oxygen, blood cultures, fluids. Delay LP. IV ceftriaxone, bloods
458
When wouldnt you lumbar puncture
Severe sepsis or rapidly evolving Severe respiratory or cardiac compromise Significant bleeding risk Signs of raised ICP (need CT)
459
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 ```
460
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 ```
461
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
462
Mild migraine management
Aspirin + metoclopramide
463
Name an antiemetic
metoclopramide
464
Severe migraine management
Triptan + Paracetamol
465
Migraine preventative measures
Propanolol, acupuncture, amitriptyline
466
Describe tension headache
30mins to 7 days. Bilateral pressing mild/moderate pain. No associated symptoms. Take paracetamol
467
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
468
Describe trigeminal neuralgia
Lasts seconds, unilateral electric severe pain with many triggers. No associated symptoms. Treat with carbamazepine
469
More than 50, jaw claudiaction, visual distrbance, tender and pulseless temporal arteries
Giant cell arteritis
470
Severe eye pain, red eyes, cloudy cornea, dilated and unresponsive pupil
Acute glaucoma
471
Headache worse on bending over
Sinusitis
472
Sudden onset thunderclap
Subarachnoid haemorrhage
473
Worse on lying down, exercise or valsalva
increased ICP
474
Fever fits and altered consciousness
Encephalitis
475
Define epilepsy
Paroxysmal event in which changes of behaviour, sensation or cognitive processes are caused by excessive hypersynchronous neural discharges in the brain
476
Are ischaemic or haemorrhagic strokes painful
Haemorrhagic
477
Temporal lobe seizure with awareness (simple partial)
Deja vu,, fear, olfactory, gustatory or auditory hallucinations
478
Ocipital lobe seizure with awareness (simple partial)
Visual phenomena such as zigzags
479
Frontal lobe seizure with awareness (simple partial)
Adversion seizures, jacksonian march
480
What is aura
A sensation percieved by a patient that preceds a condition affecting the brain
481
Temporal seizures with impaired awareness (complex partial)
Automatisms, auras, behaviour arrest, 1-2 minutes. Then post ictal confusion
482
Frontal seziures with impaired awareness (complex partial)
Complex movements like bicylce movement of legs, repeated words or phrases. Post ictal confusion
483
Gneralised absense seizure
loss of awareness and vacant expression for less than 10 seconds. Children
484
Myoclonic generalised seizure
Sudden, breif jerking of a limb face or trunk
485
Tonic generalised seizure
Body becomes stiff, can fall to the ground
486
Tonic clonic generalised seizure
Tonic phase (LOC increased tone) Clonic hase (synchronous jerking). Eyes open tongue biting. Postical confusion
487
Atonic generalised seizure
Sudden collapse with loss of muscle tone and consciousness
488
Epilepsy triggers
Sleep deprivation, missed doses, alcohol and recreational drug (withdrawal), exhaustion, intercurrent illness or metabolic disturbance
489
Which children and teenagers get epilepsy
Genetic, perinatal and congenital disorders
490
Which young adults get epilepsy
Trauma, drugs and alcohol
491
Which older adults get epilepsy
Vascular disease and neoplasms causing mass legions
492
Epilepsy investigations
Bloods, ECG, MRI, EEG, VIDEO telemetry DIAGNOSTIC
493
Management of focal seizures
Carbamazepine (lowers effectiveness of pill)
494
Management of general seizures
Sodium valproate (teratogenic)
495
How do you treat status epilepticus (seizure >5mins)
Airway, O2, IV access. Diazepam. Rectal in community, IV in hospital
496
Describe epilepsy
Aura, common from sleep, less than 2mins, rhythmical jerking, eyes open, tongue biting, incontinence, breathing stops, recovery slow
497
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
498
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
499
Ascending weakness, fasciculations, no sensory sphincter or eye loss, 50-70
MND
500
Define MND
Neurodegenerative condition caused by progressive loss of upper and lower motor neurones in the spinal cord, cranial nerve nuclei and motor cortex
501
Familial cause of MND
SOD1 gene mutation
502
Describe upper motor neurone legion
Weakness, increased reflexs, plantar and tone. No fasciculations or atrophy
503
Describe lower motor neurone lesions
Weakness atrophy fasciculation. Reduced reflexes, plantars, tone
504
What are the four clinical patterns of MND
Amyotrophic lateral sclerosis Progressive muscular atrophy Progressive bulbar palsy Primary lateral sclerosis
505
Amyotrophic lateral sclerosis
UMN and LMN
506
Progressive muscular atrophy
LMN
507
Progressive bulbar palsy
CN 9-12
508
Primary lateral sclerosis
UMN
509
Over 40, stumbling spastic gait, footdrop, weak grip, weak shoulder abduction, aspiration pneumonia
MND
510
Diangosis of MND
Clinical Electromyography confirms LMN Brain/cord MRI for excluding other things Diagnosis confirmed by steady progression over time
511
MND management
Specialist MDT. Non invasive ventilatory support and feeding (gastronomy. Riluzole
512
What drug is used in MND and what does it do
Riluzole, sodium channel blocker, inhibites glutatmate rlease
513
Define parkinsonism
Clinical syndrome characterised primarily by bradkinesia, rigidity, resting tremor and loss of postural reflexes
514
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
515
Describe spasticity
There is increased tone at the start of motion but this tops through the range of motion
516
3 cardinal features of parkinsons
``` Bradykinesia (button problems, micrographia, expressinoless face, dysphonia, dysdiadochokinesia) Resting tremor (unilateral pill rolling) Rigidity (paian, cog weel, stooped posture) ```
517
Characteristic gait of parkinsons
Slow to start walking, rapid short stride length, festination, reduced arm swing, impaired balance on turning
518
Not movement features of PD
Depression, phobias, anxiety, dementia, autonomic (constipation, increased urinary frequency. Not incontinence)
519
Parkinsons drugs to increase dopamine availability
Cocarledopa, levodopa and carbidopa(reduces SE from increased dopamine). These treat bradkyinesia and rigidity
520
Dopamine agonists used in parkinsons treatment
Ropinirole
521
Drugs which inhibit the enzymatic breakdown of dopamine in the treatment of parkinsons
Entacapone (COMT) Selegilene (MAO-B)
522
How do you treat the tremor in parkinsons
Anticholinergics- amantadine
523
Motor complications of late stage PD
Wearing off, on dyskinesias, off dyskinesias, freezing
524
Hyperkinetic movements, deranged liver function tests, kayser fleischer rings
Wilsons disease
525
Magnetic gait, incontience, dementia
Normal pressure hydrocephalus
526
Signs of cauda equina syndrome
Bilateral sciatica, bilateral flaccid leg weakness, saddle anaesthesia, bladder/bowel dysfunction, erectile dysfunction, areflexia
527
Causes of cauda equina syndrome
Herniated lumbar disc, lumbar spinal stenosis, inflammatory conditions, osteomyelitis, tumours/neoplasms, trauma
528
Diagnosis of cauda equina syndrome
MRI spine
529
Treatment of cauda equina syndrome
Surgical decompression by lumbar laminectomy
530
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
531
Clinical features of huntingtons
Irritability, depression, self neglect,behavioural problems Chorea and rigidity Dementia
532
How do you treat huntingtons
``` Chorea= sulpride Depression= SSRI Aggression= risperidone ```
533
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
534
Define myasthenia gravis
Autoimmune disease against nicotinic acetylcholine receptors in the neuromuscular junction
535
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
536
What is lambert eaton myasthenic syndrome
Paraneoplastic from small cell lung cancer. Defective Ach release but improves with exercise
537
Investigations for myasthenia gravis
Look for antiAChR and if negative look for antiMusk
538
Treatment for myasthenia gravis
Pyridostigmine (anticholinesterase), oral prednisolone
539
Define guillain barre syndrome
Acute inflammatory demyelinating ascending polyneuropathy affecting the peripheral nervous system following URT or GI infection
540
How do you treat guillain barre
IV immunoglobulin and enoxaparin
541
How does guillain barre present
Symmetrical ascending muscle weakness 1-3 weeks post infection
542
Carpal tunnel
Median nerve compression at the wrist. Tinnels or Phalens signs may be positive. Splinting and corticosteroid injections treatment
543
Clinical features of encephalitis
LOC, Confusion, seizures, headache and fever
544
Investigations of encephalitis
MRI, EEG, LP
545
Viral causes of Encephalitis
mumps, rabies, EBV
546
Define herpes zoster
Reactivation of varciella zoster virus in the dorsal root ganglia due to decreased immunity
547
Treatment of herpes zoster
Oral acyclovir. Post herpetic neuralgia=amitryptilline
548
Where do secondary brain tumours come from
Lungs, breast, melanoma, renal, GI
549
Glial cell tumours can be
Atrocytic or oligodendroliomas
550
Classification of astrocytomas
I Pilocytic II premalginant III anaplastic IV diffuse glioblastoma multiforme
551
What causes the conversion to malginant
Isocitrate dehydrogenase 1
552
Presentation of brain tumours
Headache, papilloedema, seizures, progressive neurologicla deficit
553
Investigations of brain tumours
MRI/CT
554
Treatment of brain tumours
Debulking surgery, radiotherapy, chemo and dexamethasone
555
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
556
Types of dementia
Alzheimers, vascular, lewy body, frontotemporal
557
What causes alzheimers
Accumulation of beta amyloid peptide causes progressive neuronal damage, neurofibrillary tangles, amyloid plaques and loss of ACH
558
5 Key features of alzheimers
``` Short term memory loss. Disintegration of personality and intellect Decline in language Decline in visuosptail skills Agnosia ```
559
Medication for alzheimers
Acetylcholinesterase inhibitors- donepezil
560
Antibiotics which cause C.dificle
Clindamycin, ciprofloxacin, coamoxiclav, cephalosporins
561
What is a mallory weiss tear
Linear tear in mucosa were the oesophagus meants the stomach
562
What does painless cholestatic jaundice suggest
Pancreatic cancer
563
What are varices
Distended veins from portal hypertension
564
What are the U+Es like in upper GI bleed
Only urea is raised and this is because of breakdown of blood
565
How do you treat mallory weiss tear
Minor=fluids | Major= banding
566
How do you treat varices
Banging and propanolol
567
Prehepatic cause of portal hypertension
Portal vein thrombosis
568
Hepatic cause of portal hypertension
Primary biliary cirrhosis, cirrhosis, buddchiari
569
Post hepatic cause of portal hypertension
Constrictive pericarditis, IVC obstruction
570
Causes of upper GI bleed
Mallory weiss tear, grastic and duodenal ulcer, varices
571
Causes of upper GI motility probelms
Achalasia and systemic sclerosis
572
How do you detect upper Gi motility problems
barium swallow
573
What are teh signs of limited systemic sclerosis
``` Calcinosis Raynauds phenomenon Esophageal dysfunction Sclerodactyly Telangiectasis ```
574
How do you detect systemic sclerosis
Anit nuclear antibodies
575
How do you treat upper GI motility disorders
Omeprazole, antacids and surgery
576
Define GORD
Excessive entry of gastric contents into the oesophagus through the gastrooesophageal junction
577
Risk factors for GORD
NSAIDs, large meals, hiatus hernia, obesity, prengancy, alcohol, coffee
578
Symptoms of GORD
Reflux, indigestion, heart urn, acid tast, bloatin, belching, discomfort, odynophagia
579
Diangosis of GORD
History and improvement with PPI
580
Managemtn of GORD
Weight loss, reduced alcohol, smoking cessation, avoid large or bedtime meals. Omeprazole and ranitidine (H2 antagnoist)
581
Define barrets oesophagus
Change in the lower oesophagus from squamous to columnar epithelium - metaplasia
582
Peptic ulcer disease investigation
H pylori testing and endoscopy only if over 55 or red flags
583
Treatment for PUD
Stop smoking, treat cause - omeprazole, clarithromycin and amoxicillin - stop NSAIDs
584
Wchich artery do posterior duodenal ulcers go into
Gastroduodenal artery
585
Which artery do gastric ulcers go into
Left gastric artery
586
What relieves pain in gastric
Vomitting, antacids and milk
587
What relieves pain in duodenal
Intake of food and anatacids and milk
588
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
589
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
590
Name 3 things H pylori can cause
Peptic ulcers, atopic gastritis, cancer
591
Investigations for H pylori
Endoscopy and biopsy for ulcers, C13 breath test
592
Dyspepsia features
Postprandal fullness, early satiation, epigastric burning
593
Causes of dyspepsia
GORD, IBS, PUD, lactose intolerance, anxiety or depression
594
Red flags in upper GI
Unexplain weight loss, anaemia, GI blood loss, dysphagia, upper abdo mass, persistent vomitting
595
early post prandial pain
GORD or gastritis
596
late post prandial pain
duodenal
597
Risk factors for oesophageal metaplasia
Obestiy, reflux, age
598
Risk factors for oesophageal squamous cell carinoma
Alcohol, smoking, east asia
599
Treatmetn of oesophagel cancer
Resection if fit, stent, chemo radio, palliative
600
Diangostic testing in oesophagel
Endoscopy, CT, PET
601
2 week wait for endoscopy if
Dysphagia or over 55 and upper abdo pain or reflux or dyspepsia
602
Non urgent endoscopy if
Haematemsis, over 55 with upper abso pain and anaemia, raised platelets, symptoms of GI cancer
603
Define coeliac disease
Systemic autoimmune disease trigerred by dietary gliadin
604
Describe the pathophysiology of coeliac disease
Autoimmune reaction, antiendomysial antibodies attack tissue transglutaminase enzyme which breaks down gluten
605
Risk factors for coeliac
HLA DQ2/8. T1D, AI addisons and gravves
606
Histoloical findings in the small intestine in coeliac
Increased lymphocytes in the epithelium and lamina propria, crypt hyperplasia, villous atrophy
607
Symptoms of coeliac disease
Abdo pain, bloating, diarrhoea, steatorrhea, weight loss
608
Signs of coeliac
dermatitis hepetiformis, anaemia, osteoporosis, failure to thrive
609
Where is iron absorbed
First part of the duodnum
610
Where is folate absorbed
jejunum
611
Where is B12 absorbed
Terminal ileum
612
What is dermatitis hepatiformis
Rash on the extenosr surfaces of the arms
613
Coeliac diagnosis
Tissue transglutaminase antibodies (IgA) (and endomysial antibodies. Bloods for serology, FBC and ferritin. Endoscopy and diagnosis is by small bowel biopsy
614
What would you see on a coeliac endoscopy
Atrophy and scalloping of mucosal folds, nodularity and mosaic pattern of mucosa
615
General symptoms of IBD
abdo pain, chronic diarrhoea (+- blood and mucous), weight loss
616
Describe UC
Continous inflammation that begins at the rectum to the ileocaecal valve. Cardinal symptom bloody diarrhoea. HLAB27
617
Describe crohns
Transmural and granulomatous inflammation from mouth to anus. Has skip legions. Mouth ulcers and perianal disease are classic. Smoking worsens symptoms
618
Investigations of IBD
``` Bloods: anaemia, FBC, increased CRP B12/Folate deficency, Stool MC&S, TFTs. Sigmoidoscopy Colonoscopy Diagnosed with biopsy ```
619
How do you differentiate IBD and IBS
IBD has increased faecal calprotectin
620
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
621
UC v Crohns endoscopically
UC: uniform inflammation and pseudopolyps Crohns: Skip lesions and cobblestone appearnace, commonly affects terminal ileum
622
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
623
IBD extra intestinal manifestations
Erythema nodosum, pyoderma gangrenosum, irritis, conjunctivits, episcleritis, large joint arthrits, ank spond
624
How do you treat relapses of IBD
Prednisolone then mesalazine maintenance
625
What is mesalazine
5-aminosalicylic acid
626
Prophylactic treatment for severe IBD first and second line
Azathiopine then metronidazole
627
Diarrhoea which is winter, hospital outbreaks, selflimiting
Rotavirus
628
Undercooked meat
Campylobacter jejuni
629
Poor food hygeine
Staph aureus
630
Watery travellers diarhoea
Enterotoxigenic E Coli
631
Bloody diarrhoea
Eneterohaemorrhagic Ecoli (0157)
632
Parasitic causes fo diarrhoea
Giardia lamblia and schistosomiasis
633
Investigations for infective diarrhoea
Basic obs, bloods, U&Es stool sample
634
What do you do with the stool sample in infective diarrhoea
3 samples, 1 immmediately and 2 more 3 days apart. Culture, ova&parasites, serotyping/PCR
635
Mnagement of infective diarrhoea
Exclude from work, rehydration, anitemetic, analgesia, notify public health england (food,bloody or cholera)
636
Complication of infective diarrhoea
Haemolytic uraemic syndrome (microangiopathic, haemolytic anemia, thrombocytopenia, AKI)
637
Indirect inguinal hernia
Protrusion of abdo/pelvic contents thorugh the internal inguinal ring lateral to epigastric vessels
638
Direct inguinal hernia
Protrusion of abdo/pelvic contents thorugh the abdominal wall into the inguinal canal medial to epigastric vessels
639
Define appendicitis
Acute inflammation of the appendix usually caused by obstruction of the appendix (usually by faecolith)
640
Complications of appendicitis
Rupture and gangrene leading to peritonitis
641
Presentation of appendicitis
Generalised pain which moves to mcburneys point, diarrhoea, vomitting
642
Signs of appendicitis
Pyrexial,guarding and rebound tenderness in the right illiac fossa
643
Investiagtions of appendicitis
Diagnosis with abdo CT or USS, increased WCC, rule out ectopic
644
Mangement of appendicitis
Nil by mouth, IV fluids, Abx, laparoscopic appendectomy
645
Causes of small bowel obstruction
Post op adhesions, strangulated hernia volvulus (children)
646
Casues of large bowel obstruction
Malignancy, sigmoid/caecal volvulus
647
What is ileus
Bowel ceases to function and there is no peristalsis, caused by post op and opioids
648
What is volvuls
Complete twisting of a loop of intestina around its mesenteric attachment
649
How are bowel obstructions classified
Site, extent mecahnism pathology
650
Small bowel v large bowel presentation
Constipation early in SBO, LBO has faeculent vomitting and later contipation
651
Cardinal signs of bowel obstruction
N+V, colicky abdo ppain, abdo distension, contipation, tinkling bowel sounds, hyperresonant or absent bowel sounds
652
Ivestigation of obstruction
Bloods, erect CXR (exclude perforation) abdo XR (dilated bowel loops and kidney bean sign(volvolus)
653
Mangement of obstruction
IV fluis, analgesia, antiemetics and monitor then surgery
654
Define diverticulum
Outpouching of gut wall
655
Primary peritonitis
Spontaneous bacterial peritonitis, ascites, immunoompromised. Diagnose via ascitic tap. Broad spectrum Abx, dont need surgery
656
Secondary peritonitis
Appendicitis, ectopic pregnancy, bowel ischaemia, PUD
657
Bacteria for peritonitis
Ecoli or spneumoniae (children). Post dialysis gets Staph aureus
658
Signs of ascending cholangitis
Ecoli. Charcots triad - RUQ pain - Fever - Jaundice
659
Acute cholecystits signs
RUQ pain, fever, raised inflammatory markers
660
Treatment of ascending cholangitis
Fluids, metronidazole, ERCP stenting, laparoscopic cholecystectomy
661
Typhoid antibiotic
Ciprofloxacin
662
Describe haemorrhoids
swolen veins, disrupted and dilated anal cushions. Band ligation. Get them in strainging pregancy, portal HTN and CCF. Fresh blood
663
Describe anal fissure
tear in skin around anal canal.Pain on defecation. Inspect. Hard faeces, IBD, anal cancer
664
Desribe anal fistula
Abnormal communication between anal canal and perianal skin. Crohns, Tb rectal carcinoma.
665
Pilondial sinus describe
Infected tract under skin between buttocks. Men sedentary obese. Hygeine
666
Functions of the liver
Glucose and fat metabolism, detoxification and excretion, protein synthesis, defense against infection
667
Screening for bowel cancer
Every 2 years 60-74. Faecal occult blood
668
Familial causes of bowel cancer
Familial adenomatous polyposis and hereditary nonpolyposis colorectal cancer(aggressive)
669
Risk factors for bowel cancer
Age 50, red meat low fibre, IBD, FHx, smoking alcohol and obesity
670
Red flag symptoms for bowel cancer
Abdominal pain, change in bowel habit, unexplained weight loss, chronic diarrhoea, Fe deficiency anaemia, rectal mass
671
Diagnosis of bowel cancer
Colonscopy and biopsy with histology
672
Staging of bowel cancer
TNM/ Dukes classification
673
Management of bowel cancer
Surgery, chemo, radio
674
Dukes A
Muscularis mucosae
675
Dukes B
Extension through the muscularis mucosa not lymph
676
Dukes C
Involvement of regional lymph nodes
677
Dukes D
Distant metastases
678
Causes of acute liver disease
Viral, drug, alcohol, congestion, obstruction
679
Causes of chronic liver disease
Alcohol, viral, autoimmune, metabolic
680
Presentation of acute liver disease
Malaise, nausea, anorexia, myalgia, abdo pain, bleeding, liver pain (=malignancy or obstruction). Ecephalopathy
681
Waht is hepatic encephalopathy
Liver flap, confusion, coma
682
Presentation of chronic liver failure
Ascites, oedema, haematemesis, malaise, anorexia, wasting, easy bruising, itching, hepatomegaly, abnormal LFTs, hypoglycaemia
683
Liver disease observations
Weight loss, scratching/itching, alcohol smell/withdrawal, encephalopathy
684
Liver disease hands
Clubbing, dupuytrens contracture, leuconychia, brusing, flapping tremor, palmar erythema
685
Liver disease face
Jaundice, spider naevi, parotid swelling, xanthelasma
686
Liver disease chest
Loss of body hair, spidernaevi, gynaecomastia
687
Liver disease abdomen
Ascites, caput medusae, hepatomegaly, spenomegaly, palpable gall bladder, hepatic bruit, tumour
688
Liver disease legs
Brusing oedema
689
Investigating chronic liver disease
Viral serology, immunology, biochemistry, Ultrasound scan
690
Initial test for alcoholic liver disease
Liver function tests. AST is higher than ALT, high MCV
691
Initial test for NASH
LFTs then confirm with liver biopsy
692
Initial test for chronic hep B
HBsAg
693
initial test for chronic hep C
HCV antibody
694
Initial test for primary biliary cirrhosis
Antimitochondrial antibody
695
Initial test for primary sclerosing cholangitis
Mangetic resonance cholagiopancreatography
696
Initial test for haemochromatosis
Transferrin and ferritin levels then confirm with HFE gene test
697
Initial test for wilsons disease
Caeruloplamin then confirm with 24hr urinary copper
698
Initial test for a1 antitrypsin
a1 antitrypsin level then confirm with genotype testing
699
Which serum liver enzymes are cholestatic
ALP and Gamma GT
700
Which serum live enzymes are hepatocellular
Asparate transaminase and alanine transaminase
701
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
702
When is ALT higher than AST
Chronic liver disease
703
When is AST raised higher than ALT
Cirrhosis and alocholic hepatitis
704
Which liver enzyme suggests and alcoholic cause
Aspartate transaminase
705
Causes of isolated rise in ALP
Bony mets, vitamin D defieincy, recent bone fracture, renal osteodystrophy
706
Causes of decompensation in chronic liver disease
New drugs, constipation, GI bleed, infetion, low sodium, pottasium or sugar, alcohol withdrawal
707
Consequences of liver dysfunction
Malnutrition, variceal bleeding, encephalopathy, ascites, infection, coagulopathy, endocrine changes, hypoglycaemia
708
How do you treat malnutrition
NG tube
709
how do you treat ascites
Fluid/salt restriction, diuretcs, paracentesis
710
Which haematology changes do you get from liver dysfunction
Vit K deficiency, impaired clotting factors, thrombocytopenia
711
Which endocrine changes do you get from liver failure
Gynaecomastia, impotence,, amenorrhea
712
Signs of alcoholic hepatitis
Mallory bodies and giant mitochondria
713
Stages of alcoholic liver disease
Fatty liver, hepatitis and cirrhosis
714
Describe steatosis
Acute reversible flat globules in the cytoplasm. FBC will be macrocytic if alcoholic
715
Describe hepatitis histopathology
Neutrophil infiltration, mallory bodies (hyalin aggregates), giant mitochondria
716
Symptoms of hepatitis
Jaundice, ascites, pain, hepatosplenomegaly
717
Tests for alcoholic hepatitis
``` Luecocytosis on FBC LFTs -ast/alt raised alk P raised prothrombin time longer Low albumin ```
718
Alcoholic cirrhosis histopathlogy
Mallory bodies, infiltration neutrophils
719
Symptoms of cirrhosis
Liver failure, portal hypertension, ascites, pain, varices, encephalopathy
720
Tests for cirrhosis
``` FBC= raised bilirubin adn leucocytosis U&E= low sodium, high creatitine LFT= deranged, long PT ```
721
Investigations for alcoholic liver disease
Blood tests, imaging, biopsy, ascitic tap
722
Management of ALD
Fatty liver=abstinence Hepatitis= abstinence, supplements, steroids Cirrhosis= manage complications
723
Alcohol withdrawal and managemtn
Tremors, hallucinations, agitation, delirium tremens. Give Chlorodiazepoxide
724
Treatment for alcohol dependence
Naltrexone and disulfiram
725
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
726
Autoimmune hepatitis
IgG, ANA, females. Good response to therapy.
727
Primary biliary cirrhosis
Chronic autoimmune granulomatous infiltration of interlobular bile ducts.. IgM, antimitochondrial antibodies. HCC
728
Treatment for primary biliary cirrhosis
Ursodeoxycholic acid
729
Primary sclerosing cholangitis
Primary sclerosing cholangitis, intrand extrahepatic bile ducts. Associated with UC. pANCA and ANA. Obliterative cholangitis and onion skin fibrosis
730
Haemochromatosis who gets it
Recessive, C282y. Hepcidin expression disrupted.
731
Symptoms of haemochromatosis
Iron deposition in liver heart, pancreas and joints leads to fibrosis. Tired Athralgia, grey skin, DVT, cirrhosis
732
Investigations for haemochromatosis
High ferritin, transferrin, serum iron. LFTs raised. Biopsy, genetic testing. Echo
733
Treatmetn of haemochromatosis
Venesection. Desferrioxamine iron chelator. tea, coffee, red wine
734
Pathophysiology of a1 antitrypsin
Recessive gene condition. Antitrpsin accumulation in liver and emphysema as protein defiency in blood
735
Investiagtions for a1antitrypin
Serum a1 antitrypsin low. | Biosy shows globules of alpha 1 antipsyin
736
Wilsons pathology
Copper toxicity. Decreased copper incorporation into caeruloplasmin and reuced copper excretion
737
Who gets wilsons
Autosomal recessive on 13
738
Symptoms of wilsons
Kayser Fleischer ring, grey skin, hypermobile joint. Depression, cirrhosis, tremor
739
Investigations of wilsons
Reduced serum copper, high urine copper 24hr, low serum caeruloplasmin. Do a liver biopsy. MRI basal ganglia. Genetinc testing
740
Treatment of wilsons
Penicillamine is a copper chelator Screen family No liver, chocolate, nuts, muschrooms, legumes
741
COPD and liver cirrhosis
Alpha 1 antitrypsin
742
Symptoms of hepatitis
General malaise, myalgia, GI upset, abdo pain
743
Hep A
Acute only, faecooral, travellers, foodhandlers, shellfish
744
Hep B
Blood bourne, needle stick, tattoos, sexual, vertical
745
Hep D
Needs HepB, bloody and bodily fluids. IVDU
746
Hep C
Blood and bodily fluids, IVDU, blood transfusions, needle stick, MSM
747
Hep E
Faecooral
748
Hep Vaccines
A100% B inactivated HBsAg (HBV IgG post exposure) D hepBvaccine
749
Complications of A and E hep
Fulminant hepatitis
750
Hep B C and D complications
Cirrhosis, HCC, Cholangiocarcinoma
751
Hep A and E treatment
Supportive
752
Hep B, C and D treatment
PEG IFN
753
HBsAg suggests
Acute or chronic infection. Infectious
754
antiHBs suggests
Recovered or has been vaccinated
755
antiHBc suggests
Have or recovered (proper infection)
756
Signs of cirrhosis
``` CLAPS Clubbing Leukonychia Ataxia Palmar erythema Scratch marks ```
757
General signs ofcirrhosis
Hepatomegaly, jaundice, ascites
758
Describe portal hypertension
Blockage leads to 10mmHg, collateral circulation occurs thorugh portosystemic shunt and dilation of gastro-oesophageal veins (varcies)
759
Transudate causes of ascites
Potal hypertension (cirrhosis) BuddChiari Cardiac failure
760
Exudate causes of acites
``` Pertioneal carcinoma Peritoneal TB Pancreatitis Nephrotic syndrome Lymphatic obstruction ```
761
Presenation of ascites
Abdominal distension, fullness in teh flanks, shifting dullness. Respiratory distress if tense ascites. Pleural effusion and oedema
762
Investigations for ascites
Aspiration. Albumin, Neutrophil (SBP?), MC&S, Cytology, amylase
763
Managemtn of ascites
Treat underlying cause, spironolactone Paracentesis and albumin replacement Transjugular intrahpeatic portosystemic shunt
764
Spontaneous bacterial peritonitis
Ecoli. Cefotaxime and metronidazole
765
Complications of gall stones
Biliary colic, ascending cholangitis and acute cholecystis
766
Define gall stones
Obstruction in cystic orcommon bile duct by a stone
767
Define ascending cholangitis
Infection of the biliary tree caused by obstruction of the common bile duct
768
Define acute cholecystitis
Obstruction of the neck of the gallbladder resulting in inflammation of the gall bladder
769
Signs of gall stones
Colicking RUQ pain after eating, can radiate to the right shoulder
770
Ascending cholangitis signs
Charcots triad: biliary colic, jaundice, fever (hypotension+confusion)
771
Acute cholecystitis signs
RUQ pain, fever and nausea, murphys sign
772
What is murphys sign
Pain on taking deeep breath when two fingers on RUQ
773
Diagnosis of gallstones
Abdominal ultrasound scan
774
Management of gallstones
Lithotripsy, ERCP, surgery
775
Describe prehepatic jaundice
Dark urine because of urobiliinogen and conjugated. Caused by Gilberts, haemolysis and malaria
776
Describe post hepatic jaundice
Dark urine (conjugated) and pale stool, gall stone or stricture
777
Describe heaptic jaundice
Hepatitis (all the types), ischaemia, neoplasm. Increased unconjugated
778
Difference between acute and chronic pancreatitis
Acute=reversible damage | Chronic=irreversible damage
779
Causes of acute pancreatitis
``` Gallstones Ethanol Trauma Steroid Mumps Autimmune Scorpion venom Hyperlipidaemia ERCP Drugs (azathioprine and sodium valproate) ```
780
Pancreatitis presentation
Severe epigastric pain that may radiate to the back, vomitting, cullens and grey turners
781
What is cullens sign
Perimubilical discolouration
782
What is grey turners sign
Flank discolouration
783
Pancreatitis investaigtion and diagnosis.
CT. Diagnosis= raised serum amylase X3 and serum lipase
784
Define polycythaemia
Increase in red blood cell, packed cell volume and haemoglobin concentrations
785
Causes of apparent polycythaemia
Beiing overweight, alcohol, diuretics, dehydration, stress
786
Describe primary polycythaemia
Polcythaemia vera, JAK2 mutation means the Bone marrow is increasedsensitivity to EPO so more RBC are produced. Peak in 60s
787
Causes of secondary absollute polycythaemia
Hypoxia, high altitude, abnormal RBC, tumours, renal artery stenosis
788
Symptoms of polycthaemia
Bleeding, bruising, fatigue, itchy skin
789
Signs of polycythaemia
Splenomegaly, hypertesnion, red skin, thrombocytosis
790
Polycythaemia puts you at risk of
Blood clots, MI, PE
791
Investigations of polycythaemia
History, FBC, blood film, genetic testing, U&Es, LFTs, serum EPO and red cell mass studies
792
Treatement of pvc
Venesection, hydroxycarbamide, interferon
793
Define pancytopenia
A reduction in RBC, WBC, and platelets
794
Causes of pancytopenia,
chemo, HIV, SLE, Malignancy
795
Diagnosis of pancytopenia
Bone marrow biopsy and FBC
796
How do you detect myeloblasts
Myeloperoxidase
797
How do you detect lymphoblasts
Tdt
798
Who gets AML
70s
799
Who gets AML

70s

800
Unique feauters of AML
Auer rods, Hepatosplenomegaly and gum hypertophy
801
Who gets ALL
3.5yo boys
802
What are ALL and AML linked to
Downs
803
Treatment of AML
Supportive, chemotherapy, bone marrow transplant
804
Unique presentation of ALL
Lymphadenopathy and testicular swelling
805
What are the symptoms of marrow failure
Fatigue, infection, bleeding and bruising
806
What should you give in ALL and AML to prevent tumour lysis syndrome
Allopurinol
807
What does Philadelphia chromosome cause
CML and ALL
808
Treatment of ALL
Supportive, chemotherapy and bone marrow transplant
809
Investigations in acute leukaemia
FBC, Blood film, BM biopsy, cytogenetics
810
Define CML
Uncontrolled proliferation of myeloid cells
811
Define AML
Neoplastic proliferation of blast cells derived from marrow myeloid elements
812
Define ALL
Malignancy of immature lymphoid cells
813
Who gets CML
40-60
814
What causes CML
Philadelphia chromosome causes increased tyrosine kinase activity
815
Presentation of CML
Constituional symptoms, massive splenomegaly, thrombocytosis
816
Investiagtions in CML
FBC, Blood Film, cytogenetics
817
Management of CML
Imatinib (tyrosine kinase inhibitor), hydroxycarbamide, bone marrow transplant
818
Define CLL
Accumulation of mature B cells which have escaped programmed cell death and undergone cell cycle arrest
819
Presentation of CLL
Enlarged rubbery non tender lymph nodes, constitutional symptoms, hepatosplenomegaly
820
Investigations of CLL
FBC and Rai staging
821
Treatment of CLL
Rituximab, radiotherapy, chemotherapy, stem cell transplant
822
Define myeloma
Malignant proliferation of clonal plasma cells
823
Who gets myeloma
60-70
824
Presentation of myeloma
Calcium, Renal impairment, Anaemia, Bone disease
825
Myeloma findings
Constitutional, amyloidosis, hyperviscosity, marrow infiltration, infection
826
Investigations in myeloma
FBC, blood film, U&E, urine electrophoresis, bone marrow biopsy, XRay skeletal survey
827
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
828
Complications of myeloma
Hypercalcaemia, spinal cord compression, hyperviscosity, AKI
829
Treatment of myeloma
Analgesia and bisphosphonates, blood transfusion, IV immunoglobulin. Chemo, stem cell transplant
830
Painless, rubbery nodes which hurt with alcohol
Lymphoma
831
Define lymphoma
Malignancy of mature lymphocytes that arises in the lymphatic system
832
Define leukaemia
Malignancy of lymphocyte precursors that arises in the bone marrow
833
Presentation of lymphoma
Painless lymphadenopathy, systemic symptoms, compression syndromes
834
Investigations in lymphoma
Blood film, bone marrow and lymph node biopsy, immunophenotyping and cytogenetics
835
Staging of lymphoma
Bloods, CT chest/abdo./pelvis
836
Low grade non hodgkins
Follicular
837
High grade non hodgkins
Diffuse large b cell
838
Very high grade non hodgkins
burkitts
839
Define hodgkins lymphoma
Malignant proliferation of lymphocytes and reed stern berg cells present
840
Who gets hodgkins lymphoma
30s or 70s
841
Risk factors for hodgkins
EBV, SLE, post transplant, obesity
842
Staging of hodgkins lymhoma
Ann arbor
843
Presentation of hodgkins
Painless asymmetrical lymphadenopathy (pain on alcohol), systemic symptoms, anaemia, LDH raised and hepatosplenomegaly
844
Treatment of 1-2a HL
Short course chemo then radio
845
Treatment of 2b-4 HL
Combination chemo
846
Late effects of HL
Cancers, psychological issues
847
Late effects of HL chemo
Infertility, cardiomyopathy, lung damage, peripheral neuropathy
848
NHL presentation
Bowel obstruction, bone marrow crowding out, spinal cord compression
849
Risk factor for burkitts lymphoma
EBV
850
Risk factor for gastric MALT lymphoma
H pylori
851
Treatment of NHL
Conservative if follicular, chemo, radio, bone marrow transplant
852
Tumour lysis syndrome
Large tumour burden and aggressive cancers, release of cellular components overwhelms the kidneys
853
Signs of tumour lysis syndrome
Hyperkalaemia, hyperphosphotaemia, hyperuricaemia, hypercalcaemia. Results in AKI, Seizures, death
854
Treatment of tumour lysis syndrome
IV fluids, treat high pot
855
Features of febrile neutropenia
Fevers, rigors, hypotension
856
How to treat febrile neutropaenia
Broad spectrum ab (tazosin), and take blood cultures
857
Signs of malignant cord compression
Back pain, spastic paresis, sensory level
858
Treatment of spinal cord compression
Dexamethasone, urgent MRI, chemo or R/T surgery
859
Causes of hyperviscosity syndrome
Increased immunoglobulins (myeloma), increased blood cells (leukaemia), reduced deformability of RBC (sickle cell)
860
Presentation of hyperviscosity triad
Mucosal bleeding, visual change, neurological disturbance
861
Consequences of hyper viscosity
Congestive heart failure, MI, pulmonary oedema
862
4 species of malaria
P.vivax, ovale, malariae, facilparum
863
What effect does malaria have on cells
Haemolysis, RBC sequestration and cytokine release
864
Signs of malaria
Anaemia, thrombocytopenia, coma, convulsions, acidosis
865
Diagnosis of malaria
Serial thin and thick films
866
Other tests in malaria
FBC, Clotting, glucose, ABG, U&E, blood cultures
867
Prophylaxis for malaria
Malarone
868
Treatment for malaria
Chlorquine, primaquine
869
Which diseases give protection against malaria
Sickle cell and G6PD
870
Low Hb, high WCC, platelets normal
Autoimmune haemolysis
871
Infection following blood transfusion
Probably bacterial as platelets stored at room temperature
872
What is the effect of CKD on blood
Lack of EPO therefore anaemia
873
What is the effect of renal cell carcinoma on blood
Secondary polycthaemia
874
Types of haemoglobin
A2gamma2 switches to a2b2 at 6 months
875
Diagnositc tests for anaemia
WCC, platelet count, reticulocyte count, blood film, haematinics, bone marrow biopsy
876
Signs of iron deficiency anaemia
Koilonychia, angular cheilosis, atrophic glossitis, post cricoid webs
877
Causes of iron deficiency anaemia
Menorrhagia, GI bleeding, hookworm, coeliac
878
General signs of anaemia
Breathlessness, tachycardia, fatigue, pallor of mucous membranes, hyperdynamic circulation
879
Appearnace of microcytic anaemia RBC
Microcytic and hypochromic
880
Causes of microcytic anaemia
Iron deficiency, thalassaemia, sideroblastic anaemia, anaemia of chronic disease
881
Treatment of iron deficiency anaemia
Ferrous sulfate for 3 months and treat underlying cause
882
Causes of normocytic anaemia
Blood loss, chronic disease, bone marrow or renal failure. Pregnancy and hypothyroid
883
Iron deficiency anaemia in someone without an obvious cause
Do oesophagogastroduodenoscopy and colonoscopy for GI bleed and exclude malignancy
884
Causes of anaemia of chronic disease
Inflammation, malignancy, infection, renal failure, rheumatoid arthritis
885
Treatment for anaemia of chronic disease
Treat underlying cause and give EPO
886
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
887
Causes of sideroblastic anaemia
Congenita, cancer, antiTB drugs. Ring sideroblast appearance because of iron deposits. Ferritin increased
888
Describe pernicious anaemia
Antiparietal cell and intrinsic factor antibodies. Associated with other AI, Vitiligo and hyporthyroid
889
Diagnosis of pernicious
Low Hb, raised MCV, hypersegmented neutrophils on blood film. Megaloblasts on biopsy
890
Treatment of pernicious anaemia
IV hydroxycabalamin, oral folate
891
Sources of vitamin B12
Meat, fish, dairy
892
Causes of B12 deficiency
Dietary, malabsorption, congential metabolic errors
893
Causes of B12 malabsorption
Atrophic gastritis causing pernicious anaemia or short gut syndrome preventing uptake
894
Where is B12 absorbed
Terminal ileum
895
Where is folate found
Green vegetables
896
Where is folate absorbed
Duodenum/jejunum
897
Where is iron absorbed
First part of the duodenum
898
Causes of folate deficiency
Dietary, malabsorption, drugs
899
B12 deficiency features
Lemon tinged skin, beefy red tongue, demention, paraesthesia, peripheral neuropathy
900
Increased red cell distribution width
Coeliac. Both micro and macrocytic anaemia
901
Clinical features of haemolytic anaemia
Anaemia, jaundice, gall stones, hepatosplenomegaly
902
Signs of haemolytic anaemia
Anaemia. increased unconjugated bilirubin, increased urobilinogen, increased reticulocytes
903
Glucose 6 phosphate dehydrogenase deficiency
X linked, Africa and med, bite and blister cells
904
B thalassaemia
First year of life, skull bossing, hepatosplenomegaly, treat with transfusions and splenectomy. Target cells
905
Alpha thalassaemia
Cant do without. So die. Bart’s hydrops
906
Hereditary spherocytosis
Autosomal dominant, sherical red cells become trapped in spleen and undergo haemolysis
907
Result of thalassaemia
Unmatched chains clump together and cause haemolysis and anaemia
908
Result of vessel and platelet disorders
Purpura, bleeding, prolonged bleeding
909
Result of coagulation disorders
Delayed bleeding into joints and muscles
910
Causes of reduced platelet production
Bone marrow failure, aplastic anaemia
911
Casues of destruction of platelets
Immune thrombocytopenia and Disseminated intravascular coagulation
912
What makes foetal haemoglobin
Liver and spleen
913
What makes adult haemoglobin
Bone marrow
914
Describe sickle cell
Sickle cell haemoglobin is abnormal and polymerises when deoxygenated
915
How do you diagnose sickle cell
Hb electrophoresis
916
Symptoms of a sickle cell crisis
Acute chest, dactylitis, stroke, priapism
917
How do you treat sickle cell
Hydroxycarbamide
918
What causes an increased prothrombin time
Liver disease, warfarin, DIC
919
What causes and increased activated partial thromboplastin time
Haemophilia, heparin, DIC
920
What causes an increased thrombin time
Heparin and DIC
921
What causes increased D-Dimer
DVT and DIC
922
Signs of DIC
Purpura and brusing, bleeding from cannula sights. Shistocytes on blood film.
923
Casues of DIC
Trauma, malignancy, sepsis, birth
924
Treatment of DIC
Replace platelets and give fresh frozen plasma
925
Haemolytic uraemic syndrome
After EColi. Triad of AKI, haemolytic anaemia and low platelets
926
Immune thrombocytopenia
Antibodies against platelets in children two weeks after infections
927
Vitamin K deficiency
Low 2,7,9,10. Caused by anticoagulants, biliary obstruction. Causes increased PTT
928
Vonwillebrand disease
Factor 8 problem, increased PTT
929
Haemophilia A
X linked, factor 8 deficiency. Raised APTT. Treat with desmopressin and recombinant factor 8
930
Haemophilia B
Same but factor 9
931
Risk factors for DVT
Immobility, cancer, oestrogen, surgery, thrombophilia
932
Diagnosis of DVT
Wells score and D dimer then do ultrasound. If unprovoked look for malignancy.
933
Virchows triad of venous thrombosis
Stasis of blood
934
Thrombophilias
Clotting problem. Factor V leiden and antiphospholipid syndrome
935
Treatment fo DVT
LMWH and warfarin
936
How does LMWH work
Inactivates factor Xa and thrombin (IIa)
937
How does warfarin work
Vitamin K antagonist
938
How do DOACs work
Xa antagonist
939
How to prevent DVT
Early mobilisation, compression stockings, leg elevation, LMWH
940
Name a DOAC
apXaban
941
Long bleeding time but otherwise normal suggests
Von Willebrand disease
942
Anaemic male and nothing wrong suggests
Gastroenterology
943
What should you give someone who has gout if they have other things going on like AF and DM
Colchicine
944
Symptoms of OA
Pain on movement and at end of day
945
Signs of OA
Bony swelling: Heberdens (DIPJ), Bouchards (PIPJ)
946
Secondary causes of OA
Haemochromatosis, obesity, occupational
947
What causes OA
Abnormal stresses or abnormal cartilage lead to compromised cartilage and biophysical and biochemical changes lead to cartilage breakdown
948
Biophysical changes in OA
Collagen network fracture and proteoglycan unravelling
949
Biochemical changes in OA
Inhibitors are reduced and proteolytic enzymes are increased
950
OA on XRay
Loss of joint space
951
Non pharmacological management of OA
Weight loss, exercise, aids and devices
952
Pharmacological management of OA
Paracetamol then oral NSAID if needed and intrarticular pred
953
Surgical management of OA
Joint replacement
954
Should you give NSIADs to people on warfarin
No GI bleed risk
955
Should you give steroids to people with diabetes
No upsets diabetic control
956
Describe gout crystals
Monosodium urate crystals are needle shaped and negatively birefringent under polarised light
957
Describe pseudo gout crystals
Calcium pyrophosphate crystals which are rhomboid and positively birefringent under polarised light
958
What causes decreased uric acid secretion
Diuretics, CKD, lead
959
What causes increased production of uric acid
Leukaemia, cytotoxic drugs, severe psoriasis
960
How does gout present
Acute monoarthropathy with severe joint inflammation. Caused by hyperuricaemia resulting in monosodium urate crystal deposition
961
Where is gout most common
Metatarsophalangeal joint
962
Causes of gout
Hereditary, increased dietary purines, alcohol, diuretics, trauma, leukaemia, surgery, starvation
963
Associations of gout
CV disease, DM, CKD
964
Important differential of gout
Septic arthritis
965
Investigations in gout
Bloods: serum urate
966
Non pharmacological Mangement of acute gout
Protect rest, ice, elevate.
967
1st line acute gout
NSAID max dose (ibuprofen) w/ppi or colchicine
968
2nd line acute gout
Joint aspiration and intrarticular pred
969
3rd line gout
Short course oral pred or single IM pred
970
Prevention of gout 1st line
Allopurinol
971
Prevention of gout 2nd line
Febuxostat
972
How does allopurinol work
Xanthine oxidase inhibitor
973
Prevention of gout 3rd line
Consider colchicine to prevent acute attacks
974
Presentation of pseudogout
Acute monoarthropathy of larger joints. Can be provoked by trauma illness or surgery. Calcium pyrophosphate cystal arthritis
975
Risk factors for pseudogout
Old age, hyperparathyroidism, haemochromatosis, hypophosphataemia
976
Investigations of pseudogout
Polarised light microscopy of synovial fluid
977
Treatment of acute acute of pseudogout
Cool packs, rest aspirate, intrarticular steroids. NSAIDs or Colchicine
978
Treatment of chronic pseudogout
Methotrexate
979
RA initial management
Methotrexate + Sulfalasalzine + short course of pred
980
Definition of rheumatoid arthritis
Chronic systemic autoimmune inflammatory disease characterised by a symmetrical, deforming, peripheral arthritis
981
Define OA
Non inflammatory degenerative arthritis
982
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.
983
Investigations in RA
Bloods, XRay, Ultrasound
984
Blood in RA
Rheumatoid factor
985
XRay of RA
Periarticular erosions, soft tissue swelling, loss of joint space
986
Ultrasound of ra
Synovitis, bony erosion
987
Pathophysiology of RA
Synovitis, hypertrophy, T lymphocyte and macrophage proliferation, pannus, malnutrition from cytokine effect, thin cartilage and bone exposure
988
Early signs of RA
Inflammatory signs, swollen symmetrical MCP, PIP, wrist or MTP
989
Late signs of RA
Ulnar deviation
990
Extraarticular manifestations of RA
Vasculitis, pericarditis, raynaud’s, episcleritis, fibrosing alveolitis
991
Conservative management of RA
PT, OT, Podiatry, psychological support
992
RA 1st line
Methotrexate, sulfasalazine and short term pred
993
RA 2nd line
If combination not appropriate, just methotrexate
994
Long term MA management
Try and reduce DMARD dose, short term pred for flares. Consider bioligs
995
antiTNF alpha blocker
Infliximab, etanercept, adalimumab
996
Anti CD20 blocker
Rituximab
997
Tyrosine kinase inhibitor
Imatinib
998
Does RA or OA respond to steroids
RA better
999
Describe seronegative spondyloarthropathies
Test negative for Rheumatoid factor, HLAB27 antigen.
1000
Which joints are involved in seronegative spondyloarthropathies
Inflammation of the sacroiliac joint and spine
1001
SPINEACHE acronym for seronegative spondyloarthropathies
Sauasage digit (dactylitis)
1002
Ank spond criteria
¾ in under 50
1003
Ank Spond on XRay
Syndesmophytes, sacroiliitis
1004
Ank Spond bloods
FBC, raised ESR and CRP, HLAB27
1005
Management of Ank Spond
Exercise and manage CV risk. 1st line NSAIDs, consider bisphosphonates and pred injections
1006
What are the three classic features of reactive arthritis
Urethritis, arthritis, conjunctivitis. Cant wee, cant see, cant climb a tree
1007
Define reactive arthritis
Sterile large joint arthritis affect the lower limb typically 1-4 weeks after infection
1008
Infections that cause reactive arthritis
Urethritis (chlamydia)
1009
Other features of reactive arthritis other than reiters syndrome 3
Iritis, mouth ulcers, enthesitis
1010
Reactive arthritis investigations
Bloods, culture stool/sexual health review, infectious serology.
1011
Management of reactive arthritis
Splint, aspirate, NSAIDs, corticosteroids, antibiotics. If chronic methotrexate
1012
Define psoriatic arthritis
Arthritis in patients with psoriasis or a family history of psoriasis.
1013
Presentation of psoriatic arthritis
Joint swelling, pain, stiffness, tenderness of joints
1014
Features of psoriatic
Dactylitis and onycholysis
1015
Investigations for psoriatic
Bloods raised ESR and CRP
1016
Management of psoriatic
NSAIDs, sulfasalazine, methotrexate
1017
Triad of septic arthritis
Low grade fever, impaired ROM, painful large joint
1018
Risks for septic arthritis
RA, DM, immunosuppression, IVDU, over 80
1019
Investigations for septic arthritis
Urgent joint aspiration for MC&S, blood cultures
1020
Management of septic arthritis 1st line
Flucoxacillin for 6weeks. Splint. If prosthetic then debride
1021
If penicillin allergic and septic arthritis
Clindamycin
1022
If gonococcal arthritis which antibiotic
Cefotaxime
1023
Definition of septic arthritis
Infection of the surface fo cartilage
1024
Definition of osteomylelitis
Infection of the bone that can include the periosteum, medullary cavity and cortical bone
1025
Common causative agent of septic arthritis and osteomyelitis
Staph Aureus
1026
Who gets septic arthritis
Old people
1027
Who gets osteomyelitis
Children
1028
Diagnosis of septic arthritis
Join aspiration
1029
Diagnosis of osteomyelitis
Bone cultures
1030
Management of osteomyelitis
Debridement and antibiotics
1031
Define raynauds disease
Peripheral digital ischaemia due to vasospasm
1032
Colour changes in raynauds
Normal to white to blue to red to normal
1033
Triggers of raynauds
Cold and stress
1034
Seconday raynauds causes
SLE, RA, occupational, beta blockers
1035
Treatment of raynauds
Stop smoking, keep warm, nifedipine, sildenafil
1036
Define systemic lupus erythematosus
Inflammatory multisystemic disease with antinuclear antibodies
1037
What is the common presentation of lupus
Fatigue, malaise fever
1038
SLE associations
Black, women, IBS
1039
Criteria for lupus acronym
SOAP BRAIN MD
1040
What does the lupus criteria stand for
Serositis
1041
Diagnosis of lupus
Clinical, ESR high but CRP low. Skin or renal biopsy
1042
Treatment of SLE
Avoid smoking and sunlight. NSAIDs for arthralgia and topical steroids for cutaneous.
1043
Acute severe SLE flare
IV prednisolone and cyclophosmaide
1044
Chronic managemtn of SLE
NSAIDs and hydroxychloroquine
1045
Define sjorgens
Inflammatory autoimmune disorder with lymphocytic infiltration of exocrine glands
1046
Symptoms of Sjorgens
Dry eyes, mouth, vagina. Fever, malaise, polyarthralgia
1047
Diagnosis of Sjorgens
Schirmers test. Serology ANA, RF, AntiRo and AntiLa. Biopsy showing plasma and lymphocytes
1048
Management of sjorgens
Synthetic tears and saliva, lubrication for vagina, NSAID
1049
Complications of Sjorgens
Non HL
1050
What symptoms do you get in all autoimmune conditions
Fatigue, malaise, polyarthralgia, myalgia
1051
What is the presentation of dermatomyositis
Polymyositis and skin involvement. Heliotrope rash, macular rash, subcut calcifications and gottrons papule.
1052
Define polymyositis
Inflammation and progressive necrosis of skeletal muscle fibres
1053
Presentation of polymyositis
Difficulty squatting, climbing stairs, raising hands above head. Arthralgia, dysphonia, dysphagia, fever, raynauds
1054
What causes polymyositis
Cytotoxic T cells
1055
Diagnosis of polymyositis
Creatinine kinase and aldolase
1056
Mangement of polymyositis
Oral prednisolone
1057
Presentation of limited cutaneous systemic sclerosis
Calcinosis
1058
What is the different presentation of diffuse cutaneous systemic sclerosis
Earlier organ fibrosis and diffuse cutaneous involvement
1059
Diagnosis of limited cutaneous systemic sclerosis
Anti centrome ab
1060
Diagnosis of diffuse cutaneous systemic sclerosis
AntiScl 70 and anti-RNA polymerase
1061
Management of diffuse cutaneous systemic sclerosis
Control BP, monitor echo spirometry renal function
1062
Complication of systemic sclerosis
Malnutrition
1063
What causes systemic sclerosis
Collagen deposition
1064
How do you diagnose PE
CT pulmonary angiogram
1065
Antiphospholipid syndrome
Venous and arterial thrombosis. Phospholipid antibodies. Low dose aspirin treatment
1066
Large cell vasculitis
Granulomatous disease. Giant cell arteritis and Takayasu arteritis
1067
Medium vessel vasculitis
Polyarteritis nodosa and Kawasaki disease
1068
What will you see on biopsy for GCA, polyarteritis nodosa, wegeners, churgg strauss
Granulomas
1069
Consequences of vasculitis
Stroke, MI, fever headache
1070
Signs of giant cell arteritis
Unilateral headache, scalp tenderness in temporal region, jaw cladication, amaurosis fugax, morning stiff ness
1071
Diagnosis of giant cell arteritis
Clinical, bloods.
1072
Management of giant cell arteritis
Immediate prednisolone
1073
Define polymyositis
Inflammation of striated muscle
1074
How would you differentiate polymyalgia rheumatica from polymyositis
PMR gets pain
1075
Key deatures of polyarteritis nodosa
Medium arteries. Microaneurysms. HepB. Skin rash and punched out ulcers. No glomerulonephritis or ANCA
1076
Diagnosis of polyarteritis nodosa
Renal angiography or biopsy
1077
Management of polyarteritis nodosa
Prednisolone and cyclophosamide
1078
Define granulomatosis with polyangiitis
Necrotising granulomatous vasculitis nmediated by neutrophils (cANCA)
1079
Symptoms of GPA
Cough, sinusitis, haemoptysis, haematuria, ulcers, saddle nose deformity
1080
Diagnosis of GPA
History, bloods, cANCA and PR3 ab test. Renal or lung biopsy showing granuloma
1081
Treatment of acute GPA
Prednisolone and IV cyclophosamide
1082
Maintenance of gpa
Azathioprine
1083
Churg-Strauss syndrome
Asthma, eosinophilia and vasculitis. MPO ab, pANCA. Steroids. Then long term rituximab
1084
Microscopic polyangiitis
Like wegeners but pANCA and no granuloma
1085
Fibromyalgia treatment
CBT and tailored exercise programme
1086
Define fibromyalgia
Chronic widespread pain and sensitivity to pressure at 11/18 tender points without inflammation (exclude DDx)
1087
Yellow flags of fibromyalgia
Sickness behaviour (extended rest, social withdrawal, low participation in treatment, belief that pain and activities are harmful)
1088
Investigations in back pain
Urgent MRI, FBC, U&E, LFT, ESR, CRP serum electrophoresis
1089
Define multiple myeloma
Abnormal proliferation of a single clone plasma cell
1090
Prognostic myeloma test
Serum Beta2 microglobulin
1091
Osteosarcoma
Teenagers and children. Around knee. Chemo and surgery
1092
Ewings sarcoma
5-20yo. Leg, pelvis, upper arm, ribs. Chemo and surgery
1093
Chondrosarcoma
Malignant tumour of chondrocytes. 40-70, hip pelvis shoulder. Surgery
1094
Secondarys to bone from
Breast, lung, thyroid, renal, prostate
1095
Define osteoporosis
Progressive systemic skeleteal disease characterised by reduced bone mass and microarchitectural deterioration of bone tissue.
1096
ACCESS for osteoporosis risk
Alcohol
1097
What is a T score
Score compared to a gender matched individual at peak bone mass
1098
-1 to -2.5
Osteopenia
1099
< -2.5 osteoporosis
Osteoporosis
1100
LESS THAN -2.5 AND FRACTURE

Severe osteoporosis

1101
Management of osteoporosis
More exercise, less alcohol, vitamin D supplements. Bisphosphonates.
1102
What does FRAX do
Fracture risk assessment tool. Evaluates the 10 year probability of bone fracture.
1103
Name two loop diuretics
Furosemide and bumetanide
1104
How do loop diuretics work
Act on NaK2Cl in the ascending limb
1105
Adverse effects of loop diuretics
Dehydration, hypotension, hypokalaemia so metabolic alkalosis
1106
Name two potassium sparing diuretics
Amiloride and spironolactone
1107
How do potassium sparing diuretics work
Aldosterone antagonist so acts on ENaC in the DCT
1108
Adverse effects of potassium sparing diuretics
GI upset, hyperkalaemia, metabolic acidosis, gynaecomastia
1109
Name a thiazide diuretic
Bendroflumethiazide
1110
How do thiazide diuretics work
Act on sodium chloride channels in the DCT, longer acting but not as potent as loop
1111
Adverse effects of thiazide diuretics
Hypokalaemia, metabolic alkalosis, hypovolaemia, hyponatraemia, hyperglycaemia in diabetics
1112
3 common sites where stones get stuck
Pelviureteric junction, pelvic brim, vesicoureteric junction
1113
What are renal stones made up of
Calcium oxalate (75%), struvite, uric acid or cysteine. Caused by supersaturation of urine with salt/minerals
1114
What are infection stones made up of
Magnesium ammonium phosphate
1115
What causes cysteine stones
Cystinuria which is an autosomal recessive condition
1116
How would describe colic
Waves of pain
1117
If they have a catheter in and are confused what do you suspect
UTI
1118
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.
1119
What are the other symptoms of renal colic
Rigors, dysuria, haematuria, urinary retention, nausea and vomiting
1120
Risk factors for stones
Anatomical abnormalities, FHx, hypertension, gout, hyperparathyroidism, immobile, dehydrated
1121
Differentials for renal colic
Ruptured AAA, diverticulitis, appendicitis, pancreatitis, testicular torsion, pyelonephritis, MSK
1122
Investigations for renal colic
Bloods inc calcium, phosphate urate. Urinalysis, MSU if positive. Non contrast computerised tomography kidney ureter bladder. NCCT KUB gold standard
1123
Management of renal colic
Strong analgesic= diplofenac
1124
Management of obstruction and infection
Ureteric stent
1125
Prevention of renal stones
Drink plenty of water
1126
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
1127
3 criteria for AKI
Increase in creatinine of more than of 26micromol/L in 48hr
1128
Risk factors for AKI
Age, CKD, cardiac failure, PVD, diabetes, drugs, sepsis, dehydration
1129
Prerenal AKI causes
Hypoperfusion, hypotension, renal artery stenosis, drugs
1130
Renal AKI causes
Acute tubular necrosis, AI, glomerulonephritis, vasculitis
1131
Post renal causes of AKI
Urinary tract obstruction. Stones, malignancy, BPH
1132
ACE-I and ARB effect on kidney
Results in dilated efferent arterioles, decreasing GFR
1133
NSAIDs effect on kidney
Inhibits cyclooxygenase causing excess vasoconstriction of the afferent arterial
1134
Aminoglycosides effect on the kidney
Acute tubular necrosis
1135
Investigations of AKI
Full screen. Cr, U and E, LFT, clotting, glucose, urine dipstick, autoantibodies (antiGBM, ANCA), Renal USS. U and E is diagnostic
1136
Management of AKI
Aim for euvolaemia, stop nephrotoxic drugs, treat cause, manage complications
1137
How do you treat hyperkalaemia
Insulin/dextrose, salbutamol, calcium gluconate
1138
Define CKD
GFR below 60mL/min/1.73m for more than 3 months, with or without evidence of kidney damage
1139
Causes of CKD
Glomerular disease, hypertension, interstitial disease (myeloma, TB, schistosomiasis), PCKD, SLE, Vasculitis
1140
CKD on USS
Bilaterally small kidneys
1141
Presentation of CKD
Malaise, nocturia and polyuria, itching, NVD, oedema, bruising
1142
What causes itching in CKD
High urea levels
1143
Stage one CKD
GFR over 90, with evidence of kidney damage. Check for proteinuria and haematuria
1144
Stage two CKD
60-89, kidney damage and slightly low GFR. Lower BP and give low protein diet
1145
Stage three A and B CKD
30-45,45-60 moderate reduction in GFR. control BP low protein diet
1146
Stage 4 CKD
15-29. Severely low GFR. Prepare for dialysis
1147
Stage 5 CKD
<15 or dialysis. Kidney failure.
1148
AKI v CKD: kidney size
Normal v small
1149
AKI v CKD: anaemia
No v normochromic normocytic
1150
AKI v CKD: diabetes
No v diabetes
1151
AKI v CKD: BP
Low v high
1152
AKI v CKD: time span
Rapid v slow
1153
AKI v CKD: urine output
Oligouria v polyuria and nocturia then oligouria
1154
AKI v CKD: CNS symptoms
None v In late disease
1155
Nephrotic disease triad
Proteiunuria, hypoalbuminaemia, oedema. Also severe hyperlipidaemia as liver goes into overdrive from albumin loss
1156
Causes of primary nephrotic
Minimal change disease, membranous nephropathy, focal segmental glomerulonephritis
1157
Causes of secondary nephrotic
Diabetes, hepatitis, malignancy
1158
Cause of nephrotic
Injury to podocyte foot processes
1159
What happens in minimal change disease
Fusion of footprocesses of podocytes
1160
Investigations of nephrotic
Urine dip (high protein), bloods (low albumin and biopsy in adults
1161
Management of nephrotic
Steroids in children, diuretics, ACE-I for proteinuria. Treat cause
1162
Complications of nephrotic
Infections, thromboembolism, hypercholesterolaemia
1163
Nephritic syndrome 4 things
Haematuria (red cell clasts), proteinuria, hypertension, oligouria
1164
Cause of nephritic
Immune response to podocytes so pores
1165
Causes of nephritic
Spot streptococcal glomerulonephritis, IgA nephropathy, good pastures
1166
What do red cell clasts indicate
Glomerular damage
1167
How long after URTI does IgA nephropathy happen
Days
1168
How long after URTI foes post strep glomerulonephritis happen
Weeks
1169
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
1170
Why do you get a proinflammatory response in IgA nephropathy
Alternative complement system is activated by immune complexes
1171
How do you diagnose IgA nephropathy
Mesangial proliferation
1172
How do you prevent immune complexes
Prednisolone
1173
Which bacteria cause post strep GN
Group A Beta haemolytic strep
1174
How do you diagnose post strep GN
Biopsy shows enlarged glomerular basement membrane then EM shows humps
1175
What hypersensitivity is post strep GN
3, immune complex. Then alternative complement.
1176
Management of post strep GN
Supportive
1177
Minimal change disease
Children, Cytokines damage podocytes making them flattened and lose their negative charge. Nephrotic syndrome. Selective proteinuria
1178
Association of minimal change disease
Hodgkins lymphoma
1179
Diagnosis of minimal change disease
Fused podocyte processes on EM
1180
Treatment of minimal change disease
Prednisolone
1181
Focal segmental glomerulonephritis
Hyalinosis leads to sclerosis. Diagnosed by afacement of podocytes on EM. Treat with prednisolone
1182
What is used when the patient is steroid resistant
Ciclosporin
1183
Membranous neuropathy
Immune complexes against basement membrane. Biopsy= thickened BM and C3 and IgG deposits. Treat with prednisolone
1184
Causes of nephrotic
Minimal change disease, membranous neuropathy and focal segmental glomerulonephritis
1185
Causes of nephritic
IgA nephropathy, post streptococcal glomerulonephritis, goodpastures
1186
What are the features of nephrotic which nephritic doesn’t have
Oedema, hyperlipidaemia and hypoalbuminaemia
1187
Autosomal dominant Polycystic kidney disease
PKD1 more common and more severe. PKD2 less common and less severe
1188
Pathophysiology of ADPKD
Polycystin 1 and 2 mutations mean unregulated tubular and vascular growth in the kidneys and other organs
1189
Other organ involvement of ADPKD
Liver= no affect on function
1190
Presentation of ADPKD
Nocturia, loin pain, HTN, bilateral kidney enlargement. Haematuria following trauma. UTI, pyelonephritis, stones more common
1191
Investigations of ADPKD
Ultrasound
1192
Management of ADPKD
Counselling and support for family, monitor progression, treat HTN, UTI, Stones and colic. Dialysis when needed
1193
What happens in retention
The kidneys are still producing urine but the bladder is unable to void
1194
Causes of acute bladder retention
Bladder stone, BPH, Prostate cancer, MS, prolapsed disc at S2,3,4
1195
Define BPH
Benign proliferation of musculofibrous/glandular tissue of the transitional zone of the prostate
1196
Voiding LUTS
Hesitancy
1197
Storage LUTS
Frequency
1198
Investigations for BPH
DRE smooth and enlarged
1199
Non medical prostatic hyperplasia treatment
Lower caffeine and alcohol, bladder training
1200
What is needed for BPH
Dihydrotestosterone
1201
1st line medical BPH
Alpha blockers, Tamsulosin
1202
2nd line medical BPH
5alpha reductase inhibitors, finasteride
1203
Surgical treatment of BPH
TURP, TUIP, Retropubic prostatectomy
1204
Side effects of alpha blockers
Dizziness, postural hypertension, weight gain
1205
Define prostate cancer
Malignant adenocarcinoma of the peripheral zone of the prostate
1206
Symptoms of prostate cancer
LUTS, cancer symptoms, bone pains
1207
Risk factors for prostate cancer
Family history, high levels of testosterone (obesity not a risk factor but more aggressive form)
1208
Where does prostate met to
Adjacent structures, bone lung
1209
Investigations of prostate cancer
DRE (hard and irregular), PSA, biopsy, TRUSS, imaging, bone scan
1210
How does gleason grading work
20 biopsies. First part is most common, 2nd part the worst.
1211
TNM: T for prostate 1
Non palpable
1212
T2 prostate
Palpable and confined to prostate
1213
T3 prostate
Palpable and through capsule
1214
T4 prostate
Palpable and invades other structures
1215
Prostate cancer localised treatment low rise
Active surveillance
1216
Prostate cancer progression treatment
Radical prostatectomy and radiotherapy
1217
Hormone treatment for prostate
LHRH agonist (goserelin) and antiandrogen
1218
Metastatic prostate treatment
Surgical castration and palliative care
1219
Side effects of hormone treatment
Osteoporosis, gynaecosmastia, sexual dysfunction
1220
Renal cell carcinoma
Adenocarcinoma of the PCT, highly vascular
1221
Where does renal cell carcinoma met to
Bone, liver lungs
1222
Risk factors for renal cell carcinoma
Poor lifestyle, HTN, CKD, horseshoe kidney, haemodialysis
1223
Signs of RCC
Abdo mass, haematuria, obstruction
1224
Symptoms of RCC
Loin pain, cancer symptoms
1225
Investiagtions of RCC
Bloods, urine, USS
1226
Localised RCC treatment
Radical nephrectomy
1227
Metastatic RCC treatment
Biologics
1228
Symptoms of bladder cancer
Painless haematuria
1229
3 types of bladder cancer
Transitional cell, squamous, adenocarcinoma
1230
Risk factors for bladder cancer
Rubber, azo dyes, schistosomiasis(=squamous). Chronic cystitis, smoking, male
1231
Bladder cancer diagnosis
Flexible cystoscopy, biopsy and CT urogram
1232
Where does bladder cancer met to
Paraaortic and iliac lymph nodes
1233
Management of T1 bladder cancer
Transurerthral resection of bladder tumour. And chemo
1234
Management of T2-3 bladder cancer
Radical cystectomy
1235
T4 bladder cancer management
Palliative chemo
1236
Testicular pain causes
Torsion, sti=epididymoorchitis, renal colic referred pain
1237
Testicular cancer types
Seminoma (germ cell) and non seminoma
1238
Risk factors for testicular cancer
Undescended testes, infant hernia
1239
Presentation of testicular cancer
Painless testicular lump, haematospermia
1240
Testicular cancer diagnosis
Scrotal US, biopsy, serum tumour markers
1241
Testicular cancer tumour markers
A-fetoprotein, B-human chorionic gonadotrophin, lactate dehydrogenase
1242
Seminoma unique
Young. A-fetoprotein and B-HcG
1243
Teratoma unique
B-HcG and LDH
1244
Treatment of seminomas
Radical orchidectomy and radiotherapy
1245
Treatment of no seminomas (teratoma)
Chemotherapy
1246
Staging of testicular
1=no mets
1247
Where can TCC occur
Bladder, renal pelvis, calyx, ureter, urethra
1248
Wilms tumour
Childhood tumour, primitive renal tubules and mesenchymal cells. Abdo mass and haematuria in children.
1249
Penile cancer
Irradiation or virus, ulceration and discharge. Give radiotherapy, iridum wired or amputate
1250
Backpain, withdrawn, confused
Prostate with mets to bone
1251
What makes testicular cancer more likely
Body of testes and cant separate
1252
Epididymal cyst
Clear milk fluid, above and behind testes
1253
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.
1254
Varicocele
Dilated pampniform plexus, left more than right. Bag of worms. Ligate the gonadal vein
1255
Haematocele
Blood in tunica vaginales from trauma, aspirate or surgery
1256
Epidydmoorchitis
Sudden onset testicular pain, usually caused by STI
1257
Why is varicocele more common on left
RCC invasion of left renal vein causes compression of left gonadal vein
1258
What causes testicular torsion
Twisted spermatic cord cuts off blood supply to testes, causing ischaemia
1259
Presentation of testicular torsion
Sudden onset testicular pain, inflamed and tender testical, unilateral, abdo pain, Nausea and vomiting
1260
What to do for testicular torsion
Refer to urology ASAP, can do scrotal US. Surgery
1261
Testicular lump
Cancer
1262
Acute and tender lump
Testicular torsion
1263
Definition of UTI
Pure growth of more than 10 5 organisms per ml of fresh MSU
1264
Risk factors for UTI
Female, intercourse, pregnancy, menopause, UT obstructions, malformations, immunosuppression, catheterisation
1265
What do you find on urine dipstick of UTI
Nitrites (bacteria convert nitrate to nitrites)
1266
When is it hard to spot UTI
Dementia or children
1267
Why do you get more UTI in diabetes
It weakens the immune system
1268
Organisms in UTI
Escherichia coli
1269
What is E Coli
Gram negative lactose fermenting
1270
What is proteus mirabilis
Gram negative, swarming on cultures
1271
What is klebsiella pneumonia
Gram negative
1272
What is staphylococcus saprophyticus
Gram positive cocci, lactose fermenting, catalase positive, coagulase negative
1273
What is enterococcus
Gram positive diplococci
1274
What are upper UTI
Pyelonephritis and ureteritis
1275
What are lower UTI
Cystitis, urethritis, prostatitis
1276
What are signs and symptoms of UTI
Loin/abdo pain, offensive smelling urine, haematuria, fever
1277
Investigations of UTI
GOLD= MC&S of MSU
1278
Management of UTI
Abx, fluid intake, pain relief
1279
How to prevent UTI
Hydrate, void before and after sex
1280
Signs and symptoms of cystitis
Suprapubic pain, haematuria, dysuria, frequency, urgency
1281
Uncomplicated UTI treatment
Trimethoprim or nitrofurantoin
1282
Complicated UTI treatment
Cefalexin
1283
Pyelonephritis signs and symptoms
High fever, loin pain, rigors, N and v
1284
Uncomplicated pyelonephritis treatment
Ciprofloxacin or coamoxiclav
1285
Complicated pyelonephritis treatment
Cefalexin
1286
What do beta cells secrete
Insulin
1287
What do alpha cells secrete
Glucagon
1288
What do delta cells secrete
Somatostatin
1289
Which hormones control glucose levels
Insulin, glucagon, cortisol and growth hormone
1290
Actions of insulin
-stimulates glucose uptake by insulin dependent tissues
1291
What should blood glucose always be between
3.5 and 8mmol
1292
GLUT 1
Non insulin stimulated glucose uptake
1293
GLUT 2
Low affinity transporter for Beta cells
1294
GLUT 3
Non insulin stimulated glucose uptake into brain and placenta
1295
GLUT 4
Insulin mediated glucose uptake in muscle and adipose tissue
1296
Symptoms of hypoglycaemia
(<3) dizziness, confusion, hunger, convulsions, coma, sympathetic action (tachycardia, sweating, pallor)
1297
Define diabetes mellitus
Syndrome of chronic hyperglycaemia due to relative insulin deficiency, resistance or both
1298
Secondary causes of DM
Pancreatitis, cystic fibrosis, trauma, haemochromatosis, acromegaly, cushings
1299
Diabetes Fasting plasma glucose
Over 7mmol/L
1300
Prediabetes fasting plasma glucose
5.5-7mmol/L
1301
Diabetes oral glucose tolerance test
11.1mmol/L
1302
Prediabetes oral glucose tolerance test
7.8-11mmol/L
1303
diabetes HBA1C concentration and percentage
47 or 6.4%
1304
Prediabetes HBA1C concentration and percentage
42-27 or 6-6.4%
1305
What test would you do if you suspect gestational diabetes
OGTT
1306
If you are symptomatic how many positive results do you need
Just one
1307
Define diabetes mellitus type one
Caused by insulin deficiency from autoimmune destruction of insulin secreting pancreatic beta cells
1308
Which conditions is DMT1 associated with
Vitiligo, addisons, pernicious anaemia
1309
Risk factors for DMT1
Polygenic,
1310
If theres a thin old person with diabetes and rapid progression to insulin therapy what do they have
Latent autoimmune diabetes in adults (LADA)
1311
What are the HLAs of DMT1
HLA DR3 DQ2 and HLA DR4 DQ8
1312
Symptoms of DMT1
Polydipsia, polyuria, polyphagia, fatigue and weight loss. Diabetic ketoacidosis
1313
Environmental influences of DMT1
Diet, enteroviruses, vitamin D deficiency, cleaner environment
1314
Diagnosis of DMT1
Measure glycaemic control and find autoantibodies. Diabetic consequences like retinopathy is diagnostic
1315
Treatment of DMT1
Dietary control and insulin therapy
1316
Types of insulin therapy
Rapid, short, intermediate and long acting insulin
1317
Define DMT2
Results from a combination of insulin resistance and less severe insulin deficiency
1318
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
1319
Does DMT1 or DMT2 have a stronger genetic link
DMT2
1320
Risk factors for DMT2
South Asian, African, FHx, male, obese central, lack of exercise, hyperlipidaemia, hypertension, alcohol, stress, urban environment
1321
Acute presentation of DMT2
Polyuria, polydipsia, weight loss
1322
Subacute presentation of DMT2
Lethargy, fatigue, visual blurring, pruritus vulvas
1323
Complications of DMT2
Staph skin infections, retinopathy, polyneuropathy, erectile dysfuntion, arterial disease
1324
Treatment of DMT2
Patient education, decrease alcohol, regular blood glucose measuring. Identify and manage long term complications
1325
Drug treatment of DMT2
Statins and BP drugs
1326
Metformin
Reduces gluconeogenesis by the liver and increases glucose sensitivity. It doesn’t cause hypoglycaemia or weight gain
1327
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
1328
Microvascular DMT2 complications
Diabetic retinopathy, diabetic neuropathy, nephropathy
1329
Macrovascular DMT2 complications
Increased risk fo CVD, IHD, MI and diabetic foot ulcers
1330
Signs of diabetic retinopathy
Haemorrhages, abnormal growth of vessels, aneurysm, cotton wool spots
1331
Who can get diabetic ketoacidosis
DMT1 mainly, DMT2 can but very rare
1332
Circumstances of DKA
Previously undiagnosed diabetes, interruption of insulin therapy, stress of intercurrent illness
1333
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.
1334
Signs and symptoms of DKA
N,V Abdo pain. Polyuria, polydipsia, drowsiness, ketone smelling breath, Kussmaul breathing
1335
Describe kussmaul breathing
Low deep, sighing inspiration and expiration
1336
Diagnosis of DKA
Acidosis, ketonaemia, hyperglycaemia
1337
Treatment of DKA
Saline
1338
Cause of sudden CNS decline in DKA
Cerebral oedema
1339
What is hyperosmolar, hyperglycaemic state
Hyperglycaemia and hyperosmolality. No ketosis or acidosis. Alteration of consciousness.
1340
Features of HHS
Delerium, focal neurological signs, tremors, fasciculations. Give Saline and insulin
1341
What test is used for acromegaly screening
IGF-1
1342
What test is used for acromegaly diagnosis
Glucose tolerance test
1343
What do C cells produce
Calcitonin
1344
What is released from the hypothalamus that acts of the anterior pituitary for TSH release
Thyrotropin releasing hormone
1345
What hormone is released by the anterior pituitary and acts on the thyroid
TSH- thyroid stimulating hormone
1346
What is the role of thyroid peroxidase
It binds thyroglobulin and iodine, and also couples MIT and DIT to make T3 or T4
1347
What is the role of thyroglobulin
Iodine binds to its tyrosine residues
1348
Actions of thyroid hormone
Increases metabolic rate, beta adrenergic action on the heart and gut, CNS activation, bone demineralisation
1349
What symptoms of hyperthyroid
Sweating
1350
Signs of hyperthyroid
Tremor
1351
Causes of hyperthyroidism
Graves
1352
Who gets hyperthyroid
Women 20-40
1353
Graves disease
Autoimmune with
1354
Graves unique skin sign
Pretibial myoedema
1355
Thyroid acropachy
Digital clubbing, swelling and new periosteal bone formation
1356
Graves ophthalmology
Exopthalmos, opthalmoplegia, retroorbital inflammation and swelling of the extraorbital muscles
1357
Hyperthyroid diagnosis
High T4 and T3 (more sensitive), thyroid peroxidase and thyroglobulin antibodies
1358
Graves diagnosis
TSH receptor stimulating antibodies
1359
Treatment of hyperthyroid
Propanolol for rapid symptom control
1360
How does carbimazole work
Blocks thyroid hormone biosynthesis
1361
Primary causes of hypothyroidism
Hashimotos thyroiditis
1362
Secondary causes of hypothyroidism
Iodine deficiency, pituitary failure. Amiodarone
1363
Hypo thyroid symptoms (everything a girl don’t want)
Weight gain
1364
Signs of hypothyroid
Dry, brittle hair and nails. Bradycardia, macroglossia, hyporeflexia, hoarse voice, alopecia
1365
Hashimotos thyroiditis
Lymphocytic infiltration and progressive destruction of the gland
1366
Management of hypothyroid
Levothyroxine
1367
Diagnosis of hypothyroid
Serum free T4 low
1368
Hormones released by hypothalamus
GnRH, CRH, TRH, PRH, GHRH, ADH, Oxytocin
1369
What does Gonadotrophin releasing hormone stimulate
FSH/LH release from the anterior pituitary which acts on the gonads
1370
What does Corticotropin releasing hormone stimulate
ACTH release from the anterior pituitary which acts on the adrenal cortex
1371
What does Thryotropin releasing hormone stimulate
TSH from the anterior pituitary which acts on the thyroid
1372
What does prolactin releasing hormone stimulate
Porlactin release from the anterior pituitary which stimulates the mammary gland
1373
What does Growth hormone releasing hormone stimulate
Growth hormone release from the anterior pituitary which stimulates the liver
1374
What does antidiuretic hormone stimulate
Is released from the posterior pituitary and acts on the kidneys
1375
What does oxytocin stimulate
Is released from the posterior pituitary and acts on the mammary gland
1376
Explain the action of ADH
Acts on V2 receptors to cause the insertion of aquaporin 2 channels
1377
ADH is increased by
Hypovolaemia, hypotension, anaemia, nicotine, adrenaline
1378
ADH is decreased by
Hypertension, ethanol, alpha adrenergic stimuli
1379
Define diabetes insipidus
ADH deficiency or insensitivity to its action
1380
Clinical features of diabetes insipidus
Polyuria, nocturia, compensatory polydipsia, dehydration
1381
Cranial causes of diabetes insipidus
Familial, tumours, infection, infiltrations, post surgical, trauma
1382
Nephrogenic causes of diabetes insipidus
Renal disease, sickle cell disease, drugs
1383
What can mask DI
Cortisol deficiency. So give cortisol and if still happening then its DI
1384
What is clubbing
Loss of window between nail beds
1385
Investigations of DI
Osmolality, U and E, 24hr urine volumes, waterdeprivation test
1386
Diagnosis of diabetes insipidus
Water deprivation test (urine doesn’t concentrate) Low urine osmolality, hypernatraemia, high urine volume
1387
Treatment of cranial DI
Demsmopressin which is an ADH analogue
1388
Treatment of nephrogenic DI
Thiazide diuretics
1389
What is SIADH
Inappropriate ADH secretion leads to retention of water and hyponatraemia
1390
Clinical features of SIADH
Confusion, nausea, irritable (kinda like UTI), later fits and coma
1391
Causes of SIADH
Tumour: SCLC, prostate
1392
Investigations of SIADH
U and E, osmolality, urinalysis
1393
Results of SIADH
Dilutional hyponatraemia, low plasma osmolality, urinary Na secretion
1394
Treatment of SIADH
Restrict fluid intake
1395
Functions of growth hormone
Decreases adipose tissue, increases bone growth and muscle mass
1396
Cause of acromegaly/gigantism
Pituitary adenoma (MEN-1 or AIP gene)
1397
Symptoms of acromegaly
Snoring, deep voice, increased sweating, reduced libido and arthralgia. Increased weight and size of hands and feet. Headache
1398
Signs of acromegaly
Acathosis nigricans, big supraorbital ridge, interdental separation, macroglossia, prognathism. Spade like hands and feet, tight rings
1399
Acromegaly screening
Increased IGF-1
1400
Acromegaly diagnosis
Imparied glucose tolerance test (high glucose)
1401
Acromegaly other investigations,
high calcium, bitemporal hemianopia, MRI for pituitary adenoma. Photos.
1402
Treatment of acromegaly 1st line
Transsphenoidal surgery
1403
Treatment of acromegaly 2nd line
Somatostatin analogue (IM ocreotide)
1404
What does the hypothalamus produce in response to emotional and physical stresses
Corticotropin releasing hormone
1405
What is conns and the cause
Excess aldosterone caused by solitary aldosterone producing adenoma
1406
What is the result of conns
Increased sodium and water retention
1407
How can conns present
Hypokalaemia: Hypertension, alkalosis, weakness, cramps
1408
What is the diagnosis in Conns
U and E (low renin, high aldosterone), MRI
1409
What is the treatment of Conns
Laparoscopic adrenalectomy and spironolactone
1410
What is Cushings syndrome
Chronic glucocorticoid excess
1411
What are the symptoms of cushings syndrome
Increased weight, mood changes, weakness, acne, recurrant achilles injury, gonadal dysfunction
1412
Signs of cushings syndrome
Moon face, central obesity, buffalo neck hump, bruises, muscle atrophy, purple abdo striae
1413
What are the causes of cushings
Pituitary adenoma (cushings disease), adrenal tumour, idiopathic. Taking glucorticoids (hydrocortisone)
1414
What are the investigations in Cushings
Bloods= high plasma cortisol
1415
How would you investigate a ACTH independent cause of cushings syndrome
CT adrenals
1416
How would you investigate ACTH dependent cushings
High dose dexamethasone suppression test
1417
If it is ACTH dependent and cortisol suppressed what do you do
MRI pituitary
1418
If it is ACTH dependent and cortisol isn’t surpressed what do you do
CT chest and abdo
1419
How do you treat iatrogenic cushings syndrome
Stop steroids
1420
How do you treat cushings disease
Transsphenoidal surgery
1421
How do you treat adrenal adenoma
Adrenalectomy
1422
How do you treat adrenal carcinoma
Adrenalectomy and radiotherapy
1423
How do you treat ectopic ACTH
Adrenalectomy and chemo
1424
What is Addisons disease
Primary hypoadrenalism. Destruction of the entire adrenal cortex leads to mineralocorticoid, glucocorticoid and sex hormone deficiency
1425
What are the causes of addisons
AI in Uk
1426
Symptoms of addisons disease
Weight loss, anorexia, malaise, weakness, fever, depression, syncope, confusion, myalgia
1427
Signs of addisons disease
Pigmentation, postural hypotension, general wasting, dehydration, alopecia
1428
Why do you get hyperpigmentation in addisons
Negative feedback means theres increased ACTH which is a melatonin predisposer
1429
Urgent addisons investigation
Blood sample cortisol and hydrocortisone
1430
Controlled addisons investigation
ACTH stimulation test (impaired response)
1431
What is the ACTH stimulation test
Measure plasma cortisol before and after IM Tetracosactide. synACTHen- ACTH analogue. Cortisol remains high 30 mins after
1432
Treatment of acute addisons
Saline and hydrocortisone and glucose
1433
Maintenance of addisons
Hydrocortisone (gluco-) and fludrocortisone (mineralo-). Wear steroid card
1434
Secondary adrenal insufficiency
Iatrogenic, hypothalamic pituitary disease (no pigmentation and mineralocorticoids spared)
1435
Actions of PTH
Increased renal uptake of calcium in exchange for phosphate in the PCT
1436
Which hormones affect calcium metabolism
Vitamin D, parathyroid hormone and calcitonin
1437
UV-B converts what into vitamin D3 (cholecalciferol)
7-dehydrocholesterol
1438
The liver converts vitamin D3 into what
25 hydroxyvitamin D. Via Vtiamin D3 25 hydroxylase (using vitamin D3 from diet)
1439
The kidney converse 25 hydroxyvitmain D into what
1,25-dihydroxy vitamin D (calcitriol) via 1 alpha hydroxylase
1440
Vitamin D effects
Calcium and phosphate release from bone
1441
What is primary hyperparathyroidism and its treatment
Raised/normal PTH in the presence of raised calcium. Surgery
1442
What is secondary hyperparathyroidism
Physiological PTH increased secretion to compensate for prolonged hypocalcaemia
1443
Causes of secondary hyperparathyroidism
Low Vitamin D, malabsorption, CKD, osteomalacia
1444
What is tertiary hyperparathyroidism
Development of parathyroid hyperplasia following long standing secondary hyperparathyroidism
1445
Treatment of tertiary hyperparathyroidism
Parathyroidectomy
1446
Hypercalcaemia causes
Hyperparathyroidism, malignancy
1447
Hypercalcaemia signs and symptoms
Bone pain, fractures, osteopenia
1448
If there is high everything but low phosphate what does this suggest
Primary
1449
What does just low calcium suggest
Secondary
1450
What does everything high suggest
Tertiary
1451
What is the investigation of hypercalcaemia
Serum calcium level, adjust for albumin
1452
Treatment of hypercalcaemia
Calcium, treat underlying cause. Bisphosphonates
1453
Causes of hypocalcaemia
Low serum albumin, low magnesium, malabsorption
1454
Symptoms of hypocalcaemia
Ventricular arrhythmias
1455
What is chovsteks sign
Tap on facial nerve leads to twitching
1456
What is trousseaus sign
Inflating Bp above systolic leads to carpal flexion
1457
How do you treat severe hypocalcaemia
Calcium gluconate, Cardiac monitoring. MgCl
1458
Definition of hyperkalaemia
Serum potassium level above 5mmol/L
1459
Causes of hyperkalaemia DREAD
Drugs
1460
Hyperkalaemia ECG
Wide flat/absent P
1461
Symptoms of hyperkalaemia
Fast irregular pulse, weakness, palpitations, dizziness, cardiac arrest
1462
Treatment of mild hyperkalaemia
Dietary potassium restriction and restriction of hyperkalaemia causing drugs
1463
Treatment of severe hyperkalaemia
Calcium gluconate
1464
Desribe carcinoid tumours
Group of enterochromaffin cell tumours capable of producing serotonin
1465
Where are carcinoid tumours common
Appendix, ileum, rectum, bronchioles and testes
1466
What is carcinoid syndrome
Symptoms from when the tumour releases serotonin, kinins, histamine and prostaglandins into the circulation
1467
Symptoms of carcinoid tumours
Flushing wheezing, watery diarrhoea, abdo pain, cardiac abnormalities
1468
Diagnosis of carcinoid tumours
High level of 5-HIAA, liver US confirms
1469
Treatment of carcinoid tumours
Ocreotide (somatostatin analogue) and surgery
1470
Layers of the epidermis
Stratum corneum
1471
Cells of the epidermis
Keratinocytes, melanocytes, Langerhans cells
1472
What is the function of langherhans cells
Immunity
1473
Cells of the dermis
Fibroplasts, sebaceous and sweat glands, hair follicles, Meissner and Pacinian corpuscles
1474
What sense do meissners corpuscles conduct
Light touch
1475
What sense do Pacinian corpuscles conduct
Coarse touch and vibration
1476
Hypodermis
Subcutaneous fat
1477
Functions of the skin
Sensation
1478
Inflammatory skin diseases
Acne, psoarisis, eczema
1479
Infections of the skin
Cellulitis and necrotizing fasciitis
1480
Neoplasias of the skin
BCC, SCC, malignant melanoma
1481
Ulcers of the skin
Venous, arterial, neuropathic
1482
Describe acnes vulgaris
Inflammatory disease of the pilosebaceous follicles. Affecting face, chest and upper back
1483
Steps in acne pathophysiology
Seborrhoea (high sebum production)
1484
What is a papule
Small red bump
1485
What is a pustule
White/yellow spots
1486
What is a nodule
Large red painful bumps
1487
What is a pseudocyst
Fluctuant nodules
1488
What is the presentation of acne
Papules, pustules, nodules and pseudocysts
1489
What suggest its mild acne
Open and close comedones predonminate
1490
What suggests its moderate acne
Papules and pustules predominate
1491
What suggests its severe acne
Nodules and cysts
1492
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
1493
Name a topical retinoid
Tazarotene gel
1494
What is the treatment for moderate acne
Same as above but. Clindamycin too
1495
Severe acne treatment
Refer. Isotretinoin and laser treatment
1496
Define eczema
Chronic itchy inflammatory condition. Papules and vesicles are present on an erythematous base. Commonly on face and flexure surfaces
1497
Atopic eczema is seen with
Hay fever and asthma
1498
What causes eczema
Fillagrin abnormalities cause poor barrier function and dry skin. Thinning of the stratum corneum. Allows antigen penetration and hyperreactivity
1499
Triggers of atopic eczema
Soaps and detergents, house dust mites, extreme temperatures, pollen, food, stress
1500
Eczema treatment
Avoid triggers, cut nails short.
1501
Mild corticosteroid
Hydrocortisone
1502
Calcineurin inhibitor
Tacrolimus
1503
Moderately potent corticosteroid
Clobetasone butyrate
1504
What classes as mild eczema
Areas of dry skin and infrequent scratching
1505
What classes as moderate eczema
Areas of dry skin, frequent itching and redness
1506
What classes as severe eczema
Widespread areas of dry skin, incessant itching and redness
1507
What classes as infected eczema
Weeping, crusted or there are pustules
1508
Treatment of severe eczema
Potent corticosteroid
1509
Potent corticosteroid
Flucionide
1510
Antihistamine
Chloramphenamine
1511
Treatment of infected eczema
Topical antibiotic, if localised. Generalised then flucloxacillin
1512
Define psoarisis
Chronic inflammatory skin disease due to hyperproliferation of keratinocytes and inflammatory cell infiltration
1513
How would describe the lesions in psoarisis
Monomorphic erythematous plaques covered with silvery scales
1514
What are the classic signs of psoarisis lesions
-epidermal hyperproliferation
1515
What is the most common form of psoarisis
Chronic plaque psoarisis
1516
Psoarisis but no scaling and older
Flexural psoarisis
1517
Post streptococcal throat, oval plaques
Guttate psoarisis
1518
Psoarisis, thickening of palms and soles
Palmoplantar psoarisis
1519
Non skin changes in psoarisis
Nail pitting, discolouration and onycholysis
1520
Precipiating factors in psoarisis
Trauma, lithium, stress, smoking, alcohol
1521
Proarisis treatment
E45, hydrocortisone and Calcipotriol
1522
What if psoarisis resistant
UV-B, Methotrexate and infliximab
1523
Where are venous ulcers
Medial gaitor region
1524
Where are arterial ulcers
Toes, heel and ankle
1525
What are the edges of venous ulcers like
Sloping and gradual
1526
What are the edges of arterial ulcers like
Punched out and well defined
1527
What is the wound bed of venous ulcers like
Covered with slough
1528
What is the wound bed of venous ulcers like
Covered with slough and necrotic tissue
1529
What is the size of venous ulcers
Large
1530
What is the size of arterial ulcers
Small
1531
What is the exudate level of venous ulcers
High
1532
What is the exudate level of arterial ulcers
Low
1533
What is the pain like in venous ulcers
Minimal
1534
What is the pain like in arterial ulcers
High
1535
Arterial ulcer risk factors
Arterial disease, smoking, cholesterol, dm
1536
What are the symptoms of arterial ulcers
Leg pain, worse when elevated
1537
What are the signs of arterial ulcers
Cold skin, absent peripheral pulse, shiny pale skin, loss of hair
1538
What are the investigations for arterial ulcers
ABPI below 0.8, doppler studies
1539
What is the management of arterial ulcers
Vascular reconstruction, ibuprofen, clean and covered, don’t use compression bandages
1540
What are the risk factors for venous ulcers
Varicose veins, DVT
1541
What are the symptoms of venous ulcers
Pain is minimal, better when elevated
1542
How would you describe a venous ulcer
Large, shallow, irregular, exudative
1543
What are the signs of venous ulcer
Normal pulses, leg oedema, lipodermatosclerosis
1544
What is the investigation for venous ulcer
ABPI normal
1545
What is the management of venous ulcer
Compression bandage, antibiotics, ibuprofen
1546
What is the risk factors for neuropathic ulcer
DM, Neuropathic disease
1547
How would describe the ulcer in neuropathic ulcers
Found at pressure sites, variable size, might have vallus
1548
Signs and symptoms of neuropathic ulcer
Warm skin and normal peripheral pulces, associated peripheral neuropathy
1549
Management of neuropathic ulcer
Appropriate footwear, diabetic control podiatry
1550
Define cellulitis
Bacterial infection of the subcutaneous tissue. Common on the lower leg or arm and may spread proximally
1551
Define erysipelas
Bacterial infection of the upper dermis and superficial lymphatics, more common on the face and is sharply demarcated
1552
Causative agents of cellulitis and erysipelas
Streptococcus pyogenes and staphylococcus aureus
1553
Presentation of cellutitis and erysipelas
Tender confluent areas of inflamed skin, fever and malaise
1554
Risk factors for cellulitis and erysipelas
Immunosuppresion, wounds, leg ulcers, trauma, atheltes foot, lymphoedema
1555
Management of cellulitis and erysipelas
Flucloxacillin or clarithyromycin
1556
Define necrotising fascitiits
Deep seated infection of the subcutaneous tissue that results indestruction of fascia and fat but initially spares skin
1557
Presentation of necrotising fasciitis
Severe pain which is out of proportion with the degree of skin inflammation. Systemic upset
1558
Cause of necrotizing fasciitis type 1 and 2
1:Mixture of aerobic and anaerobic following abdo surgery or diabetes
1559
Treatment of type 2
IV benzylpenicillin and clindamycin
1560
Treatment of type 1
Add metronidazole
1561
Which is the most common skin cancer
Basal cell carcinoma
1562
Describe basal cell carcinoma
Locally invasive, grows slowly, malignant neoplasm of epiderminal keratinocytes. Rarely mets
1563
Risk factors for basal cell carcinoma
UV exposure, Skin type 1, ageing
1564
Presentation of BCC (rodent ulcer)
Commonly on head and neck, has a pearly appearance with blood vessels
1565
Management of BCC
Surgical excision, or radio. Normally completely cured but theres local tissue destruction
1566
Describe squamous cell carcinoma
Locally invasive malignant tumour of squamous cells. More aggressive and likely to metastasise but still rare
1567
Risk factors for squamous cell carcinoma
UV exposure
1568
Describe the appearance of SCC
Scaly and crusty, Ill defined nodules, keratotic and may ulcerate
1569
Management of SCC
Surgical excision and radiotherapy if unresectable
1570
Define malignant melanoma
Invasive tumour of melanocytes
1571
Risk factors for malignant melanoma
UV exposure
1572
Signs of MM abcde
Assymetrical shape
1573
Symptoms of MM
Bleeding. Itching
1574
Presentation of MM
Scaly, cursty, ill defined, may ulcerate
1575
Management of MM
Surgical excision, radio if cant. Chemo if metastatic
1576
Name a non conventional therapy for psoarisis
Phototherapy
1577
Onycholysis, pitting, thickening, subungal hyperkeratinosis
Psoarisis
1578
Deep ulcerated base of skin cancer
SCC
1579
Moderate acne 1st line if on back
Oral erythromycin
1580
What type of hypersensitivity is contact dermatitis
Type IV

phase 2 (17 decks)

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