Please Flashcards
Pre-eclampsia moderate/high risk aspirin management
Take daily from 12 weeks to birth
Threadworm management
Mebendazole single dose for child and entire household
What is associated with decreased incidence of hyperemesis gravid arum?
Smoking
Main risk of termination of pregnancy and when does it happen?
Infection - unlikely to occur soon after the procedure
Iron therapy in pregnancy
First trimester 110
Second 105
Post partum 100
Management - oral ferrous sulphate - continue treatment 3 months after iron deficiency is correct to replenish stores
Treating pyrexia in non-haemolytic febrile transfusion reaction
Paracetamol
Child coughing at night
Whooping cough/ Pertussis
Management of pertussis/whooping cough
Clarithromycin
Management of bell’s palsy
Prednisolone
Layers of the abdominal wall
Skin
Subcutaneous fascia
Abdominal muscles - external oblique, internal oblique, transversus abdominus
Peritoneum
Uterus
Categories of C sections
Category 1
an immediate threat to the life of the mother or baby
examples indications include: suspected uterine rupture, major placental abruption, cord prolapse, fetal hypoxia or persistent fetal bradycardia
delivery of the baby should occur within 30 minutes of making the decision
Category 2
maternal or fetal compromise which is not immediately life-threatening
delivery of the baby should occur within 75 minutes of making the decision
Category 3
delivery is required, but mother and baby are stable
Category 4
elective caesarean
Features of acute sinusitis
Facial pain worse on leaning forward
Nasal discharge
Nasal obstruction
Management of acute sinusitis
analgesia
intranasal decongestants or nasal saline may be considered but the evidence supporting these is limited
NICE CKS recommend that intranasal corticosteroids may be considered if the symptoms have been present for more than 10 days
oral antibiotics are not normally required but may be given for severe presentations.
The BNF recommends phenoxymethylpenicillin first-line, co-amoxiclav if ‘systemically very unwell, signs and symptoms of a more serious illness, or at high-risk of complications’
Management of chronic rhino sinusitis
avoid allergen
intranasal corticosteroids
nasal irrigation with saline solution
Red flag: unilateral, epistaxis
Acute sinusitis timeline
<12 weeks
Sinuses of the head
Mechanism of methotrexate
antimetabolite that inhibits dihydrofolate reductase, an enzyme essential for the synthesis of purines and pyrimidines.
Side-effects of methotrexate
mucositis
myelosuppression
pneumonitis
pulmonary fibrosis
liver fibrosis
Anti-emetic: chemo
Ondansetron
Anti-emetic: reduced gastric motility
metoclopramide
Anti-emetic: raised intracranial pressure
Cyclizine
Discitis: common organisms
Staph aureus
Discitis: investigations and management
MRI and 6-8 weeks of IV antibiotics
Calculating anion gap
(sodium+potassium)-(bicarb+chloride)
Red traffic light: tachypnoea
> 60 in any age
Main side effect of nasal decongestants
Tachyphylaxis
Hand, foot and mouth disease cause
Coxsackie
Peutz-Jegher management
Conservative
Palliative care: secretions
Hyoscine hydrobromide
Palliative care: hiccups
Chlorpromazine
Palliative care prescribing: agitation and confusion
first choice: haloperidol
Management of metastatic spinal cord compression
Oral dexamethasone
SVCO management
dex and endovascular stenting is often the treatment of choice to provide symptom relief
Vincristine
Peripheral neuropathy, paralytic ileus, myelosuppression
Cisplatin
HOP
Ototoxicity, peripheral neuropathy, hypomagnesaemia
Normal pressure hydrocephalus
Can be idiopathic or due to subarachnoid haemorrhage, injury, or meningitis.
Presents with marked mental slowness, apathy, wide-based gait, and urinary incontinence.
Ventriculoatrial shunting only benefits patients with prominent neurological signs and relatively mild dementia but frequently leads to complications.
Breast cancer tumour marker
CA153
Neutropenic sepsis
Temperature >38oC and neutrophil count <0.5≈109/L.
Treat empirically with piperacillin/tazobactam (see p352).
Frontotemporal dementia:
Features: Personality changes, behavioural and language difficulties.
Hypertensive retinopathy features on fundoscopy
Keith-Wagener Classification
Stage 1: Mild narrowing of the arterioles
Stage 2: Focal constriction of blood vessels and AV nicking
Stage 3: Cotton-wool patches, exudates and haemorrhages
Stage 4: Papilloedema
Management of intrahepatic cholestasis in pregnancy
Ursodeoxycholic acid
When does the anomaly scan happen?
18-20+6 weeks
What type of murmur would you hear in pregnancy? Is this pathological?
Systolic murmur - it’s normal
Maternal corticosteroids
Dexamethasone
Management of a woman with known Group B streptococcus during labour?
Intrapartum antibiotics - Benzylpenicillin is antibiotic of choice.
Management of shoulder dystocia
Call for help!
McRoberts’ manoeuvre
episiotomy
Suprapubic pressure
Rubin’s manoeuvre
Zavanelli’s manoeuvre
Diagnose please and management
Herpes zoster keratitis and oral aciclovir
Diabetic retinopathy findings
Brandon Norman Chases Mad Hoes
Blot haemorrhages
Neovascularisation
Cotton wool spots
Microaneurysms
Hard exudate
FRONTAL HEADACHE WHICH HAS DEVELOPED FOLLOWING AN UPPER RESPIRATORY TRACT INFECTION WHICH IS WORSE ON LEARNING FORWARDS!
Sinusitis
Management of sinusitis
analgesia, intranasal decongestants or nasal saline.
Intranasal corticosteroids if symptoms have been present more than 10 days.
Oral phenoxymethylpenicillin if symptoms are severe.
DVLA driving rules: first unprovoked/isolated seizure
6 months if there are no relevant structural abnormalities on brain imaging and no definite epileptiform activity on EEG. If these conditions are not met then this is increased to 12 months
DVLA: patients with established epilepsy or those with multiple unprovoked seizures
12 months
DVLA: syncope : single episode, explained and treated
4 weeks
DVLA: syncope single episode, unexplained:
6 months off
DVLA: syncope more than 2 episodes
12 months off
DVLA: TIA/Stroke
1 month off
DVLA: multiple TIAs over short period of times
3 months off
DVLA: craniotomy e.g. For meningioma:
1 year off driving
DVLA: craniotomy for pituitary tumour
6 months off
DVLA: CABG
1 month off
DVLA: ACS
1 month off
DVLA: Pacemaker insertion
1 week off
DVLA: defirbillator for ventricular arrythmia
6 months off
DVLA: defibrillator for prophylaxis
1 month off
DVLA: heart transplant
6 weeks off
What would you find on LP of MS?
Oligoclonal bands
Acute phase treatment of MND
High dose steroids IV or Oral methylprednisolone for 5 days.
Parkinson’s drugs and their MOA
Levodopa
Carbydopa
MAO-B Inhibitors - sellegiline
COMT inhibitors - tolcapone
Amantadine
Ankle reflexes
S1-S2
Knee reflexes
L3-L4
Biceps reflexes
C5-C6
Triceps reflexes
C7-C8
Intrahepatic cholestasis: when should you deliver? and why?
37 weeks - due to risk of stillbirth
What are the 5 principles of the mental capacity act?
BiQWAS
1. A person must be assumed to have capacity unless it is established that he lacks capacity
2. A person is not to be treated as unable to make a decision unless all practicable steps to help him to do so have been taken without success
3. A person is not to be treated as unable to make a decision merely because he makes an unwise decision
4. An act done, or decision made, under this Act for or on behalf of a person who lacks capacity must be done, or made, in his best interests
5. Before the act is done, or the decision is made, regard must be had to whether the purpose for which it is needed can be as effectively achieved in a way that is less restrictive of the person’s rights and freedom of action
B - best interst
I - idiot decisions
T - take steps to make sure they dont have capacity
A - assume capacity unless established that they dont
T - take least restrictive option on the patient’s rights and freedom of action.
How would you assess capacity?
A person must be able to:
Understand
Retain
Make a decision
Communicate the decision back.
URMC
What is section 2?
28 days
AMHP + 2 doctors
What is section 3?
6 months
AMHP + 2 doctors
What is Section 4?
72 hours
GP and AMHP
What is section 5(2)?
A patient who is a voluntary patient in hospital can be legally detained by a doctor for 72 hours
What is section 5(4)?
Similar to section 5(2), allows a nurse to detain a patient who is voluntarily in hospital for 6 hours
What is a section 135?
A court order can be obtained to allow the police to break into a property to remove a person to a Place of Safety
What is a section 136?
Someone found in a public place who appears to have a mental disorder can be taken by the police to a Place of Safety
Can only be used for up to 24 hours, whilst a Mental Health Act assessment is arranged
Acute bronchitis management
Analgesia
Good fluid intake
Abx - doxycycline if systemically unwell.
Most common infective causes of COPD exacerbations (2)
Haemophilus influenzae and streptococcus pneumoniae
Management of infective exacerbation of COPD
Prednisolone for 5 days
Amoxicillin is antibiotic of choice.
Nebulised SABA and Ipatropium bromide
IV hydrocortisone may be used instead of prendisolone
IV theophylline
NIV or BiPaP if type 2 respiratory failure occurs.
Presentation of ARDS
Low oxygen saturations
High respiratory rate
Dyspnoea
Bilateral lung crackles
Presentation and management of allergic bronchopulmonary aspergillosis
Presentation: bronchiectasis and eosinophilia.
Management: Oral glucocorticoids
Which areas of the lungs are most affected in aspiration pneumonia?
Right middle and lower lung lobes.
Asthma: stepping down treatment
Consider every 3 months
Causes of bilateral hilar lymphadenopathy
Sarcoidosis and TB.
Lymphoma
What is bronchiectasis?
Permanent dilation of the airways due to chronic infection or inflammation
Management of bronchiectasis
Physical training - inspiratory muscle training
Antibiotics for exacerbations
Bronchodilators
Surgery for selected cases
Most common organisms in patients with bronchiectasis
Haemophilus influenza
Pseudomonas aeruginosa
Klebsiella
Strep pneumoniae
Causes of widened mediastinum
Thoracic aortic aneurysm
Lymphoma
Teratoma
Tumours of the thymus
Causes of widened mediastinum
Thoracic aortic aneurysm
Lymphoma
Teratoma
Tumours of the thymus
Causes of widened mediastinum
Thoracic aortic aneurysm
Lymphoma
Teratoma
Tumours of the thymus
Severity of COPD
Stage 1: Mild: >80%
Stage 2: Moderate: 50-79%
Stage 3: Severe: 30-49%
Stage 4: Very severe: <30%
COPD: general management
Smoking cessation
Annual influenza vaccine
One-off pneumococcal vaccine
Pulmonary rehabilitation
List 5 causes of haemoptysis
Lung cancer
TB
PE
Granulomatosis with polyangitis
Goodpasture’s syndrome
Bronchiectasis
Management of idiopathic pulmonary fibrosis
Pulmonary rehabiliation
What condition causes red-current jelly sputum?
Klebsiella
In what group of patients is Klebsiella pneumoniae more common in?
Diabetics and alcoholics
What complications are common in Klebsiella pneumonia?
Lung abscesses and empyema
Common causes of klebsiella pneumonia
Aspiration
Common organisms causing lung abscesses
Staphylococcus aureus, Klebsiella, pseudomonas aeruginosa
First line investigation for lung cancer
Chest x-ray
Investigation of choice for lung cancer
CT scan
Small cell lung cancer: paraneoplastic syndromes
ADH
ACTH
Lambert-Eaton syndrome
Squamous cell lung cancer: paraneoplastic syndromes
Parathyroid hormone related protein
Hypertrophic pulmonary osteoarthropathy
Hyperthyroidism due to ectopic TSH
Adenocarcinoma of the lung: paraneoplastic syndromes
Gynaecomastia
Hypertrophic pulmonary osteoarthropathy
Features of lambert eaton syndrome
Diplopia, ptosis, slurred speech
Aortic aneurysm screening
One USS at the age of 65 for males only.
<3cm - no follow up
3-4.4 - follow up every year
4.5-5.4 - every 3 months
> 5.5 or >1 cm growth in one year - urgent referral to vascular
Lung cancer referral criteria
> 40 and unexplained haemoptysis
or have chest x-ray findings that suggest lung cancer
Causes of upper zone pulmonary fibrosis
CHARTS
Coal workers pneumoconiosis
Hypersensitivity pneumonitis
Ankylosing spondylitis
Radiation
TB
Sarcoidosis/silicosis
Causes of lower zone pulmonary fibrosis
Methotrexate
Idiopathic
Amiodarone
Asbestosis
List 5 absolute contraindications for thrombolysis
Previous intracranial haemorrhage
Pregnancy
Oesophageal varices
Active bleeding
Seizure at onset of stroke
List 5 relative contraindications for thrombolysis
Major surgery in past two weeks
Concurrent anticoagulation INR >1.7
Active diabetic haemorrhagic retinopathy
How would you differentiate between a transudative and exudative pleural effusion?
Light’s criteria:
Exudate: >30g/L, transudate <30g/L
Exudate: raised pleural LDH, pleural protein/serum protein >0.5
Assessment of pneumonia
CURB 65
Confusion
Urea >7
Resp >30
Blood pressure <90 systolic, <60 diastolic
>65 years old
0 - treat at home
1 or 2 - consider hospital assessment
3-4 - urgent admission to hospital
Management of pneumonia
Low severity - amoxicillin
Moderate to high severity - amoxicillin and clarithromycin
Pneumonia: after care
Repeat chest x-ray at 6 weeks after clinical resolution
Management of primary pneumothorax
> 2 cm rim of air -> aspiration
If this fails -> chest drain
Management of secondary pneumothorax
<1 cm -> admit for 24 hours and give oxygen
1-2 cm rim of air-> aspiration
>50 years old and >2cm rim of air -> chest drain
Sarcoidosis features
Erythema nodosum, bilateral hilar lymphadenopathy, lupus pernio, hypercalcaemia, non-caseating granulomas.
Diagnosis of sarcoidosis
ACE levels
Management of sarcoidosis
Steroids
Management of tension pneumothorax
Needle decompression and chest drain
Shockable rhythms
VT/pulseless VF
Non-shockable rhythms
Asystole/PEA
When should you defibrilate in shockable rhythms?
Single shock by 2 minutes of CPR
If cardiac arrest is witnessed - up to three successive shocks followed by CPR
When should you administer adrenaline?
1mg as soon as possible for non-shockable rhythms
After 3rd shock in shockable rhythms and repeat every 3-5 minutes
When should amiodarone be administered?
After 3rd shock in VF/pulseless VT and 5th shock
Reversible causes of cardiac arrest
4 Hs and 4 Ts
hypoxia
hypothermia
hypo/hyperkalaemia
hypovolaemia
Tension pneumothorax
Toxins
Tamponade
Thrombosis
Reversible causes of cardiac arrest
4 Hs and 4 Ts
hypoxia
hypothermia
hypo/hyperkalaemia
hypovolaemia
Tension pneumothorax
Toxins
Tamponade
Thrombosis
Anaphylaxis adrenaline doses
<6 months: 100-150 micrograms
6 months - 6 years: 150 micrograms
6-12 years - 300 micrograms
>12 - 500 micrograms
Repeat every 5 minutes
First line investigation for prostate cancer
MRI
Management of prostate cancer
Surveillance
External beam radiotherapy
Brachytherapy
GnRH agonists (goserelin), androgen receptor blockers, bilateral orchidectomy
Surgery - radical prostatectomy
Management of pericarditis
NSAIDs or cholchicine
What’s the management of supraventricular tachycardia?
Adenosine - avoid in asthmatics
Side-effects of amiodarone
Slate grey appearance
Liver fibrosis
Pulmonary fibrosis
Bradycardia
Peripheral neuropathy
Features of aortic regurgitation
Early diastolic murmur
Collapsing pulse
De Musset’s sign
Management of aortic stenosis
Asymptomatic - observe
Symptomatic - valve replacement
What is brugada syndrome? And management?
Inherited cardiovascular disease - autosomal dominant - common in asians.
Sudden cardiac death
Management - implantable cardiac pacemaker
Cardiac tamponade triad
Hypotension
Raised JYP
Muffled heart sounds
How would differentiate cardiac tamponade vs constrictive pericarditis?
Pulsus paradoxus - abnormally large drop in BP during inspiration
Not present in constrictive pericarditis
What would you see on ECG in cardiac tamponade
Electrical alternans
Chronic heart failure management
ACE inhibitor and beta-blocker
Second line - spironolactone
Management of hypertension: diabetes
ACE inhibitors or ARBs (first-line)
HOCM: echo findings
MR SAM ASH
Mitral regurgitation
Systolic anterior motion
Asymmetrial hypertrophy
What valve is most affected in IE?
Mitral valve
Causes of IE
Staph aureus
Staph epidermis - in patients with prosthetic heart valves
Criteria for IE
Duke’s
Infective endocarditis diagnosed if
pathological criteria positive, or
2 major criteria, or
1 major and 3 minor criteria, or
5 minor criteria
Two positive blood cultures showing organisms consistent with IE
Persistent bacteraemia from two blood cultures taken 12 hours apart
Evidence of endocardial involvement
positive echocardiogram (oscillating structures, abscess formation, new valvular regurgitation or dehiscence of prosthetic valves), or
new valvular regurgitation
Minor criteria
predisposing heart condition or intravenous drug use
microbiological evidence does not meet major criteria
fever > 38ºC
vascular phenomena: major emboli, splenomegaly, clubbing, splinter haemorrhages, Janeway lesions, petechiae or purpura
immunological phenomena: glomerulonephritis, Osler’s nodes, Roth spots
Complications: MI
Cardiac arrest
Cardiogenic shock
Chronic heart failure
Tachyarrythmias
Bradyarrythmias
Pericarditis - Dressler’s syndrome
Left ventricular aneurysm
Left ventricular free wall rupture
VSD
MR
Management of orthostatis hypotension
Fludrocortisone
Cause of rheumatic fever
Streptococcus pyogenes
Diagnosis of rheumatic fever
Duke’s criteria - ACCE FRAPP
Diagnosis is based on evidence of recent streptococcal infection accompanied by:
2 major criteria
1 major with 2 minor criteria
Major criteria
erythema marginatum
Sydenham’s chorea: this is often a late feature
polyarthritis
carditis and valvulitis (eg, pancarditis)
Minor criteria
raised ESR or CRP
pyrexia
arthralgia (not if arthritis a major criteria)
prolonged PR interval
Management of rheumatic fever
Oral Pen V and NSAIDs
Management of ventricular tachycardia
Amiodarone
Lidocaine (second-line)
Wolf-Parkinson-White Syndrome - management
Amiodarone, flecanide
Radiofrequency ablation of the accessory pathway
Management takayasu’s arteritis
Steroids
Glue ear management
Grommet insertion and adenoidectomy
Management of Ramsay-Hunt syndrome
Oral aciclovir and steroids
ENT referral criteria
> 45 and unexplained neck lump or persistent hoarseness of voice
Oral cancer
Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for oral cancer in people with either:
unexplained ulceration in the oral cavity lasting for more than 3 weeks or
a persistent and unexplained lump in the neck.
Consider an urgent referral (for an appointment within 2 weeks) for assessment for possible oral cancer by a dentist in people who have either:
a lump on the lip or in the oral cavity or
a red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia
Treatment of vestibular neuronitis
Buccal or intramuscular prochlorperazine
Vestibular rehabilitation exercises for patients who experience chronic symptoms.
Meniere’s: type of hearing loss
Unilateral sensorineural hearing loss
How would you differentiate between a posterior cerebellar stroke and vestibular neuronitis?
HiNTs exam:
Nystagmus
Vertical skew
Head impulse test
Elderly patient - dizziness on head extension
Vertebrobasilar ischaemia
Acute sensorineural hearing loss management
Urgent referal to ENT
Most common bacterial cause of otitis media
Haemophilus influenza is most common cause of bacterial otitis media.
Management of benign paroxysmal positional vertigo
Epley
Brant Daroff
Betahistine
Risk factors for glue ear
Acute otitis media
Barotrauma
Eustachian tube dysfunction
Adenoidal inflammation
How would you visualise the vocal cords on examination?
Laryngoscopy
Where do pharyngeal pouches form?
Killian’s dischinence
Argyll-Robertson pupil
Classically associated with neurosyphilis or diabetes mellitus (which do not apply to this patient), an Argyll-Robertson pupil is typically small, irregular, and unresponsive to light.
Holmes- Adie pupil
Dilated pupil
Absent ankle/knee reflexes
Management of anterior uveitis
Steroid eye drops and cycloplegic (mydiatric) drops
Management of infective conjunctivitis
Chloramphenicol
Most common causative organism for bacterial keratitis in contant lense wearers and management
Pseudomonas aeruginosa - same day referral to eye specialist in contact lens wearers. Management - topical antibiotics
Optic neuritis - features, investigation and management
MS, diabetes, syphylis.
Poor discrimination of colours (particulalrly red), pain on eye movement, RAPD and central scotoma.
Ivestigation with MRI brain and orbits with contrast.
Management: high dose steroids.
Horner’s syndrome: central lesion causes
Stroke
Syringomyelia
Multiple sclerosis
Tumour
Encephalitis
Horner’s syndrome: pre-ganglionic lesion causes
Pancoast’s tumour
Thyroidectomy
Trauma
Cervical rib
Horner’s syndrome: post-ganglionic lesions causes
Carotid artery dissection
Carotid aneurysm
Cavernous sinus thrombosis
Cluster headache
Management of acute epiglottitis
Ceftriaxone and dexamethasone
Status epilepticus managementA
ABCDE
Benzo (first-line). Repeat after 10-20 mins.
Phenytoin infusion
Induction with propofol
Cerebral palsy: spastic - location of lesion and management
Paraventricular white matter - oral diazepam. baclofen
Cerebral palsy: dyskinetic - location of lesion
Basal ganglia and substantia nigra
Cerebral palsy: ataxic - location of lesion
Cerebellum
What are a small minority of patients likely to develop in chicken pox?
Group A strep necrotising fasciitis.
What would you find on duodenal biopsy in coeliac’s disease?
villous atrophy
crypt hyperplasia
increase in intraepithelial lymphocytes
lamina propria infiltration with lymphocytes
Pregnant female presenting with severe abdominal pain, low-grade fever, tachycardia and vomiting with background of fibroids.
Red degeneration of fibroids.
Management is supportive, with rest, fluids and analgesia.
Management of constipation in children
Polyethylene and movicol
Add Senna in addition to movicol if constipation does not resolve in 2 weeks.
Emergency treatment of Croup
High flow oxygen and nebulised adrenaline
Features of cystic fibrosis
Meconium ileus, malabsorption, recurrent chest infections, male infertility, female sub fertility, short stature, steatorrhoea.
Management of cystic fibrosis
Chest physiotherapy, high calorie, high fat diet, pancreatic enzymes.
Diagnosis of cystic fibrosis
Sweat test
Chemical changes seen in diabetic ketoacidosis in children
Hyponatraemia, low bicarminate and hypokalaemia
Management of cerebral oedema
Slow IV fluids, IV mannitol and IV hypertonic saline
Unresolved DKA after 24 hours?
Refer to paediatric endocrinologist
Atopic eczema in children
Avoid irritants
Topical emollients
Topical steroids
Umbilical hernias management in children
Umbilical hernias: Usually self-resolve, but if large or symptomatic perform elective repair at 2-3 years of age. If small and asymptomatic peform elective repair at 4-5 years of age.
Meckel’s diverticulum presentation
Abdominal pain, rectal bleeding (most common cause of painless GI haemorrhage in children), intestinal obstruction
Complications of mumps in children
Pancreatitis
Orchitis
SSNHL
Meningitis
Complications of perthes disease
Osteoarthritis and premature closure of the growth plates
Presentation and management of pyloric stenosis
Hypochloraemic, hypokalaemic akalosis. Projectile vomiting, dehydeation and constipation.
USS diagnosis.
Ramstedt’s procedure.
Features of PDA and management
Wide pulse pressure
Collpasing pulse
Continuous machine like murmur
Management: Indomethacin or NSAIDs
Management of Group B Strep in neonatal sepsis
Benzylpenicilin or gentamicin
Group B strep prophylaxis in pregnancy
Benzylpenicillin
What are koplik’s spots indicative of?
Measles
Shaken baby syndrome
Retinal haemorrhages, subdural haematoma, encephalopathy
Breech baby
Refer for pelvic USS at 6 weeks to check for DDH
Turner’s syndrome
SWAB
Primary amenorrhoea
Bicuspid aortic valve
Short stature
Webbed neck
Diagnosis of SUFE
AP and laternal views - internal fixation
Common fractures associated with NAI
- Radial
- Humeral
- Femoral
When should pregnant women have a whooping cough and influenza vaccine?
16-32 weeks
Painless abdominal mass in a child with haematuria?
Wilm’s tumour
What procedure is done for intestinal malrotation?
Ladd’s procedure
How does intestinal malrotation present?
Bile stained vomit
T2DM + abnormal liver tests?
Non-alcoholic liver disease
Investigation for Wilson’s disease
Serum ceruloplasmin (reduced)
Features of Wilson’s disease and management
Kayser-Fleicher rings
Psychiatric problems
Liver cirrhosis/hepatitis
Haemolysis
Management - penicillamine
Anti-HbC indicated?
Caught - previously or acutely
Gene affected in haemachromatosis
HFE gene - family testing required
Management for haemachromatosis
Venesections
Desferioxamine
Mesenteric ischaemia vs ischaemic colitis
Mesenteric ischaemia due to thrombus and affects small bowel - requires urgent surgery
Ischaemic colitis - multifactorial causes and affects large bowel - conservative management
Primary biliary cirrhosis - antibodies and management
IgM and Anti-mitochondrial
Ursodeoxycholic acid and cholestyramine for pruritis
Management of constipation in patients with IBS
Isaghula husk
Investigation for alcoholic liver cirrhosis
Fibroscan
Maximum alcohol units and advise
if you do drink as much as 14 units per week, it is best to spread this evenly over 3 days or more
test recommended for H. pylori post-eradication therapy
Urea breath test
Management of Crohn’s disease - induction of remission and maintenance regime
Induction of remission:
Oral/IV hydrocortisone
Mesalazine
Azathioprine or mercaptopurine/ Methotrexate
Maintenance:
azathioprine or mercaptopurine is used first-line to maintain remission
+TPMT activity should be assessed before starting
methotrexate is used second-line
Investigation and management for achalasia
Oesophageal monometry, barium swallow
Management: balloon dilation, Heller cardiomyotomy if persistent
Management of alcoholic ketoacidosis
Saline and thiamine infusion
Management of alcoholic hepatitis (Acute)
Prednisolone
Management of ascites
Restrict dietary sodium
Spironolactone
Ciprofloxaclin if ascitic protein >15g/L
TIPS
Antibodies found in autoimmune hepatitis and management
Anti-nuclear antibodies and/or smooth-muscle antibodies
Management: prednisolone and liver transplantation
Change in barrett’s oesophagus and management
Squamous -> columnar metaplasia.
Managemnet: High dose PPI, endoscopic surveillance with biopsies.
If any grade of dysplasia is identified endoscopic intervention is offered - ablation is first-line, endoscopic mucosal resection
Management of carcinoid tumours
Octreotide
Management of hepatic encephalopathy
Lactulose and rifaximin
What is melanosis coli
Pigmentation of the bowel wall due to laxative abuse
Investigation of primary sclerosing cholangitis
MRCP/ERCP
pANCA positive
Increased risk of cholangiocarcinoma and colorectal cancer
Small bowel bacterial overgrowth syndrome - risk factors, diagnosis and management
Risk factors: diabetes
Diagnosis: hydrogen breath test
Management: rifaximin
Diagnosis of helicobacter pylori
CLO testing, urea breath test
Management of acute pancreatitis
IV fluids, Nil by mouth and NG tube
Management of Von Willebrand Disease
Tranexamic acid for mild bleeding
Desmopressin
Investigation for phaechromocytoma
Urine metnephrines
Diabetes: sick day rules
Increase frequency of blood glucose monitoring to four hourly or more frequently
Encourage fluid intake aiming for at least 3 litres in 24hrs
If unable to take struggling to eat may need sugary drinks to maintain carbohydrate intake
If a patient is taking oral hypoglycaemic medication, they should be advised to continue taking their medication even if they are not eating much.
If a patient is on insulin, they must not stop it due to the risk of diabetic ketoacidosis.
Campylobacter jejuni management
Clarithromycin
Signs of digoxin toxicity and management
Anorexia, confusion, nausea/vomiting, gynaecomastia
Management: digibind
Features of hypothyroidism
BRADYCARDIC
Bradycardia
Reflexes slowed
Ataxia
Dru skin/thin hair
Yawning
Coma
Ascites
Round puffy eyes
Defeated demeanor
Immobile
Congestive heart failure
Management of myoedema coma
Thyroxine and IV hydrocortisone
Correct hypoglycaemia
Rehydrate and oxygen if needed
Management of thyroid storm
IV fluids
Beta blocker
Digoxin
Carbimazole + iodine
Hydrocortisone
Infection - Abx
Most common thyroid cancer in young patients and management
Papillary - thyroidectomy + node excision +/- radio
What thyroid cancer is associated with MEN2
Medullary
Test for phaechromocytoma
What is MODY?
T2DM in young patients
LADA?
Autoimmune diabetes developing later in life
Differentiating between T1DM and T2DM
C-peptide
Diagnosis of diabetes
Fasting >7
Random >11
HbA1C >48
Symptomatic - one test
Asymptomatic - two seperate occasion
Diagnosing pre-diabetes
6.1-6.9
42-47
Antibodies for hashimoto’s
Anti-TPO and anti-thyroglobulin
Management of myoedema coma and thyrotoxicosis
DPP4
Sitagliptin
GI upset
Pancreatitis
Pioglitazone
Thiazolidinedoine
Weight gain
fluid retention
CONTRAINDICATED IN HEART FAILURE
INCREASED RISK OF BLADDER CANCER
Sulfonylurea
Gliclazide
Weight gain
Hypoglycaemia
SGLT2 inhibitors
Empagliflozin
Weight loss
urinary and genital infections
Normoglycaemic ketoacidosis
GLP1 mimetics
Exenatide
GI upset
Weight loss
Risk of hypoglycaemia
Investigation of cushings
Dexamethasone suppresion test
In pituitary adenoma - ACTH and cortisol will be suppressed
Signs and symptoms of adrenal insufficiency
Salt craving
Hyperpigmentation of palmar creases
Nausea
Vomiting
Anorexia
Hypotension
Investigating Addisons
Short synacthin test
Management of Addison’s
IV hydrocortisone and flurdocortisone
Conn’s syndrome features
Hypertension
Hypokalaemia
Metabolic alkalosis
Prolactinomas features
Male: galactorrhoea, impotence
Female: Amenorrhoea, infertility, galactorrhea
Prolactinoma investigation and management
MRI
Bromocriptine
Transphenoidal surgery
Paediatric inguinal hernia
<1 year - high risk of strangulation - refer for urgent surgery
over 1 year of age are at lower risk and surgery may be performed electively
Peripheral arterial disease
Clopidogrel and statin
Ventricular tachycardia: management
Haemodynamically unstable: DC cardioversion
Stable: Amiodarone
Management of peripheral arterial disease
Statin and clopidogril
Exercise
PTSD vs acute stress disorder
PTSD >1 month
PTSD management
trauma focused CBT and SSRI
Acute stress disorder
Trauma focused CBT
Management of anorexia nervosa
individual eating-disorder-focused cognitive behavioural therapy (CBT-ED)
Maudsley Anorexia Nervosa Treatment for Adults (MANTRA)
specialist supportive clinical management (SSCM).
Family therapy in children. CBT second line
Bipolar disorder: management
Lithium remains the mood stabilizer of choice. An alternative is valproate
management of mania/hypomania
consider stopping antidepressant if the patient takes one; antipsychotic therapy e.g. olanzapine or haloperidol
management of depression
talking therapies (see above); fluoxetine is the antidepressant of choice
calluses on the knuckles or back of the hand due to repeated self-induced vomiting
Russell’s sign
De Clerambault’s
Erotomania - patient believes a famous person is in love with them
Cotard syndrome
Patient believes that they or parts of their body are dead or non-existent
S/E of ECT
Short term memory loss
Cardiac arrhythmias
Nausea
Headache
memory loss of events prior to ECT
Indications and contraindications for ECT
severe depression refractory to medication (e.g. catatonia) those with psychotic symptoms
Contraindicated in raised intracranial pressure
Meningitis and raised intracranial pressure
Do CT head first
Management of Generalised anxiety disorder
NICE suggest a step-wise approach:
step 1: education about GAD + active monitoring
step 2: low-intensity psychological interventions (individual non-facilitated self-help or individual guided self-help or psychoeducational groups)
step 3: high-intensity psychological interventions (cognitive behavioural therapy or applied relaxation) or drug treatment. See drug treatment below for more information
step 4: highly specialist input e.g. Multi agency teams
Drug treatment
NICE suggest sertraline should be considered the first-line SSRI
if sertraline is ineffective, offer an alternative SSRI or a serotonin–noradrenaline reuptake inhibitor (SNRI)
What are the five stages of grief
Denial: this may include a feeling of numbness and also pseudohallucinations of the deceased, both auditory and visual. Occasionally people may focus on physical objects that remind them of their loved one or even prepare meals for them
Anger:
Bargaining
Depression
Acceptance
DABDA
S/E of lithium
nausea/vomiting, diarrhoea
fine tremor
nephrotoxicity: polyuria, secondary to nephrogenic diabetes insipidus
thyroid enlargement, may lead to hypothyroidism
ECG: T wave flattening/inversion
weight gain
idiopathic intracranial hypertension
leucocytosis
hyperparathyroidism and resultant hypercalcaemia
Lithium monitoring
Check lithium levels 12 hours post dose. weekly until concentrations stable and then every 3 months
Thyroid and renal function every 6 months
Reversal of opioids
Naloxone
Reversal of benzodiazepines
Flumazenil
Reversal of TCAs
IV bicarbonate
Reversal of lithium
Mild to moderate - IV fluids
Severe - haemodialysis
TCA S/E
Dry mouth
Blurred vision
Constipation
Urinary retention
Features of Addisonian crisis
Hyponatraemia
Hyperkalaemia
Hypoglycaemia
Most common cause of Addison’s disease
Autoimmune
Causes of SIADH
S - small cell lung cancer
I - infection (meningitis, pneumonia)
A - abscess (cerebral oedema)
D - drugs (carbemazepine, SSRIs
H - haemorrhage (subarachnoid)
Confirmation of ovulation in investigating infertility
To confirm ovulation: Take the serum progesterone level 7 days prior to the expected next period if menstrual cycle is not 28 days
If 28 days - day 21 progesterone
Booking visit
8 - 12 weeks (ideally < 10 weeks)
Booking bloods/urine
FBC, blood group, rhesus status, red cell alloantibodies, haemoglobinopathies
hepatitis B, syphilis
HIV test is offered to all women
urine culture to detect asymptomatic bacteriuria
Early scan
11 - 13+6 weeks
Early scan to confirm dates, exclude multiple pregnancy
Down’s syndrome screening including nuchal scan
Anomaly scan
18 - 20+6 weeks
First dose of Anti-D injection
28 weeks
Baby in transverse lie
External cephalic version
Amniocentesis time
15 weeks
Chorion villus sampling
11-13+6 weeks
Transabdominally or transvaginally
Idiopathic intracranial hypertension - population and management
Obese females
Weight loss
Acetazolamide
Monochorionic diamniotic management and delivery
scan every 2 weeks
36-37+6
Diamniotic dichorionic management and delivery
Scan every 4 weeks
37-38/40
Gestational diabetes screening
24-28 weeks OGTT
Neonatal hypoglycaemia
Babies need close monitoring for neonatal hypoglycaemia, with regular blood glucose checks and frequent feeds. The aim is to maintain their blood sugar above 2 mmol/l, and if it falls below this, they may need IV dextrose of nasogastric feeding.
Gestational hypertension
> 20 weeks
No proteinuria
Folic acid dose and timing
Normal 400mcg - before contraception to 12 weeks
>30 BMI, high risk NTD - 5mg before contraception to 12 weeks
Signs of labour
Show (mucus plug from the cervix)
Rupture of membranes
Regular, painful contractions
Dilating cervix on examination
Di-George Syndrome
CATCH-22 mnemonic:
C – Congenital heart disease
A – Abnormal facies (characteristic facial appearance)
T – Thymus gland incompletely developed
C – Cleft palate
H – Hypoparathyroidism and resulting Hypocalcaemia
22nd chromosome affected
Reactive arthritis
Urethritis
Arthritis
Conjunctivitis
Aseptic joint aspiration with raised WBC
How would you manage hyperacute graft rejection
Remove the ting
Prophylaxis for contacts of meningitis
Rifampicin or ciprofloxacin
Syphillis organism
Trepanema pallidum
Bilateral upper and lower motor limb weakness
Rule out hypoglycaemia before doing CT head
Treatment of Conn’s syndrome due to bilateral adrenal hyperplasia
Spironolactone
Treatment of Conn’s syndrome due to adrenal adenoma
Surgery
Side-effects of antipsychotics
Parkinsonism (procyclidine)
Tardative diskinesia (tetrabenazine)
Acute dystonia (procyclidine)
Akisthesia (bisoprolol)
Weight gain
Reduced seizure threshold
Impaired glucose tolerance
Increased stroke and VTE
Neuroleptic malignant syndrome
Treatment of colorectal cancer: sigmoid colon
High anterior resection
Treatment of colorectal cancer: low/high rectum
Anterior resection
Treatment of colorectal cancer: anal verge
Abdomino-peroneal excision of the rectum
Treatment of colorectal cancer: Descending colon
Left hemicolectomy
Treatment of colorectal cancer: Caecal, ascending or transverse colon
Right hemicolectomy
What is Hartmann’s procedure?
Used in emerency situations, where there is bowel perforation and the risk of failure of the colon-to-colon anastamosis is high, a temporary end colostomy is created and reversed at a later date.
Most common type of bladder cancer
Transitional cell carcinoma
Bladder cancer referral criteria
Aged over 45 with unexplained visible haematuria, either without a UTI or persisting after treatment for a UTI
Aged over 60 with microscopic haematuria (not visible but positive on a urine dipstick) PLUS:
Dysuria or;
Raised white blood cells on a full blood count
Diagnosis of bladder cancer
Cystoscopy
Management of bladder cancer
Transurethral resection of bladder tumour (TURBT)
Radical cystectomy
Chemo
Radio
Successful wide local excision of breast cancer with normal margins and no lymph node metastasis, next step
Radiotherapy to prevent recurrence
Bronchiolitis: immediate transfer to hospital if:
Apnoea
Grunting
Central cyanosis
O2 <92
>70 RR
Management of intertrochanteric fracture
Dynamic hip screw
Management of subtrochanteric fractures
Intramedullary device
Management CKD induced proteinuria
ACE inhibitors
Triad of infectious mononucleosis and diagnosis
Sore throat, pyrexia and lymphadenopathy
Monospot test
Management of infectious mononucleiosis
Rest during the early stages, drink plenty of fluid, avoid alcohol
simple analgesia for any aches or pains
consensus guidance in the UK is to avoid playing contact sports for 4 weeks after having glandular fever to reduce the risk of splenic rupture
Blood transfusion threshold in ACS
80
Platelet transfusion threshold
10
Herpes and pregnancy
Oral aciclovir until delivery and then c-section
Newly diagnosed grave’s in primary care
Propranolol
Sickle cell crisis
Analgesia
Abx
Blood transfusion
Acute graft failure
Acute graft failure (< 6 months)
usually due to mismatched HLA. Cell-mediated (cytotoxic T cells)
usually asymptomatic and is picked up by a rising creatinine, pyuria and proteinuria
other causes include cytomegalovirus infection
may be reversible with steroids and immunosuppressants
Concomitant oral opioids should not be prescribed whilst a patient is using an opioid PCA
:)
ASA Grade: Healthy, non-smoking, no or minimal alcohol use
ASA 1
ASA Grade: current smoker, social alcohol drinker, pregnancy, obesity (BMI 30 - 40), well-controlled Diabetes Mellitus/Hypertension
ASA 2
ASA grade: poorly controlled Diabetes Mellitus/Hypertension, COPD, morbid obesity (BMI > 40), active hepatitis, alcohol dependence or abuse, implanted pacemaker, moderate reduction of ejection fraction, End-Stage Renal Disease (ESRD) undergoing regularly scheduled dialysis, history (>3 months) of Myocardial infarction, Cerebrovascular accidents
ASA 3
ASA grade: recent (< 3 months) of Myocardial infarction, Cerebrovascular accidents, ongoing cardiac ischaemia or severe valve dysfunction, severe reduction of ejection fraction, sepsis, DIC, ARD or ESRD not undergoing regularly scheduled dialysis
ASA 4
ASA grade: ruptured abdominal/thoracic aneurysm, massive trauma, intra-cranial bleed with mass effect, ischaemic bowel in the face of significant cardiac pathology or multiple organ/system dysfunction
ASA 5
ASA grade: A declared brain-dead patient whose organs are being removed for donor purposes
ASA 6
When do you fix undescended testis?
1 year old
Fluid resuscitation in burns
Parkland formula
(Crystalloid only e.g. Hartman’s solution/Ringers’ lactate)
Total fluid requirement in 24 hours =
4 ml x (total burn surface area (%)) x (body weight (kg))
50% given in first 8 hours
50% given in next 16 hours
Maintenance fluids in adults
25-30 ml/kg/day of water and
approximately 1 mmol/kg/day of potassium, sodium and chloride and
approximately 50-100 g/day of glucose to limit starvation ketosis
Risk of fluid overload in 0.9% sodium chloride
Hyperchloraemic metabolic acidosis
What is cyclothymia?
Milder form of bipolar - hypomania rather than mania and more frequent highs and lows
Management of Alzheimer’s
Neostigmine
Memantine (second-line)
Treatment of MRSA
Vancomycin
Teicoplanin
Linezolid
Limited cutaneous systemic sclerosis
CREST syndrome: Calcinosis, Raynaud’s phenomenon, oEsophageal dysmotility, Sclerodactyly, Telangiectasia
Anti-centromere antibodies
Diffuse cutaneous systemic sclerosis
SCL-70
scleroderma affects trunk and proximal limbs predominately
Renal complications - ACE inhibitor
Management of gout in renal impairement
Colchicine or intra-articular steroids
Abx with risk of tendon ruptures
Quinolones - ciprofloxacin
Management of reactive arthritis
NSAIDs
Refeeding syndrome
Hypokalaemia
Hypophosphotaemia
Hypomagnasaemia
Types of febrile convulsions
<15 minutes, generalised, no recurrence and complete recovery within an hour.
Complex: 15-30 minutes, focal seizure, may repeat within 24 hours
Febrile status epilepticus: >30 minutes
What is the difference between congenital adrenal hyperplasia and androgen insensitivity syndrome?
Congenital adrenal hyperplasia - lack of 21 hydroxylase enzyme which causes underproduction of cortisol and aldosterone and overproduction of androgens from birth. Abnormal genitalia seen in children. Female features: tall, facial hair, absent periods, deep voice, early puberty.
Male features: tall, deep voice, large penis, small testicles, early puberty.
Management: cortisol replacement (hydrocortisone and fludrocortisone.
Androgen insensitivity syndrome - XY but externally female. Amenorrhoea, Raised LH
Normal or raised FSH
Normal or raised testosterone levels (for a male)
Raised oestrogen levels (for a male)
Management: bilateral orchidectomy, oestrogen therapy.
Management for crohn’s
Inducing: Oral pred
Mesalazine
Azathio or mercapto/ methotrexate
Maintaning: aza/mercapto
Management for UC
UC management: inducing remission.
Mesalazine (first-line) (oral or rectal)
Prednisolone (second line)
Maintaining remission:
Mesalazine (oral or rectal)
Azathioprine or mercaptopurine
Meningitis in children <3months
Group B strep
E.coli
Mumps complications
Orchitis
Pancreatitis
Parotitis
SSNHL
Meningitis
Scarlet fever management
Pen V for 10 days
Neonatal hypoglycaemia management
Management depends on the severity of the hypoglycaemia and if the newborn is symptomatic
* asymptomatic
o encourage normal feeding (breast or bottle)
o monitor blood glucose
* symptomatic or very low blood glucose
o admit to the neonatal unit
o intravenous infusion of 10% dextrose
Kawasaki’s management
High dose aspirin and IV immunoglobulins
Myasthenic crisis management
Plasmaphoresis and IV Immunoglobulins
Gullian- barre management
IV immunoglobulins
Wernicke’s encephalopathy
CAN OPEN
Confusion
Ataxia
Nystagmus
Ophthamoplegia
PEripheral
Neuropathy
IgA vs post-streptococcus
IgA= three letters= 3 days
Post-streptococcal = 17 letter = (2-3 weeks)
> 1 cm growth aneurysm asymptomatic management
Elective vascular surgery not urgent
HIV - lung infection and prophylaxis
Pneumocistic jirovecii - co-trimoxazole
At what point should a second drug (in combination with metformin) be added to lower this patient’s HbA1c?
> 58
Side effect of anastrazole
Osteoporosis
Haemodynamically unstable AF >48 hours
DC cardioversion
Seborrhoeic dermatitis - features and management
Features
eczematous lesions on the sebum-rich areas: scalp (may cause dandruff), periorbital, auricular and nasolabial folds
otitis externa and blepharitis may develop
Face and body management
topical antifungals: e.g. ketoconazole
topical steroids: best used for short periods
