QM/BM Flashcards
How does measles present?
This child with an incomplete immunisation status likely has measles. High fever, conjunctivitis and a maculopapular rash are commonly seen shortly following the onset of symptoms. Koplik spots (areas of grey discolouration) may also be visible on examination of the oral mucosa.
What is a key piece of advice to give when prescribing isotretinoin?
Isotretinoin can potentially worsen mental health following use; it is, therefore, important to screen for pre-existing mental health conditions before prescribing it. It is also highly teratogenic; if this patient were female, they should also be commenced on effective contraception.
Where does vulval cancer most commonly present?
Labia majora
What is the positive predictive value?
Positive predictive value (PPV) is the proportion of people with a positive test who actually have the disease.
How do we re-test for H. pylori after treatment
Carbon-13 urea breath test
How does tetanus present?
This man presents with fever and gradual-onset muscle spasms and trismus of the jaw, consistent with the features of tetanus. Tetanus causes a progressive spastic paralysis and requires prompt treatment with tetanus immunoglobulin to prevent complications including respiratory failure and asphyxia.
How does serotonin syndrome present?
He is complaining of diarrhoea and appears confused. On examination, he is hyperthermic, generally hyper-reflexic and has dilated pupils.
What is a case control study?
To do
What is a cohort study?
To do
What is Capgras syndrome?
In Capgras syndrome, patients believe that someone familiar to them (eg. a friend or relative) has been replaced by an exact clone
What sign would be seen on AXR with a sigmoid volvulus?
A characteristic ‘coffee-bean’ sign
How does prodromal schizophrenia present?
Being socially withdrawn, loss of motivation in life, poor personal hygiene and lack of interest in day-to-day activities.
How does the rash differ in SLE and acne rosacea?
Rosacea: facial rash that does not spare the nasolabial folds and worsens with heat.
What is Ekbom syndrome?
In Ekbom syndrome, patients experience a delusional belief that they are infested with parasites. A feeling of ‘crawling’ in the skin is often reported. In this patient, it is most likely secondary to psychotic illness.
How do we confirm a diagnosis of pernicious anaemia?
This is a case of pernicious anaemia, which is an autoimmune condition caused by antibodies to intrinsic factor and parietal cells (which produce intrinsic factor). This causes atrophic gastritis and results in malabsorption of vitamin B12, because B12 binds to intrinsic factor in the stomach so it can be absorbed in the small intestine. The presence of anti-intrinsic factor or antiparietal cell antibodies confirms the diagnosis.
What is Sézary syndrome?
This patient has presented with a skin rash known as erythroderma. When erythroderma is present alongside lymphadenopathy and hepatosplenomegaly, a diagnosis of Sézary syndrome can be made. This is a form of cutaneous T-cell lymphoma characterised by Sézary cells in the circulation.
What are the oestrogenic SEs of HRT
Nausea and bloating
Breast swelling
Breast tenderness
Headaches
Leg cramps
What are the progestogenic SEs of HRT
Mood swings
Bloating
Fluid retention
Weight gain
Acne and greasy skin
Which autoantibodies do we test for in SLE?
Antinuclear antibodies (ANA)
Basically tests for all of anti-Ro, anti-histone, anti-sm, anti-nRNP and anti-dsDNA
Which cancer does SLE increase the risk of?
Non-Hodgkin’s lymphoma
What is suxamethonium apnoea?
Suxamethonium is a depolarising muscle blocker used to blunt airway reflexes during the induction of anaesthesia. Normally it is broken down rapidly by plasma cholinesterases, thus the effects wear off within a few minutes. If the enzyme is mutated then the breakdown can take much longer – up to 4 h. During this period the muscles will still be in a state of paralysis. That is why this patient is reliant on the ventilator, as her diaphragm is still paralysed. Some patients will have a family history of suxamethonium apnoea, as some forms are genetic.
Name an osmotic laxative. How does it work?
Macrogol. It is an inert substance which draws water into the bowel, softening stool and making it easier to pass. It is often used for bowel preparation prior to endoscopic procedures.
What is a Heller’s myotomy used for?
This is a typical description of achalasia, which is an oesophageal motility disorder characterised by a loss of oesophageal peristalsis and incomplete relaxation of the lower oesophageal sphincter. A Heller’s myotomy involves an incision of the lower oesophageal sphincter to allow food and liquid to pass through.
What is a myomectomy?
Surgical removal of a fibroid
What impact do macrolides have on the cytochrome P450 system?
Macrolides are potent inhibitors of the cytochrome P450 system and statins should be held while taking the antibiotic.
How does statin overdose present?
Statin-induced myopathy. Fatigue and widespread muscle cramps. On examination, she has tenderness of her muscles but no evidence of injury. Blood tests reveal a mildly raised creatinine kinase (CK) (double the upper limit of normal) with normal renal function.
Where would you see the philadelphia chromosome?
CML
What would be seen on XR in rickets?
Widen epiphyseal plates and bowed femurs
What is a sign of Ewing’s sarcoma on XR?
Onion-skin sign
Is gradual onset or sudden onset of symptoms associated with better recovery rates?
Sudden onset is a better indicator of good prognosis
What three electrolyte disturbances do you see in refeeding syndrome?
Hypomagnesamia, hypokalaemia and hypophosphataemia
The metabolism slows during periods of starvation. As the patient begins to receive nutrition again, cells rapidly use up magnesium, potassium and phosphate, to metabolise glucose, proteins and fats.
How do we treat shingles?
Valaciclovir
Give a common complication of trastuzumab use
Cardiotoxicity
What is trastuzumab used for?
HER-2-receptor-positive breast cancer
How do we manage whooping cough?
This child’s history is consistent with a diagnosis of pertussis (whooping cough). A thorough history may reveal a lack of vaccination and exposure through close contacts. As this child has had a cough for more than 21 days, treatment with a macrolide antibiotic is no longer recommended. She should be managed at home with safety netting advice.
What is the triad in renal cell carcinoma?
Haematuria, flank pain and mass
How does necrotising enterocolitis present?
This baby is preterm and has presented with signs of necrotising enterocolitis (NEC)(bilious vomiting, bloody stools, absent bowel sounds, systemic compromise with metabolic acidosis). NEC is a common gastrointestinal condition in preterm neonates.
How do we investigate necrotising entercolitis?
Supine abdo XR which shows dilated asymmetrical bowel loops, bowel wall oedema with ‘thumbprinting’ and pneumatosis intestinalis (gas within the bowel wall)
What is the triad in Henoch-Schonlein Purpura?
It commonly presents with a triad of purpura/petechiae on the buttocks and lower limbs, abdominal pain and arthralgia. Other features include haematuria, proteinuria, pyrexia and hypertension.
The majority of HSP cases are self-limiting and resolve completely. Therefore, simple analgesia such as NSAIDs and/or paracetamol can be used. In severe cases, steroids may be indicated.
What are the five risk factors for biliary colic?
Risk factors include the 5 F’s - female, fat (high BMI), forty, fertile, family history
Which drugs can cause pulmonary fibrosis?
The complications of amiodarone include an inflammatory pneumonitis followed by a chronic pulmonary fibrosis, which occurs in 5% of patients on amiodarone. Other drugs that can cause pulmonary fibrosis include nitrofurantoin, methotrexate, bleomycin, busulfan and sulfasalazine
How does erythema nodosum present? Where is it seen?
Raised, red, painful shin rash.
Sarcoidosis
To Do
We would expect to see an initial respiratory alkalosis as the high salicylate levels activate the brain’s respiratory centres. Later on, metabolic acidosis would develop due to the ingested salicylic acid load.
In which patients is Pneumocystis pneumonia (PCP) common in?
It usually occurs in immunocompromised patients e.g. with HIV and transplants.
How does PCP present?
Pneumocystis pneumonia (PCP) is an infection caused by the pneumocystis jiroveci fungus. Patients usually present with fever, non-productive cough and breathlessness on exertion.
How do we investigate PCP?
Bronchoscopy with bronchoalveolar lavage is the definitive diagnostic investigation, as it allows a sample to be taken, which can then be tested histologically. In practice, sputum samples for polymerase chain reaction (PCR) assays are often taken, which are less invasive and are also diagnostic of the condition.
How do we treat PCP?
Co-trimoxazole
How does pulmonary hypertension present on ECG?
P pulmonale (tall, peaked P waves)
What are aspergillomas?
Aspergillomas are formed when the aspergillus fungus clumps together in the lung cavity. It usually occurs secondary to an underlying condition - TB in this case. Although there are usually no symptoms, aspergilloma is important differential to consider in patients that present with haemoptysis.
How does bronchiectasis present on spirometry?
This would indicate an obstructive pattern
What is the Breslow thickness?
In malignant melanoma, the tumour depth is called Breslow thickness and is the most important prognostic factor. The tumour depth has important implications for staging the cancer.
Where do you see Anti-tissue transglutaminase (anti-TTG) antibodies? Which skin condition is linked to it?
Coeliac’s.
Dermatitis herpetiformis
What is the most common type of melanoma?
The most common type of melanoma is superficial spreading – accounting for up to 70% of cases.
What is erythroderma?
This is an inflammatory skin condition where widespread erythema affects >90% of the skin surface. The history of atopic dermatitis, the fact that the rash has spread to the majority of her body and the image given in the question make a diagnosis of erythroderma likely. Erythroderma should be managed supportively with fluids, emollients and by treating the underlying disease - so in this case, steroids are warranted.
What is Nikolsky’s sign? Where is it seen?
This patient has a diagnosis of Stevens–Johnson syndrome. She has presented with a prodromal flu-like illness, a rash that peels when pressure is applied (Nikolsky’s sign) and mucosal ulceration.
What is the first line treatment of acne vulgaris?
The first-line treatment for acne vulgaris is a topical retinoid with or without benzoyl peroxide or a topical antibiotic. Should this treatment be ineffective, then oral lymecycline should be considered.
What is the first-line treatment of scabies?
Scabies is a skin infection caused by the mite Sarcoptes scabiei. It is highly contagious and causes an intensely pruritic rash commonly seen in the inter-web spaces, flexures of the wrist, axillae, abdomen and groin. The first-line treatment of scabies is with topical 5% permethrin. Permethrin should be applied to cool dry skin (ie. not after a hot bath) and should be applied to the whole body (including the face and scalp). It should be left on for 12 h, with the treatment course lasting 7 days.
When would GGT be elevated?
An elevated gamma-glutamyltransferase can indicate hepatic or biliary tract disease and can aid alongside alkaline phosphatase (ALP) for this purpose as, unlike ALP, it is not elevated in bone disease.
What is a marker of hepatocellular carcinoma?
Alpha-fetoprotein (AFP) is a marker of either hepatocellular cancer or testicular/germ-cell cancer. Given the high risk of hepatocellular carcinoma in patients with Hepatitis B cirrhosis, NICE recommend 6-monthly hepatic ultrasound and alpha-fetoprotein levels in these patients if they have significant fibrosis (as determined by METAVIR or Ishak staging)
What is Trousseau syndrome? What is it associated with?
Trousseau syndrome, also known as migratory thrombophlebitis, is strongly associated with pancreatic cancer.
How does metoclopramide work?
Metoclopramide enhances gastric emptying and also has a central action for antiemesis.
What is an elevated WCC in ascitic drain?
> 250/mm3
How does an increased oestrogen present in liver cirrhosis?
In liver cirrhosis, an increased oestrogen level induces vascularisation and leads to palmar erythema, a red colouration, particularly in hypothenar and thenar eminences. Other features of increased oestrogen include the development of gynaecomastia and spider naevi.
How does Mallory-Weiss tear present?
This is a typical history for a Mallory–Weiss tear, which is a small tear in the mucosa of the lower oesophagus and is usually caused by violent vomiting. The history is typically that of a prolonged period of severe vomiting, followed by an episode of haematemesis. Definitive diagnosis is with oesophagogastroduodenoscopy (OGD).
Where is salmonella enteritidis found?
Salmonella enteritidis is the second most common cause of food poisoning in the UK. The common source of infection includes raw or undercooked eggs.
What infection can undercooked rice cause?
Bacillus cereus
What is the most common cause of food poisoning?
Campylobacter jejuni is the most common cause of food poisoning in the UK. The most common source of infection is undercooked chicken.
How does norovirus infection present?
Clinical manifestations of norovirus infection include projectile vomiting and non-bloody diarrhoea. The common sources of norovirus include shellfish, leafy greens, and fresh fruits.
How does giardiasis present?
Giardia infection is caused by Giardia lamblia which is transmitted through the faecal-oral route. It is characterised by explosive, non-bloody diarrhoea with an incubation period of one to three weeks.
How does Zollinger-Ellison syndrome present?
This is caused by a gastrin secreting neuroendocrine tumour. Excessive gastrin results in acid hypersecretion and recurrent peptic ulcer disease unresponsive to medical therapy. Surgical resection should be considered in localised disease
Give the first and second-line triple therapy
Lansoprazole, Amoxicillin + Metronidazole for 7 days
What are porphyrias?
Porphyria is a spectrum of disorders caused by defects in haem synthesis due to alterations in enzyme function or structure.
How does acute porphyria present?
Acute porphyria can manifest with gastrointestinal symptoms, e.g. abdominal pain, vomiting or neuropsychiatric features (peripheral neuropathy, psychosis, and seizure). Due to the overactivity of the sympathetic system, acute porphyria can also result in hypertension and bradycardia.
How do we investigate and manage acute porphyria?
Urine porphobilinogens are raised during an acute attack. Possible triggers of acute porphyria include antibiotics such as trimethoprim and nitrofurantoin and anaesthetic agents.
How do we screen for Zollinger-Ellison syndrome?
Fasting serum gastrin level is used as a screening test for Zollinger-Ellison syndrome. A raised fasting serum gastrin level suggests a diagnosis of Zollinger-Ellison syndrome.
What is Courvoisier’s sign?
Courvoisier’s sign refers to painless jaundice with a palpable gallbladder which is unlikely due to gallstones. It suggests an obstructing pancreatic or biliary neoplasm until proven otherwise.
What is cholestyramine?
Cholestyramine is a bile-acid sequestrant, which binds bile salts in the gastrointestinal tract and prevents their reabsorption. This helps improve the itching in patients with PBC. Patients prescribed Cholestyramine should take it 2-4 hours before any other medications, as it can interfere with intestinal absorption. According to the British Society of Gastroenterology guidelines, it is recommended as first-line therapy to manage pruritis in patients with PBC
Which is the most common autoimmune hepatitis? Which antibody tests are positive?
Type 1 - The commonest type. These patients have raised levels of anti-smooth muscle antibodies (80%), and antinuclear antibodies may also be positive (10%).
How does primary sclerosing cholangitis present on investigation? What is it associated with?
Deranged LFTs - cholestatic picture
Positive anti-smooth muscle and antinuclear antibodies and myeloperoxidase antineutrophil cytoplasmic antibody (ANCA)
Multiple beaded biliary strictures are seen on magnetic resonance cholangiopancreatography (MRCP) or endoscopic retrograde cholangiopancreatography (ERCP).
Associated with UC and increased cholangiocarcinoma risk
Give a useful screening measure for pancreatic cancer
Carbohydrate antigen 19-9 is a useful initial screening measure of pancreatic cancer.
What is creon?
Creon is a pancreatic enzyme supplement indicated for pancreatic insufficiency in cystic fibrosis.
In which patients are you likely to see anti-mitochondrial antibodies? In which patient population?
The most likely diagnosis is primary biliary cholangitis, which typically affects younger females. Positive anti-mitochondrial antibodies are found in more than 90% of individuals. It is also associated with a rise in serum IgM level.
What is notorious for causing outbreaks of non-bloody vomiting and diarrhoea in healthcare institutions?
Norovirus
How do we diagnose achalasia?
The condition described here is achalasia. This is characterised by a loss of oesophageal peristalsis and a failure of relaxation of the lower oesophageal sphincter in response to swallowing. Oesophageal manometry measures both of these things and is the gold standard test for the diagnosis of achalasia.
What is the first-line diuretic for ascites in liver cirrhosis?
Spironolactone - a potassium-sparing diuretic
WHow does typhoid fever present?
Typhoid can have an incubation period of anything from a few days to a few weeks, with transmission occurring faeco-orally, and particularly in countries with poor sanitation. Diarrhoea or constipation is common at the outset of the illness, but then often settles; later symptoms include fever, malaise, headache, cough, anorexia, sore throat, and the characteristic maculopapular rose spots, which blanch on pressure,
Which liver condition is AFP raised in?
HCC
What causes typhoid fever?
Salmonella typhi
Where would you see lamina propria infiltration with periodic acid-Schiff (PAS) positive macrophages on biopsy?
Whipple’s disease
HbSAg negative, Anti-HbS positive, Anti-HbC negative
What do these results show?
These results are in keeping with someone who has immunity secondary to a vaccine. The hepatitis B vaccine allows the immune system to mount a response against the hepatitis B surface antigen not the hepatitis B core antigen. Hepatitis B surface antigen will be negative, as there is no active infection
HbSAg negative, Anti-HbS positive, Anti-HbC positive
What do these results show?
These results are in keeping with someone who has immunity secondary to previous infection. HbSAg negative means the infection has been cleared, and the immune system has mounted a response towards both surface and core antigens. The immune system will create antibodies towards the core antigen first (Anti-HbC), however, you are only immune once antibodies have been made against surface antigen (Anti-HbS)
What do a positive p-ANCA and ANA suggest?
Primary sclerosing cholangitis - associated with UC
What is seen on biopsy in UC?
Surface inflammation with loss of goblet cells and crypt abscess
What is seen on biopsy in Crohn’s?
Transmural inflammation with non-caseating granulomas
How do we diagnose autoimmune hepatitis?
It is characterised by raised IgG, ALT, and positive anti-smooth muscle antibodies.
What is a screening tool for Giardiasis
Stool ova, cysts and parasites
Why does Crohn’s disease increase the risk of gallstone formation?
Crohn’s disease is an inflammatory bowel disease (IBD) affecting the gastrointestinal tract from mouth to anus. The most commonly affected sites include the terminal ileum and part of the colon. Terminal ileitis affects the absorption of bile salts, increasing the risk of gallstone formation.
Why is sickle cell disease asymptomatic until after birth?
In sickle cell disease, a genetic abnormality coding for the beta subunit is responsible for causing the sickle shape of the red blood cells. Fetal haemoglobin does not lead to sickling of red blood cells because there is no beta subunit in the structure.
Ho do we treat sickle cell anaemia and why?
Hydroxycarbamide can be used to increase the production of fetal haemoglobin (HbF) in patients with sickle cell anaemia. This has a protective effect against sickle cell crises and acute chest syndrome.
What is the first-line treatment for delirium tremens?
Oral lorazepam
What causes first-degree heart block?
This is caused by prolonged conduction of electrical activity through the AV node. It can be identified on ECG by finding a PR interval >200ms.
How does atropine work? What is the dose in acute bradycardia?
Atropine is an anticholinergic; it blocks the effects of the parasympathetic nervous system on the heart. This causes an increase in the heart rate and improves atrioventricular conduction.
500 µg intravenous (IV) or intraosseous (IO) can be given and repeated every 3–5 min to a total of 3 mg. It forms part of the resuscitation council algorithm for acute bradycardia.
What is the ORBIT score used for?
The ORBIT Bleeding Risk Score for Atrial Fibrillation predicts bleeding risk in patients on anticoagulation for afib, similar to HAS-BLED.
How does type A and type B aortic dissection differ?
A Type B aortic dissection is a dissection in the descending portion of the aorta, rather than the ascending. This typically causes radial-femoral delay rather than radial-radial delay.
Give a cardiac SE of azithromycin.
Azithromycin (a macrolide antibiotic) can cause a prolonged QT interval which can lead to Torsades de Pointes, a polymorphic VT. Other medications which can cause a prolonged QT interval include certain antidepressants and antipsychotics, and antiemetics such as ondansetron.
How does myocarditis present on ECG?
ECG changes that may be seen in myocarditis include sinus tachycardia, ST changes and T wave inversion.
What ECG change does hypercalcaemia cause?
Hypercalcaemia can cause a shortened QT interval and can occur in patients with end-stage renal failure and tertiary hyperparathyroidism.
How does digoxin toxicity present?
Digoxin toxicity can also cause a shortened QT interval. However, the classic ECG finding in digoxin toxicity is the reverse tick sign - down-sloping ST depression and inverted T waves. Patients would also likely experience nausea, vomiting and abdominal pain.
How does rheumatic fever present?
Commonly presents with polyarthritis, arthralgia and erythema marginatum.
Which atrial myxomas are more common?
The patient gives a history of AF, dyspnoea and weight loss, which makes a cardiac tumour more likely. Atrial myxomas are most commonly found in the left atrium.
What is the difference between Mobitz type 1 and type 2?
Mobitz type 1 block (Wenckebach block), is a type of heart block in which the PR interval gradually lengthens before a QRS complex is dropped, resulting in a pattern of progressively longer intervals followed by a skipped beat. It is characterised by a consistent number of skipped beats, as described in the scenario (every 3 or 4 QRS complexes). It is caused by a conduction problem at the atrioventricular (AV) node, which slows the electrical conduction between the atria and ventricles. Mobitz type 1 block is usually benign, but it can progress to more severe forms of heart block if left untreated.
Mobitz type 2 block is a type of heart block in which the PR interval remains constant, but QRS complexes are dropped. It is caused by a conduction problem at the level of the His-Purkinje system, which is responsible for conducting the electrical impulse from the AV node to the ventricles. Mobitz type 2 block risks progression to complete heart block and may require pacemaker implantation.
What is the most common viral cause of myocarditis?
Coxsackievirus B
What is one of the most serious side effects of gliclazide?
Hypoglycaemia
How does De Quervain’s thyroiditis present?
De Quervain’s thyroiditis is a rare cause of hyperthyroidism, consistent with the patient’s symptoms of weight loss, anxiety and sweating. De Quervain’s thyroiditis classically presents with a painful smooth goitre.
What is the 24 hour urinary free cortisol test used for?
This is a good screening test for any evidence of Cushing’s syndrome (glucocorticoid excess). However, if this were causing such refractory hypertension, there would be other features of Cushing’s syndrome found on examination, such as central obesity, abdominal striae and skin/muscle atrophy.
Why does Conn’s syndrome lead to hypertension?
In primary hyperaldosteronism, the aldosterone is elevated, which causes sodium, and thus water, retention. This increases renal perfusion pressures and therefore inhibits the secretion of renin, causing renin concentration to drop. Therefore, in Conn’s syndrome, the aldosterone to renin ratio will be abnormally high. In secondary hyperaldosteronism, the aldosterone level is elevated due to an elevated renin and activation of the renin-angiotensin-aldosterone pathway. This would result in a normal aldosterone to renin ratio. A high aldosterone to renin ratio should increase suspicion of Conn’s syndrome and be followed up with further investigations, such as a saline or fludrocortisone suppression test.
Why does spironolactone use lead to gynaecomastia?
Spironolactone decreases testosterone production and induces peripheral conversion of testosterone to oestradiol, leading to gynaecomastia. Stopping spironolactone normally resolves the adverse effects.
How do we acutely manage thyroid storm?
In patients with a thyroid storm, the priorities of management alongside supportive care are threefold: stop thyroid hormone synthesis, block release of further thyroid hormone, inhibit peripheral conversion of T4 to T3. The first priority is to stop thyroid hormone synthesis and both PTU and carbimazole will achieve this. PTU is more rapid onset and also plays a role in blocking the peripheral conversion of T4 to T3, but it has liver toxicity potential. Carbimazole does not block peripheral conversion of T4 to T3 but does block thyroid hormone synthesis and does not have the potential for liver toxicity. In thyrotoxicosis, always avoid salicylates because they are associated with displacement of thyroid hormone from thyroxine-binding globulin (TBG).
Give two common SEs of Thiazolidinediones (e.g Pioglitazone)
Fluid retention, weight gain and worsening heart failure.
What antibodies are seen in Graves disease?
Anti-TSH receptor
Which antibodies are seen in Hashimoto’s thyroiditis?
anti-thyroglobulin antibodies
An inherited mutation in which gene is associated with MEN-2a?
The RET gene is a proto-oncogene involved in kinase activation. MEN-2a is associated with medullary thyroid cancers, phaeochromocytoma, and parathyroid hyperplasia and adenomas.
What is Waterhouse-Friderichsen’s syndrome?
Waterhouse-Friderichsen’s syndrome is caused by a severe bacterial infection which results in disseminated intravascular coagulation and subsequent adrenal haemorrhage and failure.
The adrenal haemorrhage is usually bilateral but can be unilateral.
How does Waterhouse-Friderichsen’s syndrome present?
Classically patients develop a non-specific infection which progresses into a macular, petechial and subsequently purpuric rash along with septic shock.
How do screen for Cushing’s disease?
The first line screening investigations to look for Cushing’s syndrome and excess endogenous glucocorticoid production include a low dose dexamethasone suppression test, 24-hour urinary free cortisol, or midnight and 9am serum/salivary cortisol.
How do we diagnose Cushing’s disease?
High dose dexamethasone suppression test is carried out after a diagnosis of Cushing’s syndrome has been confirmed. This helps to distinguish whether the excess cortisol secretion is due to excess ACTH secretion from the pituitary gland (where high dose dexamethasone will suppress cortisol secretion) or due to another reason.
Give a key side effect of metformin use
Metformin, like all biguinides, can cause lactic acidosis. This normally occurs in conditions already associated with lactic acidosis, such as hypoxia or heart failure.
How does carcinoid syndrome present?
To do
What is De Quervain’s thyroiditis?
De Quervain’s thyroiditis is a subacute thyroiditis caused by granulomatous inflammation and destruction of thyroid cells which is often precipitated by a viral infection. It causes symptoms of hyperthyroidism due to excess release of thyroid hormone. Patients then have a hypothyroid phase. It also presents with a painful neck due to the inflammation. Its presentation is similar to Grave’s disease and a radioisotope scan can differentiate the two. It is self-resolving.
What is acute cholecystitis?
Cholecystitis is acute or chronic inflammation of the gallbladder usually due to cholelithiasis.
In acute cholecystitis, obstruction can lead to an infection caused by a number of organisms:
E.coli (most common)
Klebsiella
Enterococcus
How does acute cholecystitis present?
Right upper quadrant/epigastric pain (radiating to right shoulder tip if the diaphragm is irritated)
Fever
Nausea and vomiting
Right upper quadrant tenderness
Murphy’s sign positive
What is Boerhaave syndrome?
The most likely diagnosis is oesophageal rupture secondary to forceful vomiting, which is known as Boerhaave syndrome.
Where are femoral hernias? Where are inguinal hernias?
The pubic tubercle is an important landmark to distinguish between inguinal and femoral hernias, with the latter being inferior and lateral to it.
What is a pancreatic pseudocyst?
A pancreatic pseudocyst is a common complication of chronic pancreatitis with around 25% of patients developing these. They can present asymptomatically depending on size but the most common symptoms are abdominal pain due to obstruction as a result of the mass effect of the cyst. Diagnosis is confirmed on CT as they can be visualised well as well circumscribed collections of fluid with a thick wall. Treatment is usually with surgical drainage although a very small number will spontaneously resolve.
How do we manage pilonidal abscesses?
Incision and drainage
What is Cullen’s sign?
Cullen’s sign (superficial bruising around the umbilicus) is a rare sign for haemorrhage secondary to acute pancreatitis
How does chronic mesenteric ischaemia present?
This is a typical history of chronic bowel ischaemia with post-prandial pain, diarrhoea and bleeding. The pain occurs after eating as this is when the blood supply demands of the bowel are at their highest (in the same way that angina is brought on by exercise as that is when the heart’s blood supply demand is highest). Weight loss is common as the pain stops patients from eating. This patient also has many vascular risk factors pointing towards an ischaemic cause.
What is atelactasis?
This patient most likely has partial collapse of the lungs, known as atelectasis. It is a common cause of post-operative fever around 1-2 days after surgery and can cause shortness of breath. The examination findings of reduced air at the lung bases are typical. It most often occurs due to poor pain control, as this means patients struggle to cough to clear their lungs and have shallow breathing. A chest x-ray would likely show shadowing at the lung bases. Management includes adequate pain control, saline nebulisers and chest physiotherapy.
How does anastomotic leak present?
This is the most likely diagnosis given the clinical features and time period post-surgery. The most common presentations of an anastomotic leak are abdominal pain (sometimes peritonitis) and fever. Leaks usually present 5–7 days postoperatively. The definitive investigation for a suspected anastomotic leak is a CT scan of abdomen and pelvis with contrast. Leaks can be managed conservatively if small; however, in this case, it is likely the patient will need surgical intervention.
How do left and right sided colonic cancers present?
This gentleman is symptomatic of iron deficiency anaemia. Combined with systemic features, such as weight loss, this should raise suspicions of a malignancy. Right-sided colonic cancers often present later and in a more insidious manner with occult bleeding and anaemia. Occasionally there is a right-sided mass or vague abdominal pain on examination. The stool in the right-sided colon is semi-liquid, and so, unlike left-sided stools which are more solid, obstructive features are rarely a presenting feature
Left-sided colonic cancers present earlier than right-sided neoplasms on the whole. As the stool is more formed this side of the colon, they may also present as a bowel obstruction. Features typical of a left-sided colonic cancer include fresh rectal bleeding, tenesmus, and/or mass in the left iliac fossa or on rectal exam
What is the psoas sign?
The psoas sign can be elicited by extending the right hip and, if it is positive, the patient will feel pain in the right iliac fossa. This is caused by an appendix in the retrocaecal position that rests against the iliopsoas muscle and causes irritation. Other signs include the obturator sign, which is elicited by internally rotating a flexed right hip, which again causes pain in the right iliac fossa.
How do we manage achalasia?
This patient is displaying signs and symptoms of achalasia, failure of the lower oesophageal sphincter to relax due to degeneration of the myenteric plexus. Patients present with difficulty swallowing both liquids and swallows, in contrast to patients with an obstruction who present with difficulty swallowing solids first. The best treatment for this condition is a Heller’s cardiomyotomy which is a surgical procedure where the muscle fibers of the lower oesophagus are divided
What is ischaemic colitis?
Ischaemic colitis occurs due hypoperfusion of the large bowel, particularly in the ‘watershed areas’ where collateral blood supply is limited. This results in inflammation and injury to the colon. This patient has cardiovascular risk factors which increases the risk of ischaemic colitis. Thumbprinting on AXR is a sign of large bowel wall thickening, usually due to oedema. Haustra are thickened in regular intervals along the bowel, resembling thumbprints. This may be seen in inflammatory bowel disease, ischaemia, infections and diverticulitis. The patient’s history of presenting complaint fits the clinical picture of the hyperactive phase of ischaemic colitis where patients experience severe pain with frequent passing of loose, bloody stools. The findings on examination suggest that the patient has progressed onto the paralytic phase where the pain becomes more diffuse and constant and the abdomen becomes distended. This patient has yet to progress onto the shock phase, where patients start to display signs of septic shock
What is a Hartmann’s procedure?
This is a Hartmann’s procedure, where the sigmoid colon is removed and a colostomy is formed. The stoma can be reversed at a later date if desired. This operation is used in emergencies, particularly in diverticulitis as the sigmoid colon is the most commonly affected site.
What is the first-line management for anal fissures?
Rectal/topical nitro-glycerine is the first-line pharmacological management for anal fissures when lifestyle measures such as increased dietary fibre and simple analgesia has not worked, as recommended by NICE. It works as a vasodilator, which helps the anal sphincter to relax. Treatment of underlying constipation is also important.
How do we manage local anaesthetic toxicity?
20% intralipid infusion
Lipids bind to the local anaesthetics and reverse effects of local anaesthetic toxicity.
What is cyclizine?
H1 antagonist
What reading is used to confirm intubation?
End-tidal CO2
What is the most common complication if epidural in pregnancy?
Epidural causes maternal hypotension due to its sympathetic effects, this can result in maternal and foetal distress.
What causes obstructive shock
It is commonly due to pulmonary embolism, pneumothorax or tampondade.
Which anti-emetic is contraindicated in intestinal obstruction?
Metoclopramide
What is suxamethonium? What complication can it cause?
Suxamethonium and other depolarising muscle relaxants cause the release of potassium from cells. Inducing paralysis during anaesthesia can result in a rise of plasma potassium of up to 1 mmol/l.
This is not an issue in this patient, as her potassium is still within the reference range. However, it can become an issue if there is pre-existing hyperkalaemia.
How do we reduce post-operative N&V?
Three classes of antiemetic drugs are used first line: serotonin antagonists (ondansetron, palonosetron), corticosteroids (dexamethasone) and dopamine antagonists (droperidol).
What is the murmur in aortic regurg?
Soft diastolic
How do we calculate the anion gap?
The anion gap can be calculated by Na+ K+ – (Cl- + HCO3-)
How does hypokalaemia present on ECG?
Patients with moderate or severe hypokalaemia should have an ECG to see if there are any changes. ECG changes in hypokalaemia include flattened or inverted T waves, a prolonged PR interval and U waves.
How does acute intermittent porphyria present?
Acute intermittent porphyria is a rare genetic condition in which the synthesis of haem is affected. Patients can present with many seemingly unrelated symptoms, including abdominal, neurological and psychiatric symptoms. A key feature is red-coloured urine.
How does hypomagnesaemia present on ECG?
The blood results show hypomagnesaemia which can cause a prolonged QT interval. It is one of the causes of Torsades de Pointes.
Which ones are bad cholesterol?
LDLs
What dose of atorvastatin do we prescribe for primary prevention?
20 mg ON
80mg in secondary prevention
What is the Trousseau sign?
Trousseau sign is a sign of hypocalcaemia and is elicited by placing a blood pressure cuff over the arm and inflating it. Once inflated, spasms of the hand and forearm indicate a positive Trousseau sign.
What is the Rovsing’s sign?
Rovsing’s sign is a sign of acute appendicitis. A positive finding is when deep palpation of the left iliac fossa causes pain in the right iliac fossa.
What is the pathophysiology in Coeliac diseasE?
Coeliac disease is a T cell-mediated inflammatory autoimmune disease.
What is the rash like in Rubella?
Rubella, caused by the rubella togavirus, usually presents with non-specific symptoms and signs such as coryza, arthralgia and a rash, which classically starts on the face and moves down to the trunk, sparing the arms and legs. The child may also have some lymphadenopathy. However, this patient’s rash develops from the trunk and spreads towards the limbs, and there is no apparent lymphadenopathy. This makes roseola infantum the more likely diagnosis.
How does scleritis present?
It presents with a painful red eye that is tender on movement and associated with reduced visual acuity and photophobia.
How does episcleritis present?
The aetiology of episcleritis is often idiopathic, and it tends to occur in younger patients. It is not painful and does not affect visual acuity.
How does lichen sclerosis present compared to lichen simplex?
Lichen sclerosus is most common in postmenopausal women and presents with pale atrophic skin with loss of vulval architecture. It is often associated with urinary incontinence, as in this woman. It increases the risk of vulval malignancy.
No loss of architecture in lichen simplex
How do we manage headache triggered by coughing?
This question is asking you to think of red flags of headaches which would prompt hospital referral. Headaches triggered by coughing could be indicative of raised intercranial pressure and she would need a CT head scan to identify the cause.
What does Coxsackie virus A16 cause?
Hand, foot and mouth disease
What is isosorbide mononitrate?
A long-acting GTN - third line in treatment of angina after beta blocker
