Rahul's Differentials

Question 1

What are the ‘non-sinister’ differentials of a headache?

Answer 1

1. Tension-type headache (stress related)
2. Migraine (really common actually)
3. Sinusitis
4. Medication overuse headache - for those on migraine meds and/or analgesia
5. Temporomandibular joint dysfunciton syndrome
6. Trigeminal neuralgia
7. Cluster headache

Question 2

What are the signs of Horner’s?

Answer 2

Partial ptosis
Miosis
Anhydrosis
Enophthalmos

Question 3

What are the differentials for a large pupil?

Answer 3

Cranial nerve 3 palsy
Holmes-Adie Syndrome
Trauma
Drugs (tropicamide, atropine, cocaine, ecstasy)

Question 4

What are the differentials for a small pupil?

Answer 4

Horner's syndrome
Argyll-Robertson syndrome 
Age-related miosis
Drugs (opiates) 
Anisocoria (different sized pupils)

Question 5

List the causes of Horner’s syndrome

Answer 5

CENTRAL: 
Stroke
Syringomyelia
Multiple sclerosis
Tumour
Infection 

PREGANGLIONIC LESION:
Pancoast tumour
Thyroidectomy
Trauma 
Cervical Rib 

POSTGANGLIONIC LESION:  
Carotid artery dissection 
Carotid aneurysm 
Cavernous sinus thrombosis
Cluster headache

Question 6

State where the lesion is for MONOCULAR BLINDNESS

Answer 6

Before the nerve

Ipsilateral optic nerve lesion

Question 7

State where the lesion is for HOMONYMOUS HEMIANOPIA

Answer 7

Contralateral optic radiation

Contralateral occipital lobe

Question 8

State where the lesion is for BITEMPORAL HEMIANOPIA

Answer 8

Optic chiasm

Question 9

State where the lesion is for LEFT/RIGHT SUPERIOR QUADRANTANOPIA?

Answer 9

Contralateral temporal optic radiation

Question 10

State where the lesion is for LEFT/RIGHT INFERIOR QUADRANTANOPIA?

Answer 10

Contralateral parietal optic radiation

Question 11

State where is the lesion for HOMONYMOUS HEMIANOPIA WITH MACULAR SPARING

Answer 11

Contralateral occipital lobe infarct due to posterior cerebral artery infarct

The middle cerebral artery supplies the occipital pole

Question 12

State what is responsible for Arcuate Scotoma?

Answer 12

Glaucoma

Question 13

State what is responsible for Central Scotoma?

Answer 13

Macular Degeneration

Macular oedema

Question 14

What are the differentials for HAEMATEMESIS

Answer 14

Oesophagitis/Gastritis/Duodenitis
Bleeding peptic ulcer (gastric or duodenal) 
Oesophageal varices
Mallory-Weiss tear
Oesophageal cancer
Gastric cancer
Arteriovenous malformations 
Bleeding diathesis
Trauma to oesophagus or stomach 
Scleroderma
Hereditary heamorrhagic telangiectasis
Aorto-enteric fistula (related to an aortic graft)

Question 15

What does HAEMATEMESIS indicate?

Answer 15

It is an upper GI bleed

Question 16

First ix for Haematemesis?

Answer 16

OGD

Follow by possible erect Chest X-ray: check if the peptic ulcer has perforated resulting in pleural effusion

Question 17

What is Boerhaave’s syndrome?

Answer 17

A tear of the distal postero-lateral part of the oesophagus

Question 18

What are the two types of blood produced during HAEMATEMESIS

Answer 18

Fresh blood suggestive of an upper GI bleed

Coffee Ground blood seen due to partial digestion by stomach acids

Question 19

What are the two types of blood found in stool?

Answer 19

Tarry black stool - Malaena which is due to an upper GI hemorrhage

Haematochezia - Fresh blood in the stool suggestive of a lower GI haemorrhage (however, it could also be from an upper GI bleed)

Question 20

What is a Mallory-Weiss tear?

Answer 20

It is a laceration of the mucosa at the junction between the stomach and the esophagus

Question 21

What are EASY BRUISING, DISTENDED ABDOMEN, PUFFY ANKLES and LETHARGY suggestive of?

Answer 21

Liver failure

Question 22

What does episodic dyspepsia suggest (indigestion)

Answer 22

GORD - Gastro-oesophageal reflux disease

Question 23

Note: Jaundice is itchy so the patient may have scratch marks

Answer 23

Note: More than 4 spider naevi indicates liver disease.

Question 24

What is macrocytic anemia and what is it suggestive of?

Answer 24

A high MCV but low hemoglobin

Seen in those who consume ALCOHOL, or have VITAMIN B12 or FOLATE DEFICIENCIES

Question 25

List causes of low albumin

Answer 25

Liver failure Malnutrition (just not getting enough protein in the diet) Renal nephrotic syndrome

Question 26

What causes raised ALT, AST

Answer 26

Damage to hepatocytes seen in alcohol abuse and liver cirrhosis

Question 27

What does raised urea in the presence of a normal creatinine suggest?

Answer 27

Pre-renal uraemia - Increased urea due to increased protein ingestion due to blood in the GI tract

Question 28

What is the treatment for a bleeding oesophageal varix?

Answer 28

1. Endoscopic band ligation 2. Endoscopic sclerotherapy 3. Balloon tamponade

Question 29

What does a PPI do for a bleeding peptic ulcer?

Answer 29

Reduce chances of rebleeding

Question 30

Treatment for H. pylori?

Answer 30

Triple therapy - | PPI and a combination of two antibiotics

Question 31

Doxasosin

Answer 31

Anti emetic

Question 32

Difficulty swallowing could mean?

Answer 32

DYSPHAGIA - true difficulty swallowing could be HIGH DYSPHAGIA or LOW DYSPHAGIA which is felt a few seconds after swallowing ODYNOPHAGIA - Painful swallowing due to malignancy or infection e.g Candidiasis GLOBUS - Lump in the throat

Question 33

Ways to divide DYSPHAGIA

Answer 33

High Dysphagia | Low Dysphagia

Question 34

DDx of High Dysphagia

Answer 34

``` Stroke Parkinson's disease Myasthenia Gravis Multiple sclerosis Myotonic dystrophy MND Cancer Pharyngeal pouch ```

Question 35

DDx of Low Dysphagia

Answer 35

ACHALSIA Foreign body Cancer Stricture

Question 36

What is ACHALISA

Answer 36

The lower oesophageal sphincter does not open leading to the backing up of food

Question 37

What questions would you ask to a patient who presented with difficulty swallowing?

Answer 37

1. How long have these symptoms being going on for - a stuck food bolus will present immediately, a cancer over days - weeks, a motility issue - months to years 2. Does the painful swallowing come and go? - Persistent/progressive: CANCER INTERMITTENT: STRICTURE 3. Can you swallow solids...fluids...or both...what about saliva? Difficulty with solids then fluids --> STRICTURE Difficulty with fluids > solids --> MOTILITY ISSUE Absolute dysphagia likely due to poorly chewed food bolus

Question 38

What would someone with CREST syndrome suffer with?

Answer 38

CALCINOSIS RAYNAUD's ESOPHAGEAL DYSMOTILITY Sclerodactyly - Build up of fibrous tissue in the fingers which causes them to bend

Question 39

What is the most common type of oesophageal cancer?

Answer 39

Adenocarcinoma (the less common type is SQUAMOUS CELL)

Question 40

Velvety epithelium in the esophagus can suggest?

Answer 40

Barrett's oesophagus

Question 41

What are the RF for Oesophageal cancer

Answer 41

Adenocarcinoma: BARRETT'S OESOPHAGUS ``` Squamous cell carcinoma: Alcohol Smoking Dietary nitrosamines Aflatoxins Achalsia Plummer-Visons syndrome Hereditary tylosis Coeliac disease ```

Question 42

DIAGNOSE: Dysphagia, Hoarseness, Bovine cough

Answer 42

Damage to recurrent laryngeal nerve 1. Infiltration of the nerve by primary malignancy of the oesophagus or a mediastinal malignancy that then compresses the oesophagus causing dysphagia 2. ORTNER's syndrome - Compression of recurrent laryngeal nerve by left atrium MS --> Hypertrophy of left atrium

Question 43

What questions do you need to ask in a cough history?

Answer 43

1. How long has this been going on for (Acute or chronic) 2. Is the cough CONSTANTLY THERE or DOES IT COME AND GO? 3. Are you coughing anything up? 4. Any blood while you're coughing 5. What time does the cough usually come? When is it worst? 6. Can you describe the cough to me? Wheezy, bovine/breathy, dry, gurgling/wet?

Question 44

What environmental factors would you ask about for someone with a cough?

Answer 44

Smoking Occupation Pets Change of house/office

Question 45

NOTE: TB is often linked with foreign travel to South Asia, Central Asia or sub-Saharan Africa. IF YOU SUSPECT TB YOU MUST ASK ABOUT CLOSE CONTACTS WHO ARE ALSO COUGHING

Answer 45

Note: Neutrophillia is associated with bacterial infection | Urea is an indicator of severity in pneumonia

Question 46

What are the features of a pneumothorax on examination?

Answer 46

1. Decreased chest expansion UNILATERALLY 2. Increased resonance over area of pathology 3. Decreased breath sounds 4. Decreased vocal fremitus

Question 47

What does blood-streaked sputum suggest?

Answer 47

INFECTION OR BRONCHIECTASIS

Question 48

What does pink and frothy sputum suggest?

Answer 48

PULMONARY OEDEMA

Question 49

What does frank haemoptysis suggest?

Answer 49

TB Lung Cancer PE Bronchiectasis (also blood streaked sputum)

Question 50

Cough worse at night and better in the mornings is indicative of?

Answer 50

Asthma

Question 51

Cough worse at night especially lying down is indicative of?

Answer 51

GORD or Pulmonary Oedema

Question 52

``` List the likely causes of the following coughs: Wheezy cough Bovine/Breathy cough Dry cough Gurgling/wet cough Whooping cough ```

Answer 52

``` COPD or Asthma Vocal cord paralysis Bronchitis, Interstitial lung disease Bronchiectasis Pertussis ```

Question 53

List the DDx of DRY AND ACUTE COUGH

Answer 53

``` Asthma Rhinitis/Sinusitis with post-nasal drip Upper respiratory tract infection Drug induced e.g. ACE inhibitors Smoke/toxin inhalation Inhaled foreign body Lung cancer Pulmonary oedema ```

Question 54

List the DDx of PRODUCTIVE AND ACUTE COUGH

Answer 54

Lower Respiratory Tract Infection COPD TB

Question 55

List the DDx of DRY AND CHRONIC COUGH

Answer 55

``` Asthma GORD Post-nasal drip Smoking Lung cancer Drug induced COPD ```

Question 56

List the DDx of PRODUCTIVE AND CHRONIC COUGH

Answer 56

Bronchiectasis TB Lung cancer Recurrent aspiration

Question 57

What does Cough + Tender cervical lymphadenopathy suggest?

Answer 57

Upper Respiratory Tract infection

Question 58

What happens to vocal fremitus when there is consolidation and when there is effusion

Answer 58

It increases in CONSOLIDATION | In decraeses in effusion

Question 59

List the signs of right heart failure

Answer 59

``` Peripheral oedema Raised JVP Parasternal heave Loud or palpable heart sound Tricuspid regurgitation ```

Question 60

What are the two complications of pneumonia?

Answer 60

1. Spread of infection resulting in PLEURAL EFFUSION, EMPYSEMA, ABSCESS, SEPTICAEMIA 2. Damage to local structures in BRONCHIECTASIS, PNEUMOTHORAX

Question 61

List two obstructive airway diseases

Answer 61

Asthma | COPD

Question 62

What does FEV1 stand for

Answer 62

Forced Expiratory Volume in 1 second | Volume of air that can be forcibly blown out after a full inspiration

Question 63

What does FVC stand for

Answer 63

Forced Vital Capacity | Volume of air that can be blown out after full inspiration

Question 64

What features suggest asthma

Answer 64

``` Wheeze Breathlessness Chest tightness Cough worse at night/early morning Cough triggered by exercise, allergen, exposure, cold air on or after taking aspirin or beta-blocker History of atopic disorder Family history of asthma and/or atopy Wheeze on auscultation Low FEV1, PEF, or serum eosinophilia ```

Question 65

What are the 3 things that haemoptysis can be confused with?

Answer 65

1. Haematemesis 2. Epistaxis (especially after a posterior nosebleed) 3. Bleeding gums

Question 66

List the DDx of Haemoptysis

Answer 66

``` V - PE, Left Ventricular Failure, Bleeding Diathesis I - TB, Pneumonia, Lung abscess T - Iatrogenic, rib fracture, stab A - N/A M - N/A I - Granulomatosis with polyangiitis, SLE, Goodpasture's syndrome, N - Primary/Metastatic Lung cancer C - N/A D - Bronciectasis E - N/A F - N/A ``` Drugs: Warfarin, Crack Cocaine

Question 67

What is a Bleeding Diathesis?

Answer 67

Bleeding tendency e.g coagulopathy, severe thrombocytopenia

Question 68

What does a mass lesion/nodules on an X-ray indicate?

Answer 68

Carcinoma, TB, Abscess,

Question 69

What does Hilar Lymphadenopathy on an X-ray indicate?

Answer 69

Sarcoidosis, Infection (TB), Malignancy (Hodgkin's Lymphona, Carconoma)

Question 70

How do you confirm lung cancer in a patient?

Answer 70

A pathological sample is required for confirmation | CT-guided percutaneous fine needle biopsy is required if peripheral or BRONCOSCOPY

Question 71

Where are you most likely to find TB (Mycobacterium Tuberculosis) in the lungs?

Answer 71

The upper lobes becauses Mycobacterium tuberculosis is highly aerobic and the apices are the most oxygenated parts of the lungs.

Question 72

What are the two types of Pleural effusions and what is the difference?

Answer 72

Transudate - <25 g/L of protein in the fluid | Exudate - >35 g/L of protein in the fluid

Question 73

Causes of Transudative pleural effusions and Exudative pleural effusions

Answer 73

Transudate: Heart failure, fluid overload, constrictive pericarditis, liver failure (decrease protein production), malabsorption, nephrotic syndrome Exudative: Pathogens, Inflammatory cells, Malignant cells in the pleural space.

Question 74

What are the different types of Malignant Primary lung neoplasms?

Answer 74

``` 1. Non-small cell lung cancer (80%): ADENOCARCINOMA (30-40%) SQUAMOUS CELL (20-30%) - most common to cause haemoptysis and secrete PTHrP LARGE CELL CARCINOMA (10%) Other (5%) ``` 2. Small cell lung cancer (20%) can secrete ADH (causing HYPONATRAEMIA) or ACTH

Question 75

What are the common primary tumours that lead to lung cancer mets?

Answer 75

1. Colorectal 2. Breast. 3. Renal 4. Cervix, Ovary

Question 76

List the extra-pulmonary manifestations of lung cancer

Answer 76

1. Bone mets --> Bony pains 2. Hypertrophic pulmonary osteroarthropathy (HPOA) 3. Ectopic ACTH --> Cushingoid syndrome (muscle weakness, oedema, skin hyperpigmentation) 4. Hypercalcaemia - confusion, polyuria, polydipsia, hypotonoia, hyporeflexia, muscle weakness 5. Eaton-Lambert syndrome

Question 77

DDx of a coin lesion

Answer 77

``` Parenchymal tymor - benign, primary lung cancer, secondary lung cancer Lymph node: Lymphoma Granuloma: TB, Sarcoid Abscess Hamartoma Foreign object ```

Question 78

List the DDx of Chest Pain

Answer 78

``` Musculoskeletal pain Acute Coronary Syndrome (MI or unstable angina) Pulmonary Embolism Stable Angina Pneumothorax Pleurisy (2ndary to infection) Oesophagitis Cocaine induced coronary spasm Anxiety Peptic ulcer disease or gastritis Myopericarditis Cholecysititis Acute pancreatitis Thoracic aortic dissection Thoracic aortic aneurysm Coronary vasospasm Oesophageal spasm Boerhaave's perforation of the oesophagus ```

Question 79

What other conditions could cause a raised Troponin

Answer 79

Any condition which causes cardiac damage Coronary artery spasm Aortic dissection Myopericarditis Severe heart failure Cardiac trauma from surgery or road traffic accident PE Troponin may also be misleading in someone with renal failure.

Question 80

What are the Ix for Chest Pain

Answer 80

``` ECG Bloods: Troponin Serum cholesterol FBC U&Es - Potassium could hint at arrhythmias Inflammatory markers - WCC and CRP Capillary glucose Amylase ``` Imaging: CXR

Question 81

What is the interesting relationship between diabetics and MIs?

Answer 81

Diabetics are more likely to suffer from 'silent MI's' those without chest pain

Question 82

What would an aortic aneurysm or dissection show on a CXR?

Answer 82

A widened mediastinum

Question 83

Note: Remember in the end diagnosis of MI depends on elevated troponin or rapidly rising troponin.

Answer 83

Chest pain is not always a feature in the elderly or long-standing diabetics. ECG readings are also non-diagnostic.

Question 84

What are the drugs used to treat Acute Coronary Syndrome (think of the acronym)?

Answer 84

MONABASH Morphine/Metoclopramide (anti-emetic) Oxygen (to keep saturation above 94%) Nitrates (GTN, isosorbide mononitrate infusion) Antiplatelets (aspirin, clopidogrel, prsugrel) Beta-blockers (not for those with heart block, asthma, acute heart failure) ACE-inhibitors Statins Heparin

Question 85

What are the secondary things to do for patients with ischaemic heart disease?

Answer 85

Lifestyle changes - Smoking cessation, low-salt diet, exercise, weight loss, cardiac rehabilitation programmes Risk factor control with medication - BP control: ACEi < 55 and white CCB or Thiazide diuretics if >55 and Afro-Carribean Cholesterol reduction: Statins otherwise fibrates Diabetic control Low-dose aspirin for life and ADP receptor inhibitor

Question 86

What are the common complications of MI? (DARTH VADER)

Answer 86

``` Death Arrhythmia Rupture (septum or the outer walls) Tamponade Heart Failure Valve disease Aneurysm Dressler's syndrome (autoimmune pericarditis is 2-10 weeks after MI; simple pericarditis is 2-4 days) Embolism Reinfarction ```

Question 87

NOTE: ACS typically respond to GTN spray

Answer 87

NOTE: Pericarditis will show ST elevation in almost all leads as well as slight PR segment depression.

Question 88

What pathology can Marfan's predispose you to?

Answer 88

Dissected thoracic aorta Dissected aortic aneurysm Pneumothorax (because they are often tall and thin)

Question 89

What would you hear on auscultation if a patient had pulmonary oedema?

Answer 89

Bi-basal crackles

Question 90

Why do some patients with MI get nause and vomitting and other do not?

Answer 90

Due to the BEZOLD-JARISCH REFLEX | An inferior MI will irritate the diaphragm and a result cause vomitting.

Question 91

How would a posterior MI look like on an ECG?

Answer 91

ST depression in V1, V2, V3 with tall R waves Look for dominant R waves in V1 Inferior lead ST elevation in infarction

Question 92

Name the first investigation for a patient with query new onset angina

Answer 92

Exercise tolerance test

Question 93

What would you expect to see in an ECG of a patient who had a previous MI?

Answer 93

Abnormal Q waves - > 2mm deep

Question 94

What are the changes seen over 7 days in a patient who has a STEMI?

Answer 94

1. Tented t waves 2. ST elevation in the affected leads, with ST depression in the reciprocal leads 24-48 hours after 3. T wave inversion, 1-2 days after MI and persisting for weeks or months unless MI is treated 4. Abnormal Q waves.

Question 95

What does LOW WELLS SCORE + LOW D-Dimer indicate?

Answer 95

Low chance of a PE

Question 96

What are the 3P's of Pleuritic chest pain

Answer 96

PE Pneumonia Pneumothorax

Question 97

How would you describe Pleuritic chest pain

Answer 97

A sharp, stabbing, burning chest pain which is worse on inhaling or laughing

Question 98

What are carotid bruits a sign of?

Answer 98

Peripheral vascular disease

Question 99

List the causes of SOB

Answer 99

SOB can be due either to not enough oxygen getting around the body or increased respiratory drive. 1. Insufficient oxygen getting into the lungs - Obstructed airways - Dcreased lung volume - Decrease volume of functional lung - Inability to inflate the lungs 2. Insufficient oxygen into the blood - Damage to alveoli - Fluid between the alveoli and capillary - Disrupted blood supply 3. Insufficeint O2 around the body - Reduced cardiac output - Anaemia - Shock (blood pressure <90/60 mmHg) 4. Increased respiratory drive - Hysterical hyperventilation - Acidaemia

Question 100

What kind of cough would you expect with asthma?

Answer 100

A dry cough

Question 101

What kind of cough would you expect with pneumonia

Answer 101

A persistent, productive cough

Question 102

What are the DDx of SOB with onset of seconds-minutes

Answer 102

``` Bronchospasm (due to acute asthma or COPD) Anaphylaxis Laryngeal oedema PE Pneumothorax Flash pulmonary oedema Hysterical hyperventilation Inhaled foreign body Tension pneumothorax Acute epiglottitis/supraglottitis ```

Question 103

What are the DDx of SOB with onset hours to days?

Answer 103

``` Pneumonia Heart Failure Pleural effusion Post-op atelectassis Chronic pulmonary emboli Altitude sickness Guillian-Barre syndrome Myasthenia Gravis Acute Respiratory Distress Syndrome Lung Collapse ```

Question 104

What are the DDx of SOB with onset weeks to months?

Answer 104

``` COPD Chronic asthma Heart failure Pulmonary fibrosis Anaemia Bronchiectasis Physical deconditioning Obesity Pulmonary hypertension Mesothelioma Pulmonary tuberculosis Kyphoscoliosis Ankylosing spondylitis Motor neuron disease ```

Question 105

In a CXR what 3 things do you want to ensure? Other than patient's details and PA

Answer 105

Good penetration - not too white not too dark Adequte inspiration - So things don't look too hazy Not rotated - Spinous processes equidistant to medial ends of the clavicle

Question 106

List the features of RHF

Answer 106

Raised JVP | Peripheral oedema

Question 107

List the features of LHF

Answer 107

Bibasal cracles - suggestive of pulmonary oedema Displaced apex beat CXR showing bilateral pulmonary oedema

Question 108

List the post-operative causes of breathlessness

Answer 108

``` Atelectasis (alveolar collapse): Pneumonia Pulmonary oedema PE (classically DVTs occur 10 days after) Anaemia Pneumothorax ```

Question 109

What is the treatment for Atelectasis?

Answer 109

Physiotherapy Oxygen Analgesia

Question 110

Questions to ask in family history of suspected asthma patient?

Answer 110

``` Family history of Eczema Hayfever Nasal Polyps Allergies ```

Question 111

What are the three pillars of asthma management?

Answer 111

1. Avoid the triggers - smoke, allergens, exercise in cold air 2. Bronchodilate (open those airways!) - b2 agonists/phosphodiesterase inhibitors/antimuscarinics 3. Reduce immune response in lungs - inhaled/oral corticosteroids

Question 112

What pneumonia is common in immunosuppresed patients?

Answer 112

Pneumonia caused by the opportunistic organism: Pneumocystis jiroveci common in those with AIDS Diagnosed by performing microscopy + silver staining and culture on sputum and bronchoalveolar lavage samples.

Question 113

What kind of inhaler is the blue inhaler?

Answer 113

Salbutamol

Question 114

What kind of inhaler is the green-white?

Answer 114

Ipratropium | Antagonises muscarinic receptors preventing PNS smooth muscle contraction

Question 115

The common side effects of ACEi?

Answer 115

Cough | Issues related to kidney damage

Question 116

What are the DDx of Breast Lump

Answer 116

``` Carcinoma Benign cystic change Fibroadenoma Cyst Breast abscess Fat necrosis Periductal mastitis Galactocele Phyllodes tumour Sarcoma Duct papilloma Lipoma Sebaceous cyst Prominent costal cartillage/rib ```

Question 117

How does age affect the DDx of Breast Lump

Answer 117

<30: Physiologically normal, benign cystic change, fibroadenoma, Abscess, Galactocele 30-45: Benign cystic change, cyst, abscess, carcinoma 45-60: Cyst, abscess, carcinoma >60: Carcinoma

Question 118

What antibiotic could be used in cellulitis?

Answer 118

Flucloxacillin

Question 119

What are the RF for breast cancer?

Answer 119

``` Previous history of breast cancer Family history of breast cancer History of ovarian, endometrial or bowel cancer Radiation to the chest wall Menarche before 13 Menopause after 51 No kids (nulliparity) Having a first child after the age of 30 Not breast-feeding HRT Use of the oral contraceptive pill Obesity ```

Question 120

``` What are the follow discharges from the nipples indicative of? Blood Serous Green, brown, yellow discharge Milky discharge ```

Answer 120

Blood - Carcinoma Serous - Intraductal papilloma Green, brown, yellow - Periductal mastitis Milky - Galactocele

Question 121

NOTE: Breast cancer does not often come with the constitutional symptoms/FLAWS symptoms. However, it may present with mets in the form of...?

Answer 121

Back pain

Question 122

What are the key features to look for in a breast examination?

Answer 122

Asymmetry Contours Skin changes Nipple discharge or changes

Question 123

What is the approach for investigating solid lumps in the breast clinic?

Answer 123

Breast lumps should undergo triple assessment: 1. Clinical examination 2. Radiological examinatio a) USS if <35 years old b) Mammogram w or w/out USS if >35 years old 3. FNA or core biopsy FNA - type of cells (dysplastic or not) Core biopsy - invasion of local structures

Question 124

Where is breast cancer likely to metastasize to and how should imagine be done accordinlty?

Answer 124

Liver - CT abdomen, MRI abdomen, contrast-enhanced USS Bone - Axial skeleton via bone scintigraphy or CT or MRI Long bone imaging via bone scintigraphy or plain radiographs Chest - CT Brain - CT Some hospitals recommend CT with/out PET

Question 125

What does HYPERECHOIC on an USS mean?

Answer 125

The structure appears BRIGHTER | Seen in solid masses

Question 126

What does HYPOECHOIC on an USS mean?

Answer 126

The structure appears DARKER | Seen in fluid-filled cysts

Question 127

How does breast cancer present in a man?

Answer 127

Unilateral, non-tender, irregular surface, indistinct margins and hard consistency

Question 128

What are the causes of Gyanaecomastia?

Answer 128

``` Liver disease Drugs (cimetidine, spironolactone, phenothiazines, finasteride, anabolic steroids) Primary testicular failure Acquired testicular failure Secondary testicular failure Endocrine tumours Non-endocrine tumours ```

Question 129

What determines prognosis of breast cancer?

Answer 129

``` Tumour stage Tumour grade Hormone receptor status Tumour type Patient age Treatment type ```

Question 130

What are the risks of lymph node clearance?

Answer 130

Lymphoedema Long thoracic nerve injury Axillary vein thrombosis

Question 131

What is PRCB score

Answer 131

P - Physical examination R - Radiological examination C - Cytology (FNA) B - Biopsy (core biopsy) ``` Score: 1 - Normal for P/R; Inadequate for C 2 - Benign 3 - Probably benign 4 - Probably malignant 5 - Malignant ```

Question 132

What are the DDx of ACUTE Epigastric pain

Answer 132

``` Acute pancreatitis Perforated peptic ulcer Gastritis/Duodenitis Peptic ulcer disease (gastri or duodenal) Biliary colic Acute cholecystitis Ascending cholangitis Myocardial infarction Ruptured Abdominal Aneurysm Mesenteric ischaemia Basal pneumonia Oesophagitis (due to GORD) Non-ulcer dyspepsia Chronic pancreatitis Incomplete bowel obstruction Boerhaave's perforation Gastric Cancer Pancreatitc cancer Acute hepatitis ```

Question 133

Make a SOCRATES cheat list for the presentation of acute pancreatitis

Answer 133

``` Site: Epigastrium (could be elsewhere) Onset: 10-20 minutes Character: Deep/boring pain Radiation: To the back Attenuating factors: Sitting forwards Severity: Very severe ``` Note: Sitting forward is better for those with pancreatitis and Neutrophilia is a strong indicator of pancreatitis

Question 134

Pain that starts in epigastrium --> rest of abdomen

Answer 134

Peritonitis | Perforated gastric ulcer

Question 135

Pain that starts in epigastrium and moves up to chest

Answer 135

Likely cardiac in origin

Question 136

Pain that stays in the epigastric region?

Answer 136

Likely biliary in origin

Question 137

DDx sudden onset epigastric pain?

Answer 137

Perforation | MI

Question 138

DDx of epigastric pain that takes 10-20 minutes to come on?

Answer 138

Acute pancreatitis | Biliary colic

Question 139

DDx of a epigastric pain that takes hours to come on?

Answer 139

Inflammation that is either acute cholecystitis or pneumonia

Question 140

DDx of epigastric pain that is crushing/tightnes?

Answer 140

Cardiac

Question 141

DDx of sharp/burning epigastric pain?

Answer 141

Peptic ulcer Gastritis Duodenitis

Question 142

DDx of deep/boring epigastric pain?

Answer 142

Pancreatitis

Question 143

DDx of epigastric pain that radiates to the back?

Answer 143

Pancreatitis Leaking AAA Possibly peptic ulcer

Question 144

DDx of epigastric pain that goes to the shoulder?

Answer 144

Basal pneumonia | Subphrenic abscess

Question 145

DDx of epigastric pain that radiates to the jaw, neck or shoulder?

Answer 145

Cardiac

Question 146

DDx of retrosternal chest pain?

Answer 146

Oesophagitis | MI

Question 147

What makes acute pancreatitis better?

Answer 147

Sitting forward

Question 148

What is the surgical dogma on what makes peptic ulcers/duodenal ulcers better or worse?

Answer 148

Peptic ulcers are WORSE on eating | Duodenal ulcers are BETTER on eating

Question 149

DDx of constant epigastric pain?

Answer 149

Biliary colic

Question 150

DDx of pleuritic chest pain?

Answer 150

PE Pneumothorax Pneumonia

Question 151

List 4 conditions you want to know in a PMH if a patient has epigastric pain?

Answer 151

Biliary disease - Have you ever had gallstones before?Peptic ulcer disease - Have you ever had a peptic ulcer? GORD - recurrs

Question 152

Which drugs predispose to Peptic Ulcer disease?

Answer 152

NSAIDs Steroids Bisphosphonates Salicylates (aspirin)

Question 153

Which drugs predispose to acute pancreatitis?

Answer 153

Sodium valproate Steroids Thiazides Azathioprine

Question 154

What are the DDx of Epigastric pain?

Answer 154

``` Acute pancreatitis Perforated peptic ulcer Gastritis/Duodentitis Peptic ulcer disease (gastric or duodenal) Biliary colic Acute cholecystitis - inflammation of the gall bladder Ascending cholagnitis - Inflammation of the bile duct Myocardial infarction Ruptural abdominal aortic aneurysm Mesenteric ischaemia Basal pneumonia Oesophagitis (due to GORD) Non-ulcer dyspepsia Chronic pancreatitis Imcomplete bowel obstruction ```

Question 155

Causes of Jaundice

Answer 155

Ascending cholangitis Gallstone-induced acute pancreatitis Acute hepatitis

Question 156

List the Ix for an acute epigastric presentation

Answer 156

``` History Examination FBC CRP Amylase or lipase Liver enzymes Albumin U&Es Calcium Glucose ABG Troponin USS ECG CXR ```

Question 157

What does a raised AST and ALT indicate?

Answer 157

Damage within the liver to hepatocytes

Question 158

What does a raised ALP, GGT, Bilirubin indicate?

Answer 158

Damage within the biliary tree or compression of the biliary tree for ex. due to oedema of the pancreas

Question 159

What does a raised ALP alone indicate?

Answer 159

Problems with bone or placenta

Question 160

What does a raised GGT indicate?

Answer 160

Excessive alcohol intake

Question 161

What are the causes of acute pancreatitis?

Answer 161

``` I - Idiopathic G- Gallstones E - Ethanol T - Trauma S - Steriods M - Mumps/HIV/Coxsackie infection A - Autoimmune S - Scorpion bites H - Hyperlipidaemia/Hypercalcaemia/hypothermia E - ERCP D - Drugs (sodium valproate, steroids, thiazides, azathioprines) ```

Question 162

Treatment for a patient with pancreatitis

Answer 162

I would begin with an ABCDE approach Airway Breathing Circulation I would then treat the underlying cause e.g Gallstones through laparascopic cholecystectomy as well as give him IV fluids, Oxygen, Analgesia, Antiemetics, DVT prophylaxis, Low fat diet

Question 163

Treatment for patient with severe pancreatitis

Answer 163

ERCP within 72 hours of onset of pain along with sphincterotomy and then cholecystectomy.

Question 164

How do you prevent reoccurent in a patient who has alcoholic pancreatitis?

Answer 164

Focus on cessation of drinking.

Question 165

List the RF for peptic ulcer disease

Answer 165

Smoking | Alcohol

Question 166

Management of dyspepsia

Answer 166

Lifestyle advice - reduce/eliminate alcohol, caffeine, chocolate, fatty food and smoking, lose weight Full-dose PPI Test and treat H.pylori - C-urea breath test - Anti-Helicobacter blood serology - H.pylori positive endoscopic biopsy

Question 167

How do you treat H. pylori?

Answer 167

Triple therapy PPI + 2 antibiotics 7 day TD PPI with Metronidazole 400 mg + Clarithromycin 250 mg Amoxicillin 1 g + Clarithromycin 500 mg

Question 168

DDx of raised amylase

Answer 168

``` Acute pancreatitis (if >1000 U/L) Pancreatitic trauma Pancreatic carcinoma Perforated peptic ulcer Acute Appendicitis Acute Cholecystitis Ectopic pregnancy Pelvic inflammatory disease Mesenteric ischaemia Leaking AAA Bowel obstruction Mesenteric ischaemia Mumps Pancreatic carcinoma Opiate medications ```

Question 169

What is the triad of peritonitis?

Answer 169

Motionless patient Tenderness and guarding on abdominal palpation Absent bowel sounds

Question 170

Top DDx for pain around the face

Answer 170

Trigeminal neuralgia | Giant cell arteritis

Question 171

What are the 'red flags' that would lead to a endoscopy?

Answer 171

1. Persistent vomitting 2. Chronic GI bleed 3. Weight Loss 4. Progressive dysphagia 5. Iron deficiency anaemia 6. Epigastric mass 7. Suspicious barium meal 8. Age >= 55 with unexplained and persistent recent-onset dyspepsia

Question 172

List the 5 complications of peptic ulcer?

Answer 172

1. Haemorrhage - Bleeding esp in those on blood thinners 2. Perforation - manifests as haematemesis/melaena and leads to peritonitis 3. Penetration - Not to peritoneum but to organ parts of GI tract, food no longer makes it worse, diarrhoea, weight loss 4. Scarring - Satiety, bloating, vomitting 5. Malignancy

Question 173

What are the local complciations of pancreatitis

Answer 173

1. Necorsis of the pancreas - The pancreas is being autodigested and eventually it dies. 2. Abscess formation 3. Pseudocysts 4. Paralytic ileus - lack of movement of bowl 5. Duodenal stress ulceration 6. Fistula formation to colon 7. Obstructive jaundice due to choledocholithiasis or pancreatic oedema

Question 174

What is Choledocholithiasis

Answer 174

Gallstones in the common bile duct

Question 175

What are the systemic complications of pancreatitis?

Answer 175

``` Sepsis Shock Acute renal failure (due to hypoperfusion) Respiratory compromise Disseminated intravascular coagulation Hypocalcaemia Hyperglycaemia Pancreatic encepholopathy ```

Question 176

DDx of low faecal elastase?

Answer 176

Pancreatitis Crohn's Coeliac's Short gut syndrome

Question 177

What is the difference between Cushing's ulcers and Curling's ulcers

Answer 177

They are both peptic ulcers Cushing's ulcers are due to brain injury Curling's ulcers are due to burns

Question 178

DDx of decreased amylase clearance

Answer 178

Renal failure Macroamylasaemia Diabetic ketoacidosis Head injury

Question 179

Which 4 systems can influence the vomitting center in the medulla?

Answer 179

1. CNS 2. Vestibular system 3. Chemoreceptor trigger zone 4. CN IX and CN X

Question 180

List the DDx of nausea and vomitting due to pathology of the vestibular system

Answer 180

Benign paroxysmal positional vertigo Labyrinthitis Motion sickness Meniere's disease

Question 181

List the DDx of nausea and vomitting due to pathology of the chemoreceptor trigger zone

Answer 181

``` Hormones Electrolytes Medications Alcohol Toxins ```

Question 182

List the DDx of nause and vomitting due to pathology of the CNS

Answer 182

``` Pain Anxiety Raised ICP Meningitis Encephalitis ```

Question 183

List the DDx of nausea and vomitting due to pathology of the Abdominal/Cardiac systems affecting CN IX or CN X

Answer 183

GI obstruction GI infection Inflammation of diaphragm (as in inferior MI's) Inflammation of liver, pancreas, gallbladder, peritoneum

Question 184

What are the worrying signs of peritonitis?

Answer 184

Motionless patient Tender, rigid abdomen Absent bowel sounds

Question 185

What are the worrying signs of bowel obstruction?

Answer 185

Bilious (green) or faeculent (foul like) vomit Distended abdomen Absolute constipation Abdominal pain

Question 186

What are the worrying signs of raised ICP

Answer 186

Early morning vomitting Headache worse when lying down Nerve VI palsy

Question 187

What are the worrying signs of meningitis?

Answer 187

Stiff neck Photophobia Headache

Question 188

What are the worrying signs of meningitis?

Answer 188

Stiff neck Photophobia Headache Reduced consciousness

Question 189

What are the worrying DDx of haematemesis

Answer 189

Bleeding peptic ulcer | Oesophageal varices

Question 190

What does guarding and rigidity on palpation suggest?

Answer 190

Peritonitis

Question 191

What do absent bowel sounds and tinkling/high pitched tinkling sounds indicate?

Answer 191

Absent bowel sounds: Bowel obstruction - ileus (functional) | Tinkling/high pitched: Bowel obstruction - mechanical

Question 192

What Ix do you need to do in a patient with nausea and vomitting

Answer 192

FBC, CRP - infection, inflammation U&Es - vomiting can cause electrolyte imbalances, need baseline in case of surgery Venous Blood Gas - pH and lactate give idea of how sick patient is; metabolic acidosis+raised lactate = ill Liver enzymes - GGT + ALP = cholestatic picture AST + ALT = hepatitis Amylase - confirm/exclude pancreatitis G&S Supine abdominal radiograph - bowel obstruction, foreign body, toxic megacolon Erect chest radiograph - Air under diaphragm to indicate perforation Pregnancy test Tox screen Contrast studies Abdominal CT Head CT

Question 193

In a patient awaiting surgery for small bowel obstruction what is the management plan?

Answer 193

1. Manage patient with an A to E approach 2. Nil by mouth - reduces the risk of aspiration on induction by anaethesia 3. Drip and suck: IV fluids + aspiration of gastric contents 4. Analgesia 5. Antiemetics

Question 194

LEARNING POINT: Avoid NSAIDs in dehydrated patient or those with AKIs They are nephrotoxic!

Answer 194

LEARNING POINT: Morning sickness is most common in the first trimester

Question 195

When is surgery indicated in a patient with small bowel obstruction?

Answer 195

There are signs of strangulation or peritonism After 48 hours the obstruction has not resolved There is no history of abdominal surgery, so sinister causes are more likely

Question 196

What is the difference between D&V caused by toxins and that caused by infection?

Answer 196

A toxin from 'food-poisoning' rarely persists more than 24 hours

Question 197

What does ketonuria suggest?

Answer 197

That the patient is in metabolic starvation

Question 198

What is Kussmaul breathing?

Answer 198

Breath has sweet smell to it due to ketones The breathing is deep labored and gasping At first in acidosis - the breathing is swallow and rapid

Question 199

What is the management of DKA

Answer 199

IV fluids to rehydrate IV insulin as an infusion to suppress ketosis Monitor fluid balance, cap glucose, ketones, serum potassium Potassium therapy

Question 200

What is the management of a patient with a perforated appendix which leads to PERITONITIS?

Answer 200

Note that peritonities is high risk as the patient is at risk of deteriorating into septic shock from gut contents getting into the peritoneal cavity 1. A to E approach 2. Resuscitation with IV fluid bolus 3. Broad spectrum antibiotics 4. Analgesia 5. Antiemetics 6. Nil by mouth

Question 201

What would you give a dehydrated patient that can tolerate oral fluids?

Answer 201

Oral rehydration solution with sodium, glucose, water | Ask them to have a little and often

Question 202

What are the causes of nause and vomitting in a patient with cancer?

Answer 202

Metabolic: Hypercalcaemia, uraemia Intracranial: Raised ICP due to brain mets GI: constipation, bowel obstruction, ileus, hepatomegaly Psychogenic: anxiety Chemotherapy or opiate analgesia

Question 203

What are porthole scars?

Answer 203

Laparascopic surgery

Question 204

Which two patients with vomiting would you not prescribe metoclopramide?

Answer 204

Patient with bowel obstruction | Patient with Parkinson's

Question 205

List some complications of vomitting

Answer 205

``` Dehydration Renal impairment Electrolyte imbalance - hyponatraemia, hypocholaraemia Aspiration Aspiration pneumonia Mallory-Weiss tear in mucose of oesophagus Boerhaave's perforation Loss of tooth enamel ```

Question 206

What is the cause of Jaundice?

Answer 206

Excessive collection of bilirubin in tissues

Question 207

Extravascular breakdown of RBCs results in what abnormal cells?

Answer 207

Spherocytes

Question 208

Intravascular breakdown of RBCs results in which abnormal cells?

Answer 208

Schistocytes (it's shit if they're breaking down in your blood)

Question 209

What are the 6 pathways that can lead to jaundice?

Answer 209

1. Intravascular haemolysis 2. Extravascular haemolysis 3. Reduced hepatocyte uptake 4. Enzyme defects in conjugation 5. Hepatocyte damage 6. Bile flow obstruction

Question 210

What does pre-hepatic jaundice mean?

Answer 210

Excess production of bilirubin likely due to too much haemolysis

Question 211

What does hepatic jaundice mean?

Answer 211

Problem with hepatocytes - hepatitis

Question 212

What is PSC?

Answer 212

Primary sclerosing cholangitis

Question 213

What does post-hepatic jaundice mean?

Answer 213

Problem with the outflow of bile perhaps outside the liver - common bile duct obstruction or inside the liver (PSC)

Question 214

What is a sign of obstructive jaundice?

Answer 214

Pale stool and dark urine and steatorrhoea (foul smelling +foul)

Question 215

NOTE: All pre-hepatic jaundice is uncojugated

Answer 215

NOTE: Hepatic jaundice can be conjugated or unconjugated

Question 216

What are the DDx causes of Jaundice?

Answer 216

Intravascular haemolysis - congenital or acquired CONGENITAL: G6PD deficiency, pyruvate kinase def, sickle cell, thalassaemia ACQUIRED: artifical heart valves, blood group mismatch, DIC< malaria, HELLP syndrome in pregnant women Extravascular haemolysis CONGENITAL: Hereditary ACQUIRED: Autoimmune Reduced hepatocyte uptake: portosystemic shunts Congenital enzymatic problems: Gilbert's syndrome, Crigler-jannar syndrome Decreased excretion of bilirubin

Question 217

What is HELLP syndrome?

Answer 217

It is a variant of pre-eclampsia, seen in later stages of pregnancy or child birth H- Haemolysis EL - Elevated Liver enzymes LP - Low Platelet count

Question 218

What is an indication of extravascular haemolysis

Answer 218

Spherocytes | Splenomegaly

Question 219

What are the causes of decreased bilirubin excretion?

Answer 219

Dubin-Johnson syndrome V: Budd-Chiari syndrome (hepatic vein thrombosis) I: Viral/bacterial hepatitis (leptospirosis or Weil's disease) T: Gallstones, stricture (After ERCP) A M: Wilson's disease, haemochromatosis I: Primary biliary cirrhossi, Primary sclerosing cholangitis N: Metastatic liver cancer, hepatocellular carcinoma, pancreatic cancer, cholangiocarcinoma E: intrahepatic cholestatis of pregnancy

Question 220

What is haemochromatosis?

Answer 220

``` Absorption of too much iron Bronzed skin Polyrura Weight loss Infections ``` Diagnosis age 50 for men, 10-20 years after menopause Hemosiderosis - deposition of iron in liver, pancreas, Tx: Blood letting, medication

Question 221

List the signs of dehydration

Answer 221

Tachycardia, narrow pulse pressure, hypotension

Question 222

What do green rings around the iris/Kayser-Fleischer rings suggest?

Answer 222

Wilson's disease

Question 223

What does splenomegaly suggest?

Answer 223

Extravascular haemolysis

Question 224

What ix in someone who is jaundiced and what do you look for?

Answer 224

FBC --> Anaemia --> Blood flim Serum bilirubin levels --> Raised unconj --> Blood film Liver enzymes (ALT + AST) --> Raised --> Viral serology/ASMA, ANA, AMA, Alcohol Biliary enzymes (ALP + GGT) --> AMA, Alcohol, USS biliary tree Urine bilirubin --> positive --> USS biliary tree Serum amylase --> USS biliary tree

Question 225

DDx of microcytosis

Answer 225

Thalassaemia | iron-deficiency

Question 226

What is bilirubin in the urine indicative of?

Answer 226

Post-hepatic obsturction

Question 227

What makes up a haemolysis screen?

Answer 227

Haptoglobins (it will be depleted) LDH (released by haemolysed RBCs) Direct antiglobulin test (DATs or Coombs) Blood film

Question 228

What is Antismooth muscle antibodies positive in?

Answer 228

Type 1 autoimmune hepatitis

Question 229

What is antimitochondrial antibodies elevated in?

Answer 229

Primary Billiary Cirrhosis

Question 230

LEARNING POINT: An USS will be good at picking up mechanical obstruction of the bile duct

Answer 230

IF a mechanical obstruction cannot be identified other caused such as Primary Billiary Cirrhosis or Primary Sclerosing Cholangitis should be thought of. NOTE: Prothrombin time is an indicator of compromised liver function

Question 231

What are the outcomes for Hep B

Answer 231

Full recovery Carriers Chronic symptomatic Hep B --> cirrhosis or hepatocellular carcinoma Fulminant hepatitis

Question 232

Managment of someone with Hep B

Answer 232

``` Practice safe sex Minimise alcohol consumption Avoid sharing toothbrushes or razors Trace contacts Vaccinate current sexual partners and childre n ```

Question 233

What is the management of primary biliary cholangitis?

Answer 233

Raised Anti-mitochondrial antibodies (AMA) are indicative of PBC MX: Refer to hepatologist Confirm diagnosis via MRCP and liver biopsy Immunosuppresion (because PBC is autoimmune mediated destruction of bile ducts) Bile salt replacement - ursodeoxycholic acid Fat soluble vitamin replacement - supplement A, D, E, K Pruritis itch management - anti histamines, cholestyramine Liver transplant

Question 234

Patient with jaundice and UC, what do you immediately think of?

Answer 234

Primary sclerosing cholangitis | Elevated perinucear antineutrophil cytoplasmic autoantibodies PANCA

Question 235

List the DDx of RUQ pain

Answer 235

``` Biliary colic Cholecystitis Duodenal ulcer Pancreatitis Basal pneumonia Ascending cholangitis Gastric ulcer Small bowel obstruction Appendicitis Hepatitis (VADA) Pyelonephritis Cancer Aortic dissection AAA Inferior MI Fitz-Hugh-Curtis syndrome (Adhesions around the liver capsule due to gonorrhoeae or Chlamydia) ```

Question 236

DDx of midline, dull epigastric pain that moves to RUQ and back as well as right scapula (Boas's sign)

Answer 236

Cholecystitis

Question 237

Mx of patient with cholecystitis?

Answer 237

``` Clear fluids IV fluids Analgesia Broad spectrum antibiotics NBM Laparascopic cholecystectomy ```

Question 238

What is cholelithiasis?

Answer 238

Stone formation which can cause biliary colic (irritation of Hartman's pouch or common bile duct)

Question 239

What are the causes of ascending cholangitis?

Answer 239

Gallstones stuck in the common bile duct A stricture in the common bile duct A tumour blocking the common bile duct Bacteria being pushed into the common bile duct by ERCP

Question 240

What are the 4 components of bile?

Answer 240

Water Fats Bile salts Bilirubin Bile salts are absorbed from the terminal ileum them travel back to the liver via enterohepatic circulation. Bile salts may be recycled up to 10 times a day

Question 241

What effect do liver disease and obstructive jaundice have on blood clotting times?

Answer 241

They will increase the prothrombin time (PT)

Question 242

What are the 3 types of gallstones?

Answer 242

Bile pigment (5%) - haemolytic anaemia, total parenteral nutrition Cholesterol (20%) - fair, fat, fertile, female of forty, flatulent, oral contraceptive pill Mixed (75%) 10% of gallstones are radio-opaque and show up on x-rays; 90% of renal stones show up

Question 243

What are the complications of gallstones

Answer 243

``` Biliary colic Acute/chronic cholecystitis Mucocoele (mucus filled gallbladder) Empyema (pus-filled gallbladder) Cancer of gallbladder Cholangiocarcinoma Ascending cholangitis Obstructive jaundice Acute pancreatitis Gallstone ileus ```

Question 244

What is Mirrizzi's syndrome?

Answer 244

A gallstone in the cystic duct is big enough to compress the common bile duct leading to obstructive jaundice

Question 245

What is Courvosier's law and the idea behind it?

Answer 245

In a patient who is jaundiced, check if the gallbladder is palpable. IF IT IS PALPABLE THEN... It is unlikely the jaundice is due to gallstones Because, gallstones will cause inflammation of the gallbladder as a result it will become thickened and fibrotic. The opposite of distended and palpable, rather it will 'shrivel' up. Unlike if due to a tumour where back pressure would cause distension. So if you can feel it it's unlikely that stones are the cause.

Question 246

What is the difference between ERCP and MRCP?

Answer 246

ERCP - Endocscopic retrograde cholangiopancreatography MRCP - Magneto retrograde cholangiopancreatography MRCP is diagnostic and allows visualisation of the biliary tree ERCP allows for the removal of stones and endoscopic sphincterotomy of the sphincter of Oddi.

Question 247

What are the risks of ERCP?

Answer 247

Bleeding Perforation of the biliary tree Cholangitis Pancreatitis

Question 248

What are the DDx of RIF pain?

Answer 248

``` Appendicitis Gastroenteritis Utereric colic Inguinal hernia (Especially if encarcerated or strangulated) Epididymitis and/or orchitis Mesenteric adenitis Acute pancreatitis Testicular torsion Ectopic pregnancy Pelvic inflammatory disease Salpingitis Torsion/haemorrhage/rupture of an ovarian tumor of cyst Meckel's diverticulitis Cholecystitis Pyelonephritis Psoas abscess Small bowel obstruction Diabetic ketoacidosis Urinary tract infection Constipation Acute onset iletis Caecal volvulus Perforated peptic ulcer Caecal diverticulitis Shingels Rectus sheat haematoma Femonal hernia ```

Question 249

LEARNING POINT: In any woman who presents with abdominal pain you must perform a pregnancy test

Answer 249

LEARNING POINT: A patient with mesenteric adenitis will have mesenteric lymph node enlargement. It is often preceded by an upper respiratory tract viral infection as a result cervical lympadenopathy may be present. Mesenteric adenitis is a mild condition which causes temporary pain a patient's abdomen. It is common in children and usually resolves.

Question 250

What might blood on a PR exam suggest?

Answer 250

IBD Bleeding Meckel's diverticulum - congenital bulging of the small intestine Caecal diverticulum - outpouching of the caecum in which stool can get stuck leading to infection

Question 251

What Ix should you do a patient with RIF pain?

Answer 251

``` FBC - checking WCC CRP - inflammatory marker Venous blood gas - Raised lactate and/or metabolic acidosis --> ischaemaia or severe sepsis U&Es - giving the baseline of electrolytes Serum amylase - Glucose - DKA can cause abdominal pain LFTs Urinalysis Abdominal USS - can definitly say appendicitis but cannot rule it out CXR Abdominal CT ECG ```

Question 252

What are the DDx of a raised amylase (less than 1000)

Answer 252

``` Pancreatitis Bowel obstruction Mesenteric ischaemia Posteriorly perforated duodenal ulcer Mumps Pancreatic carcinoma Opiate medications ```

Question 253

What are the 3 indications for an ABDOMINAL RADIOGRAPH

Answer 253

Small bowel obstruction - dilated loops of bowel will be seen IBD resulting in toxic megacolon Foreign body in GI system

Question 254

How should you manage a patient with appendicits?

Answer 254

I would manage this patient firstly with an A to E approach I would give IV fluids as a bolus Give adequate analgesia NBM for solids and non-clear fluids for 6 hours prior to surgery NBM clear fluids 2 hours before surgery Appendicectomy Broad spectrum antibiotics DVT prophylaxis

Question 255

What is the management for septic shock?

Answer 255

The Sepsis Six 1. High flow oxygen --> start with 15L/min aim for 96% 2. Take blood cultures 3. Give broad spectrum antibiotics 4. Give IV fluid challenges - to increase blood pressure and reduce heart rate 5. Measure serum lactate and haemoglobin - use VBG 6. Measure accureate hourly urine output - Decreasing urine output indicates AKI

Question 256

List the possible causes of appendicits

Answer 256

Obstruction by faecolith or foreign body Lymphoid hyperplasia of Peyer's patches Fibrous strictures Carcinoid tumour

Question 257

What antibodies are used to screen for Coeliac's and what antibody do you need to watch out for?

Answer 257

Anti-endomysial antibodies Tissue transglutaminase IgA deficiency would lead to a false negative

Question 258

What is the NICE criteria for IBS?

Answer 258

More than 6 months of abdominal pain associated with bloating and altered bowel habit

Question 259

Signs of acute pelvic inflamamtory disease

Answer 259

``` Sexually active - possibly with new partner Lower abdo pain New vaginal discharge Vomiting fever Adnexel tenderness ```

Question 260

What is the management for acute pelvic inflammatory disease?

Answer 260

parenteral cephalosporin oral doxycyclin treat sexual contacts fluoroquinolone

Question 261

What are the main complications of diverticulitis

Answer 261

``` Perforation Abscess formation Fistulation into adjacent structures Chronic inflammatory strictures --> bowel obstruction Haemorrhage ```

Question 262

What disease is often called 'left-sided appendicitis'

Answer 262

Diverticulitis

Question 263

List the RF for ectopic preganancy

Answer 263

1. Previous ectopic pregnancy 2. Pelvic inflammatory disease - damage to tubes 3. Tubular procedures (Sterilisation) 4. Endometriosis 5. Pelvic surgery 6. In vitro fertilisation 7. Intrauterine contraceptive device

Question 264

Describe presentation of acute diverticulitis

Answer 264

Midline, colicky, poorly localised pain which then migrates to LIF Nausea sometimes vomitting

Question 265

Describe pain progression of ureteric stone

Answer 265

Pain migrating from left flank to iliac fossa | Patient is unable to sit still

Question 266

Sharp pain can indicate

Answer 266

Haemorrhage Perforation Torsion

Question 267

Questions to ask menstruating women

Answer 267

When was your last menstrual period? How regular are your periods? Is there any possibility you are pregnant?

Question 268

Using a PR what can you detect?

Answer 268

Pelvic abscess | Rectal malignancy

Question 269

What imaging should you request for a patient with acute diverticulits?

Answer 269

Abdominal CT with contrast DO NOT REQUEST COLONSCOPY OR BARIUM ENEMA as these could result in perforation

Question 270

What imaging should you consider in a young female patient where you are considering gynaecological problems?

Answer 270

Transabdominal with/without transvaginal ultrasound

Question 271

DDx of Flank Pain

Answer 271

``` Muscular sprain Nephrolithiasis/ureteric colic Spinal pathology (fractures, metastases, disc prolapse) Leaking/rupture AAA Testicular torsion Ectopic pregnancy Ovarian torsion Pyelonephritis Perforated peptic ulcer Renal cancer Abscess Basal Pneumonia Pancreatitis Diverticulitis Appendicitis ```

Question 272

Learning point: Make SOCRATES --> SOCRATES Bitch

Answer 272

Site, Onset, Character, Radiation, Alleviating factors, Timing, Exacerbating factors, Severity, have you ever had this before?

Question 273

Questions to ask when you suspect a UTI?

Answer 273

Any change to how FREQUENTLY you are urianting? Have you felt more URGENCY Have you experienced much PAIN while urinating? Has the urine been cloudy or foul smelling?

Question 274

Questions to ask when you suspect ureteric obstruction/prostate enlargement?

Answer 274

Does it take a while for you to get started? - HESITANCY Any reduced flow? - FLOW Have you noticed any dribbling? - DRIBBLING Have you felt after you've gone that there's still some left? - RETENTION

Question 275

What does polycystic kidney disease predipose to?

Answer 275

Pyelonephritis

Question 276

LEARNING POINT: Aciclovir and indinavir crystallize in the urine

Answer 276

LEARNING POINT: Acetazolamide causes diuresis and potential dehydration

Question 277

In a patient with ureteric stones why do measure serum calcium, phosphate and urate?

Answer 277

To identify the type of stones

Question 278

Ix for possible ureteric pain

Answer 278

``` Urinalysis Urine MC&S urea, creatinine, electrolytes FBC, CRP Serum calcium Serum phosphate Serum urate Bedside USS CT KUB for pregnanant women - magnetic resonance urogram ```

Question 279

What are some signs of renal impairment or failure

Answer 279

High creatinine High urea High potassium

Question 280

What are the four types of Kindey stones

Answer 280

Calcium (75-85%) - radio opaque, calcium oxalate or calcium phosphate or mixed Struvite (10-20%) - ammonium magnesium phosphate Urate (5-10%) Cystine (1%)

Question 281

How do you treat a patient with hypercalciuria?

Answer 281

Ix for hyperparathyroidism Thiazides (to decrease renal excretion of Calcium) Low calcium diet

Question 282

How do you treat patient with hyperuricosuria?

Answer 282

Allopurinol

Question 283

How do you treat a patient with HYPOcitraturia?

Answer 283

Potassium citrate because the citrate alkalinizes the urine to inhibit the formation of crystals

Question 284

Who usually get struvite stones and what are they due to?

Answer 284

Women Secondary to infection with a urease producing bacteria - Proteus, Pseudomonas, Klebsiella

Question 285

How do you treat urate stones?

Answer 285

Potassium citrate Allopurinol

Question 286

How do you treat cystine stones?

Answer 286

Increase fluids to dilate urinary cystine concentration Solubility of cystine like urate is pH dependent so give potassium citrate to alkalise urine and make it easier for stone to pass Cystine-binding drugs can be given - tiopronin

Question 287

Which conditions predispose to renal stone formation?

Answer 287

``` Metabolic: Hypercalciuria Hyperuricosuria Hypocitraturia Hyperoxaluria Gout Hyperuricaemic states - malignancy, G6PD deficiency Cystinuria Primary hyperpaarathyroidism Crohn's disease - oxalate stones Chronic UTI due to urease producing bacteria --> struvite stones Medullary sponge or polycystic kidneys REnal tubular acidosis Sarcoidosis ```

Question 288

What radiographic finding do you see for kindey stones

Answer 288

Kidney stones themselves Hydronephrosis or hydrourter - dilated ureters Perinephric fluid

Question 289

What is the soft tissue rim sign on a CT ?

Answer 289

A stone may be surronded by a rim of soft tissue unlike a phlebolith (calcified pelvic vein)

Question 290

What is the tail sign on a CT?

Answer 290

A soft tissue opacity which extends away from the stone lik a tail - this indicates a phlebolith not a stone

Question 291

What are the complications of kidney stones?

Answer 291

Ureteric stricture Acute/chronic pyelonephritis Renal failure Intrarenal or perinephric abscess - Dx renal mass w/ fluid level USS or radiology Xanthogranulomatous pyelnephritis - Tx: Nephrectomy Urine extravasation into pelvic cavity.

Question 292

List contraindications of NSAIDS

Answer 292

``` Asthma History of anaphylaxis Previous/active peptic ulcer Severe heart failure COX-2 selective inhibitors - promot bleeding no-no in IHD, CVS disease, PAD ```

Question 293

When to use NSAIDs cautiously?

Answer 293

Coagulation defects Renal, cardiac, hepatic impairmenet During pregnancy and breast feeding Elderly patients at risk of bleeding and renal failure

Question 294

What ar ethe indications for surgery on an unruptured AAA

Answer 294

AAA > 5.5 cm AAA diameter growing > 1 cm per year Symptomatic AAA

Question 295

What are the red flags of back pain

Answer 295

Sphincter problems Unable to self-care or walk ``` Weight loss Fever Back tenderness to palpation Thoracic spinal pain Violent trauma ``` Age<20 or >50 severe morning stiffness structural deformity nerve root pain not resolving for > 6 weeks

Question 296

RF for AAA

Answer 296

Smoking Systemic hypertension Male sex Family history

Question 297

List the DDx of Constipation related to abnormal bowel peristalsis

Answer 297

``` IBS Medications (opiates, iron supplements, calcium channel blockers) Hypothryoidism Hypercalcaemia Hypokalaemia MS Parkinson's disease Diabetic neuropahty Idiopathic megacolon Idiopathic slow transit ```

Question 298

List the DDx of Constipation related to hard faeces

Answer 298

Lack of dietary fibre | Dehydration

Question 299

List the DDx of Constipation related to bowel obstruction

Answer 299

Colorectal adenomcarcinoma Sigmoid volvulus Other pelvic masses (uterine fibroids, ovarian tumor) Colonic strictures (radiotherapy, Crohn's disease, diverticular disease)

Question 300

List the DDx of constipation related to a patient not pushing

Answer 300

Haemorrhoids Anal fissure Pelvic floor dysfunction

Question 301

What are the RED FLAGS related to bowel obstruction?

Answer 301

``` Severe, persistent constipation Absolute constipation - not passing stool OR flatus Rectal bleeding Tenesmus Intermittent mucoid diarrhoea Weight loss Iron deficiency anameia Night sweats PMH of UC or colonic polyps Strong family history of colon cancer or colonic polyps esp if family members were <60 ```

Question 302

DDx of constipation with intermittent diarrhoea?

Answer 302

``` IBS (young) Colorectal cancer (>45 years) Diverticular disease (>60 years with hx of left illiac fossa pain) ```

Question 303

Which medications are well known for causing constipation?

Answer 303

1. Opiates 2. Anticholinergics 3. Tricyclic antidepressants 4. Caclium channel blockers 5. Iron supplements

Question 304

What are the markers of colon cancer?

Answer 304

CEA (carcinoembryonic antigen) CA19-9 CA125

Question 305

What are the different imaging tools that can be used to visualise the GI tract

Answer 305

Colonoscopy Protoscopy Rigid sigmoidoscopy - only as far as sigmoid colon Flexible sigmoidoscopy - as far as splenic flexure, takes biopsies, removes small polyps CT colongraphy - abdominal CT scan + filling bowel with air (insufflation) Double-contrast barium enema - give the patient a barium enema and take plain radiographs

Question 306

List the classes of meds that can be used for constipation

Answer 306

Bulk producers - diet, methylcellulose tablets, ispaghula husks Stool softeners - Liquid paraffin, arachis oils, enemas to soften stool Osmotic laxatives - lactluose, movicol (watch out for those with renal impairment/on diuresis eg heart failure patients) Peristalsis stimulatnts - glycerol suppositoris, bisacodyl, senna can Enemas

Question 307

Ddx of polyuria and polydipsia

Answer 307

Diabetes | Hypercalcaemia

Question 308

What are the causes of HYPERCALCAEMIA

Answer 308

Bone metastasis Myeloma Hyperparathyroidism Vitamind D overdose

Question 309

How would ALP, PTH and Phosphate vary in bone mets

Answer 309

HIGH ALP LOW PTH HIGH PHOSPHATE

Question 310

How would ALP, PTH and Phospthate vary in myeloma?

Answer 310

NORMAL ALP LOW PTH HIGH PHOSPHATE

Question 311

How would ALP, PTH and Phosphate vary in Hyperparathyroidsim primary?

Answer 311

NORMAL/HIGH ALP HIGH PTH LOW PHOSPHATE

Question 312

How would ALP, PTH and Phosphate vary in Hyperparathyroidsim tertiary?

Answer 312

NORMAL/HIGH ALP HIGH PTH HIGH PHOSPHATE

Question 313

How would ALP, PTH and Phosphate vary in Vitamin D overdose?

Answer 313

LOW ALP LOW PTH HIGH PHOSPHATE (vit D increase phosphate and calcium absorption by the gut

Question 314

List the clinical features of bowel obstruction

Answer 314

Absolute constipation - not even passing flatus Colicky abdominal pain Distended abdomen Nasuea and vomitting

Question 315

What would you see on an abdominal radiograph to think bowel obstruction

Answer 315

Small bowel loops >3 cm Large bowel loops > 6 cm Large bowel loops --> >9cm risk of perforation

Question 316

How long does ileus take to resolve?

Answer 316

24-72 hours after surgery

Question 317

How can you reduce the risk of post-op ileus?

Answer 317

Local/epidural anesthesia Minismising opiate analgesia Minimising bowel manipulation Encouraging mobilisation of the patient

Question 318

List some RF for bowel cancer

Answer 318

Smoking Excercise and obesity Red meat

Question 319

List the causes of diarrhoea

Answer 319

Infectious Inflammation of the bowel - IBD, diverticular disease Increased motility - hyperthyroidism, anixety, IBS Malabsorption - coeliac's, pancreatic insufficiency An obstruction overflow - hard faeces so only soft stool can pass through Meidcations -

Question 320

Name some medications which can cause diarrhoea`

Answer 320

Laxatives, | Colchicine, Digoxin, Metformin, Thiazide diuretics, antibiotics

Question 321

What are the DDx of Diarrhoea (young, female)

Answer 321

``` Infective diarrhoea IBS Coeliac's Crohn's disease Ulcerative colitis Medications (antibiotics, laxatives) Hyperthyroid ```

Question 322

What are the DDx of Diarrhoea (old)

Answer 322

Neoplasm - villous polyps, colonic adenocarcinoma, pancreatic cancer Diverticular disease Overflow diarrhoea secondary to constipation Ischaemic colitis Microscopic colitis Bacterial overgrowth

Question 323

What is the approach to a patient with diarrhoea?

Answer 323

I would start by managing this patient through an A to E approach I would then assess them for dehydration by checking HEART RATE, BLOOD PRESSURE, MUCOUS MEMBRANES and asking if they FEEL THIRSTY I would then check the patient's electrolytes using either an ARTERIAL BLOOD GAS or VENOUS BLOOD GAS

Question 324

What is mucoid/jelly-like faeces indicative of?`

Answer 324

Salmonella infection | Villous polyps in the colon

Question 325

What are foul smelling/floating stool suggestive of?

Answer 325

Malabsorption - coeliac's Pancreatic duct obstruction - pancreatic cancer, cystic fibrosis Biliary insufficiency - cholecystectomy

Question 326

What are pale stool indiciative of?

Answer 326

Biliary/Pancreatic obstruction Chronic pancreatitis Gallstones

Question 327

What does fresh blood when a patient wipes or faeces streaked with blood indicate?

Answer 327

Anal fissure | Haemorrhoids

Question 328

What does red blood mixed in with the faeces suggest?

Answer 328

Colorectal pathology - UC, dysentery, colorectal carcinoma

Question 329

What would you ask if you want to rule out IBS?

Answer 329

Do you get symptoms at night? Ask about NOCTURNAL SYMPTOMS

Question 330

What is tenesmus indicative of?

Answer 330

A space occupying lesion in the rectum (e.g. carcinoma) | Could be colitis

Question 331

What does an alternating bowel habit suggest for example: diarrhoea --> normal --> constipation?

Answer 331

IBS | Colorectal cancer

Question 332

What would you ask to try to rule out infectious diarrhoea?

Answer 332

Has you ever had something like this before? -Yes? --> Less likely to be infectious diarrhoea

Question 333

DDx diarrhoea + vomitting

Answer 333

infective gastroenteritis

Question 334

DDx of diarrhoea + RIF pain

Answer 334

Terminal ileum inflammation like Crohn's disease, Yersinia enterocolitica infection

Question 335

DDx of diarrhoea + LIF pain

Answer 335

Diverticular disease

Question 336

DDx of relief after motions

Answer 336

IBS

Question 337

What extra abdominal manifestations are associated with IBD (crohn's and UC)?

Answer 337

Uveitis - painful red eye with loss of vision Scleritis - painful red eye with no loss of vision Episcleritis - uncomfortable red eye with no loss of vision Enteric arthritis Erythema nodosum Pyoderma gangrenosum

Question 338

What is erythema nodosum and list some causes

Answer 338

TENDER, raised, red nodules on the skin CAUSES: Crohn's, UC, oral contraceptive pill

Question 339

What is pyoderma gangrenosum and list some causes

Answer 339

Necrotic ulcers CAUSES: Crohn's, UC, oral contraceptive pill

Question 340

What effect do Coeliac disease, Crohn's disease and UC all have on a FBC?

Answer 340

They cause anaemia due to malabsorption of iron, folate and vitamin B12

Question 341

If a patient has diarrhoea and a history of recent antibiotic use what should you test for?

Answer 341

C. difficile toxin test

Question 342

List three symptoms that a patient with UC might present with?

Answer 342

Diffuse pain Bloody diarrhoea Fine between episodes

Question 343

List how a patient with Crohn's might present

Answer 343

``` Pain that is worse in the RLQ Diarrhoea Failure to thrive between episodes, weight loss episcleritis, scleritis, uveitis, erythema nodosum pyoderma gangrenosum anaemia weight loss fatigue ```

Question 344

Why would you perform an abdominal x-ray on a patient with UC?

Answer 344

They are at risk of toxic megacolon - you want to look at their bowel

Question 345

Hallmark of Crohn's?

Answer 345

Non-caseating granulmoas in bowel mucosa

Question 346

Name some of the complications of steroids

Answer 346

Diabetes Osteoporosis Cataracts

Question 347

List some of the medications used to treat Crohn's

Answer 347

Methotrexate (Folate antagonist) Azathioprine (purine synthesis inhibitor) Infliximab (anti-TNFalpha)

Question 348

What diseases is UC associated with?

Answer 348

Colonic adenocarcinoma Primary sclerosing cholangitis Cholangiocarcinoma

Question 349

What investiagtion should you carry out for Grave's disease?

Answer 349

Antithyroid peroxidase ESR (Obviously TFT's so confirm they are hyperthyroid)

Question 350

Why would you request a test for thyroid-stimulating antibodies in patient who is pregnant?

Answer 350

Because in a pregnant patient with Grave's disease the antibodies can cross the placenta which would result in a thyrotoxic fetus and such a baby would need special care at the time of delivery

Question 351

List the extra Gi manifestations of IBD in nails

Answer 351

Clubbing

Question 352

List the extra Gi manifestations of IBD in Eyes

Answer 352

Anvterior uveitis/iritis Scleritis Episcleritis

Question 353

List the extra Gi manifestations of IBD in the skin

Answer 353

Erythema nodosum - raised, red, tender nodules | Pyoderma gangreonosum - inflammatory ulceration and skin necrosis

Question 354

List the extra Gi manifestations of IBD in the joints

Answer 354

Enteric arthritis

Question 355

List the extra Gi manifestations of IBD in the blood

Answer 355

iron-deficiency anaemia Folate deficiency anaemia Vitamin B12 deficiency anaemia

Question 356

List the extra Gi manifestations of IBD in the biliary system

Answer 356

primary sclerosing cholangitis | cholesterol gallstones

Question 357

List the extra Gi manifestations of IBD in the kidney

Answer 357

Kidney stones Fat is not absorbed well Calcium is sequestered in bowel Calcium usually binds oxalate in blood, lack of calcium results in oxalate accumulation and stones

Question 358

List the extra Gi manifestations of IBD in bones

Answer 358

osteomalacia osteoporosis Calcium is not absorbed by the gut because fat is not being absorbed by the gut

Question 359

List the extra Gi manifestations of IBD that starts with A

Answer 359

Amyloidosis

Question 360

Which bacteria is likely to cause an outbreak of vomiting and diarrhoea in an institution?

Answer 360

NOROVIRUS

Question 361

Which bacteria is likely to causes BLOODY DIARRHOEA

Answer 361

E.coli strain O157 | Shigella

Question 362

Which bacteria is likely to cause watery diarrhoea a few days after a barbecue

Answer 362

Campylobacter jejuni

Question 363

Which bacteria is likely to cause diarrhoea rapidly after a meal?

Answer 363

Staphyloccus aureaus | Bacillus cereus

Question 364

Which bacteria is likely to cause diarrhoea in an elderly patient treated with antibiotics

Answer 364

Clostridium difficile

Question 365

Which bacteria is likely to cause RIF + diarrhoea

Answer 365

Yersinia enterocolitica

Question 366

What are the signs a patient may be dehydrated?

Answer 366

``` thirsty dry mucous membranes tachycardic narrow pulse pressure and/or low blood pressure dry lips, mouth, tongue prolonged capillary refill time (> 2 seconds) cool peripheries dizzy on standing ```

Question 367

What is a fluid challenge?

Answer 367

An IV blous of 250-500 mL of crystalloid given over 30 minutes to someone who is hypovolaemic After, they require assesment: - no response: not enough fluid/not hypovolaemic - transient rise in BP: not enough fluid/losing it rapidly - sustained rise in BP: enough fluid

Question 368

What is fluid maintenance?

Answer 368

If a patient cannot drink they need maintenance IV fluids to restore their fluid loss

Question 369

What is replacement fluid?

Answer 369

Extra fluids on top of the maintenance fluids to compensate for the fluids that patient loses. Must do in: febrile patients (+500 mL for every 1 degree) burns patients stoma patients

Question 370

what is a Scybalum

Answer 370

Hard faeces in the intestine

Question 371

List typical features of Crohn's when you look at the bowel

Answer 371

Transmural inflammation - entirety of bowel is affected Skip lesions - Different parts of bowel are affected Cobblestoning - Pattern of how the bowel looks Fistula formation

Question 372

Where is iron absorbed?

Answer 372

In the duodenum

Question 373

Where is folate absorbed?

Answer 373

jejunum

Question 374

Where is B12 absorbed?

Answer 374

ileum

Question 375

List the ANORECTAL DDx of Rectal Bleeding

Answer 375

``` Haemorrhoids Rectal tumour Anal tumour Anal fissure Anal fistula Solitary rectal ulcer Radiation proctitis Rectal varices Trauma ```

Question 376

List the COLONIC DDx of Rectal Bleeding

Answer 376

Diverticular disease Angiodysplasia Colitis (inflammatory, ischaemic, infective) Colonic tumour (benign or malignant) Iatrogenic (endoscopic biospy, anastomatic leakage) Vasculitis

Question 377

List the ILEO-JEJUNAL DDx of Rectal Bleeding

Answer 377

``` Peptic ulceration (including Meckel's diverticulum) Andiodysplasia Arterio-venous malformation Crohn's disease Coeliac disease Aorto-enteric fistula Small bowel tumours ```

Question 378

List the UPPER-GI DDx of Rectal Bleeding

Answer 378

``` Peptic ulcer Gastritis/duodenitis Varices Tumor Mallory-Weis tear Osler-Weber-Rendu syndrome Aorto-enteric fistula Dieulafoy lesion ```

Question 379

What is Olser-Weber-Rendu syndrome?

Answer 379

It is another term for Hereditary Haemorrhagic Telangiectasia

Question 380

Whenever speaking to a patient who has lost blood via cough or via per rectal bleeding, what is the one question you should ask?

Answer 380

How much blood have you lost? - A teaspoon? - A tablespoon - A wineglass?

Question 381

What is one reason a patient has tarry, black stool other than melaena?

Answer 381

They are on iron supplements

Question 382

What does blood mixed with stool indicate?

Answer 382

A lesion proximal to the sigmoid colon Colitis (pain/no pain) Colonic tumor (no pain)

Question 383

What does blood streaked stool indicate?

Answer 383

``` sigmoid or anorectal source Anal tumor (pain) Rectal tumor (no pain) ```

Question 384

What does blood passed immediately after stool mean?

Answer 384

Anorectal condition - haemorrhoids

Question 385

What does blood passed on its own WITHOUT stool indicate?

Answer 385

``` Diverticular disease Angiodysplasia IBD Bleeding cancer Upper GI bleed ```

Question 386

What does blood only seen on the toilet paper indicate?

Answer 386

Bleeding from the anal canal anal fissure (pain) Haemorrhoids (no pain)

Question 387

DDx of pain + PR bleed

Answer 387

anal fissure - tearing pain, may also have itch Colitis - abominal cramps Lower anal cancer

Question 388

What are your HEADLINE DDx of rectal bleeding?

Answer 388

``` Diverticular disease Angiodysplasia Haemorrhoids Colitis Anal fissure Lower GI tumors ```

Question 389

For a PR bleed which conditions should you ask about?

Answer 389

Ulcerative colitis | Upper GI bleed causes - peptic ulcer disease, chronic liver disease

Question 390

What is the relevance of anticoagulant and antiplatelet medication in a patient with a bleed?

Answer 390

They can accentuate bleeding from a lesion

Question 391

What is the relevance of long-term anticoagulation in a patient with PR bleeding?

Answer 391

Long term anticoagulation can make existing angiodysplasia more likely to bleed

Question 392

What is the relevance of NSAIDs with relation to diverticular disease?

Answer 392

NSAIDs increase the likelihood of bleeds from diverticular disease

Question 393

Which two drugs predispose patients to C.difficile infections?

Answer 393

Antibiotics | Proton pump inhibitors

Question 394

What are you looking for on a DRE?

Answer 394

A palpable mass | Blood on the withdrawn finger

Question 395

When would you not perform a DRE for renal bleeding?

Answer 395

Presence of an anal fissure or anal abscess

Question 396

You would not usually feel haemorrhoids on a DRE, what are the exceptions to this rule

Answer 396

Prolapsed haemorrhoids | Thrombosed haemorrhoids

Question 397

What is a raised urea a sign of (usually in the absence of any rise in creatinine)?

Answer 397

An upper GI bleed

Question 398

What imaging should be done in a patient with a PR bleed?

Answer 398

Proctoscopy with/without rigid sigmoidoscopy

Question 399

Ix for acute renal bleeding

Answer 399

Proctoscopy with/without rigid sigmoidoscopy if no lesion is seen then proceed... Colonoscopy - diagnostic + therapeutic Mesenteric angiography - useful if bleeding is too much for colonoscopy, good for ANGIODYSPLASIAS, embolisation can be done CT angiography - fewer complications but lacks therapeutic potential, needs contrast Technetium-99 m-labelled red blood cell scintigraphy - Upper GI endoscopy

Question 400

Angiography is an imaging technique which uses x-rays to look inside the arteries and veins

Answer 400

Use of contrast is contraindicated in patients with renal impairment and for kidney stones

Question 401

Name two causes of intermittent per rectal bleeds

Answer 401

Angiodysplasia | Dieulafoy lesion

Question 402

What is a Dieulafoy lesion

Answer 402

A ruptured submucosal artery mostly commonly rupturing at the oesophagogastric junction or small bowel or rectum

Question 403

What is a Dieulafoy lesion

Answer 403

A ruptured submucosal artery mostly commonly rupturing at the oesophagogastric junction or small bowel or rectum

Question 404

What are some of the modifications that can be made to treat internal haemorrhoids?

Answer 404

Lifestyle: Increased dietary fibre, good hydration, avoidance of straining Medical: Local anaesthetic creams, steroidal creams, laxatives PRN Surgical: rubber band ligation, Injection sclerotherapy, Infrared coagulation/photocoagulation, haemorrhoidectomy, stapled haemorrhoidopexy Doppler-guided haemorrhoidal artery ligation and rectoanal repair

Question 405

What kind of anaemia would iron deficiency anaemia cause?

Answer 405

Microcytic anaemia

Question 406

What is a normal INR?

Answer 406

An INR of 1.1 or below is considered normal An INR of 2-3 is considered normal for a patient on warfarin for disorders like AF INR: International Normalised Ratio Remember! PT is for extrinsic pathway and is the same as INR

Question 407

Where are you most likely to find colonic diverticula?

Answer 407

In the left colon and sigmoid However, right-sided diverticula have a greater propensity to bleed

Question 408

What is the CHA₂DS₂-VASc Score used for?

Answer 408

Predicts risk of stroke in patients with AF

Question 409

How would you manage an anal fissure?

Answer 409

1. High-fibre diet + laxatives +/- non-constipating analgesics 2. Topical anaesthetics (lidocaine gel) 3. GTN spray - increase blood flow + relax anal sphincter Topical diltiazem 4. Botox injections

Question 410

What surgical management could be used for an anal fissure?

Answer 410

Lateral internal sphincterectomy - However, integrity of external anal sphincter must be checked with USS Anal advancement flap

Question 411

What is the anatomical definition of 'lower' GI haemorrhage?

Answer 411

Bleeding that arises distal to ligament of Treitz at the duodenojejunal junction

Question 412

What are the classifications of internal haemorrhoids?

Answer 412

First degree: Bleed but do not prolapse Second degree: Prolapse but reduce spontaneously Third degree: Prolapse and do not reduce spontaneously but can be manually reduced Fourth degree: Prolapse and are irreducible

Question 413

What is the difference between diverticulosis, | diverticular disease and diverticulitis?

Answer 413

Diverticulosis - Outpouching of the mucosa Diverticular disease - When Diverticulosis starts causing pain or bleeding Diverticulitis - When there is diverticular inflammation

Question 414

Why are colonic diverticula considered 'false' diverticula

Answer 414

Because they lack the outer coat of muscularis propria | In Meckel's diverticulum the outpouching is covered by all layers of the bowel wall

Question 415

What are the known RF for colorectal carcinoma?

Answer 415

``` Increasing age Male sex (For rectal carcinoma) Central obesity IBD (esp UC) PMH Colorectal cancer Colorectal polyps Colorectal irradiation Familial adenomatous polyposis Hereditary non-polyposis colorectal cancer Peutz-Jeghers Juvenile polyposis Cowden's disease MYH-related polyposis Sedentary life style ```

Question 416

In which seven scenarios would you refer a patient to a specialist with regards to change in bowel habit?

Answer 416

40+, rectal bleeding, change in bowel habit (looser stool/more frequent stool), 6+ weeks 60+, rectal bleeding for 6+ weeks 60+ change in bowel habit for 6+ weeks Any age RLQ abdo mass involved with large bowel involvement Any age palpable rectal mass intraluminal Men of any age with iron deficiency anaemia Non-menstruating women with iron deficiency anaemia

Question 417

Remember, NSAIDs increase risk of bleeding in?

Answer 417

Diverticular disease

Question 418

What is Oliguria?

Answer 418

Reduced urine output <0.5ml/kg/hour or <400mL/day or <30ml/hour

Question 419

What is Oliguria?

Answer 419

Reduced urine output <0.5ml/kg/hour or <400mL/day or <30ml/hour

Question 420

What is anuria?

Answer 420

Complete absence of urinary output

Question 421

What are the pre-renal DDx of poor urine output (due to inadequate blood supply to the kidneys)

Answer 421

Hypovolaemia - dehydration, haemorrhage Hypotension - sepsis, pancreatitis Heart failure - Reduced local perfusion of kidneys - dissecting aneurysm, renal emboli

Question 422

What are the Renal ddx of poor urine output (due to damage resulting in impaired kidney function)

Answer 422

TUBULAR: Acute tubular necrosis Glomerulonephritis Interstitial nephritis (Drugs, NSAIDs, antibiotics) ``` Vascular: Vasculitides Haemolytic uraemic syndrome Thrombocytic thrombocytopenic purpura Disseminated intravascular coagulation Malignant hypertension Scleroderma ``` Malaria Legionnaires' disease Leptospirosis Multiple myeloma

Question 423

What are the Post-Renal DDx of poor urine output (obstruction to urinary flow)

Answer 423

Ureter - abdominal/pelvic mass Complication of pelvic surgery Bilateral calculi (renal stone) Retroperitoneal fibrosis Bladder: Neuropathic bladder Anticholingeric or sympathomimetic drugs Bladder stones or tumour Utrerovaginal prolapse ``` Urethra: Benign prostatic hyperplasia Blocked catheter Prostate cancer Urethral stricture Posterior urethral valve Trauma Infection ```

Question 424

What is the average amount of fluid an adult of average would intake per 24 hours?

Answer 424

3L or 30-50 mL/kg/day

Question 425

List some nephrotoxic drugs

Answer 425

``` NSAIDs ACE inhibitors Diuretics Gentamycin Vancomycin ```

Question 426

Why does haemorrhage result in a delayed drop in haemoglobin?

Answer 426

Because haemorrhage results in a loss of haemoglobin and serum in equal measure. However, haemoglobin calculated by the lab is a measure of concentration rather than actual volume

Question 427

What does a 50% increase in baseline creatinine suggest?

Answer 427

Acute Kidney Injury

Question 428

What pathology does an AKI point towards

Answer 428

renal hypoperfusion - hypovolaemia, hypotension, heart failure, reduced local perfusion of kidneys Renal

Question 429

What is frothy urine and swollen ankles a sign of?

Answer 429

Nephrotic syndome

Question 430

What is atelectasis?

Answer 430

Small areas of alveolar collapse that are common after surgery - can cause crackles

Question 431

What might you find on a USS in an individual with postrenal obstruction?

Answer 431

Dilated ureters - HYDROURETER | Dilated renal pelvis/calyces - HYDRONEPHROSIS

Question 432

What raised measure on a blood test would clinch a query hypovolaemia?

Answer 432

Raised urea

Question 433

What is the NICE recommendation for fluid maintenance?

Answer 433

Volume: 25-30 mL/kg/day Electrolytes: 1 mmol/kg/day of K, Na, Cl Glucose: 100 g/day

Question 434

What is the difference between acute/acute-on-chronic urinary obstruction vs chronic obstruction?

Answer 434

Acute/acute-on-chronic obstruction presents with pain | Chronic obstruction is painless

Question 435

What are the outcomes after a TWOC?

Answer 435

If patient doesn't fail - Alpha blocker/5a reducatease inhibtor If patient fails - alpha blocer/5a-reductase inhibitor + in-dwelling catheter and later appointment for TWOC Fails again - possible TURP (would be done if creatinine was high)

Question 436

What is the definition of an AKI?

Answer 436

AKI is an umbrella term for pathologies which damage the kidneys like ACS It is defined as Oliguria (urine output <0.5 mL/kg/hour) AND rise in creatinine (>50% of baseline)

Question 437

What happens to calcium and phosphate in chronic renal failure?

Answer 437

Low calcium | High phosphate

Question 438

What are the four complications of a catether?

Answer 438

UTI - Proteus mirabilis Urethral trauma Urethral scarring and stricture Bladder perforation

Question 439

What are the main complications of chronic urinary retention?

Answer 439

Bladder full of urine --> overflow -->INCONTINENCE Urine is stationary --> bacteria can grow --> UTI Urine is stationary --> chemicals react --> BLADDER STONES Bladder full of urine --> rise in back pressure --> HYDROURETERS and HYDRONEPHROSIS Hydronephrosis --> RENAL FAILURE ACUTE-ON-CHRONIC URINARY RETENTION BLADDER WALL HYPERTROPHY AND OUTPOUCHING

Question 440

What are the indications for dialysis in an acute setting?

Answer 440

ACUTE RENAL FAILURE (Oliguria or Anuria with deranged renal function) With ``` Severe hyperkalaemia >6.5mM (Despite max med) Severe acidosis pH <7.2 Severe pulmonary oedema Urea >30 mM and creatinine >1000microM Uraemic encephalopathy ```

Question 441

What are the DDx of Polyuria?

Answer 441

Diabetes mellitus (think steroids and Cushing's syndrome) Diuretics (medication, caffeine, alcohol, lithium) Heart failure Hypercalcaemia Hyperthyroidism Primary polydipsia Hypokalaemia Hyperuricaemia Diabetes insipidus - Chronic renal failure/hypercalcaemia due ot bone mets

Question 442

What are LUTS symptoms

Answer 442

``` FREQUENCY: How many times URGENCY: HESITANCY TERMINAL DRIBBLING INCOMPLETE VOIDING ```

Question 443

What Ix should you do in a patient who presents with polyuria?

Answer 443

Capillary blood glucose - look for DM Urinalysis - UTI, DM (glucosuria, keotnuria) Fasting plasma glucose - Diabetes mellitus Urine osmolality Electrolytes Urea, creatinine, eGFR Serum calcium - check hypercalcaemia and bone mets Thyroid function tests - hyperthyroidism

Question 444

List some of the causes of central/cranial diabetes insipidus

Answer 444

``` Head injury Pituitary tymours Craniopharyngiomas Metastases Surgery Vascular lesion Meningitis ```

Question 445

List some of the causes of nephrogenic diabetes insipidus?

Answer 445

Renal damage due to low potassium, high calcium Drugs like lithium Pyelonephritis Hydronephrosis

Question 446

What is the test to differentiate between cranial and nephrogenic diabetes insipidus

Answer 446

``` A water deprivation test 1. 24 hour urine collection is more than 3 hours 2. Weigh patient throughout 3. Deprive water 4. Give Desmopressin (ADH analogue) CRANIAL DI --> Normal urine osmolality NEPHROGENIC DI --> Low urine osmolality ```

Question 447

What is the diagnostic criteria for Type 1 Diabetes Mellitus?

Answer 447

Fasting plasma glucose >7mM Plasma glucose >11.1mM 2 hours after 75g of glucose A1C >48mmol/mol

Question 448

LEARNING POINT: Hypercalcaemia can cause constipation as well as polyuria

Answer 448

LEARNING POINT: A high calcium should be followed up with an ALP which will be high in bone metastasis and low in multiple myeloma Multiple myeloma can be investiagted using a serum and urine electrophoresis where you will look for paraprotein

Question 449

Primary polydipsia is most common in which patients?

Answer 449

Schizophrenics

Question 450

Which patients will you see DKA in ?

Answer 450

Undiagnosed type-1 diabetics Non-compliant type-1 diabetics Ill type-1 diabetics

Question 451

List the Ddx of a Groin Lump

Answer 451

``` Indirect inguinal hernia Direct inguinal hernia Femoral hernia Inguinal lymphadenopathy Saphena varix (dilated great saphenous vein) Psoas abscess/bursa Lipoma Sebaceous cyst Neuroma Femoral aneurysm/pseudoaneurysm Ectopic testis Undescended testis Hydrocele of cord ```

Question 452

What are the two main risks of hernias?

Answer 452

Bowel obstruction - interruption to bowel flow | Bowel strangulation - blood supply to a part of bowel is compromised

Question 453

What questions do you need to ask about a groin lump?

Answer 453

How long have you had it? Is the lump always there or does it every go away? Has the lump gotten bigger, smaller or stayed the same? Is the lump painful? Are there any other lumps? Has there been abdominal pain? Have you been straining/had a chronic cough? Have you been doing any heavy lifting? Have you had any recent operations to the groin? Have you had any trauma or infection in the lower limb or groin?

Question 454

What are the B symptoms of Lymphoma?

Answer 454

``` Weight loss Night sweats Fever Anorexia Pruritis - itchy skin ```

Question 455

THE NECK OF THE SWELLING IS IMPORTANT TO LOOK OUT FOR IN A HERNIA Where will the neck be for an inguinal hernia?

Answer 455

Superior and medial to the pubic tubercle

Question 456

Where will the neck be for a femoral hernia?

Answer 456

Inferior and lateral to the pubic tubercle

Question 457

Describe a simple bedside examination that can be done to differentiate between a direct and indirect inguinal hernia

Answer 457

First, reduce the hernia through the superficial inguinal ring Second, place a finger over the deep ring (the midpoint of the inguinal ligament) Third, get the patient to cough IF THE HERNIA REAPPEARS IT IS A DIRECT HERNIA

Question 458

LEARNING POINT: Inguinal hernias are more common than femoral hernias

Answer 458

LEARNING POINT: Femoral hernias are more common in women than men. They are more likely to strangulate due to narrower neck

Question 459

For which hernias should patients never wear a truss?

Answer 459

Irreducible hernia

Question 460

How can you divide your differentials for inguinal lymphadenopathy?

Answer 460

Infective and Neoplastic | Systemic and Local

Question 461

Causes of systemic infective inguinal lymphadenopathy?

Answer 461

HIV | TB

Question 462

Causes of local infective inguinal lymphadenopathy?

Answer 462

Non-specific lymphadenopathy from groin/lower limb infection/STD

Question 463

Causes of systemic neoplastic inguinal lymphadenopathy?

Answer 463

Lymphoma | Leukaemia

Question 464

Causes of local neoplastic inguinal lymphadenopathy?

Answer 464

Metastases from primary in lower limb, external genitalia or perianal region

Question 465

Which hernia is more common in women than men?

Answer 465

Femoral hernias

Question 466

Which hernia is most common in women?

Answer 466

Indirect inguinal hernias (most common in men too)

Question 467

What are three reasons why an hernia is irreducible?

Answer 467

1. It is INCARCERATED - The hernia is stuck in the abnormal position 2. It is OBSTRUCTED - The neck of the hernia creates an obstruction to the passage of flow through the bowel 3. It is STRANGULATED - The bowel has become so constricted by the neck of the hernial sac the blood supply is compromised and it will necrose rapidly from ischaemia

Question 468

What lies in the inguinal canal?

Answer 468

Male canal - ilioinguinal nerve and spermatic cord | Female canal - ilioinguinal nerve and round ligament

Question 469

What is a herniotomy?

Answer 469

Surgical excision of a hernial sac

Question 470

What is herniorrhapy?

Answer 470

Repair of a hernia using locally available tissues

Question 471

What is a hernioplasty?

Answer 471

Repair of a hernia using synthetic material such as a mes

Question 472

What is an important question to ask to screen for testicular cancer?

Answer 472

Do the testis feel heavy at all?

Question 473

When examining a scrotal mass what 4 key things do you want to touch on?

Answer 473

Can you get above the mass? No - inguinoscrotal hernia Can you palpate the testis seperately from the swelling/lump? Does the scortum transilluminate? - IT WILL GLOW IF FULL OF FLUID Is the mass tender?

Question 474

Scrotal mass - can't get above it?

Answer 474

Inguinoscrotal hernia

Question 475

Scrotal mass - can get above it, not seperate from testis, transilluminable?

Answer 475

Hydrocele

Question 476

Scrotal mass - can get above it, not seperated from testis, not transilluminable, tender?

Answer 476

Torsion Orchitis Epididymoorchitis Acute haematocele

Question 477

Scrotal mass - can get above it, not seperated from the testis, mass is not transilluminable, not tender

Answer 477

Cancer Chronic haematocele Gumma

Question 478

Scrotal mass - can get above it, seperate from testis, transilluminable

Answer 478

Epididymal cyst | Acute idiopathic scrotal oedema

Question 479

Scrotal mass - can get above it, seperate from testis, not transilluminable, tender

Answer 479

Acute epididymitis | Torsion of hydatid of Morgagni

Question 480

Scrotal mass - can get above it, seperate from testis, transilluminable, non-tender?

Answer 480

TB epididymitis | Post vasectomy sperm granuloma

Question 481

What is the single biggest risk factor for testicular tumor?

Answer 481

History of undescended or maldescended testes

Question 482

What are the two most common type of testicular tumor?

Answer 482

OLDER SERGEANTS Seminomas - men 30-50s | YOUNGER TROOPER Teratomas - men 20-30s

Question 483

Are varicoceles more on the right or left?

Answer 483

Idiopathic varioceles are more common on the left

Question 484

In men <35 with epididymo-orchitis which bacterium is the most likely source of infection?

Answer 484

Chlamydia trachomatis | Neisseria gonorrhoeae

Question 485

In men >35 with epididymo-orchitis which bacterium is the most likely source of infection?

Answer 485

E.coli

Question 486

What two things must be established for any patient who presents with acute limb weakness?

Answer 486

The time course | Where the neurological lesion is

Question 487

What does sudden onset (seconds-minutes) weakness imply?

Answer 487

Trauma - fracture | Vascular insult - stroke, TIA

Question 488

What does subacute onset (hours to days) weakness suggest?

Answer 488

``` Progressive demyelination (Guillan-Barre syndrome, multiple sclerosis) Slowly expanding haematoma - Subdural haematoma ```

Question 489

What does chronic onset (weeks to months) weakness suggest?

Answer 489

Slow growing tumour | Motor neuron disease

Question 490

What are the DDx for sudden onset limb weakness?

Answer 490

``` Ischaemic stroke TIA Haemorrhagic stroke Hemiplegic migraine Todd's palsy (post seizure paralysis) Hypoglycaemia ``` Spinal disc prolapse Spinal cord transection Spinal cord infarction Vertebral fracture Acute limb ischaemia Traumatic nerve injury

Question 491

What are the DDx for subacute limb weakness?

Answer 491

Multiple sclerosis Haematoma Tumour Abscess Transverse myelitis Guillain-Barre syndome Poliomyelitis Botulism Tetanus

Question 492

What are the DDx for gradual onset limb weakness?

Answer 492

Spinal canal stenosis Vitamin B12 deficiency Diabetes mellitus Vasculitis Myasthenia gravis Lambert-Eaton syndrome Myositis

Question 493

Questions to ask of a patient with acute limb weakness?

Answer 493

Onset and how long it has been going on for? Any speech disturbance? Any visual disturbance? Any headache? Any seizures or loss of consciousness? Any neck or back pain? (indicates spine pathology) Any trauma? RF? Have you had a stroke or TIA in the past? Do you have atrial fibrillation? Do you smoke? Has anyone in the family every had a stroke? Do you have high blood pressure? Do you have diabetes mellitus? Do you have high cholesterol?

Question 494

LEARNING POINT: A headache is unusual in stroke or TIA

Answer 494

LEARNING POINT: Sudden-onset terrible headache - SAH Unilateral headache before limb weakness - hemiplegic migraine gradual-onset headache before limb weakness - intracranial mass, subdural haemorrhage

Question 495

What happens to plantars in UMN lesions?

Answer 495

They are upwards (Babinski reflex)

Question 496

What do you see in UMN vs LMN?

Answer 496

Clonus in UMN | Wasting in LMN

Question 497

Where is the lesion in a receptive dysphasia (where the patient can speak almost fluently but can't understand)

Answer 497

Wenicke's area (temporal lobe)

Question 498

Where is the lesion in expressive dysphasia (where the patient can comprehend language but cannot find words or speak fluently)

Answer 498

Brocas area (frontal lobe)

Question 499

What kind of lesion when eyes deviate away from weak side?

Answer 499

Cortical lesion

Question 500

What kind of lesion when eyes deviate towards weak side?

Answer 500

Brain-stem lesion

Question 501

In a weak limb with LMN signs what do sensory signs indicate?

Answer 501

Sensation present --> nerve root/peripheral nerve lesion Sensation absent --> NMJ, muscular lesion

Question 502

In a weak limb with UMN signs what do sensory signs indicate?

Answer 502

Anterior spinal artery infarct spares dorsal column - light touch, vibration, position sense or proprioception BUT temperature and pain won't be felt

Question 503

How much is the MRC scale out of for limb strength?

Answer 503

it is out of 5

Question 504

How do you differentiate UMN facial weakness and LMN facial nerve palsy?

Answer 504

UMN facial weakness - sparing of forehead wrinkling and blink It will be completely lost for LMN lesion

Question 505

What is dysarthria?

Answer 505

Difficulty speaking

Question 506

What are the two types of strokes?

Answer 506

Ischaemic (80%) or haemorrhagic (20%)

Question 507

What are the DDx for a lesion in the cerebral cortex

Answer 507

Stroke Cerebral mass (tumour, abscess) Hemiplegic migraine Hypoglycaemia

Question 508

Learning point: In the organisation of the motor homunculus The lower limbs are more medial The upper limbs and face are more lateral

Answer 508

Learning point: The medial motor cortex is supplied by the ANTERIOR CEREBRAL ARTERY The rest of primary motor cortex is supplied by the MIDDLE CEREBRAL ARTERY

Question 509

List the Ix for a stroke

Answer 509

CT head scan (however, it can take up to 24 hours for infarction to be apparent on CT) FBC Blood glucose - for hypoglycaemia Blood clotting - For patients on warfarin, eclude haemophilia or coagulopathy ECG - looking for AF

Question 510

What are the 2nd line Ix for an ischaemic stroke or TIA?

Answer 510

Carotid Doppler ultrasonography - look for sources of atheromas ECG

Question 511

How should patients with stroke be assessed for disability?

Answer 511

GCS Swallowing - otherwise risk of aspiration and/or NG tube Speech and Language - Visual fields - to avoid tripping/things placed outside field of vision Gait - if they cannot walk they need prophylaxis for DVT and pressure sores

Question 512

How do you manage a patient after the acute phase of the stroke?

Answer 512

``` RF reduction Drug prophylaxis - daily antiplatelets (clopidogrel) daily statin daily ACEi/thiazide diuretics to lower BP discharge with community care follow-up by GP ```

Question 513

How do you manage haemorrhagic stroke?

Answer 513

neurosurgical and neurocritcal care evaluation admission to neuroscience ICU or stroke unit airway protection aspiration precaution

Question 514

How long does it take for TIAs to resolve?

Answer 514

80% within 1 hour and 100% within 24 hours

Question 515

What Ix is needed to determine stenosis of the carotid arteries

Answer 515

Doppler ultrasound of the carotids | listening for carotid bruits is not sensitive enough

Question 516

Name some causes of cord compression

Answer 516

``` Space occupying lesion Tumour Abscess Cyst Haematoma ```

Question 517

What is another name for rapid afferent pupillary defect?

Answer 517

Marcus Gunn pupil

Question 518

INO stands for

Answer 518

Internuclear ophthalmoplegia

Question 519

What are the two visual defects associated with multiple sclerosis?

Answer 519

Optic neuritis | Ineternuclear ophtalmoplegia

Question 520

What are the Ix for Multiple Sclerosis?

Answer 520

``` MRI- brain MRI - spine FBC Metabolic panel TFTs B12 CSF evaluation - looking for oligoclonal bands Evoked potentials test ```

Question 521

What are the grade in the MRC scale for power?

Answer 521

Grade 5 - normal Grade 4 - move against gravity/resistance by examiner Grade 3 - move against gravity Grade 2 - movement only if gravity is eliminated Grade 1 - flicker is perceptible in muscle Grade 0 - no movement

Question 522

What are some of the contraindications to thrombolysis for treatment of ischaemic strokes

Answer 522

Onset cannot be confirmed as within 4.5 hours Acute intracranial hemorrhage on CT scan Seizure at onset of stroke Symptoms of SAH Stroke or serious head injury in the last 3 months Major surgery or serious trauma within 2 weeks Previous intracranial hemorrhage Intracranial neoplasm AV malformation or aneurysm GI or urinary tract haemorrhage in last 3 weeks LP in the preceding week Platelets <100x10^9 INR >1.7 Glucose <2.7 mmol/L or >22mmol/L Positive pregnancy test Rapidly improving neurological signs SBP >185 mmHg, diastolic BP>110 mmHg Suspected acute pericarditis in addition to stroke

Question 523

What is the reference range for an INR?

Answer 523

An INR >4.5 is at risk of haemorrhage INR <2 risk of thromboembolism

Question 524

List some causes of Brown-Sequard syndrome?

Answer 524

Multiple sclerosis | Penetrating trauma to the spine or spinal fractures km

Question 525

Name site of lesion for FULL BODY HEMIPARESIS

Answer 525

Contralateral cerebral motor cortex | Contralateral corona radiata, internal capsule or pons

Question 526

Name site of lesion for LIMB HEMIPARESIS

Answer 526

Contralateral cerebral motor cortex Contralateral corona radiata, internal capsule or pons Ipsilateral spinal lateral motor tract (cervical disc prolapse)

Question 527

Name site of lesion for isolated limb weakness

Answer 527

Contralateral motor cortex Peripheral nerve root Peripheral nerve

Question 528

Name site of lesion for paraparesis?

Answer 528

Bilateral cerebral motor cortex BIlateral motor spinal tracts (Cord compression) Cauda equina (lumbar intervertebral disc prolapse) Bilateral lumbosacral plexus (Guillain-Barre syndrome)

Question 529

Name site of lesion for tetraplegia

Answer 529

Bilateral motor tracts of cervical spinal cord | Peripheral nerves

Question 530

Name site of lesion for proximal muscle weakness

Answer 530

``` Neuromuscular junction (myastenia gravis, Eaton-Lambert syndrome) Muscles or secondary to other conditions (hyperparathyroidism) or drugs (statins) ```

Question 531

What are the risk factors for gout?

Answer 531

``` Thiazide diuretics Heavy, excessive alcohol use Chronic renal failure Chemotherapy Previous history of gout History of renal stones ```

Question 532

What are the risk factors for septic arthritis?

Answer 532

Immunosuppresion: Diabetes, HIV, on steriods | Prosthetic joints

Question 533

How would you approach examining a painful joint?

Answer 533

Examine one joint above and one joint below | Then LOOK FEEL AND MOVE

Question 534

What is the difference between articular and periarticular conditions?

Answer 534

Articular - diffusely inflamed joint and pain on passive as well as active movement (pain all the time) Periarticular - one point of tenderness and worse on active movement more than passive

Question 535

What 3 nail conditions is associated with psoriasis?

Answer 535

Pitting Onycholysis Subungal hyperkeratosis

Question 536

What is uveitis?

Answer 536

Inflammation of the middle layer of the eye, Painful red eye with diminished vision Irregularly shaped pupil

Question 537

What are some signs of pulmonary fibrosis?

Answer 537

Clubbing | Fine crackles at the end of inspiration

Question 538

LEARNING POINT: Pulmonary fibrosis is associated with inflammatory arthropathies (like RA) and methotrexate

Answer 538

DON"T FORGET | RA - METHOTREXATE - PULMONARY FIBROSIS

Question 539

What investigation should you to exclude septic arthritis?

Answer 539

Arthrocentesis

Question 540

What findings are possible from arthrocentesis?

Answer 540

Gout - urate crystals, negatively birefringent, needle-shaped Pseudogout: Calcium pyrophosphate crystals, positive birefringent and rhomboid Infection: cloudy, raised WCC, raised neutrophils, bacteria on a microscope Haemoarthrosis: Blood Fracture: Presence of fat globules Just white cells - inflammatory Normal asspirate - trauma or osteoarthritis

Question 541

What kind of inflammatory arthropathies are there?

Answer 541

``` Reactive arthritis Enteric arthopathy Rheumatoid arthritis Psoriatic arthritis Rheumatic fever ```

Question 542

What are the following antibodies used to detect?

Answer 542

Rheumatoid factor - RA Anticyclic citrullinated peptid antibodies - RA Antinuclear antibody - SLE

Question 543

Where are the two most common sites for flare up of gout?

Answer 543

The big toe - podagra | The knee

Question 544

High does aspirin is sometimes contraindicated in patients with gout, why?

Answer 544

Because ti can cause hyperuricaemia by impairing urate excretion

Question 545

What is the triad of reactive arthritis (a.k.a Reiter's syndrome)

Answer 545

Uveitis - Can't see Urethritis - Can't pee Arthritis - Can't climb a tree It is usually after either gastroenteritis or sexually transmitted urethritis

Question 546

What are the likely infective organisms in native joints ?

Answer 546

Staphylococcus aureus Mycobacterium tuberculosis - immunosuppresed Neisseria gonorrhoeae - STD Salmonella - sickle cell disease

Question 547

What is the likely infective organisms in a prostehtic joint?

Answer 547

Staphyloccus epidermidis

Question 548

What are the radiographic features of osteoarthritis?

Answer 548

L - Loss of joint space O - Osteophyte formation S - Subchondral sclerosis S - Subchondral cysts

Question 549

List DDx of unilateral acutely swollen calf

Answer 549

``` DVT Cellulitis Ruptured Baker's cyst Muscular strain (torn gastrocnemius) Septic arthritis (knee, ankle) Allergic response Compartment syndrome ```

Question 550

List DDx of bilateral swollen legs?

Answer 550

``` Right heart failure Lymphoedema Venous insufficiency Pregnancy Vasodilators (Calcium channel blockers Hypoalbuminaemia: from nephrotic syndrome, liver failure, malabsorption/malnutrition or sepsis Pelvic tumor compressiong the IVC Fluid overload ```

Question 551

Key features of venous ulcers

Answer 551

Moderately painful Better when eleveated Present late because they are not painful ``` Associated with: varicose veins stasis eczema heavy legs swelling around ulcer ```

Question 552

What are some of the indications of peripheral vascular disease?`

Answer 552

Claudication Impotence Abdominal Aortic Aneurysm

Question 553

What are some RF for hypercoagulable blood you have to screen for in patients?

Answer 553

Have you had any falls or damage recently? Have you undergone any major surgery in the last 3 months? Have you been pregnant or given birth recently? Do you have any inflammatory bowel disease? Do you have cancer? Is the patient obese? Are you on the OCP or HRT? Has anyone in the family every had clots in the legs? Have you ever had clots in your legs before?

Question 554

When screening for cellulitis or septic arthritis what kinds of questions would you ask?

Answer 554

Have you had any cuts, insect bite or other wounds to your leg

Question 555

LEARNING POINT: Cellulitis can spread fairly quickly along the affected limb whereas other pathologies are likely to remain confined in the short term

Answer 555

LEARNING POINT: Radiotherapy or surgery can lead to lymphoedema Low grade pyrexia is possible with DVT

Question 556

Where are you most likely to find pressure ulcers?

Answer 556

Heel | Malleoli

Question 557

How will the different ulcers look like?

Answer 557

Venous - Irregular, sloping, white Arterial - Well defined, deep, punched out edges Neuropathic and pressure - Raised callous edges

Question 558

What are some causes of a raised D-dimer

Answer 558

``` PE DVT Cellulitis ACS Atrial fibrillation Pneumonia Vasculitis Sickle cell crises Superficial phlebitis Malignancies DIC ```

Question 559

What is Ankle-brachial pressure index (ABPI)?

Answer 559

It measured to exlcude arterial disease as a cause of the ulcer It's measured using a sphygmomanometer and portable Doppler probe ABPI = ratio of ankle systolic pressure: brachial systolic pressure ABPI <0.8 - ulcer is mixed venous and arterial and compression will make an arterial ulcer worse

Question 560

Why is it important to know FBC in any patient with ischaemic related pathology?

Answer 560

Anaemia will make the iscahemia worse

Question 561

List some of the features of compartment syndrome

Answer 561

A tense, shiny swollen limb (calf more than a joint) Painful to passive movement Progression to neurovascular compromise Can lead to Volkmann's contracture)

Question 562

What are the 6P's of acute limb ischaemia?

Answer 562

``` Pale Paralysed Paraesthesia Painful Pulseless Perishingly cold ```

Question 563

What is the appropriate management for a venous ulcer?

Answer 563

Give her enough nutrition Encourage patients to move around/lose weight Elevate the leg Give compression bandages Graduated class I or II elastic stockings Varicose vein surgery

Question 564

List some diseases which make blood more likely to clot

Answer 564

Malignancy Antiphospholipid syndrome Disseminated Intravascular Coagulation Polycythaemia

Question 565

List some drugs which make blod more likely to clot

Answer 565

Combined oral contraceptive pill HRT Heparin - caused heparin induced thrombocytopenia

Question 566

What are the risks of percutaneous angioplasty?

Answer 566

Infection Haemorrhage Haematoma Adverse reaction to the analgesia Thrombosis/embolisaition Perforation of artery Aneurysm or pseudoaneurysm Reaction to contrast dye

Question 567

List some features of venous insufficiency

Answer 567

Lipodermatosclerosis Haemosiderin staining Atrophie blanche Venous eczema

Question 568

What are the side effects of warfarin?

Answer 568

``` HAEMORRHAGE Nausea, vomiting, diarrhoea, rash Purple toes and skin necrosis Hepatic dysfunction Jaundice Pancreatitis ```

Question 569

What percentage of the population has a patent foramen ovale?

Answer 569

10% This is significant because of the 35% of the people who get thromboembolic strokes where the origin is not know, 20% have a patent formane ovale which allows a thrombus from the veins to get into the systemic circulation

Question 570

LEARNING POINT: D-dimer is SENSITIVE not SPECIFIC for DVT Even if D-dimer is negative but pre-test probability is high you would still do the scan

Answer 570

What that means if that if there is a DVT then the D-dimer will LIKELY be raised (NOT ALWAYS) however, it being raised does not SPECIFICALLY INDICATE that the patient has a DVT D-dimer is useful for excluding DVT is the Wells score is low. It should be used in conjunction with the Wells score

Question 571

What is the target INR range for a patient with a DVT?

Answer 571

2-3

Question 572

What is the target INR for a patient with an arterial thromboembolism or with DVT already on oral anticoagulants?

Answer 572

3-4

Question 573

Which organism most likely causes cellulits?

Answer 573

Staphylococcus pyogenes | Staphylococcus aureus

Question 574

List the DDx for a leg ulcer

Answer 574

``` Venous ulcer Mixed arterial/venous ulcer Arterial (atherosclerotic) ulcer Pressure ulcer Neuropathic ulcer Lymphoedema ulcer Traumatic ulcer Malignant ulcer Vasculitic ulcer Infective ulcer Hameolytic anameia ```

Question 575

How do the different types of ulcer differ in terms of pain?

Answer 575

Venous ulcers - LESS painful when elevated and drained of blood, only 30% are painful Arterial ulcers - MORE painful when elevated and drained Neuropathic ulcers - loss of sensation, NOT PAINFUL Pressure ulcers - Tender to touch, not inherently painful

Question 576

How do the different ulcers differ in terms of when they present?

Answer 576

Arterial ulcer - present early due to pain Neuropathic pain - present late due to lack of sensation Venous ulcer - presents late, long, recurrent history Pressure ulcer - develop rapidly LONG HISTORY: Marjolin ulcer (squamous cell carcinoma)

Question 577

Key features of venous ulcers

Answer 577

Moderately painful Better when eleveated Present late because they are not painful ``` Associated with: varicose veins stasis eczema heavy legs swelling around ulcer ```

Question 578

What are some of the indications of peripheral vascular disease?`

Answer 578

Claudication Impotence Abdominal Aortic Aneurysm

Question 579

Where are you most likely to find a venous ulcer?

Answer 579

On the GAITER AREA (side of the leg above the ankle) | Especially medial side

Question 580

Where are you most likely to find an arterial ulcer?

Answer 580

The ball of the foot Between the toes Between the tips of toes Lateral malleolus

Question 581

Where are you most likely to find a neuropathic ulcer?

Answer 581

Pressures areas of the foot | Beneath the metatarsal heads

Question 582

How will the different ulcers look like?

Answer 582

Venous - Irregular, sloping, white Arterial - Well defined, deep, punched out edges Neuropathic and pressure - Raised callous edges

Question 583

What Ix do you perform for a patient with an ulcer?

Answer 583

Bloods: FBC, Fasting lipids - to assess atherosclerosis Capillary gluocse: Assessing whether she has capillary gluocse Urinalysis: Venous duplex ultrasound Ankle-brachial pressure index (ABPI) Swabbing

Question 584

What is Ankle-brachial pressure index (ABPI)?

Answer 584

It measured to exlcude arterial disease as a cause of the ulcer It's measured using a sphygmomanometer and portable Doppler probe

Question 585

Why is it important to know FBC in any patient with ischaemic related pathology?

Answer 585

Anaemia will make the iscahemia worse

Question 586

Why would an arterial duplex ultrasonography of a patient's lower limbs be done?

Answer 586

It is used to assess how patent his arteries are and whether there is potential for revascularisation

Question 587

What are the 6P's of acute limb ischaemia?

Answer 587

``` Pale Paralysed Paraesthesia Painful Pulseless Perishingly cold ```

Question 588

What is the appropriate management for a venous ulcer?

Answer 588

Give her enough nutrition Encourage patients to move around/lose weight Elevate the leg Give compression bandages Graduated class I or II elastic stockings Varicose vein surgery

Question 589

What are the surgical interventions for treating varicose veins?

Answer 589

1. Avulsion/phlebectomy - small incisions are made along the varicose vein and they are then pulled out 2. Stripping - small incisions are made at the ends of the veins and a hook and wire is used to pull them out 3. Radiofrequency ablation - high-energy radio veins are used to seal the vein from within

Question 590

What are the general risks of any procedure?

Answer 590

Infection Haemorrhage Haematoma Adverse reaction to the analgesia

Question 591

List some features of venous insufficiency

Answer 591

``` Venous guttering Lipodermatoscelrosis Haemosiderin staining Atrophie blanche Venous eczema ```

Question 592

Which factors can impair ulcer healing?

Answer 592

Diabetes mellitus Anaemia Smoking Malnutrition