Random 2a Flashcards

Question

Location of two scars from CABG?

Answer 1

- Midline sternotomy - Scar on inner calf (harvest the great saphenous vein)

Answer 2

- CT coronary angiography (gold standard) - ECG - TFTs??

Answer 3

- Systolic - reduced ejection fraction (reduced contraction) - Diastolic - preserved ejection fraction (stiff muscle, so cannot relax)

Answer 4

Right-sided heart failure caused by respiratory disease, ie: - COPD (most common cause) - Pulmonary embolism - Interstitial lung disease - Cystic fibrosis - Primary pulmonary hypertension

Answer 5

ABAL: ACE inhibitor Beta-blocker (bisprolol) Aldosterone antagonist (spironolactone) Loop diuretic (furosemide)

Answer 6

- ejection systolic murmur (crescendo decrescendo|) - narrow pulse pressure - slow rising carotid pulse

Answer 7

- diastolic, soft murmur - wide pulse pressure - collapsing pulse (water hammer pulse) - austin flint murmur

Answer 8

Loud S1 Mid-diastolic murmur => RHEUMATIC FEVER

Answer 9

Pansystolic high pitched murmur => congestive HF => oedema

Answer 10

- EVAR - endovascular aortic repair - open surgery (preferred by NICE)

Answer 11

Dilation of abdominal aorta >3cm Degradation of all 3 layers of the vessels (intima, media and adventitia).

Answer 12

Degradation of all 3 aortic layers is referred to as a true aneurysm, whilst degradation of less than 3 is a pseudoaneurysm

Answer 13

Where the blood enters between the intima and media layers of the aorta

Answer 14

- Marfan syndrome and other connective tissue disorders - Men - Increased age - Smoking - Hypertension - Family history - Existing cardiovascular disease

Answer 15

Elective surgery to prevent rupture: - open surgery - EVAR (endovascular aortic repair)

Answer 16

Aneurysm rupture = tear of all aortic wall layers (more severe than aortic dissection, which is just inner wall) - ABCDE - Fluid resuscitaiton - URGENT SURGICAL REPAIR (open surgery preferred) - repair with graft

Answer 17

- severe chest pain - haemodynamic instability (hypotension + tachycardia) - collapse - death - Cardiac tamponade (due to bleeding into pericardial cavity) - Haemoptysis (bleed into airways) - Haematemesis (bleed into oesophagus)

Answer 18

<3 (normal- not AAA) 3-4.4 cm = yearly 4.5-5.4cm = 3 monthly >5.5cm (elective surgery)

Answer 19

- Rupture of an aortic aneurysm - Haemorrhagic pancreatitis (severe) - Ruptured ectopic pregnancy

Answer 20

Tear in the innermost layer of aortic wall (intima). Blood collects between intima and media layers => forms an intramural 'false lumen'

Answer 21

Right lateral area of ascending aorta This is area of highest pressure

Answer 22

- MORPHINE FOR PAIN - IV LABETOLOL (to reduce tachycardia) Type A - (first part of asc aorta) = surgical - aortic graft (EVAR) Type B - (descending aorta) = normally conservative management with BP control - may also need EVAR

Answer 23

- Cardiac tamponade - Myocardial infarction - Stroke - Paraplegia (motor or sensory impairment in the legs) - Aortic valve regurgitation - Death

Answer 24

- Saddle-shaped ST-elevation - PR depression - No reciprocal ST depression

Answer 25

- ECG - Echo - Bloods - Inflamm markers (high ESR, CRP, WCC)

Answer 26

- NSAIDs - Colchicine (used longer term, 3 mnths, to reduce risk of recurrence) - Pericardiocentesis may be required to remove fluid from around the heart if there is a significant pericardial effusion or tamponade.

Answer 27

- ABPI (ankle-brachial pressure index) - <0.9 - GOLD STANDARD = CT angiography (CT or MRI) - Duplex doppler ultrasound imaging (speed and volume of blood flow) - Buerger's test - patient lies flat, raise legs to 45 degree angle for 1 min. Positive result if legs goes pallor and then re-perfuses when dropped.

Answer 28

- 6x Ps - Low ABPI (<0.9) - Leg ulcers - Xanthomata (yellow cholesterol deposits in skin)

Answer 29

Pulseless Pallor Pain Perishingly cold Paralysis Paraesthesia

Answer 30

- Graded-exercise therapy’, diet control and smoking cessation. - STATINS - ANTI-PLATELETS - clopidogrel - Naftidrofuryl oxalate (5-HT2 receptor antagonist that acts as a peripheral vasodilator) - Endovascular angioplasty with stenting - Endartectomy - Bypass surgery

Answer 31

THROMBUS = SURGICAL EMERGENCY - revascularisation is needed within 4-6 hours or else amputation risk is increased. - Endovascular thrombolysis - use catheter and insert thrombolysis directly into the clot - Endovascular thrombectomy - use catheter to remove thrombus - Surgical thrombectomy - cut open vessel to remove thrombus - Endartectomy - Bypass surgery - Amputation

Answer 32

- VSD - Overriding aorta - lies towwards RHS, meaning deoxy blood can go through VSD and enter aorta! - Pulmonary valve stenosis (encourages blood to flow across VSD instead) => right ventricle hypertrophy => right to left shunt = cyanosis!

Answer 33

When there is a VSD, blood typically flows from left to right = therefore no cyanosis occurs. = overtime this leads to right heart overload = RV hypertrophy = higher pressures in RV than LV = shunt swaps to become RIGHT TO LEFT SHUNT = NOW IS CYANOTIC (Eisenmenger Syndrome)

Answer 34

Hypotension Raised JVP Muffled heart sounds => sign of cardiac tamponade

Answer 35

Subarachnoid haemorrhage

Answer 36

IM benzylpenicillin (in presence of non-blanching rash)

Answer 37

Last 7 days Single dose of ciprofloxacin

Answer 38

ANTIBIOTIC + DEXAMETHASONE: <3 months - cefotaxime >3 months - ceftriaxone (3rd gen cephalosporins) Dexamethasone - to reduce risk of hearing loss or neurological damage

Answer 39

lying the patient on their back, flexing one hip and knee to 90 degrees and then slowly straightening the knee whilst keeping the hip flexed at 90 degrees. This creates a slight stretch in the meninges. Where there is meningitis it will produce spinal pain or resistance to movement.

Answer 40

lying the patient flat on their back and gently using your hands to lift their head and neck off the bed and flex their chin to their chest. In a positive test this causes the patient to involuntarily flex their hips and knees.

Answer 41

Bacterial - yellow/cloudy (viral - clear) Bacterial - low glucose (bact. use up) Bacterial - high protein (bact. produce) WCC - high neutrophils (bacterial) vs high lymphocytes (viral)

Answer 42

DIC caused by meningococcal septicaemia (N.meningitidis has entered blood stream)

Answer 43

If there is a high risk of listeriosis (i.e. older age 73yo). AMOXICILLIN - to cover listeria

Answer 44

Positive in acute cholecystitis Press in upper RQ Patient inhales deeply Gallbladder will move downwards; when it comes into contact with your hand the patient will STOP inhaling (due to acute pain)

Answer 45

Ultrasound - Thick-walled gallbladder - Stones in gallbladder - Fluid around the gallbladder

Answer 46

Acute cholangitis presents with Charcot’s triad: Right upper quadrant pain Fever Jaundice (raised bilirubin)

Answer 47

- IV ANTIBIOTICS (due to infection - risk of sepsis) - ERCP - to remove gallstones, or baloon dilatation or stents for strictures - Laparoscopic cholecystectomy (remove gallbladder) - once stable

Answer 48

- IV ANTIBIOTICS - ERCP to remove gallstones if stuck in common bile duct - Laparoscopic Cholecystectomy (removal of the gallbladder) is usually be performed during the acute admission, within 72 hours of symptoms

Answer 49

Excess copper in all tissues, particularly in liver Typically younger patient - Kayser-fleischer rings (cornea) - Chronic hepatitis - leads to liver cirrhosis - Neurological symptoms - tremor, dysarthria (speech difficulties) and dystonia (abnormal muscle tone) + Parkinsonism (copper in basal ganglia) - Psychiatric symptoms - abnormal behaviour, depression, cognitive impairment and psychosis

Answer 50

Cholestyramine (bile acid sequestrant)

Answer 51

Reversible syndrome in advanced liver dysfunction. Results from accumulation of neurotoxic substances in the brain = **AMMONIA** ASTERIXIS (sign of grade 2/3 HE) - patient told to hold hand like stopping traffic, but it flaps down instead

Answer 52

Lactulose (first-line) - laxative to promote ammonia excretion Rifaximin - antibiotic

Answer 53

Acute pancreatitis

Answer 54

Higher ALT (reversed ratio) >0.8 indicates advanced fibrosis

Answer 55

>1.5 (high AST!) (2:1 ratio)

Answer 56

Hypertension + bradycardia + irregular respirations This is the response to raised ICP - in extradural haemorrhage - in head injury etc

Answer 57

This is headache with trigeminal nerve distribution. - Carbamazepine (anti-spasmodic)

Answer 58

Excess ammonia reversible syndrome COMPLICATION of advanced CIRRHOSIS ++ ASTERIXIS - hand flap (grade 2/3)

Answer 59

IV lactulose (laxative) - to exrete excess ammonia Rifaximin - antibiotic (to reduce int. bacteria producing ammonia)

Answer 60

severity of cirrhosis **A** – **Albumin - **B** – **Bilirubin - **C** – **Clotting (INR) - **D** – **Dilation (ascites) - **E** – **Encephalopathy

Answer 61

Transient Elastography (FibroScan) Used to assess the stiffness of the liver using high-frequency sound waves. It helps determine the degree of fibrosis (scarring) to test for liver cirrhosis.

Answer 62

Both caused by thiamine / VITAMIN B1 deficiency Wernicke's encephalopathy represents the "acute" phase of the disorder and Korsakoff's amnesic syndrome represents the disorder progressing to a "chronic" or long-lasting stage. ***Wernicke’s encephalopathy*** is a medical emergency with a high mortality rate. ***Korsakoff syndrome*** is often irreversible and results in patients requiring full-time or institutional care.

Answer 63

Confusion Oculomotor disturbances (eye muscle paralysis) Ataxia (difficulties with coordinated movements)

Answer 64

Memory impairment (retrograde and anterograde) Behavioural changes

Answer 65

Mainly EXCESS ALCOHOL But also: - Pancreatitis - Liver dysfunction - Vomiting / hyperemesis gravidarum - Starvation/fasting - Cancer - AIDS

Answer 66

Riluzole - can slow disease progression & extend survival by several MONTHS in ALS

Answer 67

- Nerve conduction studies (reduced signal through nerves) - Lumbar puncture for cerebrospinal fluid (showing raised protein with a normal cell count and glucose)

Answer 68

Brighton criteria: - bilateral weakness of limbs - decreased tendon reflexes - absence of alternative diagnosis - CSF cell count normal - CSF raised protein - nerve conduction studies - show reduced conduction

Answer 69

- IV IG (immunoglobulins) - 1st line - Plasmapheresis - 2nd line - VTE prophylaxis - to prevent pulmonary embolism (leading cause of death, as muscle weakness causes immobility)

Answer 70

Sympton onset 4 weeks after gastroenteritis - Symmetrical ascending weakness - Reduced reflexes - Peripheral loss of sensation - Neuropathic pain - May progress to the cranial nerves and cause facial weakness. - Autonomic dysfunction can lead to urinary retention, ileus or heart arrhythmias.

Answer 71

COMMON - Camplyobacter jejuna - CMV - EBV

Answer 72

Anti-GM1 antibodies = destruction of Schwann cells (PNS)

Answer 73

CRABBING: - C – Café-au-lait spots (more than 15mm diameter is significant in adults) - R – Relative with NF1 - A – Axillary or inguinal freckling - BB – Bony dysplasia, such as Bowing of a long bone or sphenoid wing dysplasia - I – Iris hamartomas (*Lisch nodules*) - yellow-brown spots on the iris - N – Neurofibromas (skin-coloured, raised nodules or papules with a smooth, regular surface)

Answer 74

Acoustic neuromas, which are tumours of the auditory nerve that innervates the inner ear.

Answer 75

ABCDE (+ Charcot-Marie-Tooth syndrome) - A – Alcohol - B – B12 deficiency - C – Cancer (myeloma) and Chronic kidney disease - D – Diabetes and Drugs (isoniazid, amiodarone, leflunomide and cisplatin) - E – Every vasculitis

Answer 76

Autosomal dominant Typically at 10 years old, but may be delayed until 40+ years old - High foot arches (pes caves) - Distal muscle wasting (inverted champagne bottle legs) - Loss of ankle dorsiflexion = FOOT DROP! - Reduced tendon reflexes - Reduced muscle tone - Peripheral sensory loss

Answer 77

Autoimmune condition affecting the NMJ, similar to myasthenia gravis. Antibodies against voltage-gated calcium channels (in presynaptic membrane of NMJ) VGCCs destroyed = less Ach released into the synapse, resulting in a weaker signal and reduced muscle contraction.

Answer 78

Paraneoplastic syndrome occuring alongside small cell lung cancer (but can also present as a primary AI disorder without SCLC)

Answer 79

- Amifampridine - Pyridostigmine (cholinesterase inhibitor) - Immunosuppressants (prednisolone or azathioprine) - IV immunoglobulins, or plasmapheresis

Answer 80

- Proximal muscle weakness difficulty standing from a seat. - Autonomic dysfunction - dry mouth, blurred vision, impotence & dizziness - Reduced or absent tendon reflexes

Answer 81

In Lambert-Eaton, signs and symptoms will improve after a period of muscle contraction (i..e improved muscle strength after use, or present tendon reflexes). Whereas in MG, after muscle usage, the symptoms get progressively worse (fatigued) - symptoms improve with rest!

Answer 82

Strong link with thymomas (thymus gland tumours). 10-20% of patients with MG have a thymoma. 30% of patients with a thymoma develop MG.

Answer 83

- ask patient to repeatedly blink to cause ptosis worsening - ask to look upwards - worsens diplopia when eyes moved side to side OR - repeatedly abduct arm to the side (up and down) 20 times = leads to unilateral weakness

Answer 84

Block cholinesterase enzymes that break down Ach = raised levels of Ach = brief relief of muscle weakness

Answer 85

Ach- receptor antibodies (85%)

Answer 86

- Pyridostigmine/ neostigmine - acetylcholinesterase inhibitors - Immunosuppression (prednisolone or azathioprine) suppresses Ab production - Thymectomy can improve symptoms, even in patients without a thymoma - Rituximab (mAb against B cells) - considered where other treatments fail

Answer 87

Acute worsenin gof symptoms, might be triggered by resp. tract infection => RESP FAILURE - BIPAP / intubation with ventilation - IV immunoglobulins or plasmapheresis

Answer 88

- Autosomal dominant polycystic kidney disease ⇒ predisposes to berry aneurysms - Connective tissue disorders (Marfan or Ehlers-Danlos) - Aged 45 to 70 - Women - Black ethnic origin - Family history - Cocaine use - Sickle cell anaemia - Neurofibromatosis

Answer 89

- raised RBC count in CSF - xanthochromia - yellow colour from bilirubin in CSF

Answer 90

- Craniotomy (open surgery by removing a section of the skull) - Burr holes (small holes drilled in the skull to drain the blood)

Answer 91

- Nimodipine (CCB) - prevents vasospasm (a common complication that causes brain ischaemia) SURGICAL: Treat aneurysms with endovascular coiling or neurosurgical clipping.

Answer 92

THUNDERCLAP HEACHAE, SUDDEN ONSET DURING STRENUOUS ACTIVITY - Meningism - neck stiffness, photophobia, vomiting) - Neurological symptoms (visual changes, dysphasia, focal weakness, seizures and reduced consciousness) - Third nerve palsy - oculomotor - compressed by aneurysm on posterior communicating artery

Answer 93

Idiopathic - no apparent cause. Presents with unilateral lower motor neurone facial nerve palsy. Most patients fully recover over several weeks, but recovery may take up to 12 months. - Forehead affected (unilateral) - Ptosis (unilateral) - Loss of nasolabial fold (unilateral)

Answer 94

- Aspirin 300mg daily (started immediately) - Referral for specialist assessment within 24 hours (within 7 days if more than 7 days since the episode) - Diffusion-weighted MRI scan

Answer 95

- Exclude hypoglycaemia - Immediate CT brain to exclude haemorrhage - Aspirin 300mg daily for two weeks (started after haemorrhage is excluded with a CT) - Admission to a specialist stroke centre: - Thrombolysis with alteplase (within 4hrs) - Thrombectomy - surgery to remove clot within 24hrs (with confirmed blockage of proximal anterior/posterior circulation)

Answer 96

- Carotid imaging (e.g., carotid ultrasound, or CT or MRI angiogram) - ECG (to look for atrial fibrillation)

Answer 97

Considered where there is significant carotid artery stenosis. The options are: - Carotid endarterectomy (recommended in the NICE guidelines) - Angioplasty and stenting

Answer 98

- Clopidogrel 75mg OD (alternatively aspirin plus dipyridamole) - Atorvastatin 20-80mg (usually delayed at least 48 hours) - Blood pressure and diabetes control - Addressing modifiable risk factors (e.g., smoking, obesity and exercise)

Answer 99

=> ipsilateral loss of motor function (corticospinal tract) => ipsilateral loss of sensory info about fine touch, vibration, proprioception and pressure (DCML tract) => contralateral loss of pain, temp and crude touch (spinothalamic)

Answer 100

MOTOR RESPONSE /6 VERBAL RESPONSE /5 EYE OPENING RESPONSE /4

Answer 101

Thenar muscles at base of thumb - Weakness of thumb movements - Weakness of grip strength - Difficulty with fine movements involving the thumb - Wasting of the thenar muscles (muscle atrophy)

Answer 102

Sensory symptoms in the distribution of the palmar digital cutaneous branch of the **median nerve**, affecting the palmar aspects and full fingertips of the: - Thumb - Index and middle finger - The lateral half of ring finger **Sensory symptoms** include: - Numbness - Paraesthesia (pins and needles or tingling) - Burning sensation - Pain (OFTEN WORSE AT NIGHT)

Answer 103

- Kamath and Stothard carpal tunnel questionnaire (CTQ) - a high score may replace the need for nerve conduction studies to confirm the diagnosis. - Nerve conduction studies: a small electrical current is applied by an electrode to the median nerve on one side of the carpal tunnel. Recording electrodes over the median nerve on the other side of the carpal tunnel record the electrical current that reaches them. This demonstrates how well signals are passing through the carpal tunnel along the median nerve.

Answer 104

Essential tremor improves with alcohol

Answer 105

Multiple System Atrophy: Degeneration of the basal ganglia leads to a Parkinson’s presentation. Degeneration in other areas leads to autonomic dysfunction (causing postural hypotension, constipation, abnormal sweating and sexual dysfunction) and cerebellar dysfunction (causing ataxia).

Answer 106

Lewy body dementia Type of dementia associated with features of Parkinsonism. It causes a progressive cognitive decline. There are associated symptoms of visual hallucinations, delusions, REM sleep disorders and fluctuating consciousness.

Answer 107

Carbamazapine TN - intense facial pain that can last for a few seconds to a few hours. The pain is commonly caused by light touch and can occur spontaneously as well.

Answer 108

Abortive treatment: - Oral triptan (sumatriptan) + an NSAID or paracetamol - Anti-emetic (metoclopramide or prochlorperazine) - Opiates are not used to treat migraines and may make the condition worse. Preventative treatment (if 4-5 attacks a month or interfering with QOL) - Propranolol OR topiramate (anti-epileptic; teratogenic) or amitriptyline (tricyclic antidepressant)

Answer 109

- Benzodiazepine (diazepam/midazolam/lorazepam) - repeated after 5-10 minutes if the seizure continues - After two doses of benzodiazepine = IV levetiracetam, phenytoin or sodium valproate - Third-line options are phenobarbital or general anaesthesia

Answer 110

Treatment: subcutaneous triptans (i.e. sumatriptan) Prophylaxis: verapamil (CCB) (C for CLUSTER + CCB)

Answer 111

- Acetylcholinesterase inhibitors (rivastigmine + donepezil) - MEMANTINE = NMDA receptor agonist

Answer 112

Extradural haemorrhage (LEMON SHAPE)

Answer 113

Chronic subdural haemorrhage

Answer 114

- Wells score - D-dimer - Doppler ultrasound - CT pulmonary angiogram OR ventilation-perfusion scan - to diagnose PE = 3 months DOAC (or LMWH in pregnancy)

Answer 115

- ABPI (ankle-brachial pressure index) <0.9 - Duplex Doppler ultrasound - Buerger’s test - lie patient flat, raise their leg 45º angle for 1 minute. Positive result is if the leg goes pallor and then becomes perfused when restored to normal position. The more severe the ischaemia, the lower the angle is needed to induce pallor. (see photo in SIGNS)

Answer 116

- 6Ps - ABPI <0.9 Leg ulcers Xanthomata (yellow cholesterol deposits on the skin) - Positive Buerger's test - if leg goes pale when lifted (in the second part of the test, the leg first goes blue, then turns red)

Answer 117

- ‘Graded-exercise therapy’, diet control and smoking cessation. - STATINS - atorvastatin** 80mg - ANTI-PLATELETS - clopidogrel 75mg OD - Naftidrofuryl oxalate (5-HT2 receptor antagonist that acts as a peripheral vasodilator) - Endovascular angioplasty with stenting. - Endarterectomy – cutting vessel open and removing the atheromatous plaque. - Bypass surgery – using a graft to bypass the blockage

Answer 118

THROMBUS!! - Surgical emergency, revascularisation is needed within 4-6 hours or else amputation risk is increased. - Endovascular thrombolysis - use catheter and insert thrombolysis directly into the clot - Endovascular thrombectomy - use catheter to remove thrombus - Surgical thrombectomy - cut open vessel to remove thrombus - Endartectomy - Bypass surgery - Amputation

Answer 119

Pulselessness Pallor Pain Perishingly cold Paralysis Parasthesia

Answer 120

Ventricular fibrillation Ventricular tachycardia

Answer 121

Asystole Pulseless electrical activity (PEA)

Answer 122

SMITH - Sepsis - Mitral valve path (sten/regurg) - Ischaemic HD - Thyrotoxicosis (hyperthyroidism) - Hypertension

Answer 123

Secondary HTN = identifiable cause = ROPED: - Renal artery stenosis - Obesity - Pregnancy - Endocrine (Conn's) - Drugs (alcohol, steroids, oestrogen, NSAIDs)

Answer 124

Myalgia (muscle pain)

Answer 125

- Ascites - Extertional dyspnoea - Cough - frothy pink/white sputum - Orthopnoea - breathlessness when lying flat, relieved by sitting or standing (ask how many pillows they use) - Paroxysmal nocturnal dyspnoea - suddenly waking at night with a severe attack of shortness of breath, cough and wheeze. - Peripheral oedema (ankle swelling) - Fatigue - Tachycardia - Displaced apex beat - Raised JVP - jugular venous pressure - Added heart sounds and murmurs - i.e. 3rd heart sound - Hepatomegaly, especially if pulsatile and tender

Answer 126

ABAL AceI Beta blocker Aldosterone antagonist (spironolactone/eplerenone) Loop diuretic (furosemide)

Answer 127

**ABCDE** - - Alveolar oedema - Kerley B lines (interstitial oedema) - Cardiomegaly - Dilated prominent upper lobe vessels - Pleural effusions (blunted costophrenic angle)

Answer 128

Haematopoietic stem cells => bone marrow fibrosis => affects production of blood cells

Answer 129

Erythroid cells => excess RBCs (high Hb)

Answer 130

Megakaryocytes => high platelet count

Answer 131

Myelofibrosis can result from primary myelofibrosis, polycythaemia vera or essential thrombocythaemia.

Answer 132

- Teardrop-shaped red blood cells )(poikilocytes) - Anisocytosis (varying sizes of RBCs) - Blasts (immature RBC + WCCS)

Answer 133

Bone marrow biopsy is required to confirm the diagnosis. Bone marrow aspiration may be “dry” with myelofibrosis, as the bone marrow has turned to scar tissue.

Answer 134

- Chemotherapy (hydroxycarbamide) - JAK2 inhibitor (ruxolitinib) - Allogeneic stem cell transplantation (risky but potentially curative)

Answer 135

- Venesection (excess RBCs) - Aspirin (reduce thrombus risk) - Chemotherapy (hydroxycarbamide)

Answer 136

- Anagrelide (platelet-lowering agent) - Aspirin (reduce thrombus risk) - Chemotherapy (hydroxycarbamide)

Answer 137

- Ruddy complexion (red face) - Conjunctival plethora (the opposite of conjunctival pallor) - Splenomegaly - Hypertension

Answer 138

X-linked recessive

Answer 139

Spontaneous bleeding into joints (haemarthrosis) such as the ankle, knee or elbow can lead to joint damage and deformity.

Answer 140

- Frontal bossing (prominent forehead) - Enlarged maxilla (prominent cheekbones) - Depressed nasal bridge (flat nose) - Protruding upper teeth Beta thalassaemia major = homozygous 2x deletion genes (no functioning beta-globin genes). => severe anaemia => bone marrow under so much strain to produce extra RBCs to compensate for the chronic anaemia that it expands enough to increase the risk of fractures and change the patient’s appearance ^

Answer 141

- Alpha thalassaemia - chromosome 16 - abnormal a-globin gene - Beta thalassaemia - chromosome 11 - abnormal B-globin gene

Answer 142

Abnormal haemoglobin. Autosomal recessive; mutation in B-globulin gene on chromosome 11 ⇒ HbS

Answer 143

- Vaso-occlusive crisis - Priapism - persistent erection - Splenic sequestration crisis - Aplastic crisis (parvovirus B19 infection - temp. absence of creation of new RBCs - often resolves in 1 week) - Acute chest syndrome: vessels supplying lungs clogged with RBCs - hypoxia causes further HbS polymerisation - reduces blood flow further - causes more lung damage

Answer 144

- Mantoux test (tuberculin skin test) - Interferon-gamma release assay (IGRA) Blood sample is mixed with TB antigens = if they have previously been sensitised, WBCs will release IFG.

Answer 145

- Chest x-ray - Cultures of deep sputum samples

Answer 146

- Primary TB - patchy consolidation, pleural effusions and hilar lymphadenopathy. - Reactivated TB -patchy or nodular consolidation with cavitation (gas-filled spaces), typically in the upper zones. - Disseminated miliary TB -appearance of millet seeds uniformly distributed across the lung fields.

Answer 147

“Legions of psittaci MCQs” - Legions – Legionella pneumophila. Can cause syndrome of inappropriate ADH (SIADH), resulting in hyponatraemia (low sodium). - Psittaci – Chlamydia psittaci From infected birds (parrots) - M – Mycoplasma pneumoniae - C – Chlamydophila pneumoniae In school age children. - Qs – Q fever (coxiella burnetii) Body fluids of animals = farmer

Answer 148

- Low weight or height on growth charts - Nasal polyps - Finger clubbing - Crackles and wheezes on auscultation - Abdominal distention

Answer 149

A specific acute clinical presentation of systemic sarcoidosis, consisting of: - polyarthralgia (joint pain in multiple joints) - erythema nodosum - bilateral hilar adenopathy

Answer 150

- Raised ACE - screening test - Raised calcium (hypercalcaemia) - Chest x-ray + high res CT - shows hilar lymphadenopathy

Answer 151

S1 Q3-T3 - S waves in lead I - Q waves in lead III - Inverted T waves in lead III

Answer 152

Permanent dilation of the bronchi Sputum collects (STASIS) here due to the widened tubes ⇒ chronic cough ⇒ continuous sputum production ⇒ recurrent infections

Answer 153

- Cystic fibrosis - Idiopathic (no apparent cause) - Pneumonia - Whooping cough (pertussis) - Tuberculosis - Alpha-1-antitrypsin deficiency - Connective tissue disorders (e.g., rheumatoid arthritis) - Yellow nail syndrome

Answer 154

- Tram track opacities (parallel markings of a side-view of the dilated airway) - Ring shadows (dilated airways seen end-on)

Answer 155

- High resolution CT chest(DIAGNOSTIC) - Chest x-ray - Sputum culture (for psuedomonas aeruginosa colonisation)

Answer 156

- Exudative - high protein content (more than 30g/L) - Transudative - lower protein content (less than 30g/L)

Answer 157

Related to inflammation = protein leaking out of tissues - Cancer (lung cancer + mesothelioma) - Infection (pneumonia + TB) - Rheumatoid arthritis

Answer 158

- Cirrhosis - Congestive heart failure - Hypoalbuminaemia - Hypothyroidism - Meigs syndrome

Answer 159

Triad of: - Benign ovarian tumour - Pleural effusion - Ascites

Answer 160

- Blunting of the costophrenic angle - Fluid in the lung fissures - Larger effusions will have a meniscus (curving upwards where it meets the chest wall and mediastinum) - Tracheal and mediastinal deviation away from the effusion (in very large effusions)

Answer 161

When a pleural effusion becomes infected. Pleural aspiration will show: = pus = low pH = low glucose (used up by the bacteria) = high LDH Treatment: - Chest drain - Antibiotics

Answer 162

Insert a large bore cannula into the 2nd intercostal space in the midclavicular line. A chest drain is required for definitive management once the pressure is relieved with a cannula.

Answer 163

- Increased work of breathing - Barking” cough, occurring in clusters of coughing episodes - Hoarse voice - Stridor (high-pitched inspiratory noise due to upper airway obstruction) - Low-grade fever

Answer 164

- Amoxicillin for 5-7 days (first-line) - Clarithromycin (if penicillin allergic) - Erythromycin (in pregnant women allergic to penicillin)

Answer 165

Dexamethasone

Answer 166

EMERGENCY - skip examinations - Ensure airway is secure (prepare to intubate if needed) - IV antibiotics (ceftriaxone) - Steroids (dexamethasone)

Answer 167

- Tripod position, sat forward with a hand on each knee - Sore throat + stridor - Drooling - High fever - Difficulty or painful swallowing - Muffled voice - Scared and quiet child - Septic and unwell appearance

Answer 168

Caused by S.pyogenes (group A) Strep throat = another type of pharyngitis, can also cause: - Difficulty in swallowing - Red throat with white or grey patches - Swollen lymph nodes - Fever - Loss of appetite - Nausea - Unusual taste in the mouth - General malaise

Answer 169

Ptosis Miosis (constricted pupil) Facial anhidrosis (loss of sweating)

Answer 170

Autosomal co-dominant genetic condition caused by low levels of alpha-1 antitrypsin. (this is a protease inhibitor = less inhibition of neutrophil elastase) - Liver disease (protein retention in liver) - Emphysema (lungs disease - damage to alveoli walls)

Answer 171

Alpha-1 antitrypsin offers protection by inhibiting the action of neutrophil elastase. - Neutrophil elastase breaks down elastic tissue in the lungs => bronchiectasis and emphysema - Alpha-1 antitrypsin is produced in the liver. An abnormal mutant version of the protein is made that gets trapped and builds up inside the liver cells (hepatocytes). = inflammation = fibrosis, cirrhosis + hepatocellular carcinoma

Answer 172

test for diabetes insipidus - co-peptin levels (high = confirms nephorgenic DI) - give hypertonic saline = stimulates ADH = measures co-peptin again: --> still low levels = cranial DI --> high levels = primary polydipsia

Answer 173

Genetic condition causing diabetes insipidus, diabetes mellitus, optic atrophy and deafness.

Answer 174

- PRIMARY (Conn's) = adrenal adenoma = high aldosterone, low renin - SECONDARY - low BP sensed by kidneys due to renal artery stenosis, HF etc = HIGH RENIN = high aldosterone

Answer 175

- Adrenal adenoma - secreting aldosterone (Conn’s syndrome) - Bilateral adrenal hyperplasia (most common) - Familial hyperaldosteronism (rare)

Answer 176

- Renal artery stenosis (atherosclerotic narrowing of renal artery) - Heart failure - Liver cirrhosis and ascites

Answer 177

- True (central) - either idiopathic or CNS tumours - treat with GnRH superagonist (suppresses GnRH secretion) - Pseudo - tumours drive excess androgens or gonadotropins (not GnRH)

Answer 178

- PRIMARY - Hypergonadotrophic hypogonadism (lack of oest/test = neg feedback = high GnRH) - SECONDARY/TERTIARY - Hypogonadotrophic hypogonadism (low GnRH = no gonad stimulation)

Answer 179

- Gonad trauma or mumps - Kleinfelters (47 XXY) - Turners (45 XO)

Answer 180

- Damage to hypothalamus/pit gland - GH deficiency - Constitutional delay in growth and development - Kallman syndrome (failure of migration of GnRH neurons) - also associated with anosmia

Answer 181

45 XO Can cause delayed puberty (hypergonadotrophic hypogonadism)

Answer 182

47 XXY Can cause delayed puberty (hypergonadotrophic hypogonadism)

Answer 183

Lumbar puncture - CSF shows raised RBC count - CSF shows xanthochromia - yellow colour from bilirubin

Answer 184

Worse on waking Worse on coughing Postural

Answer 185

Antibodies (anti-Ach receptor + MuSK + LRP4) INDUCE MUSCLE FATIGUE (blink to cause ptosis OR abduct arm) Forced vital capacity (spirometry) - check strength of respiratory muscles CT/MRI - check for thymoma Edrophonium test - blocks cholinesterase enzymes that break down Ach = raised levels of Ach = brief relief of muscle weakness

Answer 186

Excessive RBC breakdown = liver cannot conjugate all of the bilirubin => excess unconjugated bilirubin causes: haemolysis (i.e. in sickle cell disease, G6PD deficiency, malaria, autoimmune haemolytic anaemia)

Answer 187

Dysfunction of the hepatic cells - liver cannot conjugate bilirubin = results in conjugated + unconjugated bilirubin in the blood (’mixed picture’) Causes: hepatitis, ischaemia, neoplasm, congestive HF

Answer 188

OBSTRUCTIVE - blocks flow of bile (gallstones, malignancy i.e pancreatic cancer or cholangiocarcinoma, cholangitis, strictures) Bilirubin not excreted, but has already been conjugated by liver = conjugated hyperbilirubinaemia

Answer 189

T1DM, Graves, MS T cell-mediated

Answer 190

RA, SLE, occupational lung disorders Ag-Ab DEPOSITION

Answer 191

Goodpasture's Ag-Ab FORMATION

Answer 192

Anaphylaxis IgE-mediated

Answer 193

Seen in MS - Nstagmus (plaques in nerves of eyes) - Dysarthria (plques in brainstem) - Intention tremor (plaques in motor pathways)

Answer 194

Unknown cause Excessive bone turnover due to increased osteoclast and osteoblast activity. The excessive turnover is not coordinated, leading to patchy areas of high density (sclerosis) and low density (lysis)

Answer 195

may be **asymptomatic** - Bone pain - Bone deformity - Fractures - Hearing loss

Answer 196

- Bone enlargement and deformity - Osteoporosis circumscripta (well-defined osteolytic lesions) - Cotton wool appearance of the skull - V-shaped osteolytic defects in the long bones

Answer 197

Raised ALP (normal calcium + phosphate)

Answer 198

Monitoring - check serum alkaline phosphatase (ALP) and review symptoms. Effective treatment should normalise the ALP and eliminate symptoms. First line: Bisphosphonates Other measures include: - Calcitonin - where bisphosphonates are unsuitable - NSAIDs for bone pain - Calcium and vitamin D supplementation, if necessary - Surgery is rarely required to treat fractures, severe deformities and arthritis

Answer 199

Soft bones Due to defective bone mineralisation Caused by VIT D deficiency

Answer 200

Colecalciferol (vitamin D₃)

Answer 201

Abdo Pain, Ascites, Tender Hepatomegaly An uncommon disorder characterized by obstruction of hepatic venous outflow. The obstruction may be thrombotic or non-thrombotic anywhere along the venous course from the hepatic venules to junction of the inferior vena cava (IVC) to the right atrium.

Answer 202

Campylobacter jejuni Common cause of GBS (Shigella is another cause of bloody diarrhoea, but not a cause of GBS)

Answer 203

Gallstones - cause jaundice by obstructing the bile duct, leading to the accumulation of conjugated bilirubin. This leads to pale stools and dark urine.

Answer 204

Barium meal/swallow

Answer 205

ADHESIONS (scar tissue adhering bowel) HERNIA CANCER

Answer 206

DRIP - IV fluids to rehydrate after their vomiting SUCK - NG tube to drain stomach contents (reduces risk of vomiting + aspiration)

Answer 207

‘Intestinal angina’ **Atherosclerosis of mesenteric blood vessels** 1) Central colicky abdominal - 30 mins after eating, lasting 1-2 hours 2) Weight loss - due to food avoidance 3) Abdominal bruit (blowing sound caused by turbulent blood flow through blood vessels)

Answer 208

CT angiogram

Answer 209

- 1st line - endovascular => percutaneous mesenteric artery stenting 2nd line: - Endarterectomy (’cleaning out’ blood vessel) - Re-implantation - Bypass surgery

Answer 210

Over 50% mortality Typically caused by rapid blockage of flow through the superior mesenteric artery By a THROMBUS, or an embolus (from another site)

Answer 211

Contrast CT abdo => bowel and blood supply - Metabolic acidosis in ABG (raised lactate)

Answer 212

Breathlessness when lying flat, relieved by sitting or standing (ask how many pillows they use) ^^symptom of chronic heart failure

Answer 213

Describes the experience that patients have of suddenly waking at night with a severe attack of shortness of breath, cough and wheeze. ^^symptom of chronic heart failure

Answer 214

- Calcium (80%) - calcium oxalate & calcium phosphate - Uric acid - Struvite - Cystine

Answer 215

Uric acid stones

Answer 216

Struvite - form in the shape of renal pelvis during upper UTI

Answer 217

Asymptomatic Renal colic (loin to groin pain) Haematuria Reduced urine output Nause/vomiting

Answer 218

- Urine dipstick (haematuria) - Blood test for kidney function + calcium - Non-contrast CT KUB (kidney, ureter, bladder) - Ultrasound KUB (in pregnant women + children)

Answer 219

- NSAIDs - Anti-emetics - Watchful waiting (0-10mm) - Tamsulosin (alpha blocker)

Answer 220

Surgical interventions required in larger stones (>10mm) - Extracorporeal shockwave lithotripsy (under X-ray guidance) - Uretroscopy + laser lithotripsy - Percutaneous nephrolithotomy (nephroscope inserted in small incision in back) - OPEN SURGERY

Answer 221

- Watchful waiting - External beam radiotherapy - Brachytherapy (radioactive metal seeds = targetted radiotherapy) - Hormone therapy - androgen receptor blockers, GnRH agonists (goserelin), GnRH antagonists (degarelix) - RADICAL prostatectomy

Answer 222

Royal Marsden staging system - Stage 1 – isolated to the testicle - Stage 2 – spread to the retroperitoneal lymph nodes - Stage 3 – spread to the lymph nodes above the diaphragm - Stage 4 – metastasised to other organs

Answer 223

Two-week wait referral for: - Aged over 45 with unexplained visible painless haematuria, either without a UTI or persisting after treatment for a UTI - Aged over 60 with microscopic haematuria (not visible but positive on a urine dipstick) PLUS: - Dysuria (pain urinating) or; - Raised white blood cells on FBC

Answer 224

Flexible cystoscopy (camera through the urethra into the bladder) - rigid or flexible

Answer 225

- TURBT (transurethral resection of bladder tumour) - Intravesical chemotherapy - Intravesical BCG - thought to stimulate the immune system - Radical cystectomy = remove entire bladder

Answer 226

The classic triad of presentation is haematuria, flank pain and a palpable mass.

Answer 227

- Von Hippel-Lindau Disease - Smoking - Obesity - Hypertension - End-stage renal failure - Tuberous sclerosis

Answer 228

- Polycythaemia – due to excess EPO - Hypercalcaemia – due to secretion of a hormone that mimics the action of parathyroid hormone - Hypertension – due to various factors, including increased renin secretion, polycythaemia and physical compression - Stauffer’s syndrome – abnormal liver function tests (raised ALT, AST, ALP and bilirubin) without liver metastasis

Answer 229

**Wells score** is used when considering pulmonary embolism. The outcome decides the next step: - Unlikely: perform a d-dimer, and if positive, perform a CTPA - Likely: CT pulmonary angiogram (CTPA) or alternative imaging (see below) - CTPA: chest CT scan with an intravenous contrast that highlights the pulmonary arteries to demonstrate any blood clots - V/Q SPECT scan - Planar VQ scan

Answer 230

Inhibits prostaglandins = causes vasoconstriction of afferent arteriole = reduced GFR (hence contraindicated in CKD where GFR is already dangerously low)

Answer 231

Proximal renal tubular epithelium

Answer 232

RCC = excess EPO from kidney = excess RBCs

Answer 233

Thick ascending limb of Loop of Henle

Answer 234

Sarcoidoisis = hypercalcaemia = calcium oxalate renal stones

Answer 235

- RAISED ACE - RAISED CALCIUM (hypercalcaemia)

Answer 236

- Pelvi-ureteric junction (renal pelvis meets ureter) - Pelvic brim (overlap with common iliac artery) - Vesico-ureteric junction (ureter meets bladder)

Answer 237

Non-contrast CT kidney, ureter, bladder (NCCT-KUB)

Answer 238

Increase water intake Reduce sodium diet Exercise Reduce oxalate-rich foods Vit C reduction

Answer 239

Alpha-1 blocker in BPH => retrograde ejaculation => postural hypotension

Answer 240

Inhibitor of 5-alpha-reductase. This enzyme changes testosterone to di-hydrotestosterone, which causes the prostate to grow. Thus, less DHT = decreases prostate size

Answer 241

BPH = transitional zone Prostate cancer = peripheral zone

Answer 242

Children = minimal change disease Adults = focal segmental glomerulosclerosis

Answer 243

Renal biopsy

Answer 244

Post-strep = 1-2 weeks IgA (Berger's) = 1-2 days

Answer 245

Sodium chloride sweat test NaCl >60mmol/L

Answer 246

6 MONTHS: - 2 months of RIPE - Further 4 months of RI

Answer 247

CAPE - Cushing’s disease - pituitary adenoma releasing excess ACTH - Adrenal adenoma - adrenal tumour releasing excess cortisol - Paraneoplastic syndrome - ectopic ACTH (released from tumour somewhere other than the pituitary gland) ⇒ most common is small cell lung cancer - Exogenous steroids - patients taking long-term corticosteroids

Answer 248

Hypertension Cardiac hypertrophy Type 2 diabetes Dyslipidaemia (raised cholesterol and triglycerides) Osteoporosis

Answer 249

Where patients undergo a bilateral adrenalectomy (in cushing's), an ACTH-producing pituitary tumour may develop due to the lack of cortisol and negative feedback. Causing: - Skin pigmentation (high ACTH) - Bitemporal hemianopia - Lack of other pit. hormones

Answer 250

Synthetic ACTH Give synachten + measure baseline cortisol levels Measure at 30 + 60 mins Normally, cortisol will double => no increase = primary adrenal insufficiency (Addison's)

Answer 251

PRIMARY: ADDISONS = autoimmune destruction of adrenal glands = high ACTH (due to neg feedback from low cortisol prod.) SECONDARY: issue with production from pit. gland = low ACTH (pit gland is not producing ACTH)

Answer 252

PRIMARY: ADDISONS = autoimmune destruction of adrenal glands = low aldosterone = less Na+/water in = hypotension ==> INCREASE IN RENIN (RAAS system trying to increase BP)

Answer 253

HYPO: anti-TPO + anti-Tg HYPER: anti-TSH receptor

Answer 254

Due to pituitary issue or hypothalamus, not THYROID ITESELF => NO TSH FROM PIT GLAND - pituitary adenomas - Sheehan’s syndrome (postpartum haemorrhage causes pituitary gland necrosis)

Answer 255

- Gradual-onset, symmetrical, proximal muscle weakness, causing difficulties standing from a chair, climbing stairs or lifting overhead. - Muscle pain (myalgia), but not always. - Dermatomyositis ALSO HAS SKIN FEATURES: - Gottron lesions (hands+knees) - Heliotrope rash - Periorbital oedema - Photosensitive erythematous rash on the back, shoulders and neck

Answer 256

- Elevated creatine kinase - Autoantibodies (ANA + anti-Jo-1 in polymyositis) - Electromyography - MRI - Muscle biopsy

Answer 257

LIMITED CUTANEOUS SYSTEMIC SCLEROSIS = CREST - Calcinosis - Raynaud’s phenomenon - Eosophageal dysmotility - Sclerodactyly - Telangiectasia ----- DIFFUSE CUTANEOUS SYSTEMIC SCLEROSIS = CREST, plus: - Cardiovascular problems (e.g., hypertension and coronary artery disease) - Lung problems (pulmonary hypertension and pulmonary fibrosis) -Kidney problems (glomerulonephritis and scleroderma renal crisis)

Answer 258

- ANA - Anti-centromere (limited cut SS) - Anti-Scl-70 (diffuse cut SS)

Answer 259

- antibodies (know each) - abnormal nailfold capillaroscopy (to indicate secondary reynauds)

Answer 260

[no standardised treatment) - Immunosuppressants + steroids (in diffuse sc ss) - Nifedipine - Raynaud’s phenomenon - PPI - acid reflux - Prokinetic medications - GI symptoms - Analgesia (joint pain) - Antibiotics for skin infections - Antihypertensives (ACEi) to treat hypertension and scleroderma renal crisis

Answer 261

Autoimmune destruction of the exocrine glands, notably the lacrimal and salivary glands => causing symptoms of dry mouth, eyes and vagina. [Dry eyes and dry mouth can be called sicca symptoms] More common in women and typically presents in middle age.

Answer 262

- Anti-Ro - Anti-La - Schirmer test (<10mm travelled along filter paper)

Answer 263

- Eye problems - Keratoconjunctivitis sicca and corneal ulcers - Oral problems - dental cavities & candida infections. - Vaginal problems - Candida infection and sexual dysfunction

Answer 264

CAN’T SEE, CAN’T PEE, OR CLIMB A TREE - Bilateral conjunctivitis - Anterior uveitis - Circinate balanitis

Answer 265

ANKYLOSING SPONDYLITIS To assess mobility, particularly lumbar spine - Patient stands straight - Find L5 - Mark point 10cm above, and 5cm below L5 - Ask patient to bend forward - Measure distance between two points (if its less than 20cm, this indicates restriction of lumbar movement = supports diagnosis)

Answer 266

- Bamboo spine (in late stages) - Squaring of the vertebral bodies - Subchondral sclerosis and erosions - Ossification of the ligaments, discs and joints (structures start turning into bone) - Fusion of the facet, sacroiliac and costovertebral joints

Answer 267

Most severe form of psoriatic arthritis - Osteolysis of bones = shortening of fingers = skin folds = TELESCOPING 'PENCIL-IN-CUP ON XRAY'

Answer 268

Normal - S.aureus IVDU - pseudomonas aeruginosa Post-op joint replacement - S.epidermidis Sickle cell anaemia - Salmonella

Answer 269

- 6 weeks flucloxacillin if acute, 3 months if chronic - Surgical debridement of bone

Answer 270

- Lupus anticoagulant - Anticardiolipin antibody → two or more occasions at least 12 weeks apart can confirm the diagnosis of APS These antibodies bind to the phospholipids on the surface of cells, causing inflammation and increasing the risk of thrombosis.

Answer 271

CLOT C - clots (VTE) L - livedo reticularis (mottled lower limbs) O - obstetric loss T - thrombocytopenia

Answer 272

ANA Anti-dsDNA

Answer 273

NSAIDs Allopurinol can acutely raise the level of urate (and precipitate or worsen a flare of gout) before lowering the levels of gout. Therefore covering with an NSAID is important for reducing the risk of another flair while allopurinol therapy is initiated

Answer 274

MMR BOY (Measles, Mumps, Rubella; BCG; Oral Polio; Yellow Fever)

Answer 275

Left middle cerebral artery (look at stick man diagram on Notion stroke page)

Answer 276

Lumbar puncture 12 hours after symptom onset - CSF shows xanthochromia - yellow colour from bilirubin - CSF shows raised RBC count

Answer 277

General pop + poor dental hygiene - S.viridans IVDU - S.aureus Prosthetic valves - S.epidermidis

Answer 278

ABCDE Alveolar oedema Kerley B lines Cardiomegaly Dilated upper lobe vesssels Effusion (pleural)

Answer 279

STEMI: 1) ST-segment elevation 2) New left bundle branch block NSTEMI 1) ST segment depression 2) T wave inversion

Answer 280

Used to diagnose NSTEMI (not required in STEMI, as this is based on ECG + clinical findings) Non-specific - also raised in: - Chronic kidney disease - Sepsis - Myocarditis - Aortic dissection - Pulmonary embolism

Answer 281

DIP distal interphalangeal joints

Answer 282

DIP distal interphalangeal joints

Answer 283

Graded using the ***forced expiratory volume*** ***in 1 second*** (***FEV1***): - Stage 1 (mild): FEV1 more than 80% of predicted - Stage 2 (moderate): FEV1 50-79% of predicted - Stage 3 (severe): FEV1 30-49% of predicted - Stage 4 (very severe): FEV1 less than 30% of predicted

Answer 284

T2DM Hypertension Glomerulonephritis NSAID use PKD - polycystic kidney disease

Answer 285

Anaemia Osteoporosis CVD Encephalopathy/neuropathy

Answer 286

FBC U&Es Renal ultrasound scan Urine dip eGFR A:Cr ratio (albumin:creatinine ratio)

Answer 287

Enlarged gallbladder + painless jaundice (sign of pancreatic cancer) Courvoisier's law states that the presence of a non-tender ENLARGED/PALPABLE gallbladder means that jaundice is unlikely to be due to gallstones = therefore it is a red flag for pancreatic cancer

Answer 288

5 factors: Charcot's triad + hypotension/shock + confusion (Charcot's triad is RUQ pain, fever + jaundice)

Answer 289

Anti-fibrotics (nintedanib or pirfenidone).

Answer 290

- LUNGS: pulmonary fibrosis, mediastinal lymphadenopathy - SKIN: erythema nodosum - EYES: uveitis, conjunctivitis, optic neuritis KIDNEY: renal stones (due to hypercalcaemia) CNS: encephalopathy BONES: arthralgia, arthritis

Answer 291

Stony dull percussion - pleural effusion. Dull percussion - pneumonia

Answer 292

- DIAGNOSTIC => HRCT: high-resolution CT thorax (show honeycombing) - Spirometry (normal or restrictive >70% FEV1:FVC ratio)

Answer 293

most common organism = haemophilus influenzae. Others = strep pneumoniae, Moraxella catarrhalis

Answer 294

FEV1 <0.8 predicted (severity scale - GOLD) FEV1/FVC <0.7

Answer 295

Hyperinflation - enlarged lungs. Air pockets (bullae) Flattened diaphragm

Answer 296

Bilateral hilar lymphadenopathy Ghon focus (primary lesion) Effusions

Answer 297

Immunosuppression (HIV) Ethnicity IVDU Homeless/overcrowded housing Close contact with infected person

Answer 298

OSHITME O2, SABA, Hydrocortisone, Ipratropium, Theophylline, Mg sulfate, Escalate

Answer 299

Cold temp, exercise, dust, NSAIDs, beta-blockers, infection, stress, allergens

Answer 300

Nocturnal cough, multiple exacerbations, wheeze, recessions, hyperinflated chest

Answer 301

Ascites Portal hypertension = GI bleeding /varices /variceal bleed Hepatic Encephalopathy Spontaneous bacterial peritonitis Hepatocellular carcinoma Malnutrition Splenomegaly, thrombocytopenia, Hepato Renal Syndrome, Hepatic Failure, Infection, Pulmonary Complication, Porto pulmonary hypertension, Hepato-pulmonary syndrome (HPS), Hepatic hydrothorax, coagulation defects, Osteoporosis

Answer 302

Ca 19-9 (raised in cholangiocarcinoma, pancreatic cancer + gastric cancer)

Answer 303

- **Barium swallow** ⇒ bird’s beak sign - **Manometry** - measures muscle pressure - **OGD** *(oesophago-gastro-duodenoscopy)* to exclude oesophageal cancer

Answer 304

Surgery is curative - Balloon dilation (using endoscope) - Laparoscopic (keyhole) cardiomyotomy / Heller’s procedure - cut the muscle fibres (lower oesophageal sphincter) ⇒ causes iatrogenic GORD - so they can also perform Nissen’s fundoplication at the same time.

Answer 305

APIESAC - Aphthous ulcers (mouth) - **Pyoderma gangrenosum** (rapidly enlarging, painful skin ulcers) - **I**ritis (episcleritis, scleritis and anterior uveitis) - **Erythema nodosum** (red nodules on shins) - **Sclerosing cholangitis (PSC -** particularly with ulcerative colitis) - **Arthritis (enteropathic) - Clubbing of fingers - EYE (episcleritis, anterior uveitis) - Enteropathic arthritis (spondylarthropathy) - Erythema nodosum - Pyoderma gangrenous

Answer 306

Rovsing’s sign (palpation of the left iliac fossa causes pain in the RIF) Rebound tenderness in the RIF (increased pain when suddenly releasing the pressure of deep palpation) Central abdominal pain = moves to right iliac fossa in first 24 hours Guarding on abdominal palpation (voluntary contraction of the abdominal wall musculature to avoid pain) Tenderness at McBurney’s point

Answer 307

- ***Rebound tenderness*** in the RIF (increased pain when **suddenly releasing** the pressure of deep palpation) - ***Percussion tenderness*** (pain and tenderness when percussing the abdomen) ***Rebound tenderness*** and ***percussion tenderness*** suggest ***peritonitis***, potentially indicating a ***ruptured appendix***.

Answer 308

- Appendicitis = ruptured appendix - Stomach or duodenal ulcer perforation - Cirrhosis = **spont. bacterial peritonitis** - Pancreatitis or cholecystitis *(tend to be localised)* - Perforated diverticulum - Peritoneal dialysis - external contamination - In females - pelvic inflammatory disease

Answer 309

- Family history of bowel cancer - IBD - Diet (high in red and processed meat and low in fibre) - Obesity and sedentary lifestyle - Smoking - Alcohol Autosomal dominant: - Familial adenomatous polyposis (FAP) - HNPCC / hereditary nonpolyposis colorectal cancer (Lynch syndrome)

Answer 310

Macrolides (clarithromycin + erythromycin) Chloramphenicol => inhibit 50S subunit Tetracyclines (doxycycline) Aminoglycosides (gentamicin) => inhibit 30S subunit

Answer 311

Penicillins Cephalosporins Carbapenems Glycopeptides (vancomycin + teicoplanin)

Answer 312

Sulfamethoxazole Trimethoprim

Answer 313

Metronidazole Ciprofloxacin Trimethoprim

Answer 314

- **A** – **A**nterior uveitis - **A** – **A**ortic regurgitation - **A** – **A**trioventricular block (heart block) - **A** – **A**pical lung fibrosis (fibrosis of the ***upper lobes*** of the lungs) - **A** – **A**naemia of chronic disease

Answer 315

MODERATE:  50-75% best or predicted ACUTE SEVERE: 33-50% best or predicted LIFE-THREATENING: < 33% best or predicted

Answer 316

Oesophago-gastro-duodenoscopy (OGD) (endoscopy) is required to diagnose and treat the source of the bleeding

Answer 317

an aggregation of epitheloid histocytes

Answer 318

- High dose steroids (prednisolone) Given for 4 weeks, then weaned over further 8 weeks - Low salt diet - Diuretics - for oedema

Answer 319

- Hypovolaemia - causing low BP - Thrombosis - due to loss of albumin which normally prevents clotting, also liver responds to low albumin by producing pro-thrombotic proteins - Infection - Acute or chronic renal failure - Relapse

Answer 320

- ***Reviewing medications*** (stop NSAIDs) - ***Proton pump inhibitors*** (omeprazole and lansoprazole) - ***Antacids*** (Gaviscon + Rennie) – short term only - ***Histamine H2-receptor antagonists*** (famotidine) - ***Surgery - laproscopic fundoplication -*** tying the fundus of the stomach around the lower oesophagus to narrow the lower oesophageal sphincter.

Answer 321

liver function tests - including gamma GT and total protein ethanol coagulation tests, including INR and APTT hepatitis serology - for A, B, and C viral screen, for CMV, EBV etc ferritin and total iron binding capacity immunoglobulins and protein electrophoresis autoantibody screen alpha-feto protein alpha 1 antitrypsin serum copper, ceruloplasmin, 24 hour copper Anti-mitochondrial antibodies Anti-nuclear antibodies

Answer 322

shortness of breath, fatigue and ankle oedema

Answer 323

in small intestine - mainly jejunum - Raised intra-epithelial lymphocytes - Villous atrophy - Crypt hyperplasia

Answer 324

Infectious mononucleosis (glandular fever) causes an intensely itchy maculopapular rash in response to amoxicillin or cefalosporins.(given these for wrongly presumed tonsilittis)

Answer 325

SHATTERED FAMILY Steroid use Hyperthyroidism/hyperPTH Alcohol + smoking Thin (BMI<22) Testosterone (LOW) Early menopause Renal/liver failure Erosive bone disease (RA) Diabetes FAMILY HISTORY

Answer 326

Bisphosphonates (alendronate, risedronate, zoledronic acid)

Answer 327

first thing in the morning - empty stomach with glass of water - sit upright for 30 mins - reflux - oesophageal erosions other SEs: - atypical fractures - jaw osteonecrosis

Answer 328

A score above 0 indicates a high risk for an upper GI bleed. - Haemoglobin (**falls** in upper GI bleeding) - Urea (**rises** in upper GI bleeding) - Systolic blood pressure - Heart rate - ***Melaena*** (black, tarry stools) - ***Syncope*** (loss of consciousness) - Liver disease - Heart failure

Answer 329

Chlordiazepoxide

Answer 330

Subdural - banana (S saucy) Extradural - lemon (extra zingy)

Answer 331

Well-defined lytic lesions (described as looking “punched-out”) Diffuse osteopenia Abnormal fractures Raindrop skull/pepper pot skull - refers to multiple lytic lesions seen in the skull

Answer 332

A – Ascites H – Hepatic encephalopathy O – Oesophageal varices bleeding Y – Yellow (jaundice)

Answer 333

- MELD score every 6 months - Ultrasound + alpha-fetoprotein every 6 months for hepatocellular carcinoma - Endoscopy every 3 years for oesophageal varices

Answer 334

- Malnutrition + muscle wasting - Portal hypertension, oesophageal varices (+ bleeding varices) - Ascites + spontaneous bacterial peritonitis - Hepatorenal syndrome - Hepatic encephalopathy - Hepatocellular carcinoma

Answer 335

- Low sodium diet - Aldosterone antagonists (spironolactone) - Paracentesis (ascitic tap or ascitic drain) - Prophylactic antibiotics (ciprofloxacin/norfloxacin) when there is <15 g/litre of protein in the ascitic fluid - Transjugular intrahepatic portosystemic shunt (TIPS) - in refractory ascites - Liver transplantation - in refractory ascites

Answer 336

- Cachexia (wasting of the body and muscles) - Jaundice - raised bilirubin - Hepatomegaly (then small nodular liver as it becomes more cirrhotic) - Splenomegaly due to portal hypertension - Spider naevi (telangiectasia with a central arteriole and small vessels radiating away) - Palmar erythema caused by elevated oestrogen levels - Gynaecomastia and testicular atrophy in males due to endocrine dysfunction - Bruising due to abnormal clotting - Excoriations (scratches on the skin due to itching) - Ascites - Caput medusae (distended paraumbilical veins due to portal hypertension) - Leukonychia (white fingernails) associated with hypoalbuminaemia - Asterixis (“flapping tremor”) in decompensated liver disease

Answer 337

Pyridoxine - Isoniazid - causes peripheral neuropathy, so co-prescribe pyridoxine (vitamin B6) to prevent this.

Answer 338

-Older age - Haemochromatosis (iron deposits in joints) - Hyperparathyroidism (=high calcium) - Hypophosphatasia - Hypomagnesaemia - Hypothyroidism - Acromegaly

Answer 339

- Right-sided heart failure: commonly caused by left-sided heart failure (e.g. secondary to fluid overload). - Pulmonary hypertension is another cause of right-sided heart failure, often due to chronic obstructive pulmonary disease or interstitial lung disease. - Tricuspid regurgitation: causes include infective endocarditis and rheumatic heart disease. - Constrictive pericarditis: often idiopathic, but rheumatoid arthritis and tuberculosis are also possible underlying causes.

Answer 340

Ipsilateral loss of proprioception, vibration and fine touch

Answer 341

Contralateral loss of crude touch, pressure, pain and temperature sensation

Answer 342

SO4 sueprior oblique muscle supplied by CN4 trochlear nerve => SO controls depresssion + abduction (when disrupted, patient cannot look down when eye is adducted)

Answer 343

Give 3 Take 3 => BUFALO Blood Cultures Urine output Fluids Antibiotics Lactate Oxygen

Answer 344

Tumour lysis syndrome is a potentially lethal condition caused by the rapid death of tumour cells often following chemotherapy or rapid progression of haematological malignancies, resulting in the massive release of intracellular contents. It is an oncological emergency. Presentation => acute-onset dysuria/oliguria, abdominal pain, or weakness. Key investigations => U&E (showing raised potassium and phosphate), calcium (typically low), uric acid (raised), and ECG to detect metabolic abnormalities and life-threatening arrhythmias. Initial management => correction of electrolyte abnormalities and IV fluids.

Answer 345

It occurs due to ABO incompatibility from a blood transfusion, resulting in IgM mediated intravascular haemolysis. Patients present with features of shock, abdominal and chest pain and feeling generally unwell within minutes of the transfusion starting. The most important management step is to stop the transfusion and then begin fluid resuscitation with intravenous saline. It is also important to send a sample of the patient's blood for direct Coombs test (which will confirm antibodies have bound to the surface of the transfused red blood cells) as well as repeat blood typing and cross-matching. The laboratory should be alerted and a Datix completed

Answer 346

Clot retention is a common complication following TURP, hence most patients are advised to refrain from walking and lifting heavy weights for at least one week post-surgery. In the event of clot retention, an emergency CYTOSCOPY + evacuation of CLOTS and diathermy to the bleeding point is the definitive management.

Answer 347

- ACUTE - A delayed haemolytic transfusion reaction can occur after blood transfusion, causing haemolysis with raised bilirubin levels and LDH values, usually within a week of the transfusion.

Answer 348

TRIAD - ataxia, areflexia and opthalmoplegia. Losing his balance and the positive Romberg’s indicated ataxia. He is also areflexic. Opthalmoplegia is present as he can’t abduct his right eye. Miller-Fisher syndrome can present with the prodrome of gastroenteritis, like Guillain-Barre, which can make things a confusing. Remember that Guillain-Barre starts distally (polyneuropathy) and makes it way up. Miller-Fisher starts proximally i.e. with the eyes.

Answer 349

**Torsades de Pointes (TdP) is an arrhythmia associated with a prolonged QT interval and is life-threatening due to its potential to degenerate into ventricular fibrillation.** **Torsades de Pointes is caused by other factors such as:** - Long QT syndrome - QT-prolonging medications - Electrolyte imbalances - Bradycardia - Structural heart disease **ECG** – characterised by a **twisting/oscillating pattern** of the **QRS -** *this results from the changing axis of the QRS, which rotates around the baseline* (DANGEROUS!! - can lead to cardiac arrest!)

Answer 350

- Correcting underlying cause (e.g., electrolyte disturbances or medications) - Magnesium infusion (even if they have normal serum magnesium) - Defibrillation if ventricular tachycardia occurs

Answer 351

**RATE CONTROL:** - 1st line - beta blocker or calcium channel blocker (not both!!) - 2nd line - add digoxin or amiodarone

Answer 352

**RHYTHM CONTROL:** - Flecainide *(contraindicated in LV dysfunction or hypertrophy)* - Amiodarone *(can cause thyrotoxicosis)* - Electrical cardioversion - Catheter ablation

Answer 353

“DREAD” mnemonic: D – Death R – Rupture of the heart septum or papillary muscles E – “oEdema” (heart failure) A – Arrhythmia and Aneurysm D – Dressler’s Syndrome

Answer 354

aka post-myocardial infarction syndrome Usually occurs 2 – 3 weeks after an acute MI Rare form of pericarditis Caused by a localised immune response that results in pericarditis. Presents with pleuritic chest pain, low-grade fever and a pericardial rub on auscultation. It can cause a pericardial effusion and rarely a pericardial tamponade. Diagnosis can be made with ECG (global ST elevation and T wave inversion), echocardiogram (pericardial effusion) and raised inflammatory markers (CRP and ESR). Management is with NSAIDs (e.g., aspirin or ibuprofen) and, in more severe cases, steroids (e.g., prednisolone). Pericardiocentesis may be required to remove fluid from around the heart, if there is a significant pericardial effusion.

Answer 355

Forehead sparing is a symptom of an upper motor neuron (UMN) lesion (such as STROKE or in bELLS PALSY), which is a facial palsy that affects the lower part of the face while sparing the forehead muscles The forehead muscles are spared because the upper half of the face is innervated bilaterally, meaning it receives supply from both the same side and opposite side of the brain. This means that if paralysis is caused by an UMN lesion, the forehead is spared A patient with a UMN lesion can wrinkle their forehead, while a patient with a lower motor neuron (LMN) lesion cannot.

Answer 356

- Symptom relief - GTN spray (2x max) - Anti-anginal meds - betablocker/atenolol OR CCB/verapamil - Secondary prevention of coronary artery disease - aspirin 75mg OD and statin 80g ON

Answer 357

*group and save - reserve blood* *cross match - actually get blood*

Answer 358

- Peptic ulcers - Stomach/gastric cancer - Mallory-Weiss tears - Oesophageal varices

Answer 359

- Haematemesis - Coffee ground vomit (digested blood) - Melaena

Answer 360

High urea (RBC breakdown) Low Hb

Answer 361

Oesophago-gastro-duodenoscopy (OGD) (endoscopy) is required to diagnose and treat the source of the bleeding

Answer 362

ABATED A - A to E assessment B - bloods (Hb, urea, coags, LFTs, crossmatch 2 units) A - access (2x large bore cannula) T - transfusions as needed E - endoscopy (OGD) within 24hrs D - drugs (stop any anti-coagulants and NSAIDs) [extra steps for oesophageal varices => Terlipressin or variceal band ligation]

Answer 363

ALARMS A - anaemia L - lost weight A - anorexia (appetite) R - refractory symptoms (reflux symptoms even after M - melaena S - swallowing (dysphagia)

Answer 364

Blood, platelets and clotting factors (used in massive bleeding)

Answer 365

- H.pylori - Stress - Alcohol - Caffeine - Smoking - Spicy foods - Aspirin - Steroids *(chronic use)*

Answer 366

Zollinger-Ellison syndrome: gastrin-secreting neuroendocrine tumour

Answer 367

- Guarding - Rigidity - Rebound tenderness - Percussion - causes pain - Shoulder tip pain

Answer 368

- Adhesions (scars) - Hernia - Cancer

Answer 369

- Cancer - Diverticulitis - Volvulus

Answer 370

Contrast CT abdomen

Answer 371

4-8 weeks of high dose PPI

Answer 372

Boerhaave syndrome. Full-thickness rupture of the oesophagus, often precipitated by severe vomiting. The reduced breath sounds and dullness to percussion indicate pleural effusion, which is often seen in Boerhaave syndrome due to the leakage of gastric contents into the mediastinum and pleural space. This is a medical emergency requiring prompt treatment.

Answer 373

Entamoeba histolytica Presents with bloody diarrhoea and a liver abscess, causing RUQ pain, swinging fevers and sweats. Faecal-oral transmission Associated with travel to endemic areas and men who have sex with men

Answer 374

Oral fidaxomicin - Used when oral vancomycin unsuccessful OR - in patients who have a second episode of Clostridium difficile infection within 12 weeks of symptom resolution from their first episode (relapse).

Answer 375

Chronic mesenteric ischaemia caused by atherosclerosis in the gut supply arteries.

Answer 376

- UDCA - bile acid that protects cholangiocytes from damabge - Replacement of fat-soluble vitamins - ADEK - Cholestyramine - for pruritus

Answer 377

- Raised ALP - Anti-mitochondrial antibodies

Answer 378

Radiculopathy - pinched nerve root as it leaves spine Myelopathy - compressed spinal cord

Answer 379

Lumbar spinal stenosis => lateral and foramina stenosis = radiculopathy - compression of nerve root as it leaves spine column

Answer 380

radiculopathy typically manifests as sharp, radiating pain along a specific nerve pathway (like down the arm or leg) due to a compressed nerve root, whereas myelopathy presents with more generalized weakness, clumsiness, and coordination problems due to compression of the spinal cord itself essentially, radiculopathy affects individual nerves while myelopathy impacts the entire spinal cord function.

Answer 381

- **Urinary incontinence** - **Dementia** - **Gait abnormality** ⇒ treated with ventriculo-peritoneal shunting

Answer 382

Pancoast tumour causing Horner syndrome Lung tumour but does not typically cause cough, instead presents with shoulder pain

Answer 383

Degeneration of the dorsal columns and corticospinal tracts (pain and temperature are unaffected as the spinothalamic tract is intact)

Answer 384

When the light is shone in the right eye, both pupils constrict. When the light is moved to the left eye, both pupils dilate. QUICKLY SWING ACROSS TO LEFT EYE When light shone in left eye, the pupils dilate (left eye does not detect the light due to lesion in optic nerve = optic neuritis)

Answer 385

VITAMINS Vascular - stroke, HTN, eclampsia Infections - meningitis, encephalitis Toxins - alcohol overdose, antidepressants, antipsychotics AV malformation + space occupying lesions Metabolic - hypoglycaemia, hypo/hypernatraemia, hypocalcaemia Multiple sclerosis Idiopathic Neoplasms Stress

Answer 386

In cases of massive PE (hypotension for over 15 minutes), patients should be treated with thrombolysis (an IV bolus of Alteplase) => to restore pulmonary perfusion

Answer 387

VENTURI to reduce the risk of over-oxygenation - it is always best to use a controlled method of oxygen delivery such as a Venturi mask in COPD patients. You are giving them O2, just through a Venturi mask instead of another method, like a non-rebreathe. Patients at risk of T2RF, such as those with COPD, have adapted to be used to the lower oxygen levels that their condition leads them to have. This means their O2 saturation ranges are normal at 88-92%. If we give them too much oxygen, we can reduce their respiratory drive, which is dangerous. Venturi masks control the amount of oxygen we give the patient, to stop us doing this :)

Answer 388

VITAMINS V - Vascular: stroke, aneurysms, and other vascular malformations. I - Infection: meningitis and encephalitis T - Trauma: Head injuries and birth trauma A - Autoimmune (vasculitis) OR AV malformation: abnormal connections between arteries and veins M - MS or Metabolic: electrolyte imbalances (hypoglycemia, hypo/hypernatremia), and other metabolic disorders. I - Idiopathic N - Neoplasm: brain tumours S - Stress => Psychogenic

Answer 389

3x Ws "wet" (urinary incontinence) "wobbly" (gait disturbance) "wacky" (cognitive impairment)

Answer 390

- Pancoast tumour (lung apex) - Infection - meningitis/encephalitis - Space occupying lesion - Trauma - Stroke - MS - *Migraine or cluster headache* - Large goitre - Congenital