Random finals revision Flashcards
What is alcohol-induced lymph node pain a sign of?
Hodgkin’s lymphoma
How many days in advance of surgery should warfarin be stopped?
5 days before
check INR day before procedure to ensure <1.5
What nerve roots are damaged in Erb’s palsy and what is the resultant deformity?
C5 & 6
Internal rotation of humerus
What medications can predispose to tendon rupture?
Quinolone antibiotics e.g. ciprofloxacin
What is a Pavlik harness used for?
Development dysplasia of the hip (DDH)
What are the muscles of the rotator cuff?
SITS Supraspinatus Infraspinatus Teres minor Subscapularis
What is the principal clinical sign of adhesive capsulitis?
AKA frozen shoulder
Loss of external rotation
Osteogenesis imperfecta is a defect of ..?
Type 1 collagen
What is the inheritance pattern of osteogenesis imperfecta?
Autosomal dominant
Duchenne muscular dystrophy is a defect of which gene?
Dystrophin gene (involved in calcium transport)
How is diagnosis of Duchenne muscular dystrophy confirmed?
Raised serum creatinine phosphokinase / abnormalities of muscle biopsy
What is the emergency management of a tension pneumothorax?
Needle decompression with a large bore needle in the 2nd intercostal space, mid-clavicular line (–> chest drain)
What is the minimal acceptable urine output?
0.5ml / kg / hour
Initial antibiotic management of open fractures?
IV flucloxacillin, gentamicin and metronidazole
First line management of achilles tendon rupture?
Equinus cast (a plaster of Paris cast where foot is held in plantar flexion)
What is the gold standard test to confirm diagnosis of coeliac disease.
Upper GI endoscopy for small bowel biopsy. Must be done whilst on gluten-containing diet.
Gold standard investigation for acute RUQ / RIF pain?
Ultrasound
Gold standard investigation in pregnant woman with ?appendicitis
MRI
What are the two causes of peptic ulcer disease?
H. pylori infection (duodenal > gastric) and NSAID use (gastric > duodenal)
What diagnosis is suggested by the combination of peptic ulcer disease and diarrhoea?
Zollinger-Ellison syndrome (gastrin-producing neuroendocrine tumour). Can be associated with MEN-type 1
What is the gold standard investigation for diagnosing peptic ulcer disease?
Endoscopy with biopsy samples collected for rapid urease testing or histology
What is the recommended pathway for any patient > 55 years presenting with weight loss and dyspepsia
Urgent upper GI endoscopy within 2 weeks
Where can duodenal ulcers penetrate to?
Posteriorly into the pancreas
What investigation should be done if a patient’s H. pylori status is uncertain after endoscopy?
Carbon-13 urea breath test or stool antigen test
First line investigation for suspected Zollinger-Ellison syndrome?
Fasting serum gastrin
What is the H.pylori eradication therapy?
PPI + amoxicillin + metronidazole for 7 days
What are the 3 tumour types seen in MEN-type 1?
3 P’s
- Pituitary adenoma
- Parathyroid hyperplasia
- Pancreatic tumours
Pheochromocytoma is a typical feature of what syndrome?
Multiple endocrine neoplasia type 2 (A+B)
What is the main side effect of TNFalpha inhibitors?
May reactivate latent TB
When are TNF alpha inhibitors indicated in rheumatoid arthritis? e.g. etanercept, infliximab
Inadequate response to at least 2 DMARDs (including methotrexate)
What are the adverse effects of methotrexate use?
Myelosuppression and liver cirrhosis
Monitor FBCs and LFTs
First line treatment for acute anal fissure?
Bulk forming laxative
First line treatment for chronic anal fissure?
Topical GTN
What is the recommended management for an inguinal hernia in an infant under 1 years old?
Refer for urgent surgery (due to risk of strangulation)
What is the recommended management for an inguinal hernia in a child over 1 years old?
Refer for routine surgery
Gold standard investigation for ?renal stones
Non-contrast CT-KUB
Management of renal stones <5mm?
Expectant management, should pass within 4 weeks
Management of renal stones <2cm?
Shockwave lithotripsy
Management of renal stones <2cm in pregnant woman?
Ureteroscopy (as lithotripsy is contraindicated)
What disease is associated with anti-scl-70 antibodies?
Diffuse cutaneous systemic sclerosis
What disease is associated with anti-centromere antibodies?
Limited cutaneous systemic sclerosis
Classic presentation of ascending cholangitis?
Fever, jaundice and RUQ pain (Charcot’s triad)
What is the most common cause of ascending cholangitis?
E.coli infection
What is the management of ascending cholangitis
IV antibiotics (piperacillin / tazobactam) with ERCP after 24-48 hours to relieve any obstruction
What drugs are used to prevent pathological fracture in bone metastases?
Biphosphonates and desunomab
Latter is preferred if eGFR <30
What is the first line management for ‘provoked’ PE?
3 months of DOAC e.g. apixiban / rivaroxaban
What is the first line management for ‘unprovoked’ PE?
6 months of DOAC e.g. apixiban / rivaroxaban
What is the mechanism of action of thiazide-like diuretics e.g. bendroflumothiazide, indapamide
Block the thiazide-sensitive NaCl symporter, inhibiting sodium reabsorption in the DISTAL CONVOLUTED TUBULE
When should patient with aortic stenosis receive valvular replacement?
If symptomatic OR aortic valve gradient > 40 mmHg
Common adverse effects of thiazide diuretics?
Dehydration, postural hypotension, gout. electrolyte abnormalities (hyponatraemia, hypokalaemia, hypercalcaemia), sexual dysfunction, worsen glucose tolerance
What condition can cause widespread ST elevation?
Pericarditis
What diagnosis is suggested by sudden onset chest pain with focal neurological deficit?
Aortic dissection
Gold standard investigation for suspected acute pericarditis?
Transthoracic echocardiography
Key feature of pericarditis chest pain?
Relieved by sitting forward
First line management for pericarditis?
Colchicine +/- NSAIDs
Most common cause of pericarditis?
Viral infection (coxsackie virus)
What is the most common cause of secondary hypertension?
Primary hyperaldosteronism (Subtype = Conn’s syndrome)
First line management for stable angina?
All patient given aspirin + statin
GTN spray for acute attacks
Either beta blocker or calcium channel blocker. If not tolerated, try the other one. If still symptomatic, try combination.
What are the main presenting features of hypercalcaemia?
Stones - kidney or biliary stones
Bones - bony pain
Groans - abdominal pain
Thrones - constipation / frequent urination
Tones - muscle weakness / hyporeflexia
Psychiatric moans - confusion, depression, anxiety
What inheritance pattern is seen in hypertrophic obstructive cardiomyopathy (HOCM)?
Autosomal dominant disorder of muscle tissue caused by defects in the genes encoding contractile proteins
Management of hypertrophic obstructive cardiomyopathy?
ABCDE Amiodarone Beta blocker or verapamil for symptoms Cardioverter defibrillator (ICD) Dual chamber pacemaker Endocarditis prophylaxis
What is coarctation of the aorta?
congenital narrowing of the descending aorta
First line investigation for stable angina?
CT coronary angiogram (with contrast) to assess blood flow through the coronary arteries and to look for any narrowing or blockages in the arteries.
What type of heart disease can chronic alcoholism cause?
Dilated cardiomyopathy
What is the mechanism of action of loop diuretics e.g. furosemide, bumetanide?
Block the Na-K-Cl cotransport (NKCC) in the THICK ASCENDING LIMB OF THE LOOP OF HENLE resulting in reduced absorption of NaCl
What electrolyte dysfunctions are caused by thiazide / thiazide like diuretics?
Hypokalaemia, hyponatraemia, hypercalcaemia, hypomagnesaemia
What electrolyte dysfunctions are caused by loop diuretics?
4 HYPOS. lOOp
Hypokalaemia, hyponatraemia, hypocalcaemia, hypomagnesaemia
What foods should be avoided in patients taking warfarin?
Broccoli, spinach, kale and sprouts (rich in vitamin K)
First line management of torsades de pointes?
IV magnesium sulphate
Secondary management of MI?
He had an MI, now he DABS
DABS Dual anti platelet therapy (aspirin + prasugrel/ticagrelor/clopidogrel*) ACE inhibitor Beta blocker Statin
*Stop 2nd anti platelet after 12 months
What are the 3 drugs used for rate control in AF?
BDD
Beta blockers (1st line)
Dilitiazem (1st line)
Digoxin (2nd line)
Monotherapy then dual therapy
When should a rhythm control method be used in AF rather than a rate control?
Co-existent heart failure, first onset AF or obvious reversible cause (e.g. pneumonia)
What drugs are used in rhythm control in AF?
Flecainide
Amiodarone
Adenosine ?
Which area of myocardial infarct can result in arrhythmias?
Inferior MI (leads II, III, aVF) supplies the right coronary artery which provides blood supply to the AV node. Therefore an inferior MI can result in arrhythmias
What should be suspected when a patient experiences a sudden deterioration of renal function following commencement of ACE inhibitor therapy?
Bilateral renal artery stenosis
What causes acute heart failure with a systolic murmur post-MI?
Ventricular septal defect (rupture of the interventricular septum)
OR
Acute mitral regurgitation secondary to ischaemia/rupture of papillary muscle
Acute management of supraventricular tachycardias?
1st line - vagal manoeuvres e.g. carotid sinus massage
2nd line - IV adenosine (6mg -> 12 mg)
What is seen on histology in coeliac disease?
Histology will show presence of intra-epithelial lymphocytes, villous atrophy, and crypt hyperplasia.
Most common symptom of Crohn’s in children?
Abdominal pain
Most common symptom of Crohn’s in adults?
Diarrhoea (bloody diarrhoea suggest colitis, either Crohn’s or ulcerative)
What medications should all patients with peripheral arterial disease be started on?
Atorvastatin and clopidogrel
What is the management for an asymptomatic AAA of 4.3cm?
Annual ultrasound (3-4.4cm) \+ statin and aspirin therapy
Management of superficial thrombophlebitis?
Referral for ultrasound scan
Oral NSAIDs and compression stockings
Consider prophylactic LMWH
What is the screening programme for abdominal aortic aneurysms?
A single abdominal ultrasound for men age 65
What is the most common site of venous ulcers?
Medial malleolus
Gaiter region
Which type of leg ulcer is associated with a brown pigmentation?
Venous ulcer
Brown pigmentation = hemosiderin deposition
What type of ulcer is small, deep and has a well-defined border?
Arterial ulcer
What does an ABPI of 0.6 suggest?
Moderate
> 0.9 normal
0.8-0.9 mild
0.5-0.8 moderate
< 0.5 severe
What are the two main causes of neuropathic ulcers?
Diabetes mellitus and vitamin B12 deficiency
What is the most common cause of vitamin b12 deficiency?
Pernicious anaemia - an autoimmune disorder affecting the gastric mucosa
What is the pathophysiology of pernicious anaemia?
Autoimmune disorder
Autoantibodies to intrinsic factor +/- gastric parietal cells
What is the function of vitamin B12?
Used in the production of blood cells and the myelination of nerves (therefore deficiency causes megaloblastic anaemia and neuropathy)
Where is the most common site for a neuropathic ulcer?
Plantar surface of metatarsal head
What initial investigation is indicated in suspected chronic limb ischaemia?
Doppler ultrasound (followed by CT angiography)
What medications should be started following a diagnosis of intermittent claudication?
Atorvastatin 80mg
Clopidogrel 75mg
What is the definition of critical limb ischaemia?
Ischaemic rest pain > 2 weeks requiring opiate analgesia OR presence of ischaemic lesions/gangrene OR ABPI <0.5
What are the 6 P’s of acute limb ischaemia?
Pain Pallor Pulselessness Paraesthesia Perishingly cold Paralysis
What are the two causes of acute limb ischaemia?
Embolism (80%) - proximal source
Thrombus (20%) - atherosclerosis
How to differentiate clinically between embolic and thrombotic cause of acute limb ischaemia?
Embolic aetiology - sudden onset, no history of claudication, obvious source of embolus (AF, recent MI), normal contralateral limb with intact pulses
Thrombotic aetiology - pre-existing claudication with sudden deterioration, no obvious source of emboli, reduced/absent pulses in contralateral limb, evidence of widespread vascular disease (MI, stroke, TIA)
Embolic typically more severe as no time for compensation!
What medication should all patients presenting with acute limb ischaemia be given?
Heparin (bolus dose followed by infusion)
Which stage of acute limb ischaemia is described (Rutherford classification)
Sensory loss of foot with rest pain, mild muscle weakness, inaudible arterial doppler and audible venous doppler
Stage IIb
Which stage of acute limb ischaemia is described (Rutherford classification)
No sensory loss or muscle weakness, audible arterial doppler and audible venous doppler
Stage I
Which stage of acute limb ischaemia is described (Rutherford classification)
Sensory loss of toes, no muscle weakness, inaudible arterial doppler, audible venous doppler
Stage IIa
Which stage of acute limb ischaemia is described (Rutherford classification)
Profound sensory loss, paralysis of limb, inaudible arterial doppler, unaudible venous doppler
Stage III
What are the 4 features used in the Rutherford classification of acute limb ischaemia?
Sensory loss, muscle weakness, arterial doppler signal and venous doppler signal
What are the surgical options for AAA repair?
Open repair or endovascular repair
What is the classic triad of symptoms seen in AAA rupture?
Back/flank pain, pulsatile abdominal mass and hypotension
What are the indications for repair of an AAA?
> 5.5 cm
Expanding at > 1cm/year
Symptomatic in otherwise fit patient
Which type of stroke is suggested by isolated hemisensory loss?
Lacunar infarct (LACS)
What investigations should be done in a ‘young’ person with a stroke?
Autoimmune and thrombophilia screen
This can include tests such as antinuclear antibodies (ANA), antiphospholipid antibodies (APL), Anticardiolipin antibodies (ACL), Lupus anticoagulant (LA), coagulation factors, erythrocyte sedimentation rate (ESR), homocysteine and syphilis serology.
What medications are given for secondary prevention of stroke?
Clopidogrel (first line anti platelet)
2nd line = aspirin +MR dipyridamole
What are the time thresholds for ischaemic stroke management?
4.5 hours for thrombolysis (alteplase)
6 hours for mechanical thrombectomy (can be extended to 24 hours if evidence of salvageable tissue on CT perfusion / diffusion weighted MRI)
What is the blood supply of Wernicke’s and Korsakoff’s areas of the cortex?
Middle cerebral artery on dominant side (L>R)
What is the recommended anti platelet regimen following a stroke?
Aspirin 300mg for 14 days, then clopidogrel 75mg long term
2nd line = aspirin + dipyridamole dual therapy long term
What is the first line investigation for suspected primary hyperaldosteronism?
Plasma aldosterone/renin ratio (showing high aldosterone levels and low renin levels)
Side effects of SGLT2 inhibitors e.g. dapagliflozin?
Increased glucose secretion in urine results urinary and genital infection (contraindicated in recurrent thrush)
What are the 2 types of pleural effusion?
Transudate (<30g/L protein) and exudate (>30g/L protein)
Most common cause of pleural effusion with <30g/L protein?
<30g/L = transudate
Most common cause of transudate pleural effusion is heart failure
Most common cause of pleural effusion with >30g/L protein?
> 30g/L = exudate
Most common cause of exudate pleural effusion is infection, specifically pneumonia
What are the classic examination findings of a pleural effusion?
Dullness to percussion, reduced breath sounds and reduced chest expansion
What electrolyte abnormality is associated with SSRIs?
Hyponatraemia
First line treatment for immune thrombocytopenia purpura (ITP)?
Prednisolone
What is the management for a patient presenting with pheochromocytoma?
A then B
Alpha blockers e.g. phenoxybenzamine followed by
Beta blockers e.g. propanolol
Surgery is the definitive management
What oral antibiotic is used for a mycoplasma pneumonia?
Macrolides e.g. erythromycin
erythroMYCin for MYCoplasma
What does an increased serum urea (>10 times upper limit of normal) but a normal creatinine suggest?
An upper GI bleed
Can ureteric or gallbladder stones be seen on plain X-ray?
ureteric - >90%
gallbladder - <10%
What are steroid hormones derived from?
cholesterol
What is the most common congenital heart defect?
ventricular septal defect
x
x
When is VSD usually diagnosed?
6-8 weeks
When is PDA usually diagnosed?
3-5 days
x
x
6 year old boy with intermittent groin pain for last few months, has now developed painless limp
Legg-Calves-Perthes disease (AKA idiopathic avascular necrosis of proximal femoral epiphysis)
First line investigation for suspected Perthes disease?
X-ray
Management of Perthes disease?
Usually conservative management (NSAIDs, PT, brace) but may require surgery (osteotomy) if >50% femoral head damaged
14 year old overweight boy presents with hip pain and limp
Slipped upper femoral epiphysis (SUFE)
First line investigation for suspected SUFE?
X-ray
Management of SUFE?
Surgery
9 year old boy presents with painful hip and a limp over. last few days, he has recently been off school with a cold
Transient synovitis
First line investigation for suspected transient synovitis?
FBC/inflammatory markers: will be raised
First line investigations for suspected subarachnoid haemorrhage?
CT head, if negative perform lumbar puncture to look for xanthochromia (at least 12 hours after onset).
Most common cause of non-traumatic SAH?
Intracranial aneurysm
First line management of SAH?
Give NIMODIPINE as soon as diagnosis is confirmed to prevent delayed cerebral ischaemia and improve outcomes
what is the investigation of choice for any concerning headache?
MRI with contrast.
CT without contrast done to rule out intracranial haemorrhage OR if MRI contraindicated
What are the spinal nerve roots responsible for the knee reflex?
L3 and L4
4 and 3 for the knee
What are the spinal nerve roots responsible for the achilles reflex?
S1 and S2
1 and 2 feet
What is the dermatomal distribution of L5
down the back of the leg and dorsum of foot including big toe
What is the dermatomal distribution of S1
down the back of the leg and lateral aspect of foot
What is the dermatomal distribution of C6
along lateral aspect of arm to the thumb and index finger (six shooter)
What is the most common compressive radiculopathy?
L5 nerve root compressed by L4 disc
What nerve roots are responsible for micturition reflex?
S2,3,4 (keeps the pee off the floor)
What can cause a ‘cape-like’ distribution of sensory loss over the neck and shoulders?
Syringomyelia of cervical region
Upper motor neurone pathology of the upper extremities causes spasticity in the FLEXORS OR EXTENSORS?
FLEXORS
Upper motor neurone pathology of the lower extremities causes spasticity in the FLEXORS OR EXTENSORS?
EXTENSORS
Is atrophy a UMN or LMN sign?
Lower motor neurone
Is decreased tone a UMN or LMN sign?
Lower motor neurone
Is increased tone a UMN or LMN sign?
Upper motor neurone
Are fasciculations present in UMN or LMN pathology?
Lower motor neurone
Are increased muscle stretch reflexes a UMN or LMN sign?
UMN
What are characteristics of an essential tremor?
Symmetrical high frequency tremor involving arms, legs, face, voice, neck and tongue. Action tremor (worsened by intentional movement) / postural tremor (worsened with sustained muscle tone).
What are characteristics of a Parkinson’s tremor?
Asymmetrical low frequency tremor present at rest. Involving hands, legs, chin.
What may be seen on autopsy of a patient with Parkinson’s disease?
Lewy bodies (eosinophilic sphere-shaped inclusions in the cytoplasm) along with degeneration of the dopaminergic neurons of the substantial nigra.
What are the classic triad of symptoms seen in Parkinson’s disease?
Resting tremor, bradykinesia and cogwheel rigidity
What two medications can contribute to hypothyroidism?
Amiodarone and lithium
What three drugs should be given in a thyrotoxic storm?
Hydrocortisone, propranolol and propylthiouracil
What drugs should be given in a myxoedemic coma?
thyroxine and hydrocortisone
What is the syndrome that causes rapid enlargement of an ACTH-producting pituitary adenoma secondary to bilateral adrenalectomy for Cushing’s disease?
Nelson’s syndrome - causes hyperpigmentation and local effects (bitemporal hemianopia, nerve palsies)
What are the three parts of triple assessment of a breast lump?
Clinical assessment (history and examination), imaging (ultrasounds and mammography) and histology (fine needle or core)
What is recommended referral for unexplained breast lump in a woman under 30?
Routine referral
What is recommended referral for unexplained breast lump in a woman over 30?
Urgent 2 week suspected cancer referral
What is recommended referral for unexplained lump in axilla in a woman over 30?
Urgent 2 week suspected cancer referral
What is recommended referral for unilateral nipple changes in a woman over 50?
Urgent 2 week suspected cancer referral
What is recommended referral for skin changes suggestive of breast cancer in woman under 30?
Urgent 2 week suspected cancer referral (for any age)
What should be done when a man presents with unexplained gynaecomastia?
Testicular examination - around 2% of patients with gynaecomastia will have testicular cancer
How do intraductal papillomas of the breast present?
Most commonly present with watery or blood stained nipple discharge
Initial management of an intraductal papilloma?
Triple assessment (history+exam, imaging and histology). Intraductal papillomas require complete surgical excision.
Most common cause of infective lactational mastitis?
Staphylococcus aureus
Management of lactational mastitis?
IF obstructive - conservative management with continued breastfeeding, breast massage, heat packs and painkillers
If conservative management fails or infection suspected - first line antibiotic management = flucloxacillin. 2nd line = erythromycin. Fluconazole given if fungal infection suspected. Milk sample can be sent for C+S
Advice for patient with mastitis who is breastfeeding?
Advised to continue breastfeeding - flow of milk will help to clear the infection and the milk is safe for the baby. alternative is to express milk.
Breastfeeding patient presents with infective mastitis and is given 7 day course of flucloxacillin. She then returns with a cracked sore nipple. What do you do?
Recurrent mastitis post-antibiotic therapy is likely fungal.
Also associated with oral candidiasis and nappy rash in the infant. Both mother and baby need treated.
- Topical miconazole 2% applied to each nipple after each breastfeed.
- Oral miconazole gel or nystatin for the baby
Management of non-lactational mastitis?
Requires BROAD SPECTRUM antibiotics
1st line - co-amoxiclav
2nd line - erythromycin + metronidazole
Management of a breast abscess?
Referral to the on-call surgical team
plus antibiotics, ultrasound scan, drainage/aspiration and c+s of aspirated fluid
What is the current UK breast cancer screening program?
Mammogram every 3 years for woman ages 50-70
What patients are seen as ‘high risk’ and advised to have yearly mammogram?
- A first-degree relative with breast cancer under 40 years
- A first-degree male relative with breast cancer
- A first-degree relative with bilateral breast cancer, first diagnosed under 50 years
- Two first-degree relatives with breast cancer
What medications can be given to prevent breast cancer in women who are considered high risk AKA chemoprevention?
Tamoxifen (premenopausal)
Anastrozole (postmenopausal)
What imaging modality should be used to assess a breast lump?
Under 30 - ultrasound
Over 30 - mammogram
What are the three receptor types seen in breast cancer?
oestrogen receptor (ER), progesterone receptor (PR) and human epidermal growth factor (HER2)
What breast cancer type do the NICE guidelines suggest doing gene expression profiling on?
ER positive
PR and HER2 negative
Where does breast cancer commonly metastasise to?
2Ls and 2Bs
Lung, liver, bone and brain
What is the inheritance pattern of BRCA1 and BRCA2 mutations?
Autosomal dominant - children and siblings have 50% risk of having gene mutation
First line investigation in suspected bacterial meningitis?
Lumbar puncture
3 common types of bacterial meningitis?
Pneumococcal (strep. pneumoniae) gram +VE
Meningococcal (Neisseria meningitidis) gram -VE
Hib (haemophilus influenza type B) gram -VE
What is the disadvantage of using PPIs long term?
Increased risk of osteoporosis and fractures
What is the most common cause of ambiguous genitalia in the newborn?
Congenital adrenal hyperplasia (95% due to 21-hydroxylase deficiency)
What is the best location for total parenteral nutrition insertion?
TPN should be administered via a central vein (not peripheral as it is strongly phlebitic)
Most common complication of bacterial meningitis?
Hearing loss - 1 in 3 survivors will develop hearing loss
What causes a subdural haemorrhage?
Rupture of the bridging veins in the outermost meningeal layer (bleed between dura and arachnoid mater)
What does a subdural haemorrhage look like on CT?
Crescent shaped and not limited by cranial sutures
What type of patient gets a subdural haemorrhage?
usually elderly / alcoholic patients (atrophy in brain makes vessels more likely to rupture)
What causes an extradural haemorrhage?
Usually caused by rupture of the middle meningeal artery in the tempero-parietal region (bleed between the skull and dura mater)
What fracture is associated with an extradural haemorrhage?
Temporal bone fracture
What does an extradural haemorrhage look like on CT?
Bi-convex shaped and limited by cranial sutures
What type of patient gets an extradural haemorrhage?
Usually young patient with history of head trauma - classically hx of ongoing headache, improving neurological signs/conscious level then a rapid decline as bleed gets big enough to compress intracranial contents
What are the two main causes of subarachnoid haemorrhage?
Trauma and ruptured cerebral aneurysm
First line management of SAH?
Nimodipine
What is seen on investigations for MS?
MRI - lesions
LP - oligoclonal bands in CSF
Which type of tremor improves with alcohol?
Essential tremor
First and second line management of tonic-clonic seizures?
1st line - sodium valproate
2nd line - carbamazepine or lamotrigine
First and second line management of focal seizures?
1st line - carbamazepine or lamotrigine
2nd line - sodium valproate
Where do focal seizures start
Temporal lobes
First line management of absence seizures?
Ethosuximide or sodium valproate
Mechanism of action of sodium valproate?
Increases activity of GABA which has a relaxing effect o the brain
Side effects of sodium valproate
Very teratogenic - avoid in females
Liver damage/hepatitis, hair loss, tremor
Definition of status epilepticus
seizures lasting > 5 minutes or > 3 seizures in 1 hour
1st line management of status epilepticus in the hospital
IV lorazepam (repeat once after 10 minutes if doesn’t work) then try IV phenobarbital /phenytoin
If other benzodiazepines have been given in community, remember to give max of 2 doses of benzodiazepines before then trying phenobarbital / phenytoin
1st line management of status epilepticus in the community
Buccal midazolam / rectal diazepam
1st line management of trigeminal neuralgia?
Carbamazepine
What are the functions of the facial nerve (CN VII)?
Motor - muscles of facial expression, stapedius of inner ear, neck muscles
Sensory - taste from anterior 2/3rd of tongue
Parasympathetic - submandibular and sublingual salivary glands, lacrimal gland
How do you differentiate between an upper or lower motor neurone facial nerve palsy?
UMN facial nerve palsy - unilateral weakness NOT INCLUDING FOREHEAD
LMN facial nerve palsy - unilateral weakness INCLUDING FOREHEAD
What are the causes of an UMN facial nerve palsy
Stroke or tumour
What are the causes of a LMN facial nerve palsy
Bell’s palsy, Ramsay-Hunt syndrome
How long does a Bell’s palsy last for
Majority of patients will resolve within weeks to months
1/3rd will have residual weakness
Management of a Bell’s palsy
Prednisolone if presenting within 72 hours
Lubricating eye drops / tape for sleeping. Refer to ophthalmology if eye becomes painful (exposure keratopathy)
Refer to ENT if no improvement after 3 weeks of steroids
Management of a sore eye associated with bell’s palsy
Refer to ophthalmology - exposure keratopathy
Presentation of Ramsay-hunt syndrome?
Unilateral LMN facial nerve palsy and a painful vesicular rash in ear canal/pinna/around ear on affected side. Rash may involve anterior 2/3rds of tongue and hard palate
Management of Ramsay-hunt syndrome
Prednisolone and aciclovir (ideally within 72 hours)
What are some features of a headache that are concerning and prompt further investigation?
Constant, nocturnal, worse on waking, worse when bending forward / coughing / sneezing, associated vomiting
Whereabouts in the brain do acoustic neuromas occur?
AKA vestibular schwannomas
Occur around the cerebellopontine angle
What does bilateral acoustic neuromas suggest?
Neurofibromatosis type 2
When would you refer someone with Bell’s palsy to ENT?
If no improvement after 3 weeks of steroids.
What is the definitive management of an extradural haematoma?
Craniotomy and hematoma evacuation
Why does an extradural haemorrhae cause a fixed dilated pupil?
compression of the parasympathetic fibres of CN III
What should be prescribed for a Parkinson’s patient who is declared nil-by-mouth?
Dopamine agonist patch (to prevent acute dystonia, co-careldopa can only be given orally)
Which Parkinson’s medications are most likely to cause impulse control disorders?
Dopamine agonist therapy e.g. bromocriptine, cabergoline
But can happen with any dopamine increasing drug
Pathophysiology of myasthenia gravis?
Autoantibodies against acetylcholine receptors
Presentation of myasthenia gravis?
Muscle fatiguability, extra ocular muscle weakness (diplopia), proximal muscle weakness, ptosis, dysphagia
What tumour type is associated with myasthenia gravis?
15% will develop a thymoma
50-70% will have thymic hyperplasia
Diagnostic investigation of myasthenia gravis?
Single fibre electromyography (sensitive test)
First line management of myasthenia gravis?
Long-acting acetylcholinesterase inhibitors e.g. pyridostigmine
Immunosuppression e.g. prednisolone
CT scan to look for thymoma, thymectomy if found
Migraine prophylaxis?
Topiramate OR propranolol
Migraine acute attack?
triptan + NSAIDs or paracetamol
When is prophylaxis indicated for migraine?
2 or more attacks per month causing disability
What is the typical EEG finding of absence seizures?
Bilateral, symmetrical 3Hz oscillations during a seizure episode
How to differentiate between a true seizure and a pseudo seizure?
raised serum prolactin level
characteristic feature of cluster headaches?
unilateral extremely painful headache, occurring several times a day for weeks (“cluster”) followed by an episode free period for 1-2 years
first line management for acute cluster headache?
SC triptan and oxygen
first line management for cluster headache prophylaxis
verapamil
what type of aphasia is Broca’s aphasia?
expressive aphasia - broken speech
what type of aphasia is Wernicke’s aphasia?
receptive aphasia - fluent speech but can’t understand (what?)
which area of a stroke causes Broca’s aphasia
superior division of left MCA
which area of a stroke causes Wernicke’s aphasia
inferior division of left MCA
features of a third nerve palsy
eye ‘down and out’, ptosis and dilated pupil
how can you differentiate between a CN III palsy and Horner’s syndrome?
CN III palsy= ptosis + dilated pupil
Horner’s = ptosis + constricted pupil
Antiemetic of choice in Parkinson’s
domperidone (doesn’t cross bbb)
muscle weakness following an infection suggests…
Guillan-barre syndrome
Which infection is most associated with triggering Guillain barre syndrome?
campylobacter jejuni (gastroenteritis)
what electrolyte abnormality is associated with SAH?
hyponatraemia secondary to SIADH
what is the inheritance pattern
of Huntington’s disease
autosomal dominant
what type of disease is huntington’s disease
genetic (AD) trinucleotide repeat disorder
what gene is affected in Huntington’s disease and what is the resultant mutation?
HTT gene on chromosome 4 resulting in repeat expansion of CAG
Managaement of Lambert-eaton syndrome?
CXR of SLCL
Amifampridine to increase ACh
What is the usual age of onset of Huntington’s disease
age 30-50 but becomes more severe and earlier in age throughout generations
what is the life expectance of a patient with huntingtons disease
usually 10-15 years after first symptoms. cause of death is usually infection. (e.g. pneumonia)
what is Charcot-Marie-Tooth disease?
a hereditary disease affecting peripheral motor and sensory nerves
what is the inheritance pattern of Charcot Marie tooth disease?
autosomal dominant
what is the usual age of onset of Charcot-Marie-Tooth disease?
Usually < 10 years old
most common type of pituitary adenoma
prolactinoma
symptoms of prolactinoma in men
impotence, loss of libido, galactorrhea
symptoms of prolactinoma in women
amenorrhoea, infertility, galactorrhea, osteoporosis
management of symptomatic prolactinoma
dopamine agonists e.g. bromocriptine, cabergoline
diagnostic investigation for suspected prolactinoma
MRI
what should be done to a patients insulin regimen when in DKA
stop short acting insuline
start on a fixed rate insulin infusion and continue long acting insulin
how to differentiate between nephrogenic and cranial diabetes insipidus?
water deprivation / desmopressin test
nephrogenic DI: low urine osmolality after fluid deprivation, low urine osmolality after desmopressin
cranial DI: low urine osmolality after fluid deprivation, high urine osmolality after desmopressin
Examples of X-linked recessive conditions?
Duchenne muscular dystrophy, haemophilia A
What are the chances of a child inheriting an X-linked condition if the father is unaffected and the mother is a carrier?
Son - 50% affected, 50% unaffected
Daughter - 50% carrier, 50% unaffected
Examples of autosomal recessive conditions?
Cystic fibrosis, sickle cell anaemia
What are the chances of a child inheriting an autosomal recessive condition if the parents are both carriers?
25% affected, 50% carriers, 25% unaffected
Gender is not a factor
Examples of autosomal dominant conditions?
Huntingtons, Marfans, neurofibromatosis
What are the chances of a child inheriting an autosomal dominant condition if one parent is affected?
50% affected, 50% unaffected
Gender is not a factor
There is no carrier status
What should pregnant women avoid to reduce risk of toxoplasmosis
Cat litter, unpasteurised milk, soil, raw meat
Why should pregnant women avoid pate and soft cheese?
Risk of listeria
Why should pregnant women avoid shark, tuna, swordfish etc.?
High levels of mercury - teratogenic
Why should pregnant women avoid eating liver?
High in vitamin A - teratogenic
What features are associated with fetal alcohol syndrome?
microcephaly, IUGR/ short stature, ADHD, learning disability, kidney defects, heart defects, limb anomalies, facial deformity (smooth fulcrum, low set ears)
> 5 units/day is a risk of FAS
What is the maximum amount of units which is safe to drink in pregnancy
No number of units are considered safe in pregnancy
What is the maximum amount of caffeine recommended in pregnancy
less than 200 ug / day
roughly 1-2 cups of tea/coffee/coke
What blood tests do ALL pregnant women get at booking?
Hb, blood type and antibodies, sickle cell and thalassaemia, HIV, syphilis and Hep B
What blood tests do ALL pregnant women get at 28 weeks?
Repeat Hb and antibodies
Glucose only if high risk
Which women are considered ‘high risk’ for GD and get their glucose level checked?
BMI > 30
Ethnicity which is high risk for diabetes
FHx of diabetes
PMHx of gestational diabetes and/or previous macrosomic baby
What tests are done for the 1st trimester screening of downs syndrome? what results indicate a higher risk?
Offered at 11-14 weeks
USS - Nuchal translucency
Bloods - bHCG and PAPP-A
NT - high
bHCG - high
PAPP-A low
What tests are done for the 2nd trimester screening of downs syndrome? what results indicate a higher risk?
Offered at 14-20 weeks
Bloods - AFP, oestradiol, inhibin, bHCG
AFP - low
oestradiol - low
bHCG - high
inhibin - high
When is a pregnant woman offered CVS/amniocentesis for trisomy diagnosis?
when the risk is greater than 1/150
When is CVS used rather than amniocentesis?
CVS (chorionic villus sampling) is used earlier in pregnancy (under 15 weeks). Amniocentesis is used later in pregnancy when there is enough amniotic fluid to safely take a sample.
What antihypertensives are safe to use in pregnancy?
Labetalol, nifedipine, methyl-dopa, doxazosin
What anti-epileptics are safe to use in pregnancy?
Lamotrigine, carbamazepine, levetiracetam
Is methotrexate safe to use in pregnancy?
NO!
Teratogenic, can cause miscarriage and congenital abnormalities. Both mother and father must stop for 6 months prior to conception!
What drugs are safe to use for RA in pregnancy?
Hydroxychloroquine (usually first line)
Sulfasalazine is also safe to use. Corticosteroids can be used for flare ups.
Are NSAIDs safe for use in pregnancy?
Should generally be avoided - especially in third trimester as they can cause premature closure of the ductus arteriosus and delay labour
How do babies present that are in withdrawal due to maternal opiate use?
Present at 3-72 hours with irritability, tachypnoea, high temperatures and poor feeding
How would you manage a pregnant woman exposed to chickenpox who is unsure if she has had it before?
Check IgG levels for VSV.
If positive, she is immune and safe.
If negative - treat with IV varicella immunoglobulins within 10 days of exposure.
If presenting with rash within 24 hours and > 20 weeks gestation - treat with oral aciclovir
When is a pregnant women given anti-D Injection?
(If rhesus negative)
Routinely at 28 weeks and again at birth if the baby is rhesus positive
Any sensitising event (within 72 hours)
What can be considered a ‘sensitising event’ in regards to rhesus status?
Miscarriage > 12 weeks Abdominal trauma Amniocentesis ECV Any antepartum haemorrhage
What blood test can be done to check how much fetal blood has entered the maternal circulation in a sensitising event? When is it done?
Kleihauer test. Any sensitising event after 20 weeks
Add acid to blood sample, maternal blood will be destroyed and fetal blood will remain
Are dichorionic diamniotic (DCDA) twins identical or fraternal twins?
They can be either!
1/3rd of identical twins are DCDA
All fraternal twins are DCDA
Are monochorionic diamniotic (MCDA) twins identical or fraternal twins?
Identical twins - around 2/3rds of identical twins are MCDA
Are monochorionic mono amniotic (MCMA) twins identical or fraternal twins?
Identical twins - only 4% of identical twin pregancies
What type of pregnancy is suggested by the ‘lambda’ sign on ultrasound?
Dichorionic twin pregnancy (separate placentas)
What type of pregnancy is suggested by the ‘T’ sign on ultrasound?
Monochorionic twin pregnancy (shared placenta)
When should monoamniotic twins (MCMA) be delivered?
Planned C-section at 32-34 weeks
What do nitrites on a urine dipstick suggest?
Nitrites are produced by gram negative bacteria e.g. E.coli. The bacteria break down nitrates (a normal byproduct in urine) to nitrites.
What is the most common cause of urinary tract infection?
E.coli
How do you manage UTI in pregnancy ?
7 days of antibiotics
Nitrofurantoin (should be avoided in 3rd trimester), amoxicillin or cefalexin
When are pregnant women screened for anaemia
At booking and at 28 weeks
What can cause a microcytic anaemia in pregnancy
iron deficiency
what can cause a normocytic anaemia in pregnancy
physiological anaemia associated with increase in plasma volume
what can cause a macrocytic anaemia in pregnancy
b12 or folate deficiency
How would you manage iron deficiency anaemia in pregnancy
Iron replacement - ferrous sulphate 200mg three times daily
How would you manage b12 deficiency anaemia in pregnancy
Test for pernicious anaemia (intrinsic factor antibodies)
B12 replacement; either
IM hydroxocobalamin injection
Oral cyanocobalamin tablets
What is used for VTE prophylaxis in pregnant women
LMWH e.g. dalteparin, enoxaparin, tinzaparin
when is VTE prophylaxis started in pregnancy
if 3 risk factors - 28 weeks
if 4 or more risk factors - booking
what are the cut offs for gestational diabetes
fasting glucose > 5.6
2 hour glucose > 7.8
5-6-7-8
what is the management of gestational diabetes
if fasting glucose < 7 - trial of diet and exercise for 1-2 weeks then metformin then insulin
fasting glucose > 7 - insulin +/- metformin
fasting glucose > 6 with macrosomia - insulin +/- metformin
what is an alternative to insulin/metformin in gestational diabetes
Glibenclamide - a sulfonylurea
how is pre-existing type 2 diabetes managed in pregnancy
Managed with metformin and insulin. All other oral diabetic medications should be stopped.
Retinopathy screening at booking and 28 weeks.
Planned delivery at 37-39 weeks.
what does itching of the palms and soles of the feet in late pregnancy suggest?
Obstetric cholestasis
Other symptoms include fatigue, dark urine, pale greasy stools, jaundice.
there is no rash!! if there is a rash, think of an alternative diagnosis
How would you investigate itching in late pregnancy?
LFTs (deranged) and bile acids (raised)
What LFT raises physiologically in pregnancy?
ALP - produced by the placenta
Management of obstetric cholestasis?
Ursodeoxycholic acid
What causes skin blistering around the umbilicus which spreads to other parts of the body in pregnancy?
pemphigoid gestationis
What are the three causes of antepartum haemorrhage
Placenta praevia, vasa praevia and placental abruption
What is first line for induction of labour?
membrane sweep then vaginal prostaglandins
At what gestation would you consider external cephalic version in a breech fetus?
36 weeks in nulliparous, 37 weeks in multiparous
Successful in 60%
How to differentiate clinically between placenta praevia and placental abruption
placenta praevia - painless vaginal bleeding
placental abruption - painful vaginal bleeding
How does placental abruption prseent
Vaginal bleeding (may only be small amounts due to bleed concealed behind placenta)
Constant pain
Tender, tense uterus “woody”
Maternal shock
Management of placental abruption
If CTG / maternal vital signs normal ->
<36 weeks - admit and give IV corticosteroids for lung development.
> 36 weeks - delivery vaginally
If fetal distress/maternal shock - emergency C section
1st line investigation for suspected preterm prelabour rupture of membranes
sterile speculum examination to look for pooling of amniotic fluid in the posterior vaginal vault
Management of preterm prelabour rupture of membranes (PPROM)?
admission, regular obs to look for chorioamnionitis, oral erythromycin for 10 days, corticosteroids
consider delivery if >34 weeks
1st line management of nausea and vomiting in pregnancy
promethazine (antihistamine)
what is active management of the third stage of labour
10 IU oxytocin given IM to reduce risk of PPH
Given after delivery of anterior shoulder
Delayed cord clamping (between 1 and 5 minutes)
Controlled cord traction
Investigations for reduced fetal movements > 28 weeks?
handheld doppler
If no fetal heartbeat heard - immediate ultrasound
If fetal heartbeat heard - 20 minutes of CTG
how does epiglottitis present?
tripod posturing, mouth open, drooling, stridor, muffled voice
MEDICAL EMERGENCY - do not examine throat
what causes acute epiglottitis
Haemophilus influenza B
what is the management of acute epiglottitis?
immediate senior involvement (paeds, ENT, anaesthetics)
oxygen
IV ceftriaxone and dexamethasone
what is the recommended management for vasa praevia when it is identified early?
corticosteroids from 32 weeks to mature fetal lungs
elective c-section from 34-36 weeks
what is tocolysis?
drugs used to suppress or delay contractions/labour
describe the process of external cephalic version
Mothers are given tocolysis with IV terbutaline (a beta agonist) which reduces the contractility of the uterus, making it easier for the baby to turn.
A kleihauer test is used to determine the dose of anti-D required after ECV
what are the three symptoms that pregnant women should report if they occur?
reduced fetal movements, abdominal pain, vaginal bleeding
what are the three major causes of cardiac arrest in pregnancy?
Obstetric haemorrhage
Pulmonary embolism
Sepsis (leading to metabolic acidosis and septic shock)
what position should pregnant women be placed in to maximise cardiac output
left lateral position
moves uterus away from IVC and reduces compression
what is the most common cause of bronchiolitis
RSV - respiratory synctial virus
what age group gets bronchiolitis
Infants under 1, especially under 6 months
what causes whooping cough
Bortadella pertussis - gram negative bacteria
how does whooping cough present?
initially with mild coryzal symptoms, then after a week coughing fits usually start - classically with a loud inspiratory ‘whoop’
first line investigation for whooping cough?
nasopharyngeal / nasal swab for PCR or culture if within 2-3 weeks
if after 2 weeks, patient can be tested for anti-pertussis toxin immunoglobulin G in oral fluid (children) or blood (adults)
management of whooping cough
notifiable disease - inform public health
azithromycin
prophylactic antibiotics for close contacts if vulnerable (pregnant women, unvaccinated children, healthcare worker)
can last 8 weeks or longer
AKA ‘100 day cough’
how does laryngomalacia present
occurs in infants, peaking at 6 months
presents with inspiratory stridor which is intermittent and worse when upset / feeding / lying on back
management of laryngomalacia
supportive management - infants will usually grow out of it
presentation of croup
usually age 6m - 5y
barking cough, increased work of breathing, hoarse voice, stridor
causes of croup
parainfluenza virus (main cause) RSV, influenza, adenovirus
management of croup
oral dexamethasone (single dose) add nebuliser adrenaline if severe
most common cause of bronchiolitis
RSV
most common cause of croup
parainfluenza
cause of epiglottitis
haemophilus influenza B
cause of scarlet fever
group a strep toxins (e.g. strep pyogenes)
cause of whooping cough
bordetella pertussis
cause of slapped cheek syndrome
Parvovirus B19
abdominal pain in 5 year old child with recent viral infection?
mesenteric adenitis
what causes a continuous ‘machinery’ murmur in babies?
PDA
how to treat PDA in babies?
indomethacin or ibuprofen to close PDA - inhibits prostaglandin synthesis
prostanaglandin E can be used to keep the PDA open until surgery (if associated with another heart defect)
when can children return to school after having impetigo?
when all lesions are crusted over OR 48 hours after starting treatment
how to differentiate between gastroschisis and exomphalos (omphalocele) and what are their management plans?
gastroschisis - paraumbilical abdominal wall defect where abdominal contents are outside of body WITHOUT peritoneal covering. vaginal surgery can be attempted. immediate surgery within 4 hours of birth.
exomphalos - anterior abdominal wall defect of umbilicus with abdominal contents outside of body COVERED with amniotic sac of peritoneum. C-section indicated due to risk of sac rupture. can have gradual staged repair over 6-12 months.
what is the peak incidence of acute lymphoblastic leukaemia
age 2-5 years
slightly more boys than girls
most common childhood malignancy
first line medical management of ADHD in children?
1st line - methylphenidate
2nd line - dexamfetamine
projectile non-bilious vomiting in 6 week old infant
pyloric stenosis
Ix test feed or USS
Tx pyloromyotomy (surgery)
bilious vomit, bouts of crying and pulling legs up in 7 day old infant
malrotation with volvulus
Ix upper GI contrast / USS
Tx laparotomy “ladds procedure”
colicky pain, sausage shaped mass, red jelly stool in 6 month old infant
intussusception
Ix USS
Tx reduce with air inflation or surgery
failure to pass meconium and abdominal distension could be?
Hirschprung’s disease
Ix AXR, rectal biopsy diagnostic
Tx initially rectal washout, definitively anal pull through
OR
Meconium ileus (high link to CF)
Ix AXR, PR contrast studies - may be therapeutic
Tx PR contrast studies, NG nacetylcysteine or surgery
what is one of the only indications for the use of aspirin in children
kawasaki disease
what are the three points of referral for developmental delay
if not smiling by 10 weeks
if not sitting unsupported by 12 months
if not walking by 18 months
what is the first sign of puberty in males
testicular growth
what is the first sign of puberty in females
breast development
what is the most important test to do on a baby with jaundice lasting > 14 days
conjugated / unconjugated bilirubin
a raised conjugated bilirubin suggests biliary atresia which is a surgical emergency
what heart defect presents with cyanotic heart disease in the first 1-2 days of life
Transposition of the great arteries (TGA)
cyanotic heart disease presenting at 1-2 months is tetralogy of Fallot
what heart defect presents with cyanotic heart disease age 1-2 months
tetralogy of Fallot (TOF)
cyanotic heart disease presenting at 1-2 days of life is TGA
should the combined oral contraceptive pile stopped before surgery?
yes stop 4 weeks before surgery
what is the most common primary malignant bone tumour
osteosarcoma - malignant tumour producing bone
what is the usual age group and location of osteosarcoma?
usually seen in children and adolescents
60% involving bones around knee
what is the usual age group and location of chondrosarcoma?
usually middle age (~45)
common in pelvis / proximal femur
often large and slow growing (less aggressive than osteosarcoma)
what is the most common type of hip dislocation and the resultant deformity?
posterior hip location (90%)
shortened, adducted, internally rotated
what is reactive arthritis?
one of the hla b27 associated seronegative spondyloarthropathies
previously known as Reiter’s syndrome (triad of conjunctivitis, urethritis and arthritis following STI or diarrhoeal illness “can’t see can’t pee can’t climb a tree”)
what disease is described by a ‘pencil in cup’ appearance on x-ray?
psoriatic arthritis
what is the most common cause of septic arthritis?
overall - staph. aureus
sexually active young adults - Neisseria gonorrhoea
first line investigation for suspected septic arthritis?
synovial fluid sampling
THEN blood culture - ideally prior to Abx
management of septic arthritis
IV flucloxacillin
6-12 weeks of Abx
what is the most common cardiac manifestation of SLE?
pericarditis
what is the diagnostic investigation for multiple myeloma?
plasma / urine electrophoresis (Not fully true)
what kind of deafness is caused by pagets disease
conductive deafness!!
what antibodies may be seen in rheumatoid arthritis
rheumatoid factor and anti-CCP antibodies (latter is more specific and therefore the preferred test)
what antibodies may be seen in SLE?
ANA (+ve in >90% - sensitive but not specific)
anti-dsDNA (specific, varies with disease activity)
Anti-SM (specific, low sensitivity)
c3/c4 levels (low when disease active)
what investigations should be done in SLE?
antibodies
FBC (showing anaemia, leukopenia and thrombocytopenia)
urinalysis to look for signs of glomerulonephritis
CT chest to look for ILD
MRI to look for cerebral vasculitis
Echo to look for pericardial effusion / pericarditis
management of SLE?
skin/arthralgia - hydroxychloroquine (DMARD), NSAIDs and topical steroids
inflammatory arthritis/organ involvement - immunosuppression e.g. azathioprine
severe organ disease - iv steroids and cyclophosphamide
what antibodies are best used to monitor SLE?
anti-dsDNA and complement levels (C3/4)
what antibodies are associated with systemic sclerosis?
ANA antibodies (not specific)
limited SS (CREST syndrome) - anti-centromere antibodies diffuse SS - anti-scl-70 antibodoes
what antibodies are associated with anti-phospholipid syndrome?
lupus anticoagulant, anti-cardiolipin antibodies anti-beta-2-glycoprotein antibodies
management of anti-phospholipid syndrome
episode of thrombosis - long term warfarin
recurrent pregnancy loss - LMWH + aspirin during pregnancy
incidental antibody finding with no episode of thrombosis do not require anticoagulation
first line investigation for suspected gout
sample of synovial fluid - shows needle shaped uric acid crystals which are negatively birefringent
(pseudo gout will show calcium pyrophosphate crystals which are POSITIVELY birefringent)
management of gout
acute attack - NSAIDS, colchicine
prophylaxis - allopurinol
what disease is commonly seen in association with polymyalgia rheumatica
giant cell arteritis
investigation for suspected PMR
no diagnostic investigation
commonly raised CRP / ESR
respond dramatically to prednisolone
presentation of giant cell arteritis
visual disturbance, headache, jaw claudication. scalp tenderness (often on combing hair)
what disease is suggested by jaw claudication
giant cell arteritis - occurs as result of ischaemia of maxillary artery
investigation of choice for suspected GCA
temporal artery biopsy (100% specificity but low sensitivity due to patchy involvement)
management of GCA
prednisolone
what antibodies are associated with sjogrens syndrome?
anti-Ro and anti-La antibodies
what investigations should be done in suspected polymyositis / dermatomyositis?
inflammatory markers - raised
creatinine kinase - raised to 10x upper limit
antibodies - ANA, anti-Jo, anti-SRP
clinical features of polymyositis and dermatomyositis
polymyositis - proximal muscle weakness (insidious onset)
dermatomyositis - as above with gottrons lesions (scaly plaques over knuckles, elbows), photosensitive erythematous rash over neck, shoulders, chest and a ‘heliotrope’ rash (purple rash over face)
what is polymyositis and dermatomyositis associated with?
malignancy - paraneoplastic syndrome in 25%
how to differentiate between sciatic nerve pain and lower back pain
sciatic nerve pain will go beyond knee
positive sciatic nerve stretch test
first line management of suspected cauda equine syndrome
urgent MRI to detect level of prolapse followed by surgery (urgent discectomy)
what causes carpal tunnel syndrome
median nerve compression in the carpal tunnel
what causes cubital tunnel syndrome
ulnar nerve compression in the cubital tunnel
what age should an infant be able to sit unassisted
6-8 months
what age should a baby be able to hold its own head up without lag?
2-3 months
what age should an infant be able to stand
9-12 months
at what age should an infant develop a pincer grip?
12 months
at what age should a child be saying double syllables “rehleh” “gada”
6 months
at what age should an infant be able to say mama and dada
9 months
what is the investigation of choice for DDH
under 6 months - USS
over 6 months - Xray
what is the principal clinical sign of SUFE
loss of internal rotation of the hip
what is an important potential complication of scaphoid fractures
avascular necrosis of the scaphoid due to retrograde blood supply via dorsal carpal branch (branch of radial artery)
presentation of a meniscal tear
pain localised to the medial (most common) or lateral joint line. swelling occurs the following day, the pt then complains of pain and ‘locking’
presentation of ACL tear
a ‘pop’ usually felt or heard, deep pain in joint, swelling from haemarthrosis occurs within the hour
what examination technique can be used to identify meniscal tears?
Steinmanns test - rotation of the tibia
test is positive if lateral pain is elicited on medial rotation or medial pain on lateral rotation
what is more common, medial meniscal tear or lateral meniscal tear
medial (10x more common)
management of acute meniscal tears
supportive management. 90% unsuitable for surgery.
if persistent pain at 3 months, can consider arthroscopic partial menisectomy
rotatory instability (giving way on turning) is the principal presenting clinical complaint of which knee injury?
ACL rupture
prognosis after an ACL rupture?
1/3 compensate well and can manage ADLs and sports
1/3 manage by avoiding certain movements but can’t do high impact sports
1/3 will do poorly with frequent giving way with ADLs
what patients are good candidates for ACL reconstruction surgery?
40% of pts
professional sportsmen and those who have frequent giving way with ADLs
management of acute MCL tear?
hinged knee brace
management of acute LCL tear
usually surgical
what injury is associated with LCL tear?
common peroneal nerve injury
what age group tends to get:
quadriceps tendon rupture
patellar tendon rupture
quadriceps - >40s
patellar - <40s
what way does the patella usually dislocate
laterally
what tendons should you AVOID steroid injection due to risk of rupture
Extensor mechanism of knee
Achilles
what nerve injury is associated with Colles fracture?
median nerve compression (carpal tunnel syndrome)
what is a Colles fracture
fracture of distal radius resulting in a dorsal displacement of the radius (dinner fork deformity)
more common than smiths
what is a smiths fracture
fracture of distal radius resulting in a ventral displacement of the radius (garden spade deformity)
less common than Colles
what nerve injury is associated with anterior shoulder dislocation?
axillary nerve palsy
what nerve injury is associated with a humeral shaft fracture?
radial nerve palsy (in spiral groove)
what nerve injury is associated with supracondylar fracture of the elbow?
anterior interosseus branch of median nerve
what nerve injury is associated with posterior dislocation of the hip?
sciatic nerve injury
how to differentiate between polymyalgia rheumatic and polymyositis?
creatinine kinase
CK will be very high in polymyositis but normal in PMR
most common cays of peritonitis secondary to peritoneal dialysis?
staph. epidermidis
other causes: staph. aureus
recommended pain relief for renal colic
diclofenac (usually IM)
management of epididymo-orchitis of unknown cause?
single dose of ceftriaxone plus 10-14 days of dexamethasone
what are the 4 main causes of liver cirrhosis?
AFLD, NAFLD, hep B and hep C
what should patients with liver cirrhosis be screened for and how often?
hepatocellular carcinoma
MELD score, USS and afp every 6 months
also endoscopy every 3 years for varices
what diet is recommended for patients with liver cirrhosis
high protein low sodium
what drug is used for stable varices
propranolol
management of bleeding varices
vasopressin analogue (terlipressin) to cause vasoconstriction vitamin k and FFP for coagulopathy
1st line antibiotics for ascitic peritonitis
iv cefotaxime
management of hepatic encephalopathy
clear the ammonia
laxatives - lactulose
antibiotics - rifaximin (poorly excreted so stays in GI tract)
blood test results for haemophilia?
prolonged aptt
what is deficient in x-linked recessive disorder haemophilia A?
factor VIII
what is deficient in x-linked recessive disorder haemophilia B?
factor IX
what drug is used for medical management of an unruptured ectopic pregnancy?
methotrexate
investigation of choice for suspected pyloric stenosis?
ultrasound scan (+/- test feed)
management of haemochromatosis?
weekly venesection
management of Wilson’s disease
copper chelation with penicillamine or trientene
first line investigation for suspected haemochromatosis?
serum ferritin (raised, not reliable), serum transferrin (raised, more reliable)
first line investigation for suspected Wilson’s disease
serum caeuruloplasmin level
what is the inheritance pattern of haemochromatosis and Wilsons disease
autosomal recessive
management of acute uncomplicated diverticulitis in primary care?
oral co-amoxiclav for 5 days clear liquids (avoid solid foods) until symptoms improve, usually 2-3 days analgesia (avoid NSAIDs or opioids)
what are the three arteries that supply the abdominal organs
foregut - stomach, first part of duodenum, biliary system, liver, pancreas, spleen - COELIAC ARTERY
midgut - distal duodenum to first half of transverse colon - SUPERIOR MESENTERIC ARTERY
handgun - second half of transverse colon to rectum - INFERIOR MESENTERIC ARTERY
presentation of chronic mesenteric ischaemia
‘abdominal angina’
central colicky abdominal pain, starts 30 minutes after eating and lasts 1-2 hours
weight loss due to food avoidance
abdominal bruit
diagnostic investigation for chronic mesenteric ischaemia?
ct angiogram
what are gallstones usually made of?
cholesterol
medical management of BPH?
immediate symptomatic management - tamsulosin (alpha blocker)
reduce size of prostate - finasteride (5-alpha reductase inhibitor), may take up to 6 months to work
common side effect of tamsulosin?
postural hypotension
common side effects of finasteride?
sexual dysfunction due to reduced testosterone
what part of the prostate usually enlarges in BPH
transitional zone
what part of the prostate usually enlarges in prostate cancer?
peripheral zone
what side do varicoceles usually occur?
left side (90%)
what is the triad of symptoms seen in renal cell carcinoma?
Haematuria, flank pain, palpable mass
what features are seen in haemolytic anaemia
normocytic anaemia, splenomegaly and jaundice
what type of inheritance is seen in hereditary spherocytosis and hereditary eliptocytosis?
autosomal dominant
management of hereditary spherocytosis / elliptocytosis
folate supplementation and splenectomy
inheritance pattern of G6PD deficiency
x linked recessive
common triggers of g6pd deficiency crisis
broad beans, infections, anti-malarials, some diabetic drugs
key finding on blood film of g6pd deficicency
Heinz Bodies
management of autoimmune haemolytic anaemia
blood transfusions, prednisolone, Rituximab (MAB against B cells) and splenectomy
two types of autoimmune haemolytic anaemia
warm type - occurs at or above normal temp (most common, usually idiopathic)
cold type - occurs below normal temp (less common, associated with other conditions)
inheritance pattern of thalassaemia and sickle cell disease
autosomal recessive
what type of anaemia is seen in thalassaemia
microcytic anaemia
what are some key features of thalassaemia
signs and symptoms of anaemia jaundice gallstones splenomegaly pronounced forehead and cheekbones increased fracture risk increased absorption of iron (iron overload presents similarly to haemochromatosis)
how is thalassaemia diagnosed
FBC - microcytic anaemia
Hb electrophoresis - diagnoses the globin abnormality
DNA testing
what type of haemoglobin is seen in sickle cell disease
HbS - crescent shaped
usually HbF is replaced by HbA at around 6 weeks of life
what is sickle cell trait
when someone has only one copy of the sickle cell gene - usually asymptomatic
when is sickle cell disease screened for
newborn screening heel prick test
pregnant women are checked for carrier status
what are the age groups affected by the 4 main types of leukaemia?
ALL - <5yo and >45yo
CLL >55yo
CML >65yo
AML >75yo
ALL CeLL mates have CoMmon AMbitions
when to refer a child/young adult with suspected leukaemia directly to hospital?
any child/young adult with petechiae or hepatosplenomegaly should be referred to hospital IMMEDIATELY
initial investigation for suspected leukaemia in adults
urgent FBC within 48 hours
what is seen on blood film in ALL?
blast cells
what is seen on blood film in CLL?
smudge/smear cells
what are the three stages of CML?
chronic phase (5 years)
accelerated phase
blast phase
what is seen on blood film in AML?
blast cells with auer rods
4 features of multiple myeloma
CRAB
calcium (raised)
renal failure
anaemia (normocytic normochromic)
bone lesions/pain
prophylaxis for cluster headaches?
verapamil 1st line
other options: lithium, prednisolone
management of acute cluster headache
oxygen and subcut triptan
how to monitor standard heparin
aptt
how to monitor LMWH
anti-factor Xa
what subtypes of HPV are cancerous and would require referral for colposcopy
HPV 16, 18 and 33
what subtypes of HPV are associated with genital warts?
HPV 6 and 11
what 3 things are increased in the pathophysiology of DKA
increased lipolysis, glycogenolysis, gluconeogenesis
what virus is associated with oropharyngeal cancer
HPV
damage to what part of the brain causes dressing apraxia
parietal lobe
degenerative osteoarthritis of the spine is called…
spondylosis
stress fracture defect in the pars interarticularis of the vertebrae is called…
spondylolysis
most common location of spondylolysis
L4/L5
displacement of one vertebra over the vertebral body below it is called…
spondylolisthesis
most common location of spondylolisthesis
L5/S1
what ligament is commonly injured in inversion injuries of the ankle
anterior talofibular ligament
what congenital anomalies are associated with a type 1 diabetic pregnancy
neural tube defects and cardiac abnormalities
what protozoa is known to chronically infect HIV patients, presenting with diarrhoea
cryptosporidium parvum
painful red eye worse at night..?
glaucoma
first line investigation for suspected penetrating injury of the eye?
CT scan of orbits
convergent squint with horizontal diplopia when looking to the left..?
left 6th nerve palsy
top 2 differentials for a soft compressible groin lump with a cough impulse that disappears when lying flat
femoral hernia and saphena-varix
what is the most common groin hernia
indirect inguinal hernia
what groin hernia is much more common in men that women
direct inguinal hernia
what groin hernia occurs in children
indirect inguinal hernia
what groin hernia is more common in women than men
femoral hernia (differential: saphena-varix)
most common urinary tract neoplasm associated with painless haematuria
transitional cell carcinoma of the urothelium
how to diagnose bladder cancer
flexible cystoscopy
