Random knowledge to review 2 Flashcards
In what condition is donepezil CI?
Bradycardia
Donepezil can cause insomnia as well
Centor criteria?
CENTor criteria:
Cough absent
Exudates on tonsils
Nodes- tender cervical lymphadenopathy
Temperature>38
Transjugular Intrahepatic Portosystemic Shunt problem?
Last line for upper variceal bleed- bypasses the liver so can cause a build up of toxins that cause confusion
Causes the exacerbation of hepatic encephalopathy
What should all men with ED have checked?
Their testosterone levels
Also screen for underlying diabetes and cardiovascular disease
Treatment for benzodiazepine overdose?
Flumazenil
TB drugs memory aid?
RIPE ONGO
Rifampicin: Orange secretions
Isoniazid: Neuropathy
Pyrazinamide: Gout
Ethambutol: Optic Neuritis
How do you prevent the peripheral neuropathy from Isoniazid?
Pyridoxine (vitamin B6)
Ethambutol before treatment?
Check visual acuity before and during treatment as can cause optic neuritis
Osteoporosis blood derangement?
None
When are Howell-Jolly bodies found?
Post-splenectomy
At what fasting glucose should insulin be offered straight away for gestational diabetes?
> 7mmol/l
Is iron deficiency anaemia a cause of pruritis?
Yes
ADPKD drug treatment?
Tolvaptan
Letrozole vs Tamoxifen?
Tamoxifen for oestrogen receptor-positive breast cancer
Letrozole/anastrozole for oestrogen receptor-positive breast cancer in those after the menopause
What is a Jarisch-Herxheimer reaction?
Fever, rash, chills and headache following antibiotic administration for syphillis, also tachycardia and myalgia
Due to the rapid killing of Treponema pallidum and release of its endotoxins
Supportive management with antipyretics and it resolves within 24 hours
What is the first line treatment for syphillis?
IM benzathine benzylpenicillin
Treatment for septic arthritis?
Flucloxacillin or clindamycin for penicillin allergic
IV
4-6 weeks overall switch to oral antibiotics after 2 weeks
<3 months with fever over 38?
Refer for paediatric assessment
Visual hallucinations + dementia?
Lewy body dementia
Squint in child?
Refer to secondary care
Means eyes pointing in different directions
Can lead to amblyopia and uncorrects (brain prefers one eye)
How many tetanus jabs to be immune lifelong?
5
Is anus spared in UC?
Yes
Secretions treatment in palliative care?
Hyoscine hyrobromide or hyoscine butylbromide
What are the side effects of tamsulosin (alpha-1 adrenergic receptor antagonist)?
Dizziness and postural hypotension
What precipitiates lithium toxicity?
Dehydration
Renal failure
Drugs: diuretics (especially thiazides), ACEi/ARBs, NSAIDs and metronidazole
Features of lithium toxicity?
Coarse tremor
Hyperreflexia
Acute confusion
Polyuria
Seizure
Coma
Lithium toxicity management?
Mild-moderate toxicity may respond to volume resuscitation with normal saline- IV fluids with isotonic saline
Haemodialysis may be needed if severe toxicity
HF management?
1st line: ACEi + BB
2n line: Aldosterone antagonist (spironolactone, eplerenone) or SGLT-2 (ie dapagliflozin) if HFrEF
3rd line: Ivabradine, sacubitril-valsartan (EF<35%), Digoxin (for symptomatic relief), Hydralizine + Nitrate (Afro-Caribbean)
Cardiac resynchronisation if wide QRS (LBBB)
+ Annual flu vaccine and one-off Pneumococcal vaccine
Warfarin interactions?
General factors that may potentiate warfarin-
Liver disease
P450 ezyme inhibitors
Cranberry juice
Drugs- NSAIDs
Inducers of the P450 system will decrease INR
Inhibitors will increase the INR
P450 inducers (decrease INR)?
Antiepileptics: phenytoin, carbamazepine
Barbiturates: phenobarbitone
Rifampicin
St John’s Wort
Chronic alcohol intake
Griseofulvin
Smoking (affects CYP1A2, reason why smokers require more aminophylline)
P450 inhibitors (increase INR)?
antibiotics: ciprofloxacin, clarithromycine/erythromycin
isoniazid
cimetidine,omeprazole
amiodarone
allopurinol
imidazoles: ketoconazole, fluconazole
SSRIs: fluoxetine, sertraline
ritonavir
sodium valproate
acute alcohol intake
quinupristin
Can diabetic foot ulcers/diabetes lead to osteomyelitis?
Yes
Diverticular disease management?
Increase dietary fibre intake
Mild attacks managed conservativley with antibiotics
Absecess drained
Reccurrent episodes are indication for a segmental resection
Horner’s features?
Miosis
Ptosis
Anhidrosis (loss of sweating on one side)
Hip fracture treatments?
Intracapsular-
Undisplaced- internal fixation or hemiarthroplasty
Displaced- total hip replacement (arthroplasty) to all patients, sometimes hemiarthroplasty if not able to do much before injury
Stable intertrochanteric- dynamic hip screw
Subtrochanteric, reverse oblique or transverse- intermedullary device
Adrenaline doses?
Age Adrenaline dose
< 6 months 100 - 150 micrograms (0.1 - 0.15 ml 1 in 1,000)
6 months - 6 years 150 micrograms (0.15 ml 1 in 1,000)
6-12 years 300 micrograms (0.3ml 1 in 1,000)
Adult and child > 12 years 500 micrograms (0.5ml 1 in 1,000)
What does india ink stain on CSF analysis in meningitis point towards?
Cryptococcus neoformans
Most common fungal infection of CNSWh
What is co prescribed when starting a GnRH agonists (Goserelin) for prostate cancer?
Anti-androgen- cyproterone acetate- prevent a rise in testosterone causing a tumour flare
RUQ pain?
RUQ pain only –> biliary colic
RUQ pain + fever –> acute cholecystitis
RUQ pain + fever + jaundice –> ascending cholangitis (Charcot’s triad)
Charcot’s triad + confusion + hypotension = Reynold’s pentad (more severe ascending cholangitis)
When should parents call an ambulance in febrile convulsions?
If it lasts longer than 5 minutes
Febrile convulsions occur between the ages of 6 months and 5 years
What is prescribed if recurrent febrile convulsions occur?
Benzodiazepine rescue medication
Palliative care- severe pain with CKD treatment?
Buprenorphine or fentanyl are the opioids of choice for pain relief in pallaiative care patients with severe renal impairment
Oxycodone is preferred in mild-moderate renal impairment
Hepatitis C investigation?
HCV RNA
Which thyroid treatment worsens thyroid eye disease?
Radioiodine treatment
Lower GI bleeding cause paeds?
Neonates- NEC or malrotation
Infants/young children- intussusception
Dopamine receptor antagonist examples?
Bromocriptine, ropinirole, cabergoline, apomorphine
MAO-B inhibitors example?
Selegiline
COMT inhibitors?
Entacapone, tolcapone
VTE prophylaxis in patients with nephrotic syndrome?
Low molecular weight heparin (LMWH)
Things like DOACs and Warfarin bind to proteins in the blood- decrease in these proteins in nephrotic syndrome
When must a culture (MSU) be sent for non-pregnant women in UTI?
If there is visible or non-visible haematuria
Or over 65
Vision loss associated with Charles-Bonnet?
Age-related macular degeneration (ARMD)
Distortion of straight lines/ reduced acuity are symptoms
When to start dapagliflozin?
QRISK over 10%, cardiovascular risk factors
HbA1c target for any drug which may cause hypoglycaemia?
53
Example drug would be a sulfonylurea
Also 53 for patients already on one drug but HbA1c has risen to 58
How do you assess drug sensitivities in TB?
Sputum culture
How is pseudogout also known?
Calcium pyrophosphate deposition disease
Pseudogout presentation?
Knee, wrist and shoulders most commonly affected
Joint aspiration- weakly-positive birefringent rhomboid-shaped crystals
X-ray- chondrocalcinosis
Gonorrhoea cause?
Neisseria gonorrhoeae
Gonorrhoea treatment?
First line- single dose of IM ceftriaxone 1g
If sensitivities known and organism sensitive to cirpofoxacin that should be given 500mg orally
If ceftriaxone refused then oral cefixime and oral azithromycin should be used
Disseminated gonococcal infection classic triad?
Tenosynovitis, migratory polyarthritis and dermatitis
Later complications- septic arthritis, endocarditis and perihepatitis (Fitz-Hugh-Curtis syndrome)
Subacute unilateral visual loss, eye pain worse on movements?
?Optic neuritis
Features:
Unilateral decrease in visual acuity over hours or days
Poor discrimination of colours, ‘red desaturation’
Pain worse on eye movement
Relative afferent pupillary defect
Central scotoma
Investigation- MRI of the brain and orbits with gadolinium contrast
Management- high-dose steroids
Abdo diseases children?
Pyloric stenosis - Projectile, non-bilious vomiting at 4-6 wks old
Malrotation - Bilious vomiting, abdominal pain, acutely unwell
Intestinal atresia - Bilious vomiting if distal to ampulla of Vater, usually hours-days old
Hirschsprung’s disease - Failure to pass meconium >48 hours, abdominal distension, failure to thrive, sometimes bilious vomiting
GORD - Milky vomiting after feeds, crying, arching of back, drawing up of knees into chest, failure to thrive, <8 weeks old
GOR - Physiological, regurgitation but no symptoms or complications (‘happy spitter’)
Intussusception - Colicky abdominal pain, drawing up of knees into chest, pale, RUQ sausage-mass, refusing feeds, red-currant stools late sign, non-bilious vomiting that may become bilious if obstruction, at 6-18 months old
Can the temporal artery biopsy be false negative?
Yes as there can be skip lesions in temporal arteritis- continue the treatment
Vision complication in temporal arteritis?
Anterior ischemic optic neuropathy
Reduced fetal movement investigations?
Initially, handheld doppler to confirm fetal heartbeat- if no heartbeat detectable immediate ultrasound should be offered
If fetal heartbeat present on doppler- CTG should be used to monitor for at least 20 mins
Referral if fetal movements not felt by 24 weeks
RA and eye problems?
?Scleritis
Scleritis?
RA, SLE, Sarcoidosis associations
Features:
Red eye
Classically painful (in comparison to epscleritis)
Watering/photophobia
Gradual decrease in vision
Management- same day assessment by an opthalmologist
Oral NSAIDs first line
Oral glucocoriticoids in severe presentations
Gliptins side effects?
Pancreatitis
Pioglitazone contraindication?
Heart failure
Symptoms/signs of hypocalcaemia memory aid?
CATs go numb- Convulsions, Arrythmias, Tetany, Numbness also Trouseau’s sign and Chvostek’s sign
QT prolongation on ECG
Blood transfusions can cause hypocalaemia and hyperkalaemia
Signs/symptoms of hyperkalaemia?
Metabolic acidosis, arrythmias, muscle weakness, reduced reflexes, diarrhoea
ECG features- Absent P waves, prolonged QRS, peaked or tall tented T waves, sine wave pattern
Aortic stenosis symptoms?
SAD- syncope, angina, dyspnoea
Which UTI medication is contraindicated in pregnancy?
Trimethoprim
Initial emergency treatment for acute angle-closure glaucoma?
IV acetazolamide + timolol, pilocarpine and apraclonidine eyedrops
Definitive management for acute angle-closure glaucoma?
Laser peripheral iridotomy
Typical presentation of coarctation of the aorta?
Acute circulatory collapse at 2 days of age, mid systolic murmur maximal over the back
Management of croup?
Single dose of dexamethasone to all children regardless of severity
Hand-foot syndrome in sickle cell anameia?
Red blood cells interfere with circuation to hands and feet- causes pain, swelling and erythema
Colorectal screening age?
Every 2 years to all men and women aged 60-74 in England
Patients over 74 may request screening
Tests done in all patients with colorectal cancer for staging?
Carcinoembryonic antigen (CEA)
CT of the chest, abdomen and pelvis
Entire colon should have been evaluated with a colonoscopy or CT colonography
Patients whose tumours lie below the peritoneal reflection should have their mesorectum evaluated with MRI
Management of colon cancer?
Nearly always treated with surgery
Resectional surgery is the only option for cure in patients with colon cancer
Site of cancer Type of resection Anastomosis
Caecal, ascending or proximal transverse colon Right hemicolectomy Ileo-colic
Distal transverse, descending colon Left hemicolectomy Colo-colon
Sigmoid colon High anterior resection Colo-rectal
Upper rectum Anterior resection (TME) Colo-rectal
Low rectum Anterior resection (Low TME) Colo-rectal
(+/- Defunctioning stoma)
Anal verge Abdomino-perineal excision of rectum None
Panproctocolectomy?
Removes the colon, rectum and anus- often in HNPCC carriers
Caecal, ascending or proximal transverse colon colorectal cancer treatment?
Right hemicolectomy- ileo-colic anastomosis
Distal transverse, descending colon?
Left hemicolectomy- colo-colon
Sigmoid colon?
High anterior resection- colo-rectal
Upper rectum?
Anterior resection (TME)- colo-rectal
Low rectum?
Anterior resection (Low TME)- colo-rectal (+/- defunctioning stoma)
Anal verge
Abdomino-perineal excision of rectum- none
What is the resection of the sigmoid colon and an end colostomy fashioned in the operation called?
Hartmann’s procedure
Hypocalcaemia?
CATS go numb:
Hypocalcaemia:
Convulsions
Arrhythmia (and long QT)
Tetany
Spasm - Chvostek and Trousseau signs
(go)
Numb - paraesthesia
Imaging for multiple myeloma?
Whole-body MRI
Premenstrual syndrome (PMS)?
Emotional and physical symptoms in the luteal phase of the normal menstrual cycle- anxiety, stress, fatigue, mood swings- bloating, breast pain
Mild symptoms- lifestyle advice- low alcohol, regular meals, sleep, exercise, no smoking
Moderate- may benefit from a new-generation COCP (example is Yasminu- drospirenone 3mg and ethinylestradiol)
Severe symptoms may benefit from an SSRI
How to tell heart rate/BP in a traumatic injury?
Fast and weak- there’s a leak
Slow and strong- something in the head wrong
Cushing’s triad from raised ICP?
Hypertension, bradycardia and irregular breathing
Aimed at maintaining cerebral perfusion
Which stomas need to be spouted vs not spouted?
Small bowel spouted- so that irritant contents do not come into contact with the skin
Colonic stomas do not need to be spouted as their contents are less irritant
If having a total colectomy which sort of stoma would be formed?
Ileostomy
Location of stomas?
Ileostomy- right iliac fossa, spouted, output- liquid
Colostomy- varies, more likely on the left side, flushed, output- solid
EBV rash with what?
Amoxicillin
EBV triad?
Sore throat, pyrexia, lymphadenopathy
Other features:
Malaise, anorexia, headache
Palatal petechiae
Splenomegaly
Haemolytic anaemia secondary to cold agglutins (IgM)
Maculopapular, pruritic rash with amoxicillin
Infectious mononucleosis investigation?
Heterophil antibody test (Monospot tet)
When is ECV offered?
36 weeks for nulliparous
37 weeks for multiparous
If no contraindications:
where caesarean delivery is required
antepartum haemorrhage within the last 7 days
abnormal cardiotocography
major uterine anomaly
ruptured membranes
multiple pregnancy
Hartmann’s procedure?
Sigmoid colectomy and formation of end stoma
Is the emergency operation for things like acute siverticulitis with perforation
Which type of analgesia is best after surgery to reduce the chance of postoperative ileus and promote gastrointestinal motility?
Epidural analgesia- opioid/local anaesthetic
Lynch syndrome surgery?
Panproctocolectomy- takes the colon sigmoid and rectum- reduce risk of further malignancies
SLE management?
Basics- NSAIDs, sun-block
Treatment of choice- hydroxychloroquine
If internal organ involvement- renal, neuro, eye, consider prednisolone or cyclophosphamide
Temporal arteritis eye problem summary?
Anterior ischaemic optic neuropathy whereby inflammation of the posterior ciliary arteries causes optic nerve infarction and subsequent vision loss
Surgeries for the different aortic dissections?
Type A- Aortic route replacement surgery
Type B- bed rest and beta blockers
C-peptide levels in diabetes?
Type 1 diabetes- c-peptide levels are low
Type 2 diabetes- c-peptide levels are high
Diabetes specific antibodies point towards type 1
Anticoagulation and head injury?
CT head within 8 hours
Exam question fungal nail?
If more than 2 nails affected- oral terbinafine
If less than that amorolfine nail lacquer
Trichophyton rubrum is one of the most common dermatophyte nail infections
Which echocardiogram investigation for dissection if too unstable for a CT?
Transoesophageal
Causes of Horner’s syndrome?
Symptoms- miosis, ptosis, usually anhidrosis
Look on passmed for causes
Some can cause no anhidrosis
Mononeuritis multiplex?
RFs for it- diabetes, RA, amyloidosis, sarcoidosis
Distribution of weakness/sensory loss that doesnt make sense
> =2 single nerve lesion
Intrahepatic cholestasis of pregnancy?
Pruritis
Clinically detectable jaundice
Raised bilirubin seen in >90% of cases
Management
Induction of labour at 37-38 weeks
Ursodeoxycholic acid
Vitamin K supplementation
Gingival hyperplasia?
CCBs, Phenytoin, Tacrolimus/cyclosporin
Thiazide diuretics electrolytes?
Hypokalaemia
Hyponatremia
Hypercalcaemia
Recurrent episodes of otitis externa despite antibiotic treatment?
?Candida infection- especially if severe itching/ white, curd-like discharge
Bacterial causes are staphylococcus aureus, pseuomonas aeruginosa
Seborrhoeic dermatitis or recent swimming
Tachycardia peri arrest?
Shock/hypotension/instability- Synchronised DC cardioversion
Broad complex- amiodarone infusion
Narrow complex- vagal manouvres then adenosine
If narrow an irregular- follow A-Fib protocol
If broad and irregular- specialist help
Subclinical hypothyroidism?
TSH raised- T3, T4 normal
TSH >10 and free thyroxine in normal range- consider offering levothyroxine if the TSH level is > 10 mU/L on 2 separate occasions 3 months apart
TSH between 5.5-10 and free thyroxine in normal range-
if <65 considering offering 6 months levothyrooxine trial if the TSH level is 5.5 - 10mU/L on 2 separate occasions 3 months apart,and
there are symptoms of hypothyroidism
In older people watch and wait is often use
If asymptomatic observe and repeat thyroid function in 6 months
First line anticoagulant in reducing stroke risk?
DOACs
Should tricyclic antidespressants be stopped in dementia?
Yes
When would you start antihypertensives straight away if BP 180/120 or higher?
If evidence of target organ damage is identified- do not wait for ABPM or HBPM
Such as blood in urine, vision changes
First line drugs for spasticity in MS?
Baclofen
Gabapentin
Reducing the risk of relapses in MS?
Natalizumab
Birth defects drug timing?
Lungs mature last, heart matures first
For fluoxetine-
First trimester- congenital heart defects
Last trimester- persistent pulmonary HTN
Broad vs narrow tachycardia?
Generally speaking-
Broad is ventricular- treat with amiodarone
Narrow is SVT- adenosine
Conservative care for pneumothorax?
Primary spontaneous PTX- review every 2-4 days as an outpatient
Secondary spontaneous PTX- monitor as inpatient
MI secondary prevention drugs?
DABS
Dual antiplatelet therapy
ACEi
Beta blocker
Statin
Ticagrelor and prausgrel more widely used-
Post ACS medically managed- ticagrelor to aspirin- stop ticagrelor after 12 months
Post PCI- add prausgrel or ticagrelor to aspirin- stop second antiplatelet after 12 months
12 month period can be altered for people at high risk of bleeding or those at high risk of further ischaemic events
Stages of labour?
1st stage- onset of labour to full dilation
Latent phase 0-3cm dilation
Active phase 3-7cm dilation
Transition 7-10cm dilation
2nd stage- from full dilation to delivery
3rd stage- from delivery to when the placenta and membranes have been completely delivered
Post menopausal bleeding?
Endometrial cancer until proven otherwise
All women over 55 who present with PMB should be referred using the suspected cancer pathway
First investigation is a transvaginal ultrasound
Hysteroscopy with endometrial biopsy
Treated with surgery
Punched out lesions?
Eczema herpeticum- severe primary infection of the skin by HSV 1 or 2
Most commonly seen in children with atopic eczema and presents with a rapidly progressing painful rash
Potentially life-threatening- admit for IV aciclovir
Gastric cancer investigations?
Diagnosis- oesophago-gastro-dudenoscopy with biopsy
Signet ring cells may be seen in gastric cancer
Staging- CT scan of chest, abdomen and pelvis
Management-
Surgical- gastrectomy
Chemotherapy
DMD
Kawasaki
heart problems?
Duchenne- dilated cardiomyopathy
Kawasaki- coronary artery spasm
DMD?
Progressive muscle weakness from 5, calf pseudohypertrophy, Gower’s sign- child uses arms to stand from squatted position
Investigation- raised CK and genetic testing
Management- supportive
Management of essential tremor?
Propanolol
What are the heart sounds made by?
The valves closing
S1- Mitral and tricuspid closing
S2- aortic and pulmonary closing
(S3 is sometimes normal in athletes, sometimes pathological)- rapid filling of ventricles during diastole
(S4 always pathological- atrial contraction against stiff/non-compliant ventricle)
Which drug is contraindicated in VT?
Verapamil- important
Score for prediciting the severity of pancreatitis?
Modified Glasgow score
PANCREAS
Pa02 <8kPa
Age >55 years
Neutrophilia WBC >15x10^9
Calcium <2mmol/L
Renal function Urea >16mmol/L
Enzymes LDH >600 ; AST >200
Albumin <32g/L
Sugar Blood glucose >10mmol/L
GET SMASHED?
Passmed
Asthma new guidelines
Diagnosis and treatment
Which antibiotics can cause torsades de pointes?
Macrolides (azithromycin)
Sexual history and knee pain?
Septic arthritis from Neisseria gonorrhoeae
Gram negative diplococci
Refractory anaphylaxis?
Ongoing anaphylactic reaction that persists despite being given 2 doses of IM adrenaline
How to remember homonymous quadrantanopias?
PITS (Parietal-Inferior, Temporal-Superior)
Craniopharyngioma vs pituitary tumour visual field defect?
Bitemporal hemianopia
lesion of optic chiasm
upper quadrant defect > lower quadrant defect = inferior chiasmal compression, commonly a pituitary tumour
lower quadrant defect > upper quadrant defect = superior chiasmal compression, commonly a craniopharyngioma
Surgery prep if a long fasting period of more than one missed meal or whose diabetes is poorly controlled?
Variable rate intravenous insulin infusion- (sliding scale)
Difference between posterior MI and NSTEMI?
Tall R waves
Posterior MIs cause:
reciprocal changes in V1-3
horizontal ST depression
tall, broad R waves
upright T waves
dominant R wave in V2
Acanthosis nigricans is associated with which type of cancer?
Gastrointestinal cancer
What causes acanthosis nigricans?
T2DM
GI cancer
Obesity
PCOS
Acromegaly
Cushing’s disease
Hypothyroidism
Management of tension PTX?
Decompression of the pleural space
Needle thoracostomy (decompression) second intercostal space mid clavicular line on affected side first as quicker in emergency
Place a chest drain in the triangle of safety
Tension PTX should be diagnosed clinically
Head CT within 1 hour?
GCS < 13 on initial assessment
GCS < 15 at 2 hours post-injury
suspected open or depressed skull fracture
any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign).
post-traumatic seizure.
focal neurological deficit.
more than 1 episode of vomiting
CT head within 8 hours?
CT head scan within 8 hours of the head injury - for adults with any of the following risk factors who have experienced some loss of consciousness or amnesia since the injury:
age 65 years or older
any history of bleeding or clotting disorders including anticogulants
dangerous mechanism of injury (a pedestrian or cyclist struck by a motor vehicle, an occupant ejected from a motor vehicle or a fall from a height of greater than 1 metre or 5 stairs)
more than 30 minutes’ retrograde amnesia of events immediately before the head injury
Bloody diarrhoea, abdominal pain and fever after dodgy food?
Campylobacter
Crampylobacter
Usually self limiting
First line antibiotic would be clarithromycin
Most common cause IE?
S.aureus- especially in IVDUs
Staph epidermis is common after surgery due to indwelling lines
In which MI complication is ESR elevated?
Dressler’s syndrome
RIPE ONGO?
RIPE ONGO
Rifampicin: Orange secretions
Isoniazid: Neuropathy- prevent with pyridoxine (Vit B6)
Pyrazinamide: Gout
Ethambutol: Optic Neuritis
Gonorrhoea management?
Gram negative diplococcus
1st- Ceftriaxone
If sensitive to ciprofloxacin- give that instead
If refuse needle- cefixime oral and azithromycin oral
What causes Lyme disease?
Borrelia burgdorferi
Early features-
Erythema migrans- bullseye rash- develops on 1-4 weeks
Systemic- headache, lethargy, fever, arthralgia
Later features-
Cardio- heart block, myocarditis
Neuro- meningitis, facial nerve palsy
Lyme disease investigation?
If erythema migrans is present- start antibiotics
Enzyme-linked immunosorbent assay (ELISA) antibodies to Borrelia burgdorferi is first line
If negative but still suspected or positive and immunoblot test should be done
It is a spirochaete (like syphilis)
Management of lyme disease?
Doxycycline
Ceftriaxone if disseminated disease
Jarisch-Herxheimer may be seen (also seen in syphilis)- fever, rash, tachycardia after first dose of antibiotic
Only two BBs with evidence in heart failure?
Bisoprolol, carvedilol, nebivolol
Rare but important side effect of DPP4-inhibitors such as sitagliptin?
Pancreatitis
What should patients with MI secondary to cocaine be given?
Benzodiazepine first line
If chest pain- benzo + glyceryl trinitrate
BB poor evidence but arguements for/against
Adverse effects of cocaine?
Cardiovascular- coronary artery spasm, hypertension
Neurological- seizures
Impetigo return to school?
48 hours after treatment
Impetigo treatment?
Hydrogen peroxide 1% cream if systemically well
Topical fusidic acid
Extensive disease- oral flucloxacillin
Legionella treatment?
Macrolides such as clarithromycin
Diagnostic investigation for Legionella?
Urinary antigen
Legionella symptoms?
Flu-like symptoms including fever
Dry cough
Relative bradycardia
Confusion
Mid-lower zone patchy consolidation
Epilepsy treatment?
Generalised- M- Sod Val F- Lam/leve
Focal- Both- Lam/leve 2nd- Carbamazepine
Absence-Both- Ethosuximide 2nd- F- Lam/leve M- Sod Val
Atonic- F- Lam M- Sod Val
Myclonic- F- Leve M- Sod Val
In acute mitral regurgitation (rupture of the papillary muscle) what else can occur?
Acute hypotension and pulmonary oedema
Status epilepticus definition?
Single seizure lasting >5 mins or
> =2 seizures within a 5-minute period without the person returning to normal between them
Which drug reduces the risk of calcium oxalate stones recurring?
Bendroflumethiazide
Status epilepticus treatment pathway?
ABC- airway adjunct, oxygen, check blood glucose
First-line- benzodiazepines
Pre-hospital- PR diazepam or buccal midazolam
In hospital- IV lorazepam, repeated once after 5-10 mins
If ongoing status epilepticus appropriate to start a second-line agent such as levetiracetam, phenytoin or sodium valproate
If no response within 45 minutes- refractory status- best way to achieve rapid control of seizure activity is induction of general anaesthesia or phenobarbital
COCP cancer risks?
Increased risk of breast and cervical
Protective against ovarian and endometrial
What can cause ascites?
History of alcohol excess, cardiac failure can
Women with breast cancer and no palpable lymphadenopathy, if pre-operative axillary ultrasound negative, management?
Sentinel node biopsy to assess nodal burden
Which infection can cause lactose intolerance and foul smelling floating stool?
Giardia lamblia- giardiasis
RFs- foreign travel
Features:
often asymptomatic
non-bloody diarrhoea with steatorrhoea
Bloating, abdo pain
Lethargy
Malabsorption and lactose intolerance
Stool microscopy for trophozoite and cysts
Treatment is with metronidazole
Can myocarditis have ST elevation?
Yes, myocarditis can have ST elevation and it can be in a specific area of the heart- in contrast to pericarditis where the ST elevation is usually more widespread (affects the pericardial sack which is around the whole heart)
Myocarditis can also caused raised troponin/cardiac enzymes
Suspect it as more likely than MI in younger patients
Preceding flulike illness is characteristic and most common cause is viral
Myocarditis?
Inflammation of the myocardium- paticularly consider it in younger patients with chest pain
Causes- viral- cocksakie
(bacterial, spirochaetes (lyme disease)
Presentation- young patient with chest pain, SOB, arrythmias
Raised inflammatory markers, raised cardiac enzymes, ST elevation on ECG
Tx cause- supportive or antibiotics if bacterial
Rough/sandpaper/course rash?
Scarlet fever
Caused by streptococcus pyogenes
ORal penicllin V for 10 days
MDMA (ecstasy) poisoning?
Hyponatremia
Neuro- agitation, anxiety, confusion, ataxia
Cardio- tachycardia, hypertension
Hyperthermia
Rhabdomyolysis
Supportive
Dantrolene for hyperthermia if simple measures fail
PSC positive finding?
p-ANCA (also found in UC and autoimmune hepatitis)
Some others
Anti-dsDNA- SLE
Anti-CCP- RA
What do all cases of pneumonia get?
Repeat chest x-ray at 6 weeks after clinical resolution- ensure consolidation resolved and no underlying pathologies (such as a lung tumour)
Breast cancer screening age?
50-70 years (mammogram every 3 years)
What should be co prescribed when starting allopurinol for gout prevention?
Colchicine
Aplastic crisis in sickle cell?
Pancytopenia- severe drop in haemoglobin
Decreased reticulocyte count
Haemolytic crisis in sickle cell?
Rare- severe anaemia and jaundice
Acute chest syndrome in sickle cell?
Chest pain, cough, wheeze, SOB, tachypnoea
Pulmonary infiltrates
Vaso-occlusive crisis of the lungs
Sequestration crisis?
This would present with abdominal pain, signs of haemodynamic compromise and hepatomegaly/splenomegaly. Pooling of blood in the spleen occurs, leading to severe anaemia and haemodynamic collapse
Increased reticulocyte count
Vaso-occlusive crisis?
These could affect different organs, but would typically present with the development of acute pain due to microvascular occlusion. Other presentations include dactylitis, cerebral infarction, mesenteric ischaemia, avascular necrosis of the femoral head or priapism
Is doxycycline contraindicated in pregnancy?
Yes
What is considered early menarche?
Before age 12
Does HRT increase cancer risk?
If progestogen is added- it increases the risk of breast cancer
Increased risk of endometrial cancer if oestrogen given without progestogen- adding progestogen lowers the risk but not completely
Increased risk of VTE
Transdermal HRT does not increase the risk of VTE
Increased risk of stroke
Increased risk of ischaemic heart disease
Polycythemia vera associated with which mutation?
JAK2
Anticoaglation to prevent stroke in AF?
DOACs
Warfarin 2nd line
Actinic keratoses management?
Avoid sun
Fluorouracil cream
Topical diclofenac
Autoimmune haemolytic anaemia?
Anaemia
Reticulocytosis
Raised LDH
Low haptoglobin
Blood film- spherocytes and reticulocytes
Specific to autoimmune haemolytic anaemia- positive direct antiglobulin test (Coomb’s test)
Most common type of AIHA- warm AIHA- idiopathic, SLE, neoplasia
Management
Treat underlying disorder
Steroids (+/- rituximab) used 1st line
In cold AIHA usually IgM
PULSELESS ELECTRICAL ACTIVITY?
NOT A SHOCKABLE RHYTHM
Investigations for pericarditis?
ECG- Saddle shaped ST elevation, PR depression- most specific ECG marker for pericarditis
All patients with suspected acute pericarditis should have TRANSTHORACIC ECHOCARDIOGRAPHY
Elevated inflammatory markets and possibly troponin
Treatment of pericarditis?
Combination of NSAIDs and colchicine
Sites for venous and arterial ulcer?
Venous- above medial malleolus- painless
Compression bandaging
Arterial- occurs on the toes and heel
Punched out appearance
Painful
Difference between somatisation disorder and illness anxiety disorder (hypochondriasis)?
Somatisation- worrying about symptoms present for at least 2 year
Illness anxiety disorder- persistent belief in the presence of an underlying serious disease
SSRI and NSAID?
GI bleeding risk give a PPI
Rickets vs osteomalacia?
Rickets is vitamin D deficiency in children, osteomalacia is vitamin D deficiency in adults
Osteomalacia?
Features-
Bone pain
Bone/muscle tenderness
Fractures- especially femoral neck
Proximal myopathy- may lead to waddling gait
Ix-
Low vitamin D levels
Low calcium/phosphate
Raised ALP
X-ray- translucent bands
Vit D supplementation
Calcium supplementation
Retinal detachment?
Presence of darkening or shadows in peripheral vision
New flashes and floaters
No pain
Straight lines appear curved
Key features of frontotemporal dementia?
Disinhibition- socially inappropriate behaviour
Apathy/inertia
Loss of sympathy/empathy
Perseverative/compulsive behaviours
Hyperorality
Executive dysfunction with relative sparing of memory and visuospatial functions
Onset before 65
Insidious onset
Relatively preserved memory/ visuospatial skills
Personality change and social conduct problems
Not recommended to use AChE inhibitors or memantine in people with frontotemporal dementia
T score interpretation?
-1 to -2.5 indicates osteopenia
-2.5 or lower indicates osteoporosis
T score compares to mass of young reference population- Z score is adjusted for age, gender and ethnic factors
Chicken pox complications?
Secondary bacterial infections:
NSAIDs may increase the risk
Small area of cellulitis- some patients may have invasive group A streptococcal soft tissue infections resulting in nec fasc
Rare:
Pneumonia
Encephalitis
Disseminated haemorrhagic chickenpox
Arthritis, nephritis and pancreatitis
Can you get anosmia in Parkinson’s?
Yes often an early sign
Do you have to have protein urea for pre-eclampsia?
No,
The current formal definition is as follows
new-onset blood pressure ≥ 140/90 mmHg after 20 weeks of pregnancy, AND 1 or more of the following:
proteinuria
other organ involvement (see list below for examples): e.g. renal insufficiency (creatinine ≥ 90 umol/L), liver, neurological, haematological, uteroplacental dysfunction
Upper GI bleed/ ulcer with peritonitis?
? Perforated peptic ulcer
Epigastric pain later becoming more generalised
Diagnosis largely clinical
Upright CXR is required with acute upper abdo pain
Many with perforated ulcer will have free air under diaphragm
Insulin sick day rules?
Carry it on as normal
Make sure to maintain good fluid intake
Sick day rules for oral hypoglycaemics?
Temporarily stop most of them
Metformin
Sulfonylureas
SGLT-2 inhibitors
GLP-1
Impulse control disorders are linked with which type of Parkinson’s medication?
Dopamine receptor agonists
Cervical screening?
25-49- 3 yearly
50-64- 5 yearly
Chronic alcohol electrolyte disturbance?
Hypomagnesaemia
Patient on warfarin/DOAC/bleeding disorder with suspected TIA?
Imaging immediately to exclude a haemorrhage
TIA further investigation?
Carotid duplex ultrasound if elegible for carotid intervention
CTPA vs V/Q scan?
CTPA is preferred
V/Q scan is investigation of choice in renal impairment
Food poisoning organisms?
Staph Aureus- Short incubation
Bacillus cereus- rice
Traveller’s diarrhoea cause?
E.Coli- watery stools, abdo cramps and nausea
Prolonged bloody diarrhoa?
Incubation period > 7 days
Giardiasis- prolonged and NON-bloody
Amoebiasis- gradual onset bloody diarrhoea, abdo pain and tenderness which may last for several weeks
Carbon monoxide poisoning?
May be a discrpancy between peripheral oxygen saturations but they may have low oxygen on a blood gas
Aim for sats of 100%
Questions hint at badly maintained houses
Sepsis catagorisation score?
Sequential (Sepsis-Related) Organ Failure Assessment Score (SOFA)
When is the lactational amenorrhoea method effective?
<6 months post-partum, the women is fully breastfeeding and amenorrhoeic
Screening tool for malnutrition?
Malnutrition Universal Screening Tool (MUST)
Positive D-dimer, negative ultrasound in DVT?
Stop antigcoagulation, US again in a week
SLE investigations?
ANA positive
Anti-dsDNA
ESR to monitor, CRP usually normal unless inefection
Complement levels (C3, C4) are low during active disease
eGFR and opioids in palliative care?
<10 = fentanyl/buprenorphine
10-50 = oxycodone
> 50 = morphine
Risk factors for developmental dysplasia of the hip?
Female sex
Breech presentation
Positive family history
First born
Oligohydraminos
Birth weight >5kg
DDH screening?
Following require routine ultrasound examination:
First-degree family hip problems in early life
Breech presentation at or after 36 weeks, irrespective of presentation at birth or mode of delivery
All infants also screened at newborn and six week check using barlow and ortolani
If infant over 4.5 months then x-ray if first line to look for DDH
Barlow/Ortolani?
Balow- attempts to dislocate an articulated femoral head
Ortolani- attempts to relocate a dislocated femoral head
DDH management?
Most unstable hips spontaneously resolve by 3-6 weeks
If not a Pavlik harness in children younger than 4-5 months
Older children may require surgery
Amiodarone in advanced life support?
300mg give after 3 shocks
Further dose of 150mg given after 5 shocks
For those who are in VF/pulseless VT
Is there raised calcium in Paget’s?
No
ALP is raised
Reasons for raised calcium in malignancy?
PTHrP (PTH related protein) from the tumour
Bone metastases
Myeloma
Two main causes of hypercalcaemia?
Primary hyperparathyroidism
Malignancy
What cancer is associated with an unresolving left sided varicocele?
Renal tract cancer
Triad of- haematuria, loin pain and abdominal mass
Management renal cell carcinoma?
Nephrectomy- maybe partial if T1 tumour
Migraine prophylaxis?
Topiramte or propanolol
Propanolol CI in asthmatics
Absent ankle jerks but brisk knee jerks?
Subacute combined degeneration of the spinal cord
Also has a positive Romberg’s sign
Monitoring in HSP?
BP and urinalysis to detect progressive renal involvement
Nephritic syndrome triad?
Oedema, hypertension and haematuria
Meniscal tear key features?
Twisting, knee instability, giving way and locking due to displaced meniscal fragments
Thessaly’s test- weigh bearing at 20 degrees of knee fexion, positive if pain on twisting knee
Difference between episcleritis and scleritis?
Scleritis is painful wheras episcleritis is not
Scleritis is associated with RA and SLE
Red eye, watering and photophobia are common, gradual decrease in vision
Same day assessment by opthalmologist
NSAIDs may be used first line
Animal bite antibiotic?
Co-amoxiclav
If penicillin allergic- doxycycline and metronidazole
Co-amoxiclav also for human bites
Kawasaki disease?
High grade fever > 5 days
Conjunctival infection
Bright red, cracked lips
Strawberry tongue
Cervical lymphadenopathy
Red palms on the hands/soles of feet
Clinical diagnosis
Management:
High-dose aspirin
IV immunoglobulin
Echocardiogram
Complications-
Coronary artery syndrome
Raised ICP and LP in meningitis?
Contraindicated
Exacerbating factors for myasthenia gravis?
Beta blockers
Penicillamine
Lithium
Quinidine
Phenytoin
Antibiotics- gentamicin, macrolides, quinolones, tetracyclines
Meningitis LP?
From a comment on another question:
1) Is CSF glucose < half of serum glucose? Yes = bacteria, no = viral
2) Are lymphocytes or polymorphs predominant? Lymphocytes = TB (if bacterial), viral, or fungal. Polymorphs = non-TB bacteria
Most likely cause of irregular broad complex tachycardia in an unstable patient?
Atrial fibrillation with bundle branch block
What is penicillamine used for?
Wilson’s
Chelates copper
Alternatively- trientine hydrochloride
Causes of erythema nodosum?
NO - idiopathic
D - drugs (penicillin sulphonamides)
O - oral contraceptive/pregnancy
S - sarcoidosis/TB
U - ulcerative colitis/Crohn’s disease/Behçet’s disease
M - microbiology (streptococcus, mycoplasma, EBV and more)
RA initial investigations?
Antibodies-
Rheumatoid factor
Anti-cyclic citrullinated peptide antibody (Anti-CCP)- may be detectable up to 10 years before the development of arthritis, much more specific than rheumatoid factor
X-ray of the hands and feet
ANA positive condition?
SLE
Also Anti-dsDNA
When do you have to stop drinking clear fluids before surgery?
You are allowed to drink up until 2 hours before the operation
Non-clear liquids/fluids is 6 hours before the operation
UTI in the third trimester?
Use amoxicillin or cefalexin
Nitrofurantoin CI in the third trimester
Presenting features of biliary atresia?
Presents in the first few weeks of life with:
Jaudice- extending beyond the physiological two weeks
Dark urine, pale stools
Appetite and growth disturbance, although may be normal in some cases
Signs-
Jaundice
Hepatomegaly with splenomegaly
Abnormal growth
Conjugated bilirubin is abnormally high
Surgical intervention is the only definitive treatment
Massive painless bleed in infant?
Meckel’s diverticulum
Congenital diverticulum
Usually asymptomatic- can have abdo pain mimicking appendicitis, rectal bleeding, intestinal obstruction
Urine osmolality after fluid deprivation: Low
Urine osmolality after desmopressin: Low
?
Nephrogenic diabetes insupidus
Anticoagulation even after a single episode of resolved AF?
Yes- calculate CHADSVASC
A key investigation for acute mesenteric ischaemia?
Venous blood gas- would show raised lactate
Also a CT angiogram abdo and pelvis with contrast is needed
Drugs that cause gynaecomastia?
DISCO
Digoxin
Isoniazid
Spironolactone
Cimetidie
Oestrogen
COPD not controlled with SABA, LABA and ICS?
Triple therapy- LAMA, LABA and ICS
Keep on SABA, switch to SABA if it is a SAMA
Basically add tiotropium- LAMA
What to do before starting azithromycin prophylactically in COPD?
ECG to exclude QT prolongation as azithromycin can prolong thw QT interval
Also- CT thorax and sputum culture
Third nerve palsy pupil dilated?
Surgical cause- CT head/refer to neurosurgery
What causes Hand, Foot and Mouth disease?
Coxsackie, enterovirus
Features:
Mild systemic upset- sore throat, fever
Oral ulcers
Followed by vesicles on the palms and soles of feet
Symptomatic treatment only- no school exclusion
What does fetal fibronectin (fFN) detect?
Labour
Highly sensitive, not very specific
Why give steroids if looking like premature labour?
To mature the foetal lungs
Marker for neuropaenic sepsis?
Known cause of neutropenia and a temperature of >38 degrees
Triad for reactive arthritis?
Urethritis, conjunctivitis and arthritis
Post-STI, post-dysenteric
Breast eczema starting at the nipple?
If it starts at the nipple- it is Paget’s disease of the breat
If it doesn’t start at the nipple just areola- it is eczema
Differentiate between ductal or lobular carcinoma in situ?
Calcification is seen more in ductal than lobular- means it is visible on a mammorgram
Invasive ductal carcinoma are the most common type of breast cancer
Severe hepatitis in pregnany women?
Think hepatitis E
Seizure by location?
Temporal- rising epigastric sensation, deja vu, jamais vu, (less common auditory, olfactory hallucinations), automatisms are common- lip plucking/smacking/grabbing
Frontal- head/leg movements, posturing, post-ictal weakness, Jacksonian march
Parietal lobe- parasthesia
Occipial lobe- floaters/flashes
When to give baby vaccines in hospital environment?
If born before 28 weeks
Characteristic biochemistry for tumour lysis syndrome?
Hyperphosphatemia, hypocalcaemia and elevated renal markers- (AKI)
Symptoms- Nausea, vomiting, weakness, muscle cramps
LP findings in Guillain-Barre?
Rise in protein with a normal WCC
Also, nerve conduction studies, decresed motor nerve conduction velocity due to demyelination
Women between 16-32 weeks pregnant vaccine?
Whooping cough
Cyanaotic heart diseases and what to give before surgery?
Prostoglandin E1- maintains the ductus arteriosus
It is useful to remember the 5 T’s for cyanotic congenital heart diseases (CHD):
Tetralogy of fallot
Transposition of great vessels (TGA)
Tricuspid atresia
Total anomalous pulmonary venous return
Truncus arteriosus
What closes the ductus arteriosis?
NSAIDs- indomethacin
Test to differentiate normal neonatal cyanosis from cardiac causes?
The nitrogen washout test
Chlamydia key symptoms?
Discharge, bleeding, dysuria
Investigation- vulvovaginal swab for NAAT
Men- urine first void sample
Perthe’s under 5?
No treatment usually resolves
If over 5- surgery
Hip pain over a few weeks, limp, stiffness and reduced range of movement
X-ray- early changes
Most common neurological infection seen in HIV?
Cerebral toxoplasmosis
2nd is CNS lymphoma
Cerebral toxoplasmosis symptoms?
Constitutional symptoms, headache, confusion, drowsiness
CT usually shows single or multiple ring enhancing lesions, mass effect may be seen
Management: sulfadiazine and pyrimethamine
CNS lymphoma (related to HIV and EBV)?
Single lesion, solid (homogenous) enhancement
Thallium SPECT positive (cerebral toxoplasmosis is negative)
Treat with dexamethasone, chemotherapy with or without whole brain irradiation
Other neuro diseases in HIV?
Encephalitis
Cryptococcus- most common fungal infection of CNS
Progressive multifocal leukoencephalopathy (PML)
AIDS dementia complex
X-ray for osteoarthritis?
LOSS-
Loss of joint space (joint space narrowing)
Osteophyte formation
Sclerosis
Subchondral cysts
What is the SAAG calculation to get the SAAG number?
Serum albumin- ascites albumin
Different types of shock?
Septic
Haemorrhagic
Neurogenic
Cardiogenic
Anaphylactic
EVAR or Open surgery for AAA?
Seems to be
Open surgery- emergency or if no other major risk factors
EVAR- if have risk factors for surgery
Treatment of methotrexate toxicity?
Folinic acid
Cremaster reflex absent on affected side, pain worsens on elevation?
Testicular torsion
Elevation of testes relieves the pain + urinary symptoms?
Epididymyitis
How to remember the effects of changing sodium rapidly?
Sodium high to low- the brain will blow- cerebral oedema
Sodium low to high- the pons will die- central pontine myelinosis/osmotic demyelination syndrome
Raised bilirubin, raised reticulocytes, anaemia with low MCV
Beta-thalassaemia
Orbital cellulitis?
Unilateral swelling of the eye accompanied by proptosis and reduced eye movements
May also be pain and other visual changes
Medical emergency- admission to hospital, senior review and IV antibiotics
CT with contrast sometimes used
FBC
Clinical examination mainy
Swab for culture
Treatment for otitis media with effusion (Glue ear)?
First presentation- active observation for 3 months
Grommets
Adenoidectomy
Organic corneal foreign body?
If an organic thing is stuck in the eye- refer to opthalmology
When does HIV seroconversion occur?
3-12 weeks
Pneumonia causative organisms?
Klepsiella (KlepSTELLA) - alcoholics
Streptococcus pneumoniae - most common cause for CAP.
Mycoplasma pneumoniae - atypical, associated with erythema multiforme, haemolytic anaemia, ITP, diagnose with serology.
Legionella pneumophila - another atypical, lymphopenia and hyponatraemia, recent holiday (air conditioning units), diagnose with urinary antigen.
Staphylococcus aureus - most common in people after recent influenza infection
Can essential tremor affect your voice?
Yes it can, soft and shaky with rhythmic changes
Things that SLE causes?
SOAP BRAIN MD
Serositis - Pleurisy, pericarditis
Oral ulcers
Arthritis
Photosensitivity
Blood disorders
Renal involvement
Antinuclear antibodies
Immunologic phenomena
Neurologic disorder
Malar rash
Discoid rash
Rapid plasma reagin (RPR) test in syphilis?
How many times a solution has to be diluted so that the syphillis is undetectable
1 in 2
1 in 8 etc
If it goes up on the repeat test- more dilutions needed- syphilis not treated successfully
Anion gap calculation?
(Sodium + Potassium - (Chloride + Bicarbonate)
Normal anion gap is 8-14
Normal anion gap metabolic acidosis?
GI bicarb loss- diarrhoea
Renal tubular acidosis
Drugs- acetazolamide
Addison’s
Raised anion gap metabolic acidosis?
Lactate- shock, hypoxia
Ketones- DKA, alcohol
Urate- renal failure
Acid poisoning- salicylates, methanol
Way to tell if NG tube positioned correctly on a CXR?
If below diaphragm- if where lung is not positioned correctly probably
Are children with minimal change disease likely to have another episode?
2/3 do
First line analgesia for shingles?
Paracetamol and NSAIDs
Amitriptyline if not responding
Oral corticosteroids may be considered in first 2 weeks if pain is severe and not responding to other treatments
Guillain-Barre LP?
High protein with a normal WCC
Other investigations:
Nerve conduction studies- decreased motor nerve conduction velocity (due to demyelination)
What needs to be done in patients starting long term steroids (over 3 months)?
First- correct any hypocalcaemia/ vitamin D deficiency
Then give a bisphospohonate when the above has been done if needed
Hypocalcaemia/vitamin D deficiency needs to be corrected before starting a bisphosphonate
First line for campylobacter treatment?
Usually self limiting
Treatment if severe symptoms (high fever, bloody diarrhoea, or more than eight stools per day), symptoms have lasted more than 1 week or immunocompromised
First line is clarithromycin
Placenta praevia what is CI?
If it is a possible diagnosis (previous scan shows low placenta, high presenting part on abdominal examination or the bleed had been painless)
Digital vaginal examination should not be performed until an ultrasound has excluded placenta praevia
You can however do a speculum however this is not diagnostic for placenta praevia
Placenta praevia management?
If low-lying at 20-week scan:
Rescan at 32 weeks
No need to limit activity/intercourse unless they bleed
If still presentat 32 weeks then scan every 2 weeks
Final ultrasound at 36-37 weeks to determine the method of delivery
Elective caesarean for grades III/IV between 37-38 weeks, if grade I then can trial vaginal
I know PP goes into labour prior to elective caesarean do an emergency caesarean
PP with bleeding
Admit
ABC
Not stable- emergency caesarean
In labour/term reached- emergency caesarean
Do they screen for Hep B in pregnancy?
Yes
Vaginal candidiasis treatment?
Oral fluconazole for single dose
Clotrimazole intravaginal pessary single dose if oral therapy contraindicated
If pregnant only local treatments
Infantile colic vs spasms?
Colic- child distressed during spasms
Spasms- distressed between spasms- EED- hypsarrhythmia commonly found in West’s syndrome
X-ray findings in ankylosing spondylitis?
Subchondral erosions, sclerosis and squaring of vertebrae
Leukaemias?
ALL- most common in children
AML- mostly adults, auer rods, ATRA
CLL- Most common leukaemia overall, can transform to Non-hodgkin lymphoma (Richter transformation), smudge cells
CML- Philadelphia chromosome, Imatinib
Drugs exacerbating psoriasis?
Beta blcokers
Lithium
Alcohol
NSAIDs
ACEi
Antimalarials (Quines)
Which drugs can cause hypomagnesaemia?
Diuretics
Proton pump inhibitors
Most common organism generally in UK and in IVDUs in infective endocarditis?
Staph aureus
Tricyclic vs SSRI overdose ECG?
Tricyclic- widening of the QRS
SSRIs- prolongation of the QT
Opening snap?
Mitral stenosis
Operating System is MicroSoft
Fragility fracture in those over 75 years old?
Start bisphosphonate without the need for a DEXA scan
Wait until fracture healed to start bisphosphonate and check vit D/ calcium levels/correct them before starting
Chronic insomnia?
Trouble falling or staying asleep at least three nights per week for 3 months or longer
What is fostair and trimbow?
Fostair- inhaler with LABA and ICS
Trimbow- inhaler with LABA + LAMA + ICS
Alcohol withdrawl with liver cirrhosis?
Lorazepam not chlordiazepoxide
Why does an alcohol binge lead to polyuria?
ADH suppression in the posterior pituitary gland
Conducive hearing loss?
Anything stopping the sound getting to the ear- could be earwax
Allopurinol and ACEi?
Contraindicated
Oesophageal cancers?
Upper 2 thirds- squamous cell carcinoma (smoking, achalasia, alcohol)
Lower third- adenocarcinoma- Barrett’sn GORD
Open angle glaucoma management?
360 selective laser trabeculoplasty 1st line to people with IOP 24 or more
Prostaglandin analogue eyedrops should be used next-line
Next:
Bet-blocker eyedrops
Carbonic anhydrase inhibitor eye drops
Sympathomimetic eye drops
Surgery- trabeculectomy in refractory cases
Prostoglandin analogues?
Latanoprost
Increases uveoscleral outflow
Adverse effects- brown pigmentation of the iris, increased eyelash length
Beta-blockers- eye drops?
Timolol, betaxolol
Reduces aqueous production
Avoided in asthmatics or heart block
Sympathomimetics- eye drops?
Brimonidine
Reduces aqueous production and increases outflow
Avoid if taking MAOI or tricyclic
Haematuria malignancies?
Renal cell carincoma- painful or painless
Urothelial malignancies- 90% are transitional cell carcinoma- can occur anywhere along the urinary tract- painless haematuria
Symptoms of serotonin syndrome?
Hypertension, tachycardia, flushing and sweating, hyperflexia, clonus and muscle rigidity, fever, change in mental status- agitation
Drugs causing serotonin syndrome?
Tramadol, SSRIs, MAOIs, triptans and St Johns wort
Discontinue drugs and can give a benzodiazapine for agitation
5-HT antagonists- cyproheptadine and chlorpromazine are sometimes administered
Can tramadol cause serotonin syndrome?
Yes
What is PCP related to HIV?
Pneumocyctic jiroveci pneumonioa
All patients with CD4 count under 200 should recieve PCP prophylaxis
PCP features?
Dyspnoea
Dry cough
Fever
Very few chest signs
Pneumothorax common
CXR typically bilateral interstitial pulmonary infliltrates
Exercise-induced desaturation
Management- co-trimoxazole
C-peptide?
Made with insulin in the pancreas
C-peptide levels low in T1DM
High/normal in T2DM
Investigation for T2DM for over 40 who respond well to oral hypoglycaemic agents?
C-peptide levels
Diabetes-specific autoantibodies
Neoplastic spinal cord compression?
(Cancer symptoms)
Back pain- progressive, not relieved when lying down, worse when straining
Reduced lower limb power and diminshed pinprick sensation
Give dexamethasone and urgent MRI within 24 hours
Child with hip pain and fever?
Refer for same-day assessment- potential for septic arthritis
Dementia diagnosis?
Blood screen
Neuroimaging- MRI
Both before a diagnosis can be made
If hypomagnesemia and hypokalaemia?
Treat/replace the magnesium first before the potassium
Hypomagnesemia prevents potassium absorption
Primary hyperparathyroidism most common cause?
Solitary adenoma
Can statins cause rhabdomyolysis?
Yes
Rhabdomyolysis treatment?
IV fluids
Symptoms of oesophageal candidiasis?
Dysphagia can be a symptom
Hisotry of HIV or steroid inhaler use
Levodopa adverse effects from dosage?
End-of-dose wearing off- symptoms worsen towards the end of dosage interval
On-off phenomenon- large variations in motor performance
Dyskinesias at peak dose- dystonia, chorea and athetosis
Do not stop levodopa acutely- if you do dopamine agonist patch as rescue medication if cannot take orally
DVLA and psych?
Generally cannot drive during acute illness
Can drive again if well and table for at least 3 months
Adheres adequately to any agreed treatment plan
Free from medication that would impair driving
Subject to a suitable specialist report being favourable
Angiodema medication?
ACEi
A- Angiodema
C- Cough
E- Elevated potassium
i- 1st dose hypertension
Drugs making psoriasis worse?
BLANQ
B- beta-blockers
L- Lithium
A- ACEi
N- NSAIDs
Q- Quinines
Can smokers have a raised carboxyhaemoglobin without CO poisoning?
Yes- up to 10%
Optic neuritis?
CRAP
Central scotoma
Relative afferent pupillary defect
Acuity- unilateral decrease in visual acuity over hours/days
Pain worse on eye movement
Poor discrimination of colours- red desaturation
Ix- MRI of the brain and orbits with gadolinium contrast is diagnostic in most cases
Management- high dose steroids
Hip fracture management?
Intracapsular hip fracture:
Undisplaced- fit- internal fixation, unfit- hemiarthroplasty
Displaced- Arthroplasty if fit, hemiparthroplasty if unfit
Extracapsular hip fracture
Stable interrochanteric fractures- dynamic hip screw
If reverse oblique, transverse or subtrochanteric- intramedullary device
Croup emergency treatment?
High-flow oxygen
Nebulised adrenaline
Reed-Sternberg cells?
Hodgkin’s lymphoma
When do you have to stop eating non-clear liquids/food before surgery?
6 hours before
Clear liquids is 2 hours before
Unilateral glue ear in adult?
Refer on 2 week wait
Correction of sodium pneumonic?
From High to Low your brain will blow = Cerebral oedema
From Low to High your brain will die = Central pontine myelinolysis
Anti- HBs
Anti-HBc
In hepatitis B?
Anti-HBs = Safe (Have immunity so either immunised or previously exposed, -ve in chronic disease)
Anti -HBc = Caught (acquired infection at some point rather than immunised)
HBsAg- Ongoing infection
Anion gap?
↑AG → basically when you have added some acid (lactate, ketones, urate, aspirin, methanol)
↔AG → ABCD: Addisons; Bicarb loss (GI, RTA); Chloride (e.g. saline); Drugs (acetazolamide)
Bilateral adrenocortical hyperplasia treatment?
Aldosterone antagonist- Spironolactone
FeverPAIN?
Fever
P- Purulent tonsils
A- Adenopathy and comes on quick <3days
I- Inflamed tonsils
N- No cough or coryza
Headaches worst in the morning and when lying down?
Raised ICP
Treatment for MRSA positive on surgical screening?
Nasal mupirocin + chlorexidine for the skin
Pelvic inflammatory disease treatment?
IM ceftriaxone stat + 14 days of oral doxycycline + oral metronidazole
2nd- Oral ofloxacin and oral metronidazole
How do pancoast tumours cause a hoarse voice?
They suppress the recurrent laryngeal nerve
Gonorrhoea organism?
Gram-negative diplococci
CBT for schizophrenia?
Yes
Schizophrenia management-
Oral atypical antipsychotics are first -line
CBT offered to all patients
Close attention to cardiovascular risk-factor modification due to high rates in schizophrenic patients
When to send a urine culture in non-pregnant women wit hUTI?
Over 65
Visible or non-visible haematuria
Does psoriatic arthritis need to have skin changes?
No
Often precedes the development of skin lesions
Psoriatic arthritis vs ankylosing spondylitis?
DIP joint involvement + dactylitis + enthesitis = Think Psoriatic Arthritis.
Back pain and sacroiliitis without peripheral joint involvement = Think Ankylosing Spondylitis.
First line treatment for PAD?
Statin- if established CVD
Antiplatelet- clopidogrel is first-line in patients with PAD
Stable angina investigations?
1st- contrast-enhanced CT coronary angiography
Good way to check whether blurred vision is retractive or not?
Pinhole occluders
What suggests a recently passed stone if not one on scan?
Periureteric fat stranding
Menorrhagia treatment?
Doesn’t need contraception: mefenamic acid or tranexamic acid- both started on first day of period
Requires contraception- IUS- mirena first line
COCP
Long-acting progestogens
Hoffman and Hoover tests?
HoFFman- finger flick- to see if reflex of index finger is exaggerated or not
hOOver- differentiates between organic and non-organic paresis of the leg
LESS vs LOSS- RA and OA?
Radiological features of RA: LESS
L: loss of joint space
E: erosions (late sign) as eroded something takes a while
S: soft tissue swelling
S: soft bones (osteopenia) (early sign)
Radiological features of OA: LOSS
L: loss of joint space
O: osteophytes
S: subchondral cysts
S: subchondral sclerosis
When fluid restriction in ascites?
If the sodium is <125mmol/L
Spironolactone- especially if liver cirrhosis
Drainage if tense ascites- large-volume paracentesis requires albumin cover
Drug of choice in palliative care for reducing the discomfort of a painful mouth?
Benzydamine hydrochloride (mouthwash or spray)
Post MI- left ventricular aneurysm?
Persistent ST elevating and left ventricular failure
Thrombus may form within the aneurysm increase stroke risk- patient must be anticoagulated
Features of serotonin syndrome?
Sweating, tremor, confusion and hyperreflexia
Blood stained nipple discharge?
Intraductal papilloma
Common in younger patients
Thick, green nipple discharge, non-bloody?
Mammary duct ectasia
Most common in menopausal women
Smokers
FSH/LH in developmental disorders?
KALLman- FALL (Low FSH & LH)
TURNer- TURNed up (High FSH/LH)
HIV diagnosis?
HIV antibodies
p24 antigen
Combination tests- (HIV p24 antigen and HIV antibody) are now standard for HIV diagnosis and screening
Testing for HIV in asymptomatic patients should be done at 4 weeks after possible exposure
After an initial negative result when testing for HIV in an asymptomatic patient, offer a repeat test at 12 weeks
Vision colour change after drugs?
Sildenafil- blue tinge to vision called cyanopsia
Digoxin- can cause visual disturbances such as blurry vision, halos around lights and yellow-greeen colour perception
Treatment for legionella?
Erythromycin/clarithromycin
Diagnostic test of choice- urinary antigen
May be a hyponatremia present
Woman over 30 with unexplained breast lump?
Urgent referral using suspected cancer pathway
If under 30 it would be a non urgent referral
Refer if over 50 with discharge, retraction or other changes in one nipple
Oral or IV aciclovir for chickenpox in pregnancy?
Oral aciclovir
PMS managment?
Mild- lifestyle advice
Moderate- new generation COCP- Yasminu (drospirenone 3mg and ethinylestradiol)
Severe- SSRI- continuously or just during the luteal phase of the menstrual cycle
Two key investigations for rheumatoid arthritis?
Rheumatoid factor
Anti-CCP
First line for muscle spasticity in multiple sclerosis?
Baclofen, Gabapentin
First line for reducing risk of relapse in MS?
Natalizumab
Specific drugs in MS?
Fatigue- exclude other problems- amantadine
Spasticity- baclofen and gabapentin first line
Bladder dysfunction- ultrasound first to assess bladder emptying
If significant residual volume- intermittent self-catheterisation
If no significant resifual volume- anticholinergics may improve frequency
Oscillopsia (visual fields appear to oscillate)- gabapentin is first line
Amiodarone in ALS?
300mg after 3 shocks
Further dose of 150mg for after 5 shocks
For patients in VF/pulseless VT
Lidocaine is an alternative if amiodarone is not available
Drugs causing torsades de points (long QT and polymorphic ventricular tachycardia)?
ABCDE
A- AntiArrythmetics
B- AntiBiotics
C- AntiCychotics
D- AntiDepressants
E- AntiEmetics
Basically
Tricyclics
Antipsychotics
Erythromycin
Hypothermia
Subarachnoid haemorhage
Chloroquine
Pre-eclampsia tirad?
New-onset hypertension
Proteinuria
Oedema
How is osteomyelitis diagnosed?
MRI
Osteomriitis
Remember diabetic foot ulcer can lead to osteomyelitis
/
First line antiemetic for nausea and vomiting due to raised ICP?
Cyclizine
Dexamethasone can also be used
How long c.diff stay in a side room?
Until at least 48 hours after last episode of diarrhoea
Developmental dysplasia of the hip?
Ultrasound- unless over 4.5 months and then x-ray
Management-
Most spontaneously stabilise by 3-6 weeks of age
Pavlik harness- children younger than 4-5 months
Older children my require surgery
Diagnostic investigation for lymphoma?
Excisional node biopsy- Burkitt’s starry sky appearance
Thiazides side effects?
HyperGLUC
High glucose
High lipids
High uric acid
High calcium (but low in urine so can be used for stones)
Lung cancers and paraneoplastic syndromes?
SCLC
ADH
ACTH
Lambert-Eaton syndrome
SCC
Parathyroid hormone-related protein
Adenocarcinoma
Gynaecomastia
Does the malar rash spare nasolabial folds in SLE?
Yes
Most important opioid conversions to remember?
PO morphine to SC- divide by 2
PO codeine to PO morphine- divide by 10
Heart failure and hypertension?
Cannot give CCBs such as nifedipine
Only amlodipine
Under 3 with a limp?
Specialist referral
When to refer for carotid endarterectomy in TIA/stroke?
Within the distribution of the carotid artery
50-99% stenosis evaluated for possible enarterectomy
The endarterectomy should be performed on the side of the brain that had the stroke- so if symptoms on the right hand side do it on the left
TIA preferred investigation?
MRI- including diffusion-weighted and blood-sensitive
Side effects of lithium?
LITHIUM
Lethargy
Insipidus (diabetes)
Tremor
Hypothyroidism
Insider (gastrointestinal)
Urine (increased)
Metallic taste
Kaposi’s sarcoma?
Purple papules or plaques on the skin or muscosa
Caused by HHV-8
Link to HIV
Side effects of levothyroxine therapy?
Hyperthyroidism- overtreatment
Reduced bone mineral density
Worsening of angina
AF
Levothyroxine interactions?
Iron, calcium carbonate
Absorption of levothyroxine is reduced, give at least 4 hours apart
Loop and end stoma difference?
Loop has two openings
End has one
Malnutrition criteria?
BMI less than 18.5
Unintentional weight loss greater than 10% within the last 3-6 months
BMI of less than 20 and unintentional weight loss greater than 5% within the last 3-6 months
Puerperal pyrexia?
Causes:
Endometritis- most common
UTI
Wound infections- perineal tears + caesarean section
Mastitis
VTE
If endometritis suspected patient should be referred to hospital for IV antibiotics (clindamycin and gentamicin) until afebrile for greater than 24 hours
HIV and adrenal insufficiency?
Adrenal insufficiency affects around 10% of HIV patients
Hashimoto’s thyroiditis other name?
Autoimmune thyroiditis
After the menopause breast cancer?
Anastrozole/Letrozole
Haemorrhageg after tonsillectomy?
Primary haemorrhage- occurs within the first 6-8 hours folowing surgery- immediate return to theatre
Secondary haemorrhage- 5-10 days after surgery- associated with wound infection- admission and antibiotics
Lower lobe fibrosis causes? (everything else assume upper zone)
DAIM
Drugs- amiodarone + bleomycin + methotrexate
Asbestosis
Idiopathic
Most connective tissue disorders except ankylosing spondylitis
Occupational asthma investigation?
Serial measurements of peak expiratory flow at and away from work
Is abnormal head impulse test in HiNTs exam vestibular neuronitis or posterior circulation stroke syndrome?
Vestibular neuronitis
Impaired fasting glucose/impaired glucose tolerance?
Impaired fasting clucose- 6.1-7
Impaired glucose tolerance- OGTT 2-hour value 7.8-11.1
Aspirin or no aspirin in TIA?
Aspirin
If on blood thinners get a CT head first to rule out haemorrhage even though symptoms have resolved
Malaria symptoms?
Intermittent fevers, myalgia and headaches
Thrombocytopenia and presence of trophozoites on a blood film
If falciparum malaria give aresunate
If not falciparum can also give chloroquine
Hypocalcaemia ECG?
Prolonged QT
Rememver Trousseau’s and Chvostek’s sign
Different types of Hodgkin’s lymphoma?
Most common- nodular sclerosing
Best prognosis- lymphocyte predominant
Worst prognosis- lymphocyte depleted
Hypercalcaemia ECG?
Shortening of the QT interval
Haemophillia and factors?
Haemophilia A- VII (8)
Haemophilia B- IX (9)
PITS and optic radiations?
PITS refers to the visual field- Parietal inferior, temporal superior.
Optic radiatons are opposite so it would be a superior optic radiation in the parietal lobe
Coarse crackles, haemoptysis, clubbing, persistent productive cough, SOB, wheezing?
Bronchiectasis
Permanent dilatation of the airways secondary to chronic infection or inflammation
Back pain with bilateral leg neurological symptoms?
Lumbar discitis or abscess
On a background of fever/sepsis
Gluttae psoriasis?
After an infection
‘Tear drop’, scaly papules on trunk and limbs
Most cases resolve spontaenously within 2-3 months
Reassure and topical agents if symptomatic
Anticoagulants in STEMI?
Always aspirin
If PCI, then prasugrel (the Ps)
If thrombolysis, then ticagrelor (the Ts)
If on anti-coagulants then clopidogrel (the Cs)
Neuropathic pain?
Do not stack drugs
Switch from one monotherapy to another
(diabetic neuropathy, post-herpatic neuralgia, trigeminal neuralgia, prolapsed intervertebral disc)
First line- amitriptyline, duloxetine, gabapentin or pregabalin
If first line doesn’t work tey one of the other three- switch don’t add
Tramadol can be used as a rescue therapy for exacerbations of neuropathic pain
Most common cancer for tumour lysis ayndrome?
Burkitt’s lymphoma
Starry sky appearance on microscopy
Linked to Epstein-Barr virus
Traveller’s diarrhoea?
E.coli
Antivirals for shingles?
Yes, for the majority of patients within 72 hours unless under 50 with mild pain and rash and no underlying features
Antivirals reduce the incidence of post-herpatic neuralgia
Bipolar types?
Type I disorder- mania and depression- most common
Type II disorder- hypomania and depression
Test for squint?
Corneal light reflection test
Screening test for squint
What is amblyopia?
The brain fails to fully process inputs from one eye and over time favours the other eye
Types of squint?
Concomitant- imbalance in extraocular muscles- convergent more common than divergent
Paralytic- due to paralysis of extraocular muscles
BV treatment?
Oral metronidazole 5-7 days- even throughout pregnancy
Topical metronidazole or topical clindamycin are alternatives
Eczema herpeticum?
Worsening of eczema that requires IV antivirals
Severe primary infection with HSV 1 or 2
Children with history of atopic eczrema and a rapidly progressing painful rash
How does myoglobinuria cause renal failure?
Tubular cell necrosis
How much to increase morphine by each time?
30-50%
Disease with symptoms that mimic peripheral arterial disease but pain gets better/worse when walking uphill/downhill?
Lumbar spinal stenosis
Claudication symptoms- sitting bettwe than standing and easier to walk uphill rather than downhill
Aspirin overdose?
Ringing in ears
Starts as a respiratory alkalosis- simulation of resp centre- turns into a metabolic acidosis- salicylic acid
Peptic ulcer disease with perforation?
No OGD
Do an erect chest x-ray to look for air under the diaphragm
Critical limb ischaemia vs acute limb-threatening ischaemia?
Critical limb ischemia- more chronic comes on over time
Acute limb-threatening ischaemia- more sudden onset
Raised CRP and white cells after surgery?
Generally to be expected
Common pneumonia after influenza infection?
S.Aureus
Painful genital ulceration vs painless genital ulceration?
Painful- genital herpes
Painless- syhphilis
Investigation for genital herpes?
Nucleic acid amplification tests (NAAT)
Painful genital ulceration- primary infection more severe than recurrent episodes
Management-
Saline, analgesia, topical anaesthetic agents
Oral aciclovir
ROSIER socre?
-1- loss of conciousness/syncope
-1 seizure activity
+1- asymmetric facial weakness
+1- asymmetric arm weakness
+1- asymmetric leg weakness
+1- speech disturbance
+1- visual field defect
Bell’s palsy where facial paralysis shows no sign of improvement after 3 weeks?
Refer urgently to ENT
De Quervain’s tenosynovitis?
Sheath containing extensor pollicis brevis and abductor pollicis longus tendons are inflamed
Affects females 30-50 years old
Pain on radial side of the wrist
Tenderness over the radial styloid process
Abduction of the thumb against resistance is painful
Finkelstein’s test- the examiner pulls the thumb of the patient in ulnar deviation and longitudinal traction. Patient with tenosynovitis pain over radial styloid process and along the length of extensor pollisis brevis and abductor pollicis longus
Management-
Analgesia
Steroid injection
Immobilisation with thumb splint
Surgical treatment
Herpes 1 and 2?
HSV 1- most likely oral (cold sores)
HSV 2- most likely genital herpes
What to screen for when starting rituximab?
Could be for lymphoma treatment
Screen for hepatitis B
Which drugs do you screen for TB before starting?
Infliximab
Etanercept
Which cranial nerves are affected by vestibular schwannomas?
Cranial nerves V, VII and VIII
Vertigo, sensorineural hearing loss, tinnitus
Absent corneal reflex
Facial palsy
Pott’s fracture?
Bimalleolar ankle fracture
Forced foot eversion
How long to be a depressive episode?
Two weeks
Recurrent episode of C.difficile within how long give oral fidaxomicin?
Recurrent episode within 12 weeks- initially treated with oral vancomycin
Fitz-Hugh-Curtis syndrome?
Complication of pelvic inflammatory disease
Liver capsure becomes inflamed causing right upper quadrant pain
Occurs in chlamydia or gonorrhoea
Gluttate psoriasis?
Can be triggered by streptococcal throat infection
CLL and new B-symptoms?
Richter’s transformation- change from CLL to large cell lymphoma
Way to remember the salter classification?
SALTR
S- straight through
A- above
L- lower
T- through all three
R- rammed (crush or something)
Schistosomiasis is associated with which type of cancer?
Squamous cell carcinoma of the bladder
Tests important when starting TB drugs?
Liver funcion test
Optic and renal tests for ethambutol
Other drugs can all cause hepatitis
Ankle fratures management?
Weber A- CAM boot with weight bearing
Weber B- radiograph to assess syndesmosis + mortis for ankle stability. If instability- surgery. If not, CAM boot
Weber C- fracture will most likely involve syndesmosis and ankle instability- requires surgery- ORIF
Ottawa ankle rules?
X-rays only necessary if there is pain in the mallleolar zone and- inability to weight bear for 4 steps
Tenderness over the distal tibia
Bone tenderness over the distal fibula
Hand preference before what age is abnormal?
12 months
Milestone referral points?
No smile at 10 weeks
Cannot sit unsupported at 12 months
Cannot walk at 18 months
Hand preference before 12 months abnormal- may indicate cerebral palsy
Epididymo-orchitis?
Infection of the epididymis +/- testes resulting in pain and swelling
Subacute onset of testicular pain and swelling associated with dysuria
Pain relieved by elevating testes (positive Prehn’s sign) which would be negative in torsion
Unilateral testicular pain swelling
Urethral discharge may be present but often urethritis is asymptomatic
Investigations- in younger adults assess for STI, in older adults with low-risk sexual history- send a mid-stream urine for microscopy and culture
Management-
If STI urgent referral to sexual heealth clinic- ceftriaxone and doxcycline
If enteric organisms ssend MSU- treat with oral quinolone (ofloxacin) for 2 weeks
Pleural effusion- chest drain or aspirate first?
Aspirate first then chest train
Resulting management determined by aspirate-
If exudate/empyema then drain
If transudate then can be medially managed without chest drain
Pleural fluid that is purulent or turbid/cloudy or clear with a pH less than 7.2 a chest drain should be placed
Campylobacter antibiotic management?
Often self limiting
But clarithromycin
If you want to get rid of camper, put some mycin their tent
Clarithromycin for atypical bacteria
6 Ps of acute limb ischaemia?
Pale
Pain
Pulseless
Perishingly cold
Paraesthesia
Paralysis
Management of acute limb-threatening ischaemia?
Initial management-
ABC approach
Analgesia - IV opioid often used
IV unfractionated heparin is usually given to prevent thrombus propagation, paticularly if patient unsuitable for immediate surgery
Vascular review
Definitive management:
Intra-arterial thrombolysis
Surgical embolectomy
Angioplasty
Bypass surgery
Amputation- for patients with irreversible ischaemia
What would q waves in lead II, III, aVF indicate?
Previous inferior MI
(Q waves are a sign of previous myocardial infarction)
Wellen syndrome?
Critical stenosis of LAD- chest pain resolves but still need immediate coronary angiography or PCI
Deep T wave inversion or biphasic T waves in V2-V3
Many characteristic circular target lesions?
Erythema multiform- target lesions initially seen on the back of hands/feet before spreading to the torso
Causes- viruses
Idiopathic
Bacteria- mycoplasma
Drugs- penicillin, sulphonamides, carbamazepine, allopurinol
CTD
Sarcoidosis
Malignancy
Oral cancer virus association?
Human papillomavirus (HPV)
PCOS hormone results?
Raised LH:FSH ratio
Testosterone normal or mildly elevated
SHBG is normal to low
Rotterdam criteria for PCOS?
2 of 3:
Infrequent or no ovulation
Clinical and/or biochemical signs of hyperandrogenism (hirsutism, acne or elevated levels of total or free testosterone)
Polycystic ovaries on ultrasound scan (presence of more than 12 follicles) in one or both ovaries and/or increased ovarian volume
3 days fever, then 3 days rash?
6th disease- roseola infantum
Caussed by human herpes virus 6 (HHV6)
CKD mineral bone disease?
CKD causes low vitamin D and high phosphate
High phosphate causes osteomalacia
Low calcium due to the lack of vit D, high phosphate
Secondary hyperparathyroidism
Management:
Reduce dietary intake of phosphate is first-line
Phosphate binders
Vit D
Parathyroidectomy in some cases
Phosphate binders- sevelamer
Osteomalacia presentation?
Lack of bone mineralisation- most common cause is a lack of vitamin D- malabsorption/lack of sunlight/poor diet
Diffuse bone pain and tenderness, proximal myopathy and a waddling gait
Termed rickets in children, osteoamlacia in adults
Bloods- low vit D, low calcium, raised ALP
Vit D supplementation
Ocular trauma?
Hyphema (blood in the anterior chamber of the eye) warrants urgent referral to an opthalmic specialist
Main risk is raised intraocular pressure- blockage of angle and trabecular meshwork with erythrocytes
Assessment for orbital compartment syndrome
Eye pain/swelling
Proptosis
Rock hard eyelids
Relevant afferent pupillary defect
Management- urgent lateral canthotomy to decompress the orbit
Drug treatment for stroke?
Aspirin for first 14 days
Clopidogrel after that lifelong
What blood marker rises after an acute episode of anaphylaxis?
Serum tryptase
PTSD drug treatment?
Venlafaxine or SSRI
Markers for cancer?
CA-125- Ovarian
Carcinoembryonic antigen (CEA)- colorectal
Alpha-fetoprotein- Testicular and hepato
CA19-9- Pancreas
CA15-3- Breast
Unilateral polyps in the nose?
Refer to ENT
Nasal polyposis associations?
Samter’s triad
Asthma, aspirin sensitivity and nasal polyposis
Unilateral or bleeding refer
Topical corticosteroids can shrink polyp in size
Which hepatitis strains increase the risk of hepatocellular carcinoma?
Strains B, C, D
Management for hepatitis A and E
Supportive- complications rare
Limits for orthostatic hypotension to be diagnosed?
A drop in systolic BP of 20mmHg or more (with or without symotoms)
A drop to below 90mmHg on standing even if the drop is less than 20mmHg (with or without symptoms)
A drop in diastolic BP of 10mmHg with symptoms
Difference between vitamin K and prothrombin complex concentrate (PCC) for warfarin reversal?
PCC for rapid temporary reversal of warfarin’s effect- within minutes- use in emergency situations
Vitamin K- takes longer to act but is necessary for a longer term warfarin reversal
Tetralogy of fallot hand symptoms?
Finger clubbing
Type of heart condition that can remain symptomless in childhood but progess to symptoms in adulthood?
Atrial septal defect
Causes an ejection systolic murmur
Hypokalaemia symptoms?
Muscle weakness, fatigue, ECG findings- reduced t-wave amplitude, PR prolongation and QT prolongation
After how many weeks do you need anti-d prophylaxis in women who are resus D negative?
After 10 weeks gestation
Glaucoma screening age for those with a positive family history?
From 40 years old
ITP?
Immune thrombocytopenia
Typically follows an infection or vaccination
Features
Bruising
Petechial or purpuric rash
Bleeding less common
Bloods- isolated thrombocytopenia
Usually no treatment
If platelet count very low or significant bleeding-
Corticosteroids
IV immunoglobulins
Platelet transfusions
Double duct sign?
Pancreatic cancer
Opioids in renal failure?
Mild to moderate- oxycodone
More severe- alfentanil, buprenorphine and fentanyl
Crohn’s and gallstones?
Yes
Crohn’s gives you stones
CRABBI for myeloma?
Calcium
Renal- could lead to protein urea?
Anaemia
Bleeding
Bones
Infection
Open angle glaucoma vs closed angle glaucome definitive management?
Closed angle- laser peripheral iridotomy
Open angle- Laser trabeculoplasty
Pioglitazone contraindinications?
Bladder cancer
Heart failure
SGLT-2 and recurrent UTIs?
Contraindication
Delirium drug management?
Haloperidol if criteria met
Careful in Parkinson’s- sometimes atypical antipsychotics quetiapine or clozapine if they require urgent treatment
New BP >180/120 and retinal haemorrhage or papilloedema?
Admit for specialist assessment
How to cause pain in a scaphoid fracture?
Longitudinal compression of the thumb (telescoping of the thumb)
Tenderness over the anatomical snuffbox/ schapoid tubercle and ulnar deviation of the wrist
Investigation of choice for an ectopic pregnancy?
Transvaginal ultrasound
Generally transvaginal if gynae and early pregnancy
Transabdominal ultrasound after 12 weeks pregnancy
Can SGLT-2 inhibitors cause foot ulcers?
There is an incrased risk of lower-limb amputation
Prevention of thrombotic events in polycythaemia vera?
Aspirin
Venesection first line treatent to keep the haemoglobin in the normal range
Chemotherapy- hydroxyurea
When can you not use IV dexamethasone in meningitis?
Septic shock, meningococcal septicaemia or if immunocompromised or in meningitis following surgery
Presentation for Mycoplasma pneumoniae?
Affects younger patients- atypical pneumonia
Presents with a dry cough, mild fever, malaise and
classically an erythema multiforme rash
Diagnosis- mycoplasma serology
Treatment- doxycycline or a macrolide
Also associated with cold autoimmune haemolytic anaemia
Difference between critical limb ischaemia and acute limb-threatening ischaemia?
Acute- sudden and out of nowhere (thrombus)
Critical- at the end of a process, slowly getting worse- atherosclerosis etc
Unstable braod-complex tachycardia?
Instable ventricular tachycardia- synchronised cardioversion
Checking for diabetic foot disease?
Ischaemia- palpate for dorsalis pedis pulse and posterior tibial artery pulse
Neuropathy- 10g monofilament used on various pars of the sole of the foot
Which tablets can affect levothyroxine absorption?
Iron and calcium carbonate
Think of this if newly tired and recently started on these as a new medication
Wernicke’s encephalopathy/Korsakof’s syndrome?
COAT RACK
Coat for Wernicke’s
Rack for Korsakoff’s
Confusion
Opthalmoplegia/nystagmus
Ataxia
Thiamine deficiency
Retrograde amnesia
Anterograde amnesia
Confabulations
Korsakoff’s psychosis
Fibroadenoma excision?
If >3cm surgical excision is usual
Osteoporosis drgus?
Anastrazole and omeprazole can cause it
Inhaled corticosteroids less likely than systemic
Somatisation vs conversion disorder (functional neurological disorder)?
Somatistaion is multiple symptoms patient refusing to accept reassurance or negative results
Conversion disorder- neurological deficit possible in response to a traumatic experience
Status epilepticus treatment?
Oh My Lord Phone the Anaesthetist
Oxygen
Midazolam (PR diazepam or buccal midazolam)
Lorazepam
Phenytoin
Anaesthesia- rapid sequence induction
Now generally levetiracetam before phenytoin
NSAIDs in AKI?
NSAIDs stopped apart from aspirin at a cardio-protective dose- aspirin 75mg
DIANA
D- Diuretics
I- iodinated contrast
A- ACEi/ARB
N- NSAIDs
A- aminoglycosides
Kawasaki disease features?
High-grade fever for >5days +
CRASH
Conjunctival injection
Rash
Adenopathy
Strawberry tongue
Hands and feet swelling/desquamation
GnRH and gynae?
Yes- goserelin. buserelin
Treatment for venous ulceration?
Compression banding
Important to check ABPI for arterial flow
Most common cause of very raised ALT/AST in the 10,000s, transaminitis?
Paracetamol overdose
Stop metformin if critically ill?
Yes- due to the risk of metformin-associated lactic acidosis
Which foods are ok to eat in coeliac?
Corn, potatoes, rice
All gluten free
Staghorn stone compisition?
Struvite
Associated with urinary tract infections caused by Proteus
Most common stone composition?
Calcium oxolate
Papillary muscle rupture associations?
After posterior MI usually
Acute mitral regurgitation- but with a early-to-mid systolic rather than pansystolic
Acute hypotension and pulmonary oefema may occur
Continue anticoagulation in AF even if have had successful catheter ablation?
Yes- as per CHADS-VASc
If 0- 2 month anticoagulation ecommended
If over 1- longterm anticoagulation reccomended
GnRH agonists for fibroids?
Goserelin etc- same as prostate cancer management
Side-effects
Menopausal symptoms- hot flushes, vaginal dryness
Loss of mineral bone density
Investigations for Guillain-Barre?
LP- rise in protein with a normal white cell count
Nerve conduction studies- decreased motor nerve conduction velocity (due to demyelination)
Hyper or hyponatraemia with MDMA?
HYPOnatraemia
Either due to excessive water consumption or SIADH
SSRI also causes hyponatraemia
Contraindications to LP in meningitis?
Signs of raised ICP
Signs of severe sepsis or rapidly evolving
Meningiococcal sepsis
Lhermitte’s sign?
Tingling in hands when flexing neck
Associated with MS
Paraneoplastic features for renal cell carcinoma?
EPO- polycythaemia
ACTH- Cushingoid body habitus and hypertension
Renin- hyperaldosteronism (hyperNa, hypoK, HTN)
PTHrP- hypercalcaemia
Cannonball metastses are characteristic of renal cell carcinoma
Management for renal cell carcinoma?
Partial or total nephrectomy depending on tumour size
Urea proportionally higher than creatinine?
Dehydration
Is Lewy-body dementia fluctuating?
Yes
Differentiating brain abscess from meningitis/encephalitis?
Brain abscess- causes more focal neurology whereas meningitis/encephalitis causes more generalised neurological defecit
An example of this could be weakness of the left hand
Subacute degeneration of the spinal cord?
Progessive unsteadiness, tingling sensation, ataxic gate, distal sensory loss, positive Romberg’s, absent ankle jerks
Lack of vitamin B12- can result from bariatric surgery etc
Drug that causes nephrogenic diabetes insipidus?
Lithium
Herpes management in pregnancy?
If over 28 weeks and first episode- caesarean
If recurrent episode- low risk of transmission
(still give aciclovir in both anyway?)
Primary, secondary, tertiary hyperparathyroidism?
Primary- High PTH (or inappropriately normal), high Ca, low phosphate- solitary adenoma
Secondary- High PTH, low calcium, elevated phosphate- parathyroid glad hyperplasia due to chronically low calcium (renal disease)
Tertiary- High PTH, high calcium, low phosphate- corrected underlying renal problem but still the parathyroid gland hyperplasia
ITP treatment?
Children- no treatment self resolving
Adults- oral prednisolone
Bruising, petechial rash following an infection
Is nitrofurantoin contraindicated in breast feeding?
Yes
Should you examine throat in croup?
No for same reason as normal epiglotitis
Stridor can be a feature of croup
Causes of gingival hyperplasia?
PANIC
Phenytoin
AML
Nifedipine/amlodipine- both CCBs
Inherited, idiopathic
Ciclosporin
Does postoperative ileus have bowel sounds?
No
Management of BP over 180/120
If signs of end organ damage/ life threatening symptoms- refer for a specialist assessment
If none of the above apply- urgent tests for end organ damage
Most important prognostic factor in paracetamol overdose?
Arterial pH
Weber’s test meaning?
Conductive hearing loss- lateralises to the affected ear
Sensorineural hearing loss- lateralises to the unaffected ear
(Rinnies- air better than bone is normal/sensorinueiral
Bone better than air is conductive)
Blood gas disturbance caused by aspirin?
Salicylate overdose can cause a mixed primary respiratory alkalosis and metabolic acidosis
Causes hyperventilation then as lactate increases causes the metabolic acidosis
HNPCC genes involved?
MSH2
MLH1
Hand preference before when is abnormal?
12 months
COPD LTOT?
O2 of 7.3-8 kPa
and one of the following:
Secondary polycythaemia
Peripheral oedema
Pulmonary hypertension
Hypercalcaemia treatment?
Rehydration with normal saline
Bisphosphonates potentially after rehydration
Can you see a false lumen on CXR?
No
But you can see a widened mediastinum
Aortic dissection investigations?
CXR- widened mediastinum
CT angiography- investigation of choice- false lumen
Transoesophageal echocardiography (TOE)- More suitable for unstable patients who are too risky to take to CT scanner
Acne oral antibiotic?
Try an oral antibiotic before referring if only a topical has previously been used?
Even if TSH in normal range still could be secondary hypothyroidism as inappropriately normal for example if cannot produce as much as needd due to a non-functional adenoma?
Generalised hypopituitarism etc think pituitary adenoma
Difference between type 1 and type 2 respiratory failure?
Type 1- O2 low, CO2 normal or low
Type 2- O2 low, CO2 high
Thrombosed haemorrhoids treatment?
Significant pain and tender lump
Purplish, oedematous, tender subcutaneous perianal mass
If patient presents within 72 hours then referral for consideration for excision
Otherwise if over 72 hours then manage with stool softners, ice packs and analgesia
Prostate cancer investigation?
Multiparametric MRI is first-line
Hypothyroidism electrolyte disturbance?
Euvolaemic hyponatraemia
Gestation diabetes treatment?
> 7 at diagnosis- start on insulin straight away
If not then diet exercise, then metformin then ADD insulin if still not controlled
What is included in the combined test for antenatal testing?
Nuchal translucency measurement + serum B-HCG + pregnancy-associated plasma protein A (PAPP-A)
Quadruple test- alpha-fetoprotein, unconjugated oestriol, human chorionic gonadotrophin, inhibin A
Combined test results?
Down’s- HCG up, PAPP-A down, thickened nuchal translucency
Patau (13) and Edward’s (18) similar result but HCG lower
Quadruple test results?
Down’s- everything down apart from HI- HCG and Inhibin A raised
Edward’s- Everything down inhibin A normal
NTD- AFP up rest normal
Further test if higher chance of Down’s on combined or quadruple tests?
Non-invasive prenatal screening test (NIPT)
Renal stones management?
Treatment:
Stone <5mm- expectant treatment
Stone <2cm- lithotripsy
Stone <2cm + pregnant- uteroscopy
Stone complex- nephrolithotomy (invasive)
Hyydronephrosis/infection- nephrostomy
Imaging:
Non-contrast CTKUB
Pain reliever
IM Diclofenac
Meningitis prophylaxis for household members?
Ciprofloxacin or rifampicin
Lamotrigine potential adverse effect?
Stevens-Johnson syndrome
Is right heart failure associated with hepatomegaly?
Yes- firm, smooth, tender liver edge that may be pulsatile
Common causes of hepatomegaly?
Cirrhosis- if early disease, later liver decreases in size, associated with a non-tender, firm liver
Malignancy- metastatic spread or primary hepatoma- hard, irregular liver edge
Right heart failure- firm, smooth, tender liver edge that may be pulsatile
In which type of lung cancer are cavitating lesions more common in?
Squamous cell carcinoma
Kyphoscoliosis?
A restrictive lung disease linked to ankylosing spondylitis
Ankylosing spondylitis can also cause pulmonary fibrosis
What to give for headache caused by raised intracranial pressure due to brain cancer (or metastases)?
Dexamethasone
This would be palliative treatment
Are hepatitis viruses DNA or RNA?
All RNA apart from Hep B which is DNA
VTE 3 or 6 months PE with cancer?
6 months- not an easily reversible cause (unlike stopping COCP or post surgery)
Pleural effusion management?
Diagnostic aspiration with 21G needle- send fluid for pH, protein etc to work out the cause
Chest drain for symptomatic relief
If infection- do a chest tube
Might need to treat underlying cause
First step in asthma age 11 and under?
Twice- daily paediatric low-dose inhaled corticosteroid (ICS) + short-acting beta2 agonist (SABA) as needed
if MART pathway
Paediatric low-dose MART + SABA as needed
Paediatric moderate-dose MART + SABA as needed
Sodium correction?
Sodium low to high the pons will die (osmotic demyelination syndrome which can cause a spastic quadriparesis)
Sodium high to low the brain will blow- cerebral oedema
What can you use for acute hyponatraemia?
Hypertonic saline (3% NaCl)
But be careful can correct sodium too quickly
Varices treatment?
To prevent bleeding in varices that are not currently bleeding- propranolol
To treat bleeding oesophageal varices- terlipressin
Immunosuppression skin cancer?
Squamous cell carcinoma
Subacute degeneration of the spinal cord symptoms?
Hyperreflexia, loss of proprioception and loss of vibration sense
Distal sensory loss/tingling + absent ankle jerks/extrensor plantars + gait abnormalities/Romberg’s positive
Anorexia G’s and C’s?
Most things low, Gs and Cs raised:
Growth hormone
Glucose
Salivary glands
Cortisol
Cholesterol
Carotinaemia
Damage to radial nerve?
Wrist drop
Horner’s syndrome?
Can be due to compression from pancoast tumour of the lung
Miosis (small pupil)
Ptosis
Enopthalmos (sunken eye)
Anhidrosis (loss of sweating on one side)
Central lesions cause anhidrosis of the face, arm and trunk- stroke, syringomyelia, MS
Pre-ganglionic just face- Pancoast’s tumour, thyroidectomy, trauma
Post-ganglionic lesions- no anhidrosis- carotid artery dissection, carotid aneurysm, cavernous sinus thrombosis, cluster headache
How long after COCP to start ulipristal?
5 days
Cervical cancer management that best preserves fertility?
Cone biopsy
Gold standard generally is a hysterectomy +/- lymph node clearance
More advanced tumours might have radiotherapy/chemotherapy
PITS pneumonic extra big?
PITS- Parietal inferior, temporal superiors
AND
PITS- PITuitary Superior
Pituitary superior visual loss as tumour is below/ affects lower nerve fibres which recieve from upper visual dield
Craniopharyngioma is lower visual field problems
Posterior vitreous detatchment vs retinal detatchment?
PVD- floaters
RD- curtain over vision
Heart failur esymptoms with new AF?
Cardiovert
Psoriasis management?
Regular emollients
First-line-
Potent corticosteroid applied once daily plus a vitamin D analogue once daily
Applied seperatley- morning/evening
Second line- vitamin D analogue twice daily
Third-line- a potent corticosteroid applied twice daily for up to 3 weeks
or
A coal tar preparation applied once or twice daily
Common side effect of nexplanon implantable?
Most effective form of contraception
Common side effect is irregular bleeding
Can be managed using a co-prescription of the COCP
Does positive Rinne’s mean healthy or not?
Yes positive Rinne’s means normal
Raised ICP investigations?
DO NOT do an LP- only can do those for things like IIH when other causes ruled out
Non-contrast CT head first to rule out any mass lesions that could cause brain herniation
Tip is if asking for most appropriate next step it is rarely something complicated if a first line investigation
Pupil dilation in CN3 palsy?
Something compressing the nerve
Such as a posterior communicating artery aneurysm
Biliary colic vs cholecystitis?
Biliary colic just the RUQ without fever- no LFT/inflammatory marker derangement
Cholecystitis- RUQ + fever
Moat common complication of thyroid eye disease?
Exposure keratopathy
Do you give antibiotics in preterm labour?
Seems to be only if membranes have broken- avoid NEC
Tocolytics and steroids to mature lungs if in labour
Under what CD4 count in HIV for pneumocytis jiroveci prohylaxis?
200
HAART- highly active anti-retroviral therapy is started on diagnosis
Oral co-trimoxazole is the drug of choice for pneumocytis jiroveci pneumonia
Lots of problems to do with pituitary?
TSG, LH, FSH- potentially HIGH prolactin
Think a non-functioning pituitary adenoma
Nephrotic syndrome complication?
Increased risk of thromboembolism related to loss of antithrombin III
Can cause a renal vein thrombosis
Most common cause of endocarditis following valve surgery?
Staph epidermis
CT finding in aortic dissection?
CT ANGIOGRAPHY
False lumen
X-ray would be a widened mediastinum
Rapidly progressive painful rash?
Potentially on a background of atopic dermatitis
Eczema herpeticum- IV antivirals
Glasgow score for pancreatitis?
Components of Glasgow score for pancreatitis (PANCREAS)
PaO2 (<8kPa)
Age (>55)
Neutrophilia (WCC > 15 x 109/L)
Ca2+ (<2mmol/L)
Renal function (urea >16mmol/L)
Enzymes (LDH >600 iu/L or AST >200 iu/L)
Albumin (<32g/L)
Sugar (blood glucose >10mmol/L)
Management of aortic stenosis for low/medium risk vs high operative risk?
Surgical aortic valve replacement for medium-low risk
Transcatheter aortic valve replacement for high operative risk patients
Syphilis stages?
Primary- penis, secondary- systemic
Primary- localised features
Secondary- Systemic symptoms- fevers, lymphadenopathy
Rash on trunk, palms, soles, buccal snil track ulcers, condylomata lata (painless, warty lesions on the genitalia)
Teriatry features
Gummas
Ascending aortic aneurysms
Congenital syphilis treatment-
Blunted upper incisor teeth
Keratitis
Saber shins
Rhagades (linear scars at the angle of mouth)
Saddle nose
Deafness
Propylthiouracil?
Antithyroid drug- second line to carbimazole if that is not tolerated
BP targets?
Less than 80- clinic- 140/90, ABPM- 135/85
Over 80- clinic- 150/90, ABPM- 145/85
Gold standard investigation for TB?
Sputum culture
Hyperdense vs hypodense on CT?
HYPOdense is dark- old on CT
HYPERdense is light- new on CT
Acute blood is bright (hyper)
Dry blood is old (hypo)
Can amylase be raised in small bowel obstrution?
Yes
If choosing between abscess and cyst?
Remember abscess infective/raised temp etc
Acute pancreatitis complications- pseudocysts/pancreatic abscess
Tangentiality vs circumstantiality?
Circumstantiality- circle- comes back round to answer just excessive detail
Tangentiality- goes on a tangent without returning to the topic or question
Is it safe for a mother to breastfeed with hepatitis B?
Yes
Hep B for breastfeeding
Myeloid leukaemias?
Granulocytes may be seen on blood film
CML vs CLL key feature?
CML- massive splenomegaly
CLL- lymphadenopathy
Acute vs chronic leukaemias on bloods?
If only blasts- immature cells- acute
If all stages are present/developed ones- chronic
Epilepsy and contraception?
Lots of epilepsy medications are enzyme inducers- carbamazepine, phenytoin etc
Lamotrigine
CI things like COCP, POP, Nexplanon
Use copper IUD, Mirena
Is creatine kinase raised in polymyalgia rheumatica?
No it is normal
It is ESR that is raised
Cancers associated with asbestos exposure?
Mesothelioma
Most common is lung cancer, especially is with smoking history as well
Where is the caecum?
Start of the large intestine
Right hemicolectomy if tumour there
Hyponatraemia after SAH most common cause?
SIADH
Tocolytics examples?
Terbutaline, nifedipine, Mg2+
Psoriatic arthritis?
Symmetric polyarthritis
Asymmetrical oligoarthritis
DIP joint disease (spared in RA)
Psoriatic skin lesions
Periarticular disease- tenosynovitis, enthesitis, dactylitis
Nail changes- pitting, onycholysis
X-ray- pencil in cup
Treatment by rheumatologist-
mild- NSAID
Moderate- methotrexate
What are mirror image nuclei?
Reed-Sternberg cells
Hodgkin’s lymphoma more likely to have systemic B symptoms
CKD and anaemia?
Could be reduced EPO- usually normochromic normocytic anameia- eGFR commonly less than 35
Also could be reduced absorption of iron
Antibodies in Graves?
IgG antibodies to the TSH receptor causing thyrotoxicosis
Corneal abrasion investigation?
Fluorescein staining
Topical antibiotic used to prevent secondary bacterial infection
Features:
Eye pain
Lacrimation
Photophobia
Foreign body sensation and conjunctival injection
Decreased visual acuity in the affected eye
Get the antibodies the right way round in thyroid issues
/
Globus pharyngis/hystericus?
Dysphagia- history of anxiety- intermittent symptoms- painless
Courvoisier’s law?
In the presence of painless obstructive jaundice, a palpable gallbladder is unlikely to be due to gallstones
Positively birefringent rhomboid-shaped crystals?
Pseudogout
What causes psudogout?
Raised calcium pyrophosphate
RFs-
Increasing age
Hyperparathyroidism
Low magnesium, low phosphate
Haemochromatosis
Wilson’s disease
Acromegaly
Pseudogout x-ray?
Chondrocalcinosis
Gold standard investigation for diagnosis of mesothelioma?
Thoracoscopic biopsy
Other lung cancers- bronchoscope and biopsy
Amaurosis fugax that resolves- is it a stroke or is it a TIA?
If vision loss truly monocular- ipsilateral internal carotid artery or retinal artery pathology- not a TIA
If visiion loss affects both eyes or is hemianopic (same side of vision on both eyes)- TIA/stroke affecting the posterior circulation or occipital cortex
Most important investigation in venous ulceration?
Ankle-brachial pressure index (ABPI)- assess for poor arterial flow which could impair healing
Compression banding is the main management- need a good enough arterial flow for this
What type of anal fissure is concerning and needs to be referred?
A lateral one
PAD vessels and presentation?
Iliac stenosis- claudication causing buttock pain
Femoral stenosis- claudication causing calf pain
Stopping medications before OGD?
1 day- gaviscon
2 weeks- PPIs
3 days- ranitidine
4 weeks- antibiotics
1, 2, 3, 4
Classification for hip fractures?
Garden classification
CK 2-4 times normal?
Less likely to be rhabdomyolysis as massively raised
Exercise can induce CK elevation- and cause haematuria too
Contrast or no contrast for CT looking for ureteric stone?
No contrast- can’t see the stone
In urology generally only use contrast if suspecting cancer
Diarrhoea within 6 hours- quick onset?
Bacillus cereus, Staphylococcus aureus
How long contraceptions take to become effective?
Instant- IUD
2 days- POP
7 days- COCP, injection, implant, IUS
Most common reason for hip replacement revision?
Aseptic loosening of the hip replacement
Beta thalassemia?
Microcytic anaemia, HbA2 raised
Major- first year of life with failure to thrive, severe anaemia
Trait- often asymptomatic, diagnosed later potentially- reticulocytosis less common than in major
Pneumothorax- no symptoms?
Conservative care regardless of pneumothorax size
Felty’s syndrome?
Triad of RA, spelenomegaly and neutropenia- patients present with recurrent and severe infections
Which lymph nodes does ovarian cancer spread to first?
Para-aortic lymph nodes
Be careful with auscletation zones?
A P T M
Parvovirus infection causing aplastic crisis reticulocytes?
Causes a reticulocytopenia rather than a reticulocytosis
Aplastic crisis in sickle cell sudden fall in haemoglobin and reduced reticulocytes
High reticulocyte count suggests sickle cell anaemia- sequestration crises cause increased reticulocytes (precipitated by high altitude eg going on a plane)
CKD anaemia?
FIX iron before giving EPO
Patient presenting with stroke even if within the 4.5 hour period?
Non-contrast CT head to rule out haemorrhagic stroke
Before aspirin
Before thrombolysis/thrombectomy
Salicylate (aspirin) poisoning metabolic acidosis/alkalosis?
1st- respiratory alkalosis
2nd- metabolic acidosis
BV pH?
High vaginal pH >4.5
Clue cells on microscopy
Positive whiff test (addition of potassium hydroxide results in fishy odour)
What distinguishes scleritis from episcleritis?
Pain in scleritis- associated with RA also SLE/sarcoidosis
No pain in episcleritis
Short incubation period severe vomiting?
Staphylococcus aureus
Before a PSA test people should not have?
Ejaculated in the previous 48 hours
Exercised vigorously, for example cycling, in the pervious 48 hours
Had a urological intervention such as a prostate biopsy in the previous 6 weeks
Had a UTI in the previous 6 weeks
Thymomas associated with which condition?
Myasthenia gravis
Ix patients with suspected septic arthritis?
Synovial fluid sampling
Prostate cancer most common ethnicity?
Afro/caribbean
Palivizumab?
Prophylaxis of bronchiolitis in high risk patients
Magnesium treatment duration pre-eclampsia?
Until 24 hours after last seizure or 24 hours after delivery
Magnesium sulphate respiratory depression treatment?
Calcium gluconate
While giving magnesium sulphate measure urine output, reflexes, respiratory rate and oxygen saturations
Persistent air leak or insufficient lung reexpansion despite chest drain insertion or recurrent pneumothoraces?
Referral to a thoracic surgeon
Video-assisted thoracoscopic surgery (VATS)
Mydriasis and sudden eye pain?
Acute glaucoma?
RA treatment?
Give DMARD monotherapy straight away +/- a short course of bridging prednisolone
Methotrexate (sulfasalazine, lefunomide, hydroxychloroquine)
Monitoring response to treatment with CRP and DAS28
RA flares managed with corticosteroids
TNF inhibitors if an inadequate response to at least 2 DMARDs- incuding methotrexate- etanercept (reactivation of TB risk) and infliximab are options
How much atropine in symptomatic bradycardia before pacing?
6 bolus in total (up to 3mg)- 5 more after initial one
External/transcutaneous pacing
Adrenaline infusion
Transvenous pacing if no response- specialist help
Undiagnosed vaginal bleeding?
Contraindication to HRT
HRT contraindications?
Current or past nreast cancer
Any oestrogen-sensitive cancer
Undiagnosed vaginal bleeding
Untreated endometrial hyperplasia
Vaccines commonly offered to pregnant women in the UK?
Influenza and pertussis
When can insert IUD/IUS after pregnancy?
Within 48 hours or after 4 weeks
POP anytime post partum
Women require contraception after day 21 after giving birth
COCP do not use in first 21 days due to the increased risk of VTE
UKMEC 4 if breastfeedig <6 weeks post partum
Skin condition associated with reactive arthritis?
Keratoderma blennorrhagica
Also possible to get circinate balanitis
Bishop’s score interpretation?
Score of <5 indicates labour is unlikely to start without induction
Score of > or equal to 8 indicates a high chance of spontaneous labour
If Bishop’s score < or equal to 6- vaginal prostaglandins or oral misoprostol
If Bishop’s score over 6- amniotomy and an intravenous oxytocin infusion
Remember membrane sweep can be done first
Signet ring cells in which type of cancer?
Gastric cancer
Gold standard test/screening for HIV?
HIV p24 antigen
HIV antibody
Epididymo-orchitis organism if low risk sexual history?
E.coli
If STI- chlamydia/gonorrhoeae
Patients with type 1 and a BMI over 25 drug in addition to insulin?
Metformin
Hypoglycaemia management?
In the community:
Initially- oral glucose in liquid, gel or tablet form 10-20g
Maybe a HypoKit- injection of glucagon
In a hospital setting-
Quick acting carbohydrate
If patient unconcious or unable to swallow, subcutaneous or intramuscular injection glucagon may be give
Or IV glucose 20% through a large vein
Does Bell’s palsy spare the upper face?
No
It is lower motor neurone- BeLL’s palsy
UMN lesions spare the forehead- a stroke etc
IN BELLS FOREHEAD AFFECTED- UNABLE TO RAISE EYEBROWS
Symphysis-fundal height?
Measured from the top of the pubic bone to the top of the uterus in centimetres
It should match the gestational age in weeks to within 2cm after 20 weeks
For example, if 24 weeks then a normal SFH would be 22 to 26 cm
Staphylococcal toxic shock syndrome?
Severe systemic reaction to staphylococcal endotoxins related to infected tampon use
Diagnostic criteria-
Fever- high
Hypotension
Diffuse erythematous rash
Desquamation of rash, especially palms and soles
Involvement of three or more organ systems- GI, mucous membrane erythema, renal failure, hepatitis, thrombocytopenia, CNS involvement
Management:
Removal of infection focus- retained tampon
IV fluids
IV antibiotics
Investigation to do if stroke under the age of 55 with no obvious cause?
Autoimmune and thrombophilia screening
Duchenne muscular dystrophy investigation?
Genetic testing now used rather than a muscle biopsy for diagnosis
Features:
Progressive proximal muscle weakness
Calf pseudohypertrophy
Gower’s sign- child uses arms to stand up from a squatted position
There is a raised CK
Classification system used to stratify risk post myocardial infarction?
Killip class
Reccomended times in a day for diabetics to monitor capillary blood glucose?
Before each meal and before bed
Why no insulin first in HHS?
Risk of central pontine myelinolysis due to the rapid increase in sodium concentration as, even though the patient is dehydrated, insulin will send glucose into cells, taking water with it, so sodium will rise quickly as it is now in a more concentrated vasculature
What is used to stage COPD?
FEV1
COPD severity (FEV1): 20-30-20-30
Stage 1 (Mild): >80%
Stage 2 (Moderate): 50-79%
Stage 3 (Severe): 30-49%
Stage 4 (Very severe): <30%
High risk symptoms in paediatrics?
Pale/mottled/ashen/blue
No response to social cues
Appears ill to a healthcare professional
Does not wake or stay awake if roused
Weak, high-pitched or continuous cry
Grunting
Resp rate over 60
Moderate or severe chest indrawing
Reduced skin turgor
Age less than 3 months with temp over 38
Non-blanching rash
Bulging fontanelle
Neck stiffness
Status epilepticus
Focal neurological signs
Focal seizures
Itchy, purple, papular rash?
Lichen planus
Potent topical steroids
Viral meningitis management?
Self limiting
If any suspicion of bacterial meningitis or encephalitis- IV antibiotics and antivirals
Weight gain on steroids? ESPECIALLY WITH BRUISING ETC
CUSHING’S SYNDROME
Hypokalaemia, metabolic alkalosis
Same disturbance present in primary hyperaldrostronism
Opposite present in addisons
Hyperkalaemic, metabolic acidosis
How long do symptoms have to be present to diagnose chronic fatigue syndrome
3 months
Itchy vagina cream?
Epaderm or diprobase
Liver transplant in paracetamol overdose criteria?
Arterial pH <7.3, 24 hours after ingestion
Or all of the following
Prothrombin time >100 seconds
Creatinine >300
Grade III or IV encephalopathy
Calculation for serum osmolality?
2xsodium + glucose + urea
Carotid investigation after TIA?
Carotid doppler (duplex ultrasound)
AMA (anti-mitochondrial antibodies) positive
Raised serum IgM?
Primary biliary cholangitis
Use ursodeoxycholic acid
Pulse oximetry and carbon monoxide poisoning?
Falsely high due to similarlities between oxyhaemoglobin and carboxyhaemoglobin
Airway problems with ?c-spine problems?
Jaw thrust
If no c-spine concern- head tilt chin lift
Drug associated wit a significant increase in mortality in dementia patients?
Antipsychotics
When IV isotonic normal saline and when IV 3% sodium chloride in hyponatremia?
Use the 3% if Na less than 120- acute presentation
What type of laxative is movicol paediatric plain?
Osmotic
Differentiating between osteomalacia and Paget’s?
Osteomalacia- decreased Ca, increased PTH, increased ALP
Paget’s- normal Ca, normal PTH, increased ALP
Typically an older male with bone pain and an isolated raised ALP in Paget’s
COCP cancer risk?
COCP increases the risk of cancers you screen for (cervical and breast)
COCP is protective for cancers common in older age (ovarian and endometrial)
Tetanus and wounds?
If a patient has had 5 doses of tetanus vaccine, with the last dose < 10 years ago, they don’t require a booster vaccine nor immunoglobulins, regardless of how severe the wound is
If over 10 years
If tetanus prone wound- reinforcing dose of vaccine
High-risk wound- reinforcing dose of vaccine + tetanus immunoglobulin
If vaccine history unknown- reinforce vaccine all wounds
Tetanus prone or high risk- vaccine + immunoglobulin
Upper zone fibrosis?
CHARTS
C - Coal Worker’s Pneumoconiosis
H - Histiocytosis
A - Ankylosing Spondylitis
R - Radiation
T - TB
S - Sarcoidosis/Silicosis
Learn centor and FEVERpain?
/
Varicose veins?
Occur due to incompetent venous valves- RFs- increasing age, female gender, pregnancy, obesity
May present for cosmetic reasons, aching, throbbing or itching
Also-
Skin changes- varicose eczema, haemosiderin deposition causing hyperpigmentation, hard/tight skin, hypopigmentation
Bleeding
Superficial thrombophlebitits
Venous ulceration
DVT
Investigation:
Venous duplex ultrasound- will demonstrate retrograde venous flow
Management-
Majority do not require surgery:
Leg elevation
Weight loss
Regular exercise
Graduated compression stockings
Reasons for referral:
Pain, disco,fort, swelling
Skin changes secondary to chronic venous insufficiency (pigmentation and eczema)
Superficial thrombophlebitis
Active or healed venous ulcer
Treatments:
Endothermal ablation
Foam sclerotherapy
Surgery
Causes of postpartum haemorrhage?
Tone (uterine atony)- vast majority of cases
Trauma (e.g. perineal tear)
Tissue (retained placenta)
Thrombin (e.g. clotting/bleeding disorder)
How much blood is defined as postpartum haemorrhage?
Loss of >500ml of blood after a vaginal delivery
Management PPH?
A to E approach- cannulae, lie the woman flat, bloods, warmed crystalloid infusion
Mechanical- palpate the uterine fundus and rub it to stumulate contractions
Catheter to prevent bladder distension and monitor urine output
Medical
IV oxytocin
Ergometrine (unless history of hypertension)
Carboprost IM (unless history of asthma)
Misoprostol
Potential for tranexamic acid
Surgical
RCOG state intrauterine balloon tamponade is first line ‘surgical’ where uterine atony is only or major cause
B-lynch suture
Ligation of the uterine arteries or internal iliac arteries
If severe- hysterectomy sometimes performed as life-saving procedure
RA and carpal tunnel?
RA causes it
Patients with high blood glucose on bloods but asymptomatic?
Must be high on two seperate occasions to diagnose T2DM so remeasure
Mitral stenosis?
Loud S1 as the valve closes
Opening snap in diastole as the mitral valve opens
Does hyperaldostronism always cause a raised sodium?
Not always
But hypokalaemia and hypertension are the one to look for
Renin down aldosterone up- check aldosterone:renin ratio
Definitive vs first line for obstruction?
X-ray first line
CT definitive
CKD cutoffs?
CKD clock
120-90- stage 1 if physical signs of CKD
90-60- stage 2- only if physical signs of CKD
60-45- stage 3a
45-30- stage 3b
30-15- stage 4
15-0 stage 5
Omeprazole and clopidogrel?
Omeprazole reduces the effectiveness of clopidogrel
One, two– buckle my shoe.
Three, four– kick the door.
Five, six– pick up sticks.
Seven, eight– shut the gate.
S1,2 = ankle jerk
L3,4 = knee jerk
C5,6 = biceps and brachioradialis
C7,8 = triceps
Learn innervations
L5 does everything
Check lower back pain- prolapsed discs
Femoral vs inguinal hernia?
Femoral inferolateral to the pubic tubercle
Inguinal hernia above and medial to the pubic tubercle
MILF
Medial- Inguinal
Lateral- Femoral
Femoral hernia management?
Urgent surgical repair- higher risk of strangualtion
Urinary incontinence first line treatment?
Urge incontinece?
Schizoid?
Schizoid avoid people
When is whole breast radiotherapy offered in breast cancer management?
After wide local excision
What are the two surgeries for breast cancer?
Wide local excision- small tumour in large breast, solitary lesion, peripheral tumour, under 4cm
Mastectomy- large tumour in small breast, multifocal lesion, peripheral tumour, over 4cm
Whole breast radiotherapy reccomended in wide local excision to prevent recurrence
When is FEC-D chemotherapy used in breast cancer?
If axilary nodal disease
Angina management?
Management of angina:
1. Start everybody on statin + aspirin for 2ndry prevention
2. Also begin monotherapy with B blocker or CCB (verapamil) - depending which one more sensible
3. Dual therapy (B blocker and CCB) - but can’t use rate limiting verapamil, have to switch to long acting CCB like amlodipine
4. Get PCI or CABG assessment (can give a 4th drug whilst waiting, eg nicorandil, ivabradine etc)
Angina still not controlled on BB and CCB?
Refer for PCI/CABG- add third drug whilst waiting
a long-acting nitrate
ivabradine
nicorandil
ranolazine
Also add one of those if on monotherapy and cannot tolerate the other drug (for example BB and asthma)
Do you give DC shocks in bradycardia?
No even if in shock, syncope, heart failure
Try raise heart rate
Atropine up to 3mg (500mcg at a time)
Transcutaneous pacing
Adrenaline/isoprenaline
Transvenous pacing
Epididymo-orchitis investigation?
Guided by age of the patient (STI likelihood)-
Under 35- NAAT- looking for chlamydia/gonorrhoea- if unknown ceftriaxone and doxycycline
Over 35- Mid stream urine culture- looking for E.Coli- treat with quinolone (ofloxacin)
Sarcoidosis and calcium
Hypercalcaemia
Do you do PCI if symptoms present for over 12 hours?
No
If the patient presents within 12hrs and PCI can be achieved within 120 mins = management is PCI
If the patient presents with sx longer than 12hrs or PCI is not achievable within 120 mins (e.g. PCI centre is 3hrs away) = Fibrinolysis is management
PCI still considered if evidence on ongoing ischaemia
Mitral regurgitation post MI?
Ventricular septal defect
How to cardiovert if AF presenting within 48 hours of symptom onset?
DC cardioversion
Unless contraindicated them amiodarone
Amiodarone/flecainide contraindications?
Amiodarone- hypothyroidism
Flecainide- heart failure
Cushing’s syndrome vs Cushing’s disease
Cushing’s syndrome- adrenal adenomas
Cushing’s disease- pituitary adenoma causing excess ACTH secretion
IUS mechanism of action?
Prevents endometrial proliferation
Ankylosing spondylitis second line?
First line- oral NSAIDs
Second line- Anti-TNF- etanercept
Should urine osmolarity mirror urine osmolarity?
Yes, if they are very different there is a problem- could be SIADH or diabetes insipidus
Sodium down is SIADH, raised in diabetes insipidus
Most common cause of viral meningitis?
Enteroviruses- coxsackie virus
Acute limb threatening ischaemia investigation?
Handheld arterial doppler
Then ankle-brachial pressure index (ABI) if signs present on doppler
Positive head impulse test?
Not a stroke
DIC bloods?
Platelets- low
Prothrombin time/APTT- raised
Bleeding time- raised
ITP bloods?
Platelet count decreased
PT/APTT- normal
CML and leukocyte alkaline phosphotase?
Leukocyte alkaline phosphotase is decreased in CML
Also in CML-
Fatigue, sweats, weight loss
Splenomegaly
Do BB make myasthenia gravis worse?
Yes
Scar turning into a cancerous lesion?
SCC
Non-healing, painless ulcer
Rapidly enlarging
Bacteria responsible for acne?
Propionibacterium acnes
Prophylactic antibiotics before appendicectomy?
Yes- reduces wound infection rates
Pseudo-Cushing’s causes?
Alcohol excess/ severe depression
LArge bowel obstruction most common cause?
Colorectal cancer
Egg shell calcification of hilar nodes?
SIlicosis- upper zone fibrosis associated with mining
Secondary prevention of CVD in peripheral arterial disease?
Statin 80mg
Clopidogrel 75mg
IgG vs IgM haemolytic anaemia?
IgG- warm (Greece)
IgM- cold (Moscow)
Mycoplasma pneumoniae association?
Autoimmune haemolytic anaemia
General features of haemolytic anaemia?
Anaemia
Reticulocytosis
Low haptoglobin
Raised lactate dehydrogenase (LDH)
Blood film: spherocytes and reticulocytes
Specific featres of autoimmune harmolytic anaemia- positive direct antiglobulin test (Coombs test)
Warm AIHA treatment?
Treat any underlying disorder
Steroids (+/- rituximab)
Samter’s triad for patients with aspirin sensitivity?
Aspirin sensitivity, asthma and nasal polyps
Nail bed melanoma more likely in Afro-Caribbean?
Acral lentiginous melanoma
Legionella pneumonia antibiotic and other atypical bacteria?
Atypical bacteria (not strep, steph etc) is treated with clarithromycin/doxycycline
Give those if atypical
Inactivated vaccines?
HAIR
Hep A
IM influenza
Rabies
Pulsus paradoxus?
Abnormally large drop in BP during inspiration
Seen in tamponade
Hormonal therapy for prostate cancer?
GnRH agonists- Goserelin
Cause a testosterone flare initially then reduce to lower levels
Need to be covered with an anti-androgen when starting due to a tumour flare
Cyproterone acetate, bicalutamide
Age when following a fragility fracture a DEXA scan is not required?
Women over 75
Or if postmenopausal/ man over 50 with a vertebral fracture
Access site for PCI?
Radial artery preferred over femoral artery
Other names for Reed-Sternberg cells?
Large multinucleate cells with eosinophillic nucleoli
Mirror image nucleoli
Do you get an eosinophilia in Hodgkin’s lymphoma?
Yes
Hypothermia ECG findings?
Jeez Its Bloody Freezing
- J waves (osborne waves)
- Irregular rhythms
- Bradycardia
- First degree heart block
Avoid verapamil in which condition?
Heart failure
Also don’t give with beta-blockers
SCLC paraneoplastic syndromes?
ADH- causes SIADH- low sodium
ACTH- hypertension, hyperglycaemia, hypokalameia, alkalosis, muscle weakness
Lambert-Eaton syndrome
Driving and diabetes?
All patients on insulin must inform the DVLA
Legal to drive if hypoglycaemic awareness + 12 months no severe hypos
HPV testing process remember?
Positive hrHPV- tests for cytology first
THEN colposcopy if abnormal
If normal- repeat at 12 months
Can spinal stenosis present with unilateral leg pain?
Yes- pain improving on sitting down or crouching down
Weakness of the leg
Lack of smoking history
Lack of cardiovascular history
Periorbital vs orbital cellulitis?
In periorbital- absence of painful movements, diplopia and visual impairment
Middle loss vs peripheral loss in vision?
Middle loss- macular degeneration (can be age related)
Peripheral loss- primary glaucoma
Can you get hyperlipidaemia in nephrotic syndrome?
Yes
Remember to give VTE prophylaxis in nephrotic syndrome
Haptoglobin in haemolytic anaemias?
In haemolysis, free haemoglobin is released which then binds to haptoglobin
This means that in haemolytic anaemias haptoglobin is reduced
Most common cause of vaginal itching?
Pruritus vulvae
Irritant contact dermatitis
Other dematitits
Lichen planus
Lichen sclerosis
Psoriasis
Differentiate between L5/S1 problems?
Big toe- L5 (largest of the 5)
Little toe- S1 (smallest 1)
Where is the S1 sensory loss?
Posterolateral aspect of the leg, lateral aspect of foot
Weakness in plantar flexion of foot
Positive sciatic nerve stretch test (also positive L5)
Are relfexes in tact in L5 nerve route compression?
Yes
L3.4- knee reflex
S1, S2- ankle reflex
When to send a urine culture in female non-pregnant UTI?
Urine culture if
Aged > 65
Visible or non-visible haematuria
Rheumatic fever?
Follows an infection with Streptococcus pyogenes
Characterised by fever, rash, arthralgia and ejection systolic murmur
Rash, arthritis, murmur
Management-
Oral penicillin V
NSAIDs
Treatment of complications- HF
Major/minor criteria for rheumatic fever?
Major:
Erythema marginatum
Sydenham’s chorea- late feature
Polyarthritis
Carditis and valvulitis
Subcutaneous nodules
Minor:
Raised ESR/CRP
Pyrexia
Arthralgia
Prolonged PR interval
Live attenuated vaccines?
MI BOOTY
MMR
Intranasal influenza
BCG
Oral rotavirus
Oral polio
Typoid
Yellow fever
Which vaccines can you not give in HIV positive patients?
Live attenuated vaccines- such as BCG, MMR, intranasal influenza
How to work out SAAG?
Serum albumin - ascitic albumin
Appendicitis bloods?
Neutrophil predominant leucocytosis seen in 80-90% of people
Puberty order?
Boys- grapes, drapes, grow , blow
Girls- boobs, pubes, grow, flow
Only cranial nerve to act contralateral?
Trochlear CN4
STI + joint problems?
Could either be septic or reactive arthritis
Temperature could be the differentiator
(Gonorrhoea classically with septic, chlamydia in reactive)
What characteristics are associated with Legionella?
Lymphopenia, hyponatraemia and deranged LFTs
Hyperkalaemia ECG?
Tall-tented T waves, small P waves, widened QRS
REMEMBER VESTIBULAR NEURONITIS
Vestibular neuronitis and labyrinthitis both present after recent illnesses
Differentiated by vestibular neuronitis not being associated with hearing loss and tinnitus whereas labyrinthitis is
SLE invstigations?
99% ANA positive
Anti-dsDNA
Can monitor with ESR
Complelent levels (C3,C4) are low during active disease
Vomiting in Addison’s disease?
Potenitally take the hydrocortisone IM
If intercurrent illness hydrocortisone doubled with fludrocortisone staying the same
ORBIT?
Assessing bleeding risk in Afib from anticoagulation
O- older >75 (1point)
R- reduced Hb (2 points)
B- bleeding history (2 points)
I- insufficient renal function eGFR <60 (1point)
T- treatment with a nanti platelet agent (1 point)
Women at high risk of pre-eclampsia?
75mg aspirin from 12 weeks until the birth of the baby
L5 route compression movement problem?
Weakness in foot and big toe dorsiflexion
Reflexes intact
When can external cephalic version be performed?
For transverse lie if the amniotic sac has not ruptured
After 36 weeks
If doesn’t work caesarian
Nuclear scintigraphy reveals patchy uptake?
Toxic multinodular goitre
Thyroid gland that contains a number of autonomously functioning thyroid nodules- causes hyperthyroidism
Treatment is radioiodine therapy
Rosacea with predominant flushing but limited telangiectasia?
Brimonidine gel can be considered
Generally for rosacea:
Topical ivermectin first line
Combination of topical ivermectin + oral doxycycline for moderate-to-severe papules and/or pustules
Difference between drug-induced parkinsonism and Parkinson’s disease?
Motor symptoms are generally rapid onset and bilateral
Rigidity and rest tremor uncommon
Intestinal angina (chronic mesenteric ischaemia) triad?
Severe, colicky post-prandial abdominal pain
Weight loss
Abdominal bruit
Needing blood in acute setting?
Group and save- for if you require blood at later date, saves the blood type as reference- not for an acute setting
Crossmatch x(6) units- crossmatch allows for blood now or in the near future- for acute settings
Prothrombin complex concentrate- for the reversal of warfarin- not indicated if the patient is not on warfarin
If cannot get above a testicular swelling on examination?
Inguinal hernia
Cough impulse may be present, may be reducible
Difference between sigmoid volvulus and caecal volvulus?
Sigmoid presents with large bowel obstruction, caecal with small bowel obstruction
Sigmoid coffee bean sign
Sigmoid more common 80% of cases
Pontine haemorrhage presentation?
Reduced GCS, paralysis and bilateral pin point pupils
Pin point pupils point to pons
Investigations for Wilson’s disease?
Slit lamp examination- Kayser-Fleischer rings
Reduced serum caeruloplasmin
Reduced total serum copper
Increased 24 hour urinary copper excretion
Management: penicillamine
Keloid scar treatment?
Intra-lesional steroids
KelOID, sterOID
Aortic regurgitiation features?
Early diastolic murmur
Collapsing pulse
Quinkie’s sign- nailbed pulsation
Wide pulse pressure
De Musset’s sign- head bobbing
TRALI vs TACO?
Can differentiate TRALI from TACO
TRALI- hypotension
TACO- hypertension
Summary transfusion reactions?
Just fever- non-haemolytic febrile reaction- slow infusion and paracetamol
Just itch and urticaria- mild allergic- pause transfusion + antihistamine
Anaphylaxis- stop + adrenaline
Fever + hypotension- either acute haemolytic (abdo pain) or TRALI- stop and fluids
Hypertension, fluid overload signs (TACO)- stop infusion + furosemide
FIrst step if a patient had a urine output <0.5ml/kg/hour postoperatively?
Consider a fluid challenge- 500ml bolus
Hypovolaemia most common cause of post-operative oliguria
IgG vs IgM hepatitis serology?
IgG- chronic
IgM- acute
Can obstructive sleep apnoea cause hypertension?
Yes
Iliotibial band syndrome?
Common cause of lateral knee pain in runners
Tenderness 2-3cm above the lateral joint line
Activity modification and iliotibial band stretches
Physiotherapy referral
Vaginal candidiasis treatment?
SINGLE dose oral fluconazole
Management of alcoholic hepatitis?
Glucocorticoids
Maddrey’s discriminant function used to determine who would benefit from glucocorticoid therapy- calculated using prothrombin time and bilirubin concentration
Pentoxyphylline sometimes used
GGT characteristically raised
Ratio of AST:ALT is normally >2, a ratio of >3 is strongly suggestive of acute alcoholic hepatitis
Newborn positive heel prick for CF?
If they have a raised immunoreactive trypsinogen (IRT)
They then get a sweat test which will be high in CF
Abnormally high sweat chloride
Tear drop poikilocytes?
Myelofibrosis
Myelofibrosis?
Myeloproliferative disorder- thought to be caused by hyperplasia of abnormal megakaryocytes
Cholesteatoma?
Conductive hearing loss
Chronic smelly ear discharge with recurrent glue ear
Chronic smelly ear discharge?
Cholesteatoma
Kaposi’s sarcoma?
Caused by HHV-8 (human herpes virus 8)
Presents as purple papules or plaques on the skin or mucosa
Organophosphate insecticide poisoning treatment?
Atropine
There is features of accumulation of acetylcholine- SLUD
Salivation
Lacrimation
Urination
Defecation/diarrhoea
Other name for endometrioma?
Chocolate cyst
Rupture causes acute abdo pain and free fluid in the pelvis
Do you need to recheck for H.pylori after symptoms have resoled?
No need to check for H.pylori eradcation if symptoms have resolved
Right sided tenderness on PR exam?
Think appendicitis
Mesenteric adenitis?
Inflamed lymph nodes in the mesentery. Similar symptoms to appendicitis. Often follows recent viral infection- needs no treatment. More common in children.
When to add metformin in T1DM?
If the BMI is over 25
Can you use NSAIDs for gout in stage 4 kidney disease?
No- would have to use oral steroids if both NSAIDs and colchicine are contraindicated
Which area of the brain does Alzheimer’s disease affect?
Hippocampus in the medial temporal lobe
Sudden onset unilateral sensorineural hearing loss?
ENT emergency- same day discussion with the on call ENT specialist, along with the initiation of treatment with high dose corticosteroids- typically prednisolone
Is Meniere’s constant or episodic?
Recurrent episodes
Complication of cataracts surgery?
Endophthalmitis
Painful, red eye following cataract surgery- inflammation of the aqueous and/or vitreous humour
One of the reasons you don’t do bilateral cataract surgeries
Rocuronium vs suxamethonium method of action?
Both neuromuscular blocking rugs
Act in different ways
Rocuronium- non-depolarising, antagonist leaving fewer receptors available for acetylcholine
Suzamethonium binds to and activates the receptor first causing muscle contraction then paralysis
SALTER?
SALTER
Type 1 - S- Straight across/Slipped (growth plate)
Type 2 - A- Above (growth plate and methaphysis)
Type 3 - L- Lower (growth plate and epiphysis)
Type 4 - T- Through (metaphysis, growth plate, and epiphysis)
Type 5 - ERasure of growth plate or cRush (compression injury)
Nail changes and arthritis?
Psoriatic arthritis
Innocent murmurs?
Innocent murmurs heard in systole as blood flows rapidly, diastolic murmurs more indicitive of pathology
Venous hums- continuous blowing nous heard just below the clavicles
Still’s murmur- low-pitched sound at the lower left sternal edge
If neutropenic sepsis suspeected (recent chemo + fever)?
IV antibiotics started immediatley- not not wait for WBC count
Start Tazocin
Normal FEV1/FVC ratio in an adult?
0.7
Restrictive lung disease- normal or increased
Obstructive lung disease reduced
Osteomalacia low phosphate?
Yes, low phosphate, low calcium, raised ALP
Low vit D
Give vit D
DPP-4?
Sitagliptin
Seem to be quite ok to start as have not many side effects
In STEMI when going for PCI- Prasugrel?
Yes- give BEFORE the PCI
Clopidogrel if already on an anticoagulant
Ends up being dual antiplatelet therapy as they will already have been given aspirin
Delirium causes?
PINCH ME
Pain
Infection
Nutrition
Contipation
Hydration
Metabolism
Environmental changes
Primary vs secondary dysmenorrhoea?
Primary- no underlying pathology- pain starts at menarche- pain starts with or within a few hours of the period starting- give NSAIDs such as mefenamic acid, COCP second line
Secondary dysmenorrhoea- develops many years after the menarche- result of underlying pathology- pain typically starts 3-4 days before the onset of the period- endometriosis, adenomyosis, PID, IUDs, fibroids
Refer all patient with secondary dysmenorrhoea to gynae for investigation
Do not miss compartment syndome- tip?
Any neurovascular defecit in trauma cases- refer to an orthopedic surgeon
Key dates antenatal care timetable?
Booking visit- 8-12 weeks
Down’s screening with nuchal scan- 11-13+6 weeks
Anomaly scan- 18-20+6 weeks
Anti-D given at 28 and 34 weeks
HSP symptoms?
Palpable purpuric rash
Abdo pain
Polyarthritis
Features of IgA nephropathy- haematuria, renal failure
Treatment- analgesia
Monitor BP and urinalysis
Unilateral glue ear (otitis media with effusion)?
Refer in adult
Glue ear in children
Active observation 1st- 3 months
Grommit insertion
Adenoidectomy
Otitits media with effusion is different from acute otitis media
URTI symptoms + amoxicillin causing a rash?
?Glandular fever
Classic triad of sore throat, pyrexia, lymphadenopathy
Over what age for PMB and referral on 2ww?
55
For primary prevention of CVD, what should you aim for reduction in non-HDL?
40% reduction- if it does not reduce by 40% or more consider increasing the dose of atorvastatin to 80mg
Chronic pancreatitis?
Pain
Steatorrhoea
DM
CT pancreas
Faecal elastase can be used to assess exocrine function if imaging inconclusive
Management:
Pancreatic enzyme supplements
Analgesia
Antioxidants
When to take aspirin during pregnancy to prevent pre-eclampsia?
1 or more high risk factor
2 or more moderate risk factors
High risk factors
Hypertensive in previous pregnancy
CKD
Autoimmune: SLE/antiphospholipid
DM
Chronic HTN
Moderate RFs
First pregnancy
Age 40+
Pregnancy interval of >10 years
BMI over 35
FH pre-eclampsia
Multiple pregnancy
AS valvular gradient to consider valve replacement?
> 40mmHg
Incomplete miscarrige management if evidence of infection/increased risk of haemorrhage?
Vacuum aspiration
Ankle fracture managment?
Prompt reduction- closed reduction quickly
Can then do an ORIF- open reduction internal fixation if required
?
HINTS test outcomes?
Peripheral-
Head impulse test- abnormal
Nystagmus- none or unidirectional
Test of skew- no vertical skew
Central
Head impulse test- normal
Nystagmus- bidirectional or vertical
Test of skew- vertical skew
Syphilis is painless ulcers. what would be painful ulcers?
Herpes simplex
Lymphogranuloma venereum (LGV) is another cause of painless ulcers caused by Chlamydia, treat wit hdoxycycline
Myxoedemic coma?
Treat with thyroxine and hydrocortisone
Severe untreated hypothyroidism- obesity, non-pitting oedema, dry skin, hair loss + bradycardia, mild hypotension, hypothermia
Dermatitis herpetiformis?
Cutaneous manifestation of coeliac disease
Rhabdomyolysis way to tell from bloods?
CK is massively raised- over 10,000
Radiotherapy or surgical decompression for spinal metastases?
If fit for surgery- surgical decompression of the spinal cord
If not fit for surgery- external bean radiotherapy
Opioid in repiratory disease after surgery?
Probably avoid- epidural might be best
Increased ratio of LH:FSH?
PCOS
Inflammatory back pain vs mechanical back pain?
Inflammatory back pain not improved with rest and is improved with activity
Mechanical back pain is worse with activity and relieved by rest
Lymphogranuloma venerum?
Another flashcard as well, endemic in MSM- proctitis, ulcer and tender inguinal lymphadenopathy
ST elevation vs tall tented t waves?
Seems to be that T waves are seperate entities to the QRS
Whereas ST elevation the lot is raised
Respiratory acidosis in COPD exacerbation treatment? (type 2 respiratory failure)
Non- invasive ventilation
pH for an NG tube to be safe to use?
If the aspirate is less that 5.5
Beta-thalassaemia trait?
Mild hypochromic, microcytic anaemia- microcytosis is characteristically disproportionate to the anaemia- e.g. blood cells are much smaller but not that much anaemia
HbA2 raised > 3.5%
Renal replacement therapy (haemodialysis) indications?
Uraemia (pericarditis, encephalopathy), acidosis, pulmonary oedema, hyperkalaemia
What happens if you drain a pneumothorax too quickly?
Reexpansion pneumothorax
Anomaly scan dates?
18-20+6 weeks
Alcoholic hepatitis treatment?
Prednisolone- can use Maddrey’s formula to determine
Pentoxyphylline also sometimes used
Arterial vs venous ulcer location?
Arterial- lateral malleolus
Venous- medial malleolus
Tracheo-oesophageal fistula?
Complication of long term ventilation
Abnormal connection between the trachea and oesophagus leading to choking episodes during feeding, recurrent aspiration and pneumonia
Requires surgical correction
Imaging that can be done for acute pancreatitis?
US- looks for gallstones etc
Potentially contrast-enhanced CT
CHICKENPOX Exposure?
Any doubt about mother previously having chicken pox- check maternal varicella antibodies
Give antivirals 7-14 days post exposure
If get chickenpox- oral aciclovir within 24 hours
Prominent U wave on ECG?
Hypokalaemia
Also ST depression and T wave flattening
Sildenafil and nitrates?
Contraindicated
Another side effect if sildenafil is blue discolouration to vision
SBA rules for penile ulcers?
Painful ulcer + Painful lymph nodes in LEDC: Chancroid
Painful ulcer(s) + Painful lymph nodes: Genital Herpes
Painless ulcer + Painful lymph nodes in LEDC: LGV
Painless ulcer + Painless lymph node: Syphilis (Tropenema)
Key is multiple painful ulcers in genital herpes
Recent sore throat, rash, arthritis, murmur?
? Rheumatic fever
Treat with one off dose of IV benzylpenicillin or a course of oral penicillin V
Bloods for post-streptococcus glomerulonephritis?
Raised anti-streptolysin O titre
Pain on radial side of wrist, tenderness over radial styloid process, abduction of thumb against resistance painful?
De Quervain’s tenosynovitis
Do Finkelstein’s test- pull thumb in ulnar deviation
What counts as raised intraocular pressure?
Over 24
Which drugs should all patients be offered after MI?
Aspirin
Clopidogrel (or another needs dual anti platelet therapy)
ACEi
BB
Statin
Heart attack in which territory most likely to cause arrythmias?
Inferior
II, III and aVF
Right coronary arteries supply blood to the AV node so infarction can cause arrythmias
Hypercalcaemia?
Hypercalcaemia- Bones, stones, moans, thrones and groans
Hypocalcemia- Muscle twitching (tetany), perioral paraesthesia, prolonged QT
Hypernatraemia- Thirst + dehydration, weakness, lethargy, irritability, confusion, coma
Hyponatraemia- Anorexia, nausea & malaise (followed by) headache, irritability, confusion, weakness, decreased GCS and seizures
Hyperkalaemia- ECG changes (Tall tented T waves, small P waves, wide QRS, VF, potentially sinewave like ECG); symptoms are therefore cardiac-like (rapid pulse, chest pain, headache)
Hypokalaemia- Muscle weakness, hypotonia, ECG changes(U wave, long PR, long QT, small or absent T waves)
Spider naevi vs telangiextasia?
Spider naevi refill from the centre
Telangiectasia fill from the edge
Chronic hep B with sudden deterioration?
?Hepatocellular carinoma
Transudates vs exudates?
Transudates are systemic
Exudates are local to the lung
Pleural effusion fluid to serum protein ratio?
Pleural effusion fluid/serum protein ratio is >0.5 in an exudate
Light’s criteria
Pleural fluid protein/serum protein >0.5
Pleural fluid LDH/serum LDH >0.6
PPleural fluid LDH more than two-thirds the upper limits of normal serum LDH
SNRI monitoring?
BP as they can cause hypertension
Electrolyte disturbance with SSRIs?
Hyponatraemia
Is HIV a notifiable disease in the UK?
No it is not
Hypomagnesaemia?
Presents similar to hypocalcaemia
Can be caused by PPIs, alcohol, diarrhoea
Features-
Paraesthesia
Tetany
Seizures
Arrhythmias
Decreased PTH- hypocalcaemia
Caesarean and speed?
Cat 1- within 30 minutes
Cat 2- within 75 minutes
Cat 3- required but mother and baby stable
Cat 4- elective carsarean
Croup- what is given regardless of the severity?
A single dose of dexamethasone
AFP and HCG in seminomas?
Usually normal
Optic neuritis?
Optic neuritis = CRAP
Central scotoma, RAPD/Red desaturation, Acuity decreased, Painful eye movements
Which hepatitis are spread through the faecal oral route?
Hepatitis A and E
A and B are vaccinated
You can only get D if you have B
Ruddy complexion
Gout
Peptic ulcer disease
Pruritus after a warm bath?
Polycythaemia
Varicose veins/ chronic venous insufficiency investigation?
Venous duplex ultrasound
May demonstrate retrograde flow
Calcimimetic for hyperparathyroidism?
Cinacalcet
Paediatric constipation?
MSO
Movicol
Stimulant
Osmotic
Vestibular neuronitis treatment?
Prochlorperazine
If does not resolve symptoms- vestibular rehabilitation exercises
Primary biliary cholangitis Ms?
IgM
Anti-Mitochondrial antibodies
Middle aged females
Umbilical vs inguinal hernia in children?
Inguinal- repair ASAP
Umbilical- manage conservatively
Triad for renal cell carcinoma?
Haematuria, loin pain, abdominal mass
Is a CXR recommended for all patients with a PE?
Yes, to exclude other pathology
Most common organism in cellulitis?
Streptococcus pyogenes
Fibrocystic disease (fibroadenosis)?
Most common in middle-aged women
Lumpy breasts which may be painful
Symptoms may worsen prior to menstruation
Types of burns?
Superficial –> blanching erythema
Partial thickness (Superficial dermal) –> blisters
Partial thickness (Deep dermal) –> white; and patches of non-blanching erythema
Full thickness –> painless
Most common cause of neutropenic sepsis?
Staphylococcus epidermis
Pityriasis rosea?
Herald patch on trunk that spreads
Erythematous, oval, scaly patches
Potential recent history of viral infection
Self limiting- disappears after 6-12 weeks
Magnesium sulfate toxicity (eclampsia)?
Low RR is key
Muscle paralysis, absent reflexes
Give calcium gluconate
SBO vs LBO?
Be careful- if vomiting and no/late constipation- SBO
If constipation but no vomiting/very late vomiting- LBO
SBO- adhesions from previous surgery, hernias
LBO- malignancy, diverticulitis, volvulus
White cell casts/sterile pyuria?
Acute interstitial nephritis
Will also be an eosinophilia
Look for a cause-
Most common antibiotics- penicillin
Rifampicin
NSAIDs
Allopurinol
Furosemide
Muddy brown casts?
Acute tubular necrosis
Thumb squaring?
Osteoarthritis
Bony enlargements such as Heberden’s and Bouchard’s
Heberden’s at DIP, Bouchard’s at PIP
Does RA spare the DIPJs?
Yes
Is adenosine CI in asthmatics?
Yes verapamil is preferable
Heparins action?
Activates antithrombin III
LMWH- inhibits factor Xa
Standard does more
Most common meningitis complication?
Sensorineural hearing loss
Also:
Seizures
Focal neurological defecit
Sepsis/abscess
Raised ICP
Are varicoceles associated with infertility?
Yes
Reduced fetal movements?
Refer if not developed by 24 weeks
Initally handheld doppler
If no fetal heartbeat- immediate ultrasound
If fetal heartbeat present- CTG
Loin pain, haematuria and pyrexia of unknown origin?
?Renal cell carcinoma
Systemic onset JIA?
Pyrexia
Salmon-pink rash
Lymphadenopathy
Arthritis
Uveitis
Anorexia and weight loss
Pauciarticuar JIA-
Joint and pain swelling- medium sized joints
Limp
ANA may be positive in JIA
4 or more joints affected
Indications for urgent surgical valve replacement in infective endocarditis?
Congestive cardiac failure
Severe valvular incompetence
Hand muscle innervation?
LOAF muscles- median, all other muscles- ulnar
LOAF-
Lateral two lumbricles
Opponens pollicis
Abductor policis brevis
Flexor policis brevis
Most common type of breast cancer?
Invasive ductal carcinoma in situ
COPD LTOT?
> 7.3kPa of oxygen or
7.3-8kPa and one of-
Secondary polycythaemia
Peripheral oedema
Pulmonary hypertension
How to check for leakage after an anastomosis surgery to join the colon?
Gastrogaffin enema
Adrenaline doses?
0.5mg for anaphylaxis- 0.5ml 1:1000
Cardiac arrest 1mg- either 10ml 1:10,000
When to consider anaemia of chronic disease?
Hb low
Serum iron low
TIBC low
Ferritin riased
Normocytic or maybe microcytic anaemia
IDA would be low ferritin high TIBC
How many AKI stages?
3
Stage 1- 1.5.1.9- all the 1s
0.5 for 6
Stage 2- 2-2.9- all the 2s
0.5 for 12- another 2
Stage 3- >3x- all the 3s
0.3 for 24 hours- another 3
Breech baby investigation?
Ultrasound pelvis in every breech baby at 6 weeks
Acute pancreatitis systemic complication?
Acute respiratory distress syndrome
Second line for GAD after sertraline?
SNRI- duloxetine or venlafaxine
NOF fracture first line analgesia?
Iliofascial nerve block
Torsades de pointes ECG?
Like AM cover Arctic Monkeys
Administer magnesium
Do you give fluids for superficial epidermal burns?
No- equivalent to a sunburn etc
Give IV fluids for other burns with greater than 15% total body surface area coverage
Rubella symptoms?
Similar to measles but
Pink rash from the face
Not masses else so put when ruled out other things, some lymphadenopathy present
Morphine oral to subcutaneous?
Divide by 2
Organisms causing post splenectomy sepsis?
Streptococcus pneumoniae
Haemophilius influenzae
Meningococci
Restarting COCP?
Breastfeeding- 6 weeks post partum
Not breastfeeding- 3 weeks post partum due to VTE risk
Women only require contraception after day 21
VTE prophylaxis in pregnancy?
DOACs/warfarin contraindicated
LMWH is the treatment of choice
How to investigate AKI with an unclear cause?
Renal tract ultrasound within 24 hours
Acute vs chronic pancreatitis most common causes?
Acute- gallstones
Chronic- alcohol excess- important
Chronic pancreatitis symptoms?
Pain worse following a meal
Steatorrhoea
Diabetes mellitus- typically 20 years after symptoms begin
CT- pancreatic calcification
Functional tests- faecal elastase to assess exocrine function
Give pancreatic enzyme supplements + analgesia
What is inflammatory back pain?
Ankylosing spondylitis etc
Mechanical back pain is hurt back
Brain abscess treatment?
Ceftriaxone (3rd generation cephalosporin) and metronidazole
Seems metronidazole used in all abscesses
Ring enhancing lesions on a CT scan are characteristic of abscesses
Causes of false VDRL/RPR (syphilis tests)?
SomeTimes Mistakes Happen
SLE, TB, Malaria, HIV
Non-treponemal tests- VDRL/RPR- can give false positives
Treponemal-specific tests- TP-EIA, TPHA- specific for syphilis
Positive non-treponemal test + positive treponemal test
consistent with active syphilis infection
Positive non-treponemal test + negative treponemal test
consistent with a false-positive syphilis result e.g. due to pregnancy or SLE (see list above)
Negative non-treponemal test + positive treponemal test :
consistent with successfully treated syphilis
Adrenaline doses?
Under 6- 150
6-11- 300
12+- 500
Broad complex vs narrow complex timings?
Broad >0.12 QRS
Narrow <0.12 QRS
ARE PROPHYLACTIC ANTIBIOTICS REQUIRED BEFORE AN APPENDICECTOMY?
YES
Spontaneous bacterial peritonitis?
Form of peritonitis usually seen in patients with ascites secondary to liver cirrhosis
Features
- ascites
- abdominal pain
- fever
Diagnosis
Paracentesis- neutrophil count over 250
Most common organism is E.coli
IV cefotaxime usually given
Antibiotic prophylaxis for ascites?
Patients with fluid protein <15 and cirrhosis
Previous spontaneous bacterial peritonitis
Give ciprofloxacin for prohylacis
Subacute thyroiditis (de quervains and ESR?)
ESR Raised in hypoerthyroidism (phase 1)
Also a painful goitre
Bleeding + haemoarthroses?
Haemophilia
KEY THING TO REMEMBER ABOUT REACTIVE ARTHRITIS?
READ ALL THE OPTIONS
REMEMBER REACTIVE ARTHRITIS CAN HAPPEN WITH STIs NOT JUST STOMACH RELATED ILLNESSES
URETHRITIS, ARTHRITIS AND CONJUNCTIVITIS
Disseminated gonococcal diseae?
Tenosynovitis, migratory poly arthritis and dermatitis
Haemophilia overview?
Haemophilia A= factor 8 (A=8)
Haemophilia B= factor 9
Prolonged APTT, normal PT and bleeding time
Bleeding into joints- haemoarthroses
Post surgical or post trauma prolonged bleeding
X-linked recessive- only affects men
Investigation of choice for polycythemia vera?
JAK2 mutation
Risk for starting TNF-inhibitors?
Reactivation of TB
Do CXR before starting them
Severe UC exacerbation investigation?
Sigmoidoscopy not colonoscopy due to risk of perforation
Transfuse at what Hb?
<70
Choice of antiemetic?
Generally
Give cyclizine for everything unless the cause is
Gastric motility- metoclopramide
Chemically mediated- ondansetron
Parkinson’s disease- domperidone
Sodium valproate causes pancreatitis?
Yes
Pseudomembranous colitis?
Severe inflammation of the large intestine caused by C.difficile
Test for diagnosis and screening in HIV?
HIV p24 antigen and HIV antibody
At 4 weeks and 3 months
Genital herpes investigation?
NAAT- nucleic acid amplification tests
IS IT BIPAP OR CPAP IN COPD EXACERBATION?
BIPAP REMEMBER IT
CPAP is for sleep apnoea
7.25-7.35 BiPaP
Less then 7.25 intubate and ventilate
CKD extra medication to take?
Statin
Ecstasy poisoning electrolyte imbalance?
Hyponatraemia
Can use dantrolene
Alcohol withdrawl symptoms timeline?
Alcohol withdrawal
symptoms: 6-12 hours
seizures: 36 hours
delirium tremens: 72 hours
Causes of lithium toxicity?
Dehydration
Renal failure
Drugs: diuretics (especially thiazides), ACEi/ARB, NSAIDs and metronidazole
Lithium toxicity features?
Coarse tremor
Hyperreflexia
Polyuria
Acute confusion
Seizure
Coma
Is WBC raised in ALL?
Not necessarily because immature blasts
ITP?
Isolated thrombocytopenia
ALL can present with DIC, what are the signs of DIC?
Prolonged PT and APTT
Reduced fibrinogen
Elevated fibrin degradation products (d-dimer)
Thrombocytopenia
Also- anaemia, leukopenia
With systemic symptoms fever, fatigue, pain it raises the suspicion of ALL
ACL vs meniscus?
ACL swelling very quickly, pop heard at injury, no locking/catching, feels like it will give way
Meniscus swelling takes longer >24 hours, locking/catching, no true instability
RA joint aspiration?
Can be turbid and yellow with a high white cell count- predominatly neutrophils
Glue ear with Down’s or cleft palate?
Refer to ENT
Breast lump in under 30?
Non-urgent referral
Drug for restless legs syndrome?
Dopamine agonists- pramipexole, ropinirole
Exclude iron deficiency
Guillain-Barre management?
IV immunoglobulins
VTE prophylaxis
Extra heart sounds?
S3 threee → cannot breeeeeath → LVH or cardiomyopathy (dilated)
S4 foooour → drop on flooor → HOCM
S3 normal in under 30, S4 normal in over 40 (3 for 30, 4 for 40)
Orbital compartment syndrome?
Secondary to retrobulbar haemorrhage- true opthalmic emergency
Features- history of trauma-
Eye pain/swelling
Proptosis
Rock hard eyelids
Relevant afferent pupillary defect
Management-
Urgent lateral canthotomy to decompress the orbit- before diagnostic imaging
Blood in anterior chamber of the eye (hyphema)?
If not orbital compartment syndrome which needs immediate treatment
Urgent referral to opthalmology
Synchonised or unsynchronised shock?
Presence of a pulse
If pulse- give synchonised
If no pulse- unsynchronised
Don’t shock an unshockable rhythm such as PEA, asystole
Life threatening asthma criteria?
PEFR <33%, O2 sats <92% + CHEST
Cyanosis
Hypotension
Exhaustion
Silent chest, poor respiratory effort
Tachy/brady/arrhythmia
SBP causative organism?
Three C’s
e.Coli
Ciprofloxacin for prophylaxis
Cefotaxime IV to treat
Can you get TB after having the TB vaccine?
Yes it would seem so- it offers limited protection- it is a live attenuated vaccine- no evidence it works over the age of 35
Features of TB- haemoptysis, night sweats, fever and lymphadenopathy
Travel to high TB areas
SOB, weight loss
Hyponatraemia can be seen- TB associated with SIADH
Placental abruption management?
Fetus alive and < 36 weeks
No distress- admit and steroids
Distress- Immediate caesarean section
Fetus alive > 36 weeks
No distress- deliver vaginally
Distress- immediate caesarean
Fetus dead- vaginal delivery
Ureteric obstruction due to stone stone + infection?
Urgent decompression
Site of epistaxis?
Anterior nasal septum bleeds- more common
Posterior nasal septum bleeds- more severe
Usually an insult to Kiesselbach’s plexus
Open angle glaucoma vs closed angle glaucoma treatment?
Open angle- treat if >24 IOP
Laser trabeculoplasty first line
Prostoglandin analogue eye drops next- Latanoprost
Beta-blocker drops- timolol
Carbonic anhydrase drops- dorzolamide
Constrictive pericarditis presentation?
SOB
RHF- elevated JVP, oedema
Pericardial knock- loud S3
Kussmaul’s sign positive
CXR pericardial calcification
How long for conttraceptives to become effective?
IUD- immediate
2 days- POP
7 days- COCP, injection, implant, IUS
WHEN TO USE PROPHYLACTIC CIPROFLOXACIN FOR SBP?
IF THE SAAG IS LESS THAN 15
Amitriptyline and BPH?
Contraindicated
Hyponatremia during TURP? TURP syndrome
Caused by irrigation with glycine which is hypo-osmolar
Presents with CNS, respiratory and systemic symptoms
Latent autoimmune diabetes of adulthood vs maturity onset diabetes of the young
Latent autoimmune diabetes of adulthood- type 1 diabetes presenting later
Maturity onset diabetes of the young- type 2 diabetes presenting in younger people
Hypercalcaemia?
Painful bones, psychiatric moans, abdo groans
Uric acid levels in gout measurement?
If uric acid level over 360 it supports the diagnosis
If uric acid level <360- repeat the uric acid level measurement at least 2 weeks after the flare has settled
Synovial fluid analysis gout?
Needle shaped negatively birefringent monosodium urate crystals under polarised light
How long symptoms present to diagnose chronic fatigue syndrome?
At least 3 months
Other name for chronic fatigue syndrome?
Myalgic encephalomyelitis
TIA caused by AF?
Give a DOAC- treat the underlying cause
Start it immediately
After stroke DOAC is started after 2 weeks aspirin
If no AF after stroke use clopidogrel after 2 weeks aspirin
Same management for TIA without AF
AST:ALT ratio of 2?
Alcoholic hepatitis
AST is higher for spirits- GGT also characteristically raised
ALT is higher for lard- non-alcoholic steatohepatitis (NASH)
Glucocorticoids often used during acute episodes of alcoholic hepatitis
Sickle cell- pulmonary infiltrates?
Acute chest syndrome
Pain relief, oxygen, antibiotics, transfusion
Can nitrofurantoin cause pulmonay fibrosis?
Yes
Most common place for Crohn’s?
Ileum
Optic neuritis?
CRAP
c- central scotoma
r- red desaturation/ RAPD
a- acuity decreased
p- painful eye movement
Insulinoma or?
Could be sulfonyl urea overdose- causes increased insulin secretion from the pancreas
Type 1 vs type 4 hypersensitivity?
P4tch test: for type IV sensitivity
Pr1ck test: for type I hypersensitivity
TB treatment regime?
RIPE for first 2 months
RI for next 4 months
Latent TB is treated with 3 months of RI (with pyridoxine) or 6 months of isoniazid (with pyridoxine)
> 60 with a new onset iron-deficiency anaemia?
Urgent colorectal cancer pathway referral
FIT test and refer on 2ww for colonoscopy
FIT test for over 60 with anaemia even without iron deficiency
TIA and referral?
Within a week- specialist appointment within 24 hours
Over a week ago- specialist appointment within a week
Potential complication of panretinal photocoagulation
A decrease in night vision
Smith fracture?
Reverse colles fractures
Hand goes down
Lupus pernio?
In sarcoidosis
Similar rash to SLE but purple in colour
Sarcoidosis has a raised serum calcium
Non-falciparum malariua treatment?
Plasmodium vivax, plasmodium ovale
Artemisinin-based combination therapy (ACT) or chloroquine
Patients with ovale or vivax malaria should be given primaquine following acute treatment with chloroquine to destroy live hypnozoites and prevent relapse
Felty’s syndrome?
Splenomegaly and neutropenia in a patient with arthritis
Anaemia as well
RA + Splenomegaly + low white cell count
Wilson’s disease blood results?
Reduced serum caeruloplasmin (carries copped)
Reduced total serum copper
(although free copper increased)
Increased 24hr urinary copper excretion
Management penicillamine (chelates copper)
DDH RFs?
Fat, female, first born, foot-first, family history
Hand osteoarthritis affected joints?
CMCs and DIPJs more than the PIPJs
Heberden’s nodes at the DIP
Bouchard’s nodes at the PIP
The Levine Scale for murmurs?
Grade 1 - Very faint murmur, frequently overlooked
Grade 2 - Slight murmur
Grade 3 - Moderate murmur without palpable thrill
Grade 4 - Loud murmur with palpable thrill
Grade 5 - Very loud murmur with extremely palpable thrill. Can be heard with stethoscope edge
Grade 6 - Extremely loud murmur - can be heard without stethoscope touching the chest wall
Ascending cholangitis causative organism?
Most commonly E.Coli
When to do a pregnancy test after a medically managed miscarriage?
3 weeks after
Management of RA flares?
Corticosteroids- oral or IM
REMEMBER REACTIVE ARTHRITIS!!!!!!!!!!!!!!!! ESPECIALLY POST STI!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
DIFFERENTIATE IT FROM SEPTIC
REMEMBER- CAN’T PEE, CAN’T SEE, CAN’T CLIMB A TREE
DOAC length in PE/DVT with active cancer?
3 to 6 months (could be 6 months as an answer)
Investigation for acute cholecystitis?
Ultrasound scan
Cause of extradural haematomas?
Fracture of the pterion which is where the middle meningeal artery is located
When to rescan to see if placenta praevia has resolved?
At 32 weeks if low lying on the 20 week scan
If still present at 32 rescan ever 2 weeks
Final ultrasound at 36-37 weeks
Grades 3/4 elective caesarean at 37/38
If woman with known placenta praevia goes into labour- emergency caesarean
Brachial plexus injuries?
Erb-Duchenne paralysis- damage to C5/6 roots- winged scapula, caused by breech presentation
Klumpke’s paralysis- damage to T1, loss of intrinsic hand muscles
Due to traction
T1 bring in the thumb
Treatment of otitis externa?
Topical antibiotic or combined topical antibiotic and steroid are both first line
Second line are oral antibiotics (flucloxacillin) if the infection is spreading
If patient fails to respond to topical antibiotics then the patient should be referred to ENT
What is a FAST scan?
Focused assessment eith sonography for trauma
Can detect free fluid in the abdomen and chest
Lacunar stroke?
Involves perforating arteries around the internal capsule, thalamus and basal ganglia
Presents with 1 of the following-
Unilateral weakness of face, arm, leg or all three
Pure sensory stroke
Ataxic hemiparesis`
Gential herpes investigation?
Nucleic acid amplification tests (NAAT)
UC flare that is affecting the whole colon (extensive disease)?
Both topical and oral aminosalicylate- this is because rectal cannot help the whole of the colon so need an oral agent too
Can alcohol excess cause neuropathy?
Yes
Chronic pancreatitis and diabetes?
Can cause it although can take a while
What do patients with CKD (especially those on dialysis) have a significantly higher risk of?
Cardiovascular diseases- ischaemic heart disease
WHICH IS WORSE CRITICAL LIMB ISCHEMIA OR ACUTE LIMB ISCHEMIA?
ACUTE- THIS HAS THE 6 P’s
Pale
Pulseless
Painful
Paralysed
Paraesthetic
Perishingly cold
How to treat severe cellulitis?
Co-amoxiclav, clindamycin, cefuroxime, ceftriaxone
B symptoms and Hodgkin’s lymphoma?
Associated with a poorer prognosis
Weight loss, fever, night sweats
Hodgkin’s has Reed-Sternberg cells
Severe hepatitis in a pregnant woman?
Hepatitis E
A and E spread faecally- vowels and bowels
B, C, D spread by blood
Ureteric stones vs renal stones?
Renal stone management is the classic one learnt
Ureteric- shockwave lithotripsy +/- alpha blcokers if under 10mm
If over 10mm- uretoscopy
Aortic transection?
Tear through all walls of aorta due to trauma
May be ok for a while due to a haematoma but then sudden death
Testicular fixation surgery name?
Orchidopexy
Genital warts management?
Caused by HPV 6 & 11
Small fleshy, may bleed or itch
Management-
Topical podophyllum or cryotherapy- depends of the loaction and type of lesion
Multiple, non-keratinised are best treated topically
Solitary, keratinised warts respond better to cryotherapy
Starting long term steroid therapy?
<65 years old- DEXA scan
> 65 years old- bisphosphonate
Should all pregnanct women take vit D?
Yes
What should people with heart attack secondary to cocaine be given?
IV benzodiazapines
Cocaine toxicity treatments?
Generally benzodiazapines
Chest pain- benzos + GTN
Hypertension- benos + sodium nitroprusside
Conduction dysphasia affects which part of the brain?
Arcuate fasciculus
Where is osteomyelitis most likely to affect?
In children- minors- metaphysis
In adults- elders- epiphysis
PSC investigation?
MRCP/ERCP
Do you shock a bradycardia?
NO atropine 500 milligrams up to max of 3mg
Transcutaneous pacing
Isoprenaline/adrenaline infusion
Transvenous pacing
De Quervain’s?
Painful goitre and globally reduced uptake of iodine-131, raised ESR
Key investigation is the thyroid scintigraphy with the globally reduced uptake of iodine-131
Usually self limiting
Is dialysis ineffective at removing tricyclics?
Yes
Key investigation for diagnosing CKD?
Albumin:creatinine ratio (ACR)
Rubella distinguisher from measles?
Suboccipital and post auricular lymphadenopathy and pink rash
Chalazion vs stye (hordeolum)?
Stye painful and caused by s.aureus
Chalazion painless, sterile lymphogranuloma
Standby medication COPD?
If had an exacerbation within the last year- keep a short course of oral corticosteroids and oral antibiotics at home
Type 1 vs type 4 hypersensitivity?
Type 1 rapid- anaphylaxis- IgE
Type 4- slower no antibodies (dermatitis, scabies)
Tuberculoid leprosy?
Whitened skin lesions, nerve damage
TB risk factors potentially
Nec fasc
Type 1- mixed anaerobes and aerobes
Type 2- Strep pyogenes
SGLT-2 is a RF
Perineum most common site (Fournier’s gangrene)
Rapidly worsening cellulitis- pain out of keeping with physical features
Management- urgent surgical referral for debridement
IV antibiotics
In pregnancy of unknown location what does a bHCG of over 1500 point to?
A diagnosis of ectopic pregnancy
Beta thalassemia?
MCV low
In major- Hb very low and MCV very low, symptoms
In trait- Hb slightly low, MCV very and disproportionatley low, often asymptomatic
