Resp, Rheum, Gastro, ID Flashcards
Severe copd medication
Roflumilast = pde4 inhibitor
If FEV1<50% and >2 exacerbations in 12 months despite other meds
LTOT indications
po2 7.3-8 and one of the following:
polycythaemia
peripheral oedema (cor pulmonale)
pulmonary htn
It induces pulmonary vasodilation which improves pulmonary htn
Factors which improve copd survival
lung vol reduction surgery
stop smoking
ltot
Asthma diagnosis
feno (>50 adults, >35 child)
eosinophilia (adults only)
then once this is found then confirm with spriometry improving fev1 by 12% and 200ml or fev1 >10% predicted or if PEF variability if >20%
Complications of chest drain
surgical emphysema
post surgical reexpansion of pulmonary oedema
lung fibrosis affecting upper zones
silicosis
pneumworkers
ank spond
radiation induced
tb
allergic alveoli’s
lung fibrosis affecting lower zones
ipf
drugs
ra/sle
asbestos
xray findings of pulmonary fibrosis
patchy opacities
what type of lung cancer do you get cavitating lesions
squamous
Asbestos lung diseases
pleural plaques (benign only)
pleural thickening
asbestosis - related to length of exposure, lower lobe fibrosis (sob, clubbing, basal inspired crackles, restrictive)
mesothelioma - not related to length of exposure
remember lung cancer (not mesothelioma) is still the primary malignancy associated with asbestos
mesothelioma symptoms
sob / chest pain
dry cough
never hemopytsis
weight loss
pleural effusion
MRC scale
0 - sob only when stren ex
1 - when hurrying/walking up slight hill
2 - walks slower than most people same age or stop for breath
3 - stops for breath 100m
4 - too sob to leave house
Pneumonia vs bronchitis features
acute bronchitis has no xray changes
no focal chest signs in bronchitis but may have wheeze
no sputum, sob, wheeze normally in bronchitis
less systemic symptoms in bronchitis
Acute bronchitis mx
if crp >100 give doxy
Indication for cxr for asthma exacerbation
Indication for abg
CXR: life threatening, suspected pneumothorax, not responding to treatment
ABG: oxy <92
When to admit for asthma exacerbation
life threatening
severe if not responding to initial treatment
previous near fatal
preg
attack despite use of steroids at night
Mx for pneumothorax:
- no risks + assymp
- high risk + assymp
- no risks + symptomatic
- high risk + symptomatic
- no risks + assymp: conservative and review 2-4 days as outpatient
- high risk + assymp: monitor inpatient then follow up 2-4 weeks outpatient
- no risks + symptomatic: ambulatory device, needle aspiration, if aspiration fails then chest drain
- high risk + symptomatic : chest drain
High risk characteristics for pneumothorax
underlying lung disease
>50 + smokes
bilateral
significant hypoxia
Which lung cancer causes SIADH, cushings and Lambert eaton
SCLC
Which cancer causes hypercalcaemia, hyperthyroidism and hypertrophic pulmonary osteoarthropathy
Squamous
Which cancer causes gynaecomastia, and hypertrophic pulmonary osteoarthropathy
Adenocarcinoma
Contradindications for lung cancer surgery
Mets
Poor health
fev1<1.5
malig pleural effusion
vc paralysis
svco
Indications for NIV BIPAP in copd exacerbation
resp acidosis ph 7.25-35
t2resp failure
pul oedema
Obstructive lung disease fev1 and fvc findings and common conditions
fev1 SIGNIFICANTLY reduced
fvc reduced or normal
copd/asthma/bronchiectasis
Restrictive lung disease fev1 and fvc findings and common conditions
Fev1 reduced
FVC SIGNIFICANTLY reduced
pul fibrosis, asbestosis, sarcoidosis
Features of sarcoidosis
Erythema nodosum
Bilateral hilar lymphadenopathy seen on CXR
Arthralgia
SOB, non productive cough
Hypercalcaemia
Lupus pernio
What is TLCO and causes of raised/decreased
rate of gas diffusion from alveoli to blood
inc: asthma
dec: pul fibrosis, pneumonia, ppe, emphysema
Common features of pneumonia types:
- strep pneum
- legionella
- mycoplasma
- klebsiella
- staph aures
- strep: cold sores, rust sputum
- legionella: hyponat, deranged lfts, dec lymphocytes. Urinary ag and erythromycin
- Mycoplasma: erythema multiforme, dry cough - serum serology, doxy
- Klebsiella: alcoholics, red jelly sputum, upper lobes
- staph aures: cavitating lesion!!
What is lights criteria
if any of 1 of these then likely to be exudative:
Pleural LDH/serum LDH 0.6>
Pleural protein/serum protein >0.5
Pleural Fluid LDH >2/3 upper normal limit of serum LDH
Complication of NIV
pneumothorax
Causes of non resolving pneumonia
Complication: empyema, abscess
Host: immunocomp
Abx: indeq dose/aborption
Organism - resistant
Second diagnosis: pe, cancer
Severity of copd
1: mild: fev1 >80%
2: mod: fev1 50-79%
3: sev: 30-49%
4: v sev: <30%
Medicine for pulmonary fibrosis
pirfenidone
Medicines which can cause extrinsic allergic alveolitis
amiodarone
methotrexate
bleomycin
nitrofuratoin
penicillamine
cyclophosphamide
Symptoms of osteomalacia
Bone pain
Bone tenderness
Proximal myopathy
Waddling gait
Inc ALP
Causes of osteomalacia
Vit D deficiency
CKD
Antiepileptics
Liver cirrhosis
Coeliac
Malignant bone tumours:
- osteosarcoma
- ewings sarcoma
- chondrosarcoma
- osteosarcoma: most common esp in children. Occurs in long bones. Xray shows conman triangle + sunburst appearance
- ewings sarcoma: most in children. Occurs in pelvis and long bones. Xray shows onion skin appearance.
- chondrosarcoma: tumour of cartilage, in middle aged.
Feltys syndrome
RA
Splenomegaly
Neutropenia
Extra articular manifestations of rheumatoid arthritis
A- anaemia, amyloidosis, arteritis
C- cord compression, cvs disease, carpal tunnel syndrome
P- pericarditis, pleural disease, pulmonary disease
S- sjogrens, scleritis, splenomegaly
Poor prognostic factors of RA
- presence of anti ccp/ rf
- poor functional status when presenting
- sudden onset
Symptoms of psoriatic arthritis
Assymmetrical dactylitis esp DIPJs
Enthesitis
Sacroilitis
Psoriatic plaques
Nail pitting/onchylosis
Arthritis mutilans
Risk factors for pseudo gout
Haemochromatosis
Hyperparathyrodisim
Low Mg/Pi
Acromegaly
Wilsons
Osteomyelitis with someone with sickle cell causative organism
salmonella
Ehlers Danlos vs Marfans
Both autosomal dominant
Marfans is a fibrillen defect. Causes tall, high arched palate, arachnodactyl, scoliosis, aortic aneurysm (so needs regular echo), blue sclera
Ehlers Danlos is type 3 collagen affected. Causes fragile skin, recurrent joint dislocation, easy bruising, aortic regurgitation, SAH, retinal haemorrhages
What cancer does sjogrens increase the risk of
NHL
Pseudogout vs gout crystals
Gout: - bifringent monosodium urate
Pseudogout: + bifringent pyrophosphate crystals
Organism causes of reactive arthritis
Salmonella
Shigella
Campylobacter
Chlamydia
When to skip DEXA scan and go straight to bisphosphonates
Vertebral fracture
On steroids + ( >65 or previous fragility fracture)
>75 + fragility fracture
Features of ankylosing spondylitis
Anterior uveitis
Apical lung fibrosis
Aortic reorg
AV block
Amyloidosis
Achilles tendonitis
Most common xray feature of ankylosing spondylitis
Sacroilitis
What causes anterior ischaemic optic neuropathy in GCA
Occlusion of posterior ciliary artery
Features of polymyositis
Proximal muscle weakness
Respiratory muscle weakness / ILD
Dysphagia
Dysphonia
Raynauds
Inc CK
Anti Jo + mi2
Malignancies associated with polymyositis
Lung
Breast
Ovarian
Gastric
Features of stills disease
Arthralgia
Salmon pink maculopapular rash
Pyrexia worse in afternoon
Lymphadenopathy
Inc ferritin
Diagnosis of exclusion when RF/CCP ruled out
Raynauds syndrome vs phenomenon
Syndrome: idiopathic
Isolated ALP rise in person with bone pain +/- cranial nerve deficits
Pagets (disease of excessive clast + blast so uncontrolled bone turnover)
Xray findings for pagets
Osteolyisis
Lytic lesions
Thickened skull
Bossing of skull
Bowing of tibia
Rash on soles/palms in reactive arthritis
Keratoderma blenorrhagica
Skin features of dermatomyositis
Photosensitivity
Macular rash on back/shoulder
Heliotrope rash in periorbital region
Grottens papules on extensor surfaces
Dry + scaly hands with plaques
Causes of stridor in post thyroidectomy
Haematoma in pre tracheal fascia
Recurrent laryngeal nerve damage
Removal parathyroid = hypocalc = laryngospasm
PSC vs PBC
PSC: intrahepatic and extrhepatic bile ducts become fibrotic so less bile leaves liver leading to liver inflammation and cirrhosis
PBC: interlobular bile duct inflammation in liver causing cholestasis and back pressure into liver leading to dec exretion of cholesterol/bile acids/bilirubin leading to inflammation hence liver cirrhosis
Features of PSC
RUQ pain
Fatigue
Cholestasis: jaundice, pruritus, inc ALP/bilirubin
Liver cirrhosis
Ix for PSC
MRCP
pANCA +
Cholestyramine
Gene associated with coeliac
HLADQ2
Biopsy findings for coeliac
villous atrophy
crypt hyperplasia
intraepithelial lymphocytes
infiltration of lymphocytes in lamina propria
Urgent 2ww OGD criteria
Dysphagia
Upper abdo mass
>55 + weight loss + dyspepsia
Features of acute liver failure
RUQ pain
Jaundice
Hepatic encephalopathy
Hepatorenal syndrome
Inc INR
Hypoalbuminaemia
Action of terlipressin
ADH analogue causing splanchnic vasoconstriction hence inc BP
Grades for hepatic encephalopathy
- irritable, constructional apraxia, reversed sleep cycle, poor memory
- confused, lethargic, asterix
- drowsy, incoherent
- coma
Mx for hepatic encephalopathy
lactulose
rifaximin prophylaxis
When to recheck urea breath test
If still symptoms
Features of haemochromatosis
Arthralgia
Fatigue
Erectile dysfunction
Bronze appearance
Liver cirrhosis
Inc ferritin + transferrin, dec TIBC
What is achalasia
Failure of oesophageal peristalsis and relaxation of LOS
Ix and Mx of achalasia
Ix: oesophageal manometry (excessive LOS tone), barium swallow (bird peak - dilated oesophagus), cxr (widened mediastinum)
Mx: pneumatic balloon dilatation, Heller cardiomyotomy, botulin injection to sphincter
What cancers associated with hepatitis
b and c
Features of autoimmune hepatitis
Liver cirrhosis
Acute hepatitis
Amenorrhoea
ANA/SMA/LKM1 ab
Liver biopsy shows necrosis
ALT, ALP, ALT: ALP in paracetamol overdose
High ALT, low ALP, high ALT: ALP
Features of Wilsons disease
liver cirrhosis
neuropsychiatric + speech
Excessive salivation
Kayser Fleischer rings
RTA
Blue nails
Inc Cu and dec ceruloplasmin
Alcoholic liver diseasee LFTS
Inc yGT
High AST:ALT
Ascites SAAG levels <11 vs >11 causes
> 11 means portal htn so liver cirrhosis, liver mets, RVH, Budd chairi
<11 means hypo albumin so peritoneal malignancy, pancreatitis, bowel obstruction
What is Budd chiari
Hepatic vein thrombosis where inc risk of polycythemia vera, pregnancy, thrombophilia and COCP
Budd chiari symptoms
sudden onset severe abdo pain
ascites
hepatomegaly
Features of PBC
Middle aged woman with abdo pain
Inc bile acids: steatorrhoea, pruritus
Inc bilirubin: jaundice
Inc cholesterol: xanthalasma
liver cirrhosis end stage
rule of m’s!! Middle aged, igM, Mitrochondrial ab
Ix + mx for PBC
Lfts cholestatic (inc alP/bili)
AMA antimitrochondrial ab
IgM
Liver biopsy diagnostic
Ursodeoxycholic acid, colestyramine, fat soluble vitamins, liver transplant
Associations of PSC vs PBC
PSC: UC, cholangiocarcinoma, cirrhosis, strictures
PBC: sjogrens, RA, hypothyroidism, hepatocellular carcinoma
Complications of liver cirrhosis
Hepatorenal syndrome
Encephalopathy
SBP
Malnutrition
Varices
Symptoms and signs of liver cirrhosis
Confusion
Bruising
Pruritus
Fatigue
Weight loss
Asterixis
Jaundice
Hepatomegaly
Ascites
Palmar erythema
Spider naevi
Gynaecomastia
Caput medusa
HIV + diarrhoea only - causative organism
cryptosporidium parvum (if not started on antiretroviral therapy then this should resolve)
Features and mx of campylobacter
Prodrome fever/headache
Abdo pain (mimics appendicitis)
Bloody diarrhoea
Clarithromycin if immunocompromised
Most common organism causes of acute food poisoning
staph aures
bacillus cereus esp if rice
clostridium perfringens
Abx for cellulitis if
1. allergy to penicillin
2. on face
3. pregnant
- clarithromycin
- coamoxiclav
- erythromycin
Combination test for HIV
p24 ag and HIV antibody test
(4th generation hiv test)
AIDS defining illnesses (CD4<300)
kaposis sarcoma (hhv8, brown spots + resp issues)
tb
cervical lymphoma (ebv, single lesion on ct)
CMV
Pneumocystitis jirovecci pneumonia (dry cough, desaturated on exercise, pneumothorax, hepatomegaly - cotrimazole if CD4 <200)
Cryptosporidium (diarrhoea only)
Oesophageal candidiasis
Toxoplasmosis (ring enhancing lesions on CT - needs pyrimethamine and sulphadiazine (remember if no HIV no treatment)
Hairy leukoplakia
Contact with HepB patient mx
If responded to vaccine just booster
If haven’t responded to vaccine then booster + hep bh immune globulin
Mx of tetanus prone wound
If <10 years since vaccine just debridement
If >10 years, tetanus booster vaccine, if high risk wound also tetanus Ig
Gold standard Ix and Mx for typhoid fever
Ix: stool culture
Mx: IV ceftriaxone, need 3 neg cultures before work
Definition of pyrexia of unknown origin
> 38C
ill for >3 weeks
1 week inpatient ix
think infection (tb/endocarditis), malig, autoimmune
Causative organism of dengue fever
arbovirus (flavivirus)
Features of dengue fever
Sudden onset fever
Severe myalgia
Retro-orbital headache
Pleuritic chest pain
Maculopapular rash 5 days post fever
Features of HepC
Initial transient rise in ALT/jaundice
Fatigue
Arthralgia
Then 80% go on to develop chronic cirrhosis
HCV ag +
Responds well to antivirals
Hepatocellular carcinoma big complication
What to do if hep b + pregnant
babies born need complete course of vaccination + hepbIg
Is there inc risk of hepatocellular cancer in HepA
No
Most common hep in world via faecal oral. RNA. IgM ab.
Which type of hepatitis is only DNA virus
HepB
Features of allergic bronchopulmonary aspergillosis
bronchiectasis
eosinophilia
inc igE
sputum: eosinophils + fungal hyphae
needs steroids
Features of lymes disease
borrelia burgdorferi
erythema migraines
headache
fatigue
arthralgia
heart block
facial nerve palsy
Needs doxycycline
Mx of alcoholic ketoacidosis
iv thiamine and 0.9% nacl
Prophylactic abx if ascites + low ascitic fluid protein <15
oral ciprofloxacin
What kind of pulmonary fibrosis in ankylosing spondylitis
apical fibrosis
Why is clubbing a bad sign in COPD
Don’t get clubbing in COPD, think cancer!!
How long do u need symptoms to have chronic fatigue syndrome diagnosis
3 months
Borders for chest drain
Base of axilla, lateral pectoralis major, 5th intercostal space, anterior latissimus dorsi
Best marker for assessing function of liver
prothrombin time
Features of diphtheria
grey pharynx /tonsils
sore throat
fever
complete heart block
needs IM penicillin
Mx legionella pneumonia
erythromycin
What is a parapnuemonic effusion
pleural effusion for pneumonia
Organism causes of lung abscess
aures
kleb
pseudo
How to know if COPD patient is retainer
inc pco2
normal ph
high bicarb
Fat embolism triad
petechial rash
sob
confusion
Hypertrophic pulmonary osteoarthropathy
clubbing
arthralgia
periostea new bone formation
Example of a SAMA, LABA, LAMA
SAMA: ipratropium
LABA: formeterol
LAMA: tiotropium
Signs of severe c diff infection
WCC > 15 * 10 9/L
a significant rise in creatinine
hypotension
ileus
toxic megacolon
Lymphoma associated with H pylori
B cell MALT lymphoma
Lymphoma associated with coeliac
enteropathy T cell associated lymphoma
Prophylactic abx for ascites
oral cipro
Ix for liver cirrhosis
fbc (thrombocytopenia)
lfts (dec albumin)
clotting (inc inr)
liver screen (Ama/sma, caerulop, hep b/c, iron studies)
uss (nodules, ascites, enlarged portal vein)
fibroscan
endoscopy every 3 years
afp every 6 months
Abx choice if allergic to penicillin + bite
doxy + metron
Do you give abx for pyrexia unknown origin
no
Symptoms of typhoid fever
fever
malaise
abdo pain
constip/diarr
dry cough
rose spots
bradycardia
hepatosplenomegaly
LP findings for meningitis
bacterial: dec glucose, inc protein
viral: dec protein
tb: dec glucose, inc protein
Features diphtheria
grey mucus membrane
cervical lymphadenopathy
heart block
needs IM penicillin + antitoxin
xray findings for psoriatic arthritis
periarticular erosions
bone resorption
pencil cup (central joint erosions)
hypersensitivity type of sle
3
B cells
