Revision Flashcards
when should you never prescribe the combined oral contraceptive pill
FHx of thrombophilia
when should you never prescribe doxycycline
if patient< 12
what condition should you consider before prescribing furosemide
gout
what condition should you consider before prescribing an NSAID
hypertension
what should you consider before considering prochlorperazine
if patient pregnant
when should you not prescribe naproxen
if patient on warfarin- increased risk of GI bleeding
when in pregnancy is trimethoprim contraindicated
first trimester- folate antagonist
what antibiotic is first line for UTI in pregnancy
nitrofuratoin
give examples drugs you should monitor (4)
ACEi (BP, renal function, electrolytes)
warfarin
DMARDs
chemotherapy
how long is exclusive breastfeeding recommended for
first 6 months
what supplements should babies get
vit d from birth (not if on formula)
vit A,C and D from 6 months
what BMI decile would mean a child is overweight
> 91st
98th obese
99.6th clinically obese
what is the treatment for a baby with a suspected cows milk intolerance
2-4week lactose exclusion with extensively hydrolysed infant formula followed by a reintroduction of cows milk (if symptoms return then confirms diagnosis)
what condition is dermatitis herpetiformis associated with
coeliac disease
what percentage weight loss is recommended for BMIs of 25-35
5-10%
>35 15-20%
what does an insulin ratio mean
insulin to carb
e.g. 1:10 will need 1 unit for 10g of CHO
should T1DM patients carb count alcohol
no as increased risk of hypo following consumption of alcohol
does high fibre reduce CVD risk
yes
how does fibre reduce colon cancer risk
fibre fermentation creates short chain fatty acids which have anti-proliferative effect
what GI condition can exclusive enteral nutrition induce remission
crohns disease in paediatric patient
what is parenteral nutrition
the provision of all nutrients, fluids and electrolytes directly into a central or peripheral vein (indicated for an inadequate or unsafe oral and/or enteral nutritional intake or a no functional inaccessible or perforated GI tract.
what are the red flags for spinal pain
thoracic pain fever and unexpected weight loss bladder of bowel dysfunction ill health/ presence of other medical illness progressive neurological deficit disturbed gait, saddle anaesthesia age of onset <20 or >55
what are the yellow flags of pain
psychosocial factors shown to be indicative of long term chronicity and disability (predictors of response to treatment)
- negative attitude that back pain is harmful or potentially severely disabling
- fear avoidance behaviour and reduced activity levels
- expectation that passive treatment will be beneficial rather than active treatment
- tendency to depression, low morale, and social withdrawal
- social or financial problems
- compensation issues
what are the reds flags for cauda equina
bilateral sciatica
severe/ progressive neurological deficit of the legs (major weakness)
difficulty initiating micturition or impaired sensation of urinary flow- may lead to irreversible retention with overflow incontinence
loss of sensation of rectal fullness- may lead to reversible faecal incontinence
perianal, perineal or genital sensory loss (saddle anaesthesia/ paraesthesia)
laxity of anal sphincter
what are the red flags for a spinal fracture
sudden onset severe central spinal pain which is relieved by lying down
Hx of trauma/ strenuous lifting in people with osteoporosis/ corticosteroid users
structural deformity
point tenderness
what are the red flags for cancer associated spinal pain
> 55y/o
gradual onset of symptoms
severe unremitting paint hat remains when supine, aching night pain that prevents/ disturbs sleep and aggravated by straining
thoracic pain
localised tenderness
no symptomatic improvement after four-six weeks of conservative low back pain therapy
unexplained weight loss
PHx of cancer (esp breast, lung, prostate, GI, renal, thryoid)
what are the red flags for infection associated back pain
fever TB recent UTI diabetes Hv of IVDU HIV infection immunosuppressants
what are the trigger words for neuropathic pain
shooting numb stabbing electric feel pain tingling burning traditional pain killers don't help emotional impact
what is anticholinergic syndrome
when antocholinergic drugs (e.g. amitriptyline) blocks M3 muscarinic receptors (parasympathic nervous system) causing anorexia, blurry vision, constipation/ confusion, dry mouth, sedation/ stasis of urine, drowsiness and QT prolongation
what dosing technique should you use with anticholinergic drugs
start low go slow and be aware of side effects
dont use post MI or in the manic stage of BPAD
when is creatine most effective in showing kidney function
when patient underweight or elderly
what BP medication can cause a cough
ACEi (e.g. lisinopril- increases bradykinin levels)
name a side effect of amlodipine
ankle swelling
what is edoxaban
anti-coagulant: inhibits factor 10a
prescribed based on patient weight
what is a coagulopathy
tendency to bleed due to inability to coagulate blood
doacs vs warfarin go
doacs cause less major bleeds, dont need monitoring and have faster onset
but cant be reversed unlike warfarin (vit K) and cant be given to patients with mechanical heart valves
name the doacs
dabigatran
apixaban
edoxaban
rivoroxaban
what is leucopenia
reduction in leukocytes (WBC)
what happens when steroids are stopped too quickly
adrenal insufficiency/ crisis
how is gentamicin given
IV only
how could you clinically differentiate intracranial heamorrhages
subdural- subclinical, slow deterioration
extradural- lucid period, quick deterioration
subarachnoid- thunderclap headache
treatment pathway asthma
SABA as required
consider low dose ICS to diagnose- if helps symptoms prescribe as regular
if >3 times a week use of SABA or disturbing sleep add in LABA to ICS and SABA
increase ICS or add LTRA
when should you do peak flow
3-4x a day to look for diurnal variation, low value usually in morning, cough at night
can you give SAMA and LAMA at the same time
no
how many puff of salbutamol should you take in suspected asthma attack
10
what does PRHrP released by Sqclc cause
hypercalcaemia with normal PTH
what can pancoast tumour cause
SVC syndrome, horners, vocal cord palsy (recurrent larhyngeal nerve)
how long should you give DOACs in DVTS
provoked- 3 months
unprovoked 6 months
more than 2 unprovoked lifelong
if renal impairement give LMWH
what scoring system for DVT and PE
wells score (>2 DVT >4 PE)
Tx for PE
calculate wells score (if <4 do d dimer, if +ve immediate CTPA)
if >4 admit for CTPA with interim DOAC if needed
if unstable unfractionated heparin and thrombolysis (alteplase/ streptokinase)
if stable CTPA and DOAC
continue anticoagulation for at least 3 months (DOAC)
what are the features of horners
anhidrosis
ptosis
miosis
what is in the paediatric sepsis 6
give high flow oxygen
obtain IV or IO access for: blood cultures, blood glucose (treat if low), blood lactate/ gas
give IV/IO abx
if shocked
fluid resus
consider early inotropic support
involve seniors early
how should you start child CPR
5 rescue breaths then 15 to 2
what drugs do you stop in AKIs
nephrotoxics- ACEi, ARBs, NSAIDs, aminoglycosides (gent, -micins)
drugs that increase comps: duiretics, metformin, anti-hypertensives
what are the indications for anticoagulants
venous thrombosis, AF, prophylaxis
what factors is def the haemophilias
a- 8
b- 9
what does APPT measure and what raises it
intrinsic system (8+9) raised in heparin, haemophilias, DIC and liver dissease
what does PT measure and what raises it
extrinsic (2,7)
measured as INR (0.9-1.2)
raised by warfarin, vit k def, liver disease and DIC
what is the anticoagulation after DVT or PE
offer apixaban or rivaroxaban for at least 3 months
if provoking factor no longer presence can stop after 3
if active cancer 6 months
if unprovoked or risk factors remain then calculate has bled score (stop anticoag if >4) and chadvasc score if risk of stroke to decide on lifelong anticoagulation
what drugs should be stopped before surgery
acei, arbs
nsaids,
warfarin 5 days before (INR<1.5)
DOACS- 24hrs if low risk, 48hrs if high bleeding- dont stop if op no bleeding risk)
all diabetic meds (except long acting insulin)
contraceptive pill and HRT if major op
what antiemetics are best post op
5HT3 receptor antagonists (odansetron)
dexamethasone, prochlorperazine
Cyclizine for opioid nausea
what antiemetic is best for chemo
ondansetron
dexamethasone
what antiemetics for motion sickness
cyclizine
hyoscine hydobromide
promethazine (sedating)
what are mild opioids
codeine
dihydrocodeine
what are strong opioids
morphine
oxycodone
what score for DVT
wells (calculate before doing dimer)
if 2 or more DVT likely do USS then d dimer if that is negative. if cant to USS in 4 hours do d dimer then intermin coagulation.
if d dimer +ve scan negative stop any interim coag and repeat USS in a week
if wells score 1 or less DVT unlikely do a d dimer, if thats +ve do USS
what score for PE
wells
>4 PE likely do CTPA, if CI offer anticoagulation
if 4 or less do d dimer, if positive do CTPA
what anticoagulation for DVT and PE
apixaban or rivaroxaban
if APS or renal impairment LMWH
what is acute cholecystitis
impaction of stone in neck of gallbladder
continuous RUQ/ epigastric pain, fever, vomiting, murphys sign positive
what causes biliary colic, how is it different to acute cholecystitis
cause by stone in cystic duct or common bile duct
doesnt have inflammatory component to cholecystitis (local peritonism, fever, increased WCC)
what are the features of chronic cholecystitis
chronic inflammation + colic
flatulent dyspepsia, nausea, distension, fat intolerance
treatment- cholecystectomy
what is ascending cholangitis
infection of bile duct
what are the features of ascending cholangitis
RUQ, fever and jaundice
rigors
tx- piperacillin, tazobactm
when is ERCP used
common bile duct clearance- stone in CBD
when should you consider antibiotics in sinusitis
when symptoms lasting for >10 days or symptoms of bacterial infection (purulent discharge, severe pain, fever) or systemically unwell
what is the centor criteria
tonsilitis: 3 or more bacterial fever anterior cervincal tender nodes no cough tonsilar exudates
what are the urgent referalls for red eye
acute closed angle glaucoma
anterior uvetitis
scleritis
acute iritis
what causes of red eye also cause decreased visual acuity
acute glaucoma
anterior uveitis
what cause of red eye causes painful eye movements
scleritis
what is the pupil like in anterior uveitis
small, may have synechiae which distort pupil via adhesions
how do you diagnose ant uveitis
slit lamp- leukocytes in anterior chamber
what is the uvea
iris, cillary body, choroid
what is the eye like in acute angle closure glaucoma
hard, fixed dilated pupil, hazy cornea
what is the treatment for acute angle closed glaucoma
urgent referal, avoid darkness (dilates pupil more)
beta blocker (timolol) - decreases aqeous production
pilocarpine- constricts pupil, opens angle
IV acetazolamide- decreases aqueous production
analgesia, antiemetic
once IOP controlled peripheral iridectomy
treatment for herpes simplex corneal ulcer
aciclovir (NOT steroids as this causes full thickness involvement)
treatment for GCA
40mg
if visual involvement 60mg pred
tapered over a year,
what is the treatment for optic neuritis
high dose methylpred for 72 hours then pred for 11 days
white retina W/ cherry red spot=?
central retinal artery occlusion
tx for crao
occular massage, surgical removal of aqueous, treat RF
signs of CRVO
dot and flame haemorrhages
cotton wool spots
macular oedema
swelling of optic disc
treatment for open angle glaucoma
prostaglandins, pilocapine, sympathetmetics, trabeculoplasty: latanoprost increase outflow
beta blockers, alpha adrenergics (-nidine), carbonic anhydrase (azetazolamide)- decrease aqueous production
normal IOP
<21
what biochemical signs does pagets have
isolated rise of ALP
treatment for psoriasis
potent steroid + vit d once daily 4 weeks
vit d twice daily 8-12 weeks
potent steroid + vit d 2x daily/ coal tar
v potent
dithranol, phototherapy (PUVA), systemic tx (methotrexate, ciclosporin, acritrenin (oral retinoid), biologics)
(if face, flexures or genitals use mild-mod steroid)
list steroids mild to mod
hydrocortisone
betnovate
dermovate
acne treatment
mild: topical retinoid (adapalene, tretinoin) or BP or clindamycin
mod: combo of 2 of above, oral abx (doxy, tetra, erythrcycline) with topical BP
severe: isotretoin
treatment for rosacea
avoid sun and alcohol, soap substitutes
mild- topical metronidazole or azelaic acid
mod to severe: oral tetra- doxycycline, isotretinoin
lasers
what laxative for hard stools
osmotic- lactulose, laxido
softeners- docusate
what laxatives for stimulant issue
senna
what can be used to reduce ammonia is hepatic encephaopathy
lactulose
how do you take bisphosphonates
on empty stomach, sit up for thirty minutes
convert 40mg of oxycodone to morphine
80mg morphine
oxycodone is 2 times as potent as morphine, need to divide the daily dose of morphine by 2 to get oxycodone dose
daily dose of 120mg morphine, how much is breakthrough dose
20mg
breakthrough dose is 1/6th daily dose
what type of infusion is a syringe driver
subcut
500mg of morphine oral, covert this to subcut morphine
250mg
divide oral doses by 2 to get subcut doses
what electrolyte abnormality do PPIs cause
hyponatraemia
what should you prescribe is someone who is diabetic with proteinuria
ACEi
anticholinergic side effects
constipation, dry mouth, dry eyes, blurred vision, urinary retention, tachycardia, cog impairment, falls
examples of anticholinergic drugs
oxybutin, ipatopium, tolteridine, amitriptyline
what electrolyte imbalance can thiazides cause
hyponatraemia
what electrolyte imbalance can SSRIs cause
hyponatraemia
what drugs for acute confusion
haloperidol
if alcohol withdrawal benzos long acting: chlordiazepoxide
how long is an emergency detention and who can authorise it
72 hrs
fy2 and above
does not authorise tx, no right of appeal
how long is a short term detention, what does it allow and who can do it
28 days
assessment and treatment
approved mental practitioner and MHO
right of appeal
how long is a compulsory treatment order, what does it allow and who can authorise it
6 months
one medical practitioner, one MHO then report from 2 independent doctors (2x AMP or AMP + GP) who make care plan
mandatory tribunal
reviewed at 6 months, right to appeal
what does bronchial breathing suggest
consolidation or fibrosis
what electrolyte abnormalities happen in refeeding syndrome
hypophosphataemia (rhabdomyolysis, leucocyte dysfunction, respiratory failure, cardiac failure, hypotension, arrhythmias, seizures, coma, and sudden death)
hypomagnesium and hypopotassium
what order should you replace calcium and phosphate
and magnesium and potassium
replace calcium before phosphate (or will cause hypocalcaemia)
replace magnesium before potassium as potassium needs calcium to go up
what is HHS
hyperosmolar hyperglycaemic state
happens in type 2
presents with polydipsia, polyuria, dry, shock, acute cos impairment
hyperglycaemia, hyper serum osmolality, volume depletion
NO KETOACIDOSIS
treatment for HHS
IV fluids with potassium replacement
insulin
thromboprophylaxis
treatment for alzheimers
anticholinesterase inhibitors: donepezil, rivastigamine, galantamine
memantine (NMDA antagonist) in late stage
antipsychotics
what medications for incontinence should you avoid in eldery
tolterodine and oxybutin
use mirabegron
management for parkinsons
avoid levodopa as long as possible
DA ropinirole and pramipexole
antichoingerics in young, MAO-B inhibitors (-giline)
levodopa- given as co-beneldopa or co-careldopa to prevent nause and vomiting
what are the signs of spinal cord compression
pain: in spine, worse on straining, radicular (band like burning e.g. around rib cage, precedes weakness)
weakness: bi or unilateral
altered sensation: proprioception, light tough
urinary problems: retention
bowel problems: constipation
Ix for Spinal cord compression
urgent MRI of spine
Treatment for spinal cord compression
16mg IV dexamethaxone, followed by 8mg po bd (to reduce vasogenic oedema)
radiotherapy mainstay of tx
surgery if appropriate
chemo
if you suspect spinal cord compression what should you do
arrange urgent MRI and start dexamethasone 8mg bd
radicular pain= ?
cord compression
symptoms of superior vena cava obstruction
swelling of face, neck, one or both arms distended veins SOB HA lethargy late- injected conjunctiva, sedation
Ix for SVC obstruction
cxr- is there a mass/ foreign body
venogram- is there a clot
CT chest
treatment for SVC obstruction
clot- thrombolysis with alteplase, anticoagulation (LMWH, warfarin)
extrinsic compression- steroids, chemo, radio, stent
what side of lung tumour causes SVC obstruction
right
what can cause hypercalcaemia in cancer pt
humoural (PTHrP)
bone destruction
tumour production of vit D (lymphomas)
symptoms of hypercalcaemia
nausea, anorexia thirsty polydipsia, polyuria constipated confused poor concentration, drowsy
Ix for hypercalcaemia
U+Es to look for dehydration
phosphate (low in hyperparathryoidism)
if no known malignancy myeloma screen
ts for hypercalcaemia
rehydrate first - several L of saline
bisphosphonates (pamidronate after rehydrated)
symptoms + signs of cardiac tamponade
SOB
fatigue, palpitations, pericarditis (chest pain improved by sitting forward), symptoms of advanced cancer
JVP distention, pulsus paradoxus (fall in pressure during inspiration), soft heart sounds/ pericardial rub, tachycardia with low BP
IX for tamponade
CXR
ECG
echo (rim of pericardial fluid)
cytology of fluid
tx for tamponade
pericadiocentesis
pericardial window
does perciardial tamponade cause systolic or diastolic heart failure
diastolic
what is neutropenic sepsis
sepsis in a patient with a neutrophil count less than 0.5 or <1 in cancer patients or who have had chemo in the last 21 days
tx for neutropenic sepsis
antibiotics within 1 hr of admission
give immediately before septic screen/ blood tests
what is CO2 like in a PE
low (blowing it off with tachypnoea)
Ix for Pe
CTPA ABGs O2 sats ECG bloods
tx for PE in malignancy
LWMH for 6 months
consider rivaroaban if recurrent DVTs/PE
what is 8/500 co-codamol
8mg codeine with 500 mg paracetamol
100mg of codeine = ? morphine
10
morphine is 10 times as strong as codeine
what is the pain ladder
mild- paracetamol
mod- co-codamol 30/500, dihydrocodeine, tramadol
severe- morphine, diamorphine, oxycodone, hydromorphine, methadone
adjuvants: NSAIDs, TCAs, anticonvulsants. steroids, anxiolytics, muscle relaxants, antimuscarinics
what should you prescribe with opioid
anti-emetic and laxative
what drugs can be used as muscle relaxants
diazepam, baclofen
what drugs can be used as antimuscarinics (for colicky pain)
hyoscine butylbromide
how do you convert oral tramadol dose to oral morphine dose
divide tramadol dose by 10
how do you convert oral morphine to SC diamorphine
divide by 3
what are the anticipatory care medications
Opioid for pain and/or breathlessness: morphine 2mg SC
anxiolytic or sedative for anxiety, agitation or breathlessness: midazolam 2mg sc
anti-secretory medications for resp secretions: hyoscine butylbromide 20mg sc
anti-emetic for n+v: levomepromazine 2.5-5mg sc
what are the dexa results meaning
t scores
1- -1 normal
-1 to -2.5 osteopenia
-2.5 or less osteoporosis
talk me through the bone protection guidelines girly xx
calculate Qfracture/frax score (10 year risk of fragility fracture) for all high risk (>65 women, >75 men, RFs)
if score 10% or more do DEXA
if -1 to -2.5 modify risk factors
if less than -2,5 bone protection (once weeklr bisphosphonate)
consider bone protection in those taking steroids
offer HRT to young post menopausal women
rank these from least to most potent:
methyl pred, betamethason, hyrocortisone, cortisone, prednisolone, dexamethasone
cortisone, hydrocortisone, methyl pred, pred, dex
what drug first line for delirium
haloperidol
benzos if have PD
what can be used to treat acute pulmonary oedema
high flow oxygen
IV furosemide
IV diamorphine (vasodiltor, reduces CO)
digoxin
what is a modified release preparation
12 hourly tablets
who should adenosine not be given to
asthmatics
what are the signs of brugada syndrome on ECG
st change - coved/ saddle
which brain bleed has a period of lucidity
extradural lemon shaped (lens shaped), MMA, associated with skull fractures, young men, LOC following lucidity after injury
who gets subdural haematomas
old people on blood thinners, slow decline in cognition
what is laryngomalacia
congenital cause of stridor in infants
resolves usually by 12-24 months
what are the features of epiglottitis
dsypnoea, dysphagia, drooling, dysphonia (muffled voice)
stridor is a late sign
tripod position
distinguished from retropharyngeal abscess by xray
what is seen on cray in croup
steeple sign of subglottis
what is quinsy
peritonsilar abscess
what occurs sooner physiological or breast feeding jaundice
physiological- after 24 hours
breast feeding- usually in 2-3 weeks, can be in first
in sufficient intake- first week not getting enough calories
what are the alarm symptoms of dyspepsia
anaemia loss of wight anorexia recent progression malaena/ haematemesis swallowing difficulties (dysphagia) (think malignancy)
how does phenytoin affect COCP
induces liver enzymes, reduces efficacy of CoCP
what are the features of osteomalacia
bony pain
vit d and calcium def (calcium can be normal)
high PTH
what is the most important step in HHS
IV fluids first
insulin when rehydrated
what contraception for dysmenorrhoea
COCP
what causes CNIII palsies
intracranial anuerisms, diabetes and extradural haematomas
difference between somatosism and conversion disorder
Conversion disorder is characterised by voluntary motor or sensory function deficits that suggest neurological or medical conditions but are rather associated with clinical findings that are not compatible with such conditions. Somatic symptom disorder is characterised by one or more somatic symptoms that are distressing or result in significant disruption of daily life.
tender mass in RIF- UC or crohns
crohns
how do you tell the difference between an indirect and a direct inguinal hernia
indirect goes down towards scrotum
direct above pubic tubercle
indirect can be controlled by pressure at the internal ring (halfway between pubic tubercle and ASIS)
what type of incontinence does oxybutin help with
OAB
what type of incontinence does duloxetine help with
stress
treatment for STEMI
300 mg aspirin - continue indefinitely unless CI
presenting in 12 hours: reperfusion therapy (PCI or fibrinolysis)
-PCI available in 120 mins: prasugrel if not on AC, clopidogrel if on anti coagulant, if >75 and high bleeding risk offer tricagrelor or clopidogrel instead of prasugrel
- PCI not available in 120 mins: fibrinolysis= alteplase, streptokinase, antithrombin (fondaparinux) at same time, ECG 60-90 mins after fibrinolysis, give tricagrelor (or clopidorgrel if high bleeding risk)
medical management:
-tricagrelor or clopidogrel if high bleeding risk
treatment for NSTEMI/ unstable angina
300mg aspirin and continue indefinitely
antithrombin (fondaparinux) unless high bleeding risk or immediate angiography
calculate grace score (6 month mortality), ECG, troponin I/ T
intermediate or high risk (>3%): if unstable offer immediate angiography +/- PCI, if stable offer in 72 hours
give prasugrel with aspirin (or clopidogrel if on AC), give unfractionated heparin if getting PCI
low risk: <3%
(young people may still benefit from PCI)
tricagrelor (or clopigrel if high bleeding risk)
what drugs used for secondary prevention following an MI
ACEi (arb if intolerant) indefinitely dual antiplatelet (aspirin + another e.g. clopidogrel) for 12 months beta blockers 12 months/ indefinitely if LVEF reduced statin (atorvastatin 80mg)
if LVEF reduced start aldosterone antagonist 3-14 days after MI
what lifestyle changes for secondary prevention following an MI
exercise, stress, Mediterranean diet, alcohol, smoking
cant drive with unstable angina
stop driving for a week after PCI
when should a statin be started for primary prevention
in those with a QRISK2 score >10%, CKD, T1DM, >85 who smoke/ HPTN, severe obesity
(atorvastatin 20mg)
management of AF
if unstable DC cardioversion (+ amiodarone if unsuccessful)
heparin for anticoagulation in the acute setting
treat underlying cause: HPTN, valvular disease, HF, IHD, infection, cancer, alcohol, hyperthyroid, electrolytes
if <48 hrs: rate (BB, RL CCB (verapamil/ diltiazem), digoxin if sedentary)/ rhythm (cardioversion, flecainide, amiodarone)
if >48 hours: rate control, need to be anticoagulated for 3 weeks before rhythm control
assess CHA2DS2VASc score (stroke risk) and ORBIT bleeding risk
anticoagulation if CV score 2 or more, 1 if man: apixaban, dabigatran, rivaroxaban (if DOAC CI warfarin) (do not offer anticoagulation to those <65 with 0 (men) or 1 (women) CHV score)
rate control: beta blocker or diltiazem/ verapamil or digoxin if sedentary
(do not offer amiodarone long term)
rhythm control if rate control unsuccessful: flecainide, amiodarone, electrical cardioversion, ablation
amiodarone not flecainide if ischaemic or structural HD
what can you not prescribe verapamil and ditiazem with
alpha blockers, ACEis, arbs, antipyschotics, amiodarone, beta blockers, digoxin, NSAIDS LOADS
how is heart failure diagnosed
HX, exam, ECG, NT-proBNP, if high echo (>2000 in 2 weeks, 400-2000 in 6 weeks)
management for chronic HF
diuretics- mineralocorticoid receptor antagonist (spironolactone) if reduced ejection fraction: -ACEi (or ARB) (if intolerant to both hydralazine and nitrate) -BB if still symptoms: -sacubitril if EF <35% or -ivabridine sinus rhythm EF<35% or -hydralazine and nitrate or -digoxin
treatment for stable angina
GTN (2nd dose after 5 mins, ambulance 5 mins after 2nd dose)
BB/ CCB (combo of two if not helped- must be -dipine ones (dihydropyridine))
if not helping: long acting nitrate (isosorbide), ivabradine, nicorandil
if still not helping referral for revascularisation surgery (CBG)
consider aspirin 75 mg
consider ACEi
Statin
what should you do for people with BPs in clinic between 140/90- 179/119
ABPM
if 135/85-149/94 : lifestyle advice + tx if >80 or CVD/ organ damage/ high CVD risk (>10%)
150/95 lifestyle + tx
what should you so for people with BP in clinic of 180/120
refer same day if papilloedema/ life threatening symptoms or suspected pheochromocytoma
anti hypertensives immediately
what are the BP targets
<80 140/90 clinic 135/95 ABPM
>/= 80 150/90 clinic 145/95 ABPM
what is the tx pathway for HPTN
hypertension with type two diabetes or <55: ACEi/ ARB -> A + CCB or thiazide (indapamide) -> A + C + T
>55 or black african or african-caribean : CCB + C + A/T -> C + A + T
resistant: spironolactone if potassium <4.5
alpha (sin) or beta blocker if >4.5
what bugs usually cause infective endocarditis
commonest- staph aureus: amox + gent / fluclox if sepsis
prosthetic valve/ abnormal valves/ IVDU- staph epidermidis: vancomycin and gent
dental- viridans ( beta lactam (penicillin, cephalosporins) +/- gent, vancomycin
what is S1
closure of mitral and tricuspid valves
start of systole, pulse felt at same time
what is S2
closure of aortic and pulmonary valves
start of diastole
what causes a split S2
inspiration, pulmonary stenosis
what grade of murmer has a thrill
4-6
Murmur: ejection systolic, crescendo decrescendo, radiates to carotids, loudest on expiration when patient sitting forward, slow rising pulse
AS
most common cause calcification, bicuspid valve, rheumatic heart disease
Murmur: pansystolic, radiating to axilla, loudest on expiration lying on left side
MR
Ax- IE, MI, rheumatic HD
murmur: early diastolic, crescendo decrescendo, left sternal border 3/4th ICS
AR
bicuspid valve, RHD, IE, aortic dissection
collapsing pulse
AR
murmur: mid diastolic, rumbling, opening click, low volume pulse, heard loudest over…
MS
congenital
… apex
mid systolic click, late systolic murmur
mitral prolapse
pan systolic murmur over left 4th ICS
tricuspid regurg
what sided murmurs are loudest on inspiration
right- tricupsid regurg, pulmonary stenosis
soft diastolic murmur, loudest at 3/4th ICS at left sternal edge, loudest on inspiration
TS
ejection systolic, loudest on inspiration, a waves
pulmonary stenosis
does smoking make UC or crohns worse
crohns
treatment for crohns
inducing remission:
- monotherapy if 1 epsiode in 12 months: steroid/ budesonide (sulfsalazine or mesalazine (5-ASA) - less effective)
- add azathioprine if 2 or more episodes (or methotrexate if CI)
-infliximab/ adalimumab if severe
maintenance:
-azathioprine/ metacaptopurine monptherapy
-methotrexate
treatment of UC
inducing remission: mild mod (max 6 stools a day, no pyrexia, pulse <90, no anaemia, ESR<30)- topical (proctitis/ proctosiggmoiditis/ left sided UC)/ oral aminosysalicylate (5-ASA/ sulfasalazine) (or both) -steroid short term -biologics severe acute: -Iv steroids/ ciclosporin/ surgery (if no improvement at 72 hours or worsening symptoms: stools >8x/day, pyrexia, tachycardia, colonic dilatation, abnormal bloods) maintaining remission: -topical/ oral aminosalicylate (5-ASA) -azathioprine
where does UC affect
distal to ileocecal valve (end of large intestine)
left sided UC common
who should you test for H pylori
uncontrolled dyspepsia with no alarm symptoms (no response to lifestyle changes, antacids, one month course of PPI)
patients at high risk, previous ulcer/bleed, unexplained IDA after endoscopy exclude malignancy
what tests for h pylori
urea 13c breath test
stool helicobacter antigen test
(not within 2 weeks of ppi and 4 weeks of abx)
treatment for H pylori
triple therapy: PPI and 2 abx (consider previous ones tried)
1st line: amoxicillin + clarithromycin/ metronidazole (depending on previous use) for 7 days
if that doesn’t work try the other one for another 7 days
if penicillin allergic
- PPI + clarithromycin + metronidazole
tx for dyspepsia
weight loss, eating (alcohol, coffee, chocolate, fatty foods), smoking
- PPI for 4 weeks, h pylori test if this doesnt help
- endoscopy if alarm symptoms/ GI bleed
- offer H2RA if still inadequate response (-tidines)
what drugs can cause dyspepsia
calcium antagonists, nitrates, theophyllines, bisphosphonates, cortitosteroids, NSAIDs
what are the alarm symptoms
nice 2 weeks:
dysphagia
>55+ weight loss with: upper abdo pain/reflux/ dyspepsia
anaemia loss of weight anorexia recent progression malaena/haematemesis swallowing difficulties
what laxatives for diverticulosis
bulk forming (high fibre diet, lots of water)
when should you suspect diverticular disease
(diverticulosis asymptomatic)
DD- intermittent abdo pain in left lower quadrant with constipation, diarrhoea and occasional large rectal bleeds
-pain triggered by eating and relieved by passage of stool/ flatus
what are the symptoms of acute diverticulitis
constant abdo pain, severe and localising to left lower quadrant with:
fever
or
sudden change in bowel habit and significant rectal bleeding/ mucus
or
Tender LLQ, Hx of DD
complicated if:
- mass palpable- abscess
- adbo rigidity and guarding- perforation
- signs of sepsis
- signs of fistula
- signs of obstruction
Ix for acute complicated diverticulitis
if inflam markers raised contrast CT within 24 hours
tx for acute diverticulitis
systemically well- paractamol
unwell/ cormorbid- abx (co-amoxiclav/ cefalexin + met)
complicated- IV abx (same as above)
surgery if continuing symptoms
what antibiotics cause C diff
clindamycin, cephalosporins, co-amoxiclav, ciprofloxacin
Cephalosporins: ceph or cefts
what are the severities if c diff infection
mild- normal WCC, <3 loose stools
mod- wcc <15, 3-5 stools/ day
severe- wcc >15, increased serum creatinine, temp >38.5, evidence of severe colitis
life threatening- hypotension, partial/ complete ileus, toxic megacolon
tx for c diff
mid/ mod/ severe- oral vanc for 10 days (2nd line fidaxomicin)
if that ineffective- oral vanc IV met 10 days
further episodes (<12 weeks fidaxomicin, >12 weejs oral vanc, both 10 days)
life threatening: vanc + IV met 10 days
what scan for renal stones
non contrast CT
what abdo stuff do you use USS for
gall bladder and biliary tree
renal tract
appendicitis
chronic pancreatitis
duodenal biopsy endoscopy or colonscopy
endoscopy
imaging for pancreatitis
ct
what bug:
incubation 1-6 hours
starchy food (rice)
baciluus cereus
what bug: 1-6 hours
rood temp food
milk/ meat/ fish/ cream
staph aureus
what bug: bloody diarrhoea
beef, raw milk, petting zoos
ecoli 0157 (causes HUS)
notify health protection unit
stool toxin
what bug: 2-5 days, most common cause, raw poultry, GBS
campylobacter
what bug: poultry, meat, raw eggs, 12-48 hours
salmonella
travellers diarrhoea
e coli
what bug: kids, mild watery, not bloody
rotavirus
what bug: winter vomiting big, explosive D+V, cruise ships
noravirus
treatment for hepatic encephalopathy
lactulose
if persistent symptoms add rifaximin
what prophylatic antibiotic in acute variceal bleed
ceftriaxone IV
what prophylatic treatment to prevent bleeds in oesophageal varcies
small- diagnostic and annual andoscopy
medium to large- beta blocker +/- band ligation
what is wernickes encephalopathy
reversible thiamine def that causes: confusion, ataxia and opthalmoplegia
tx with thiamine and magnesium replacement
what is korsakoffs
irreversible hypothalamic damage and cerebral atrophy due to thiamine deficiency
confabulation due to retrograde amnesia, unable to make new memories, lack of insight and apathy
tx for withdrawal
chlordiazepoxide
acamprosate after acute withdrawal to reduce cravings
disulfram for chronic dependence
what are the CAGE questions
ever tried to/ felt like you should cut down
angry at criticism
guilt over drinking
eye opener
what does HBsAg mean
surface antigen
first thing to arise after infection
converted to anti-HBs and HBsAg cleared in resolved infections
presence for >6 months = chronic infection
HBeAG
positive and chronic
shows high viral replication and infectiousness
Anti-HBe
inactive, carrier disease
immunity from previous infection
anti-HBc
current or previous infection
persists for life
anti-HBc IgM
infection in last 6 months
anti-HBc IgG
chronic or past infection
anti-Hbs
previous vaccination or cleared infection
HBV DNA
viral replication
increased risk of cirrhosis and hepatocellular cancer
HBV DNA
viral replication
increased risk of cirrhosis and hepatocellular cancer
what is positive in previous hep B vaccination
anti-HBs only
when is HbsAg -ve
vaccination
cleared infection
when is HbeAg -ve
vaccination
cleared infection (anti-HBe +ve)
chronic infection inactive carrier (anti-HBe +ve)
treatment for PBC
ursodeoxycholic acid
colestyramine for itch
treatment for PSC
transplant
colestyramine for itch
hypertension + hypokalaemia=?
primary hyperaldosteronism
- 2/3rds due to aldosterone producing adenoma (conns syndrome), surgery
- 1/3rd due to bilateral adrenal hyperplasia, treated with spironolactone
commonest cause of pneumoniae
strep pneumoniae
describe what happens in barretts
intestinal metaplasia
squamous to columnar with goblet and paneth cells
is bicarb an acid or a base
base
what does a high base excess mean
alkalotic
what is the rate of insulin infusion for DKA
0.1 units /kg/hr
what does SSRI + statin risk
GI bleed- give PPI
when can you insert a copper IUD after birth
within 48 hours or after 28 days
a bishops score of 5 or less indicates what
labour is unlikely to start without induction
how should you alter medication in addisonian patients with intercurrent illness
double hydrocortisone, same fludrocortisone
how do you tell small from large bowel
small has valvulae conniventes that go whole way across bowel
large bowel has haustra
what are the size limits for the bowels
small 3cm
colon 6cm
caecum 9cm
where is the ceacum
start of large bowel,
RIF
what does a small bowel obstruction look like
coiled spring
central
can see valvulae conniventes
what does a large bowel obstruction look like
haustra
what does a sigmoid vovulus look like
coffee bean in left lower quadrant
ahaustral
as distal bowel ascending, transverse and descending bowel may be dilated
what does a caecal volvulus look like
right lower quadrant
haustra
distal colon collapsed
looks like a fetus
what is riglers sign
can see both sides of bowel
means theres air in abdomen
what are the features of IBD on a-xray
thumbprinting: thickening of haustra
lead pipe colon: loss of normal haustral marking secondary to chornic colitis
toxic megacolon: dilatation of colon
is a subcapital hip # intra or extra capsular
intra
what surgery should you stop the COCP/HRT 28 days prior to
any lasting over 30 mins
emergency surgery
(dont need to do it for e.g. tooth extractions or varicose vein surgery)
what causes osteomalacia
vit D def
what biochem is seen in osteomalacia
low vit D, low calcium, low phosphate
high ALk phos and PTH
what is the empirical tx for gonorrhoea
IM ceftriaxone
what does gonorrhoea look like on gram stain
gram -ve diplococci
what is the anticoagulation in a DVT
LMWH for 5 days then DOAC
if active cancer then DOAC
what causes a cavitating pneumonia in the upper lobes, seen in diabetics and alcoholics
klebsiella
what is pseudomonas aeruginosa like
commin in bronchiectasis and CF patients
causes ground glass on CT
symptoms of mycoplasma pneumoniae
flu like, HA, arthalgia, dry cough
what is legionella pneumonia like
flu like symptoms, dry cough, fever, myalgia, hepatitis, diarrhoea and vomiting
bi basal consolidation
who gets staph areus pneumonia
IVDU, young, elderly, comorbid
people after the flu
blood stained nipple discharge= ?
duct papilloma (malignant potential so gets removed)
what will duct ectasia have
green brown discharge
abscess
smoking
how long should people eat gluten for before testing TTG
6 weeks
what is the management for acute upper urinary tract obstruction
nephrostomy
best test for liver function
PT
pain when exposed to cold
vasoclusive crises in sickle cell
what does FFP contain and help with
blood proteins and CFs
when low INR/ PT
what does CLL transformin to
non hodgkins lymphoma (richters transformation)
what med should you stop beofre coronary angioplasty
metformin
lactic acidosis
can you attempt external cephalic version after membranes have ruptured
no
Tx for suspected PE
admit immediately if unstable or pregnant/ post partum. everyone else calculate wells score and admit if >4
CTPA, DOAC for interim
if <4 do d dimer, DOAC if cant be done in 4 hours
if positive do CTPA, if -ve stop DOAC
(LMWH if renal impairment or pregnant)
tx for confirmed PE
DOAC
LMWH if CI ot APS
3 months if provoked, 6 months if unprovoked or cancer
if patient unstable thrombolysis (alteplase)
difference between schizoid and schizotypal PD
schizotypal had ideas of refence, odd beliefs and behaviours
when should patients with a mild diverticulitis flare be admitted
if symptoms dont improve in 72 hours
what iron study results in Haemochromatosis
high transferrin sats
raised transferrin
low TIBC
difference between acute and critical limb ischaemia
acute: pale, pulseless, pain, paralysis, paraesthesia, perishingly cold
critical: pain at rest for >2 weeks aften at night not helped by analgesia
what prophylaxis following spontaneous bacterial peritonitis
ciprofloxacin
what antiemetic for intracranial tumours
dexamethasone
do you need to x-ray an ng tube with apsiriate <5.5
no
treatment for thrush
oral fluconazole
clotrimazole pessart
topical imidazole if vulval symptoms
when is mastectomy preferred to WLE
mutlifocal tumour
large, central tumour
DCIS >4cm
treatment after breast surgery
radiotherapy for all WLE and mastectomy for T3-4 tumours
if hormone receptor positive:
-tamoxifen for pre and perimenopausal (blocks oestrogen receptors in breast)
-aromatase inhibitors for post menopausal (anastrozole) (prevent peripheral conversion of oestrogen)
HER2 +ve: trastuzumab
how do the glaucoma drugs work: B blockers
reduce aqueous secretion
how do the glaucoma drugs work: prostglandins
increase aqueous outflow through uveoscleral route
how do the glaucoma drugs work: sympathomimetics (brimonidine)
reduce secretion and increase outflow
how do the glaucoma drugs work: miotics (pilocarpine)
opening aqeous drainage in trabecular meshwork
how do the glaucoma drugs work: laser cycloablation
destroys secreting bit of ciliary body
what treatment should be offered first in open angle glaucoma
prostaglandin analogue (latanoprost)
(2nd line beta blocker, CAinhibitors, symps)
more advanced laser
how do the glaucoma drugs work: carbonic anhydrase (dorzolamide)
reduce aqueous
treatment for acute angle closure glaucoma
pilocarpine drops acetazolamide IV beta blockers steroids analgesia and anti-emetic surgery: iridotomy
first line antiplatelet following a stroke
clopidogrel
can acute pancreatitis cause hyper or hypocalcemia
hypo
tx for thredworm
oral mebendazole
what Das 28 score to qualify for biologics
> 5.1
what should you give instead of morphine in patients with renal impairment
oxycodone
what should be the first test in reduced fetal movements
doppler
do no need to stop ARBs in ACEis
yes
what is used as prophylaxis for meningitis
ciprofloxacin
test for Achilles rupture
USS
tx for chronic vestibular neuronitis
vestibular rehab
prochlorperazine for symptom control in acute setting
what is the main risk factor for cholangiocarcinoma
PSC
vision worse going down stairs
trochlear nerve palsy
do patients >75 with fragility # need a dexa
no start bisphosphonates
when do you give amiodarone in CPR
when its a shockable rhythm after 3rd shock and then after every 2nd shock
what weeks if you miss 2 pills should you consider emergency contraception
pill free week
week 1
what happens if you miss 1 pill
take asap, even if its 2 in one day
what happens if you miss 2 pills in week 2
no need for emergency contraception
what happens if you miss 2 pills in week 3
finish current pack, start next pack right with no pill free interval
what general advice for missing 2 pills
use condoms until pills taken for 7 days in a row
chlamydia psittaci pneumonia
birds, dry cough
pneumocystitis pneumonia
immunosuppressed
common HAP bugs
staph aureus, pseudomonas, klebsiella
when should you consider an antibiotic in an acute exacerbation of COPD
signs of infection, change in volume or colour of sputum
give amoxicillin/ doxy
COPD treatment pathway
SABA/SAMA
if no response stop SAMA, add LABA + LAMA
if asthmatic features (asthma, atopy, high eosinophils, diurnal peak flow variation, variation in FEV1) then LABA + ICS
LAMA+ LABA + ICS (+SABA)
paediatric asthma pathway
SABA
ICS
LTRA
LABA
what does a protein content of 45 in a pleural effusion mean
exudative, effusions >30 exudate, <30 transudate
what causes transudative effusions
congestive HF
liver cirrhosis
severe hypoalbuminemia
nephrotic syndrome
what causes exudative effusions
malignancy infection, if purulent empyema trauma - can be bloody, food particles oesophageal rupture pulmonary infarction pulmonary embolism
what are the normal BM levels
4 -> 7 (fasting) 11.1 (random)
HbA1C <42 (6%)
what blood sugars should diabetics aim for
4-7 before meals
5-9 2 hrs after
4-7 bed time
HbA1C <48 (6.5%), if on hypoglycaemic drugs <53 (7%)
if goes above 58 (7.5%) lifestyle advice and add another drug aim for 53
what is a pre diabetic HBA1C
42-47
when can you diagnose T2DM
HBa1C of 48 or more
random of 11 or more, fasting of 7 or more
if symptomatic can diagnose off one result, if not repeat test
dont use HBA1c on children, pregnant women, acutely unwell…
what are the gliptins
DPP-4 inhibitors
what weight effect does piaglitazone have
gain
what are the gliflozins
SGLT2 inhibitors
what effect do GLTT2 inhibs have on weight
loss
what are: glimepiride, glipizide, tolbutamide
what weight effect do they have
sulfonylureas (also glicalzide) #gain
what is renin like in primary and secondary hyperaldosteronism
primary low, adrenals making too much aldosterone
secondary high, BP in kidneys low so body making more renin
what causes hyperaldosteronism
primary: conns syndrome (adrenal adenoma) , bilateral adrenal hyperplasia
secondary: renal artery stenosis
screening tool for hyperalsosteronism
renin: angiotensin ratio
low renin primary, high renin secondary
treatment for hyperadlosteronism
primary: spironolactone, removal of adenoma, angioplasty for stenosis
tx for acromegaly
transphenoidal surgery
somatostatin analogues: ocreotide
pegvisomant (GH antagonist) if resistant
what causes SIADH
too much ADH (vasopressin):
SCLC, too much from post pit: infection, post op, menigitis, medications (thiazides, carbamazepine)
features and tx for SIADH
hyponatraemia, high urine osmolarity, high urine sodium
correct sodium slowly to prevent central pontine myelinolysis
features of diabetes insipidus
lack of response to ADH- nephrogenic (lithium) or cranial (tumours, injury, infections)
polydipsia, polyuria, hypERnatraemia
Ix for diabetes insipidus
water deprivation test: (desmopressin stimulation test)
avoid fluids for 8 hours and measure urine osmolality
give desmopressin and 8 hours later measure urine osmolality again:
-cranial will concentrate after desmopressin
-nephrogenic will not concentrate
management for DI
demopressin
tx for hyperprolactinaemia
if <10mm bromocriptide
if >10mm bromocriptide then surgery
treatment for pheochromocytoma
alpha blockade (phenoxybenzamine) then beta blockade then surgery
what scan for suspected pancreatic cancer
CT
what test for stomach cancer
upper GI endoscopy
what scan for gall bladder and liver cancer
USS
what age do unexaplined breast lumps get referred on suspected cancer pathway
30
what test if CA125 if higher than expected
USS
What are the minor and major criteria for suspected melanoma referall
major : change in size, irregular shape or colour
minor: diameter 7mm or more, inflammation, oozing, change in sensation
how urgent do SCC and BCCs need to be referred
BCC routine SCC Urgent (2 weeks)
when is ulceration in mouth worrying
if there for >3 weeks
how quick should you refer children with new neuro signs
very urgent- MRI in 48 hours
how urgent is a suspected adult and child leukaemia referal
very - under 48 hours
referal for lymphadenopathy and spenlomegaly, fever, nightweats, SOB, pruitus or weight loss (lymphoma) in adults and children
adults 2 weeks, children 48 hours
referral for bone and soft tissue sarcomas adults and children
adults 2 weeks
children 48 hours
referal for child wilms tumour (haematuria, abdo mass)
48 hours
what is CK in rhabdomyolysis
> 10,000
how to tell primary from tertiary hyperparathyroidism
tertiary may have abnormal renal function- seen in chronic renal failure
PTH can be high or inappropriately normal in primary, always high in tertiary
perineal ulcer, tender lymphadenopathy and proctitis
lymphogranuloma venereum
is the lymphadenopathy tender in herpes
yes
features of pernicious anaemia
AI atrophic gastritis
anti gastric parietal cell antibodies
B12 def- macrocytic anaemia
does coeliac cause a micro or macro cytic anaemia
micro
how to tell the difference between IgA and post infectious GN
IgA- haematuria few days after URTI
PI- 2 weeks after infection
are duodenal ulcer better or worse after eating
relieved by eating
treatment for prolonged QRSs followinf tricyclic OD
sodium bicarb
amiodarione can cause pulmonary fibrosis, what would the diagnostic test be
CT chest
when should LP be done to diagnose SAH
at least 12 hours after symptom onset to look for xanthochromia
treatment for SLE
NSAIDs- joint stiffness and pain (naproxen), avoid in hypertension
hydroxychloroquine: constitutional and cutaneous symptoms
IV methylpred for immediate relief, oral steroids for a short a time as possible
if not responding: methotrexate, azathioprine, mycophenolate, biologic agents
signs of rheumatoid arthritis on x ray
reduced joint space
articular erosions
periarticular osteopenia
soft tissue swelling
tx for RA
dmard within 3 months: methotrexate, lefunomide, sulfasalazine
bridging steroids
features of PMR
elderly, myalgia of hip and shoulder girdle with morning stiffness
15% have GCA
raised CRP and PV/ESR
responds to 15 mg steroids tapered over 18 months
treatment for GCA
40mg pred, 60mg if visual involvement
features of polymyositis
symmetrical proximal muscle weakness
dysphagia may occur
anti Jo-1, SRP, ANA and RNP
ILD commoner in those with Jo-1
inflam markers raised, CK 10x normal
EMG
pred 40mg with immunosuppressants: methotrexate/azathioprine
features of dermatomyosis
those of PM but with gottrons paules, V shaped rash, heliotrope rasg
management and Ix as for PM
what are the ANCA positive vasculitis
microscopic polyagnitis
granulomatosis with polyangiitis
eosinophilic granulomatosis with polyangitis
what are the large vessel vasculitis
giant cell (temporal) takayasu arteritis
symps- low grade fever, weight loss, arthralgia and fatigue
ESR, PV and CRP raised
Tx steroids, steroid sparing agents (methotrexate, azapthioprine)
features of granulomatosis with polyangitis
nose bleeds, deafness, recurrent sinusitis, nasal crusting (collapse of nose), haemoptysis, cavitating lesions on x ray
cANCA
features of eosinophllic granulomatosis with polyangitis
late onset asthma, rhinitis and raised peripheral blood eosinophil count
features of eosinophllic granulomatosis with polyangitis
late onset asthma, rhinitis and raised peripheral blood eosinophil count
microscopic polyangitis causes what
GN
tx for anca vasculitis
Iv steroids and cyclophosphamide
what mediated HSP
IgA
features of HSP
URTI
few weeks later purpuric rash over bottocks and legs, abdo pain, vomiting and joint pain
self limiting
what are the nephritic GN
IgA (12-72 hours post infection, IgA deposits on mesangium, proteinuria)
post step (2-3 weeks post infection, oedema)
HSP (purpuric rash, abdo/ joint pain , IgA)
Anti-GBM (renal disease and pulmonary haemorrhage)
rapidly progressing (lots of causes, failure in weeks/days)
treatment for nephritic syndrome
IgA- ACEi/ARB to reduce proteinuria, steroids if this doesnt help
HSP- steroids
PS-abx
Anti-GBM- plasma exchange, steroids and cyclophosphamide
rapidly progressing- steroids and cyclophosphamide
what is nephrotic syndrome
proteinuria (>3g/24hrs)
hypoaluminaemia
oedema
what can cause nephrotic syndrome
GN
pre-eclampsia, lupus, DM, myeloma, amyloid
what can cause nephrotic syndrome
GN
pre-eclampsia, lupus, DM, myeloma, amyloid
Tx for nephrotic syndrome
fluid and salt restriction, furosemide
treat cause
ACEi/ARB to reduce proteinuria
Abx, thromboprophylaxis
what are the nephrotic GN
minimal change (idiopathic, NSAIDs, lithium, HL; light microscopy normal, electron podocyte effacement, pred)
focal segmental glomerulosclerosis- ACE/ARB, steroids in primary disease
membranous- (malignancy, infection, AI, drugs - gold, spikes of silver stain, thickened basement membrane)
membranoproliferative- immune complex of C3, electron dense deposits on membrane, ACEi/ARB
what are the pre renal causes of AKI
hypoperfusion: decreased plasma volume decreased CO vasodilation renal vasoconstriction (NSAIDs, ACEi, hepatorenal syndrome- concurrent liver cirrhosis/ failure)
what are the renal causes of AKI
glomerular interstitial (drugs, infection, infiltration- sarcoid)
what are the post renal causes of AKI
stone, malignancy, stricture, clot, extrinsic compression
treatment for AKI
fluid resus monitor fluid balance, K+ assess for proteinuria USS in 24 hours check liver function check platelets - if low check film for haemolysis (TTP, HUS) treat cause
stages of CKD
GFR: 1= >90 and evidence of kidney damage 2=60-89 and evidence of kidney damage 3a= 45-59 3b= 30-44 4= 15-29 5=<15 failure
management for CKD
refer when stage 4-5/ declining gf/ genetic cause/ proteinuria despite tx/ poor BP control
ACE/ARB for BP and proteinuria
glycaemic control
salt restriction <2g
treat: anaemia, renal bone dystrophy (high phosphate low vit D) (phospahte binders, diet low in phosphate, vit D supplements), iron for restless legs, antiplatelets, statins
RRT
tx for gout
acute: NSAID, colchine, steroids if CI
lifestyle (low urate- alcohol, red meat)
prophylaxis: allopurinol/ febuxostat
VTE prophylaxis for patients with renal impairment
LWMH or unfractionated heparin
VTE prophylaxis in palliative care
LMWH
what do you do for people with a negative USS but positive D dimer for DVT
stop interim anticoagulation and repeat USS 6-8 days later
can you drive after stroke/ TIA
1 month after TIA, 3 months if multiple
stroke 1 month, notify DVLA if residual neuro deficit
what is the secondary prevention following a stroke
antiplatelet (not if paroxysmal AF) : aspirin in first two weeks then clopidogrel 75mg (if CI 75mg with modified release dipyridamole 200mg). Dual therapy aspirin + clopidogrel if high risk of TIA for 90 days statin: 80mg atorvastatin HPTN control anticoagulation: (for all inc AF) DOAC
what are the iron studies like in IDA
decreased ferritin, increased total iron binding capacity
what should you consider in microcytic anaemia that is not responding to iron
sideroblastic- will have high iron and sideroblasts
what are howell jolly bodies seen in
hyposplenism (sickle cell, IBD, amyloid)
what is rouleaux seen in
chronic inflammation, myeloma
what are schistocytes seen in
intravascular haemolysis (DIC, HUS, TTP)
what are spherocytes seen in
sherocytosis, autoimmune haemolytic anaemia
what must you always check before giving folate
B12 levels as replacing folate without B12 may precipitate subacute combined degeneration of spinal cord
what biochem markers in haemolytic anaemia
increased unconjugated bilirubin and urobilinogen
increased LDH
how to tell intravascular from extravascular haemolysis
splenomegaly in extravascular
free plasma haemoglobin in intra
what are the causes of haemolytic anaemia
acquired: coombs test +ve -drug induced -AIHA (extravascular haemolysis, warm IgG steroids, cold IgM keep warm coombs -ve: -autoimmune hepatitis -hep b/c -post infection, drugs microagiopathic haemolytic anaemia: mechanical damage, intra, Ax: DIC, HUS, TTP, pre-eclampsia, mechanical valve, infection
hereditary:
- G6PD def, x linked,
- sherocytosis
abx seen in autoimmune hepatitis
ASMA, ANA, LKM1
tx for AI hepatitis
steroids
azathioprine for sparing
transplant if needed
what is the inheritance of sickle cells
AR
prevent for sickle cell crises
hydroxycarbamide
what is the inheritance of beta thalassaemias
recessive
heterozygous- carrier, minor or trait
intermediate- moderate anaemia, homo/hetero
major- hetero, lifelong transplant, hair on end bones, bossing, extramedullary haemotpoesis
is VwF def a coagulopathy or bleeding disorder
bleeding- VWF aggregates platelets
what inheritance are the haemophilias
x linked recessive
when do you give platelets and FFP
platelets when <20
FFP to replace clotting factors: DIC, warfarin OD hen vit k would be too slow e.g. liver disease TTP
what is seen in TRALI
white out
what does LMWH target
factor Xa
what does warfarin target
vit K
what malignancy:
uncontrolled immature blast proliferation, children
anaemia, infections, bleeding (marrow failure)
tx: fluids, allopurinol (TLS), transfusion, IV abx, chemo, marrow transplant
Acute lympoblastic leukaemia
what blood malig:
auer rods
AML
what blood malig:
40-60, philadelphia chromosome, imantinib
CML
which blood malig:
rubbery nodes, often asymptomatic, progresive accumulation of functionally incompetant B cells
CLL
what blood malignancy:
reed sternberg cells, young adults and elderly, alcohol induced node pain, ann arbour staging
HL
what blood malignancy:
b cells, includes MALT
NHL
what myeloproliferative:
JAK2, itchy after hot bath, venesection
PCV
treatment for thrombocythaemia
aspirin
which myeloproliferative disorder :
teardrop RBCs, marrow fibrosis, massive hepatosplenomegaly
myelofibrosis
which blood malignancy:
IgG, paraprotein on urine/ electrophoresis, osteolytic bone lesions, hypercalcaemia, marrow failure, renal impairment (light chain deposition), roulaeux
myeloma
what tests for myleoma
serum and urine electrophoresis
Tx for myeloma
analgesia, bisphosphonate, chemo, transfusions
which jaundice:
normal urine and normal stools
pre-hepatic cause
unconjugated bili is not water soluble
which jaundice:
dark urine + normal stools
hepatic cause
conjugated bili, able to get into bowel
which jaundice:
dark urine + pale stools
post hepatic obstructive
conjugated bili, unable to get into bowel
abx for animal bite
co-amoxiclav
most common side effect with POP
irregular bledding
what should all patients with peripheral arterial disease be taking
antiplatelet (clopid) and a statin
abx for neutropenic sepsis
piperacillin with tazobactam
what test for post H pylori eradications therapy
urea breath test
what is a comp of fluid resus in DKA
cerebral oedema- monitor kids and YA especially for it
dose blockage of the cystic duct cause jaundice
no, neither dose blockage of the gall bladder
why is mastoiditis an emergency
risk of meningitis, cranial nerve palsies, osteomyelitis, hearing loss, osteomyelitis, carotid artery spasm
what drug for babies in womb to help prevent resp distress
dexamethasone
normal nuchal translucency
<3.5mm at 11-14 weeks
when is a postural drop in BP significant
20 or more systolic/ below 90/ >10 with symptoms
what is anastrozole
aromatase inhibitor
what is a normal FEV1
> 80%
what is the breast cancer screening programme
mammography every 3 years for women aged 50-70
what abx for GBS prophylaxis
benzylpenicillin
can you take statins in pregnancy
no
what drugs are bad in G6PD def
sulpha drugs (sulphasalazine, sulphonylureas)
what eGFR is metformin CI
<30
what Tx for fasting glucose >7 in pregnancy
insulin
if <7 lifestyle changes for 2 weeks then metformin if still high
what does irradiating blood prevent
transfusion associate graft versus host disease
what form of ventilation in acute COPD exacerbation
BiPAP
when can hypertonic saline be given
acute severe hyponatraemia <120
first line investigation for prostate cancer (after PR and PSA)
MRI
then TRUS biopsy
tx for trichomonas vaginalis
oral metroniazole
how long should you be faste for before surgery
6 hours
what are the biochem markers of myleoma
calcium up, phosphate normal/up, ALP normal
biochem markers of bone mets
calcium, phosphate and alp all up
phosphate in primary hyperparathyroidism
down
potassium up or down in cushings and addisions
cushings down
addisons up
normal UO
1500, 200 in stool, 800 insensible
can you use 5% dextrose for resus
no
how to calculate the anion gap
(Na+ + K+) - (Cl- + HCO-)
what do you need to be careful of when treating hyponatraemia
replacing too quickly can cause central pontine demyelination
treatment for K>6.5 or >6 with ECG changes (tall tented T waves, increased RR, widened QRS, sine wave)
10ml of 10% calcium chloride (or 30ml 10% of calcium gluconate) IV over 5-10 mins (cardioprotective)
IV insulin (10u in 25g glucose- 50ml of 50%) over 30-60 mins (re-uptakes K)
salbutamol neb
renal replacement
how to differentiate thyroid cancers
most common, young patients= papillary
middle aged, haem spread= follicular
MEN, calcitonin= medullary
causes of hypocalcaemia with raised phosphate
CKD
hypoparathyroidism
causes of hypocalcaemia with normal/ low phosphate
vit D def (helps absorb phosphate and calcium from gut)
osteomalacia (raised ALP)
acute pancreatitis
tx for hypercalcaemia
rehydrate
bisphosphonates
how much of ions and sugar and water do you need a day
1mmol/kg/day of sodium potassium and chloride
50-100g/kg/day glucose
25-30ml/kg/day water
what ion can be raised by thiazides
hypercalcaemia
what nerve does froments test test
ulnar
tx for prolactinoma and acromegaly
prolactinoma- dopamine agonists (bromocriptide, cabergoline) for both macro >10mm and micro (surgery rarely needed)
acromegaly- transhenoidal surgery, somatostatin analogues (ocreotide), GH antagonist (pegvisomant)
(A= SS and surgery ASS)
first line tx for superficial thrombophlebitis
NSAIDs
what is used to reverse warfarin in emergency
prothrombin complex concentrate
what is the desirable INR for invasive procedures
<1.5
how should warfarin be managed before and after surgery
(low risk patients) withhold 5 days before, day before check INR and give vit K if >1.5
restart usual dose on day of procedure
stop for surgery? loop diuretics
yes (omit morning of)
stop for surgery? K sparing diuretics
yes (omit morning of)
stop for surgery? beta blockers
no
stop for surgery? acei and arbs
yes (omit morning of)
stop for surgery? CCbs
no
stop for surgery? DOACs
yes stop 48 hours before
stop for surgery? clopidogrel
stop 7 days before
stop for surgery? inhaled steroids
no
stop for surgery? first gen antipsychotic
no
stop for surgery? 2nd gen antipsuchotic
yes stop 12 hours before
stop for surgery? bisphosphonates
omit on day
stop for surgery? NSAIDs
stop 24 hours before, 72 if naproxen
how do you change insulin for surgery
for multiple daily doses continue the daily long acting basal insulin subcut (glargine, determir, degludec)
for major surgery five VR IV insulin (actrapid)
aim for first on list, omit all medication and insulin expect long acting on morning of if AM, restart as usual with meal post op (if once daily regime or breakfast routine give half dose at lunch)
if PM 50% reduction in insulin dose at breakfast, omit oral meds at breakfast, fast after breakfast and omit lunchtime meds
VRII if major surgery
how do you change oral diabetic meds for surgery
if poorly controlled or major surgery treat as insulin controlled diabetes (long acting + VRII)
give all usual day before except SUs
if AM omit all morning meds, take any missed drugs with lunch
if PM give morning doses, omit lunch time doses and give any missed doses with late lunch
if not eating/ drinking after op start VRII 2 hours before op and restart oral hypoglycaemics when eating
what are the antihistamine anti-emetics
cyclizine, promethazine
what anti-emetic for gastrointestinal or biliary disease
metoclopramide (prokinetic- stimulates gastric emptying, can cause tardive dyskinesia)
what can domiperdone be used for
antiemetic for dopaminergic drugs (PD)
what anti emetic for menieres
prochlorperazine
cyclizine
what anti-emetic for migraines
metoclopramide or prochlorperazine
what is the orbit score
>/= 75 1 point reduced Hb 2 points bleeding history 2 points eGFR <60 1 point on antiplatelet 1 point
0-2 low risk
3 medium risk
4-7 high risk
what is the chadvasc score
CHF 1 HPTN 1 age >/= 75 2 Age 65-74 1 DM 1 stroke/tia/VTE 2 vascular disease 1 female 1
can apixaban be used in CKD
yes
what is the feverpain criteria
fever purulence attends rapidly (within 3 days) inflamed tonsils no cough or corzya
score 0-1 do not offer an antibiotic, seek help if dont improve within a week
2-3 no antibiotic/ back up prescription (not needed immediately, use if no improvement in 3-5 days/ worsening (likely streptococcal)
4-5 immediate abx/ back up prescription
abx= phenoxymethylpenicillin
what is the centor criteria
tonsilar exduate
tender anterior cervical lymphadenopathy
fever
absence of cough
0-2 no abx
3-4 immediate/ back up abx
abx phenoxymethylpencillin
which is the most common cause of malaria
plasmodium falciparum - more likely if cerebral involvement
causes fever, cough, HA, malaise, diarrhoea,
ix and tx for malaria
ix- giemsa stained thick and thin blood smears, rapid diagnostic test
tx: chloroquine or hydroxychloroquine
difference between gram -ve and positive
-ve pink, has thin peptidoglycan cell wall
+ve purple, thick peptidoglycan wall
is staph areus coagulase negative or positive
positive
how to beta lactam antibiotics work
inhibit cell wall synthesis
what antibiotics contain a beta lactam ring
(all cause penicillin allergy!)
penicillins
cephalosporins (ceph and cef)
clavulanic acid
findings in LP in bacterial meningitis
cloudy, turbid
high pressure
>100 WBC (leukocytes)
glucose low, protein high
findings in viral meningitis LP
clear, normal/ elevated pressure
WBC elevated, primarily lymphocytes
glucose normal (low in HSV), protein high
findings in fungal meningitis (LP)
clear/ cloudy
elevated pressure
WB elevated, glucose low
protein elevated
findings in tb meningitis LP
opaque, fibrin web
elevated pressure
WBC high, glucose low, protein high
specificity
the ability of a test to correctly identify those withOUT the disease
sensitivity
the ability of a test to correctly identify patients WITH a disease
prevalence
the percentage of people in a population who have the condition of interest
incidence
number of new cases over a period of time
randomised control trial
gold standard of clinical trial, treatment vs placebo
case control study
two groups identified on a differing characteristic (disease/condition) then explores retrospectively as to the cause of that characteristic
cohort study
cohort of people followed to determine rate of disease/ risk factors prospective- people divided into two groups based on exposure to RF an then followed for several years to determine incidence
retrospective when cohort selected from the past and data is collected in past or present of how many people in that group were exposed to risk factor/ develop disease
cross sectional study
data collected at specific time and point, don’t interfere, looking at incidence or prevalence of disease
what is the bowel screening programme
people aged between 60 and 74 to return a faecal immunochemical test (FIT) kit every 2 years to detect the presence of blood in the stool.
localising features of a temporal seizure
HEAD
hallucinations (auditory, gustatory, olfactory)
Epigastric rising/ emotional
Automatism (lip smacking, grapping, plucking)
Deja vu/ dysphagia post ictal
localising features of the frontal lobe
head/leg movements, posturing, post-ictal weakness, jacksonian march
(motor)
parietal localising features
(sensory) paraesthesia
occipital localising features
(visual) floaters/ flashes
what are the first rank symptoms of schizophrenia
auditory hallucinations (thoughts spoken aloud, third person, commentary)
though withdrawal/ insertion/ interruption
thought broadcasting
somatic hallucinations
delusional perceptions
passivity phenomena
