Revision Topics Flashcards
Age of premature menopause
< 40
Who should be offered a DEXA scan to screen for osteoporosis
All post-menopausal women > 65
Conservative management of menopause
Vaginal estrogen creams
Reduce risk of osteoporosis by smoking cessation and vitamin D
What are the 2 main health problems caused by menopause
Osteoporosis
Cardiovascular disease
Indications for HRT
Menopausal symptoms
Premature menopause until age 51, even if asymptomatic
Women < 60 at risk of osteoporotic fracture who aren’t suitable for other treatments
Risks of HRT
Endometrial cancer if unopposed
Breast cancer
Thrombotic disease - DVT, PE, stroke, CHD
Main contraindications to HRT
If still have uterus can't have unopposed Undiagnosed vaginal bleeding Breast/endometrial cancer Untreated endometrial hyperplasia VTE Untreated HTN MI, angina, coronary artery disease
What medications can be used for hot flushes associated with menopause that aren’t HRT
SSRIs - Paroxetine
Clonidine
Gabapentin
Actions of parathyroid hormone in response to low Ca
Increased osteoclast activity
Increased renal Ca reabsorption and PO4 excretion
Increased vitamin D levels
Overall effect of PTH on serum Ca and PO4
Increases serum Ca
Decreases serum PO4
Causes of primary hyperparathyroidism
Solitary adenoma
Parathyroid gland hyperplasia
Parathyroid gland cancer
Chronic renal failure commonly causes which type of hyperparathyroidism
Tertiary hyperparathyroidism
A paraneoplastic syndrome commonly from SCLC that causes high Ca
Parathyroid hormone related protein
Symptoms of high parathyroid hormone
Pruritus Bone pain/fractures/osteopenia High BP Ca deposits in skin Sx of high calcium - weak, tired, low mood, polyuria, polydipsia, renal stones
Medication used to lower PTH levels
Cinacalcet
Angiotensinogen comes from which organ
Liver
Angiotensin converting enzyme comes from which organ
Lung
Symptoms of hypocalcaemia
Cramps Perioral numbness Muscle spasm Chvostek sign Confusion Seizures
Actions of angiotensin II
Vasoconstriction
Aldosterone release from the adrenal cortex (Na retention)
Typical presentation of erythema multiforme
Target lesions
Initially back of hands/feet then spread to torso
Upper limbs > lower limbs
Mild pruritus
Main precipitating factor for erythema multiforme
Herpes simplex virus
At what percentage of body surface area affected does Stevens-Johnson syndrome become Toxic Epidermal Necrosis
When > 30% of the skin is affected
What is the name of the sign when mild lateral pressure separates the epidermis
Nikolsky’s sign
Percentage body area needed to be affected in erythroderma
90+ %
Classical presentation of squamous cell carcinoma
Painless, non-healing, bleeding ulcer
Everted edges
Floor of ulcer resembles granulation tissue and bleeds easily
Is SCC or BCC more common
BCC
Risk factors for squamous cell carcinoma
Sun Skin type Radiation Chronic immunosuppression Actinic keratosis Bowen's disease Chemical carcinogens
What is a Marjolin’s ulcer
An aggressive form of SCC that typically develops from areas of chronically damaged skin such as ulcers (e.g., pressure ulcers, osteomyelitis) and scars (e.g., burn scars)
What is Bowen’s disease
Squamous cell carcinoma in situ
What infection is Bowen’s disease associated with
HPV 16 and 18
Keratin pearls are a histological finding of which skin disease
Squamous cell carcinoma
What is Keratoacanthoma and how do they characteristically look
A benign skin tumour
Common in the elderly
Rapid growth on sun exposed areas
Round erythematous nodule with a central crater
What is Moh’s microsurgery used for
Skin cancers - removes them later by layer so best method for ensuring its all removed whilst also ensuring uninvolved skin is spared
What is the most common type of skin cacner
BCC
Risk factors for basal cell carcinoma
Sun exposure Skin type Gorlin syndrome Arsenic exposure Radiation Chronic immunosuppression
What is Gorlin syndrome
A genetic condition that puts you at risk for multiple BCCs and other tumours
Topical chemotherapy for some skin cancers
Imiquimod
5-FU
Risk factors for melanoma
UV Skin type Numerous nevi Immunosuppression Xeroderma pigmentosum
Clinical features of melanoma
Pruritic, bleeding
Asymmetry
Irregular border with indistinct margins
Colour change of various pigmentation within the same lesion
Diameter >6mm
Evolving in regards to size, shape or colour
Types of melanoma
Superficial spreading Nodular Lentigo maligna Acral lentiginous Amelanotic Uveal
What is the most common type of melanoma
Superficial spreading
Describe lentigo maligna
A type of melanoma common in the elderly on sun exposed areas
Large and irregularly shaped patch with irregular pigmentation and slow horizontal growth
Describe Acral lentiginous
A type of melanoma common in dark skinned ethnicities
Irregularly shaped brown/black nodule that may ulcerated
Affects the palms/soles/nailbed/mucous membranes
Biopsy of choice in suspected skin cancers
Full thickness excisional biopsy with safety margins
What system is used to stage melanomas based on thickness/depth
Breslow scale
2 pre-cancerous skin lesions that can develop into SCC
Actinic keratosis
Leukoplakia
Describe a typical actinic keratosis
Sun exposed area
Small lesion with rough surface, sandpaper like texture. Grow and become erythematous and scaly
Treatment options for actinic keratosis
Cryotherapy Topical Imiquimod or 5-FU Phototherapy Curettage Excision SUN SCREEN
Difference between hypertrophic and keloid scars
Hypertrophic don’t grow beyond the boundaries of the original lesion whereas keloid scars do
Typical appearance of seborrheic keratosis
Darkly pigmented plaques or papules Sharply demarctaed Soft, greasy, wax like texture Stuck on appearance May be itchy/bleed/increase in number over time
Slowly growing skin coloured/brown nodule mainly on lower legs, sometimes related to bites/skin trauma
Pinching the lesion produces a central dimple (Fitzpatrick’s sign)
Dermatofibroma
What are the 3 main types of nevus
Junctional
Compound
Intradermal
Describe a junctional nevus
Flat, well demarcated brownish macule
Growing at the dermal-epidermal junction
Describe a compound nevus
Elevated lesion
Arising from a junctional nevus
Describe an intradermal nevus
Elevated lesion that may be hard/fibrotic and grow hair
Causes of acanthosis nigricans
T2DM PCOS Cushing's Steroids Oral contraceptives
What is a solar lentigo
Benign skin lesion
Flat brown macules or patches induced by sun exposure - usually on the cheeks and backs of hands
Delirium tremens typically occurs how many days after alcohol cessation
3 days
Typical triad of symptoms in Wernicke’s encephalopathy
Mental status change/confusion
Gait ataxia
Occulomotor dysfunction/nystagmus
Which vitamin is Thiamine
B1
What is the main feature of Korsakoff syndrome
Loss of short term memory and confabulation as a result
Symptoms of polymyalgia rheumatica
Morning stiffness of proximal limb muscles
Lerthargy, depression, anorexia, low grade fever
Symptoms of GCA
What is polyarteritis nodosa
A medium vessel vasculitis
Who gets polyarteritis nodosa
Middle aged men with Hep B infection
Typical angiography description of polyarteritis nodosa
‘Beading’ appearance - numerous microaneurysms
What is the life-threatening complication of Kawasaki disease and how do you check for it
Coronary artery aneurysm
Echocardiogram
6 Key features of Kawasaki disease
High grade fever for >5 days Conjunctival injection Bright red, cracked lips Strawberry tongue Cervical lymphadenopathy Red palms and soles of feet which later peel
Management of Kawasaki disease
High dose Aspirin
IV immunoglobulins
Echocardiogram
What is Scarlet fever
A reaction to toxins produced by group A strep (usually strep pyogenes)
Organism that can result in scarlet fever
Group A Streptococci - usually Strep Pyogenes
Typical features of Scarlet fever
Fever 1-2 days
Malaise, headache, nausea, vomiting
Sore throat/strep throat
Strawberry tongue
Fine punctate erythematous rash that spares the palms and soles, rough sandpaper texture, later desquamation around fingers/toes
Flushed appearance with circumoral pallor
Treatment for Scarlet fever
Oral Penicillin V for 10 days
What is the most common complication of scarlet fever
Otitis media
Rheumatic fever usually occurs how long after what infection
2-6 weeks after Streptococcus Pyogenes infection
Major criteria for Rheumatic fever
Erythema marginatum (ring shaped) Sydenham's chorea Polyarthritis Pancarditis Subcutaneous nodules
Minor criteria for Rheumatic fever
Raised CRP/ESR
Pyrexia
Arthralgia
Prolonged PR interval
Causes of osteomalacia
Vitamin D deficiency
Renal failure
Anticonvulsants
Liver cirrhosis
Pagets disease - are Ca, PO4, ALP high, normal or low
Normal Ca and PO4
Raised ALP in isolation
Treatment for Pagets disease
Bisphosphonates
First line treatment for dysfunctional uterine bleeding
Progesterone only contraception (usually coil)
Treatment options for dysfunctional uterine bleeding/menorrhagia
Progesterone only contraception (coil) or combined contraception
NSAIDs - Mefanamic acid
Antifibrinolytics - Tranexamic acid
D+C if want future children
GnRH analogues if want future children
Endometrial ablation/resection/hysterectomy if they don’t want more children
3 main types of fibroids
Intramural
Subserosal
Submucosal
Which medications can shrink fibroids
GnRH analogues (injection) Ulipristal acetate
Surgical treatment of fibroids in someone who wants future children
Myomectomy
Hysteroscopic resection
A differential for menorrhagia caused by endometrium growing into the myometrium
Adenomyosis
Treatment for myasthenia gravis
Pyridostigmine (cholinesterase inhibitor)
In myasthenia gravis, what are antibodies directed against
ACh receptors
Myasthenia gravis can be associated with a benign tumour of ?
Thymus gland (Thymoma)
Features of myasthenia gravis
Sx worsen with muscle use and improve with rest
Eye muscle weakness - ptosis, diplopia, blurred vision
Bulbar muscles - slurred speech, chewing/swallowing difficulties
Proximal limb weakness
Respiratory muscle weakness
Diagnosis of myasthenia gravis
EMG
ACh receptor antibody screen
Tensilon/Edrophonium test
In Lambert Eaton syndrome what are antibodies directed against
Voltage gated Ca channels
Management of myasthenic crisis
Plasmapheresis
IV immunoglobulin
Airway management
Monoclonal proteins found in Multiple Myeloma
IgG > IgA > Bence Jones
Abnormal production of monoclonal IgM suggests which plasma cell dyscrasia
Waldenstrom’s macroglobulinaemia
Multiple myeloma a) best initial test b) confirmatory test
a) serum protein electrophoresis
b) bone marrow biopsy
Diagnosis of organ damage in multiple myeloma
Hypercalcaemia
Renal insufficiency
Anaemia
Bone lesions on MRI
Diagnostic criteria for multiple myeloma
10+ % of clonal bone marrow plasma cells in biopsy plus at least one of;
- Organ damage - Ca, Renal, Anaemia, Bone lesions
- 60+ % clonal plasma cells in bone marrow
- Serum free light chain ration 100+
- > 1 focal lesion on MRI
Rouleaux formation on blood smear indicates which disease
Multiple Myeloma
Treatment of multiple myeloma
Chemotherapy
Stem cell transplant
Immunotherapy
Bisphosphonates, blood transfusion, EPO
What is the most common plasma cell dyscrasia
MGUS (monoclonal gammopathy of undetermined significance)
What is MGUS
Monoclonal gammopathy of undetermined significance
Monoclonal immunoglobulins in serum WITHOUT CLINICAL SYMPTOMS
< 10% plasma cells in marrow
No evidence of organ damage
Watch and wait as usually precedes multiple myeloma
Organism that cause croup
Parainfluenza virus
Organism that causes bronchiolitis
RSV
Organism that causes epiglottitis
HiB
Organism that causes whooping cough
Bordetella pertussis
Organisms that cause bacterial tracheitis
Staph aureus
Group A beta-haemolytic strep
Treatment of croup
Stat steroids
Management of whooping cough
Antibiotics
Admit if < 6 months old
Management of epiglottitis
Call anaesthetics and ENT
IV Cefotaxime
Management of bacterial tracheitis
Emergency airway management
Cefotaxime and Flucloxacillin
Stepwise management of chronic asthma in children
SABA \+ Steroid If < 5 + Motelukast If > 5 + LABA Refer, add PO prednisolone if >5
Children below what age should really be using a spacer with their inhaler
< 8 years old
Treatment of severe asthma in a child
- Sit up, high flow 100% oxygen
- Salbutamol 5mg nebulised in 4ml saline with Ipratropium bromide 0.25mg
- Hydrocortisone 100mg IV or Prednisolone soluble tablets (1-2mg/kg max 40)
- Consider one IV magnesium sulphate dose 40mg/kg over 2omins
- Aminophylline 5mg/kg IV over 20mins then IV infusion. Give with ondansetron to prevent vomiting
- Nebulisers continuously until improving then reduce frequency. Give Ipratropium 8hrly if needed
- Consider starting CPAP in the ED. If refractory or exhausted take to ITU
Primary biliary cholangitis features
Raised ALP Fatigue Pruritus Pressure point hyperpigmentation Xanthelasma, Xanthomata Clubbing, hepatosplenomegaly May progress to liver failure
Diseases associated with primary biliary cholangitis
Sjogrens
RA
Systemic sclerosis
Thyroid disease
Primary biliary cholangitis significantly increases the risk of which cancer
Hepatocellular cancer (20 X)
Antibodies associated with primary biliary cholangitis
Anti-mitochondrial antibodies - M2 subtype are highly specific
Smooth muscle antibodies
Management of primary biliary cholangitis
Cholestyramine for pruritus
Ursodeoxycholic acid
Fat soluble vitamin supplementation
Liver transplant
Diseases associated with primary sclerosing cholangitis
Ulcerative colitis
Crohn’s
HIV
Features of primary sclerosing cholangitis
Cholestasis –> jaundice and pruritus
RUQ pain
Fatigue
Standard diagnostic investigation for primary sclerosing cholangitis and the characteristic finding
ERCP or MRCP
‘Beaded’ appearance of biliary strictures
Management of primary sclerosing cholangitis
Cholestyramine for pruritus
Ursodeoxycholic acid
Liver transplant
What features would make you consider encephalitis rather than meningitis
Altered mental status
Seizures
Focal neurological findings (weakness, visual disturbance, aphasia, cerebellar finding, behaviour change)
What type of organism usually causes encephalitis
Virus
HSV, Japanese encephalitis
Vertigo: Recent viral infection Sudden onset Nausea and vomiting Hearing loss
Viral labyrinthitis
Vertigo:
Recent viral infection
Recurrent vertigo attacks lasting hours or days
No hearing loss
Vestibular neuritis
Vertigo:
Gradual onset
Triggered by change in head position
Each episode lasts 10-20 seconds
BPPV (benign paroxysmal positional vertigo)
Vertigo: Vertigo Hearing loss Tinnitus Sensation of pressure/fullness
Meniere’s disease
Vertigo:
Elderly patient
Dizziness on neck extension
Vertebrobasilar ischaemia
Vertigo: Hearing loss Vertigo Tinnitus Absent corneal reflex Signs of neurofibromatosis type 2
Acoustic neuroma
How can you explain what PSA is to a patient
A protein made by the prostate gland
Who is eligible for PSA testing if asymptomatic and ask for it
Men age 50+
Things to avoid in the lead up to a PSA test
Don’t ejaculate 48hrs before
Don’t exercise 48hrs before
Also can’t have it if you have a UTI or have had a prostate biopsy in the past 6 weeks
What are the 4 H’s and 4T’s for reversible causes of cardiac arrest
- Hypoxia
- Hypovolaemia
- Hyperkalaemia/Hypokalaemia/Hypoglycaemia/Hypocalcaemia/Acidaemia
- Hypothermia
- Thrombosis – coronary or pulmonary
- Tension pneumothorax
- Tamponade
- Toxins
What are the ‘shockable’ rhythms of cardiac arrest
Ventricular fibrillation
Ventricular tachycardia
What are the ‘non-shockable’ rhythms of cardiac arrest
Asystole
Pulseless electrical activity (other than TV)
Management of shockable rhythms
Compressions (30:2) and five first shock straight away
Shock every 2 minutes (every 5 cycles of CPR)
With the third shock give 1mg IV Adrenaline and IV Amiodarone
Give Adrenaline after every other shock
Consider Amiodarone again after 5th shock
Management of non-shockable rhythms
Chest compressions 30:2
Give 1mg IV Adrenaline straight away
Give further Adrenaline every 5 cycles of CPR
What 2 substances can cause pupil dilation in overdose
Benzodiazepines
Tricyclic antidepressants
ECG changes in tricyclic antidepressant overdose
Sinus tachycardia
Broad QRS
Long QT interval
Reversal of warfarin
Vitamin K
Prothrombin complex
Reversal of heparin
Protamine sulphate
What do you give if someone has taken too many beta blockers and is bradycardic
Atropine
Typical features of measles
Erythematous maculopapular rash Palms and soles spared Desquamation days later Prodromal illness - cough, coryza, conjunctivitis Koplik spots Fever, malaise, lymphadenopathy
Typical features of scarlet fever
Erythematous maculopapular rash Fine, rough, feels like sandpaper Linear petechiae in groin/joint folds Desquamation weeks later Sudden onset high fever Red flushed face with perioral pallor Strawberry tongue Recent strep throat infection/tonsillopharyngitis
Typical features of rubella
Pink maculopapular rash
Only lasts 3 days
Mild systemic disease
Red petechiae on soft palate
Typical features of slapped cheek
Maculopapular confluent rash that eventually becomes lace-like Initially red, flushed cheeks Mild systemic disease Arthritis Pruritus worse in sunlight
Presentation of HSP
Usually 3 days after a cough Purpuric rash on legs, buttocks Abdo pain Nephritis + haematuria High BP
Presentation of HUS
Usually 5-10 days after bloody diarrhoea in children
Low platelets
Microangiopathic haemolytic anaemia
Decreased renal function
5 key features of TTP
Microangiopathic haemolytic anaemia Low platelets AKI Neuro sx Fever
Secondary causes of ITP
Lymphoma Leukaemia SLE HIV HCV
Key features of Kawasaki disease
Fever >5 days
Bilateral conjunctival injection
Change in mucous membranes/strawberry tongue
Change in extremities - erythema and then desquamation of hands
Polymorphous rash
Cervical lymphadenopathy
Hungtington disease inheritance pattern
Autosomal dominant
Typical features of Huntington disease
Age 30-50
Initially - chorea, oculomotor disorders, hyper-reflexia, autonomic dysfunction
Later - hypokinetic, akinetic, dysarthria, dysphagia, dementia, depression, aggression
Neck lumps:
Midline, painless, firm
Elevates on swallowing and tongue protrusion
Thyroglossal duct cyst
Neck lumps:
Lateral to midline, anterior to sternocleidomastoid
Painless, firm
Doesn’t move on swallowing
Branchial cleft cyst
Neck lumps:
Posterior triangle
Transilluminates
Soft, compressible, painless
Cystic hygroma
Antiplatelet medication
Aspirin
Clopidogrel
Ticagrelor
Bilateral conjunctival injection
Change in mucous membranes/strawberry tongue
Change in extremities - erythema and then desquamation of hands
Polymorphous rash
Cervical lymphadenopathy
Kawasaki disease
Microangiopathic haemolytic anaemia Low platelets AKI Neuro sx Fever
TTP
Usually 5-10 days after bloody diarrhoea in children
Low platelets
Microangiopathic haemolytic anaemia
Decreased renal function
HUS
Usually 3 days after a cough Purpuric rash on legs, buttocks Abdo pain Nephritis + haematuria High BP
HSP
Maculopapular confluent rash that eventually becomes lace-like Initially red, flushed cheeks Mild systemic disease Arthritis Pruritus worse in sunlight
Slapped cheek/Parvovirus
Pink maculopapular rash
Only lasts 3 days
Mild systemic disease
Red petechiae on soft palate
Rubella
Erythematous maculopapular rash Fine, rough, feels like sandpaper Linear petechiae in groin/joint folds Desquamation weeks later Sudden onset high fever Red flushed face with perioral pallor Strawberry tongue Recent strep throat infection/tonsillopharyngitis
Scarlet Fever
Erythematous maculopapular rash Palms and soles spared Desquamation days later Prodromal illness - cough, coryza, conjunctivitis Koplik spots Fever, malaise, lymphadenopathy
Measles
Well score for:
a) DVT likely
b) PE likely
a) 2+
b) >4
Difference in calf circumference of ?cm indicates DVT
> 3cm
CTPA findings that are pathognomonic for PE
Wedge shaped infarction with pleural effusion
Medication to treat hyperprolactinaemia
Cabergoline or Bromocriptine (dopamine agonist)
What is the common cause of aplastic crisis in sickle cell disease
Parvovirus B19
Dactylitis is a finding of which blood disease
Sickle cell
Medication for sickle cell that can reduce number of crises
Hydroxyurea
Skull XR finding in myeloma
‘Raindrop’ appearance
