SAQ Learning Points Flashcards
Bone pain and low calcium due to kidneys:
Renal Osteodystrophy.
Low Ca, bone pain
Tx: Vit D, Calcium supplements, Low phosphate diet.
Vitamin D has it’s OH groups added in liver and kidneys.
Dialysis indications in AKI
- Volume expansion refractory to diuretics (e.g. pulm oedema)
- Hyperkalaemia refractory to therapy (insulin/dex, fluids, salbutamol)
- Acidosis refractory to medical therapy
- Uraemia
Gout; X-ray findings, start time for allopurinol?
Xray: No loss of joint space, Periarticular erosions
Start allopurinol 3 weeks after acute attack.
Pseudogout Risk Factors
- Hyperparathyroidism
- Hypothyroidism
- Wilson’s Disease
- Haemachromotosis.
Graves Disease; Treatments, and specific signs
Tx: Carbimazole and Propylthiouracil (pregnancy)
Specific Signs: Opthalmoplegia, Exopthalmos (and Proptosis), Thyroid acropachy, Pretibial myoedema.
Sickle-cell anaemia; Long-term treatment, management of sickle crisis?
Long-term: Hydroxycarbamide (Hydroxyurea), Folic Acid, Antibiotic prophylaxis, vaccines.
Sickle crisis: Analgesia, IV fluids, antibiotics, Oxygen, +-Transfusion.
Myeloma; What is it? Tests? Features + complications?
B-lymphocyte plasma-cell neoplasia; monoclonal antibodies (Mostly IgG).
Tests: Serum/Urine electrophoresis; monoclonal band. FBC/U&E. Bone marrow?
Features/Complications: CRAB; ++Calcium, Renal failure, Anaemia, Bone pain. Bacterial infection susceptibility due to monoclonal antibody dominance.
Gastritis; Bacterial causes, test for this, more features? Treatment of bacterial cause.
Gastritis caused by H.Pylori
Test: Urease breath test; give carbon-13/14 urea, H.P breaks it down to ammonia and CO2; measure C-13 CO2 for positive result.
More features; MALT lymphoma; management is to eradicate H.P
H.P eradication; PPI, Amoxicillin, Metronidazole (Clary instead of amox if needed).
Jaundice; types. Pancreatic cancer; Tumour marker? How is bilirubin formed?
Jaundice; choleostatic, intrahepatic, pre-hepatic. DON’T SAY CIRRHOSIS AS INTRAHEPATIC, say something like paracetemol overdose instead.
Pancreatic cancer; Ca19-9.
Bilirubin = Hb > Haem + iron > Porphyrins (e.g, biliverdin) > bilirubin.
What differentiates stroke from TIA?
Most common type of stroke and what is the most common cause of this? And what is the treatment for this?
> 24 hours symptoms or death = stroke. Otherwise TIA; This is now kinda been replaced with imaging as diagnosis; Diffusion weighted MRI best.
Most common (85%) = ischaemic
Cause of this most commonly = carotid stenosis/plaque.
Tx: Carotid endarterectomy
Epilepsy; definition:
A couple of types:
Ward treatment:
What is Todd’s palsy?
An idiopathic tendency to have seizures; transient abnormal electrical activity in the brain
Types (Where does it start, conciousness? Other features?) E.g; focal to general tonic-clonic seizure.
Nasopharyngeal airway, pillow, NOTHING IN MOUTH, Recovery position, IV loraz, O2, senior help.
Todd’s palsy; motor dysfunction for a while after seizure.
Hernia; Definition. Embryological cause of indirect hernia.
Obstructive hernia vs strangulated hernia.
Def: The protrusion of a structure through the wall that usually contains it.
Embry: Descent of testis through processus vaginalis; failure of this to close
Obstructive: Poo can’t go through
Strangulated: Blood can’t go through.
Haemorrhoids:
Internal vs external?
Investigations?
Symptoms?
Tx: Lifestyle and invasive.
Internal/external, above/below dentate line.
Ix: FBC, Sigmoidoscopy
Sx: itch, PR bleed, discomfort, mucous, soiling.
Tx: ++Fibre ++water, topical NSAIDS/steroids…. Then band ligation or haemorrhoidectomy
PSA; things that elevate it?
Grading for Prostatic cancer?
Intercourse, PR exam, UTI, prostatitis, catheter
Gleason grading–
<6 = not cancer
6+ = cancer
9/10 = High-grade cancer
Trauma X-rays;
Trauma further scans:
?C-spine injury… What would you avoid in initial ABCDE treatment.?
Trauma Xray Lateral Cervical spine, AP chest (ideally erect).
Further scans: CT head, CT Abdomen.
C-spine injury: Avoid head tilt (Jaw thrust instead); potentially avoid Naso-pharangeal airway (?Basal skull fracture).
Laryngeal Nerve: which side is more prone to injury?
Which laryngeal muscle does it not supply?
Sx unilateral palsy?
Left; longer course
Cricothyroid; supplied instead by superior thyroid.
Sx: quiet voice, cough, SOB, hoarsness.
Acute limb pain; no pulses, diagnosis?
6 symptoms
3 common causes
Why is tx needed quickly?
Tx?
Acute limb ischaemia
Pain, Pulseless, Paralysis, Pallor, Perishing cold, Parasthesia.
Thrombus (e.g from AF), arterial aneurism, iatrogenic damage, Trauma.
6h until irreversible damage
Oxygen, LMWH, IV fluids; THROMBOLYSIS or Arterial bypass.
Heparin Mechanism
DOAC Mechanism
Warfarin Mechanism
Heparin = Activates Antithrombin III (3 lines in an H) > This deactivates Xa to X.
DOAC: Direct Xa inhibitor.
Warfarin: Prevents vit K recycling; reducing II, VII, IX, and X (1972).
Difference between Critical Limb Ischaemia and Acute Limb Ischaemia?
CLI is an extension of peripheral vascular disease; when you have constant pain and have to hang leg over bed. ALI is it’s own diagnosis similar to Stroke, acute mesenteric ischaemia, etc; emoli in most cases.
Multiple large blisters; common populations this affects?
What causes this?
Investigations:
Sign in this disease?
Treatment?
Pemphigoid Vulgaris; Ashkanazi Jews + Indian
(Bullous Pemph is more in elderly).
Defunct desmosomes; autoimmune
Ix: Skin biopsy + autoantibodies
Nikolsky’s Sign; Separation when skin is rubbed.
Tx: Systemic steroids / immunosuppression.
Melanoma; risk factors
-Sun exposure
-Fare skin (Fitzpatrick skin type)
-Moles and lentigo
-Fam Hx, sunburn
Diabetic vs Hypertensive retinopathy: Stages
DR vs HTR: Haemorrhage type?
DR vs HTR? Cotton-wool spots?
Different stages signs?
DR: Non-Prolif and Prolif
HTR: 1,2,3,4
DR: Blot/spot haemorrhage
HTR: Flame haemorrhage
Both DR and HTR have cotton wool spots.
DR: Non-Prolif: Cotton + Blot Haem
Prolif: Retinal neovasc +- vitrious haem.
HR: 1. Arterial constrict 2. AV nipping 3. Cotten/Flame 4. Palliloedema
DR Mneumonic? Soak up the blood with cotton, then later replace the broken vessel.
HTR: Mneumonic: Constrict to stop blood flow, thickened walls compress on veins, arteries spur blood out in a flame, then pressure gets too much for the eye.
Pregnancy: Due date from last period?
Palpable uterus from what week?
Triple test vs Quad?
Quad in T21, T18, T13?
Just add 37 weeks to last period; 9 months + 7 days.
Week 12
Triple: Oestriol, hCG, AFP. Quad: Add Inhibin
T21: IBEA, Up,Up,Down,Down
T18: IBEA, Same,Down,Down,Same
T13: IBEA, Same,Same,Same,Up
Gestational Diabetes;
Mechanism of macrosomia?
Complications of GD?
Risks in future?
Macrosomia due to ++Glucose in blood > ++Insulin in blood > ++Fat deposition in foetus.
Shoulder dystocia (+-erbs palsy), sudden foetal death, commonly perinatal hypoglycaemia, polyhydramnios.
Future increased risk of both GD and T2DM.
Miscarriages:
Threatened
Inevitable
Incomplete
Complete
Missed
(Loss of pregnancy before 24 weeks)
Threatened: Os closed, foetus alive; Vaginal bleeding.
Inevitable: Os open; foetus still alive
Incomplete: Os open, foetus dead and most content expelled.
Complete: Os closed, all content expelled
Missed: Os closed, foetus dead inside uterus.
Stress Incontinence:
Causes
What worsens it?
What causes retention?
What tx for stress (And mechanism?)
Causes: pregnancy, vaginal birth, post-menopause (–Oestrogen), obesity, chronic constipation.
Worsens? Diuretics and sedatives.
Retention? Oxybutynin and NSAIDs.
Tx for stress incont? Duloxetine; SNRI; Noradrenaline builds up in synapse and this has sympathetic effect > ++Tone.
MMSE (Not recommended by NICE):
6CIT (Recommended by NICE):
MMSE: Time, place, following instructions, repetition, attention, recall.
6CIT: Year, month, Give address, Current time, 20-1, months of year in reverse, Repeat address.
Pyloric Stenosis
Base and electrolyte disturbance?
Palpation location?
–K+ –Cl- Metabolic alkalosis
RUQ, lateral border of rectus.
Neonates:
TORCH Screen?
Causes of Neonatal Jaundice <24h.
Fun fact about Conjugated bilirubin?
TORCH screen for neonatal infections: Toxoplas, “Other”, Rubella, CMV, Herpes.
Causes <24h: Rhesus or ABO issue, G6PD, Spherocytosis, Some of the amovementioned infections, hepatitis.
Conj Billi cannot cross the BBB so, while a high level is always pathological, it is not so toxic as unconj.
TB:
4 drugs + duration
Why four drugs?
Why ++Rates of TB?
Nodules on shins? Other diseases with this?
RIPE, Rifampcin, Iozoniazid, Pyrazinimide, Ethambutol; 6,6,2,2 months.
Four drugs to combat multi-drug resistance.
++Rates because: ++HIV, ++Use of immunosupressive drugs, ++Poor socioeconimic conditions and crowding
Erythema Nodosum; Sarcoid, Leprocy, Crohns, UC, COCP.
Rhabdomyolysis:
Causes?
Blood chemical that causes?
Name of effect on kidneys?
Urine: molecule found, and urine microscopy findings:
Causes: Long lie, ++Exercise, NMS, seizures, burns.
CK
Acute Tubular Necrosis (Myoglobin solidifies in renal tubules).
Molecule: Myoglobin
Findings: Muddy-brown casts.
Rapidly Progressing Glomerulonephritis
Causes:
Findings in urine and blood?
Acute treatment?
Special tests:
Quick AKI + Cresents in the Glomeruli
Causes: Goodpasture’s, GPA, SLE, Microscopic Polyarteritis.
Urine blood + protein. Blood: ++K+, Creatinine, ++Urea.
Acute treatment: Treat ++K+, Steroids.
Special: ANCA
(c = GPA/microPolyArt
p = maybe microPolyArt),
Anti-GlomBaseMembrane (GoodPasture’s)
SLE:
Treatment for this, and treatment for Anti-Phospholipid syndrome?
Complications / Features of APLS?
SLE Tx: NSAIDs, Hydroxychloroquine, Long term low-dose steroids.
APLS Tx: Aspirin, Clopidogrel, Warfarin, LMWH.
Features APLS: “CLOT”: Clotting issues, Livido Reticularis, Obstetric Issues, Thrombocytopoenia.
(Livido reticularis: Blotchy erythema on the limbs; blood flow issues).
What can repeated episodes of hypoglycaemia cause in a diabetic patient?
A lack of awareness of such hypoglycaemic events (Leading to potential eventual hypoglycaemic coma).
T2DM Triad?
Fasting glucose of what?
2h-post glucose what?
How much glucose in GTT?
Weightloss, Polydipsia, Polyuria
Fasting glucose (Before glucose) of >7
2h after glucose of >11.1
GTT = 75g of glucose in 250ml water.
CML:
FBC on chronic?
Film signs of chronic vs acute?
Treatment drug name, mechanism of action, and route?
FBC: High white cells
Film: Acute: Only blasts, chronic: Full spectrum of lifecycle of cell lineage.
Treatment? Imatinib, Tyrosine Kinase Inhibitor.
AML? Stands for?
IX:
Supportive Tx alongside chemo?
Acute MyeLOID leukaemia
Ix: Blood film + Bone marrow (After FBC of course)
Supportive tx: Blood transfusion, platelet transfusion, antibiotics, antifungals, antivirals, counselling.
Liver Cirrhosis
Tx for ascites?
Ix on drained ascites?
Ascites tx: Fluid restriction, low salt, spironolactone, ascitic drainage.
Drained ascites: Look for MCS, Albumin/LDH/Glucose, cytology, WCC.
Acute Mesenteric Ischaemia:
Artery supply to foregut, midgut, hindgut?
Causes of AMI?
Tx for it? Pre-surgical and surgical?
Arteries: Fore: Coeliac trunk, Mid: Superior mesenteric artery, Hind: Inferior MA.
AMI causes: arterial OR venous emboli, acute on chronic artery disease.
Tx: Fluids, Abx, LMWH, analgaesia, then resection of ischaemic bowel.
Spleen;
Red pulp and white pulp function?
Indication for removal?
Howell-Jolly bodies?
Red pulp: Filter RBCs
White pulp: Lymphoid tissue
Remval if: Cysts, neoplasia, hypersplenism, rupture.
Howell-jolly bodies are remnants of the nuclei in RBCs. They are MADE even if there is no pathology, but they are NORMALLY FILTERED by the spleen; so no-spleen = they show up.
Advantages and disadvantages of laparoscopic surgery over open?
Advant:
Less pain-relief needed,
less likely to bleed
?Infection risk less?
Smaller incision and cosmetic issues
Disadvant:
Longer surgeries needed
Vision less
Need for specialist equipment and training.
Renal stones:
Why pain in groin?
Why pain in ureter?
Procedure for acutely obstructed and infected ureter?
Groin pain: somatic groin nerves and visceral ureter nerves follow same path and get confused in brain
Peristalsis vs blockage > Squashed + ischaemia.
PERcutaneous nephrOSTOMY (Non-infected; stenting is ok, but do not insert a foreign body into an infected site)
Knee Injuries:
Unhappy triad?
Autograft for ACL?
Better description of lateral ligament test?
Unhappy triad: Lateral collateral, ACL, medial meniscus
(Think of the knee joint adducting forcefully, pressure medial side, extended lateral side, and kicked forward because of a tackle)
Patella tendon, quad tendon, hamstring tendon
One hand stabilises femur, other stabilises ankle; abduct KNEE joint for medial, adduct KNEE joint for lateral (So think about what the foot-hand is doing).
Hip Fractures:
Classification system?
Main breakdown of this system and respective managements?
Hemi vs total hip replacement?
Garden 1-4
1-2: Little risk of avascular necrosis; Fixation with DHS or nail
3-4: High risk; Hemi or total arthroplasty
Total if: Could walk in and out of hospital, not too comorbid, and are expected to keep ADLs up for 2 years.
Facial Nerve Branches (5)
Temporal
Zygomatic
Buccal
Marginal Mandibular
Cervical
BPPV:
Pathogenesis:
Medical management?
Otolith (Ear stones) within the endolymph; movement displaces these, and when they move this causes the endolymph to move.
Epley, and consider Beta-Histine (H1 agomist; dilates vessels in inner ear).
Open-Angle Glaucoma:
Patho compared to closed:
2 Investigations:
4 Medical Treatments:
Surgical treatment for
1. Open angle
2. Closed angle
Acute closed is acute angle (Gonio) closure, more acute pain. Open is when the angle is open, so the issue is more likely to be due to poor trebecular absorption.
TonoMETRY (Pressure) and Gonioscopy (Visualisation of the iridocorneal ANGLE)
Topical:
-B-Blocker (Timolol)
-Carb-Anhydrase Inhib (Acetazolamide)
-Prostaglandin Analogue
-Parasympathomimetics (Pilocarpine)
Surgical: (Basically solve problem)
1. Trabeculectomy
2. Laser Peripheral Iridotomy
ARMD: wet vs dry?
Test for distorted (wobbly) vision?
Test to look closely at the retina?
Treatment: 2 medical.
Wet: Quicker; new vessels which push the retina and cause the wobbly lines.
Dry: Slower, no neovascularisation.
Distorted vision: Amsler Grid
“Optical Coherence Tomography” - used to look at the thickness of the retina, the vessels, and the nerves.
Tx: Medical; Anti-VEGF.
Vitamin C, E, Carotine, and Zinc.
Baby blues, PPD, PPP incidence rates
Medical cause of baby blues and PPD:
Time frame for
1. PP Psychosis
2. PP Depression
50%, 5%, 0.5% (Roughly)
Hormonal changes, post-partum thyroiditis.
Time frame:
PP Psychosis: 48-72 hours, within 2 weeks.
PP Depression: Within 3 months.
Pre-Eclampsia Definition:
Test for toxicity of MgSO4?
BP >140/90 + Proteinuria after 20w pregnancy
MgSO4: Reflexes
Cervical Ectropion, what is it?
CIN I, II, III, what are they?
Tx for CIN?
Columnar epithelial growth outside cervical os on the normal squamous epithelium; looks red.
CIN I, II, III: Pre-malignant, invading through basement membrane; 1/3, 2/3, and 3/3 of epithelium respectively. III is high-grade, I is low grade.
Tx? CIN I + <25y : Active surveillance
Other: Large-Loop Excision Transformation Zone (LLETZ)
Alcohol Abuse Disorder Definition.
4 Signs of addiction
Disulfiram mechanism?
Problematic Pattern of use for over 12 months.
4 signs: 1. Failure of absitence attempts. 2. Narrowing of alcohol repetoire. 3. Tolerance / Withdrawal 4. Persistant use despite affect on life.
Disulfiram: Inhibits acetaldehyde dehydrogenase; buildup of acetaldehyde causes unpleasant symptoms.
Febrile Convulsion:
Admission criteria:
> 5 mins indicates:
Criteria: First episode or anything suggesting complex: >15 mins, focal, or >2 episodes in 24 hours.
- Need for benzos
- Parents should call ambulance
Rheum:
Dermatomyositis: Eye findings and red lesions on hands?
Antibodies for Dermato… ?
Ank Spond: Two “chest” findings.
Eye: Heliotrope
Hands: Gottron’s papules (Red papules on each knuckle)
Jo-1, Mi-2, ANA, RF.
Ank Spond: Aortic Regurg and Apical Pulm Fibrosis.
Name Early and Late Transfusion Reactions:
What is a “massive” transfusion?
Early: TRCO, TRLI, Acute haemolytic reaction (T2 hypersensitivity), Allergic/Anaphylactic (T1).
Late: Sepsis, Delayed hypersensitivity, transfusion-related purpura
Massive = >10 Units (Or total blood volume) within 24 hours.
Coeliac vs Crohns vs UC
Endosc/Histology findings
Coeliac: Crypt hyPERplasia and villous atrophy.
Crohns: Skip lesions, full thickness of wall, ++Goblet cells, strictures, rose-thorn ulcers.
UC: Continuous, mucosa only, loss of haustrations, ulcers
Coeliac: Associated autoimmune diseases?
Rash?
Cancers associated?
Thyroiditis, T1DM
Dermatitis herpetiformis
T-Cell lymphoma, Gastric, Oesophageal.
Amputation: Indication
Amputation: Considerations
Stages of wound healing: (4)
Critical PAD, Critical venous, critical nervous, necrotising fascitis.
Considerations: Maintain as many joints as possible (prosthesis consider), consider artery supply to stump (Recurrent artery supply?), consider stump dimensions for fitting prosthesis.
- Haemostasis (Plug forms)
- Inflammation (Macrophages + mesh)
- Proliferation (Vessels, collagen)
- Remodelling. (Scar improves)
PPROM:
Treatment:
Bishop score 5 criteria?
Erythromycin, IV Dexamethasone. Consider short course of tocolytics (atosiban / Nifedipine) to allow time for steroids to work
- Cervical effacement
- Cervical position
- Cervical consistency
- Cervical dilation
- Foetal station
Infective Endocarditis Criteria?
(Name 4 findings of IE on examination)
Blood culture rules?
Duke:
Major: Echo, 2x blood cultures, or specific blood cultures, new regurg.
Minor: Immune findings; Roth spots, janeway etc. Evidence of bacteraemia, fever >38, Risk factors, Embolic phenomina.
Take !!3!! blood cultures 30 mins apart, before antibiotics started, at 3 different sites.
OSA:
Scale used:
RF:
Cor Pulmonale meaning?
Epworth sleep-scale: Essentially how easily they fall asleep in the day.
RF: Alcohol, obesity, nasal polyps, large adenoids, large tonsils.
R heart failure due to pulmonary hypertension.
Large, medium, small vascultides?
Causes of mononeuritis multiplex?
Large: GCA, Aortitis
Medium: Kawasaki, Polyarteritis Nodosa.
Small: eGPA (Cheurg-Stra), GPA, AGBMD (GoodPast), HenSchPurpura.
Mononeuritis Multiplex: RA, AIDS, DM, Polyarteritis Nodosa,
Shingles: Virus?
Name of sign and SPECIFIC name of the branch of nerve which causes the rash on the nose?
Why don’t we like this sign?
HHV 3
Hutchinson’s Sign: Nasocilliary branch of Ophthalamic branch of Trigeminal Nerve.
Sign that sensation to cornea can be lost > Lost corneal reflex > Chronic abrasions to eye.
Obs Choleostasis: Main investigations
Main treatments:
Bile acids + LFTs
Antihistamines, Vit K, Ursodexycholic acid, consider induction of labour/Csec; especially if bile acids are raised >100.
Remember to rule out HELLP
Shoulder Dystocia:
Risk Factors: Before labour causes and causes during labour
2 Physical Interventions / Maneuvres?
Before labour: Macrosomia / GestDM / Obese mother
During labour: Prolongued labour / Use of oxytocin /
McRobert’s Manouvre (Mother hyperflexes hips)
Suprapubic pressure (Push shoulder down)
Cord Prolapse: Risk factors?
What to do?
RF: Low lying / placenta praevia / Polyhydramnios / Abnormal lie / Pre- or artificial rupture of membrane.
Don’t touch cord , Hold foetal head in ,
Foetal Blood Sampling:
Normal foetal pH?
Contraindications to blood sampling?
When would you do FBS?
pH above 7.25
Abnormal presentation, maternal infection, foetal bleeding, prematurity
.
Deprivation of Liberty; Things to remember:
Capacity; They need to lack this for the decision which puts their liberty in question.
MHA: Would it be better to use this?
Must be in patient’s best interests.
Must be avoided if possible.
Time frame: Should be as short as possible; no longer than a year.
Representative: Can someone, unpaid, vouch for this?
High calcium, refractory, treatment?
Chlamydia and Gonorrhoea ix of choice?
Why mouth unable to open in quinsy?
Treatments for miscarriage?
Hypokalaemia?
IV Bisphosphonates for ++Calcium
Chlam: First-catch + NAAT. Gonorr: Microoscopy + Gram-stain.
Quinsy: Pus causes pterygoid muscle spasm
Misscarriage: If needed: Analgesics, antiemetics, and consider misoprostol.
Hypo-K: Palpitations, hyporeflexia, hypotonia, bradypnoea.
2ww referral breast lump:
Non-lactational mastitis treatment?
Herceptin pre-treatment screen?
Gallactorrhoea, isn’t associated with what?
Over 30, NOT for nipple discharge, but for lump with or without pain. >50 for unilateral discharge or the others.
Non-lac: Co-ammox 14 days.
Herceptin: Echocardiogram
Gallactorrhoea NOT associated with breast cancer.
