SBA Questions Flashcards
A healthy year old man , 30, progressive severe retrosternal pain improved sitting foreword with a pericardial friction rub what would you see on the ECG?
Saddle shaped ST segment - Pericarditis
61 year old has exertion all chest tightness relived by rest - first degree heart block what will the PR interval be like
PR interval is greater than 200ms
43 year old African man has hypertension and diabetes mellitus whats the First line treatment
Ramipril - Always with diabetes give an ACE - I
normally African would give CCB - amlodipine
Asthma , hypertension, 67, tachycardia and irregularly irregular rhythm ( AF ) , high heart rate . BP and low resp rate how would you treat his hypertension and provide rate control
First line is beta blocker but if they are asthmatic you cant so give Verapamil ( CCB )
78 year old has hypertension and - Progressive lengthening of the PR interval with a dropped QRS what is this?
Second degree heart block : Mobitz 1 or wenckerbach pehnomenon
50 year old has leg pain on exertion and cramping in right calf when walking , worse if on an incline what is the first line Investigation?
ABPI and Duplex Ultrasound - Intermittent claudication of Periphral vascular disease ! Not DVT can be caused by atherosclerosis and 6 Ps : Pain, Pallor, pulselessnes,s parastehsia, paralysis, cold
First line is lifestyle , second is revascularisation , 3 is amputation
78, Fiti, Unwell, dizzy nausea , smoking, T2DM , no chest pain, hypotensive and ST elevation what blood test would you do?
Troponin - Atypical MI
35 year old man A and E with palpitations SOB, dizzy, chest pain , narrow complex tachycardia and SVT, valsalva and carotid sinus massage don’t work what do you do
Cardio version with adenosine - In shock straight to cardio version
What is a major complication of ACE inhibitors
HyperKalaemia
What does hyperkalemia show
Tall Tented T waves
Hypokalaemia
U waves, ST depression , T wav inversion
Mitral valve prolapse, low grade fever chills , fatigue , purple lesions on hand , dental surgery what investigation would you do ? What organism
Blood culture - Viridans Streptococci ( dental root canal )
Any person - Staph aureus
59 year old man comes to A and E with tearing chest pain , High BP. Absent pulse whats the gold standard investigation
CT angiography : Aortic Dissection - false lumen
First like USS may be if your desperate
18 feel unconscious swimming, congenital prolonged QT - what abnormal heart rhythm is he at risk of ?
Torsades de pointes - long pause on ECG between QRS and T wave ( long repolarisation time )
TDP is like the AM wave !!
65 has SOB acute , left sided chest pain worsened, bed bound , ECG shows regular Raytheon with R wave in V1 and slurred S wave in V 6 what is it showing ?
Right bundle branch block - William and Marrow acronyms
Only look at V1 and V6
Right loos like M =in V1 and W in V 6
William: W in V1 and M in V6
R wave: Bit going up (M) slurred S ( W) - RBBB
What is the underlying cause of the RBBB?
Pulmonary Embolism - Acute SOB, pleuritic chest pain, bed bound, recent surgery
Infant with Trisomy 31 has a pan-systolic Murmer at the left parasternal border whats the diagnosis
Ventricular septal defect: Downs most commen congential hear is VSD - 30%
TOF - 5%
What causes Rheumatic Fever?
Streptococcus Pyogenes - autoimmune condition and antibodies against it targets tissue - molecular mimicry - valvular damage
A 79 year old gentlemen has palpitations and lightheaded - go away , 120 bpm but irregular no clear P waves or ischaemia whats first line treatment ?
Metoprolol - haemodynamic ally stable and paroxysmal atrial fibrillation - use beta blocker if contraindicated digoxin or amlodipine, amiodarone is ventricualr tachycardias
30 has mild SOB, ejection systolic radiating to carotids what is it ?
Aortic Stenosis - ejection systolic loudest in aortic radiates to carotids
Mitral regurgitation - pan systolic radiating to the axilla
65 has chest pain radiation and ST elevation whats the immediate management ?
Morphine, aspirin, oxygen , GTN ( dont give atenolol
MONA : Morphine, oxygen, nitroglycerin, aspirin
79 crushing chest pain abnormalities in leads 2,3, and avF which artery is occluded ?
Right coronary artery - inferior leads
1, AVL and V 5 os LCx
V1-V4 is LAD
Cyanotic one month baby failure to thrive - TOF includes what defects :
Overriding aorta
Pulmonary valve stenosis
VSD
Right Ventricular hypertrophy
SOB worse on lying down , snores, stops breathing at night, peripheral oedema, basal crackles and raised JVP whats the first line to manage fluid overload?
Furosemide ( Loop diuretic ) - Congestive cardiac failure
Thiazide diuretics and aldosterone antagonists are second line
Other first lines are ramipril and bisoprolol
66 attends wellness check a GP , 30bpm no SOB, fit and well , hypertension and bronchiectasis , ECG shows 3 degree heart block what should you do?
No associations between P waves and QRS association , regular rate no connection - 3 degree - cardiac emergency - send directly to A and E - pacemaker
Escape rytham - bizarre QRS - wider
How does apixaban work?
Inhibits Factor Xa - DOAC
Warfarin is 1972 via vitamin K
Heparin inhabits thrombin
28 year old female has palps and dizziness - no medical conditions however drinks 47 units of alcohol and cocaine - saw tooth ECG , no P waves given diagnosis what is the definitive treatment ?
Atrial Flutter is saw tooth - definitive is catheter ablation of the circuit
BB are short term
81 collapsed , blacked out , light headed on standing , HTN, IHD, BPH and ex smoker, OD, bisoprolol, Ramipril, amlodipine, Bentroflumethiazie, tamsulosin all normal = but low sodium what caused the collpase?
Postural hypertension secondary to medications - tamsulosin and anti hypertensives - postural hypotension
Which is considered in CHAD3DS2-VSC ?
Age greater than 75 Female Sex History of CCF Previous stroke / TIA Hypertension DM Stroke/ TIA/ thromboembolism Vascular disease 65-74 Sex
23 has an ECHO after father passed away on a bike ride - HOCM what can you see on the ECHO?
Diastolic vetnricualar dysfunction ) LVhypertrophy, thickened septum, obstructs aortic valve
Exertion also dyspnoea, cough with pink frothy sputum perform a history and examination - heart failure
List some clinical signs of heart failure
What are the possible X ray findings
What blood test would confirm
How would you manage it
- Peripharal oedema, Orthopnea ( increased venous return - more oedema ) Paroxysmal nocturnal dyspnoea , bibasal creptiations
- Alveolar oedema, kerley B lines, Pleural effusion , cardiomegaly , dilated upper lobe vessel ( upper lobe diversion , ABCDE
- BNP N-terminal -pro-B Type natureitic peptide )
- Bisoprolol, Ramipril and furosemide : ACEI, Beta blocker , aldosterone antagonsit and loop diuretics ABAL
What is the difference between essentials and secondary hypertension
What Lifestyle advice would you offer a patient to reduce blood pressure
Name the most common cause of secondary hypertension
What scoring system assess risk of CVD disease
What type of medication for a score greater than 10%
Name a common side effect of this medication
Essential has no identifiable cause and secondary has one
Lifestyle: reduce salt / alcohol / caffeine, healthy balanced diet, regular exercise stop smoking
Commonest : Conns or Primary hyperaldosteronsism
QRISK score would then give a statin ( myalgia is the side effects ) - 10 years ( N and V)
55 Y/O post surgery coughing up blood streaked sputum and sharp unilateral chest pain worse on inspiration : BMI 30 and smokes 20 , high rate and resp rate:
What’s the diagnosis
What scoring tool would assess risk of her condition
List some risk factors
What’s the gold standard investigation and management
Pulmonary embolism - blood sputum, unilateral chest pain worse when breathing in
Wells score
Age, trauma, pregnancy, surgey , obesity, oestrogen,smoking
CT pulmonary angiogram and then treat with LMW heparin and warfarin
First line is Doppler - dual anticoagulant
28, chest pain, aching muscles and joints, sweaty and pale, bruising and track, small main fuel nodules ( Oslers nodes ) high tempurature normal ECG, haemturia
What is it ?
Which Pathogen ?
What is the next investigation
Gold standard investigation?
Infective endocarditis - Staphylococcus aureus, blood cultures, transesophageal echo
65 year old ongoing tight pain that comes and goes, raised BMI, sat down at rest, 2o smoking an HTN meds: ECG shows prinzmetals
How do you distinguish prinzmetals from unstable.
Give 2 non modifiable and 3 modifiable risk factors for angina
What lifestyle Advice would you give
What pharmacological Mangement
ST elevation in prinzmetals - transmural ischaemia in unstable causes ST depression due to subendocardial ischaemia
2 Non modifiable : Age, FH and ethnicity ( Angina is more commen in females MI in males)
Modifable: BMI, Smoking , diet , inactivity, stress, HTN, cholesterol and diabetes
Weight loss via exercise and diet and smoking cessation
First line : CCB e.g. Verapamil all Anginas get GTN
A 23 year old lady has unintentionally lost 8kg of weight over the last 8 months and is suffering from episodes of fatigue. She also complains of nausea, headaches, generalised abdominal pain and is feeling terrible overall. How would her cortisol levels react to the Synacthen test if she had secondary adrenal insufficiency?
Short ACTH no change long ACTH increase
-Synacthen stimulates the adrenal glands to secrete corticosteroids in secondary adrenal insufficiency
A deficit in which hormone in this patient’s condition has caused the development of hyperpigmentation?
ACTH - POMC proopiomelanocortin
Where do carcinoid tumours usually metastasise to>
Liver! - neuroendocrine tumours
A plasma aldosterone/renin ratio is performed and a diagnosis of primary hyperaldosteronism is made. Which electrolyte imbalances are associated with this condition?
Hypokalemia and hypernatremia
To much aldosterone - increases sodium reabsorption and water follows sodium - high sodium and hypertension and potassium is drawn out
Hypokalemia@ Weakness, flaccid paralysis and hyporeflexia
High aldosterone and low renin
With PTH, calcium and phosphate levels would you expect to find with someone with hyperparathyroidism caused by renal disease?
High PTH, low calcium and high phosphate - hypocalcaemia due to decreases 1-25 dihydroxycholecalciferol levels - more PTH and high phosphate as kidneys cant excrete it
A 54 year old man with known DMT2 presents into the clinic complaining that his medications are not working. He is still presenting with symptoms despite compliance to medication. However, recently he has developed a loss of appetite and an upset stomach. After taking some investigations the patient is said to have lactic acidosis with severe liver failure.
He is currently on triple therapy for his diabetes taking metformin + sulfonylurea + SGLT-2 inhibitor (glifazone), as well as, Ramipril for his hypertension.
Metformin: Increases sensitivity, causes weight loss but GI disturbances, peripheral neuropathy and lactic acidosis
Sulphonylureas: Increase insulin secretion in B cells but GI disturbances, hypoglycaemia and weight gain
Pioglitazone: Reduces reistance but bone fractures , weight gain and bladder cancer and is contraindicated in HF and bladder cancer
DPP-4: Increase DPP-4 to increase insulin and lower glucagon - headache and acute pancreatitis but is cardioprotective
SGLT-2 Inhibitors: Inhbit cotransporter to reduce glucose reabsoprtion and increase excretion of glucose but can cause UTI, general pruritis , DKA and back pain - cardioprotective but CI in T2DM
A 48 year old lady presents to your surgery complaining of numbness and tingling in her right hand. She also appears to have large hands, rough/tanned skin and a prominent jaw and forehead. None of her clothes fit as she has also gained 10kg in the last year. Which nerve roots are associated with the condition presented above?
Carpal tunnel syndrome: C5/6-T1 median nerve of the medial and lateral brachial plexi cords
A 45 year old woman presents to her GP complaining of feeling unsteady. She has mentioned that she has become increasingly more sweaty recently despite it being the winter months. Along with this she is saying that she has begun to eat more than usual. But what’s confused her most is that despite this, she is still losing weight.
However, what’s been most worrying for her is that she has begun to develop what seems to be waxy discoloration to her lower legs which she describes as orange peel appearance.
Which antibody is most likely to be associated with the condition presented above?
Graves - TSH receptor antibodies
Hashimotos - Anti TPO
Anti DsDNA- SLE
Anti thyroglobulin is hashimotos
Graves triad: Goitre , orbitopathy, pretibial myxoedema
A 15 year old boy with poorly controlled type 1 diabetes comes to A&E with a 2 day history of abdominal pain, vomiting and fruity smelling breath. What is the diagnostic criteria for his suspected condition?
Ketones >= 3 mmol/L, glucose > 11 mmol/L and pH < 7.3
A 52 year old male has noticed that his skin is becoming coarser and his shoes no longer fit. Looking over past pictures he has noticed overall enlargement in peripheral limbs. He was initially referred for surgery but is no longer fit enough to undergo the procedure as he is suffering from heart failure as a result of this condition. What is the next best management for him regarding this condition (not heart failure)?
Somatostatin analogue
1st line - transsphenoidal surgery 2nd line - Somatostatin analogue (SSA) octreotide or lanreotide SE: pain at injection site, abdo cramps, flatulance, loose stools, ↑ gallstones, impaired glucose tolerance \+/- Dopamine agonist if GH secretions persist 3rd line - GH-receptor antagonist (GHRA) pegvisomant 4th line - Radiotherapy
An elderly gentleman is difficult to rouse and appears less responsive than usual. He is currently recovering from a chest infection in hospital and has a patent cannula for medications/fluids. Significant PMH includes type 2 diabetes and ischaemic stroke which caused him to become NBM. His blood glucose is currently 2.3 mmol/L. What is the best management for this patient?
IV glucose - NBM so oral glucose is not an option and there is no point giving glucagon because they dont have enough glucose stores
A young gentleman presents to the GP practice complaining of sweating more than usual. Under further investigation he tells you that he has also noticed more frequent headaches and a feeling of his heart pounding his chest. He tells you that this has gotten him more anxious recently as this has never happened before.
Given the diagnosis, what is the mechanism of action for the first line treatment given to this patient?
Blocks the alpha-adrenergic receptors leading to vasodilation
1st line in hypertensive crisis - phentolamine
2nd line is sodium nitroprusside
Hyper / Hypo hypothyroidism
What is the difference in symptoms between the two? List 5 for Hyper and 5 for hypothyroidism.
How does first line management differ in Hyperthyroidism + Hypothyroidism?
What is the most common cause of hypothyroidism in the developing world?
Hyper: Sweating, heat intolerance, weight loss, manic restlessness, palpitations, preorbital myxoedema, erythematous oedematous lesions, thyroid acropachy , diarrhoea, oligomenorrhea , anxiety and tremor
First line: Propranolol, carbimazole and iodine
Hypo: weight gain , lethargy , dry cold, yellow skin, non pitting oedema, dry coarse scalp, constipation, menorrhagia, carpal tunnel and decreased tendon reflexes
1st line is levothyroxine
Developing : iodine deficiency and hashimotos thyroditis
What glucose levels are seen in a non diabetic, pre-diabetic and diabetic?
Describe the management plan in a patient with newly diagnosed diabetes mellitus type 2 + what would be the follow up management if symptoms progress?
What are some complications of DM?
HBA1c less than 42, then 42-47 then 48 and over
Lifestyle modifications - Diet, Exercise, Weight loss
Monotherapy - Metformin
Dual therapy - if HbA1c rises to 58mmol/mol (7.5%)
Triple therapy - if HbA1c rises to 58mmol/mol (7.5%)
Metformin
DPP4 inhibitor
SU, Pioglitazone
SGLT-2 inhibitor
Thiazolidinedione
insulin based therapy ONLY WHEN MEDS FAIL
Insulin or Glucagon-like peptide (GLP) analogues
GLP analogues - incretin mimetics
Incretins - gut peptides that work by increasing insulin release.
If 58 mmo/L / 7.5% or higher then step up the treatment
Acute - DKA, HHS, hypoglycaemia
Chronic
Microvascular - retinopathy, nephropathy, erectile dysfunction, neuropathy (10-20 years after diagnosis in young patients)
Macrovascular - atherosclerosis, ACS, stable angina, PVD, stroke
Diabetic foot and ulcers
Cushing’s syndrome and Cushing’s disease
What is the difference between Cushing’s disease and Cushing’s syndrome?
Which investigation can be used to differentiate between the two conditions?
How does a patient with Cushing’s syndrome present (5 marks)?
Cushing’s syndrome refers to the state of elevated cortisol levels
Cushing’s disease is specifically caused by an ACTH secreting pituitary tumour (pituitary adenoma)
Dexamethasone suppression test
Overnight
Cushing’s syndrome (including disease) is confirmed when there is no suppression
48 hour
Cushing’s syndrome (not including disease) = no suppression
Obesity, buffalo hump,purpura, abdominal striae, muscle weakness, poor wound healing, hypertension, moon facies, thin skin, amenorrhea,
You are an F1 on the endocrine ward and your consultant shows you lots of different ranges of TSH and T3/T4 levels and asks you to interpret the results.
Which conditions would most likely cause the following TSH and T3/T4 results?
You are an F1 on the endocrine ward and your consultant shows you lots of different ranges of TSH and T3/T4 levels and asks you to interpret the results.
TSH: Low T4: High
TSH: High T4: Normal
TSH: High T4: Low
TSH: Low T4: Low
- Primary hyperthyroidism e.g. graves disease, thyrotoxicosis
- Poor thyroxine compliance or subclinical hypothyroidism
- Primary hypothyroidism e.g. hashimotos
- Secondary hypothyroidism
A patient comes into the Hospital with suspected DKA.
What are the first line treatments you would offer?
What ecg changes are seen in a patient with hyperkalemia (list 4)?
What arrhythmia is a consequence of untreated hyperkalaemia?
A patient comes into the Hospital with suspected DKA.
What are the first line treatments you would offer?
IV Fluids (0.9% Sodium Chloride)
IV insulin +/- Potssium
What ecg changes are seen in a patient with hyperkalemia (list 4)? Go - Absent p waves Go Long - prolonged PR Go Tall - Tall T waves Go Wide - Wide QRS ‘Sine’ Wave appearance
What arrhythmia is a consequence of untreated hyperkalaemia?
Ventricular Tachycardia
Occurring due to cell membranes becoming partially depolarised resulting in a lower threshold potential -> Ventricles contract quicker
Shane is 34yr old male with Down’s syndrome. He has recently been complaining of increasing breathlessness and fatigue over the last 3 or 4 weeks. Upon looking at his medical record, you also notice he has been getting infections much more commonly than normal.
On examination you note bruising on his legs but otherwise normal. Which of the following are you most likely to see on a peripheral blood film?
Auer Rods
Bone marrow infiltration and failure will lead to: Bruising / bleeding - thrombocytopenia Infections - leukopenia Breathless, fatigue, pale - Anaemia (pancytopenia if all 3 are present)
Acute myeloid leukaemia: Age points to AML , ALL is younger and CNS - smudge cells
Katie, a 25-year old student has been struggling with tiredness for a few months. She presented to the GP having developed weakness and pins and needles in her hands and feet, and difficulty with balance and walking. She has been following a vegan diet for the past 7 years.
What blood tests would you carry out and what would you expect the results to be? (3 marks)
What blood tests would you like to carry out and what would the likely results be? (3 marks)
FBC
↓Hb
↑MCV (macrocytic anaemia)
Blood film
Hypersegmented neutrophils (>5 lobes) and presence of oval macrocytes
Serum cobalamin ↓
6 month baby A and E high fever and rashes that don’t disappear , unwell in pain what is it
Meningitis - non blanching rashes indicative of meningococcal infection and fever
GB: Weakness of legs and arms, campylobacter - cant close eyes
Encephalitis: Weakness and sleepiness
Pneumonia: Non productive cough and breathing difficulties
IE: Fever and new murmer
Alice has meningitis causes by a fungus infection what findings on LP
Bacterial : Granulocytes, protien high and glucose low
TB and Fungal: Lymphocytes present protien high glucose low
Viral lymphocytes , protien high and glucose normal
19 and headache that comes and goes , studying for exams around whole forehead but no cough or cold or fever ?
Tension headaches - bilateral pain behind eyes, under stress, low sleep
Cluster: Headache is unilateral with pain in episodes, rhinorrhea and tears
Migraines: Unilateral puking photo, sound phobia and aura
Sinusitis: bilateral hurts in all, fever and sickness
Temporal Aura: Sharp unilateral pain that comes for a few seconds that goes away when touching or shaving face
23 unilateral headache 3 years comes and goes, weird zig zag lines before getting headaches, father has it to and asthma what is the prophylactic treatment?
Migraine with aura - normally beta blockers but asthmatic so topiramate ( anti epileptics )( not in pregnancy ) - contraceptive
Verapamil is used for cluster
Sumatriptan is first line for migraines with an NSAID
Amitriptyline used if both cant be
Mary has severe pain on one side of her head that comes and goes very tender and intermittent jaw claudication ?
It is Giant cell arteritis - jaw claudication and severe pain
First line is CRP and ESR
Gold standard is Temporal artery biopsy
Treat with prednisolone - vessel Inflammation
Can causes vision loss, stroke , blindness ( temporal close to optic )
Sarah is presenting to A and E with a seizure after collapsing , lost conciousness, 12 weeks pregnant diazepam and lorazepam didn’t help - arms and legs flailing and jaw clenching ?
Generalised tonic clonic seizure - failing and clenching more then 5 minutes its now become status epilepticus
Because lorazepam didn’t work your then you give lorazepam again then phenytoin
Epilepsy is seizures of unknown cause she is pregnancy so it may be pre eclampsia
2 or more 24 hours apart and Eliminate all causes e.g. electrolyte imbalances
If they didn’t have epilepsy lamotrigine - pregnancy
Weird jerks, all the time , lost structure -19 year old boy
Focal seizures - Jacksonian march - arms to back - to leg
To young for Huntington’s chorea - 40 and no FH and no behavioural change
petit mal - absence seizures, staring loss of awareness
Jack is 59 - stroke like symptoms - headaches, feeling dizzy, nauseous, homonymous heminapoia , weak , HT, Hcholestroal and diabetes what is first line investigation ?
Order CT scan - positive for Ischaemic stroke - IV alteplase can be given within 4.5 hours so use aspirin and mechanical thrombectomy ( 6-24)
Posterior stroke but if it was double vision also posterior circulation - lateral Rectus and superior oblique
Amaurosis fugax
Check to make sure its not haemorrhagic
72 year old man has unusual hemiparesis cant life arm and leg but can feel what is he having:
Lacunar stroke - motor not sensory function - penetrating arteries not main
Stroke aetiology: AF, atherothromboembolism of carotid
Strokes are either : Total or partial anterior circulation Posterior TIA Lacunar
Sudden onset headache, soreness around neck and shoulders and photophobia whats the next step in management worst in first 3minutes
Subarachnoid haemorrhage - severest pain in first 3minutes then gets not as bad - CT scan
This is Menigism : headache, photophobia and neck stiffness ( SAH and Menigitis , migraines ) LP 12 hours after onset to allow xanthochromia
Migraine : Mild to moderate is paracetomal and high is rescuer with sumatriptan
What are complications of menigism:
- Hydrocephalus and vasospasm - nimodipine
- seizures, rebleeding and electrolyte imbalances
67 has confusion in A and E with traumatic flow to the head , recovered quickly, past medical history, high cholesterol, crescent shaped haaematoma on the left with midline shift what is the most common cause and 4 risk factors:
Subdural haemorrhage - rupture of the bridging veins
- hypertension, trauma, age, alcohol, infant abuse shaken babies, and anticoagulants
Acute - younger
Chronic in olde r-n atrophy stretches bridging veins - ruptured due to trauma
Joe is 59 detained under mental health act, acting strangely , rude comments, addenbrookes normal but atrophy of the right frontal lobe what is the diagnosis ?
Acting weird and histopatholhou of Alzheimer’s: Neurofibrillay tangles, beta amyloid s, atrophy , loss of ACH productions
Jane is 30 with acute pain onset in left eye, seeing double cant tell colours apart, more tired, dragging foot, lesions in white matter? How would you manage
Multiple Sclerosis - optic neuritis :2 episodes disseminated in time and space
Methylpredisalone - gabapentin is for pain
Propranolol
Types of MS
Relapsing remitting,progressive primary and secondary progressive
4 cardinal brain tumours Sympotyms?
Raised ICP, focal neurological deficit. visual disturbances, seizures, lethargy
Lung tumour can metastases to : Brain liver adrenal and bone
Lung tumours met from: Bowery, bladder, breast, renal cell carcinoma
Name 5 places prostate can golf L prostate, kidney, breast and bone
43 year old has progressive difficulty walking and lower back pain, tripping and cant climb stairs, tingling and numbness , food poisoning , what is the most important parameter to moniter?
Guillian Barre syndrome - gastroenteritis , ascending polyneuropathy
FVCapacityb - monitor pulmonary function because of ascending neuropathy to diaphragm - failure
A 40 year old is referred to a neurology clinic - double and blurred vision more tired no abnormalities which of the following tests is she positive for?
Myasthenia gravis - gets worse towards end of day - antibodies to ACH receptors
If its negative to Anti - MUSK
Bedside test: ICE PACK test and upgaze
Scan - Thymus CT
Lambert Eaton - SCC - antibodies to pre synaptic voltage gated calcium channels
Not MS no pain
A 28 year old construction worker has night numbness and tingling , shaking hands relives symptoyms, no weakness of ahnds - affects thumb , index and middle fingers, no wasting , wore normal, tapping the wrist with a tendon hammer reproduces symptoms - tinnels test
Median neuropathy and carpal tunnel syndrome - construction worker and afects thumb, index and half of middle - median nerve
Tinnels positive and phalens test
Aetiology: Idiopathic, pregnancy, high BMI, wrist fractures, RA, severe oedema and HF, occupation
Electrophysiology - prolongation of action potential - EMG
TX: Wrist splints 1st line in mild or pregnancy
Corticosteroid injections
Surgical related if severe, non pregnant - definitive
Median nerve - flexion loss rock
Radial - extension loss paper
Ulnar - finger abduction and abduction loss scissors
69 presents with back pain and dragging right foot, Dorsiflexion weakness, normal inversion and sensory loss of medial aspect whats the cause?
Foot drop - emergency is cauda equine but most common is common peroneal nerve palsy and L5 rediculopathy
In spinal nerve compression - lose sphincter and bladder control - high storage gait
Common peritoneal never e- lose version and sensory loss due to compression a fibula neck e.g. leg crossings , kneeling bakers cyst and platers casts
An 84 year old man has a pill rolling tremor at rest:
What imaging would confirm diagnosis and what do your expect to see
What lesion in the brain
Apart from tremor give 2 other clinical Parkinsons hallmark
Name 2 other causes of Parkinsonism
Name 3 medications
What about if tremor when anxious relived by alcohol
Parkinsons
Use DATscan - substantia nigra - degradation and degeneration
MRI lesion would be Lewy bodies
Tremor, bradykinesia and rigidity
Multi - system atrophy, drug inducesd, progressive supranucleur palsy and cortico-basal degeneration
Medications: Levodopa ( Dyskinesia , involuntary movement, falls , postural hypertension) Dopamine agonist - bromocriptine , bropinarol ( pulmonary fibrosis, increase gambling and impulsivity )MOA_-B inhibtors
Benign or essential listening tremor
You are a junior doctor in GP a 70 year old man is struggling to wee whats the first line?
Tamulosin - BPH its an alpha blocker which allows relaxation of the prostate muscle
Which arteries supply 80% of the blood to the brain
Internal Carotids - supply 80% with 20% being vertebral
A 16-year-old boy presents to A&E with severe pain in his left groin area that started when he was playing football with his friends. On examination, the left side of his scrotum is red and swollen and his cremasteric reflex was absent on the left. What is the diagnosis?
testicular torsion
Hydroceles, varicoceles, and epididymal cysts are normally painless. In someone with epididymitis the presentation is similar but, the cremasteric reflex would be present. The cremasteric reflex involves the testis moving upwards when the inner thigh is stroked.
What isnt a cause of ischaemic stroke: Vasculitis, embolism, thrombosis, carotid artery dissection, aneurysm rupture
Aneurysm rupture
A 52-year-old man presents after having another episode of severe pain down the left side of his abdomen. He previously had an episode a few days ago. He says the episodes don’t last very long but when they happen, he can’t get comfortable and describes the pain as the worst pain he has ever felt in his life. He says he sometimes feels sick when the pain happens. What would be the best investigation to perform?
This presentation is consistent with kidney stones. NCCT-KUB is the gold standard investigation for kidney stones.
An 81 year old lady atends your GP practce asking about her
risk of having a stroke. She has a past medical history of type
2 diabetes and hypertension and is on warfarin. Which of the
following factors does not increase her risk of having a
stroke?
Gender
NM: Male, older age, FH, ethnciity, APL
Modifable: HTN, DM, CVD, PVD, Hyperlipidaemia, excessive alcohol use
A 72-year-old man has recently been diagnosed with chronic kidney disease (CKD). Some blood tests have been done which show his glomerular filtration rate (GFR) is 48ml/min/1.73m2. Which stage of CKD is this?
GFR is how well the kidneys are able to filter blood and is an indication of kidney function. Normal GFR should be at least 90 which is stage 1. Stage 2 -> GFR between 60 and 80 Stage 3a -> GFR of 45-59 Stage 3b -> GFR of 30-44 Stage 4 -> GFR of 15-29 Stage 5 -> GFR of less than 15
A 21 year old student presents to A&E with reduced consciousness following a
head injury which he sustained afer getng in a fght at the pub several hours
ago. You take a history from his friend who has brought his to A&E.
His friend tells you that he did not lose consciousness afer hitng his head on
the ground but was drowsy and confused. He then improved and was okay for
a couple of hours apart from having a headache. He then started vomitng and
became unresponsive. What do you think is the most likely diagnosis?
Extradural haemorrhage - lucid interval
A 7 year old girl presents to the out of hours GP with fever,
headache and a rash. On examinaton she has a stf neck and keeps
covering her eyes to avoid looking at the bright lights in the clinic
room. What do you expect the rash to look like?
Non Blanching petechial rash
A 32 year old gentleman presents to your GP practce complaining
that his legs feel weak. On further questoning, the weakness
started in his ankles a couple of days ago but is now afectng the
whole of his legs. He says that he’s fnding it really hard to walk
upstairs and stand up from the sofa. He has no other symptoms. He
is normal ft and well and takes no regular medicaton. He had a bit
of a cold a few weeks ago but he tells you it wasn’t anything
serious. What is the most likely diagnosis?
Guillian Barre syndrome
A 78 year old woman atend your memory clinic with her daughter.
Her daughter tells you that her memory has been getng worse
over the past 12 months. Recently her neighbours have found her
wandering around the street late in the evening. She is otherwise
well and take no other medicaton apart from a multvitamin. What
is the most likely diagnosis?
Alzheimers
A 78 year old woman atend your memory clinic with her daughter.
Her daughter tells you that her memory has been getng worse
over the past 12 months. Recently her neighbours have found her
wandering around the street late in the evening. She is otherwise
well and take no other medicaton apart from a multvitamin. What
is the most likely diagnosis?
Cheese Oral contraceptive Caffiene Anxiety Travel Exercise
a. Defne an ischaemic stroke. (2 marks)
b. Give 2 modifable and 2 non-modifable risk factors for a
stroke. (4 marks)
c.
You perform a neurological examinaton. Other than his
facial droop, list 2 other signs you may fnd? (2 marks)
d. What is the 1st line investgaton? (1 mark)
e. Your 1st line investgaton shows no sign of a haemorrhagic
stroke, what inital treatment would you give? (1 mark)
jckxbzbzlx
) zxxz
List 3 signs of Parkinson’s disease (3 marks)
Bradykinesia, rigidity, tremor, postural instability…
b.
Explain the pathophysiology of Parkinson’s disease (2 marks)
Progressive neurodegeneraton of dopaminergic neurons in the substanta
nigra resultng in dopamine defciency which results in reduced movement
initaton - increased inhibiton of the thalamus
c. Name 2 other diferental diagnosis. (2 marks)
benign essental tremor, lewy body dementa, drug induced parkinsonism,
stroke, PSP, MSA, Wilson’s disease
d. Give 1 pharmacological and 1 non-pharmacological aspect of PD management (2 marks)
Pharmacological: levodopa, dopamine agonists, MOAB inhibitors
Non-pharmacological: physio, OT, SALT, deep brain stmulaton
e.
Name 1 complicaton of Parkinson’s disease (1 mark)
Reduced quality of life, depression, treatment side efects, dementa,
constpaton
a
A 73 year old right-handed man presents with sudden onset weakness of his right arm and leg and slurred speech. He
has a history of ischaemic heart disease, diabetes and uncontrolled hypertension.
On examinaton, he is alert and is able to provide a history, although his speech is not normal. He has facial asymmetry,
and profound weakness of his right arm and leg. Non-contrast CT scan done within 40 minutes of symptom onset shows
no obvious acute pathology. Blockage of which artery is likely to be responsible for his syndrome?
Left middle cerebral
Anterior - personality and legs
21 girl seizures
Lamotrigine
Carbamazepine would be if he would
A 30 year old man is referred to the clinic with sensory loss on his litle fnger and the lateral half of his ring fnger. He
has weakness bending his fngers although he can bring his thumb up vertcally with good resistance. Refexes are
preserved. Which nerve has he injured?
Ulnar
Radial - base of thumb and back of hand
median is indez and middle and half of the ring on palmar sid e
A 72 year old woman is reviewed in neurology outpatents for ongoing management of her Parkinson’s disease.
She was diagnosed 3 years ago when she notced a subtle right side restng tremor and generalised slowness of
movement. She takes co-careldopa daily, and last year was started on entacapone to reduce her end-of-dose efect.
Recently she has notced the development of slow writhing movements of her upper limbs, most prominent in the
morning.
What is the underlying cause of the patent’s new symptoms?
Long term levodopa - writhing movements of the limsb
progression of parkinsons - ridgidty nad trenir
A 68 year old man with a history of hypertension obesity and type 2 diabetes presents with fatigue, swollen legs and itchiness GFR is 20 whats the diagnosis
Stage 4 - know CKD and AKI - water retintion, fatigue, toxin metabolise build up ( urea ) 1 - above 90 2 - 60 - 89 3A: 45- 59 3b : 30-44 A 15-29 5 less then 15 renal failure
Lightheadeness and dizziness out of bed or office chair, fainted , what medication is doing this:
Tamulosin- BPH can cause postural hypertension
furosemide can cause it to but they are CI in CKD
50 year old man presents to A and E with a 1 hour history of sudden onset left sided flank pain radiating to groin - stabbing 10/10 nauseous and IV tiny
NCCT - KUB ( renal colic ) - sudden onset ipsilateral pain radiating down groin, loin to groin cant sit still
Gold standard - NCCT KUB - contrast can damage
Renal ultrasound younger and reoccurring
Watch and wait. Treat , tamsulosin, anti emetic , surgical innervation
KUB - X ray is first line but cant see pure Uric acid
76 PMS women has pain urinating and frequancy - has previous epsiodes which are treated with NFT:
E.Coli ( Klebsiella second )
Facial oedema - total body swelling, face , abdomen scrotum and fever had a viral illness and fever, heavy protienuria what is it - 5 year old?
Minimal change disease !
IgA is post tonsillitis an dis nephritic - haemturia and mimial protienuria
Hoskins - 20 or 75, painful lump after a night alcohol
Acute glomerulonephritis post strep adults
A 70 year old has puffy legs and fatigue - Periphral oedema but normal - antibiotics for infection which antibiituc causes AKI
Gentamicin
What can chloramphenicol do
Bone marrow suppression and amoxicillin can cause hypersensitivity
6 year old feels under weather - puffy barely pees, bacterial tonsillitis, protien and blood in the urine
Post streptococcal glomerulonephritis
IGA nephropathy = 2 days
Post strep is 1-3 weeks
Wilma Tumor - mass
50 year old - haemorrhagic stroke, well no fever or dysuria, recurrent UTI, FH of CKD and passed away from a stroke at 65
Renal USS- haemorrhagic stroke and CKD, recurrent UTIs, FH, PKD
75 year old has difficulty Uric ting and bone pain, prostate is hard and irregular , lost weight which part of the prostate is abnormal?
Peripharal zone becomes cancerous
Transitional zone is BPH
A 74 year old male has haemturia and and lethargy with background of schistosomiasis what kind of bladder cancer is it ?
Squamous cell carcinoma - schistosomiasis
Normally urethilial carcinoma
Which cancers spread to the bone
Kidney Thyroid Breast Prostate Lung
Modes of cancer transport
Haematological
Peritoneal
translimical
Lymph node
Worsening left scrotal pain and white urethral discharge, tender erythematosus swollen left scrotum, intact cremasteric reflex and relief with elevation
Epididymo - orhcitis
Cysts , hydrocele and tumour - painless lump
Testicular torsion is an acute emergency - phrens reflex negative
19 has dysuria - unprotected oral and veg animal intercourses , slight white dispatcher no tenderness - chlamydia what is the first line management?
Doxycycline
Not good in pregnancy - erythromycin or amoxicillin or axirthyromsyicb
34 otherwise healthy fever, haemturia, increased frequancy right sided back OAB, - pyelonephritis whats the classical triad
Nausea and vomiting, fever and loin /flank pain - E.coli , female, vesicles ureteric reflux
Cephalaxin
Take sample before MSU
Broad spectrum then specific
66 - urgency’s nd frequancy , 12 times a day and. Times a night she leaks urine occurs as she stands up which nerve contracts the detrusor
Pelvic nerve
Symapethic is hypogastric nerves fight and flight - relaxes ( T12 - L2)
Parasymapethic Pelvic S2-S4
Pudendal is sphincter somatic ( S2-S4
KNOW BRACHIAL PLEXUS, lower limb innervation ( mononeuropathy s )
35 non specific set half discomfort - 2cm by 1cm smooth painful mass, testicular cancer and referred to US what is associated with the diagnosis ?
Increased serum alpha feta protien - all testicular cancers raise AFP
Germ cell - raise afp and HCG
Gynacomasteia
Hyper thyroidsm
52 has so we pain down left side of the abdomen - worst pain whats the best investigation ?
Non contrast CT of the kidneys ureter and bladder - kidney stones but if pregnant it was US
What is an example of land field group A strep?
Streptococcus pyogenes - clindamycin
A 28 year old man attends A and E with a 3 month of history of night sweats , weight loss and a persistent productive cough with red blood what would you do ?
Ziehl Neelson stain on sputum - 1 pink bacilli is positive
Man is diagnosed with TB and starts treatment but is worried about red orange urine?
Rifamapicin
Isoniazid: Numb and tingly extremeties
Ethambutamol : Ocular side effects
Rifampicin is orange red urine
Pyrazinamide - arthalgia
What is coagulase positive
S.aureus
Which class of antibiotics target cell wall?
Glycopeptides, cephalosporins, penicillins and carbapenams
Macrolides inhibit protien synthesis and are used in cases of penicillin allergy
Which two species of malaria can persistent
P.ovale and P.Vivax - 14 day primaquine
A man presents for a routine visit with elevated ALT and a history of IVDY want to investigate for HBV what is indicative of active HBC
Hepatitis B surface antigen - HBsAG
75 year old man has a history of productive cough, dyspnoea and pleuritic chest pain with a low grade fever whats the most common cause of CAP
S. Pneumoniae ( atypical are mycoplasma , chalmydopjila , legionella - went on holiday stayed in hotel hot country )
What do you do first bloods or antibiotics in Sepsis?
Bloods
19 year old student has a fever non blanching rash and photo sensitive - lumbar puncture is turbid high opening pressure high WBC and low glucose whats happening
Bacterial mengitis
What’s the best way to detect viruses
PCR
What cells do HIV infect
CD4
What do you give staph infections
Flucloxacillin
What should you watch out for in antibiotic questions
Penicillin allergy ( usually give a macrolides
Mark is a 63 year old man coming to the clinic with dark stool. He complains of vomiting and occasionally having diarrheal. He has a 30 pack year history and drinks 22 units of alcohol per week. He feels abdominal pain that has been getting worse pver the last few months. He has been on ranitidine for 2 years now. He’s lost 9kg in the last few months. He has also been diagnosed with UC in the past. His bloods show anaemia and thrombocytosis whats the diagnosis?
Gastric Adenocarcinoma- melena and weight loss, haemetemesis
Colon adenocarcinoma would have fresh red blood mixed with stool
SCC are only in the oesophagus - progressive diffculty eating then swallowing
UC: Fresh red blood and mucus but no weight loss or constipation, diarrhoea
Haemorrhoids - blood when wiping not mixed with stool
Patient complains of abdominal pain that has been lasting months. it is localized to the epigastrium. The pain is the worst when he eats. He has been omeprazole and ranitidine but it has not madae the illness go away. He is then given a “test” that shows the patient has H.pylori. What is the necessary treatment and diagnostic test for this?
Omeprazole, amoxicillin and clarithrpmycin
Test: Stool antigen test or C-Urea Breath Test
John is an avid smoker with a 20 pack history. He has a family history of colon cancer. He has had recent weight loss. He explains that he has difficulty swallowing everything and so he has barely been able to eat, Many times when he tries to eat stuff, they tend to regurgitate. He also explains that he has shortness of breath at exertion and sometimes his fingers tend to get very white and cold. What is the most likely diagnosis?
Systemic sclerosis
Differential: Oesophageal Squamous cell Carcinoma but no progression.
Fibrosis all over the body. In lungs causes restrictive dyspnoea. In esophagus it stiffens causing no peristalsis. In small peripheral vessels causes raynaud’s.
Patient comes in with a 3-week history of severe constipation and abdominal pain. At the A+E, he looks very unwell and has vomited a few times since arriving at the hospital. He has T 38.2, HR 111 and RR 24. What is the most likely diagnosis? What is the gold standard investigation for this?
Diverticulitis - almost always with constipation and fever
Differential: appendicitis because only causes pain on the right
Gold standard: CT (can’t colonoscopy because perforation)
Diverticular disease: colonoscopy
This is caused by constipation causing unwell patient and fever
weakness in intestinal wall - poo gets stuck
How does volvulus present?
Coffee bean sign
No fever would be present
19 year old patient previously diagnosed with borderline personality disorder presents to the hospital extremely unwell. His eyes are barely open and is extremely confused and disoriented. His sclera has yellowed on examination. His mom explains that there was an empty bottle of capsules next to him but is not sure what it was.
What is the most likely drug he has overdose on?
What treatment does he need to recieve?
One of the nurses suspect it is Wilson’s disease, the doctor examines the patient’s eye and finds no clinical feature of it. What is the doctor looking for?
Paracetamol
Jaundice
n-acetylcysteine (IV)
Charcoal only if it’s been within the hour
Confused disoriented
Kayser fleischer ring
Name two features of acute liver failure
nausea vomiting malaise Jaundice - itching ascites pain on right side
bleeding
coagulopathy
confusion
encephalopathy
Name two features of chronic liver failure
Ascites, gastro-oesophageal varices, peripheral oedema, jaundice triad, clotting dysfunction, malnutrition (bile not produced and liver not storing/processing nutrients).
40, pain in his abdomen pain is in epigastrium radiating to the back, vimited, gallstones what investigation?
Serum amylase or lipase - acute pancreatitis
Hypercalceamia can cause it
alcohol and gallstones
Where do you get gaurding?
Perforated appendicts -
Jane contrinues drinkinh ahbits - pancreatic calcification?
Chronic pancreatitis, give
creaons and ceolaic is a risk factor caused by gallstones and alcohol, risk
Max ia a 50 year old gentleman presenting to the A&E with acute pain in his right upper quadrant. This happened after she had a mukbang session eating Fish & Chips. He denies any chest pain, SOB or recent trauma. He had felt nauseous but has not vomited. He bowel movements are normal. He had a past medical history of gallstones. Max leads a sedentary lifestyle and stays at home 100% of the time. His obs is only remarkable for raised temperature. O/E RUQ tenderness, positive murphy’s sign
What’s the definitive treatment of this disease?
Laparoscopic cholecystectomy
Jaundice + cholangitis
Fever
Worse on fatty foods
RF for gallstone -> Fat, female, forty, fair
Tom is a 55 year old gentleman with a history of sever alcoholic cirrhosis, he is confused and unable to giev a full history. He later comlains dark colouring of his stools. He has a past medical history of liver disease and hypternsion. His obs are temp 36.6, RR 18, PR 113, BP 80/60, mmHg & O2 98%
O/E confused hepatomegaly and jaundice
His relevant bloods are RBC 78 (90-110), WBC 80 (70-90), Urea 90 (70-80), Creatinine 75 (70-80)
Diagnosis?
Rapture of oesophageal varices
Blood loss
Hyptertension
shock
Urea -> internal bleeding
Mallory-Weiss tear -> self limiting
Peptic ulcer disease -> no epigastric pain and history of NSAIDs
Anal fissure -> bright red blood and straining down there
Max is a healthy 23 yo male who had recently returned from sri lanka on a volunteering trip. He had not had any vaccinations or prophylaxis prior to the trip. HE reported symptoms of fever, nausea and vomiting, and also felt generaly unwell. Blood tests show IgM antibodies in response to the hepatisis A virus. O/E RUQ pain with hepatomoegaly
Cause?
Hepatisis A acquire by eating contaminated food
Hep A -> dirty food
Hep B -> unprotected sex
Hep C -> IVDU
higher ALT + higher billirubin
Dark urine & normal stools
Julian comes to the GP complaining of yellowing to his skin. He freuquently gets pain in his RUQ after meals. He has had gallstones in the past and he thinks it might be the same problem again.
What wou;d be raised on his LFT?
What other symptoms would he have?
GGT and ALP bilirubin
Dark urine and pale stools
Gillbert causes pre-hipatic jaundice
Name 4 risk factors for gallstone formation
dehydration, high cholesterol diet, obesity,
Fat, female, forty, fair
Name 3 types of gallstones
Cholesterol, black/brown pigmented stones
Black gallstone causes
sickle cell, systic fibrosis,
25 yo man, GP with 3-month history of diarrhea, abdominal pain and weight loss. He undergoes a biopsy which confirms Cronh’s disease
List 3 diagnoses
Name a blood test an an imaging test to aid with diagnosis
List 2 histological features from biopsy
List 3 differences between uC and Cronh’s
Name a lifestyle modification for him
How to maintain remission for his condition?
Malignancy, uc, ibs, coeliac
diverticular
colonoscopy, cobblestone apperance, rosthrone ulcer, skip leisions, blood calprotectin
transmural inflamation
goblet cell
non-caseating
lympocytic infiltration
UC endoscopy mouth ulcers clubbing apthous pyoderna gangrenosum eryhtmous nodusum uveitis episcleritis anchilosing spondelitis prednicalone acute long line azathiprine second line methotraxate
stop smoking
A 21-yo female vomits blood after drinking
Mallory weiss tear
38 yo man complains of intermittent abdominal pain. It’s relieved by eating. C-urea breath test is positive. Diagnosis? Appripriate drug treatment?
Duodenal Ulcer
Omeprazoe, clarithromycin and amoxicillin
17 yo abdominal pain, bloating for 6 months, intermittent loose and smelly pale stools with no blood or mucus. Past history of B12 deficiency and mum is on levothyroxine for thyroid disease. She is pale , her abdomen is tender but soft with no guarding. Digital Rectal examination is normal. Which most likely appropriate investigation?
Coeliac of course
Total immunoglobulin A + IgA tissue translutaminase - 1st line serology
80 to man 1 week ibality to open bowels or pass wind, denies previous episodes and presented due to abdominal distension, discomfort and nausea. Reports that noticed PR beeding several months ago but was painless and infrequent. Denies issues with constipation but notes that over the last 2 months he noticed more frequent loose stools and significant weight loss. An abdominal radiograph revelas dilated loops of large bowel. What is the likely cause of the obstruction?
Rectal cancer
Which coronary artery is most commonly occluded in an MI
LAD V1-V4
A 32 has lethargy and blurred vision and suspects MS which myelin producing cells are destructed:
Oligodendrocytes not Schwann cells !
Which hormone acts on the leydig cells to produce testosterone
Lutenising hormones
FSH acts on Sertoli cells
GNRH causes release of LH and FSH
24 2 month history, 3-4 loose motions with blood - UC is suspected which part of the bowel is affected?
Rectum - starts in rectum then spreads
Crohn’s is terminal ileum
What sort of hypersensitivity is anaphylaxis?
T1 is within 1 hour IgE mediated and is anaphylaxis
2 is IgG or IgM hours to days e.g. haemolytic anaemia
3 is immune complex mediated 1-3 weeks and causes serum sickness and SLE
4 is T cell mediated days to weeks e.g. SJS and rash
56 SCLC male is lethargic and disoriented - low sodium what is the mechanism of action of the hormone being secreted to excess?
Insertion of aquaporin channels- ADH
Unilateral tremor, ridgitiy and bradykin ease what is dysfunctioning?
Substantia nigra
28 year old female is referred to colposcopy - what time of epithelium lines the endocervix
Endocervix - mucous secreting simple columnar epithelium
Ectocervix? Stratified squamous non kertainxed
How does testicular torsion present?
Acute onset testicular pain with absent cremasteric reflex
A 65 year old male presents to outpatient clinic for his abdominal aortic aneurysm screening. He is found to have a dilation of the abdominal aorta just above the level of the bifurcation of the abdominal aorta into the common lilac arteries. The level of the bifurcation corresponds to which spinal level?
L4
CT scan left precentral gyrus what defect what symptoms is it likely to result in?
Weakness of the right side of the body
52 year old has a 5 day history of facial pain nasal congestion and headaches worse leading foreward - which sinus is most affected in sinusitis
Maxillary
What does beclomethasone do?
Decreases cytokines formation , decreases micro vascular permeability ,reduces bronchiol hyperesponsivness and inhabits eosinophil influx
Smooth muscle is relaxed by salbutomal
2 week wait colonoscopy - mass in sigmoid colon , mass in sigmoid colon biopsy confirms adenocarcinoma in the sigmoid which lymph nodes has it gone to ?
Inferior mesenteric nodes
Para aortic - testes ovaries and adrenal glands ?
What is an effect of angiotensin 2?
Release of aldosterone
Sudden thunderclap headache + Menigism + PKD history what is it?
SAH
Cushings triad
Physiological nervous system : WIdening pulse pressure, bradycardia, irregular respiration’s
62 year old female presents to ED with Abdo pain localised to RUQ jaundice what is it most likely to be?
Ascending cholangitis - charcots : Jaundice, RUQ and fever
6 month history of weight loss etc etc - CML whats the abnormality?
T(9:22)
Teenage boy has an injury from rugby - mid shaft humeral fracture whats at risk?
Radial nerve -
Neck - axillary nerve
Mid shaft - radial
Lower supachorniol - medial nerve and brachial artery in front of
What is the mechanism of action of ondansetron?
5-HT3 receptor Antagonsit
Beta blocker CVD
H1 - antiemetic on histamine - ethinze
D2 - dopamine - domperiomde ad methocloparime
NK-1 neurokinine -
What does the right testicular vein drain into
IVC
Process of columnar epithelium into mature sqaumous epithelium is what
Metaplasia
38 year old female has a 6 month history of fatigue blood tests below what’s that anaemia cause? Low MCV
Iron deficiency
What is the ovarian cancer bio marker?
CA 125
CA 19-9 - pancreatic
CEA- colon
PSA - prostate
HER- 2 breast cancers and BRACA
What do penicillins do?
Inhibit cross linking in peptidoglycan cell walls?
What epithelium lines the oesophagus?
Stratified sqaumous non keratinised
A 47 year old male has an AKI = potassium 6.5 which ECG changes are hyperkalemia
Tall tented T wave
What is a node of ranvier?
A junction between two Schwann cells
A 71 year old has stiff hands worse in the mrinubg - periarticalr erosions and loss of joint space
Rheumatoid arthritis
What do bronchiole walls lack
Hyaline cartilage -
Bronchi - bronchiole is
Primary, secondary, tertiary - lobar - segmental bronchi ( C shaped hyaline Cartilage ) smaller airways dont need it
Obstructuvive v.s. Restrictive
Measure air you can expel
Obstructive: FEV1 low FVC normal ratio abnormal
Restrictive: FEV1 and FVC low normal ratio
Which bacteria usually causes resp symptoms:
Haemophilus influenzae
Pseudomonas - skin and wounds
UTI -e.coli
Which electrolyte do you need to watch in DKA?
Potassium - in trolled lypoliss- excess ketones
72 tear old is hypotensive, tachycardia, abdo pain high lactate, AF, what next?
CT angiogram - thrombus SMA
78 year old female stroke ward - right MCA unsafe swallow, pyrexial, tachypnoeic and tachycardia - aspiration pneumonia which lobe is affective?
Right middle lobe
Patient and parter - husband has sickle cell and they have a son with it no PMH what is the probability of them having another child with sickle cell?
50
72 memory clinic - dementia what screening test?
MOCA
40 year old Caucasian - blood pressure over 150/100 whats first line
Ramipril
22 female - lethargy ABdo pain, diarrheo and weight loss , IDA
Biopsies are taken duodenum and jejenum
Where would you find ciliates columnar epithelium with goblet cells?
Trachea
What kind of cartilage makes up the menisci?
Chondrocytes and fibroblasts surrounded by type 1 and type 2 collagen
What are the main types of cartilage?
Hyaline - most widespread , avascular , skeleton of the fetus, resp tract up until bronchioles, chondrocytes
Elastic: Avascular surrounded by perichondium, 2 collage, more elastic tissue, external ear, epiglottis and auditory tube
Fibrocartilage - avascular no perichondium, T 1 collagen , intervertebral disks, mandible, sternocalvicualr and pubic sympshss , aligns along lines of stress
What does a vein not contain?
Internal elastic lamina
Tunica intima, media and adventitia
Which layer do atherosclerotic plaques form
Tunica intima
Skin functions?
Protection, water barrier, body tempurature regulation, non specific defence, excretion of salt synthesis of vitamin D, sensory organ
Merkel s cells are neural cresct
Langerhands are dendritic c- A trap cells
What are the agranulocytosis
Lymphocyte and monocytes
Neutrophils, eosphinols and basophils do
Where do you find osteocytes
How’s ship lacunae
Haversian down and volkammans across
Describe a hepatic sinusoid
Blood in, bile out
Triad on edges and porta; vein in the Middle
Stellate- stoors nad scars
PERIS stain - Kupffer cells blue due to hemosederin
What are the symptoms of hypocalcaemia:
Convulsions, arrhythmias, tetany, numbness, chvosteks and trousseaus
Myeloma symptoms
C: Hypercalcaemia : Groans ( constipation), stones, bones and moans ( psychic)
R: Renal injury ( AKI, creatinine, high urea, low eGFR)
Anaemia: Breathlessness, fatigue
Bone destruction: Pathological fractures
Which type of antibody does warm AIHA involved:
IgG
What can you see in G6PD?
Bite cells, Heinz bodies
What is a decreased haptoglobin a feature of?
Haemolytic anaemia
What do blood tests show in haemolytic anaemia:
Normocytic, increased LDH, increased uncojugated bilirubin, decreased haptoglobin, increased reticulocyte count
What’s sickle cell pathology?
Beta globin chains on chromosome 11 misshapen , normally glutamic acid to valine and results in HBs - aggregates with other HBs and RBC polymerises when deoxygenated causing a sickle cell red blood cell
Fetal haemoglobin is 2 alpha and 2 gamma - no symptoms until a few motnhs
Give signs of Polycythaemia?
High haemoglobin, facial flushing, intermittent itching, worse in the path, alcohol, high altitude, obstructive sleep apnoea, JAK2 mutation
What are the two types of Polycythaemia?
Primary: JAK2 mutation - Polycythaemia Vera
Secondary: Alcohol, chronic hypoxia , obstructive sleep apnoea, living at altitude , lung disease, smoking, EPO secreting tumours,
Sam has a 3 year old bloody diarrhoea for 5 days after eating some dodgy cottage pie at nursery , purpurin rash, fatigue not producing much urine, oliguria,
Haemolytic uraemia syndrome : Microangiopathic haemolytic anaemia, thrombocytopenia and renal impairment
DIarrheoa shiga toxin associated
FBC: Anaemia and thrombocytopenia, haemolysis , LDH and bilirubin, peripheral blood smear and schistocytes, U and E shows raised creatinine and electrolyte abnormalities , supportive
Fever, chills , Diarrhoae , Africa, mosquitos , no prophylaxis, 38 degress and mild jaundice whats the treatment
Oral hydroxychloroquine
How do you diagnose malaria:
Giemsa, thin and thick blood films
Mild - oral hydrozyquinie
Sevre is IV artesunate and priaquine - notify PHE h
SLE is also treated with anti malarials
What does IDA show on film
Microcytic hypochromic RBC ( anisocytosis and poikilocytosis )
Also TAILS
Signs: Koilonychia, angular stomatitis, atrophic glossitis , pallor
A 70-year-old male complains of pain in his upper abdomen, with fever, night sweats and weight loss. Examination reveals enlargement of his liver and spleen. A full blood count shows raised basophils, eosinophils and neutrophils. Which of the following would most likely be implicated in this scenario?
Philadelphia chromosome is in 95% of patients with chronic myeloid leukaemia ( CML ) translocation between the long arm of 9:22 resulting in an ABL proto-oncogene ese from chromasone 9 being fused with BCR gene from chromosome 22 - the resulting BCR-ABL codes for a protien with tyrosine kinase activity
50-70 anaemia an dlethargy weight loss and sweating splenomegaly granulocytes increase
Q.2 A 24-year-old woman with known sickle cell disease presents with sudden onset severe right leg pain and 6 days of fever. She has noticed that her right leg is slightly swollen, and she is unable to weight bear on the affected leg. Which of the following would most likely cause her symptoms?
Osteomyelitis is usually S.Aureus but in sickle cell its salmonella
Diffrentials are capilalry infarction secondary to intravascular sickling
Q.3 A 68-year-old male presents with exertional fatigue. He is otherwise well with no significant past medical history, and he is not on any medications. His blood results highlight the following abnormal readings:
Multiple myeloma:
Bence jones protiens cause RBC to aggregate - rouloux
C
R
A
B
lethargy, infection, hypercalcaemia, renal failure, carpal tunnel, neuropathy, hyperviscocity
Monocolonal invesyogations, bence jones, rain drop skull which is different from primary hyperpaprathyrodism pepper pot
Where are smudge cells seen?
Chronic lymphocytic
Chronic lymphocytic leukaemia (CLL) is caused by a monoclonal proliferation of well-differentiated lymphocytes which are almost always B-cells (99%). It is the most common form of leukaemia seen in adults.
Features
often none: may be picked up by an incidental finding of lymphocytosis
constitutional: anorexia, weight loss
bleeding, infections
lymphadenopathy more marked than chronic myeloid leukaemia
Investigations
full blood count: lymphocytosis, anaemia
blood film: smudge cells (also known as smear cells)
immunophenotyping is the key investigation (confirms CLL)
A 58-year-old man presents to his GP with increasing tiredness, accompanied by bruising on his legs. He also complains of aching bones. He has no previous illnesses. On examination, he is pyrexial and pale, has bony tenderness over the sternum and tibia, and has petechiae on his legs. A bone marrow biopsy was taken and stained, showing the following: Auer rods
AML
cute myeloid leukaemia is the more common form of acute leukaemia in adults. It may occur as a primary disease or following a secondary transformation of a myeloproliferative disorder.
Features are largely related to bone marrow failure:
anaemia: pallor, lethargy, weakness
neutropenia: whilst white cell counts may be very high, functioning neutrophil levels may be low leading to frequent infections etc
thrombocytopenia: bleeding
splenomegaly
bone pain
Acute promyelocytic leukaemia M3
associated with t(15;17)
fusion of PML and RAR-alpha genes
presents younger than other types of AML (average = 25 years old)
Auer rods (seen with myeloperoxidase stain)
DIC or thrombocytopenia often at presentation
good prognosis
What does Rituximab do?
Binds to CD20
Rituximab is a monoclonal antibody that is used in various conditions including CLL and Non-Hodgkin’s Lymphoma. It acts by binding to the CD20 protein on the cell surface of B-cells and induces lysis. All the other answers are red herrings and are just there to confuse you.
Q7: 68F has been admitted to the frailty unit after a fall at home. On examination she has a dislocated hip and lacerations over her body. She has a BMI of 30 and is on HRT for her post-menopausal symptoms. You consider her to have a significant risk for VTE and begin her on prophylactic treatment. What is the mechanism of action for the prescribed medication?
LMWH
Patient presents with signs of DVT and this is confirmed using a doppler ultrasound. Prophylactic treatment for DVT is using LMWHs and this is the MOA.
LMWH works by binding to ATIII and inhibiting factor Xa. (indirect inhibition)
Warfarin works by inhibiting the reduction of Vitamin K and thus inhibiting production of factors 10,9,7,2 (1972)
DOACs such as apixaban directly inhibit X 🡪 1st line treatment
This is how UH works.
This is the MoA of clopidogrel, an antiplatelet. You wouldn’t use this for DVT.
Whats in Curb 65?
Confusion Urea > 7 mmol/L Respiration rate >30 BP <90 systolic OR <60 diastolic 65 - aged over 65 years
0-1 - Amoxicillin 500mg TDS (Doxycycline 200mg OD then 100mg OD, Clarithromycin 500mg BD)
1-2 - Amoxicillin 500mg TDS PLUS Clarithromycin 500mg BD
3+ - Coamoxiclav 500/125mg 3 TDS orally or 1.2 g TDS IV (levofloxacin) PLUS Clarithromycin 500mg BD
How do you treate achalasia
CCB+nitrates you can do balloon diltation and BOTOX
What are LFTs in alcohol abuse?
High AST, high ALT, high GGT
Q8: A 5 year old female presents to A&E with a widespread purpuric rash and recurrent episodes of epistaxis. Parents report that she has been recently ill with Covid-19 two weeks ago. She complains of headaches and nausea while seated in the A&E department. Bloods show a markedly low platelet count. There is no FHx of bleeding disorders.
Immune thrombocytopenic purpura
ITP is most common in ages 2-6 years old and presents with purpura and nosebleeds. It can also cause N+V, headaches, and bleeding gums. It is an autoimmune condition that can present after a viral infection and is self-limiting in nature. It is treated with prednisolone, IVIg and platelet transfusions.
TTP presents similarly, however has a different pathophysiology and is more common in adults. TTP is a lack of the VWF cleaving protein and on blood film will show fragmented erythrocytes as well as raised creatinine, bilirubin and reticulocytes.
SJS and bullous pemphigoid are dermatological conditions and do not present this way but are just there to confuse you.
Haemophilia doesn’t usually present this way and has a massive genetic component as well as being a largely male disease.
A 3Y old male patient with Down’s Syndrome presents to clinic with a two week history of shortness of breath and fatigue. On examination you find hepatosplenomegaly, lymphadenopathy and drooping of the right side of his face.
Acute lymphoblastic leukaemia
ALL is more common in children aged 2-4 years and has an association with Down’s syndrome. ALL affects the lymphoblasts and therefore presents with symptoms of anaemia, thrombocytopenia and neutropenia.
AML presents similarly but is much more common in adults and therefore is unlikely to be the answer in this situation.
CML also affects adults and presents with B-symptoms such as weight loss, fatigue, night sweats and bone pain.
Hodgkin’s lymphoma has a bi-modal incidence and affects young adults and the elderly and characteristically in exam questions has the patient experiencing pain when drinking alcohol.
Kawasaki’s disease is a vasculitis and doesn’t present this way.
What do you know about hodgkins?
Hodgkin’s Lymphoma classically presents with the presence of Reed-Sternberg cells. It is also seen with B-symptoms and non-tender rubbery lymph nodes.
ABVD is the mnemonic to remember for the chemotherapy drugs that are used to treat Hodgkin’s.
A- Adriamycin
B- Bleomycin
V- Vinblastine
D- Dacarbazine
A 31 year old obese patient came into A and E complaining of a painful, swollen leg. She has a past medical history of breast cancer (undergoing treatment), antiphospholipid syndrome, and varicose veins. Her current medications include her chemotherapy regimen, vitamin D and an IUD (intrauterine device). The results of her investigations are as follows: D dimer test (positive), Proximal leg vein ultrasound (Confirms DVT). Which of the following is not a risk factor for her DVT:
Contraceptive device
Risk factors for DVT: Obesity Recent surgery Long haul flights Active cancer/chemotherapy Immobilization Dehydration Oral contraceptive Hypercoagulability (i.e. Antiphospholipid syndrome) Previous DVT/PE Varicose veins Pregnancy Major trauma
D dimer is sensiitve ( true negatives ) not specific ( true positives )
DOACS
LMWEH
A 62-year-old man has poorly controlled type 2 diabetes. His GP started him on gliclazide treatment in addition to metformin with the aim of improving his glycaemic control. However he presents to the local emergency department 3 days later after feeling tired and very SOB. When asked about any allergies, he remembered when a doctor told him to not take primaquine due to an inherited disease - but he doesn’t remember its name. On examination he appears visibly jaundiced. A blood film reveals the presence of Heinz bodies and bite cells.
What investigation would confirm the diagnosis?
G6PD enzyme assay
Glucose 6 phosphate dehydrogenase deficiency is a X linked inherited condition which predisposes a patient to haemolytic anaemia due to oxidative stress. The crises in this case was aggravated by gliclazide
Jaundice, pallor, SOB, anaemia, dark urine, nausea, splenomegaly
A 44 year old man comes into A and E with significant bruising, epistaxis, fever and gingival bleeding. He ends up being diagnosed with DIC. FBC analysis reveals low fibrinogen levels, what blood product can be used to treat this?
Cryoprecipitate
PCC usually given for the reversal of warfarin during bleeds, head trauma or prior to surgery
FFP can be used to treat clotting abnormalities (PT or APTT elevated)
Packed red cells for chronic anaemia
Beriplex is a type of PCC. (Note vitamin K can also be given to reverse warfarin)
Cryoprecipitate is the correct answer. It is rich in fibrinogen
70 Y/O male patient with an advanced, high-grade liver cancer is undergoing an intense chemotherapy regimen. The patient has a past history of CKD and alcohol dependence.
Which of the following drugs should be prescribed to the patient during their cancer treatment?
Allopurinol - xanthine oxidase inhibtors
What is used in acute alcohol withdrawel?
Chlordiazepoxide is a benzodiazepine used in acute management of alcohol withdrawal. Not suitable here as even though we are told the patient has a PMH of alcohol dependence, we are not told he is currently experiencing alcohol withdrawal
A 87 year old patient comes into clinic complaining of lethargy, SOB, weight loss, and left upper quadrant discomfort. On examination, sub conjunctival pallor and splenomegaly are noted. The patient has a number of investigations and is, subsequently, diagnosed with philadelphia chromosome chronic myeloid leukemia. What is the first line management?
Imatinib - tyrosine kinase inhibtor
hydroxyurea can be used but is not first line
A 33 y/o lady presents with headache, fever, and diarrhoea. She mentions she recently returned from a month-long trip to Djibouti. You order a thick and thin blood film and subsequently diagnose her with malaria. You prescribe her chloroquine as well as primaquine.
Which species of malaria require treatment with primaquine (as well as the normal treatment)?
plasmodium vivax and ovale
A 17 year old presents to your gp clinic with fatigue, pallor and dyspnea upon exertion.Upon further history, you find that she is a vegetarian and has had heavy periods . Her vital signs are all normal.
a ) Name 3 causes of microcytic anaemia
[2]
b) Name 3 causes of macrocytic anaemia
Microcytic : Thalassemia, IDA, lead deficiency, sideroblastic
Macrocytic: B12 and folate deficiency, alcohol use, reticulocytotics
give some signs and symptoyms of anaemia
Pallor Beefy red tongue ( b12 deficiency) angular cheilitis(b12) Hyperdynamic circulation if sevre Jaundice (haemolytic anaemia)
Fatigue Dyspnoea Faintness Palpitations Headaches Tinnitus
What differentiates megoblastic and normoblastic on film?
Hypersegmented neutrophils and megoblasts
A 5 year-old boy from India presents to your GP practice, his mother complains that he is constantly tired, failing to grow and has gradually been developing a large tummy. On examination, you note chipmunk facies, pallor, hepatosplenomegaly, and jaundice. The mother also states that they have a family history of dysfunctional RBC
Thalassemia
Alpha is far east beta is mediterranian, asia, africa
FBC: microcytic anaemoa, WBC, platlets Peripheral smear 0 microcytic hypochromic Skull X ray : hair on end Genetic testing Gel elctrophoresis is gold
Minor treat: non
Intermediate: not transfusion dependent
Major: transfusion dependent and chelation to prevent iron overload
A 77 y/o male patient presents to A&E with with severe rectal bleeding and vomiting blood. You notice on the drug charts that the patient usually takes warfarin due to recurrent clots in the past. The patient mentions that he recently got back from a 7-day bender in Ibiza and had forgot to take his warfarin during that time. When he got back, he decided to take a weeks worth of tablets to make up for the ones he missed.
What would you prescribe to this patient to reverse the effects of warfarin? (Give 2 examples)
Vitamin K or Beriplex
Warfarin inhibits hepatic production of vitamin K-dependent coagulation factors and cofactors. Vitamin K must be in its reduced form for synthesis of coagulation factors. It is then oxidised during the synthetic process. An enzyme called vitamin K epoxide reductase reactivates oxidised vitamin K. Warfarin inhibits vitamin K epoxide reductase which prevents reactivation of vitamin K and coagulation factor synthesis.
A 58 y/o presents to clinic with fatigue, pallor, and headache. He mentions that his symptoms began a few weeks after undergoing an ileocecal resection to remove a tumour. A blood count and film is carried out and the patient is subsequently diagnosed with pernicious anaemia.
Name 5 other signs and/or symptoms of pernicious anaemia:
Parasthesia Pallor Fatigue Headache Numbness Peripheral neuropathy Pallor dyspnoea. anorexia, tachycardia, lemon yellow skin , red sore tongue ( glossitis ) angular stomatitis, loss of proprioception, weakness and ataxia
A 26 year old male presents with haemoptysis, a strong cough, wheeze, chronic nosebleeds and a saddle-nose deformity. A urine dipstick reveals haematuria and proteinuria. Blood test reveals cANCA positive.
Granulomatosis with polyangitis
cANCA positive
Hearing loss, sinusitis, nose bleeds
Saddle shaped nose due to perforated septum
Treated with steroids and immunosuppressants
- Mary is a 62y/o lady presenting with dry eyes. She has a PMH of SLE, for which she takes hydroxychloroquine. Mary tells you she has also been more tired than normal lately, and when you ask about her diet she tells you she drinks a lot of water as her mouth gets very dry.
Sjorgens syndrome
Secondary as she already has SLE
Bloods - anti ro and anti la , ANA,RF , CRP, ESR, FBC
Schrimers eye test and the and rose benagl staining
Lymphocyte mediated autoimmune disease characterised by destruction of the minor glands, lacrimal glands and joints
Symptomatic ce..g eye drops, vaginal lubricants, muscarinic agonists
triad of Xerostomia, Xerophthalmia and inflammatory arthritis
can lead to NHL an itchiness and dryness in vagina, dysphagia, gastritis MALToma, Pericarditis, CVS
What are the complications of SLE?
Key features: Photosensitive malar rash - butterfly rash that gets worse with sunlight Arthralgia Myalgia 85% positive for ANA 70% anti-dsDNA positive Cardiovascular disease Infection Anaemia of chronic disease Pericarditis Pleuritis Interstitial lung disease Lupus nephritis Neuropsychiatric SLE Reccurent miscarriage Venous thromboembolism
An 18 year old male presents to his GP with progressive back pain and stiffness. You decide to send him for a spinal x-ray to investigate which reveals a bamboo spine on the x-ray.
What gene would you associate with this disease?
Name 3 other findings you would expect to see on the x-ray.
Give an example of an Anti-TNF drug that you would prescribe this patient.
Ankylosing spondylitis, HLA b27
Squaring of the vertebral bodies
Subchondral sclerosis and erosions,
Syndesmophytes
Ossification of the ligaments, discs and joints,
Fusoion of the facet , sacroiliac and costovertebral joints
Etancerpt, adalimubab
- Margaret is a 61-year-old dear who has limped into your GP surgery looking in discomfort. She says she has pain in her left knee, which is worse when she has to walk down to the shops or walk her dog. When you ask about joint stiffness, she says they are stiff for about 25 minutes when she wakes up, and then after that it becomes the pain that limits her. It has gone on for some years but she has had enough.
What is your differential diagnosis?
What might you see on an X-Ray of her knee?
What is the cause of these changes? (think about
cartilage physiology)
Other than analgesia, what management options does Margaret have?
1, Osteoarthritis
2. Loss of joint space, osteophytes, subchondral sclerosis and subchondral cysts
- Loss of bone cartilage , weaker - bone on bone surface erosion ) imbalance between cartilage being worn down and chondrocytes repairing it - structural joint issues
- NSAIDS, sodium hyaluronate injections
Intraarticular steroid infection and joint replacement
What are S+S of osteoarthritis?
Assymetrical monoarticular arthirits, joint pain, decreased function, stiffness less then 30 minutes, increased with activity
What are risk factors of osteoarthritis?
Age, Sex, obesity, joint injurie, stress, genetics, bone deformities, diabetes, hemochromatosis
- A 66 year old patient presents to the GP with bone pain. They have recently had a few fractures which resulted in them going to A+E. You also notice that when they walk in there is some bone deformity in their left leg. You send them for some testing.
How would the skull in this patient appear on x-ray?
Which LFT would you expect to be raised?
What type of drug would you use to treat this patient?
Pagets disease of the bone
Cotton wool appearnce due to patches of osteoblast and osteoclast activity- patches of increased and decreased density
ALP
Bisphosphonates
What hand things do you see in RA v.s. Osteoarthirtis?
Osteoarthritis: Boutinerres, swan neck, ulnar deviation and z thumb, nodules
Bouchards and heberdens
What are some extra-articular manifestations of RA?
Episcleritis, Pericarditis, raynauds, peripheral neuritis, anaemia, raynauds
How do you manage RA?
DMARDS: Methotrexate, leflunomide, sulfasalzaine
2 of the above
3: Add in a biologic e..g TNF alpha infliximab, adalinumab, etancaerot
4: Methotrecate and rituximab
What are some RA complications?
Feltys syndrome: RA + Splenomegaly+ neutropenia
Anaemia of chronic disease
Pulmonary fibrosis
Amyloidosis
What are some diffrential diagnosis of joint pain and stiffness?
Osteoarthritis - degenerative arthritis Polymyalgia Rheumatica: Inflmmatoru disorder causing pain, stiffness inflammation in the shoulders, neck muscle nad hips Gout Septic RA
- Taylor presents to their GP complaining of muscle pain, fatigue and weakness in both hands and forearms, and their shoulders over the last few weeks. On examination you find Gottron lesions on their knuckles and elbows, a photosensitive rash on their face and some subcutaneous calcinosis. You conduct a blood test and their results show positive for ANA, a creatinine kinase of 1200 U/L, and Anti-Jo-1 antibodies.
What is the differential for this patient?
Dermatomyositis
Dermatomyositis = chronic inflammation of the skin and muscles
Polymyositis = chronic inflammation of the muscles (only)
Creatinine Kinase: normally under 300 Also raised: Rhabdomyolysis AKI MI Statins Strenuous exercise
Muscle pain, fatigue, weakness Occurs bilaterally Typically affects proximal muscles Shoulder and pelvic girdle Develops over weeks
If there is no skin involvement = polymyositis
If there is skin involvement = dermatomyositis
What are some skin symptoms and antibodiees in dermatomyositis?
Skin symptoms: Gottron lesions (erythematous plaques) Photosensitive erythematous rash on back, shoulders and neck Purple rash on face and eyelids Periorbital oedema Subcutaneous calcinosis
Antibodies:
Anti-Jo-1: poly+derm
Anti-Mi-2: derm
ANA: derm
9a. Vitamin D metabolism is important for the absorption of calcium and phosphate from the intestine, therefore important for bone mineralisation.
Which of the following substances is not involved in bone metabolism?
Parathyroid Hormone 1-alpha-hydroxylase Antiphospholipid antibody Oestrogen Calcitonin
Antiphospholipid antibody - thrombosis and miscarriages
Oestrogen regulates bone metabolsism and inhibits remodelling protective against osteoporosis!
Calcitonin lowers blood calcium
9b. Vitamin D metabolism is important for the absorption of calcium and phosphate from the intestine, therefore important for bone mineralisation.
i. What condition might cause an adult to have brittle bones due to insufficient vitamin D?
ii. What condition occurs in a child?
iii. Why do you not get this condition in adulthood?
9c. i. What does a T-Score of -2 mean?
ii. What is the first-line treatment for osteoporosis?
Osteomalacia
Rickets
Epiphyseal plates fused already
Osteopenia
Bisphosphonates
Osteomalacia & Ricketts
Osteomalacia is a disease of defective bone mineralisation, due to Vitamin D deficiency.
Presentation: fatigue, bone pain, bone and muscle weakness, and pathological / abnormal fractures.
Investigation: serum 25-hydroxyvitamin D low, serum calcium & phosphate low, serum ALP high, PTH high, z-ray may show osteopenia, DEXA may show low bone mineral density
Management: vitamin D supplementation (colecalciferol)
Give three bisphosphonates?
Alendronate, risendronate and zolendronic acid
How does the T score work?
More then -1 is normal
-1 to 2.5 is osteopenia
-2 to -2.5 osteoporosis
Add a fracture and its sevre
- Susan is a 55 year old female who has presented to you with a severe unilateral headache in her forehead. She has also had some blurred vision and tenderness of the scalp. Her blood test results in an ESR of 73.
Do a temporal artery biopsy if it shows multinucleated giant cells - GCA
Raised ESR
Give 40-60mg pred
- Which of the following is not a true regarding gout?
Negatively birefringent on polarised light microscopy
Monosodium urate crystals
Allopurinol is first-line treatment during acute flare
Tophi may deposit within the ear
Needle-shaped crystals
Allopurinol is not first line in an acute flare ! - colchine + NSAIDS are is
Where does pseudogout usually present?
Knee - chondrocalcinosis is pathognmonic
Sharon is a 54 year old female who presents to your GP practice with a main complaint of chronic widespread pain and tenderness. She complains that her muscles feel stiff in the morning. She also has had difficulty sleeping, and therefore is tired and has low mood and concentration. You determine that the pain is musculoskeletal, not arthritic.
What is your diagnosis?
Fibromyalgia - risk factors are psychosocial
Fibromyalgia = Disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory and mood issues
Poor diet can increase fibromyalgia pain, but isn’t a risk factor.
Repeated nerve stimulation results in the sensitization of the brain’s pain receptors, causing them to overreact to stimuli
Severe pain in 3-6 different areas, or milder pain in ≥7
What are some risk factors for fibromyalgia
Neurosis: depression, anxiety, stress Dissatisfaction at work Overprotective family or lack of support Middle age Low income Divorced Low educational status
- Colin is a 78-year-old man who has a long history of osteoarthritis. He underwent a knee replacement 3 days ago, and now has an acutely swollen knee that is hot to the touch, stiff, and he can’t move it due to severe pain. He has a fever of 38.1 and is lethargic.
Septic arthirits- S.aureus
joint aspiration and culture
Flucloxacillin + rifampcin
Jules is a 14 year old who has presented to you with a complaint of bone pain with swelling around their knee. The swelling hasn’t gone down despite ibuprofen use over the last week. Jules has a PMHx of hereditary retinoblastoma.
Based on their symptoms and PMHx:
Osteosarcoma
X ray. MRI , biopsy
Surgery
Mary is a 37 y.o lady presenting to her GP with a 2-week history of difficulties swallowing. She has no problem drinking but solid food tends to get stucked somewhere around her sternum. There is no pain on swallowing and she has not regurgitated food back out.
She denies any weight loss, fever or recent trauma.
Past medical history of GORD. Her mum had a disease which she could not recall but affected her skin badly.
O/E: Patches of shiny skin bilaterally on her arms up to her shoulder. Limited ROM of fingers. White discoloration over her knuckles
Based on the most likely diagnosis, which would be most useful for diagnosis of the pathology? (+++)
Serum nucleur antigens -
Limited - anticentromere
Diffuse - Antitopoisomeras, Anti scl70 and anti RNA polymerase 3
Chimdi is a 1 year-old boy who had recently moved from Nigeria to the United Kingdom. During his 1st week here, he started having fever and felt generally unwell. When you examined him, he was tender to touch over his left hip. His vitals are temp: 38, RR: 40, 120bpm, 95 O2%. Later, you had found out from his parents that he had sickle cell disease.
Further investigations were ordered and it was confirmed that Chimdi had osteomyelitis of his left hip and was given antibiotics for it.
Based on the history above, what is the most likely causative organism? (++)
Salmonella
Malcolm is a 25 y.o gentleman presenting to his GP with pain in his lower back for 3 months. He also gets stiffness in the back in the morning, however that improves with exercise. He has a family history of arthritis. He has Crohn’s for which is well controlled with medications.
His obs are normal. On examination, he has redness in both eyes. Based on the above, what is the most likely diagnosis? (+)
Ankylosing spondylitis
Psoriatic : psoriasis, nail pitting and sausage
RA: females
Reactive: Cant see, cant pee cant climb, recent infection
Osteoarthritis : Worse with ifnection
What are some key signs of seronegative spondyloarthropathy?
Sausage digits Psoriasis Inflammatory back pain NSAIDS Enthesitis ( heel ) Arthritis crohns and colitis / elevated CRP but can be normal HLA - B27 Uveitis
A 82 y.o gentleman presents to the GP with a 2 month history of back pain. The pain is localised and does not radiate at all. He has also been feeling very tired recently and you notice that he seem to look really pale. Over the past 2 months, Jim been constantly getting pneumonia. Jim used to work in the petrol industry. His obs are normal. His relevant blood results are: Hb: 97 (110-130) Creatinine: 260 (<176) Urea: 49 (<30) CRP 63 (<40) Based on the history, which is the best investigation to confirm the diagnosis. (++)
Multiple myeloma: CRAB and serum electrophoresis ( IGG A or light protien chains _
Clonal bone marrow greater than 10% + CRAB + serum electrophoresis, prognostic is CRP an dLDH
Malcolm has a red hot swollen joint. He also has a fever and is systemically unwell. His blood pressure is low.
How would you manage this patient? (2)
Name 3 risk factors for septic arthritis? (1)
Malcolm is sexually active, what is the most likely causative organism for his septic joint? (1)
Sepsis 6 and joint fluid aspiration
Immunosuppresents diabtes , HIV old age, IVDU
Neisseria gonorrhoea
63 y.o. Patient comes in with left sided knee pain. She says she’s had it for a few months now and hurts whenever she tries to move it. She also thinks she’s been having hearing difficulties on her right ear as of late. She is given a bone isotope test thats shows areas of abnormal bone turnover with decreased osteoclast action. The main areas found affected were the right side of skull and left knee.
What is the most likely diagnosis:
What is the first line treatment for her:
Pagets
Zolendronate
John 42 y.o. Man comes to clinic with freaking out as he is afraid that he has lung cancer. He screams that he has recently had a cough and has been coughing out blood. He says he has hd weight loss recently too. His father had lung cancer while his mother had an autoimmune disease that he can’t remember the name of. He says recently he has been peeing less and the color is usually very dark reddish brown but he just thought it was because he had been drinking too much alcohol.
When investigated, his blood showed that he was positive for Anti glomerular basement membrane antibodies.
Urine dipstick showed:
Blood +++
Protein +
Nitrites
What is the most likely cause of his symptoms:
GOODPASTURES - affects lungs and glomerulus - anti GBM
Mary 33 y.o. Woman comes into clinic complaining of pain and swelling of joints all over. Her fingers, wrist and knees hurt the most on both sides. She says that the pain and stiffness is worse in the morning but thankfully gets better as the day goes by.
What is the best biochemical blood marker to test for to diagnose her:
Name two clinical features/ deformities commonly found on the arms/hands of patients:
Name one sign of this illness seen on xrays:
What is the one joint never affected by this illness:
What marker is used to monitor progression of this illness:
Anti - CCP ulnar deviation, boutonnieres, swan , X Loss of joint space, soft tissue swelling, bony erosions DIPJ CRP
Mary is 34 y.o. Woman who has been trying to conceive for the last 10 years. However she is always unsuccessful as the last four times she was pregnant, she ended up having a miscarriage. She and her partner have had fertility consultation. Her ovaries, fallopian tube and uterus were all normal and she has no history of STD. His sperm count was also normal. When further questioned, Mary rememebered that her mom did also tend to have miscarriages a lot and so the doctor believes this could be autoimmune caused.
What is the most likely diagnosis?
Antiphospholipid syndrome - stops the egg implanting and inhibts grow of foetal cells also thrombosis
Patient has been diagnosed with systemic lupus erythematosus (SLE).
List one risk factor for this illness:
List two clinical manifestations of this illness:
What are two gold standard biochemical marker used to diagnose this illness:
Describe the ESR and CRP changes caused by this illness:
What is the first line management for this illness:
FH, idiopathic, Epstien barr, hydralazine, isoniazid
Malar rash , symmetrical small joint arthralgia, renal glomerulonephritis, lungs pleural effusion, heart pericarditis , cns seizures and psychosis
anti dsDNA - specific anti ANA - sensitive low speecific
Normal CRP high ESR
Oral corticosteroids ( pred ) and high dose corticosteorids ( methylpred)
Risks for gout?
Thiazides, s, stopping an d starting allopurinonal surgeyr, trauma, red meats and seafood, alcohol ( beer), dehydration
What do you see in X rays for osteoarthritis ?
Loss of joint space
Osteophytes
Subchodnral sclerois
Subchondral cysts
What do you see in RE?
Loss of joint space
Erosions of bone
Soft bones - osteopenia
Soft tissue swelling
What are risk factors for back pain and management?
Trauma and thoracic pain Unexplained weight loss Neurological findings/ nocturnal pain Age over 55 or under 25 Fever Immunocomporsed Steroid History of cancer or TB
E.g. mets causing spinal cord compression
Nsaids are 1 codeine second
exercsie and physio thirst
What do you prescribe for osteoporosis?
Bisphosphonates ( flu like symptoms, hypocalcamiea ) and V.D and calcium
8 year old boy has waddling gait, underweight malnourshied, wrist bony swellings,
Rickets - excessive non mineralised osteoid
What is black water fever ?
A rare complication of anaemia where RBC haemolysis leads to dark urine
What chromosomal abnormality is associated with multiple myeloma?
t11:14
- You see a 50-year-old male in A&E who has presented with breathlessness, bone pain and a severe infection.
His temperature is 39.1, his heart rate is 110 and his blood pressure is 130/85. He tells you this is the 3rd
severe infection he has had in 6 months and thinks they are causing him to lose weight. On examination, you
note hepatosplenomegaly and see some gum hypertrophy.
a) What is the most likely diagnosis for this man? (1 mark)
b) What would you expect to see on a bone marrow biopsy? (1 mark)
c) What 2 things are associated with this cancer? (2 marks)
d) Give 3 treatments this man is likely to receive (3 marks)
AML
Auer rods
Downs syndrome and radiatoin
treat: Transfuse, allopurinal, IV antibiocts, chemotherpay, steroidfs, transplant
- You are a medical student on placement where you see a patient with diagnosed chronic lymphoblastic
leukaemia. You have the opportunity to speak with him and examine him.
a) What age would you expect this man to be? (1 mark)
b) What would you expect to find on examination? (2 marks)
c) What would you expect to see on a blood film? (1 mark)
d) What treatment would this man be receiving? (2 marks)
e) What is a complication of CLL that you should be aware of? (1 mark)
Over 60
Lymphadenopathy, - enlarged rubbery non tender, sweating, anorexia splenomehaly
Smudge cells
Rituximab, and bruton kinase inhibtors e.g. ibrutinib chemotherpay, allopurinaol
Richters transformatoin to aggressive lymphoma
- You see a 17-year-old male with fever and night sweats. He admits to sometimes drinking with his friends
and tells you that over the last 2 months he gets painful lumps in his neck and armpits when he drinks. He
has no significant family history, does not smoke or take any recreational drugs.
a) What investigations would you want to order before making a diagnosis and what signs would you
expect to see reported in the results? (6 marks)
b) What is the most likely diagnosis for this patient? (1 mark)
c) What would you be the treatment plan for this patient? (3 marks)
FBC: Anaemia, thrombocytopenia high ESR
CXR- wide mediastinum
Blood film : Reed sternberg cells !!
Hodkins
Chemotherpay ABVD
Marrow transplant
. A 35-year-old male presents with increased urinary frequency, pain on urination and mild back pain. He is
pyrexic, tachycardic and tachypnoeic. You send a urine sample which returns positive for a UTI. You explain
the diagnosis to the man, and tell him that he will need antibiotics to get rid of the infection. At this point, he
tells you that he has G6PD deficiency.
a) What is the function of G6PD? (2 marks)
b) What are 3 of the common symptoms of G6PD deficiency? (3 marks)
c) What would you see on a blood film for this man? (2 marks)
d) What antibiotic is now contraindicated for his UTI? (1 mark)
Protects RBC against oxidative stress
Fatigue, SOB< pallor and palpatations
Bite cells and reticulocytes
Cant give nitrofurantoin
An 80-year-old man recently had a fall which resulted in a fracture neck of femur. He successfully underwent
a total hip replacement and is currently being warded in the NGH. During the ward rounds, being a good F1
doctor, you assess and examine him. It is noted that he has a swell in his left calf only. It appears slightly pale
and it is painful when you squeeze it.
a) What is the most likely diagnosis? (1 mark)
b) Pain and pallor are 2 out of the 6 symptoms for acute limb ischaemia. What are the 4 other symptoms?
(4 marks) (HINT 6 P’s)
c) Name 1 possible complication. (1 mark)
d) What is the first line investigation? (1 mark)
e) What is the name of the Scoring system used in making a diagnosis? (1 mark)
f) List 4 factors in the scoring system. (4 marks
DVT
Pulselessness, pallor, paresthesia , , paralysis, pershingly cold
PE
D- Dimer if positive do a gold standard US
Wells score - Clinical features - HR -Immobilization -Previous PE or DVT Hemoptysis Malignancy over 4 likley
You took some bloods as part of SEPSIS 6, and the results are shown below.
• Platelet Count: Low
• Prothrombin Time: Elevated
• APTT: Elevated
• Bleeding Time: Elevated
• Fibrin Degradation Products: High D-Dimer: Elevated
• Fibrinogen levels: Low Coagulation Factor Levels: Low
a) What haematological condition does this patient have? (1 mark)
b) Explain its pathophysiology (3 marks)
c) What does a sepsis 6 involve? (6 marks) (HINT – Give 3, take 3)
d) Which antibiotic is to be prescribed for the complicated UTI caused by E. coli? (1 mark)
Disseminated intravascular coagulation
Platlets are acitvated leading to microthrombi NO Tissue damage causes the release and and activation of tissue factor this leads to widespread clot formation and platlet consumption and coagulation factors - increased plasminogen leads to more fibronlysis clotting and breathing
Tissue factor release coagulation - intrisnic and extrinsicn thrombosis which are fibrinolysed causing bleeding
Give flood, antibiocts, oxygeb, take urine output , cultures and LDH
Trimethoprim or NFT
What do you see JAK -2 mutation in?
Polycythaemia ruby vera
Acute dehydartion, obesity, HTN . alcohol
. Psoriasis is a systemic, immune-mediated, inflammatory skin disease that can be associated with arthritis
(psoriatic arthritis).
Name 2 ‘hidden’ places where psoriasis can be found on the body. (2 marks)
Behind the ear, inside the ear, nails, onokylysis, scalp, umbilicus, genitals, soles of the feet
A patient presents to A&E with a hot, swollen, tender, and restricted knee joint and a high fever. They are
diagnosed with septic arthritis and their knee joint is urgently aspirated
List 5 risk factors for septic arthritis. (5 marks)
Over 80 Pre existing RA DM Immunosuppresion Joint surgery Prosthetic joiny Recent intraarticualr injections Trauma
A 73-year-old lady with previously diagnosed cancer starts to experience unremitting bone pain, which has
begun to wake her up at night. CT scans reveal bone metastases in her spine, rib, and pelvis.
What primary cancer might this patient have? Suggest two. (2 marks)
Breast Lung Kidney Thyroid Prostate
SLE: Multisystem inflammator disorder name two autoantibodeis
ANA and antidsDNA and antismith
Stat drug classes for osteoporsis ?
Bisphosphonates e.g. alendronic acid, zolendronate
taken once a week on an empty stomach must be taken standing up for hald na hour
Where do heberdens and bouchards occur?
Heberdens at the distal interphalnageal joint
Bouchards at the proximal interphalangeal joint
What’s a volvulus
Torsion of the colon on its mesenteric axis which contains vasculature , lymphatics and nervous supply to the bowel
Results in comprised blood flow and closed loop obstruction
Coffee bean sign
Significant sigmoidoscopy and rectal tube
Colicky pain, Abdomianl pain and absolute constipation
What’s the portal triad?
Hepatic artery, portal vein and bile duct
What’s the functional unit of the liver?
Sinusoid - Kupffer and stellate cells ( scarring )
Hep B serology
HBsAg : Found in acute infection prescience of 6 months implies chornic
HbeAG: Found in acute infection persistence implies viral active replication and can be used to distinguish between active and inactive chronic infections
HBV- DNA: Implies viral replication in acute and chronic
Anti HBS: Immunity through immunisation or cleared infection
Anti HBC - previous or current infection
Anti IgM: Infection within 6 months
IgG : Long term
Anti HbE; Seroconversion for life
Where do you see lead pipe?
UC - pseudopolyps
C
Digestion and lipid absorption?
Orlistat is a lipase inhibitor
Small novel disease - bile salt malabsorption
Itchy skin, dark urine , pale stool?
Cholangiocarcinoma of the pancreatic head
Pre hepatic is haemolysis e.g. malaria or H.anaemia or sepsis, red cell breakdown produces biliribun faster then the liver can take to up but its unconjugated - normal urine
Hepatic: Gilberts, viral hep, paracetomal - dark urine
Post hepatic: Obstruction e.g. gallstones , cholangiocarcinoma etc Dark urine and pale stool
52 year old female abdo pain and vomiting gallstones and asthma, icteric sclera and tender in RUQ>
Ascending cholangitis - bile synthesised in liver and stored in the gall bladder
Gallstones: Cholesterol or pigment stones in gallbladder
Biliary colic: temporary obstruction of the cystic duct: intermittent epigastric /RUQ pain after pain
Acute cholecystitis: Obstruction of the gallbladder - inflammation - persistent pain and murphys sign ( can have an a calculus cholecystitis)
Ascending cholangitis: Infection of the biliary tract - gallstones, ERCP. Cholangiocarcinoma : Charcots triad of jaundice , fever, pain and RUQ
Acute pancreatitis: GET SMASHED , sever epigastric pain, vomiting, low grade fever, cullens and grey turners sign
Severe generalised abdomianl pain, N and V, irregularly irregular pulse, ABG shows lactate and acidosis
Acute mesenteric ischaemia
Causes by thrombus , embolism , non occlusive ( Shock0, venous or artieral embolism
CT with contrast
Coeliac Trunk
SMA- midgut ( halfway duodenum to 2/3 across transverse colon ) - ileocolic, right colic , midcolic,
IMA: to superior 1/3 of rectum - left colic, marginal artery , sigmoid , superior rectal and mid ad inferior are from internal iliac !
What do you find on coeliac disease?
Biopsy: Crypt hyperplasia
Villus atrophy
Increased intraepithelial lymphocytes
Lamina propria lymphocyte infiltration
DIverticulitis
Risks: Diverticular disease , smoking , obese
Sigmoid colon usually and sometimes ascending
Signs: Abdo pain N and V Fever Change in bowel habit Blood is rare
CT
ABx+ Fluids + analgesics
Surgery !
Upper GI bleed?
Varicose - vomit red blood
Mallory wise -LOS
Ulcer - duodenal to gastro duodenal and gastric - left gastric
Haematemesis
Melena
Long capillary refil
Regular IBS,IV acces take blood - g + s and cross match, rests Blatchford Stop NSAIDS> aspirin, warfarin Arrange upper GI Endosocpy,y NBM Rockfall score post endosocpy
Bile Physiology?
Bile primary salts is formed from cholesterol using 7 alpha hydroxylation - colic acid and chenodeoxycholic acid which are secreted to gut where they are converted to deoxycolic and lithocholic acid via bacteria conjugated by glycine and taurine - so you get 8 conjugated bile salts , CCK contracts gall bladder - 95% reabsorbed
Which cranial nerves are involved in swallowing
Vagus
Soft palatable blocks nasophyranic
Epiglottis blocks await
Red: Weigjt loss, anorexia, anaemia, rapidly progression -palpable mass
Achalasia, benign stricture, malignancy, pharyngeal pouch, MG
LFTs?
ALT: Liver specific
ALP: Bile duct specific , raise in bone e.g. mets and pagets
AST: Alcohol specific
GGT: Differentiates between bone and liver
Albumin
PT/INR
Portal hTN?
Hypersplenism - moderate anaemia, neutropenia, thrombocytopenia
Marked ascites, capital Medusa
OEsophegeal varicose
B12 absorption
Cobalamin is water soluble- DNA synthesis, myelin synthesis and RBC synthesis
Intrinsic factor is needed and produced by gastric parietal cells
Most common is pernicious anaemia
- gloss it’s, leatherargy and meagolobastic Macrocytic
IM b12 - hypersegement neurtrophls
Progressive symmetrical poly neuropathy
Which signs are associated with acute appendicitis?
Rosvigs - press on LIF and you feel pain on the right
Psoas - hand on thigh and push it up against resistance - flex psoas - pain
Obturator - medial appendix - flex hip and knee and internally rotate - uses obturatro- pain
Mcburney’s: pressing on mc Burney rebound exhibits pain
Murphys: Cholecytitis
Pain in umbilicus migrating
Low grade fever, constipation/ diarrhoea
N and V
WCC+ CRP raised
Pregnancy in girls - ectopic
USS/CT
Mitselshemrt pain
When your symptoyms get better - perforated appendix !
Which acts on parietal cells to control stomach acid secretion ?
Histamine - ECL
ACH - PNS acts by vagus receptors and ECL cells for histamine
Gastrin - g cells increases calcium and stimulates ECL
Somatostatin - delta cells , inhibits histamine and gastrin
Gastric acid is stimulated by gastrin, ACH, histamine and is inhibited by somatostatin
CCK is released from enteroendocrine in response to fatty chyme and binds to delta cells to release somatastin and reduce acid
Distended abdomen, vomiting, constipation and colicky abdominal pain which imaging technique would you do?
CT abdomen
Small bowel obstruction
What is the lateral border of the antecubital fossa?
Brachioradialis
Blood is taken from antecubital vein !
Lateral border: Brachioradialis ( extensor )
Medial ( flexors of medial epicondyle ) e.g. pronator there’s
Superior border is epicondyle line
Biceps tendon is inside
Brachial artery and vein
Median and radial nerve
Ulnar is around medial epicondyle
What does the long thoracic nerve innervated?
Serratus anterior - winged scapula
C5,C6,C7
Main deep: Latissamus Doris and trapezius
Then deep t this: Rhomboid - retraction of scapula
Roatation cuff: Supraspiantus, infraspinatus, teres minor, teres major isn’t !
Sub scapularis is the 4
Deltoid is on top
What does the head of the radius Articular with
Capitulum of the humerus:
Head and ridge - anatomical neck but the surgical neck is below - higher fracture chance
Greater tubercle - attaches rotator cuffs
Biceptial groove between greater and lesser tubuercule for the long head of the biceps
Deltoid tuberosity for deltoid
Posterior radial/ spiral groove for radial nerve
Condyles and lateral is capitulum and the lumps are the trochleor
Head of the radius articulates with capitulum
Ulnar arituckakr with the trochleor - olecranon porcess articulates into olecranono fossa , head of ulnar is near the wrists
Epicondyles medialandlateral
What do you find in the popliteal fossa?
Popliteal nerve Poliptal artery Popliteal vein Tibial nerve Common perineal ( fibulae nerve )
Superiomedial border - semimembranous muscle
Superior lateral border - biceps femurs
Infromedial border - medial head of gastrocnemius
Medial lateral: Lateral head of gastrocnemius and plantar is
Popliteal artery , popliteal vein, tibial nerve and common perineal nerve ( branches of sciatic)
Short saphenous vein passes between heads of gastoneaemus
Can get bakers cysts
What does cutaeous innervation to the index finger?
Median and radial nerve
Ulnar does pinkie and half of the ring finger
Median does - From middle of the ring finger - anterior is median nerve and nail beds
Radial does posterior part of muffle of ring finger and hand of other 3 fingers
Hand muscles
Superficial: Pronator teres, Flexor carpi radialias,palmaris longus, flexor carpi ulnaris
deep: flexor digitorrium profundus, flexor polllicus longus and pronator quadrate s
Numbness over right shoulder and restricted movement, cant abduct beyond 15 degrees, loss inferior deltoid
Axillary: Semsory regimental badge and does teres minor and deltoid
Exits at subscalaris at quandarangular space - compression risk and posterior circumflaex -lateral cutanus nerve
What’s the medial border of the femoral triangle ?
Top: Inguinal ligament, lateral is sartorius
Adductor longus !
Sartorius is lateral
contains femoral nerve , common femoral artery, femoral vein gives of great saphinous
Flood : Ileopsoa is floor
NAVI
A 31 year old female has tingling in her thumb index and middle fingers which gets worse at night, Sympotyms get worse when she holds her wrist in flexion whats been affected?
Median nerve - CTS
Compression of the median nerve within the carpal tunnel - pain numbness and parastehsia in the lateral 3 digits
Female, increasing age, pregnancy and obesity , DM, RA, hypothyroidism , repetitive movements
Tinels and phalens
Clinical diagnosis or nerve conduction studies
Management - splint and corticosteroid injections
Shake arm
Carpal tunnel decompression
Palm is spared
Mid shaft humeral fracture what would present?
Wrist drop
Surgical neck - nerve axillary gets damaged - deltoid and rotator cuff weakness of shoulder abduction
Shaft: Spiral radial nerve groove - wrist drop - triceps and extensors
Claw Hand: ulnar nerve - change extend
Sign of benediction: median nerve
Musculocutanus: Weakness of elbow flexion: Biceps brachii, brachialis and Cora o brachialis
Ok sign
Spread fingers
Swelling and when knee is flexed at 90 degrees you get significant tibial excursion when force is applied in the anterior direction
Anterior crucial efforts ligament
Patellar ligament is a continuation of the quadriceps femoris
Lateral and medial collateral - Prevnts excessive medial or lateral movement
Medial : Medial epicondyle of femur and medial condole of the tibia
LCL: Lateral epicondyle and depression on the fibula head
Cruciate ligaments connect femur and Tibia - anterior cruciate attaches at anterior intercondyle region
Blends with medial meniscus and ascends posterior Ely to attach to the femur at the intercondyle fossa and prevents anterior dislocation
Posterior cruciate: Posterior intercondyle to anterior medial femoral condole ( prevents posterior dislocation of the tibia onto the femur:
AC injury:
Twisting knee whilst weight baring no contact
Rapid joint swelling , pain and instability
Lachmans test and anterior draw test
X ray excludes bony injuries and MRI
Manages: RICE and Rehab
Tendon or graft
Can get bony emulsion of the lateral proximal tibia - segulds fracture
MRI is gold
A tree surgeon falls with his harm in a full abducted position above the head what would you see?
Claw hand
Long thoracic is adherent to wall of the thorax
Klumpers palsy - claw hand ulnar nerve
Brachial Plexus?
Upper part : Erbs palsy e.g. traumatic birth waiters tip - pronated internally rotate cant flex elbow
C5-T1
RTDCB
Musculocutaneus : Biceps brachii, brachialis an coracobrachialis and skin overlying
median and ulnar supply below elbow
Median - most of anterior foramen and ulnar is hand but median does LOAF
Pain in elbow after painting worse carrying heavy objects improves on rest its recreated with wrist extension and forearm supination with an extended elbow and maximal pain is never the insertion of the common extensor tendon whats caused it ?
Lateral Epicondylitis and medial epicondylitis
Repetitive overused - microtears -fibrosis - tendinosis
Pain affecting elbow radiating down forearm
Examination: Local tenderness, cozens and mikes
CLinical or USS and MRI
Modify activity analgesia, corticosteroid injection
Pain in right hip, leg is shortened and internally rotated which artery’s branches supply the had of the femur?
Femoral - Profundus femoris !
Fetus is obtruator artery - obdurate ligament
Breaking of femur neck?
High risk of avascular necrosis
Fell on wrist and pain on movement and tender in anatomical snuff box what has je fracture?
Scaphoid - retrograde blood supply
Blood supply
Snuffbox: Radial arter, nerve and cephalic vein floor is the scaphoid
X ray may need to do 2 10 days apart
Immobilise
MRI is most definitive
What do you see on X ray for osteoarthritis
Loss of joint space
Osteophytea t joint margins
Subchondral cysts
Subchondral sclerosis
RA: Lojs, periaticualr erosions, osteopenia and soft tissue swelling
