SBA revision Flashcards
Hernias
•Direct inguinal
hernias arise from a weakness in the posterior wall of the inguinal canal,
allowing abdominal viscera to protrude ‘directly’ through the back of the
inguinal canal.
•In indirect inguinal hernias, the abdominal contents pass
through the deep inguinal ring and along the inguinal canal. The hernial
sacs in both conditions will protrude through the superficial ring and
produce a swelling in the groin. These two types of hernia are differentiated
on examination by reducing the hernia, placing a finger on the deep inguinal
ring and asking the patient to cough. As you are blocking the deep inguinal
ring with your finger, an indirect inguinal hernia should not reappear as a
groin lump when the patient is asked to cough. Therefore, if the hernia
appears again when the patient increases their intra-abdominal pressure (by
coughing), it suggests that it is a direct inguinal hernia. This test is very
crude and error prone — definitive diagnoses are often made in theatre.
•Spigelian hernias occur when
abdominal contents herniate through the linea semilunaris, typically
occurring inferior and lateral to the umbilicus.
•Obturator hernias occur
through the obturator canal and they present with inner thigh pain when the
hip is internally rotated (Howship–Romberg sign).
Extra murmurs
•Austin-Flint murmur- AR •Graham-Steell murmur -PR •Gibson murmur - PAD •Carey-Coombs murmur - thickened mitral valve •Barlow murmur -MVP
GCS
Glasgow coma scale (GCS) criteria: Eyes 1— No eye opening 2— Eyes open in response to pain 3— Eyes open to verbal command 4— Eyes open spontaneously Verbal 1— No verbal response 2— Incomprehensible sounds 3— Inappropriate responses 4— Confused conversation 5— Oriented
Motor
1— No motor response
2— Abnormal extension in response to pain (decerebrate posture)
3— Abnormal flexion in response to pain (decorticate posture)
4— Withdraws from pain
5— Purposeful movement towards painful stimulus
6— Obeys commands for movement
Minimum = 3; Maximum = 15
Glomerulonephritis
Minimal change disease is - youngkids
Membranous glomerulonephritis - adults
Nephritic syndrome : hematuria more prominent than proteinuria
IgA nephropathy - most common cause of glomerulonephritis, after URTI
Henoch–
Schönlein purpura (IgA in older kids) - triad ; Abd pain, arthritis, purpuric rash
MI locations
Anterior MI — left anterior descending coronary artery — V1–4
Lateral MI — left circumflex coronary artery — aVL, I and V5–6
Inferior MI — right coronary artery — II, III and aVF
Posterior MI — posterior descending artery — ST depression in V1–4
Pancreatitis serum
Acute - serum amylase/lipase
Chronic - Faecal elastase
Pancreatic cancer - CA19-9
CHA2DS2-VASc
used to assess the risk of stroke in patients
with atrial fibrillation, and, hence, determine the benefit of long-term
anticoagulation.
Congestive heart failure
Hypertension
Age >75 yrs (2 points)
Diabetes mellitus
Stroke/TIA symptoms previously (2 points)
Vascular disease (e.g. peripheral artery disease)
Age 65–74 yrs (1 point)
Sex category (Female = 1 point)
2 or more- offer DOAC
QRISK2
predict the risk of cardiovascular disease based on
traditional risk factors such as blood pressure and smoking status. It is used
to decide whether to give primary prevention (e.g. statins).
ABCD2
predicts
a patient’s risk of stroke in the days following a TIA.
GRACE
is used for risk
assessment and triaging of patients with ACS.
CURB-65
(Creatinine, Urea,
Respiratory rate, Blood pressure, >65 yrs) is used to assess severity of
community-acquired pneumonia. A score of 2 warrants hospital admission.
A score of 3 or more is considered ‘severe’ pneumonia and should be
considered for ITU admission.
Causes of CKD
diabetes mellitus (most common), hypertension, idiopathic, glomerulonephritis, pyelonephritis, vasculitides, polycystic kidney disease, reflux nephropathy and obstructive nephropathy.
Examination signs
○psoas sign — achieved by
lying the patient on their left-hand side, straightening their right leg and
then passively extending their right hip. If pain is elicited, this suggests that
the appendix is retrocaecal.
○Rovsing’s sign - when palpation of the left iliac fossa causes pain in the
right iliac fossa.
○Obturator sign - is pain on flexion and internal rotation of
the hip and indicates that the appendix lies close to the obturator internus.
○Aaron’s sign is referred as epigastric pain when pressure is applied over
McBurney’s point.
○ Murphy’s sign is the cessation of inspiration when two
fingers are placed below the right costal margin in the midclavicular line
and the patient is asked to take a deep breath in. This is suggestive of
cholecystitis.
Skin cancers
○squamous cell carcinoma (SCC) is one of most common - SCCs
typically arise in sun-exposed areas and have raised, everted edges with an
ulcerated centre and a keratotic core.
○A keratoacanthoma is a variant of
SCC which grows rapidly but does not metastasise.
○Basal cell carcinomas -most common type of skin cancer. A skin lesion with
raised pearly edges and fine telangiectasia on the surface. It grows across
the skin but never metastasises.
○Melanoma - worst. an asymmetrical pigmented skin
lesion with an irregular border. rapid growth and metastasis
○actinic keratosis - is a very common, non-
malignant skin lesion that occurs due to sun damage. It has a thick, crusty
surface.
AAA surveilance
3–4.5 cm (every year)
4.5–5.4 cm (every 3 months).
>5.5 cm open repair or endovascular aneurysm repair (EVAR),
AIDS defining disease
○Kaposi’s sarcoma ○candidiasis (of the oesophagus, trachea, bronchi or lungs), ○cervical cancer ○Burkitt’s lymphoma ○cytomegalovirus retinitis, ○mycobacterium avium complex ○Pneumocystis jiroveci ○pneumonia and ○toxoplasmosis.
Treating overdose
○Paracetamol - IV n-acetylcysteine ○Opiate Overdose — Naloxone ○Benzodiazepine Overdose — Flumezanil ○Organophosphate Poisoning — Atropine ○Aspirin Overdose — Sodium Bicarbonate
Anaemias
○Haemolytic uraemic syndrome (HUS) is a triad of microangiopathic
haemolytic anaemia (MAHA), acute renal failure and thrombocytopaenia. It
most often occurs following a diarrhoeal infection by E. coli O157 in
children. N.B. The clotting screen is normal in HUS.
○ Thrombotic thrombocytopaenic purpura (TTP) has the same features as
HUS with the addition of fever and fluctuating neurological signs.
○ Disseminated intravascular coagulation (DIC) is widespread activation of
the clotting cascade resulting in low platelets, low Hb and low fibrinogen
with a high APTT/PT.
Cancer staging
TMN - most cancers
Gleason staging - prostate cancer
Breaslow thickness - melanoma
Dukes staging - Colorectal cancer
Rectal masses
A
lump that protrudes with defecation and requires manual reduction suggests
haemorrhoids or rectal prolapse.
Grades of haemorrhoids:
Grade 1: no prolapse
Grade 2: prolapse on defecation but reduces spontaneously
Grade 3: prolapse requires manual reduction
Grade 4: remain persistently prolapsed and cannot be reduced
Type 1
rectal prolapse occurs when only the rectal mucosa protrudes through the
anus and type 2 occurs when all layers of the rectum protrude through the
anus, creating a mass which has palpable, concentric muscular rings.
Lax anal tone
MI complications
○Dressler’s syndrome is a type of pericarditis that arises 2–10 weeks after an
MI.
○presents in the same
way as viral pericarditis — pleuritic chest pain that is relieved by sitting
forward, fever and a pericardial rub.
○ simple post-MI pericarditis which occurs within 2–4 days of an MI.
PVD
○ Intermittent claudication is a cramping pain in the lower
limb muscles that occurs on exercise and is relieved by rest.
○ Critical limb
ischaemia is a more severe form of PVD characterised by rest pain, night
pain and tissue loss (e.g. arterial ulcers, gangrene). This patient has all the
main features of critical limb ischaemia.
○ Leriche syndrome is a type of
intermittent claudication resulting in buttock claudication, erectile
dysfunction and weak distal pulses, due to aortoiliac stenosis.
○ PVD can be diagnosed using ABPI: 0.5–0.9 = peripheral vascular
disease; <0.5 = critical limb ischaemia.
○ Acute limb ischaemia is caused by sudden cessation of blood flow to a limb
by a thrombus or embolus (usually from AF). Chronic DVT causes leg
swelling, pain and skin discolouration.
CXR findings of HF
ABCDE Alveolar oedema Kerley B lines Cardiomegaly Upper lobe diversion Pleural Effusion
Anaemia
Macrocytic anaemia - low Hb and High MCV
Multiple Myeloma - haematological malignancy xtised by excessive proliferation of plasma cells
CRAB Hyper-Calcaemia Renal Failure Anaemia Bone pain constituents
TB scenario
Weight loss Night sweats Cervical lymphadenopathy Erythema Nodosum CXR consolidation - main on upper lobes
Investigation - Sputum sample: acid-fast bacilli using Ziehl-Neelsen stain
Sputum culture
Urinary tract stone prevalence order
calcium oxalate -75% Magnesium ammonium phosphate (struvite) - 15% Urate - 5% Hydroxyapatite - 5% Cysteine -1%
Suspected pancreatitis
Transabdominal US - 1st line ; inflammation, calcification and free fluid
CT - staging and detecting complications
MRCP - used instead of CT id contrast in contraindicated - renal insufficiency
ERCP - therapeutic potential - stent placement, sphincterotomy - only indicated in confirmed gallstones
Amylase - half liffe of 10-12hrs don’t exclude pancreatitis due to mild or normal amylase
Breathing signs
Cushing’s reflex - physiological response to raised intracranial
pressure, characterised by a triad of high blood pressure, bradycardia and
irregular breathing. ( Trauma)
Kussmaul sign - paradoxical rise in JVP on inspiration, which occurs in
patients with impaired right ventricular filling (e.g. constrictive pericarditis,
restrictive cardiomyopathy).
Cardiac tamponade triad
Beck’s triad -
raised JVP, muffled heart sounds and low
blood pressure
Features of ascending cholangitis
Charcot’s triad - right upper quadrant pain, jaundice and fever with rigor C - coloured yellow H -Hot; fever A - aaaah ; pain R C - Cholangitis O T S
Reynold’s Pentad -
Charcot’s
Confusion
Shock
VT cause and management
a type of broad complex tachycardia. many causes: coronary artery disease, valvular disease, electrolyte imbalances (e.g. low Mg2+) and long QT syndrome
If stable - IV amiodarone
treat underlying cause
No pulse - ALS
Advanced Life Support (ALS)
Defibrillate
2. Perform CPR for 2 mins and then defibrillate again
3. Administer IV adrenaline after the 2nd defibrillation is delivered, and
repeat every 3–5 mins
4. If the abnormal rhythm persists after the 3rd defibrillation, administer IV
amiodarone.
supraventricular
tachycardia
Admin Adenosine
Bowel obstructions
presents with acute generalised abdominal pain,
nausea, vomiting and absolute constipation
most common causes of
bowel obstruction are tumours, adhesions, volvuli and hernias
caecal volvulus - embryo sign’
sigmoid volvulus - ‘coffee bean sign
adhesions - likely to mention
previous abdominal surgery
Onycholysis
a common nail condition characterised by painless
separation of the fingernail or toenail from the nailbed.
DR PITHS:
• Drugs (e.g. tetracyclines, oral contraceptive and diabetes drugs)
• Reactive arthritis, Reiter’s syndrome (rare)
• Psoriasis
• Infection (especially fungal)
• Trauma
• Hyper- and Hypothyroidism (rare)
• Sarcoidosis, Scleroderma (rare)
Language and Trauma
Wernicke’s area - inability to understand language, will be able to produce fluent, but non-sensical, speech
Broca’s area - inability to produce fluent speech, despite intact
understanding of language.
Treating
hyperkalaemia
10 mL 10% calcium gluconate
Drawing blood too fast can lead to red cell lysis,
releasing all the intracellular potassium into the sample. another
set of bloods should be taken urgently.
Henoch–
Schӧnlein purpura (HSP) Triad
arthritis, abdominal pain and a purpuric rash
(usually on the buttocks and lower legs)
HSP is a form of IgA nephropathy
in which immune complexes are deposited in the skin, mucous membranes,
joints and organs. HSP mainly occurs in children under the age of 10 years
and tends to occur after a respiratory tract infection.
Nephritic syndrome
IgA, Infection, Immune complexes
Damage to glomerulus due to deposition of immune complexes and inflammation
Kidneys - Glomerulonephritis
Arteries - Vasculitis
Synovial Joints - Arthritis
Post infection - Post strep, pharingitis, skin infection
Diffuse proliferative GN
Autoimmune
IgA nephropathy - Berger’s disease - teens and 20s - Haematuria, Oedema, HTN
Treatment - Bed rest, Diet restriction, Anti hypertensive meds Acei, Anti inflam steroids
Nephrotic Syndrome
Kidney disease causing
proteinuria>3.5g/24hrs
Hypoalbuminemia - hyperlipidaemia
oedema
causes - Minimal change disease - kids Membrano proliferative - white adults Focal segmental glomerulosclerosis - black adults autoimmune - SLE Malignancy Infections - heps, HIV Diabetes Nephropathies Drugs - NSAIDs
Symptoms Proteinuria Frothy urine oedema hypercoagulability
JVP waveforms when do you see Large V waves Slow Y descent Cannon A waves Raised JVP with absent pulsation
Cannon A waves occur when the atria and ventricles contract simultaneously - most commonly caused by complete heart
Large V waves are seen in tricuspid regurgitation
Slow Y descent is associated with tricuspid stenosis.
Raised JVP with absent pulsation occurs in superior vena cava obstruction.
acute
mesenteric ischaemia triad
Severe abdominal pain, normal abdominal examination and shock -due to occlusion of the superior mesenteric artery Arterial/venous thrombosis Embolism Hypotension
Chronic mesenteric ischaemia
occurs due to a
combination of a low-flow state, such as heart failure, and atherosclerotic
disease
It presents with ‘gut claudication’ (poorly localised, colicky, postprandial abdominal pain), PR bleeding and weight loss
Granulomatosis with polyangiitis
Wegener’s
granulomatosis
systemic vasculitis that is characterised by a triad of
upper and lower respiratory tract involvement (nosebleeds and
haemoptysis) and glomerulonephritis (haematuria and proteinuria).
‘saddle nose’
It is strongly associated with the
presence of cytoplasmic anti-neutrophil cytoplasmic antibodies (cANCA).
Goodpasture’s syndrome
autoimmune condition attacking the basement membrane in the kidneys and
lungs leading to renal failure and haemoptysis
Anti-GBM antibodies are the hallmark of Goodpasture’s syndrome
Perinuclear anti-neutrophil cytoplasmic antibody (pANCA) Anti-GBM cytoplasmic anti-neutrophil cytoplasmic antibodies (cANCA). anti-LKM) and ASMA)
(pANCA) Inflammatory conditions
including ulcerative colitis, primary sclerosing cholangitis, microscopic
polyangiitis and Churg–Strauss syndrome (Eosinophilic granulomatosis with polyangiitis (EGPA)).
Anti-GBM - Goodpasture’s syndrome
Granulomatosis with polyangiitis (Wegener’s)
Anti-liver/kidney microsomal
(anti-LKM) antibodies and anti-smooth muscle antibodies (ASMA) are
present in autoimmune hepatitis.
SEPSIS
Heart rate > 90 bpm • Respiratory rate > 20/min or PaCO2 < 4.3 kPa • Temperature > 38°C or < 36°C • White cell count < 4 × 109 /L or > 12 × 109 /L
HOCM
HOCM can be
distinguished from other forms of cardiomyopathy because it has several
specific clinical findings on examination: jerky carotid pulse, ejection
systolic murmur and a double apex beat. family history
of sudden death
Dilated
cardiomyopathy
inherited, alcohol
abuse, post-viral myocarditis and thyrotoxicosis
restrictive
cardiomyopathy
Causes include amyloidosis, sarcoidosis and
haemochromatosis
infectious
mononucleosis (also known as glandular fever)
non-specific flu-like symptoms (fever, malaise, sore throat) along with
cervical lymphadenopathy and splenomegaly
Ampicillin and amoxicillin
should not be given to patients with suspected infectious mononucleosis
because it causes a widespread maculopapular rash in nearly all of these
patients.
TB treatment
All four drugs are started at the same time
Rifampicin and Isoniazid — 6 months
Pyrazinamide and Ethambutol — 2 months
These drugs can be remembered using the mnemonic: RIPE
N.B. Pyridoxine (vitamin B6) is given alongside TB treatment because
isoniazid leads to vitamin B6 deficiency, which causes peripheral
neuropathy
