SBA revision Flashcards
Amenorrhoea + High Oestradiol, High Prolactin
Low LH
Low FSH
Pregnancy
- Elevated oestradiol (secreted by placenta) , suppressed LH/FSH
Prolactin also rises in pregnancy
Causes of gynaecomastia?
Gynaecomastia describes an abnormal amount of breast tissue in males and is usually caused by an increased oestrogen:androgen ratio. It is important to differentiate the causes of galactorrhoea (due to the actions of prolactin on breast tissue) from those of gynaecomastia
Causes of gynaecomastia physiological: normal in puberty syndromes with androgen deficiency: Kallman's, Klinefelter's testicular failure: e.g. mumps liver disease testicular cancer e.g. seminoma secreting hCG ectopic tumour secretion hyperthyroidism haemodialysis drugs: see below
Drug causes of gynaecomastia spironolactone (most common drug cause) cimetidine digoxin cannabis finasteride gonadorelin analogues e.g. Goserelin, buserelin oestrogens, anabolic steroids Ramapril (rare) Thiazide diuretics (Rare)
Very rare drug causes of gynaecomastia tricyclics isoniazid calcium channel blockers heroin busulfan methyldopa
Drug cause sof Gynaecomastia?
spironolactone (most common drug cause) cimetidine digoxin cannabis finasteride gonadorelin analogues e.g. Goserelin, buserelin oestrogens, anabolic steroids
SBHG levels - what conditions decrease/increase it?
SHBG levels may be decreased in: Obesity Hypothyroidism Androgen use Nephrotic syndrome Cushing's disease, and Acromegaly. Levels may be increased in: Hepatic cirrhosis Hyperthyroidism, and Oestrogen use. SHBG levels fall when testosterone production increases, with oestrogens increasing SHBG synthesis in liver. Pregnancy leads to increased oestrogens and thus increases SHBG synthesis.
What are mirror movements and what syndrome are they seen in?
Mirror movements (for example, clicking the fingers of the right hand and seeing a similar involuntary movement in the left hand) are characteristic of X linked Kallmann’s syndrome.
Causes of hypergonadotrophic hypogonadism?
Causes of hypergonadotrophic hypogonadism (high FSH, low oestradiol)
Gonadal dysgenesis 45 XO (Turner syndrome)
Gonadal dysgenesis 46 XY (Swyer syndrome)
Gonadal dysgenesis 46 XX
Familial gonadal dysgenesis 17-hydroxylase deficiency
Galactosaemia
Ataxia telangiectasia
Myotonia dystrophica
Autoimmune disorders
Chemotherapy/radiation therapy (ovarian cytotoxicity)
Resistant ovary syndrome
Menopause, premature ovarian failure.
In the case of women who are taking the combined oral contraceptive pill, because of inhibition of the pituitary by raising concentrations of oestrogen, the secretion of FSH is inhibited.
What is Mendelson syndrome?
Mendelson’s syndrome is chemical pneumonitis caused by aspiration during anaesthesia, especially during pregnancy. Aspiration contents may include gastric juice, blood, bile, water or an association of them.
The risk of aspiration - Mendelson’s syndrome - can be reduced through appropriate anaesthetic measures (i.e. cricoid pressure) and through prior use of acid suppressant therapy. Pressure applied posteriorly through the cricoid cartilage can be utilised to occlude the oesophagus and reduce the risk of regurgitation during induction. In most adults, cricoid pressure would be reserved for rapid sequence induction (or any other situation where they were thought to be at high risk of aspiration). But in pregnancy they are felt to all be at high risk of aspiration, cricoid pressure is much more frequently used.
Why do you get hyperthyroidism in pregnancy?
Because B-HCG can mimic TSH
What is Omental Cake?
The diagnosis is omental carcinomatosis (cake), secondary to ovarian carcinoma.
There is extensive ascites filling the anterior abdomen. In addition there is abnormal soft tissue related to the omentum of the bowel. This is known as omental cake, which is commonly associated with ovarian carcinoma - this patient had a raised CA 125.
Other common associations are stomach and pancreatic carcinoma.
What is the Pearl Index?
Methods of contraception are compared by the Pearl index.
A high Pearl index stands for a high chance of unintentionally getting pregnant; a low value for a low chance.
The Pearl index will be determined by the number of unintentional pregnancies related to 100 women years. For example, 100 women can use contraception for one year each with the method that is going to be examined. If three pregnancies occur during this period in this group, the Pearl index will be 3.0.
To give some examples, the Pearl index of condoms is 3-12 and that of the OCP is 0.1 to 1.
Hyperthyroidism in pregnancy?
Mx?
Graves’ disease is the commonest cause of hyperthyroidism in pregnancy, and the incidence is roughly 1 in 500 to 1 in 2,000.
Radio-iodine is absolutely contraindicated in pregnancy due to the risk to the fetal thyroid.
The most appropriate treatment is carbimazole/Propylthiouracil and as both drugs cross the placenta the minimal dose of each should be used so as to render the patient euthyroid. It needs careful monitoring of TFTs and dose adjustment.
Both carbimazole and PTU are excreted in small amounts in breast milk. Usually they are of no consequence and breast feeding is not absolutely contraindicated however it is obviously not ideal to take either whilst breastfeeding.
Testicular tumour age groups?
The main differentiating factor here is the age of the patient. Teratomas are tumours that more commonly occur in patients of the age group 20-30 and seminomas in the age group 30-50.
Features of infants of diabetic mothers?
Hypoglycaemia (as the fetus has been exposed to high circulating glucose levels resulting in the insulin hypersecretion and hence macrosomia) Congenital abnormalities Talipes Congenital heart defects Polycythaemia Hypocalcaemia Birth injuries/shoulder dystocia.
A 22-year-old man returned from a trip to West Africa two days ago. He is complaining of multiple painful ulcers on his penis. He admits to having unprotected sex with a local woman a few days before he left the country.
On examination there are multiple ulcers on his penis, they have a purulent base and bleed when they are touched, the edges are undermined. He has left sided inguinal lymphadenopathy.
- Chancroid (gram -ve Haemophilus ducreyi)
- Common in tropics, incubation period 3-10days
- Tx: Abx eg. Cipro + STI screen
Other causes of ulcers:
- LGV (chlamydia trachomatis) - PC usually solitary ulcer that may be painless, and can be associated with urethritis and proctitis
- HSV/HZV - both also present with multiple painful ulcers, but incubation period typically longer
- Primary syphilis (Painless, indurated)
Which Hep is most common in gays?
HBV - Especially as it is more transmissable by sex than HCV
Von Willebrand’s disease?
Von Willebrand’s disease is the most common hereditary bleeding disorder with autosomal dominant inheritance.
It is caused by a deficiency of von Willebrand factor, which causes platelets to adhere to the blood vessel wall and to each other.
The coagulation profile depends on the subtype of vWD but in the most common (and mild) cases it will show:
Normal platelet count
Prolonged bleeding time
Normal (slightly prolonged) APTT, and
Normal PT.
Diagnosis is confirmed with reduced ristocetin co-factor or reduced vWF factor concentrations.
Because factor VIII is bound to vWF while inactive in circulation it is possible to have relatively reduced factor VIII too, which can prolong the APTT in addition to bleeding time.
In haemophilia A (an isolated defect in factor VIII) there would be a very prolonged APTT with normal vWF levels. Bleeding time would be less abnormal.
Haemophilia B : F9 deficiency (X-linked)
Post-partum thyroiditis?
Tends to occur within the three months of delivery followed by a hypothyroid phase at three to six months, followed by spontaneous recovery in one third of cases. In the remaining two-thirds, a single-phase pattern or the reverse occurs.
Management is centred on symptomatic treatment using beta-blockers for relief of tremor or anxiety, and observation for the development of persistent hypo- or hyperthyroidism.
Carbimazole and propylthiouracil (PTU) are thyroid peroxidase inhibitors. They are used in thyrotoxicosis however post-partum thyroiditis is usually transient, therefore symptomatic treatment (with beta-blockers) should be enough.
Radioactive iodine is used in thyrotoxicosis that has not responded to PTU or carbimazole. Lugol’s iodine is part of the treatment of a thyrotoxic storm, in which the patient would be much more clinically unwell and is not the diangosis here.
Epilepsy & pregnancy
In pregnancy total plasma concentrations of anticonvulsants fall, so the dose may need to be increased.
Lamotrigine is probably the best choice of antieptileptic for generalised epilepsy in women of child-bearing age. It doesn’t have any major known teratogenic effects but it cannot conclusively be said to be safe. She should receive high-dose folate supplements.
Screening with alpha fetoprotein (AFP) and second trimester ultrasound are required. Vitamin K should be given to the mother prior to delivery.
APS antibodies?
Anticardiolipin antibodies may be found.
Venous thrombi occur more often if lupus anticoagulant is positive and arterial thrombi if IgG or IgM antiphospholipid antibody are positive. Long term warfarin is indicated.
SERMs?
Raloxifene is the first of the so-called selective oestrogen receptor modulators.
There are fundamentally two types of oestrogen receptor, alpha and beta, distributed at locations such as breast, uterus, bone and in the vasculature.
Raloxifene acts as an oestrogen agonist at some sites, for example, bone to increase mineralisation, but acts as an antagonist at other sites, for example, uterus/breast (preventing endometrial/breast hyperplasia).
It differs from tamoxifen in this regard, because tamoxifen (another SERM) acts as a partial agonist at the endometrium, so can promote endometrial hyperplasia.
- Clomifene is also a SERM
Tamoxifen:
In breast tissue, the drug acts as an antagonist at the oestrogen receptor although it acts as an agonist at other tissues in the body such as the endometrium. Since oestrogen receptor positive breast cancers require the action of oestrogen on the neoplastic cells to grow, blockade at the level of the receptor by tamoxifen reduces the risk of neoplastic transformation or tumour growth. However, in the endometrium, tamoxifen is an agonist at oestrogen receptors and this has the potential to promote carcinomatous growth. For this reason, use of tamoxifen is generally restricted to a maximum of five years to reduce the likelihood of endometrial cancer.
Another site where tamoxifen acts as an agonist is at bone. The effect of activation of oestrogen receptors on bone is to inhibit osteoclast activity and so it acts as a bone density protector and reduces the incidence of osteoporosis.
When in prostate cancer based on PSA would hormonal therapy be indicated?
Hormonal therapy not routinely recommended for men with prostate cancer who have a biochemical relapse unless they have:
- Symptomatic local disease progression
- Any proven mets
- PSA doubling time
Haematuria one stop clinic?
In the haematuria clinic the following tests are carried out:
Urine for microscopy, culture and sensitivity - to rule out an infection as the cause of the bleeding.
Urine cytology - high grade bladder cancer will show malignant cells on cytology.
Cystoscopy (flexible) - endoscopic procedure to visualise the bladder mucosa in order to identify bladder lesions or stones.
Ultrasound of the renal tract - to identify any renal tumours.
What is Fournier’s gangrene?
Fournier’s gangrene is a true urological emergency. Early recognition and surgical debridement is the key to successful treatment.
Fournier’s gangrene is a necrotising fasciitis of the perineum which can rapidly spread to the skin of the entire scrotum and penis (1-2 cm/h). Mortality is high and averages 20-30%.
Risk factors include
Diabetes mellitus (most common)
Alcohol dependence
Immunosuppressive therapy
Longstanding steroid therapy
Malnutrition
HIV
Extremes of age and
Low socio-economic status.
Cellulitis is a non-necrotising inflammation of the skin and subcutaneous tissues, a process related to acute infection that does not involve the fascia or muscles.
A scrotal abscess presents in a similar way to Fournier’s gangrene and often requires surgical intervention to drain the abscess. On examination there is tenderness and swelling but no signs of rapid spread of infection or necrosis.
Causes of elevated Ca125
Causes of an elevated CA 125 include: Ovarian cancer Endometrial cancer Tumours of the pancreas, GI tract, lung and breast Benign gynaecological disease, such as cysts and endometriosis Early pregnancy Follicular phase of menstrual cycle, and Cirrhosis or hepatitis.
Menopause hormone levels?
Elevated follicle-stimulating hormone (FSH) and luteinising hormone (LH) together on blood tests three months apart are consistent with the menopause.
Elevated testosterone can occur in a minority of patients post menopause and is consistent with ovarian hyperthecosis. In some women, this will be severe enough to cause hirsutism.
B-HCG and gestational age?
Detection of beta hCG forms the basis of the pregnancy test. Beta hCG is elevated in serum around eight days after conception, and it is detectable in urine one to two days later. Implantation occurs around six to seven days after conception. Serum beta hCG levels rise exponentially in early pregnancy to peak around week 10/40.
Although there are broad reference ranges for different gestational ages, there is a lot of intra-individual and intra-pregnancy variation. This means that a level of 7500 IU/l could indicate a gestational age of five to seven weeks in a healthy pregnancy. A more accurate estimation of gestational age is obtained by ultrasound
Beta hCG testing of serum will establish if the patient is pregnant and provide a baseline to enable serial results to be compared. In normal pregnancies beta hCG will double around every two days until it reaches a peak at week 10/40. For a patient with early pregnancy, monitoring of serial beta hCG measurements is useful in detecting a likely ectopic pregnancy. If serum beta hCG increases more slowly than normal an ectopic pregnancy is likely.
What is ovarian hyperthecosis?
Ovarian hyperthecosis describes the presence of luteinised theca cell nests in the ovarian stroma. When compared with the closely related condition of PCOS, hyperthecosis is associated with more severe hyperandrogenism and virilisation. Testosterone concentrations are much higher than in PCOS and may exceed 7 nmol/L (levels depend on the method used for laboratory analysis).
Ovarian hyperthecosis accounts for most of the cases of hyperandrogenaemia in postmenopausal women, although its prevalence in younger women is much lower, affecting less than 1% of women with elevated androgens in their reproductive years.
Causes of elevated prolactin?
Stress - causes mild degrees of elevation of prolactin to around 600-800 IU/L.
Effects of medication including treatment for anti-psychotics, metoclopramide, certain anti-depressants and anti-epileptics. This is a very heterogenous group and can cause at times marked elevations in prolactin, which are usually asymptomatic.
Hypothyroidism.
Pregnancy
Lactation and nipple stimulation.
Prolactinoma.
Pituitary mass causing compression of the pituitary stalk - this will reduce the tonic inhibitory effect of dopamine on prolactin release, causing increased prolactin secretion.
Pregnancy biochemistry?
Pregnancy is associated with: raised prolactin, low LH, low FSH, raised oestrogen, raised progesterone, where progesterone is usually greater than oestrogen.
Changes in pregnancy compared to non-pregnant women:
Dilutional effect causing:
low Na+
low K+
low albumin and gamma globulins
low Hb - mainly dilutional, although iron deficiency is also common
low urea, creatinine and urate
low TSH and low free T4 - hCG is structurally similar to TSH and suppresses fT4 production
Increased WCC and platelets
Increased cholesterol and triglycerides
Increased ESR
Increased alkaline phosphatase - the placenta produces this.
Obstetric cholestasis diagnosis?
LFTs or bile acids need to be abnormal in order to make the diagnosis. However, bilirubin is raised in only a minority of cases and visible jaundice is rare. Elevated transaminases and/or GGT are much more common.
Obstetric cholestasis is associated with:
Perinatal mortality
An increased incidence of passage of meconium
Premature delivery
Fetal distress
Delivery by caesarean section
Postpartum haemorrhage.
Hypertension in pregnancy values?
Mild hypertension:
Diastolic blood pressure 90-99 mmHg,
Systolic blood pressure 140-149 mmHg.
Moderate hypertension:
Diastolic blood pressure 100-109 mmHg,
Systolic blood pressure 150-159 mmHg.
Severe hypertension:
Diastolic blood pressure 110 mmHg or greater,
Systolic blood pressure 160 mmHg or greater.
NICE recommend the use of low dose aspirin in women at high risk of pre-eclampsia from 12/40 until the birth of the baby. However, this is an unlicensed indication, and treatment benefits and risks should be thoroughly discussed with the patient to allow her to make an informed choice.
Women at high risk are those with any of the following:
Hypertensive disease during a previous pregnancy
Chronic kidney disease
Autoimmune disease such as systemic lupus erythematosus or antiphospholipid syndrome
Type 1 or type 2 diabetes
Chronic hypertension.
Women with one or more of the following characteristics are also at moderately increased risk of hypertensive disorders in pregnancy:
First pregnancy
Age 40 years or older
Pregnancy interval of more than 10 years
Body mass index (BMI) of 35 kg/m2 or more at first visit
Family history of pre-eclampsia
Multiple pregnancy.
Many anti-hypertensive medications which are commonly used in non-pregnant adults are unsuitable during pregnancy. This includes ACE inhibitors which are considered teratogenic. Many beta blockers such as atenolol also carry risks to the fetus, particularly of bradycardia and apnoea if taken just before birth.
Pre-eclampsia recurrence risk?
For women with uncomplicated or mild pre-eclampsia in one pregnancy, their risk of developing:
Gestational hypertension in a future pregnancy is about 1 in 2-6 (13-53%).
Pre-eclampsia in a future pregnancy is about 1 in 6 (16%).
For women with severe pre-eclampsia in one pregnancy or with complications such as HELLP syndrome or eclampsia, the risk of pre-eclampsia in a future pregnancy is:
About 1 in 4 (25%) if their previous pregnancy led to delivery before 34 weeks
1 in 2 (55%) pregnancies if it led to delivery before 28 weeks.
NICE diabetes preconception advice?
The NICE guidelines on Diabetes in pregnancy (NG3) state that women with diabetes who are planning to become pregnant should be advised:
That the risks associated with pregnancies complicated by diabetes increase with the duration of diabetes
To use contraception until good glycaemic control has been established
That medications for diabetes including insulin regimens will need to be reviewed before and during pregnancy
If it is safely achievable, women with diabetes who are planning to become pregnant should aim to maintain their HbA1c below 48 mmol/mol (6.5%)
Even if 48 mmol/mol (6.5%) cannot be safely reached, women should be reassured that any reduction in HbA1c towards the target is likely to reduce the risk of congenital malformations
Women with diabetes whose HbA1c is above 86 mmol/mol (10%) should be strongly advised to avoid pregnancy
Women with diabetes who are planning a pregnancy should take folic acid at a dose of 5 mg per day.
Pregnancy and diabetes : Which meds are safe/avoided?
Treatment should be supplemented with insulin to obtain a target HbA1c
Pregnancy & Diabetes: Labour advice?
Women with diabetes in pregnancy:
May require a dextrose infusion during labour to maintain the blood glucose between 4-7 mmol/L
Can have a vaginal delivery, but should be offered elective induction of labour or caesarian section after 38 weeks
Should have access to fetal monitoring in the weeks prior to delivery to identify any fetal distress
Should give birth in a place permitting rapid access to neonatal resuscitation facilities
Give birth to babies with a risk of neonatal hypoglycaemia - babies should be observed for 24 hours after birth to ensure any hypoglycaemia is detected and treated
Are at increased risk of hypoglycaemia during breastfeeding.
Smear test screening?
Women aged 25-49 years living in England are routinely recalled for screening every three years.
Women receive their first invitation for cervical screening at 25 years of age. They are not invited earlier as changes in the young cervix can be normal and result in unnecessary treatment.
Provided the smears remain negative and there are no symptoms to suggest cervical cancer, the routine recall is three years for women aged 25-49 years.
Women aged 50-64-years-old are routinely recalled for a smear every five years.
After the age of 65 years, women are only screened if they have not had a smear since the age of 50 years (including those who have never had a smear) or those who have had recent abnormal smears.
This is because due to the natural history and progression of cervical cancer, it is highly unlikely women over 65 years old will go on to develop the disease.
Antibiotics for UTI in pregnancy
Amoxacillin/penicillin drug of choice
Trimethoprim is folate antagonist should be avoided in first trimester
Doxycycline - should be avoided as associated with discolouration of teeth, skin, phototoxicitiy, tinnitutus and multiple skeletal developmental abnoralities.
- CI Throughout pregnancy
- Should term use during breast feeding okay as minimal accumulation in breast milk
Nitro - CI in porphyria/G6PD. Best avoided beyond 38wks as immature red cell enzyme system of neonates may increase risk of haemolysis
- Found in breast milk so NOT suitable for breast feeding mothers.
Microgynon 30?
COCP containing oestrogen ethinylestradiol (30ug) and levenorgestrel (150ug)
Some classes of antibiotics, such as metronidazole, are enzyme inducers when used in short courses, and additional barrier methods of contraception are mandatory while using the antibiotic and for four weeks after discontinuing it.
Other drugs which cause hepatic enzyme induction which are likely to cause contraception failure include anticonvulsants, antivirals, antifungals and some over-the-counter herbal remedies including St John’s Wort. A comprehensive drug history is very important in all patients.
ALL
ALL is the most common representing 23% of childhood cancers, with an annual rate of 30-40 per million.
Age of less than 2 and greater than 9 at presentation suggests adverse prognosis.
The chromosomal abnormality in ALL involves a translocation in the 11q23 region.
It does affect the meninges which is why prophylactic cranio-spinal irradiation and intrathecal methotrexate is given.
It carries a good prognosis with a cure rate of 80%. However male sex carries a worse prognosis.
The peak incidence is 2 years in females and 3 years in males.
Sites of involvement may include testes and meninges, which carry a poor prognosis. Meningeal disease may be prevented by intrathecal chemotherapy and cranial radiotherapy, but not in all cases.
Relapse on treatment and male sex carry a poorer prognosis.
The prognosis is poor if the age is less than 1 year or greater than 9 years.
Treatment is usually for two years in girls and three years in boys.
Commonest site for osteoclastoma?
Approximately 50% of giant cell tumours (osteoclastomas) are located around the knee at the distal femur.
Next commonest site is the proximal tibia, with the proximal humerus and distal radius representing the third and fourth most common sites, respectively.
Most commonly giant cell tumours are solitary lesions; less than 1% are multicentric.
Ewing’s?
Ewing’s tumour occurs at a younger age than osteosarcoma and its range of incidence is primarily between 5 - 30 years.
The patient usually presents with pyrexia pain and may have an elevated erythrocyte sedimentation rate.
The tumour involves a long bone, particularly the diaphysis. Forty per cent of cases of Ewing’s sarcoma are found in the axial skeleton, usually pelvis. With large tumours the site of origin is inferred from the centre of radius of the mass.
The tumour is primarily destructive and ill-defined and erodes the cortex of the bone.
Its cellular origin is obscure but is thought to be derived from undifferentiated mesenchymal cells in the medulla of the bone.
There is an early periosteal reaction and a classical appearance of this tumour is of a lamellated series of periosteal reactions showing an onion skin appearance. The elevation of the periosteum gives rise to the Codman’s triangle appearance.
Cancers causing bone mets?
Breast (35%), prostate (30%), bronchus (10%), kidney (5%) and thyroid (2%).
Bone metastases occur in 30% of patients with malignant disease.
They usually present with:
bone pain
a lump
pathological fracture
hypercalcaemia, or
cord compression.
Ten per cent of patients with bone metastases will develop a pathological fracture.
Radiological changes usually occur late and bone scintigraphy is the most sensitive investigation available to detect metastatic spread.
Most metastases are osteolytic but some tumours, particularly prostate carcinoma, cause osteosclerotic lesions.
Wernicke’s?
B1 (thiamine deficiency)
Ataxia, confusion + ocular disturbances
Wernicke’s encephalopathy is a neuropsychiatric disorder caused by thiamine deficiency which is most commonly seen in alcoholics. Rarer causes include: persistent vomiting, stomach cancer, dietary deficiency. A classic triad of nystagmus, ophthalmoplegia and ataxia may occur. In Wernicke’s encephalopathy petechial haemorrhages occur in a variety of structures in the brain including the mamillary bodies and ventricle walls
Features nystagmus (the most common ocular sign) ophthalmoplegia ataxia confusion, altered GCS peripheral sensory neuropathy
Investigations
decreased red cell transketolase
MRI
Treatment is with urgent replacement of thiamine
GBS
Classic Guillain-Barré syndrome (GBS) is an acute, ascending, and progressive neuropathy characterised by
Ascending weakness
Paraesthesias and
Hyporeflexia.
In severe cases muscle weakness may lead to respiratory failure. Severe labile autonomic dysfunction also may occur.
Maximal weakness typically occurs two weeks after the initial onset of symptoms but may evolve early and abruptly. Two thirds of patients have a history of gastrointestinal or respiratory infection from one to three weeks prior to the onset of weakness.
Lymphomas, particularly Hodgkin’s disease, pregnancy, surgery, and drugs can cause it.
Wegener’s?
Onset of Wegener’s granulomatosis may be insidious or acute, and the full spectrum of the disease may take years to evolve.
Presenting complaints include:
Severe haemorrhagic rhinorrhoea
Paranasal sinusitis
Nasal mucosal ulcerations (with consequent secondary bacterial infection)
Serous or purulent otitis media
Hearing loss
Cough
Haemoptysis, and
Pleuritis.
Renal involvement is prominent and frequently dominates the patient’s clinical picture. Glomerulonephritis with proteinuria, haematuria, and red cell casts typically precedes functional renal impairment.
Serum complement levels are normal or elevated. The erythrocyte sedimentation rate (ESR) is elevated.
Leukocytosis is present.
Anaemia may be profound.
Antinuclear antibodies and LE cells are absent. High titres of antineutrophilic cytoplasmic antibodies (ANCA) are almost invariably present and may provide a relatively specific and sensitive marker for diagnosing the disease and sometimes for following its course.
Which tumours produce ectopic ACTH?
Presentation?
Small cell lung cancer is the most common tumour associated with ectopic ACTH production. Other types of tumours include tumours of the Thymus Pancreas Thyroid Adrenal gland.
Patients with paraneoplastic (ectopic) adrenocorticotropic hormone production present with
Polyuria and polydipsia (from elevated blood glucose)
Oedema
Muscle wasting
Fatigue
Hypertension
Hypokalaemia
rather than the classic clinical features of hypercortisolism (for example, moon faces, striae, or buffalo hump).
Laboratory evaluations reveal excessive cortisol production (for example, elevated 24 hour urine-free cortisol) and lack of dexamethasone suppression of morning cortisol levels.
Plasma ACTH levels greater than 200 pg/mL suggest ectopic ACTH production and warrant a search for an underlying malignancy, especially a primary lung or pancreatic tumour.
Definition of blindness?
Legally blind: 6/60 or worse in better eye with correction
WHO: 3/60 or worse or unable to count fingers in daylight at 3m
Drug causes of osteoporosis?
Corticosteroids Heparin Cyclosporin Methotrexate, and Cytotoxic therapy.
How long after isolated episode of mania controlled by medication can you drive?
After a period of three months of remaining stable and well
Olanzapine SE?
Akathisia (restlessness, or an inability to sit still) is a typical side effect associated with the use of the atypical antipsychotic olanzapine. Others include: Agranulocytosis Hyperprolactinaemia Hyperglycaemia Depression, and Anxiety.
Termination of oculogyric crisis?
IV procyclidine
Inferior/posterior dislocation of lens cause?
This would be consistent with a diagnosis of homocytinstinuria.
In Marfan’s syndrome the lens often dislocates in an upward and outward direction.
Other causes of lens dislocation include homocystinuria. and following cataract surgery.
Sinusitis organism & Abx of choice?
Studies have shown that 70% of cases of community-acquired acute sinusitis in adults and children are caused by Streptococcus pneumoniae and Haemophilus influenzae.
Second line therapies include ciprofloxacin and co-amoxiclav. First and second generation cephalosporins are not generally favoured.
Management of acute opiate withdrawal?
A good way of managing acute opioid withdrawal in patients who are actively using heroin is to titrate codeine to effect. It can be given in 30-60 mg doses and repeated each 30 minutes until the symptoms have begun to subside.
If a patients normally takes methadone then their dispensing pharmacy should be contacted to confirm their dose prior to administration. Codeine could be used in the meantime to alleviate symptoms of opioid withdrawal.
Pott’s cancer?
Pott’s cancer is a scrotal cancer caused by coal tar exposure.
ALL good and bad prognostic factors?
Good prognostic factors FAB L1 type Common ALL Pre-B phenotype Low initial WBC
Poor prognostic factors FAB L3 type B, T cell type Philadelphia translocation, t(9;22) Increasing age at diagnosis Male sex CNS involvement High initial WBC (e.g. > 100).
Pea stuck in ear. Mx?
Suction with or without sedation is the most appropriate method in this case.
Irrigation is contraindicated for soft objects, organic matter or seeds, which may swell when exposed to water.
Syringing the ear is an option for many foreign bodies, providing that the tympanic membrane is not perforated. However, it should not be used for vegetable matter, since vegetable matter may swell in the presence of water.
Use of any implement (such as a hook) that may push the pea further into the ear canal should be avoided.
Use of a general anaesthetic for this sort of incident is too risky and magnetic probe would obviously be of no use here.
Frontal lobe lesions
Lesions of the frontal lobe include difficulties with task sequencing and executive skills.
Other symptoms include:
Expressive aphasia (receptive aphasias are due to a temporal lobe lesion)
Primitive reflexes
Perseveration (repeatedly asking the same question or performing the same task)
Anosmia, and
Changes in personality.
