September Flashcards
Which of these is a contraindication for using epidural anaesthesia during labour?
Coagulopathy is the only answer which contraindicates using epidural anaesthesia in labour - all other answers make using epidural anaesthesia more likely.
A 74-year-old woman is reviewed. She recently had ambulatory blood pressure monitoring that showed an average reading of 142/90 mmHg. There is no significant past medical history of note other than hypothyroidism. Her 10-year cardiovascular risk score is 23%. What is the most appropriate management?
Newly diagnosed patient with hypertension (> 55 years) - add a calcium channel blocker
Importance: 57
This patient has stage 1 hypertension and is below 80 years of age. However, as she has a raised cardiovascular risk score treatment should be offered. In this age group, —- are first-line.
Newly diagnosed patient with hypertension (> 55 years) - add a calcium channel blocker
This patient has stage 1 hypertension and is below 80 years of age. However, as she has a raised cardiovascular risk score treatment should be offered. In this age group, calcium channel blockers are first-line.
– for patients who are going to take long-term steroids should start immediately
Start oral — + ensure calcium and vitamin – replete
Bone protection
alendronate
D
The low calcium and phosphate combined with the raised alkaline phosphatase point towards—-.
osteomalacia
Progressive multifocal leukoencephalopathy is caused by the —-virus or – virus
JC virus or BK virus
When prescribing fluids, the potassium requirement per day is —-
NICE also recommends that patients have —ml/kg/day of water.
As this patient weighs 62kg that means the patient should receive approximately –L of fluid in a 24 hour period.
If the patient is receiving 1-litre bags of fluid then one should contain – mmol and the other – mmol potassium to ensure an adequate potassium intake
1 mmol/kg/day
25-30
1.5 - 2
40—20
A known sequela of pancreatitis is hypo—.
Lipase from pancreatic cells breaks down mesenteric and peripancreatic fat.
This results in the liberation of free fatty acids that bind —, decreasing the circulating concentration.
calcemia
calcium
It is important to remember that A—) antibody is positive in approximately 40% of patients who test negative for Rheumatoid Factor.
Therefore— is an important diagnostic test for RA.
Anti-CCP (cyclic citrullinated peptide) antibody is positive in approximately 40% of patients who test negative for Rheumatoid Factor.
Therefore Anti-CCP is an important diagnostic test for RA.
The bacteria responsible for Acne is — which is an anaerobic rod. This is important because it means traditional beta-lactam antibiotics are ineffective in treating infections caused by this and so –+—+— must be used in managing acne.
Propionibacterium acnes
tetracyclines, macrolides or trimethoprim
— is a condition characterised by seizures in a pregnant woman with –.
Early signs of — include hypertension and proteinuria. Other symptoms of — include abdominal pain, nausea, vomiting and visual disturbance.
Prolonged hyperemesis gravidarum can result in —- and — abnormalities, which could result in seizures.
Eclampsia
pre-eclampsia
dehydration and metabolic abnormalities
Acute —- is a complication of myocardial infarction
Intravenous — such as— is the best pharmacological treatment for this patient as this method of administration has better bioavailability since the patient is severely dyspnoeic with very poor vital signs.
IV —- are also recommended by NICE guidelines for the treatment of acute heart failure.
Nitrates are not routinely offered.
Oral antibiotics are not required as there are no signs of infection and the clinical presentation is in keeping with —-.
pulmonary oedema
The most likely diagnosis in this patient is acute pulmonary oedema or heart failure due to past history of myocardial infarction. Intravenous diuretics such as furosemide is the best pharmacological treatment for this patient as this method of administration has better bioavailability since the patient is severely dyspnoeic with very poor vital signs. IV diuretics are also recommended by NICE guidelines for the treatment of acute heart failure. Nitrates are not routinely offered. Oral antibiotics are not required as there are no signs of infection and the clinical presentation is in keeping with acute pulmonary oedema.
The Royal College of Obstetrics and Gynaecology suggest that — pressure should be used to improve the effectiveness of the — manoeuvre’ in their shoulder dystocia guidelines.
suprapubic
McRoberts
Women who have migraine with — should stop the pill immediately - this is because the — component of the COCP can increase the risk of the women having an —.
A — contraceptive pill is therefore the only alternative contraceptive medication that can be prescribed
aura
oestrogen
ischaemic stroke
progesterone only
—- is a common cause of haemolysis in patients with glucose-6-phoshate dehydrogenase deficiency (antibiotic)
Ciprofloxacin
Patients with —- often get relief from shaking their hands and this may be an important clue in exam questions
carpal tunnel syndrome
An ambulatory blood pressure reading of greater than or equal to — mmHg confirms a diagnosis of stage 1 hypertension.
However, the National Institute for Clinical Excellence (NICE) suggest that antihypertensive treatment should be offered only if the person is:
aged — with stage 1 hypertension with one or more of, —x5
If stage 2 hypertension is diagnosed then —
Lifestyle advice should be reinforced in all patients
135/85
less than 80 years
- target organ damage,
- established cardiovascular disease,
- renal disease,
- diabetes, and/or a
- 10 year cardiovascular risk of 10% or more.
antihypertensive medication should be started regardless of age.
The primary mode of action of the contraceptive implant is to prevent ovulation.
Implants may also prevent sperm penetration by altering the — and possibly prevent implantation by thinning the —, but this is not their primary mode of action.
to prevent ovulation
cervical mucus, endometrium
– is a risk factor for shoulder dystocia
Diabetes mellitus
— is first line in children suspected of Mycoplasma pneumonia.
Otherwise, amoxicillin is first line, with —- indicated if the child presents with pneumonia associated with —.
—- is used for suspected meningitis, and — is an antiviral.
Erythromycin
co-amoxiclav -influenza
Benzylpenicillin
aciclovir
Dysphagia equally to both solids and liquids from the outset is suggestive of —-.
A — which shows a grossly expanded oesophagus that tapers at the lower oesophageal sphincter (—’ appearance) confirms the diagnosis.
achalasia
barium swallow
‘bird’s beak
Drug treatment of essential hypertension can be summarised as follows, but for a more detailed explanation see the link below;
Step 1; Age <55 -
. Age >55 or of — origin - –
Step 2; – + —
Step 3; – + – + —
Step 4; consider further —– and seeking expert advice
Step 1; Age <55 - ACE inhibitor. Age >55 or of black African or Caribbean origin - calcium channel blocker
Step 2; ACE inhibitor + calcium channel blocker
Step 3; ACE inhibitor + calcium channel blocker + thiazide-like diuretic
Step 4; consider further diuretic or beta-blockade or alpha blocker and seeking expert advice
— in Grave’s disease indicates severe eye pathology
The severity of Grave’s eye disease can be graded using the mnemonic NOSPECS
Corneal involvement
No signs / symptoms
Only signs (e.g: upper lid retraction)
Signs & symptoms (including soft-tissue involvement)
Proptosis- is protrusion of the eyeball. Exophthalmos means the same thing, and this term is usually used when describing proptosis due to Graves disease.
Extra-ocular muscle involvement
Corneal involvement
Sight loss due to optic nerve involvement
For — in acute ischaemic stroke, an extended target time of 6-24 hours may be considered if there is the potential to salvage brain tissue, as shown by imaging such as CT perfusion or diffusion-weighted MRI sequences showing –
thrombectomy
limited infarct core volume
Women with hypothyroidism may need to —- their thyroid hormone replacement dose by up to 50% as early as —-weeks of pregnancy
Women with hypothyroidism may need to increase their thyroid hormone replacement dose by up to 50% as early as 4-6 weeks of pregnancy
– levels are now the first-line test for acromegaly
Serum IGF-1
Key information for the different types of thyroid cancers:
1) Papillary - 65%, generally --- ----. Metastasis to --- lymph nodes. --- can be used as a tumour marker. Characteristic --- eyes on light microscopy. --- prognosis
2) Follicular - 20%, generally —-.
Metastasis to — and –.
—- can be used as a tumour marker.
—- prognosis
3) Medullary - 5%, sporadic or part of — syndrome. It originates from the — cells which produce — - can be used as a tumour marker.
4) Anaplastic - very rare. —- patient. — prognosis
5) Lymphoma - 5%, might present with dysphagia or stridor
MEN SYNDROME
MEN ? - Mucosal neuroma, marfanoid appearance, medullary thyroid carcinoma, phaeochromocytoma
MEN ? - Parathyroid hyperplasia, medullary thyroid carcinoma, phaeochromocytoma
MEN ? - Pituitary adenoma, parathyroid hyperplasia, pancreatic tumours
Key information for the different types of thyroid cancers:
1) Papillary - 65%, generally young females. Metastasis to cervical lymph nodes. Thyroglobulin can be used as a tumour marker. Characteristic Orphan Annie eyes on light microscopy. Good prognosis
2) Follicular - 20%, generally women >50 years old. Metastasis to lung and bones. Thyroglobulin can be used as a tumour marker. Moderate prognosis
3) Medullary - 5%, sporadic or part of MEN2 syndrome. It originates from the parafollicular cells which produce calcitonin - can be used as a tumour marker.
4) Anaplastic - very rare. Elderly patient. Very poor prognosis
5) Lymphoma - 5%, might present with dysphagia or stridor
MEN SYNDROME
MEN 1 - Pituitary adenoma, parathyroid hyperplasia, pancreatic tumours
MEN 2A - Parathyroid hyperplasia, medullary thyroid carcinoma, phaeochromocytoma
MEN 2B - Mucosal neuroma, marfanoid appearance, medullary thyroid carcinoma, phaeochromocytoma
This patient has subclinical hypothyroidism (very mildly raised — but normal — and –)
management of patients with subclinical hypothyroidism and recommend a ‘—’ approach in patients over the age of 80 years old.
If the patient here were below 65 years of age and was symptomatic then she may have been offered a trial of –. Moreover, it may well be worth rechecking her TFTs but NICE recommend doing so in – months time.
A very severe rise in — (>10 mU/L) in a younger patient (<70 years old) would prompt treatment with — replacement.
This patient has subclinical hypothyroidism (very mildly raised TSH but normal T3 and T4)
NICE CKS have published guidance on the management of patients with subclinical hypothyroidism and recommend a ‘watch and wait’ approach in patients over the age of 80 years old.
If the patient here were below 65 years of age and was symptomatic then she may have been offered a trial of levothyroxine. Moreover, it may well be worth rechecking her TFTs but NICE recommend doing so in 6 months time.
A very severe rise in TSH (>10 mU/L) in a younger patient (<70 years old) would prompt treatment with levothyroxine replacement
– are associated with an increased risk of urinary tract infections
Sodium-glucose co-transporter 2 inhibitors
Human papilloma viruses –and– are non-carcinogenic and associated with genital warts
6 and 11
Woman with – metastases- most likely to originate in the breast
bone
— is the most specific tumour markers from the options in cases of pancreatic cancer.
CA19-9
Neoplastic spinal cord compression
Investigation
Management
investigation
urgent MRI: the 2019 NICE guidelines recommend a whole MRI spine within 24 hours of presentation
Management
high-dose oral dexamethasone
urgent oncological assessment for consideration of radiotherapy or surgery
Lung Cancer type:?
most common type in non-smokers
peripheral lesion
adenocarcinoma
— is the most common cause of SVCO
Small cell lung cancer
Nasogastric tubes are safe to use if pH
5.5
Ascites: a high SAAG gradient (> 11g/L) indicates portal —
SAAG = serum-ascites albumin gradient
SAAG = (– albumin concentration) - (– albumin concentration)
A high SAAG (>11 g/L) is an indication of —-.
This is because increased hydrostatic pressure forces fluid out of the vascular spaces, concentrating – albumin.
hypertension
SAAG = serum-ascites albumin gradient
SAAG = (serum albumin concentration) - (ascitic albumin concentration)
A high SAAG (>11 g/L) is an indication of portal hypertension. This is because increased hydrostatic pressure forces fluid out of the vascular spaces, concentrating serum albumin.
Common peroneal nerve lesion can cause weakness of foot — and foot —
dorsiflexion
eversion
PHaeochromocytoma - give P–before beta-blockers
Phenoxybenzamine is a preferred α-blocker; however, prazosin, terazosin, doxazosin can also be used.
