Signs/symptoms/management of common conditions Flashcards
1
Q
Gastro-oesophageal reflux disease:
- symptoms? 6
- extra-oesophageal symptoms? 3
A
- heart burn (dyspepsia) esp after meals, relieved by antacids
- belching/burping
- food/acid regurg
- increased salivation (water brash)
- painful swallowing odynophagia
- fullness feeling
- nocturnal asthma
- chronic cough
- laryngitis/sinusitis
2
Q
Gastro-oesophageal reflux disease:
- risk factors?
- triggers?
- causes?
A
- caucasian
- obese
- pregnant
- smoking
- some drugs (eg Ca channel blockers)
- alcohol
- coffee
- fizzy drinks
- chocolate
- fatty foods
- spicy foods
- hiatus hernia
- loss of sphincter tone
- abdominal pressure
3
Q
Gastro-oesophageal reflux disease:
- non-pharm treatments? 7
- pharm treatments? 3
- further investigations? 3
A
- reduce triggers
- loose weight
- stop smoking
- take off drugs that relax muscles (Ca channel blockers, nitrites, anti-cholinergics)
- take off drugs that irritate stomach (NSAIDs, bisphosphonates)
- raise head off bed (not extra pillows)
- small meals, don’t eat 3 hours before bed
- antacids
- alginates (gaviscon)
- PPIs (better than H2-blockers)
nb antacids and alginates only relieve symptoms, don’t stop progression
- try giving pharm treatments and see if symptoms subside
- endoscopy (if symptoms >4wks on treatment or cancer red flags)
- if endoscopy negative, 24hr oesophageal ph monitoring
nb only do barium swallow if suspect hiatus hernia
4
Q
Gastro-oesophageal reflux disease:
- differentials? 5
A
oesophagial:
- oesophagitis from corrosives/candida/etc
- hiatus hernia
Gastric:
- gastritis (eg nsaids, h pylori)
- gastric or duodenal ulcer
Other systems:
- cardiac (or pulm) disease
5
Q
peptic ulcers
- two types? (which most common)
- most common causes? 2
- other risk factors? 3
- difference in symptoms between two types of ulcer?
A
- duodenal (90%) and gastric (10%)
- H pylori (85%)
- drug-induced (NSAIDs, SSRIs, steroids)
- smoking
- increased age
- poor gastric emptying/increased acid secretion
duodenal ulcer = pain before meals or at night (relieved by eating!) (50% asymptomatic)
gastric ulcer = pain after/during meals (also more likely to be asymptomatic)
6
Q
peptic ulcer disease:
- investigations? 2
- non-pharm treatments? 5
A
- C13 breath test (most accurate, non-invasive h pylori test)
- if over 55 or ALARMS signs: endoscopy
nb there are other, less used, tests
- stop NSAIDs
- reduce stress
- reduce alcohol consumption
- stop smoking
- eat less trigger food
7
Q
peptic ulcer disease:
- pharm treatments? 2
A
if h.pylori:
- triple therapy (2 Abx + PPI)
if drug-induced:
- stop drugs
- PPI (or H2-antagonist)
nb two Abx are norm clarithromycin plus amoxicillin or metronidazole
8
Q
red flags for peptic ulcer disease? 7 (6 are in an acronym)
A
- over 55years
ALARMS
- A = anaemia
- L = loss of weight
- A = anorexia
- R = recent onset/progressive symptoms
- M = melaena/haematemesis
- S = swallowing difficulty
9
Q
peptic ulcer disease:
- differentials? 7
A
- functional (non-ulcer) dyspepsia
- gastritis or duodenitis
- GORD/oesophagitis
- hiatus hernia
- gastric malignancy
- pancreatic cancer
- gallstones
(- duodenal crohns)
(- TB)
(- lymphoma)
also think of possible resp or cardiac conditions
10
Q
IBS:
- risk factors? 2
- triggers? 4
- age + gender affected?
A
- FH
- mental health conditions
- stress/anxiety
- mensturation
- gastroenteritis
- certain foods/drinks
- onset norm in 20s
- 2x more women
nb there is no demonstrable abnormalities in GI tract
11
Q
IBS:
- most common symptoms? 6
A
- crampy abdo pain (relieved by defecation/passing wind)
- diarrhoea +/or constipation
- feeling of incomplete evacuation
- passing mucus
- abdo bloating + distention
- excessive wind
nb symptoms often worse after food
nb symptoms are chronic (>6 months)
12
Q
IBS:
- less common symptoms? 5
- signs on examination? 2
A
- lethargy
- nausea
- back ache
- urinary urgency/frequency +/- incontinence
- dyspareunia (pain during sex)
examination is normal, bar:
- general abdo tenderness
- abdo distension
13
Q
IBS:
- investigations?
- differential diagnosis? 7
A
investigations are focused on excluding other conditions:
- crohn’s disease (blood tests + endoscopy)
- UC
- food intolerances (eg lactose, good history)
- coeliac disease (serology)
- colorectal cancer (risk factors, onset)
- ovarian cancer (risk factors, onset)
- endometriosis (symptoms)
14
Q
IBS:
- non-pharm treatments? 4
- pharm treatments? 3
A
depends on prevailing symptoms (eg avoid sorbitol sweeteners if diarrhoea, cut dietary fibre if constipation)
- alter diet
- avoid triggers
- CBT (second line)
- probiotics
- analgesics (norm avoid NSAIDs)
- smooth muscle relaxants (eg mebeverine)
- low dose amitryptyline or citalopram (second line)
focus of treatment is symptom control
15
Q
Gallstones:
- who does it affect? 4
- other risk factors? 7
A
- female
- fat
- fourty
- fertile
- diabetes mellitus
- crohns disease
- oral contraceptive
- HRT
- pregnancy
- smoking
- recent weight loss
nb gallstones are common!
16
Q
gallstones:
- 4 different presentations?
incl signs/symptoms
A
biliary colic (most common):
- pain in RUQ (often severe)
- pain lasts >30 mins (<8 hrs)
- pain may radiate to back
- may have nausea + vomitting
- no fever or abdo tenderness
acute cholecystitis (2nd most common):
- same as biliary collic
- PLUS fever + tenderness in RUQ (+ve murphy’s sign)
cholangitis (rare):
- same as cholecystitis
- PLUS jaundice
(- rigors)
gallstone pancreatitis (rare):
- severe pain, radiating to back
- nausea/vomitting common
17
Q
gallstones:
- bloods? 2
- other investigations? 1
A
- FBC (looking for ^WCC in cholecystitis)
- LFTs (obstructive jaundice)
- ultrasound is first line + most accurate imaging
nb even if imaging + bloods are normal, gallstones are not rulled out
nb can use MRCP or ERCP as follow up
nb xray very rarely helpful!
18
Q
gallstones:
- non-pharm treatment? 1
- pharm treatment? 2
- surgical treatment? 1
A
- avoid fatty foods/drinks that trigger symptoms
- analgesia
- Abx (if clinical signs of infection)
- cholecystectomy
nb if gallstones are in gallbladder and asymptomatic then leave alone
- only if symptomatic or visualised in bile duct then treat with surgery
19
Q
differential diagnosis for gallstones:
- liver? 2
- bile duct? 2
- pancreas? 2
- stomach? 3
- other GI? 2
A
- liver cancer
- acute hepatitis
- chorangiocarcinoma
- bile duct strictures
- pancreatitis
- pancreatic cancer
- PUD
- gastritis
- GORD
- IBS
- IBD
20
Q
differential diagnoses for acute appendicitis:
- GI? 8
- urological? 3
- gynaecological? 6
- other? 2
A
- perforated ulcer
- acute cholecystitis
- pancreatitis
- gastroenteritis
- diverticulitis
- intestinal obstruction
- meckel’s diverticulum
- crohns disease
- cystitis
- pyelonephritis
- right uteric colic
- ectopic pregnancy
- torted ovary
- ovarian cyst
- endometriosis
- dysmenorrhoea
- Pelvic inflammatory disease/salpingitis
- mesenteric adenitis
- diabetic ketoacidosis
21
Q
fibrocystic breast disease:
- cause?
- risk factors? 2
A
aka fibrocystic breast condition (FBC)
not fully understood, could be dt hormone levels as condition becomes rarer post-menopause
- age (30-50 highest risk)
- HRT may increase risk (contraceptive pills may decrease risk)
22
Q
fibrocystic breast disease:
- clinical presentation?
- mobile/tethered?
- where on breast?
A
breast lump(s)
can cause discomfort (in a cyclical menstural pattern)
- intermittent/persistent breast aching or tenderness
- breast skin/nipples may be tender/itchy
- smooth (norm mobile) lumps w defined edges
- most often in upper, outer section of breast
23
Q
fibrocystic breast disease:
- investigation? 1
- non-pharm treatment? 2
- pharm treatment? 1
A
possibly mammogram or MRI if really suspicious
- well-fitting, supportive bra (to reduce pain)
- hot or cold compress
- OTC pain killers
nb most don’t require invasive treatment
24
Q
breast carcinoma
- risk factors? 13
- % of breast cancers that are found in men?
A
nb most related to increased unopposed oestrogen
- nulliparity (or 1st preg >30years old)
- NOT breastfeeding
- early menarche
- late menopause
- oestrogen containing contraceptives
- HRT
- increased age
- high BMI
- high alcohol intake
- lots of chest radiation
- FH
- BRCA 1 + 2 genes
- PMH of breast cancer
1% of breast cancers are found in men
nb 1 in 9 women will get breast cancer in their life
- a quarter are picked up by mammography screening
25
breast carcinoma:
| - symptoms/signs? 4
- lump in breast (often tethered + poorly demarcated)
nb malignant lumps are often painless
- nipple changes (shape, nipple bleeding)
- skin changes (tethering, peau d'orange)
- enlarged axillary lymph nodes
26
breast carcinoma:
| - investigations? 4
triple assessment (for all breast lumps!)
- clinical examination
- radiology (US if <35, mammography + US if >35)
- histology/cytology (norm from US guided core biopsy)
if found to be malignant, sentinel node biopsy
27
breast carcinoma:
- specific pharm treatment? 3
- surgical treatment?
- chemo/radiation treatment?
- tamoxifen (for oestrogen receptor +ve tumours)
- herceptin (for Her +ve tumours)
- aromatase inhibitors (eg anastrozole) reduce peripheral oestrogen synthesis, only used in post-menopausal women
depending on stage:
- wide local excision
- total mastectomy +/- breast reconstruction
- axillary node clearance (if sentinel node +ve)
adjunct chemo used in all but those with best prognosis
radiotherapy used in many
- can also radiate axilla if don't want surgical clearance
nb tamoxifen increases risk of uterine cancer, warn patients!
28
MI/ACS:
- most common cause?
- non-modifiable risk factors? 3
- modifiable risk factors? 8
rupture/erosion of the fibrous cap of atheromatous plaque in coronary artery -> platelet-rich clot + vasoconstriction produced by platelet release of serotonin + thromboxane
nb can rarely be dt vasospasms or vasculitis
- older age
- male
- FH (1st degree relative had IHD <50)
- hyperlipidaemia
- hypertension
- metabolic conditions (diabetes)
- poor diet
- lack of exercise
- stress/depression
- smoking
- cocaine use
29
MI/ACS:
- symptoms? 8
- what is a silent MI?
- who is most likely to get a silent MI? 2
- acute central chest pain (>20 mins)
- pain in L arm, jaw or back
- anxiety (impending doom)
- fatigue
- nausea
- sweatiness
- palpatations
- SOB
MI presents without chest pain
- elderly
- diabetics
30
MI/ACS:
| - signs? 3
nb history often more important!
- pale/grey
- sweaty (can't fake!)
- high pulse
nb may be signs of heart failure (^JVP, , 3rd heart sound, basal crepitus)
nb may also hear pericardial rub
31
MI/ACS:
- bloods? 5
- other investigations? 1
- troponin
nb creatinine Kinase -MB rarely used now
- FBC
- U+Es
- glucose
- lipids
- ECG (ST elevation or new LBBB)
nb in 20% of ACS, ECG is normal initially!
can do CXR to exclude differentials but don't delay treatment to do!
32
MI/ACS:
- initial pharm treatment? 7 (acronym)
- treatment for STEMI? 2
BROMANCE
- beta-blockers
- reassurance
- oxygen
- morphine (IV)
- aspirin
- nitrates (GTN)
- clopidogrel
- antiEmetics (eg metoclopramide)
(nb sometimes give a NOAC as well for VTE prophylaxis)
nb don't give B blockers if:
- bradycardiac
- hypotensive
- heart failure
- asthmatic
- fibrinolytics (rTPA)
- PCI surgery
33
MI/ACS
- long-term pharm treatments? 5
- long-term non-pharm treatments? 4
- aspirin
- clopidogrel
- statin
- B blocker (norm metoprolol)
- ACE inhibitor
- more exercise
- control diabetes (if relevant)
- better diet
- stop smoking
34
differential diagnosies for MI/ACS:
- cardiovascular? 5
- resp? 2
- GI? 3
- other? 1
angina
- pericarditis
- myocarditis
- aortic dissection
- PE
- pneumonia
- pneumothorax
- oesophageal spasm
- GORD
- acute pancreatitis
- MSK pain
35
Angina pectoris:
- three types?
- pathophysiology?
- stable angina
- unstable angina
- prinzmetal (variant) angina
normally atheroma -> reduced O2 supply to heart muscle -> pain
(other rarer causes)
variant angina = spasms in coronary artery
36
Angina pectoris:
- modifiable risk factors? 4
- unmodifiable risk factors? 6
- high fat diet
- smoking
- lack of exercise
- psychological stress
- age
- male
- FH (IHD <50yrs)
- diabetes
- hypertension
- elevated CRP
37
Angina pectoris:
- three features of stable angina (according to NICE)?
- triggers for stable angina, bar physical exertion? 3
- associated symptoms? 4
- constricting discomfort in:
- -- front of chest
- -- neck
- -- shoulders
- -- jaw
- -- arms
- precipitated by physical exertion
- relieved by rest or GTN within about 5 mins
- emotion
- cold weather
- heavy meals
- dyspnoea
- nausea
- sweating
- light-headedness
38
Angina pectoris:
- non-pharm management? 3
- pharm management? 4
- stop smoking
- loose weight
- more exercise
- GTN spray (contraindicated w Viagra)
(- consider long-acting nitrate)
- Beta-blocker (or Ca channel blocker)
- Aspirin
- Statin (if high chol)
nb can give K+ channel activator (eg nicorandil) if unresponsive
nb get diabetes and HTN under control too
nb consider surgery if bad
39
Angina pectoris differentials:
- CVS? 7
- Resp? 3
- GI? 4
- MSK? 4
- psych? 1
CVS
- MI
- unstable angina
- prinzmetal angina
- dissecting thoracic aneurysm
- pericarditis
- acute HF
- arrhythmias
Resp
- PE
- pneumothorax
- pneumonia
GI
- peptic ulcer
- ruptured oesophagus (boerhaves*)
- GORD
- pancreatitis
MSK
- costochondritis
- rib fracture
- arthritis
- pulled muscle
Psych
- anxiety/panic attack
40
AF
- commonest causes? 4
- other causes?
- what percentage are idiopathic ('lone AF')?
common:
- IHD (+/ MI or heart failure)
- HTN
- valvar heart disease
- hyperthyroidism
other:
- congenital heart disease
- caffeine/alcohol/stimulants
- sick sinus syndrome
- wolf-parkinson white
- acute infection (e.g. pneumonia)
- PE
- low K or Mg
10% are idiopathic
41
AF:
| - risk factors? 3
- excessive alcohol + caffeine intake
- obesity
- age
42
AF:
- symptoms? 4
- signs? 1
- palpitations
- chest pain/dyscomfort
- dyspnoea
- faintness
nb often asymptomatic
- irregularly irregular pulse
nb if caused by valve disease then will hear a murmur (nb often mitral valve disease)
43
AF:
- bloods? 3
- other test needed? 1
- findings on other test? 2
- U&E
- troponin
- thyroid function test
- ECG
- absent P waves
- irregular QRS complexes
nb consider echo to look for structural abnormalities
44
AF:
- three TYPES of treatment?
- outline above treatment and which patients each would be suitable for
1) treat underlying cause
- suitable for:
- -- acute precipitating event (alcohol toxicity, infection, hyperthyroidism)
2) Rhythm control
- suitable for:
- -- younger patients (<65)
- -- highly symptomatic
- -- concurrent CCF
- -- recent onset AF (<48hrs)
- how:
- -- echo (TOE) to check for thrombus, treat with lmwh or warfarin prior to cardioversion (4 wks if thrombus found or >48hrs after start of AF)
- -- pharmacological or electrical cardioversion
```
Rate control:
- suitable for:
--- older patients (>65)
--- previous cardio version failure
- how:
--- Warfarin (or dabigitran)
--- Beta blocker (or rate-limiting Ca channel blocker)
(--- if fails, add amiodarone or digoxin)
```
45
Essential Hypertension:
- systolic/diastolic definition of high BP?
- % prevalence in 45-54 yo?
- % prevalence in over 75s?
- % that is actually secondary to another condition (e.g. conn's syndrome)
over 140/90mmHg
- 30% of 45-54 yo
- 70% of over 75s
5% is secondary
46
Essential Hypertension:
- non-modifiable risk factors? 3
- modifiable risk factors? 4
- afrocarribean ethnicity
- increased age
- FH
- diabetes
- obesity
- high salt intake
- high alcohol intake
- smoking
47
Essential HTN:
- bedside tests/investigations? 3
- blood tests? 3
- BP (incl 24-hr BP monitor)
- fundoscopy (hypertensive retinopathy)
- urine dipstick (protein)
nb can also do an ECG (looking for LVH or myocardial ischaemia) or possibly even an echo
nb on cardio exam may find LV heave or artery bruits
- blood cholesterol
- fasting glucose
- U&E (see kidney damage)
48
Essential HTN:
- non-pharm management? 6
- pharm control for all? 1
- 1st line drug for <55 yo?
- 1st line drug for >55 yo + black ethnicity of any age?
- weight loss
- exercise
- low fat diet
- reduce salt intake
- reduce alcohol intake
- stop smoking
- statin (also diabetes control if relevant) (which one??)
<55 yo
- ACE inhibitor (or ARB if hate cough) (which ACE inhibitor??***)
>55 yo or black
- Ca channel blocker (or thiazide diuretic) (Which Ca channel blocker???***)
49
DVT:
| - Risk factors? 10
- increased age
- obesity
- past DVT
- pregnancy
- synthetic oestrogen
- trauma
- surgery (esp pelvic or orthopaedic)
- immobility
- cancer
- thrombophilia
50
DVT:
- symptoms + signs
- scoring system used?
- blood test?
- imaging?
- red
- painful
- swollen
- hot
must be UNILATERAL
- WELLS
- D-dimer (very sensitive, not specific)
(- nb could do specific bloods if suspect thrombophilia)
- ultrasound of leg
51
DVT:
- treatment?
- prevention? 3
- high dose LMWH
- or high dose LMWH with warfarin then take LMWH off
(nb warfarin is pro-thrombotic for first 48hrs)
- low dose LMWH
- TED stockings
- stay mobile
52
DVT:
- infectious differential diagnoses? 3
- other DD? 4
- cellulitis
- superficial thrombophlebitis
- insect bite
- ruptured baker's cyst
- sprain/rupture achilles tendon
- physical trauma (imvl haematoma)
- peripheral (stasis) oedema (or lymphedema)
nb other rarer causes (e.g. compartment syndrome)
53
Common causes of heart failure:
- Right-sided? 4
- Left-sided? 4
Right-sided
- LVF
- pulmonary stenosis
- Right ventricular MI
- lung disease (cor pulmonate)
Left-sided
- Left-ventricular MI
- hypertension
- aortic stenosis
- mitral or aortic regurg
nb CCF = right AND left failure
nb rare causes include steroids, come chemo, cocaine and other stuff
54
Signs + symptoms of heart failure:
- Right-sided? 6
- Lef-sided? 10
Right-sided
- peripheral oedema
- ascites
- nausea
- anorexia
- pulsation in neck + face (RHF -> tricuspid regurg)
- murmur (+/or 3rd 'gallop' heart sound)
Left-sided
- fatigue
- wheeze (cardiac 'asthma')
- SOB
- poor exercise tolerance
- displaced apex beat
- cold peripheries
- nocturnal cough (+/- pink frothy sputum)
- orthopnoea
- paroxysmal nocturnal dyspnoea (PND)
- nocturia
nb think logically about the back-up of fluid when each side of the heart has failed
55
Heart failure:
- blood tests?
- other investigations? (and what they show)
- BNP
- FBC
- U&E
(- LFT, may cause hepatic-congestion)
- ECG (indicate cause)
- CXR (ABCDE)
- -- Alveolar oedema (bat wing shadow)
- Kerley B lines (interstitial oedema)
- -- Cardiomegaly (heart width >50%)
- -- Dilated prominent upper lobe vessels
- -- pleural Effusion (blunting of angles)
- Echocardiogram
- -- valvular defects, previous MI, ejection fraction, hypertrophy etc
56
Heart failure differential diagnoses:
- conditions causing dyspnoea? 5
- conditions causing peripheral oedema? 6
dyspnoea DD:
- COPD
- asthma
- PE
- lung cancer
- anxiety
peripheral oedema DD:
- prolonged inactivity
- venous insufficiency
- nephrotic syndrome
- hypoalbuminaemia
- some drugs (some Ca channel blockers, NSAIDs)
- obesity
57
Diabetes Mellitus type 2:
- pathogenesis?
- norm age of onset?
- non-modifiable risk factors? 6
- modifiable risk factors? 3
- medications that increase risk? 3
- pathogenesis?
decreased insulin secretion +/- insulin resistance
- 40-50 (but can get MODY)
- family history
- PMH of gestational DM
- PMH of polycystic ovary syndrome
- PMH of HTN
- black or asian ethnicity
- low birth weight
nb metabolic syndrome = high blood sugar, high cholesterol, HTN + central obesity
- obesity
- inactivity
- low fibre/high sugar diet
(nb smoking + alcohol also increase risk)
- statins
- corticosteroids
- thiazide diuretic + B blocker
58
type 2 Diabetes Mellitus:
| - symptoms? 12
MOST type 2 DM is ASYMPTOMATIC until complications occur!!
- poyluria
- polydipsia
- increased hunger
- fatigue
- unexplained weight loss (or gain?)
- blurred vision
- headaches
- recurrent infections
- poor wound healing
- recurrent vaginal thrush
- acanthosis nigrocans
- numbness/tingling of feet
59
type 2 Diabetes Mellitus:
- signs on examination? 2
- blood tests? 2 (incl abnormal numbers)
- diagnostic criteria? 2
- other bedside test? 1
- diabetic retinopathy
- diabetic nephropathy
- blood glucose (see below)
- HbA1c >48mmol/L
- symptoms of hyperglycaemia PLUS fasting glucose of >7mmol/L or random glucose of >11mmol/L (or HbA1c >48mmol/L)
- asymptomatic but with two separate positive glucose blood tests
- urine dipstick
60
type 2 Diabetes Mellitus:
- non-pharmacological treatment? 3
- 3 classes of drug used (bar insulin)? + examples?
- what's 1st line etc?
- loose weight
- more high fibre/low sugar diet
- exercise more
- metformin
- sulphonylureas (gliclazide)
- thiazolidinediones (pioglitazone)
metformin is first line (titrate up to minimise GI upset + monitor renal function)
gliclazide as mono therapy or w metformin is 2nd line
thiazolidines are third line if metformin +/- gliclazide contraindicated or not adequate (even then you'd norm start on insulin)
nb many other drugs as well...
61
type 2 Diabetes Mellitus:
- monitoring blood tests? 2
- what needs monitoring for? 3
- HbA1c
- U&E (see kidney function)
- diabetic retinopathy
- diabetic neuropathy (foot care)
- diabetic nephropathy (see above)
62
iron deficiency anaemia:
- GI causes? 2
- gynae causes? 3
- other causes? 2
nb often multifactorial
most commonly seen in pre-menopausal women
- GI bleeds (most common cause in men + post-men women)
- malabsorption (IBD, coeliac, gastrectomy etc)
- menstruation (most common cause in pre men women)
- pregnancy
- PV bleeding (e.g. haemorrhage in childbirth)
- inadequate dietary intake (rare!! e.g. vegans)
- blood donation
nb hookworm common causes of PR bleeds in tropics
63
iron-deficiency anaemia:
- common symptoms? 4
- less common symptoms? 9
nb if develops chronically, often few symptoms as body adjusts
- fatigue
- dyspnoea
- faintness
- palpitations
- headache
- tinnitus
- taste disturbances
- pruritis
- lack of conc/irritability
- pica (abnormal food cravings)
- glossitis
- dysphagia
- impairment of body temp regulation (esp in preg)
64
iron deficiency anaemia:
- signs? 5
- blood tests? (incl findings) 2
- other investigations? 2
- pale palmar creases
- koilonycia
- glossitis
- angular chelitis
- pale conjunctiva
- FBC
= low Hb, low MCV, low MCH, low MCHC
- ferritin
= low (nb also low in infection)
- endoscopy
- colonoscopy
(- stool microscopy if hookworm suspected)
nb faecal occult blood rarely used as poor sensitivity
65
iron def anaemia:
| - treatment? 2
- treat underlying cause
| - ferrous sulphate tablets
66
iron def anaemia:
- differential diagnoses for microcytic anaemia? 4
- other? 3
- thalassaemia
- anaemia of chronic disease
- sideroblastic anaemia
- lead poisoning
- hypothyroidism
- heart failure
- cancers
(anything that presents with fatigue)
67
osteoarthritis:
| - risk factors? 7
- female (3:1)
- over 50
- family history of OA
- obesity
- high or low bone density
- joint injury or occupational/recreational stresses on joints
- joint malalignment (could be dt rare things like marfans)
68
osteoarthritis:
- symptoms/signs?
- which hand joints affected? (names)
- appearance on plain x-rays? 4 (incl acronym)
pain
- when being used
- worse at end of day
- background rest pain
- crepitus
- limited range of movement
- stiff when start moving (BUT <30mins)
nb often starts unilateral
- DIP (herbeden's nodes)
- PIP (bouchards nodes)
```
LOSS
L - Loss of joint space
O - Osteophytes
S - Subarticular sclerosis
S - Subchondral cysts
```
OA is normally a clinical diagnosis (only do x-ray if trying to exclude another cause for pain)
in OA, CRP may be slightly raised
69
osteoarthritis:
- non-pharm management? 2
- pharm management? 5
- surgery?
- exercise to improve muscle strength
- loose weight (if obese)
- paracetamol
- topical NSAIDs
- topical capsaicin (from chilli)
- oral NSAIDs
- mild opiods
- intra-articular steroid joint injections
- joint replacement
70
osteoarthritis: differential diagnoses:
- other types of arthritis? 8
- other causes of joint pain? 6
- Rheumatoid Arthritis
- psoriatic arthritis
- ankylosing spondylitis
- gout
- pseudo gout
- reactive arthritis
- arthritis associated w connective tissue disorders (e.g. SLE)
- septic arthritis (esp if one joint)
- fibromyalgia
- fracture of bone adjacent to joint
- major ligament injury
- bursitis
- bone metastases
- primary cancer
71
prolapsed disc:
| - risk factors? (incl age affected) 6
- middle aged (35-50)
- men>women
- physically demanding work (heavy listing etc)
- obesity
- smoking (causes faster degeneration of discs)
- FH
72
prolapsed disc:
- main symptom and what makes better/worse etc?
- associated symptoms? 3
- what to check for?
back pain (normally lumbar so lower back)
- worse with movement, esp hunching forward
- fast onset
```
leg pain (often worse than the back pain)
- searing sharp, electric shooting pain
```
- numbness/pins + needles in legs
- muscle weakness (incl foot drop)
not all slipped discs cause symptoms, many people will never know they have slipped a disc
CAUDA EQUINA!!
- ask re bladder + bowel control + saddle anaesthesia
73
prolapsed disc:
- clinical test?
- prognosis?
- when to refer?
- imaging?
- Lower limb neuro/MSK exam
- sphincter tone + saddle anaesthesia (rule out caudal equina)
90% of people get better in 6 weeks
if not beginning to improve after 6 weeks or red flag symptoms
then get MRI
74
prolapsed disc:
- non-pharm treatment?
- pharm treatment?
- when to consider surgery?
- physiotherapy
- analgesia
- severe or increasing neurological impairment (e.g. foot drop or bladder symptoms)
75
differential diagnoses for prolapsed disc? (8)
- spondylolisthesis
- spinal stenosis
- ankylosing spondylitis
- arthritis
- pregnancy
- muscle spasm
- chronic disc disease
- cauda equina syndrome
76
depression:
- which age group highest in?
- which gender higher in?
- risk factors? 10
- elderly
- female (2:1)
- stressful life events (esp multiple)
- personality (low self-esteem, very self-critical)
- family history
- PMH of depression
- giving birth
- loneliness
- alcohol abuse
- substance abuse
- hypothyroidism
- chronic medical problems
(and many more)
77
depression symptoms:
| - physical? 9
- fatigue
- insomnia, w early morning wakening (or hypersomnia)
- loss (or gain) of appetite
- loss (or gain) of weight
- constipation
- amenorrhoea
- psychomotor retardation (slow speech, slow movement, slow thinking)
- loss of libido
- unexplained aches + pains (often present w head/back ache)
78
depression symptoms:
| - psychological? 10
- loss of interest or pleasure
- lack of emotional reactivity
- diurnal variation in mood
- pessimistic thoughts
- poor concentration/attentiveness
- indecisiveness
- no motivation/being reclusive
- guilt + worthlessness (low self-esteem)
- anxiety feelings
- thoughts of self-harm/suicide
79
what is the negative cognitive triad in depression?
self: worthlessness
world: critical, guilt
future: hopelessness
the cycle of pessimistic thoughts seen in depression
80
depression:
| clinical examinations? 3
- mental state examination
- PHQ-9
- screen for risk (see below)
```
= suicide + self-harm
- past attempts
- current thinking/plans
- acute stressors
= risk to self
- able to cope at home
- basic living skills
- intoxication
= risk to others
- forensic history
- impulsivity
- any dependents
```
81
depression:
| - non-pharm treatment? 5
- CBT (or other talking therapy)
- manage underlying physical conditions
- manage alcohol/drug missuse
- exercise
- good sleep hygiene + diet
82
depression:
- pharm treatment? 4
describe when use different types (and examples of drug names)
```
SSRIs
= 1st line (same efficacy as tricyclics but fewer side effects)
- fluoxetine (best for younger people)
- citalopram
- sertraline
```
```
Tricyclics
= sometimes used, also for nerve pain, migraines, fibromyalgia + other things (bit of a marmite drug)
- amitriptyline
- nortriptyline
- lofepramine
```
NaSSA
= often used as also has an anti-histamine effect which helps with insomnia
- mirtazapine
SNRIs
= often used by psychiatrists when SSRIs haven't worked
- venlafaxine
- duloxetine
83
differential diagnoses for depression:
- psychiatric? 6
- CNS? 4
- endocrine? 3
- drug-induced? 3
- infectious? 2
- other? 3
- bipolar disorder
- dysthymia
- PTSD
- eating disorders
(nb above, plus anxiety, are often co-morbid w depression)
- chronic fatigue syndrome (CFS/ME)
- dementia
- post-concussion syndrome
- MS
- parkinsons
- brain tumours
(nb depression does not produce focal neurological signs, if found should look for other causes of low mood)
- hypothyroidism
- hypoparathyroidism
- cushings syndrome
- OCP (particularly progesterone only)
- anti-epileptic drugs
- interferons
(and many others)
- syphilis
- toxoplasmosis
- SLE
- anaemia
- folate deficiency
nb insomnia + sleep apnoea can also mimic depression
nb also grief
84
anxiety:
| - types? 7 (+ differences between them)
generalised anxiety disorder (GAD)
- consistent feelings of excessive, unrealistic worry + tension with little/no reason
social phobia
- feel overwhelming worry + self-conciousness about everyday social situs, fixate about other judging you/beng embarrassed or ridiculed
panic disorder
- acute terror that strikes at random
- manifests as panic attacks (+ fear of getting panic attacks)
agoraphobia
- fear of open spaces/public transport/leving home etc
- but more complex than that
phobias
- intense fear of a specific object or situation disproportionate to risk of object/situ
- go to great lengths to avoid it
PTSD (EMDR or DBT)
OCD (CBT)
- obsession (thought based) is an unwanted + unpleasant thought/image or urge that enters your mind
- compulsion (behaviour based) is a repetitive behaviour or mental act that you feel you need to carry out to try to temporarily relive the unpleasant feelings brought on by the obsessive thought
85
anxiety:
| - risk factors? 5
- environmental stressors/trauma (sexual assault, violence, bullying)
- FH
- substance dependence or abuse
- cognitive styles of negative thinking
- chronic illness
nb anxiety is a normal feeling/emotion in response to a stimulus but when it occurs without stimulus or after that has disappeared then this is a medical condition
86
anxiety:
- psychological symptoms general to all forms? 2
physical symptoms general to all forms? 10
- symptoms specific to PTSD? 4
- panic, fear, uneasiness
- not being able to stay calm + still
- sleep problems
- cold, sweaty, numb or tingling hands/feet
- dry mouth
- tense muscles
- SOB
- palpitations
- chest pain/tightness
- nausea
- dizziness
- headaches
- re-experiencing (flashbacks/nightmares/physical sensations on remembering)
- avoidance
- emotional numbing
- hyperarousal
87
treatment:
- GAD? 4
- social phobia? 4
- panic disorder? 3
- agoraphobia? 3
- other phobias? 3
- PTSD? 3
- OCD? 2
GAD
- group/online therapy
- CBT
- mindfullness/applied relaxation
- antidepressants (if above not effective)
social phobia
- online CBT/self help
- CBT
- psychotherapy
- antidepressants (if above don't work)
panic disorder
- CBT
- antidepressants
- propranolol (used like a blue inhaler in asthma)
agoraphobia
- self help + lifestyle changes
- CBT
- medication (rarely)
```
other phobias
- self help
- CBT
- mindfullness
(rarely meds)
```
PTSD
- CBT (or psychotherapy)
- EMDR (eye movement desensitisation + reprocessing)
- antidepressants
OCD
- CBT
- antidepresssants
88
differential diagnoses for anxiety
- psychiatric? 2
- medications? 2
- cardiac? 2
- endocrine? 2
- respiratory? 2
nb this is not an exhaustive list!! (it also excludes the different types of anxiety)
- schizophrenia/psychosis
- mania
- withdrawal from alcohol (+ benzodiazepines, cocaine, marijuana + SSRIs)
- certain stimulants (amphetamines, asthma meds, caffeine)
- AF (or other arrhythmia)
- angina
- pheochromocytoma
- hyperthyroidism
- asthma
- COPD
loads of other things as well!!!
89
alcohol dependence:
| - what are the 4 CAGE questions?
C - ever felt you ought to Cut down on your drinking?
A - have people Annoyed you by criticising your drinking?
G - ever felt bad or Guilty about your drinking (e.g. if it lead you to neglecting your responsibilities or relationships)
E - ever had an Eye-opener to steady nerves in the morning? (drinking to relieve withdrawal symptoms is telling sign)
90
alcohol dependence:
- risk factors? 6
- symptoms? 12
- male
- high alcohol intake
- FH of alcoholism
- PMH of mental health problems
- low self-esteem
- stress
- drinking ALONE
- drinking in the MORNING
- having high alcohol TOLERANCE
- becoming VIOLENT/ANGRY when asked about drinking habits (i.e. denial)
- not EATING/eating poorly
- neglecting personal HYGIENE
- MISSING works/school dt drinking
- making EXCUSES to drink
- CONTINUING to drink when legal/social Econ problems develop
- alcohol CRAVINGS
- WITHDRAWAL symptoms when not drinking (shaking, nausea, vomitting, sweating, anxiety)
- BLACK OUTS after a night of drinking
91
alcohol dependence, what can it put you at risk of/lead to:
- GI tract? 3
- other GI? 2
- neuro effects? 4
- other effects? 3
- oesophageal varices
- peptic ulcers
- GI cancers
- liver cirrhosis
- pancreatitis
- dementia
- depression
- nerve damage
- wernickes encephalopathy
- high blood pressure
- macroytic anaemia
- impotence
(if in pregnancy: foetal alcohol syndrome)
92
alcoholism:
- withdrawal symptoms/signs? 6
- non-pharm treatments? 2
- pharm treatment to prevent complications?
- pharm treatment to use for medically-induced withdrawal?
- pharm treatment which causes bad reaction to alcohol?
- increased pulse
- low BP
- tremor
- confusion
- fits
- hallucinations (delirium tremens)
- group therapy (e.g. AA)
- CBT/psychotherapy
- oral (or IV) thiamine to protect against/treat Wernickes/Korsakoffs
- benzodiazepines (norm chlordiazepoxide) - slowly taper off, a GABA agonist (similar effect to alcohol)
disulfarim
- causes acetaldehyde build up (like metronidazole) -> nausea, headaches, palpitations etc
nb lots of relapse, especially if underlying psychological + social issues not
nb don't prescribe NSAIDs or anticoagulants to patients with/high risk of oesophageal varies as increases bleeding risk!
93
dementia:
- main risk factor?
- genetic risk factors? 2
- other risk factors? 9
AGE
- mutation in amyloid precursor protein gene (esp in young-onset)
- APOE4 subtype (for alzheimers
- mild cognitive impairment
- learning difficulties
- CVD risk factors (diabetes, smoking, high cholesterol etc)
- heavy alcohol consumption
- stroke
- parkinsons disease
- depression
- low educational attainment
- low social engagement + support
94
dementia:
| - symptoms? 7
- memory loss (esp recent memories)
- difficulty concentrating
- difficulty with ADLs
- struggling to follow a convo or find the right word
- being confused re time + place
- mood changes
- weight loss + changes in sleep patterns
and many others!
95
dementia:
| - important aspects to consider when managing patients with dementia? 9
- treat any underlying cause (e.g. reduce vascular risks, give B12 etc)
- get a care coordinator
- assess capacity
- develop routines (helps with confusion)
- plan ahead (look to move into care home before needed so not rush)
- organise activities during day to keep up stimulation
- who will care for carers?
- screen for depression (common) + treat w SSRI
- ensure calorie intake is sufficient
- avoid drugs that impair cognition (tricyclics, sedatives etc)
96
dd for dementia:
- psych/neuro? 4
- drugs? 6
- other? 2
- normal age-related memory changes
- mild cognitive impairment
- depression (weeks to months)
- delirium (hours to days)
- benzodiazepines
- analgesics
- anticholinergics
- antipsychotics
- anticonvulsants
- corticosteroids
- vitmin deficiency
- hypothyroidism
97
causes of lymphadenopathy:
- reactive + infective? 3
- reactive + non-infective? 6
- infiltrative?
REACTIVE + INFECTIVE
- bacterial (e.g. pyogenic, TB, brucella, syphillis)
- viral (EBV, HIV, CMV, infectious hepatitis)
- others (toxoplasmosis, trypanosomiasis)
REACTIVE + NON-INFECTIVE
- sarcoidosis
- amyloidosis
- berylliosis
- connective tissue disease (e.g. SLE, rheumatoid)
- dermatological (eczema, psoriasis)
- drugs (e.g. phenytoin)
INFILTRATIVE
- benign histiocytosis
- haem cancers (lymphoma or leukaemia - ALL, CLL, AML)
- metastatic cancers (breast, lung, bowel, prostate, kidney, head/neck)
98
describe which lymph nodes you feel for in a neck exam (and where they are)
9
- supraclavicular (incl on the left: virchov's, normally gastric Ca)
- anterior cervical (anterior to SCM)
- posterior cervical (posterior to SCM)
- tonsilar (under corner of mandible)
- submandibular
- submental (under chin)
- preauricular
- post auricular (around mastoid)
- occipital
https: //doctorslounge.com/oncology/diagnosis/lymph_node/cervical.htm
99
difference in presentation between inflammatory/infective causes of lymphadenopathy + malignant causes?
incl associated symptoms
inflam
- acute
- painful/tender
- red
- swollen
- specific to drainage of particular area (e.g. external ear infection -> pre-auricular nodes)
- other signs of infection (tonsillitis, glandular fever etc)
lymphoma or leukaemia
- painless
- generalised lymphadenopathy (esp post triangle, axillae + inguinal)
- nodes are enlarged + rubbery
- systemic B symptoms (pallor, fatigue, weight loss, night sweats, fever, hepatomegaly)
metastatic cancer
- enlarged painless nodes at drainage site of where organ is (e.g. breast -> axillae)
- symptoms/signs of underlying cancer
100
stroke: focal signs in:
- cerebral infarcts?
- brainstem infarcts?
- lacunar infarcts?
cerebral infarcts (50%)
- contralateral sensory loss
- contralateral hemiplegia (initially placid then rigid)
- dysphasia
- homonymous hemianopia
- frontal sparing!!
brainstem infarcts (25%)
- quadriplegia
- disturbances of gaze or vision
- locked-in syndrome
lacunar infarcts (35%)
= basal ganglia, internal capsule, thalamus + pons
- ataxic hemiparesis
- pure motor
- pure sensory
- cognition/conciousness intact (except thalamic stroke)
nb signs can be localising but often more generalised and imaging is only way to identify specific area
- symptoms are hugely variable!!
nb haemorrhagic strokes can give meningial signs (photophobia, neck stiffness etc) but may not
101
differential diagnoses for stroke or TIA? 12
- seizure (+ post-ictal states)
- migraine
- syncope
- sub-arachnoid, sub-dural or epidural bleed
- other mass lesion
- hypoglycaemia
- hyponatraemia
- MS
- focal neuropathy (e.g. bells palsy)
- hyperglycaemia
- other encephalopathies
- trauma
- functional hemiparesis
102
symptoms (+ signs) of:
- sensory neuropathy? 6
- motor neuropathy? 4
- autonomic neuropathy? 7
sensory:
- numbness
- pins & needles (burning, feels funny)
- affects extremities first (glove + stocking)
- difficulty handling small objects (eg buttons)
- signs of trauma on hands/feet
- diabetic + alcoholic neuropathies are typically painful
motor:
(nb often progressive, may be rapid)
- weak or clumsy hands
- difficulty in walking (falls, stumbling)
- wasting + weakness most marked in distal muscles (eg foot drop)
- reflexes reduced or absent
autonomic:
- postural hypotension
- erectile dysfuntion/ejaculation failure
- decreased sweating
- constipation
- nocturnal diarrhoea
- urine retention
- horners syndrome
103
commonest mononeuropathy?
- nerve roots?
- symptoms? 3
- clinical tests? 2
- treatment? 3
carpal tunnel syndrome
= median nerve (C6-T1)
- aching pain in hand + arm (esp at night)
- parasthesiae in thumb, index + middle fingers)
- may be sensory loss + weakness/wasting over/of thenar eminence
Tinel's test: tap over wrist to induce symptoms
Phalen's test: maximal wrist flexion for 1 min mauy elicit symptoms
nb neither of these are very reliable
- splinting
- local steroid injection
- decompression surgery
104
FIRST line drug treatments for:
- generalised tonic-clonic, tonic, atonic + myoclonic? 2
- absence seizures? 3
- partial seizures +/- secondary generalisation? 1
generalised tonic-clonic, tonic, atonic + myoclonic
= lamotrigine (better tolerated + less teratogenic)
= sodium valproate
absence
= sodium valproate
= lamotrigine
= ethosuximide
partial +/- generalisation
= carbamazepine
nb these are for preventionof seizures not during seizures
also nb there are many other drugs and usage depends on co-morbidities, interactions and plans for pregnancy
105
drug treatment for prolonged or repeated seizures, incl status epilepticus
rectal or IV benzodiazepines
- eg diazepam, lorazepam
nb this makes sense as these are GABA agonists and so act as CNS depressors, reducing the neuronal excitability quickly
106
migraine:
- risk factors? 3
- triggers for attacks? (incl acronym) 9
- FH (v important)
- female (2:1)
- obesity
CHOCOLATE
```
C - Chocolate
H - Hangovers
O - Orgasms
C - Cheese
O - Oral contraceptives
L - Lie-ins
A - Alcohol
T - Tumult (stress/distressed)
E - Exercise
```
nb triggers are only seen in 50%
107
migraine:
- three types?
- typical presentation of attacks?
migraine withOUT aura
- unilateral throbbing/pulsating headache
- lasting 4-72 hours
- nausea/vomitting + fatigue
- photophobia +/or photophobia
- worsened by moving around/daily activities
migraine WITH aura
- see above, PLUS....
- aura precedes headache by minutes + may occur during
- auras can be visual (distorting visions of lines, dots, zig zags, scotoma +/or hemianopia), sensory (e.g. parasthesia in arms) +/or motor (dysarthria, ataxia, ophthalmoplegia etc)
migraine variants
- get unilatreral aura-like symptoms but without the headache
- poorly understood
108
migraines:
- investigations?
- treatment of attacks? 3
- meds for prevention? 2
- what drugs are contraindicated for migraines WITH aura?
- none needed, all on history
unless suspect a different cause
treatment for attacks
- NSAIDs (least likely to induce a post-analgesia headache)
- a triptan (e.g. sumitriptan)
- antiemetic (e.g. metoclopramide)
only use drugs for prevention if attacks are very frequent and disabling and medication-overuse headaches are occurring dt repeated treatment of acute attacks
prevention
- topiramate (an anti-epileptic - nb a teratogen)
- propranolol
^nb these are first line, consult neurologists if failure of these
COMBINED oral contraceptive pill (though fine if no aura)
109
migraines
| - differential diagnoses? 4
- tension type headache
- meningitis
- subarachnoid haemorrhage
- TIA
nb in TIAs, the maximum deficit is present immediately + headache is unusual
if take good history then normally easy to rule out other causes
110
tension headache:
- classical presentation?
- risk factors?
- investigations?
- management?
- what can mimic it? 3
- BI-lateral tightening pain around head
- non-pulsating
- no nausea/vomiting (though anorexia may occur)
- often radiates to neck
- may be tenderness of scalp muscles
- stress/sleep disturbance
- squinting
- poor posture
- dehydration
- noise
nb similar headaches may be caused by depression, caffeine withdrawal etc but these don't technically count as tension headaches
- BP + papilloedema
- relaxation techniques (yoga, massage, light exercise)
- mild painkillers (paracetamol or ibuprofen)
- analgesia-overuse headaches
- migraine without aura
- pain referred from neck
always make sure to ask about social history and OTC drug Hx in these presentations
111
UTI
- risk factors? 10
- commonest causative organism?
- female
- sexual intercourse
- exposure to spermicide for women (on condoms)
- pregnancy
- menopause
- immunosuppression
- diabetes
- catheter
- abnormality of tract (incl past surgery)
- kidney stones
- E. coli
112
lower UTI:
- urinary symptoms? 4
- systemic symptoms? 6
- frequency
- urgency
- dysuria
- foul-smelling urine (+ cloudy +/or blood)
- suprapubic ache/pain ( can get back pain in men)
- non-specific malaise
- nausea
- fatigue
- fever
- delirium (esp in elderly)
113
lower UTI
- tests? 2
- when to do each?
dipstick (leucocytes + nitrates)
- everyone (though if repeated in women just go on history)
midstream urine sample (MSU)
- male
- pregnant
- child
- immunosuppressed
- very ill
- not improving after empirical Abx
114
lower UTI:
- 1st line treatment? (incl length)
- 1st line treatment in pregnancy?
- when to treat in pregnant women?
- when to treat in catheterised people?
nitrofurantoin
- women = 3 days
- men = 7 days
cefalexin (or other cephalosporin)
screen for + treat any bacteruria in pregnancy (whether symptomatic or not)
catheterised people always have bacteruria - only treat if symptomatic
don't forget analgesia!!
115
lower UTI:
- prevention advice? 2
- differential diagnoses? 5
- drink plenty of water
- drink cranberry juice (not if on warfarin)
- urinary TB (esp if MSU is negative)
- STIs (incl chlamydia)
- thrush
- urethral syndrome
- BPH (in men)
116
nephrotoxic drugs
- causing pre-renal damage? 4
- causing intra-renal damage? 8
- need dose reduction in renal failure to avoid toxicity? 2
PRE-RENAL
- NSAIDs
- ACEi (but good for CKD)
- ARBs
- any drug that causes excess GI loss (diarrhoea/vomiting) -> hypoperfusion
INTRA-RENAL
- x-ray contrast
- diuretics*
- lithium
- methotrexate
- aminoglycosides (gentamicin)
- cephalosporins
- vancomycin
- most Abx*
NEED DOSE REDUCITON
- digoxin
- anti epileptics
basically just check BNF when prescribing for someone with CKD!
nb many infrarenal toxicity is due to inflammation following a hypersensitivity reaction to the drug
nb I may have missed some...
117
CKD:
- what conditions predispose to CKD? 7 (commonest 4?)
- other risk factors? 3
- diabetes (common)
- HTN (common)
- Cardiovascular disease
- polycystic kidney disease (common)
- structural renal tract disease, renal calculi or prostatic hypertrophy (common)
- multi system disease with possible kidney involvement (e.g. SLE, myeloma)
- PMH of AKI
- FH of stage 5 CKD or hereditary renal disease
- patients on known nephrotoxic drugs
- increasing age
118
CKD symptoms:
- neuro? 3
- systemic? 3
- urinary? 2
- skin? 2
- GI tract? 2
- peripheral? 2
nb early stage has no symptoms (but can still be picked up on bloods etc)
- decreased mental sharpness
- insomnia
- headaches
- lethargy (anaemia)
- muscles cramps (low vit D)
- exertion breathlessness (anaemia)
- blood in urine
- nocturia
- abnormally pale (anaemia) or pigmented (dt retained urochromes and hemosiderin deposition) skin
- pruritis
- poor appetite + weight loss
- nausea
- peripheral oedema
- erectile dysfunction
119
CKD:
- clinical signs?
- bloods? 6
- other investigations? 2
- imaging?
often none!
- may be signs of cause, e.g. diabetes
To be counted as CHRONIC must be shown to be long-standing - look at old eGFRs
- FBC (anaemia)
- U+Es (calculate eGFR)
- glucose (diabetes)
- Vit D
- calcium
- phosphate
- PTH
(- autoantibody screen)
- BP
- urine (protein, blood)
- USS
nb consider renal biopsy only if kidneys are normal size + cause of CKD is not clear from other investigations
120
CKD:
- stages? 6
incl eGFR values
stage 1) >90
stage 2) 60-89
stage 3A) 45-59
stage 3B) 30-44
stage 4) 15-29
stage 5) <15
nb to diagnose stage 1 or 2, must be haematuria, proteinuria or known renal structural abnormality
121
CKD:
- recommended dietary changes? 4
- other lifestyle advice? 4
- other drug management? 6
- treatment for end-stage disease? 2
- sodium restriction
- fluid restriction
- phosphate restriction (certain foods)
- potassium restriction (certain foods)
- stop smoking
- do regular exercise
- moderate alcohol intake
- loose weight (if overweight)
- stop nephrotoxic drugs (incl ibuprofen)
- give vit D + calcium
- treat HTN (with ACEi or ARBs)
- treat high cholesterol (with statins)
- control diabetes
- treat any other underlying cause
- dialysis (blood or peritoneum)
- renal transplant
122
Benign prostatic hyperplasia/hypertrophy (BPH):
- who is affected?
- symptoms? 9
- men >50
- nocturia
- frequency
- urgency
- hesitancy
- poor stream/flow
- post-micturition dribbling
- overflow incontinence
- haematuria
- UTIs
123
BPH:
- clinical investigation? 1
- bloods? 2
- other investigation? 1
- imaging? 1
- PR (enlarged smooth prostate)
- U+Es
- PSA (BEFORE do PR exam)
- mid-stream urine (MSU)
- trans-rectal USS +/-biopsy
124
BPH:
- lifestyle advice? 2
- peeing advice? 3
- pharm management? 2 (incl examples)
- surgical management?
- avoid caffeine
- avoid alcohol
- relax when voiding
- void twice in a row to aid emptying
- 'train' bladder by holding on/distracting to increase time between voiding
selective a1 blockers
- e.g. tamsulosin, doxazosin)
- reduces smooth muscle tone
5a-reductase inhibitors
- finasteride
- decreases conversion of testosterone to more potent type (which promotes prostate growth)
lots of different options
- most common is TURP (transurethral resection of the prostate
125
asthma:
- risk factors? 6
- three factors that contribute to airway narrowing?
- PMH atopic disease
- FH atopic disease
- exposure to tobacco smoke (or other lung irritants)
- social deprivation
- low birth weight
- obesity
1) bronchial muscle constriction (triggered by a variety of stimuli)
2) mucosal swelling/inflammation (dt mast cell + basophil degranulation)
3) increased mucus production
126
asthma:
- symptoms? 3
- common triggers? 8
- drugs which exacerbate? 2
- intermittent dyspnoea (diurnal variation)
- wheeze
- cough (often nocturnal) w sputum
- cold air
- exercise
- emotions
- allergens (dust mite, pollen, fur)
- infection
- smoking
- passive smoking
- pollution
- NSAIDs
- B blockers
127
asthma:
- clinical signs?
- conditions which often co-exist?
- clinical testing/diagnosis?
- symptomatic wheeze on auscultation
(- can get hyper inflated chest, but only if severe)
- other atopic (hayfever, eczema)
- gastric reflux
- peak flow
spirometry
- FEV1/FVC ratio reduced (should be 90% in kids + 70% in adults)
- FEV1 improves with salbutamol
128
asthma:
- suggested lifestyle changes? 3
- pharmacological treatment ladder? (5 steps)
- stop smoking
- avoid precipitants
- weight loss (if overweight)
1) occasional SABA as required
(if used >1 a day or at night then go step 2)
2) add daily inhaled steroid (e.g. beclomethasone)
(before step 3, check inhaler technique, adherence + removal of triggers)
3) change to LABA/inhaled steroid dual inhaler (don't take LABA alone)
- if no response, stop LABA + increase inhaled steroid dose
4) raise inhaled steroid dose or add other agents:
- oral theophylline
- oral B2-agonists
- LTRA
* refer to specialist at this point*
5) add daily steroid tablets
129
acute severe asthma:
- presentation?
- signs of severe attack?
- signs of life-threatening attack?
- acute breathlessness + wheeze
severe:
- unable to complete sentences in one breath
- RR >25
- pulse >110
- PEF 33-50% of predicted (or best)
life threatening:
- PEF <33% of predicted or best
- silent chest, cyanosis, feeble respiratory effort
- arrhythmia or hypotension
- exhaustion, confusion, coma
- poor ABG results
130
acute severe asthma:
- management?
- what to monitor? 3
- stay calm!
- nebuliser salbutamol (keep going, can't really overdose)
- oxygen
- oral prednisalone
- repeat salbutamol
- continue reassessing
- add ipratropium
GET HELP!!
- RR
- pulse
- O2 sats
131
COPD:
- definition?
- definition of chronic bronchitis?
- factors which make COPD more likely than asthma? 5
- genetic risk factor?
progressive + prolonged airway obstruction
- FEV1 <80% predicted
- FEV1/FVC <0.7
- with little or no reversibility
- cough
- sputum production on most days for 3 months of 2 successive years
- symptoms improve if stop smoking
- age of onset >35years
- smoking (active or passive, or pollution related)
- chronic dyspnoea
- sputum production
- minimal diurnal or day-to-day FEV1 variation
- a1-antitrypsin deficiency
132
COPD:
| - difference between a pink puffer and a blue bloater?
blue bloater
- mainly bronchitis
- earlier
- near normal PaO2
- cyanosed
- wheezing
- overweight
pink puffer
- mainly emphysema
- later
- low PaO2 and high CO2
- severe breathless
- quiet chest (hyper inflated lungs on x-ray)
- cachexic
133
COPD:
- symptoms? 4
- signs? 4
- cough
- sputum
- dyspnoea
- wheeze
- tachypnoea
- use of accessory muscles
- hyperinflation (barrel chest)
- wheeze
134
COPD:
- non-pharm treatment? 3
- what is the general progression of inhalers? 3
- end-stage treatment?
- stop smoking
- exercise
- pneumococcal + flu vaccine
1) SABA or SAMA (short-acting muscarinic antagonist)
2) add LABA or LAMA
3) add inhaled steroid
- long term oxygen therapy (LTOT)
^contraindicated in smokers
nb can also consider surgery to remove bullae but rarely done
135
pleural effusion:
- commonest causes of transudates? 2
- rare causes of transudates? 2
- causes of exudates? 3
- heart failure
- hypoalbuminaemia (liver failure)
(- hypothyroidism)
(- meig's syndrome - ovarian fibroma)
infection
- pneumonia
- TB
inflammation
- RS
- SLE
malignancy
- bronchial carcinoma
- mets
- lymphoma
- mesothelioma
136
pleural effusion:
- symptoms? 2
- commonest signs? 3
- other signs? 3
asymptomatic if small
- dyspnoea
- pleuritic chest pain
on affected side:
- decreased expansion
- stony dull to percussion
- decreased breath sounds
- bronchial breathing (above effusion dt compression)
- tracheal deviation away from effusion, if large
- signs of underlying cause (liver disease, clubbing, SLE rash etc)
137
pneumonia:
| - definition?
an acute LRTI associated with fever, symptoms + signs in the chest AND abnormalities on the CXR
138
pneumonia:
- commonest organism in CAP?
- other typical CAP organisms?
- atypical CAP organisms?
strep pneumoniae (commonest)
typical
- Haemophilus influenzae (common w COPD)
- moraxella catarrhalis
atypical
- mycoplasma pneumoniae
- staph aureus (IVDU)
- legionella (water borne)
- chlamydia
nb 15% are caused by viruses
139
pneumonia:
- resp symptoms? 4
- other symptoms? 4
- productive cough (w green sputum)
- dyspnoea
- pleuritic pain
- haemoptysis
- fever
- rigors
- anorexia
- malaise
140
pneumonia:
- sign most commonly seen in elderly?
- score used to assess severity?
confusion (can be only sign in elderly)
CURB-65
```
C - confusion
U - urea (in blood)
R - RR
B - BP
65 - over the age of 65
```
score 1 for each! determines whether treatment as outpatient or admitted
141
pneumonia:
- imaging?
- bloods? 4
- other bedside tests? 2
CXR
- FBC (raised WBCs)
- U+E (look for urea)
- LFTs (just cos)
- CRP (severity)
- O2 sats
- BP (see if getting septic)
142
pneumonia Abx treatment:
- first line if CAP with low CURB?
- first line if CAP with high CURB?
- first line if CAP with penicillin allergy?
- if caused by MRSA?
low CURB
- amoxicillin (initially 5 days)
high CURB
- co-amoxiclav (initially 7 days)
(- add clarithromycin if not clearing!)
penicillin allergy
- clarithromycin
nb always consult trust guidelines
nb above are for typical organisms - atypicals use other things (check guidelines)
- vancomycin
if hospital acquired, culture + treat organism
143
Pneumonia:
- non-Abx medication? 3
- follow up required?
- analgesia
- fluids
- oxygen (to keep up sats)
^all depend on severity
also physio to help cough
CXR in 6 weeks
144
pneumonia:
| - main resp DDx? 3
- PE
- pulmonary oedema
- bronchial carcinoma
145
peripheral vascular disease:
- underlying pathogenesis?
- risk factors?
atherosclerosis, which narrows the affected arteries
- "angina in the legs"
- over half have concurrent IHD
```
CV risk factors
- smoking
- dyslipidaemia
- obesity
- diabetes
- HTN
etc
```
nb rarely caused by vasculitis, trauma or more rare things
146
peripheral vascular disease:
- presentation of chronic limb ischaemia? (incl 4 stages)
incl signs, symptoms
specific clinical test for end stage??
1) ASYMPTOMATIC
2) INTERMITTENT CLAUDICATION
- cramping pain in calf, thigh or buttock after walking a given distance
- reproducible + relieved by rest
3) ISCHAEMIC REST PAIN
- worse at night (i.e. when legs up)
- reduced peripheral pulses
4) CRITICAL ISCHAEMIA (ulceration + gangrene)
- 'pushed out' painful arterial ulcers
- postural/dependent colour change
- burning pain at night, relieved by hanging legs over side of bed (as gravity helps)
- very long capillary refill (on toes)
Buerger's angle
= angle that leg goes pale when raised off the couch
- less than 20 degrees in severe ischaemia
147
peripheral vascular disease:
- clinical/bedside investigation? (incl values)
- bloods? (incl reasons) 5
- other investigation?
- imaging? 2
ABPI (ankle-brachial pressure index)
- normal = 1.2-0.9
- PVD = 0.5-0.9
- critical limb ischaemia <0.5
^nb beware falsely high results from incompressible calcified atherosclerosis, e.g. DM
- HbA1c + glucose (exclude DM)
- ESR/CRP (exclude arteritis)
- FBC (anaemia, polycythaemia)
- U&E (renal disease)
- lipids (dyslipidaemia)
- ECG (cardiac ischaemia)
nb screen for thrombophilia + serum homocysteine if <50 years old
- colour ultrasound of leg
- if considering intervention: MR/CT angiography to map extent etc
148
peripheral vascular disease:
- non-pharm treatment? 3
- pharm management of risk factors? 3
- medical treatment? 1
- surgical treatment? 3
- stop smoking
- loose weight
- graduated exercise (improves collateral circulation)
- treat HTN
- treat cholesterol
- prescribe clopidogrel or aspirin
peripheral vasodilators (think of like how nitrates are used for angina)
- percutaneous transluminal angioplasty (i.e. balloon)
- surgical reconstruction
- amputation (last line!! beware phantom limb pain!)
149
name of peripheral vasodilator given in peripheral vascular disease?
when recommended for use?
naftidrofuryl oxalate
offers modest benefit
- recommended only in people who don't want surgery + exercise fails to improve symptoms
150
DDx for pain in lower limb when walking (except peripheral vascular disease)? 5
- sciatica
- spinal stenosis
- entrapment syndrome
- DVT
- muscle/tendon injury
151
varicose veins:
- when people should see their GP? 3
- treatment options available?
- when treatment given?
- causing pain or discomfort
- skin over veins is sore/irritated
- aching in legs is irritating at night + disturbing sleep
- endothermal ablation (heat used to seal veins)
- sclerotherapy (uses foam to close veins)
- ligation + stripping (surgically removed)
on NHS
- if complications, such as ulcers + repeated thrombophlebitis
nb can get done privately
nb often recur even after treatment
