surgery/rheum Flashcards
investigations (blood tests) for erectile dysfunction
lipids
cholesterol
free testosterone (9am-11am)
- if testosterone high, then do FSH, LH and prolactin
FIT screening programme is offered to who
Ages 60-74 years
Every 2 years
(in England)
(Age 50-74 in Scotland)
Over 74 can request screening
colchicine main side effect
diarrhoea
if NSAIDs and colchicine are contraindicated in gout, what can be given
oral steroids
e.g. prednisolone 15mg/day
When should you offer urate-lowering therapy (e.g. allopurinol) to patients with gout?
After their first attack of gout
ULT especially recommended if:
>2 attacks in 1 year
Tophi
Renal disease
Uric acid renal stones
Prophylaxis if on diuretics or cytotoxics
Breast screening programme (mammogram) is offered to women from which age and is how often
Age 50-70 years
Every 3 years
after 70 can self-refer
What is first line for back pain
NSAIDs
+ PPIs
if there is sciatica then follow neuropathic pain guidelines
investigation of choice for non-specific back pain
MRI
semen analysis usually needs to be performed twice following a vasectomy at what time frame
at 12 weeks after
X-ray findings:
Bone destruction and formation
Soft tissue calcification
Codman triangle (from periosteal elevation)
Sunburst appearance
What is the diagnosis
Osteosarcoma
In children and young people with unexplained bone swelling and pain, what should be arranged
Urgent direct access x-ray (within 48 hours)
if this suggests bone sarcoma then urgent referral (48 hrs) for specialist assessment
What are 3 benign bone tumours
- Osteoma
- Osteochondroma (exotosis) - most common
- Giant cell tumour
Xray shows double bubble or soap bubble appearance
What is the diagnosis
Giant cell tumour
(benign)
- tumour of multinucleated giant cells within a fibrous stroma
What are 3 malignant bone tumours?
- Osteosarcoma
- Ewing’s sarcoma
- Chrondrosarcoma
Osterosarcoma is associated with mutation of which gene
Rb gene
association with retinoblastoma
X-ray of bones shows onion skin appearance - what bone tumour is this
Ewing’s sarcoma
osteoma tends to be associated with what syndrome
Gardner’s syndrome
(variant of familial adenomatous polyposis - FAP)
cartilage-capped bony projection on the external surface of a bone is typically seen with which benign bone tumour?
osteochondroma (exotosis)
what is the benign bone tumour that is multinucleated giant cells within a fibrous stroma?
giant cell tumour
what malignant bone tumour is a small round blue cell tumour?
Ewing’s sarcoma
What bone tumour is associated with a t(11;22) translocation?
Ewing’s sarcoma
What bone tumour is a malignant tumour of the cartilage?
Chondrosarcoma
What four groups should be advised to take vitamin D supplementation?
- All pregnant + breastfeeding women - 10ug daily
- Children aged 6 months to 5 years (unless if having formula milk)
- Adults >65 years
- People who are not exposed to much sun i.e. housebound
When to avoid colchicine in renal impairment
Reduce dose if eGFR 10-50
Avoid if eGFR <10
what is initial dose of allopurinol and target serum uric acid level
100mg OD
Titrate every few weeks
Aim for serum uric acid <360
(or <300 if tophi, chronic)
What is the second line agent for urate-lowering prophylaxis in gout if allopurinol is not tolerated or ineffective
Febuxostat
For patients taking leflunomide, effective contraception is required for at least how long in women and men after stopping?
2 years - women
3 months - men
Stopping leflunomide (DMARD) has a very long wash out period of up to 1 year. This requires the administration of…?
Cholestyramine
For SLE, which test has the highest positive predictive value (most SPECIFIC)?
anti-dsDNA
Highly specific (>99%)
Less sensitive (70%) - i.e. not present in everyone!
For SLE, which test is the best to rule it out i.e. most sensitive but low specifity
ANA
T scores in DEXA scans are based on bone mass of young reference population. Z scores are adjusted for what 3 factors?
- Age
- Gender
- Ethnic factors
T score ranges for normal, osteopenia and osteoporosis
> -1.0 = normal
-1.0 to -2.5 = osteopenia
< -2.5 = osteoporosis
Patients with gout who already take allopurinol - should allopurinol continue during the attack or not?
Continue with acute attack treatment
greater trochanteric pain syndrome is also called
trochanteric bursitis
Meralgia paraesthetica - compression of lateral cutaneous nerve of thigh; causes a burning sensation over which part of the thigh?
Antero-lateral
Meralgia paraesthetica = burning sensation over antero-lateral aspect of thigh.
What nerve is compressed?
Lateral cutaneous nerve of thigh
what hip pain cause is common in pregnancy due to hormonal changes leading to ligament laxity?
pubic symphysis dysfunction
pain over pubic symphysis radiating to groin + medial thigh.
what is an uncommon hip pain condition sometimes seen in third trimester of pregnancy with raised ESR?
transient idiopathic osteoporosis
Low calcium
Low phosphate
Low vitamin D
Raised ALP
Bone pain
What is the likely cause?
Osteomalacia
What does x-ray show in osteomalacia?
Translucent bands
Looser’s zones
Pseudofractures
Treatment of osteomalacia
Vitamin D supplementation (with loading dose)
+/- Calcium supplementation
Treatment of polymyalgia rheumatica
Prednisolone
e.g. 15mg/OD
treatment of giant cell arteritis (temporal)
High dose glucocorticoids
If no visual loss - high dose prednisolone
If visual loss - same-day opthalmology review, IV methylprednisolone first then pred
Women and men on methotrexate need to avoid pregnancy and use effective contraception for how long
At least 6 months after treatment has stopped
What blood tests are regularly monitored on methotrexate
FBC
U+Es
LFT
Before treatment and repeated weekly until stabilised, then every 2-3 months
What should be co-prescribed with methotrexate
Folic acid 5mg once weekly
Taken >24 hours after methotrexate dose
Avoid prescribing what 3 drugs with methotrexate
Trimethoprim
Co-trimoxazole
High-dose aspirin
Treatment for methotrexate toxicity
Folinic acid (Calcium folinate)
Patients who are on long term steroids (>7.5mg daily prednisolone for 3 months or longer) should be prescribed what without the need for a DEXA scan
Bisphosphonate
alendronate 10mg OD or 70mg weekly
or risedronate 5mg OD or 35mg weekly
What patients should be offered bone protection with bisphosphonates (+/- vit D/calcium if also low)?
Over 65 with fragility fracture
Under 65 with DEXA T score less than -1.5
If there is a T score between 0 and -1.5 with no history of fracture and no history of steroid use, what should be management
Repeat DEXA scan in 1-3 years
Restore calcium, vit D levels
Differences between:
(a) external haemorrhoids
(b) internal haemorrhoids
(a) external haemorrhoids - below dentate line, painful, thrombose
(b) internal haemorrhoids - above dentate line, painless
What are the features of internal haemorrhoids:
Grade 1-4
Grade 1: do not prolapse
Grade 2: prolapse but reduce spontaneously
Grade 3: manually reduce
Grade 4: cannot be reduced
Treatment of haemorrhoids
- Soften stools - increase fibre and fluid
- Topical local anesthetics + steroids
- Outpatient rubber band ligation > injection sclerotherapy
- Surgery for large symptomatic haemorrhoids that do not respond
If a patient presents with acutely thrombosed external haemorrhoids (purple, oedematous tender subcut perianal mass) within 72 hours, what is the treatment
Refer for excision
Otherwise with stool softeners, ice packs, analgesia
Achilles tendinitis is classically associated with which inflammatory disease?
Ankylosing spondylitis
Dactylitis (inflammation of digits) is seen with which 2 kinds of disease
- Arthritis - psoriasis and reactive
- Sickle cell disease
management of people with secondary Raynaud’s phenomenon
- referral to secondary card
- 1st line = CCBs e.g. nifedipine
- IV prostacyclin (epoprostenol) infusions
4 medical indications for circumcision
- phimosis
- recurrent balantitis
- balanitis xerotica obliterans
- paraphimosis
- it is important to exclude hypospadias
what does circumcision reduce the risk of three things
- penile cancer
- UTIs
- STIs
A newborn baby is noted to have bilateral clubfoot (Talipes equinovarus). What is the treatment?
- Ponseti method - manipulation and progressive casting starting soon after birth, usually corrected after 6-10 weeks
- Achilles tenotomy may be needed
- Night time braces until child is 4 years
BNF advises to treat mastitis with antibiotics (fluclox) if what four criteria
- if systemically unwell
- nipple fissure present
- if symptoms do not improve after 12-24hours of effective milk removal
- if culture is +ve
what medication increases risk of cataracts
steroids!
prednisolone
risk factors for osteoporosis
age
female sex
steroids
alcohol + smoking
low BMI
rheumatoid arthritis
medications that can worsen osteoporosis
steroids
SSRIs
antiepileptics
PPIs
long term heparin
Abdominal aortic aneurysm screening by ultrasound scan occurs for who
Men >65
Men and women with strong FHx of triple A
What diameter of aorta is considered aneurysmal in triple A screening
> 3cm
Risk factors for the development of aneurysms
Smoking
Hypertension
Syphilis
Connective tissue diseases
management of erectile dysfunction
- PDE-5 inhibitors - e.g viagra (sildenafil), alprostadil
- Vacuum erection devices
- Young man - refer to urology
- Advise to stop cycling
Women going for surgery who take the COCP - how early before surgery should this be stopped
4 weeks before
4 risk factors for varicose veins
- age
- female
- pregnancy
- obesity
investigation for varicose veins and what will this demonstrate
venous duplex ultrasound
shows retrograde venous flow
Management of varicose veins
- Conservation - leg elevation, weight loss, exercise, TED stockings (only AFTER ABPI is done!)
- Referral to secondary care if significant symptoms (pain, swelling), previous bleeding from the veins, skin changes, thrombophlebitis, venous leg ulcer
- Endothermal ablation
- Foam sclerotherapy
- Surgery - ligation or stripping
First line for cyclical mastalgia
supportive bra and simple analgesia (paracetamol, NSAIDs)
When is referral considered for cyclical mastalgia
If not responded to conservative measures after 3 months
Or affecting QoL or sleep
Hormonal agents such as bromocriptine and danazol may be used/ effective
first line for osteoarthritis
topical NSAIDs
especially in knee or hand
Livedo reticularis is seen with which condition
SLE
Carpal tunnel syndrome shows weakness and wasting where /in which muscles?
Weakness of thumb abduction - abductor pollicis brevis
Wasting of THENAR eminence (thumb + index finger)
What condition do patients get relief from shaking their hands?
Carpal tunnel syndrome
Compression of what nerve in carpal tunnel syndrome
Median nerve
What is the treatment for carpal tunnel syndrome
6 week trial of corticosteroid injection, and wrist splints at night
If fails or severe symptoms - surgical decompression
What are the four seronegative arthritis - negative RhF but positive for HLA-B27?
Psoriatic arthropathy
Ankylosing spondylitis
Reactive arthritis
Enteropathic (IBD) arthritis
What nail changes are seen in psoriatic arthritis
pitting
onycholysis
X-ray - erosive changes
new bone formation
periostitis
pencil-in-cup appearance
what bone disorder causes this?
psoriatic arthritis
management of psoriatic arthritis
managed by rheumatologist
- mild - NSAIDs
- moderate/severe - DMARDs like methotrexate, or monoclonal antibodies, apremilase (PDE4 inhibitor)
causes of acute pancreatitis
- get smashed
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune (e.g. PAN)
Scorpion venom
Hypertriglyceride, hyperCa, hypothermia
ERCP
Drugs - azathioprine, thiazides, steroids
Surgical joint replacement for hips - most common type of operation
cemented hip replacement
post-operative recovery for hip replacement advice
physiotherapy
walking sticks/crutched for up to 6 weeks
avoid flexing hip >90 degees
avoid low chairs
do not cross legs
sleep on your back for 6 weeks
Baker’s cysts are a distension of the bursa. What is the difference between primary and secondary Baker’s cysts?
Primary - no cause. Usually in children.
Secondary - usually caused by OA. Usually in adults.
If alendronate, risedronate or etidronate cannot be taken then strontium ranelate or raloxifene may be given based on what
Strict T-scores
i.e. less than -3.5
Triad of reactive arthritis
Urethritis
Arthritis
Conjunctivitis
At what age do NICE recommend that we start to assess women regarding their risk suffering a fragility fracture?
65
What is the most important investigation to monitor Marfan’s syndrome ?
Echocardiogram
What inheritance is marfans syndrome
autosomal dominant
what cardiovascular conditions are seen with Marfan’s syndrome
dilation of aortic sinuses (90%)
aortic aneurysm
aortic dissection
mitral valve prolapse (75%)
Abdominal aortic aneurysm screening is done for men >65. What is classed as normal and no further scanning/action is needed
Aorta < 3cm
Abdominal aortic aneurysm screening is done for men >65. When do you rescan?
3-4.4cm = small aneurysm, rescan every 1 year
4.5-5.4cm = medium aneurysm, rescan every 3 months
> 5.5cm = large aneurysm - refer within 2weeks to vascular
Elective endovascular repair (EVAR) can be done to treat abdominal aortic aneurysm. What is the complication of this?
Endo-leak
Stent fails to exclude blood from aneurysm
What is classed as high rupture risk for abdominal aortia aneurysm?
Large aneurysm = >5.5cm
OR
Rapidly enlarging >1cm per year
refer to vascular surgery within 2 weeks for EVAR or open repair
when starting allopurinol, what should be used too as ‘cover’?
colchicine
A child with a suspected Baker’s cyst requires what to confirm the diagnosis
ultrasound
Sciatica symptoms usually settle within
4-6 weeks
Rheumatoid arthritis 1st line treatment
DMARD monotherapy e.g. methotrexate!
+/- short course of bridging prednisolone
NICE recommends using a combination of what to monitor response to treatment of rheumatoid arthritis
CRP and disease activity (DAS28 score)
Flares of rheumatoid arthritis are usually managed with
corticosteroids
oral or intramuscular
The current indication for TNF-inhibitor in rheumatoid arthritis is what..?
Poor response to at least 2 DMARDs
What are 3 examples of TNF-inhibitors that can be used in rheumatoid arthritis (if poor response to 2 or more DMARDs)
etanercept
infliximab
adalimumab
Rituximab mechanism of action
anti-CD20
Two 1g IV infusions are given two weeks apart
Two risk factors for Achilles tendon disorders
- quinolone use e.g. ciprofloxacin
- hypercholesteraemia
- audible ‘pop’ in ankle while running
- sudden onset pain in calf or ankle
- inability to walk
what is the diagnosis?
Achilles tendon rupture
Achilles tendinopathy (tendinitis) presents with gradual back heel pain worse after activity with morning pain + stiffness.
What is the treatment?
- Analgesia
- Calf muscle eccentric exercises - physio or self directed
For Achilles tendon RUPTURE (pop in ankle), examination should be conducted using what…?
Simmond’s triad
looking for abnormal angle of declination (more dorsiflexion)
what is the imaging modality of choice for suspected achilles tendon rupture
ultrasound
management of suspected achilles tendon rupture
acute referral to ortho
Morton’s neuroma is a benign neuroma affecting what nerve
intermetatarsal plantar nerve
- pain in 3rd inter-metatarsophalangeal space
Loss of sensation distally in toes, and Mulder’s click is seen in what condition
Morton’s neuroma
- try to hold neuroma between finger and thumb and squeeze, causes a click
Management of Morton’s neuroma
- avoid high heels
- metatarsal pad
- refer if symtoms >3 months
- specialists can give metatarsal dome orthotic
- or corticosteroid injection and neurectomy
Ottawa rules for ankle injury and doing ankle x-ray
- Pain in the malleolar zone and any of:
- bony tenderness at lateral malleolar zone
- bony tenderness at medial malleolar zone - Inability to walk 4 weight bearing steps immediately after the injury and in ED
Pain following hip resurfacing (metal-on-metal bearing) should be referred for investigations such as
MRI
to exclude pseudotumour
What should patients taking etanercept (i.e. for rheumatoid arthritis) do when they get an infection
Stop etanercept until infection is cleared
Pain on the radial side of the wrist/tenderness over the radial styloid process
Pain on ulnar deviation of the wrist
What is the diagnosis
De Quervain’s tenosynovitis
De Quervain’s tenosynovitis is where there is inflammation of the sheath containing what two tendons
extensor pollicis brevis
abductor pollicis longus
what is the test done for diagnosis of De Quervain’s tenosynovitis
Finkelstein’s test
pulls thumb of patient in ulnar deviation
causes pain over radial styloid
management of De Quervain’s tenosynovitis
- analgesia
- steroid injection
- immobilisation with thumb splint (spica)
- surgery sometimes neededc
3 features of antiphospholipid syndrome
- thrombosis
- recurrent miscarriages
- livedo reticularis
what antibodies are seen in antiphospholipid syndrome
anti-cardiolipin
anti-beta 2 GP I
lupus anticoagulant
what blood results for platelets and APTT are in antiphospholipid syndrome
low platelets
high APTT
management of anti-phospholipid syndrome
- primary thromboprophylaxis - low dose aspirin
- secondary thromboprophylaxis:
- first VTE: lifelong warfarin, target INR 2-3
- recurrent VTE: lifelong warfarin, consider adding aspirin, target INR 3-4
- arterial thrombosis - lifelong warfarin, target INR 2-3
Calcium supplementation has been linked to an increased risk of
myocardial infarction
roughened red papules over the extensor surfaces and are seen in dermatomyositis are called…?
Gottron’s papules
Heliotrope rash in periorbital region
Photosensitive
Gottron’s papules
Proximal symmetrical muscle weakness
What is the diagnosis
Dermatomyositis
What are gottron’s papules
red papules
over extensor surfaces of fingers
seen in dermatomyositis
What antibody is seen in dermatomyositis
ANA +ve (80%)
Aminoacyl-tRNA (30%)
Patients with long saphenous vein superficial thrombophlebitis should have what investigation
USS
to exclude underlying DVT
What does NICE recommends for the management of hot flushes in men undergoing hormonal treatment (gonadorelin analogue injections) for prostate cancer?
cyproterone acetate
FRAX may be used for patients aged…
40-90
What underlying conditions are screened for with dermatomyositis diagnosis?
Underlying malignancy
What is the chance of siblings and children of a patient (who is BRCA1 positive) also having the gene?
50%
age adjusted upper limits for PSA:
(a) 50-59 years
(b) 60-69 years
(c) >70 years
(a) 50-59 years - 3
(b) 60-69 years - 4
(c) >70 years - 5
acute versus chronic anal fissure time frame
acute < 6 weeks
chronic >6 weeks
management of acute anal fissure (<1 week)
- soften stool - high fibre diet with fluids. bulk-forming laxatives are 1st line. if not tolerated then lactulose
- lubricants before defecation
- topical anaesthetic
- analgesia
management of chronic anal fissure (>6 weeks)
- topical GTN
- if not effective after 8 weeks then referral to secondary care for surgery - sphincterotomy or botulinum toxin
trigger finger is associated with abnormal flexion of digits. what 2 diseases is it associated with?
rheumatoid arthritis
diabetes
management of trigger finger
- steroid injection
- finger splint afterwards
- surgery for those who have not responded to steroid injections
What side-effect of diclofenac is it most important to warn patients about?
Diarrhoea
male sterilisation failure rate
1 in 2000
In osteoporosis, 10 year fracture risk/DEXA scan should be reassessed after how many years of treatment with alendronate
after 5 years
hip/groin pain
snapping sensation at hip
sensation of locking
what is the diagnosis
acetabular labral tear
what is a contraindication to circumcision in infancy
hypospadias
chronic prostatitis treatment
prolonged course of quinolone
Brown-green nipple discharge is most commonly associated with
duct ectasia
Sulfasalazine is a DMARD used in rheumatoid arthritis and IBD. What 2 instances should you avoid using it?
- G6PD deficiency
- Allergic to aspirin or sulphonamides
What are adverse effects of sulfasalazine on:
(a) fertility
(b) lungs
(c) haem
(d) eyes
(a) fertility - oligospermia
(b) lungs - pneumonitis, lung fibrosis
(c) haem - myelosuppression, Heinz body or megaloblastic anaemia
(d) eyes - coloured tears, stained contact lenses
What are two common medication causes of drug induced lupus
- procainamide
- hydralazine
How can testicular cancer be categorised
Germ cell tumours (95%)
- Seminomas
- Non-seminomas = embryonal, yolk sac, teratoma, choriocarcinoma
Non-germ cell tumours
- Leydig cell tumours
hCG is elevated in what type of testicular cancers
Germ cell tumours:
seminomas - in 20%
non-seminomas - in 80%
AFP is elevated in what type of testicular cancers
Germ cell tumour:
Non-seminomas
LDH is elevated in which type of testicular cancers
40% of germ cell tumours
What are tumour markers in testicular cancers and for which types
Germ cell tumours
- LDH in 40%
- hCG 20% of seminomas
- AFP and/or beta-hCG in 80% of non-seminomas
Is prognosis good or bad for testicular cancers
Generally excellent
If stage 1, the 5 year survival rates are:
- seminomas = 95%
- teratomas = 85%
Lump separate from body of testicle
Posterior to testicle
Non-tender
What is the diagnosis
Epididymal cyst
3 associated conditions with epididymal cysts
- polycystic kidney disease
- cystic fibrosis
- von Hippel-Lindau syndrome
management for epididymal cysts is usually supportive. if they are larger or symptomatic what are the options?
surgical removal or sclerotherapy
hydrocele can be divided into:
1. communicating
2. non-communicating
what are the differences
- communicating - patent processus vaginalis so fluid drains into scrotum
- non-communicating - excess fluid production within tunica vaginalis
hydroceles can develop secondary to what 3 things
- epididymo-orchitis
- testicular torsion
- testicular tumours
Soft non-tender swelling of hemi-scrotum
Anterior and below the testicle
Can get above the mass
Transilluminates
What is the diagnosis
Hydrocele
What is the management of infantile hydroceles
If they do not resolve spontaneously by the age of 1-2 years, infantile hydroceles are repaired
Management of hydroceles in adults
Ultrasound is done to exclude underlying cause e.g. tumour
Conservation approach generally
Varicocele is usually associated with what complication
infertility
varicoceles are more common on what side
left side
what is management of varicocele
- usually conservation
- surgery if very painful
what investigation is done for varicocele
ultrasound with doppler studies
All patients with peripheral arterial disease should take what 2 medications
clopidogrel and statins
severe peripheral artery disease or critical limb ischaemia may be treated by what 3 techniques
- EVAR - endovascular revascularisation
- percutaneous transluminal angioplasty +/- stent
- for short segment stenosis and high risk patients - surgical revascularisation
- for long segment lesions or multifocal
- surgical bypass, endarterectomy or open techqnieues - amputation if not appropriate for above
what two drugs (after clopidogrel + Statins) are licensed for use in peripheral arterial disease
- naftidrofuryl oxalate - vasodilator
- cilostazol - phosphodiesterase III inhibitor, antiplatelet + vasodilator. not recommended by NICE
What is the limit to the number of generic sildenafil that can be prescribed to NHS patients with erectile dysfunction?
No limit!
Patients on DMARDs should not receive what type of vaccines
Live vaccines
Shingles vaccine is available on NHS for people aged over what
over 70 years
hydroxychlorquine is only considered for initial DMARD rheumatoid monotherapy if what type of disease
if mild or palindromic disease
All children aged between what ages should be given vitamin D supplementation
6 months and 5 years
What two types of anti-oestrogen drugs exist and can be used for treatment of breast cancer (ER +ve)
- Selective Oestrogen Receptor Modulators (SERMs) - e.g. tamoxifen
- Aromatase inhibitors - e.g. anastrozole
Tamoxifen is a selective oestrogen receptor modulator (SERM). How does this act for management of ER+ve positive breast cancer?
Oestrogen receptor antagonist
Partial agonist
SEs: hot flushes, VTE, endometrial cancer
What cancer risk does tamoxifen increase
endometrial cancer
Aromatase inhibitors (e.g. anastrozole, letrozole) mechanism of action in ER+ve breast cancer
Reduces peripheral oestrogen synthesis
What is the main adverse effect of aromatase inhibitors (anastrozole and letrozole) for ER+ve breast cancer, and what investigation is done before starting patients on them due to this side effect
Osteoporosis
recommends a DEXA scan when starting patients on it
What is the analgesia of choice for renal colic
NSAIDs
if contraindicated, then IV paracetamol
For patients who require admission for renal stones and colic, first line is NSAIDs for analgesia. What other analgesia can be given in these groups?
- IV paracetamol
- Parenteral analgesia - e.g. IM diclofenac
- Alpha-blockers! e.g. tamsulosin
Investigation of choice for renal stones/colic
Non-contrast CT KUB
USS in pregnant women and children
Management of renal stones <5mm
These will pass spontaneously within 4 weeks of symptoms onset
Renal stones are not managed conservatively if …?
- Greater than 5mm
- Ureteric obstruction due to stones with infection
- Renal developmental abnormality e.g. horseshoe kidney and previous renal transplant
What are the 3 options in non-emergency setting for treatment of renal stone removal
- Shockwave lithotripsy
- Percutaneous nephrolithotomy
- Ureteroscopy
What method of renal stone removal is most suitable in pregnancy
Ureteroscopy
What method of renal stone removal treatment is suitable for:
Stone burden of less than 2cm in aggregate
Lithotripsy
What method of renal stone removal treatment is suitable for:
Stone burden of less than 2cm in pregnant females
Ureteroscopy
What method of renal stone removal treatment is suitable for:
Complex renal calculi and staghorn calculi
Percutaneous nephrolithotomy
What method of renal stone removal treatment is suitable for:
Ureteric calculi less than 5mm
Manage expectantly
Caclium stones - what can be done to prevent this
(a) dietary
(b) medications
(a) high fluid intake, low protein, low salt diet
(b) thiazide diuretics
What 2 medications are useful for preventing oxalate stones
cholestyramine
pyridoxine
what two medications are useful for preventing uric acid stones
- allopurinol
- oral bicarbonate - i.e. urinary alkalinisation
Discoid lupus erythematosus is characterised by
follicular keratin plugs
management of discoid lupus erythematosus
- topical steroid cream
- oral anti-malarials e.g. hydroxychloroquine
- avoid sun exposure
Well-demarcated erythematous plaque with a ragged white border on his penis
Present with Reiter’s syndrome: urethritis, arthritis, and conjunctivitis
What is the cause of this penile rash?
Circinate balanitis
myxoid (mucous) cysts are benign ganglion cysts usually found on distal, dorsal aspects of fingers. what condition usually affects the surrounding joint?
osteoarthritis
A solitary right-sided varicocele requires what kind of referral
urgent referral to urology
Sitting is better than standing and patients may find it easier to walk uphill rather than downhill
what is the likely diagnosis
lumbar stenosis
investigation for lumbar stenosis
MRI
treatment for lumbar stenosis
laminectomy
Osteoarthritis: x-ray changes
LOSS
Loss of joint space
Osteophytes at joint margins
Subchondral sclerosis
Subchondral cysts
first-line investigation in suspected prostate cancer
MRI multiparametric
results are reported on a 5-point Likert scale
If >3 = biopsy is done
Management for:
(a) Grade I (mild) varicoele
(b) Grade II or III - asymptomatic and normal semen
(c) Grade II or III - symptomatic or abnormal semen
(a) Grade I = observe
(b) Grade II or III - asymptomatic and normal semen = semen analysis every 1-2 years
(c) Grade II or III - symptomatic or abnormal semen = surgery
Patients with new synovitis - where should they be referred
Urgent referral to rheumatology
Patients with Sjogren’s syndrome have an increased risk of which malignancies
lymphoid
What antibodies are seen in Sjorens syndrome
Rheumatoid factor
ANA +ve
Anti-Ro
Anti-La
Schirmer’s test is useful for diagnosis of what
sjorens syndrome
filter paper near eye to measure tear formation
management of sjorens syndrome
- artificial tears and saliva
- pilocarpine - to stimulate saliva formation
ankylosing spondylitis gene association
HLA-B27
What is the pain pattern in a patient with ankylosing spondylitis
Stiffness worse in morning
Improves with exercise
Pain at night
Improves on getting up
Clinical examination of ankylosing spondylitis shows reduction in which back/chest movements
REDUCED
lateral flexion
forward flexion - Schober’s test
chest expansion
Following a complete prostatectomy, the PSA level should be
undetectable
i.e. <0.2ng/ml
Ganglion cyst management
- often disappear spontaneously after a few months
- surgical excision if severe symptoms or neurovascular manifestations
what should be corrected before giving bisphosphonates
hypocalcaemia
low vitamin D
adverse effects of bisphosphonates
- oesophageal reactions
- osteonecrosis of jaw
- atypical stress fractures of proximal femoral shaft
Frozen shoulder (adhesive capsulitis) affects external rotation > internal rotation.
How long does the episode typically last for?
6 months to 2 years
n.b. it is bilateral in 20%
rheumatoid factor can be detected by what 2 tests
rose-waaler test
latex agglutination test
NICE recommend xrays of what in all patients with suspected rheumatoid arthritis
hands and feet
cauda equina syndrome causes
- commonest = central disc prolapse, usually at L4/5 or L5/S1
- tumours
- infection
- trauma
Low back pain
Bilateral sciatica
Reduced sensation in peri-anal area
Decreased anal tone
what is the diagnosis + investigation of choice
cauda equina syndrome
urgent MRI
Rx = urgent decompression
Lateral epicondylitis: pain is worse on what wrist movement
worse on resisted wrist extension/suppination whilst elbow extended
Finasteride treatment of BPH may take how long before results are seen
6 months
The maximum dose of 1% lidocaine for a 66kg person is
20ml
hydroxychloroquine monitoring
ask patient about visual symptoms and monitor visual acuity annually using the standard reading chart
Management of mortons neuroma
avoid high heels
metatarsal pad
ocular complications with rheumatoid arthritis
keratoconjunctivitis sicca
episcleritis
scleritis
cataracts (from steroids)
keratitis
charcot (neuropathic) joint describes a joint that has become badly disrupted and damaged secondary to a loss of…
sensation
caused by diabetes/ syphilis
CREST syndrome refers to which type of systemic sclerosis
limited systemic sclerosis
what does CREST stand for in limited systemic sclerosis
Calcinosis
Raynaud’s phenomenon
oEsophageal dysmotility
Sclerodactylyl
Telangiectasia
What antibodies are associated with limited cutaneous systemic sclerosis (CREST)
anti-centromere
What antibodies are associated with diffuse cutaneous systemic sclerosis (CREST)
anti scl-70
where does diffuse cutaneous systemic sclerosis versus CREST limited cutaneous systemic sclerosis affect in the body?
Limited/CREST - face + distal limbs
Diffuse - trunk + proximal limbs
Which of the systemic sclerosis (diffuse or limited/CREST) leads to respiratory involvement too?
Diffuse
Interstitial lung disease and pulmonary arterial hypertension
what is the most common type of breast cancer
invasive ductal carcinoma
NICE recommend offering a PR and PSA test to men with any of the following five unexplained symptoms:
- erectile dysfunction
- haematuria
- lower back pain
- bone pain
- weight loss, especially in the elderly.
Ehler danlos syndrome is autosomal dominant. what is a useful tool to assess hypermobility
beighton score
Sensory loss of posterolateral aspect of leg and lateral aspect of foot, weakness in plantar flexion of foot, reduced ankle reflex, positive sciatic nerve stretch test
what nerve lesion
S1
what score is used to predict prostate cancer prognosis
gleason score
higher the score = worse the prognosis
What antibodies and enzyme are raised in polymyositis (inflammatory disease with proximal muscle weakness)
Anti-Jo 1
Raised CK
Polymyositis (anti-Jo antibodies and raised CK) is treated with… ?
High dose corticosteroids
Azathioprine as a steroid-sparing agent
meralgia parasthetica symptoms are motor or sensory?
only sensory
there is no motor weakness
how are symptoms of meralgia parasthetica in the upper lateral aspect of the thigh reproduced and therefore diagnosed?
- deep palpation below the ASIS (pelvic compression) - this is for diagnosis
- and by extension of the hip
treatment of meralgia parasthetica
injection of the nerve with local anaesthetic
Felty’s syndrome triad
Rheumatoid arthritis
Splenomegaly
Low white cell count
What is the maximum safe dose of lidocaine
Maximum safe 3mg/kg
What are the removal times for non-absorbable sutures in:
(a) face
(b) scalp, limbs, chest
(c) hand, foot, back
(a) face - 3-5
(b) scalp, limbs, chest - 7-10
(c) hand, foot, back - 10-14
Venous ulcers are often treated with …
compression bandaging
this is acceptable if ABPI >0.8 (i.e. there is no PAD) - so remember to check ABPI first as peripheral arterial disease (<0.8) is a contraindication for this
ankle brachial pressure index - what are the values for:
(a) calcified, stiff arteries
(b) normal
(c) acceptable
(d) peripheral artery disease
(a) calcified, stiff arteries >1.2
(b) normal 1.0-1.2
(c) acceptable 0.9-1.0
(d) peripheral artery disease <0.9
<0.5 = severe PAD that needs urgent referral
what nerve is compressed in cubital tunnel syndrome
ulnar nerve
where is there tingling/numbness in cubital tunnel syndrome
tingling and numbness of 4th and 5th finger
pain is worse when leaning on elbow
what investigations should be done for BPH
- urine dipstick
- U+Es
- PSA
- Urinary frequency-volume chart - for at least 3 days
- IPSS score for LUTS
treatment of BPH
- alpha-1 antagonists e.g. tamsulosin
- 5 alpha-reductase inhibitors e.g. finasteride
- combination of above
- or add antimuscarinic (anti-ACh) e.g. tolterodine can be tried with alpha-1 antagonist
- surgery - TURP
what medications are first line for BPH
ALPHA-1 ANTAGONISTS
e.g. tamsulosin, alfuzosin
2nd line = 5-alpha reductase inhibitors
inguinal hernia - 75% of abdominal wall hernias
what is their anatomy
superior and medial to pubic tubercle
what are definitions of direct and indirect inguinal hernias and how is it relevant to management
direct - through posterior wall of inguinal canal
indirect - through inguinal canal
not relevant!
management of inguinal hernias
- treat all
- mesh repair
- hernia truss if not fit for surgery
When should patients return to work after:
(a) open repair of inguinal hernia
(b) laparoscopic repair of inguinal hernia
(a) open = 2-3 weeks
(b) laparoscopic = 1-2 weeks
what is the anatomy of femoral hernia
Below and lateral to the pubic tubercle
treatment of femoral hernia
URGENT surgical repair
risk of strangulation and obstruction
what test is done to assess meniscal tear
Thessaly’s test
acute bacterial prostatitis
14 day course of quinolone (e.g. ciprofloxacin)
Rheumatoid arthritis 1st line treatment initially is a DMARD and short-term bridging prednisolone. What are some examples of DMARDs
Methotrexate
Sulfasalazine
Leflunomide
Hydroxychloquine - only used in mild or palindromic disease
What needs to be monitored with leflunomide (DMARD)?
FBC
LFTs
Blood pressure
Which of the three DMARDs (methotrexate, leflunomide, sulfasalazine) is safe in pregnancy and breastfeeding?
SULFASALAZINE
Methotrexate - avoid pregnancy for 6 months after stopping
Leflunomide - avoid for 2 years in women, 3 months in men
