Things I got Wrong Pt.2 Flashcards
What is first line in the treatment of hallucinations in patients with PD and symptoms of psychosis?
Quetiapine
What is first line in the treatment of agitation in patients with PD?
Benzodiazepines
Which cancers commonly metastasise to the brain?
Breast, lung and melanoma, colon, kidney and thyroid
Which drugs can worsen the symptoms of MG?
Beta-blockers, several antibiotics and antimalarials, Lithium
What are the side effects of neostigmine/pyridostigmine?
increased salivation, lacrimation, sweats, vomiting, excessive pupillary constriction, diarrhoea
What are the signs of corticobasal degeneration?
- decline in movement, speech, memory, and swallowing
- stiffness, shakiness, jerky movements, difficulty with balance, and difficulty controlling the muscles of the face and mouth
- Alien limb phenomenon refers toinvoluntary motor activity of a limb in conjunction with the feeling of estrangement from that limb.
What are the signs of progressive supranuclear palsy?
Impaired vertical gaze
What are the signs of multiple system atrophy?
- Neurons of multiple systems in the brain degenerate, affecting more than just the basal ganglia
- Results in Parkinson’s symptoms plus autonomic dysfunction (postural hypotension, constipation, abnormal sweating, sexual dysfunction) and cerebellar dysfunction (ataxia)
What is the definition of a stroke vs TIA?
- TIA: a transient episode of neurologic dysfunction due to the focal brain, spinal cord, or retinal ischemia without acute infarction or tissue injury. (<24h)
- Stroke: an episode of neurological dysfunction caused by focal cerebral, spinal, or retinal cell ischaemia, with evidence of acute infarction. (>24h)
- Ischaemia = hypoxia, infarct = complete loss of blood flow resulting in cellular death
What would an MRI show in Huntington’s disease?
MRI shows atrophy of the caudate nucleus and putamen
What does a positive Rhomberg’s test indicate?
An issue with the dorsal column medial lemniscus - the patient has lost proprioception, so they rely on visual stimuli to maintain balance (negative in cerebellar syndromes)
What are some signs of cerebellar syndrome, and what can cause it?
DANISH
Dysdiadochokinesia
Ataxia
Nystagmus
Intention tremor
Slurred speech
Hypotonia
Negative Rhomberg’s
Can be caused by carbamazepine or phenytoin
What are the side effects of valproate?
VALPROATE
Vomiting, alopecia, liver toxicity, pancreatitis/pancytopenia, retained fats, oedema, appetite increase, tremor/teratogenic
What are the side effects of carbamazepine?
Carbamazepine - CARBA MEAN - confusion, ataxia, blurred vision, aplastic anaemia, bone marrow suppression, eosinophilia, agranulocytosis, neutropenia. Also an enzyme inducer.
What is the management of mild MS?
- Betaferon - injection site reactions, flu like symptoms, mild intermittent lymphopenia, mild to moderate rises in liver enzymes, decrease after a few months - first line!!
- Glatiramer acetate
What is the management of moderate MS?
- Fingolimod, dimethyl fumarate
What is the management of severe MS?
- Nataluzimab - modified lymphocyte trafficking - prevents then crossing the BBB and causing damage
- Ocrelizumab (CD20) - depletes lymphocytes
- Stem cell transplantation
What medications should children with minimal change disease be started on?
Steroids
Penicillin V (prevents sepsis and peritonitis)
Pneumococcal vaccines
What antiemetic can cause acute dystonic reactions, and what is it’s mechanism of action?
Metaclopromide - antidopaminergic
What are the signs of juvenile myoclonic epilepsy?
Myoclonic jerks (often described as clumsiness in the morning)
Absence seizures
Generalised tonic clonic seizures
Commonly in the morning, when sleep deprived, in an otherwise health teenager
What is the management of postural hypotension?
Conservative
- Ensuring they are hydrated
- Compression stockings
- Increased salt in the diet
- Foot exercises before standing
- Rise slowly from the chair before standing
- Medication review (nitrates, diuretics, anticholinergics can all trigger it)
Medical
- Fludrocortisone
- Midodrine
What medication is associated with an increase in mortality for dementia patients?
Antipsychotics
What would be seen on a head CT of a patient with Alzheimer’s?
Widespread cerebral atrophy mainly involving the cortex and hippocampus
What are they types of MND?
Amylotrophic lateral sclerosis (UMN and LMN)
Bulbar palsy (cranial nerves 9-12)
Primary lateral sclerosis (UMN)
Progressive muscular atrophy (LMN)
What are the signs and symptoms of subacute combined degeneration of the spinal cord?
- dorsal column involvement
- distal tingling/burning/sensory loss is symmetrical and tends to affect the legs more than the arms
- impaired proprioception and vibration sense
- lateral corticospinal tract involvement
- muscle weakness, hyperreflexia, and spasticity
- upper motor neuron signs typically develop in the legs first
- brisk knee reflexes
- absent ankle jerks
- extensor plantars
- (Up down up)
May also be ataxia and a positive Rhomberg’s test
What is internuclear ophthalmoplegia? How does it present?
Impaired adduction of the eye on the side of the lesion, with nystagmus of the abducting eye - caused by a lesion in the medial longitudinal fasciculus on the side of the eye that fails to adduct
What visual field change is consistent with optic neuritis?
Central scotoma
What is the flow of CSF through the brain?
The CSF passes from the lateral ventricles to the third ventricle through the interventricular foramen (of Monro). From the third ventricle, the CSF flows through the cerebral aqueduct (of Sylvius) to the fourth ventricle.
Describe lateral medullary syndrome (Wallenberg) and where in the brain it affects:
- Caused by a PICA stroke
- Affects the cerebellum and lateral medulla
- Ipsilateral Horner’s syndrome, pain and temperature loss on the face, contralateral pain and temperature loss in the body
- Also dysphagia and cerebellar signs like nystagmus, dysdiadochokinesia and ataxia
Describe Weber syndrome and where in the brain it affects:
- A single branch of the posterior cerebral artery that supplies the midbrain
- Ipsilateral third nerve palsy
- Contralateral weakness in the upper and lower limbs
Describe lateral pontine syndrome and where in the brain it affects:
- Anterior inferior cerebellar artery
- Symptoms similar to Wallenberg’s
- Ipsilateral facial paralysis and deafness
Describe Phalen’s test:
Wrist flexion for a maximum of 60 seconds elicits paraesthesia in
the median nerve distribution.
Describe Tinel’s test:
Tapping over the median nerve at the wrist elicits paraesthesia in
the median nerve distribution.
What are the risk factors for carpal tunnel syndrome:
Pregnancy, menopause, oral contraceptive pill, obesity, trauma,
diabetes mellitus, hypothyroidism, rheumatoid arthritis,
acromegaly, amyloidosis, dialysis, repetitive activities, local
compression (e.g. lipoma, ganglion).
What investigations might be done for carpal tunnel syndrome?
Electroneurography, electromyography, ultrasonography, MRI
scan.
How can carpal tunnel syndrome be managed?
Splinting, local corticosteroid injection, carpal tunnel release
surgery, physiotherapy
What is the wearing off phenomenon with regards to levadopa?
A gradual decrease in the effectiveness of levodopa over time
What is the on/off phenomenon?
A sudden change in symptoms, such as alternating between periods of activity and motor difficulty.
What are some symptoms of a SOL?
Vomiting, papilloedema, seizures, focal neurology, decreased
conscious level, headache
What are some common sites for osteoporotic fractures?
- Hip fracture (neck of femur)
- Distal radius
- Proximal humerus
- Wrist fracture
- Vertebral fracture
How are NOFs categorised?
- Garden classification
- Grade I– incomplete fracture andnon-displaced
- Grade II– complete fracture andnon-displaced
- Grade III– partialdisplacement(trabeculae are at an angle)
- Grade IV– fulldisplacement(trabeculae are parallel)
What are the signs of a NOF?
- Pain ni the groin or hip which may radiate to the knee
- Not able to weight bear
- Shortened, abducted or externally rotated leg
What imaging would you do for a NOF and what might you see?
AP and lateral x-ray - disrupted Shenton’s line
How might grade 1-2 intracapsular fractures be managed?
Non-displacedintra-capsular fractures may have an intact blood supply to the femoral head, meaning it may be possible to preserve the femoral health without avascular necrosis occurring. They can be treated withinternal fixation(e.g., with screws) to hold the femoral head in place while the fracture heals.
How might grade 3-4 intracapsular fractures be managed?
Displacedintra-capsular fractures (grade III and IV) disrupt theblood supplyto the head of the femur. Therefore, the head of the femur needs to be removed and replaced with a hemiarthroplasty or total hip replacement
What are the risk factors for osteoporosis?
- Steroid use
- Hyperthyroidism and hyperparathyroidism
- Alcohol and tobacco
- Thin
- Testosterone decrease
- Early menopause
- Renal or liver failure
- Erosive/inflammatory disease
- Dietary calcium decrease/Diabetes
What are the rules for taking bisphosphonates?
Swallow w hole, take in fasting state, wash dow n w ith plenty o f
w ater, rem ain u p rig h t for 30 m inutes after taking the tablet, avoid
food and drink for 30 m inutes after taking the tablet. (1
What are some common side effects of bisphosphonates?
Abdominal pain, dyspepsia, nausea, abdominal distension,
oesophageal ulceration, upper GI bleed.
What are some severe side effects of bisphosphonates?
Osteonecrosis of the jaw, atypical fractures
What are some complications of myeloma?
Hypercalcaemia, acute kidney injury, hyperviscosity, recurrent
bacterial infections/neutropenia, anaemia, thrombocytopenia.
Think of the CRAB criteria
How is myeloma investigated?
Bloods - raised Ca2+, raised urea and creatinine, low Hb
Urinary Bence Jones protein (urine protein electrophoresis)
Serum protein electrophoresis
Biopsy of posterior superior iliac crest
X-ray (lytic lesions)
Many others
What do radiographs typically show in myeloma?
Lytic lesions
What are the5 key distressing palliative care symptoms identified by the Liverpool Care Pathway, and how are they managed?
Pain (morphine)
Agitation (midazolam)
Nausea (cyclizine),
Respiratory tract secretions (hyoscine butylbromide/
hydrobromide)
Dyspnoea (morphine).
PRAND
Liverpool Care Pathway is no longer used as a concept, in favour of individual care plans.
What is myeloma?
Bone marrow cancer involving the plasma cells, that result sin high quantities of a single antibody being produced
What ECG changes are seen in hypothermia?
J waves, QT prolongation (and PR and QRS prolongation), bradycardia, AF, progressing to VF and then asystole
Jesus Quist it’s Bloody Freezing
What are the risk factors for hypothermia in the elderly?
- Chronic conditions
- Learning or physical disabilities that might stop them from moving around
- Poor socioeconomic background - less able to afford heating, might have poorly insulated homes
- People >65
- People with chronic cardiac or respiratory conditions
- Malnourishment
What are the signs and symptoms of hypothermia?
Grumbles (ie., negative outlook, shivering, clouding of judgment), fumbles (i.e., touch each finger with their thumb to check fine motor movement, shivering), mumbles (i.e., slurring of words), stumbles (i.e., inability to walk), tumbles (loss of consciousness, potential for heart problems, medical emergency)
Cold, grey skin
What investigations might you do for someone who is hypothermic?
- ECG
- Bloods
- CXR - aspiration pneumonia, pulmonary oedema
How might you manage someone who is hypothermic?
- Reduce heat loss (bring them somewhere warm, remove wet clothing)
- Rewarm them (warm oxygen, heated IV saline, warm blankets, heat lamps - aggressive warming is better)
- Severe might require peritoneal lavage, haemodialysis etc
How does mirabegron help in urge incontinence?
B3 agonists (second line med for overactive bladder) - promoting sympathetic activity which increases detrusor relaxation and prolongs the filling stage
What are the criteria for a DOLS?
- 18+
- Person must be suffering from a mental disorder
- Must be a resident of a nursing home, or a patient in hospital
- Must lack capacity to decide for themselves about the restrictions which are proposed so they can recieve the necessary care and treatment
- The proposed restrictions would deprive the person of their liberty
- The restrictions would be in the person’s best interests
- Whether the person should be instead be considered for detainment under the mental health act (section)
- There is no valid advanced decision to refuse treatment that would contradict with a DOLS
What is a court appointed deputy, and when are they appointed?
A court-appointed deputy is someone who is legally authorized to make decisions for a person who lacks the mental capacity to do so themselves. Cannot be a family member. Done if there is no LPA, and there is doubt whether decisions will be made in someone’s best interests.
What is the role of an IMCA?
An IMCA is a trained advocate who supports people who can’t make or understand important decisions about their lives, such as those with dementia, learning disabilities and brain injuries. IMCAs are a legal safeguard for people who lack mental capacity and don’t have a family member or friend who can represent them.
What are the 3 core changes in dementia?
- Agnosia - can’t recognise things
- Apraxia - can’t do things very well
- Aphasia - can’t talk like normal
Anatomically, why are young children more prone to otitis media?
They have short, horizontal Eustachian tubes / their Eustachian tubes function poorly
What are the signs and symptoms of pre-eclampsia?
Headache / visual disturbance or blurriness / nausea and vomiting /
upper abdominal or epigastric pain / oedema / reduced urine output / brisk
reflexes
What is a complication of pre-eclampsia (not eclampsia)?
HELLP syndrome
Haemolysi, elevated liver enzymes, low platelets
What is the difference between PD and benign essential tremor?
Essential tremor worsens when holding arms outstretched [1 mark]
- Essential tremor worsens with activities such as writing whereas
Parkinson’s tremor improves with purposeful actions [1 mark]
- Essential tremor is often symmetrical where PD is often asymmetrical [1
mark]
- Essential tremors has autosomal dominant trait where PD has no
genetic trait [1 mark]
- Essential tremor is higher frequency than PD [1 mark]
- Essential tremor improves with alcohol whereas PD tremor has no
change [1 mark]
Define a seizure:
Transient episodes [1 mark]
of abnormal [1 mark]
electrical activity in the brain [1 mark]
What follow up needs to take place in a first fit in a child?
An urgent referral to a paediatric neurologist (within 2 weeks)
What are the 2 tests recommended by NICE in patients at risk of falls?
Turn 180 test
Timed Up and Go Test
Name some management strategies that might be put in place to prevent someone from having further falls:
Strength and Balance training / Home Hazard Assessment / Med Review
/ Vision Assessment
Why might urine be dark following a fall?
Myoglobinuria secondary to rhabdomyolysis
What is the treatment for rhabdomyolysis?
IV fluids
What are some differentials for an infective exacerbation of COPD?
Pneumonia / Pulmonary Embolism / Pneumothorax / Pleural Effusion
What signs and symptoms might you see during an infective exacerbation of COPD?
Wheeze / Fever / Cyanosis / Peripheral oedema / Confusion / Fatigue / Productive cough /
Yellow-green phlegm / Drowsiness / Marked reduction in ADLs / Increased SOB
What should you monitor in patients recovering from an asthma attack?
Peak expiratory flow
Oxygen saturations
What is the stepwise management of an acute asthma attack?
Oxygen
Salbutamol nebs
Ipratropium bromide nebs
Hydrocortisone IV
MgSO4
Aminophylline
Escalate
What type of drug is salbutamol?
Short acting beta 2 agonist
What non-pharmacological intervention should be offered to patients with schizophrenia?
CBT
What are some side effects of atypical antipsychotics?
Weight gain / Dyslipidemia / Hyperprolactinemia / Nipple discharge /
Impaired glucose tolerance
What are some side effects of the IUD?
(Short term) spotting or cramping after insertion / heavier periods /
more painful periods / infection / it can fall out
How might women present with chlamydia?
post-coital or intermenstrual bleeding / increased or purulent
vaginal discharge / cervical discharge / deep dyspareunia / dysuria / pelvic pain
/ pelvic tenderness
How might men present with chlamydia?
Dysuria / urethral discharge / urethral discomfort / testicular pain /
epididymo-orchitis / reactive arthritis
What screening tests might be used for depression?
PHQ-9 / HADS / BDI-II
Why should people on SSRIs and NSAIDs be prescribed PPIs?
Risk of GI bleeding
What is protective against endometrial cancer?
COCP / Mirena / Increased pregnancy / Cigarette smoking
What is the treatment for endometrial cancer in post menopausal women?
Total abdominal hysterectomy
With bilateral salpingo-oophorectomy
Name some notifiable diseases:
Acute encephalitis / Acute infectious hepatitis / Acute meningitis /
Botulism / COVID-19 / Diphtheria / HUS / Group A Strep / Malaria /
Meningococcal Septicaemia / Monkeypox / Mumps / Plague / Rabies / Rubella /
Scarlet fever / Smallpox / Tetanus / TB / Whooping Cough / Yellow Fever
Describe the phenotypic model of frailty:
Describes a group of patient characteristics
(unintentional weight loss, reduced muscle strength, reduced gait speed, self-reported exhaustion and low energy expenditure) which, if present, can predict poorer outcomes. Generally individuals with three or more of the characteristics are said to have frailty (although this model also allows for the possibility of fewer characteristics being present and thus pre-frailty is possible).
What is the other model of frailty (not phenotypic)?
Cumulative Deficit Model
Describe the Cumulative Deficit Model?
Described by Rockwood in Canada, it assumes an accumulation of deficits (ranging from symptoms e.g. loss of hearing or low mood, through signs such as tremor, through
to various diseases such as dementia) which can occur with ageing and which combine to increase the ‘frailty index’, which increases the risk of adverse outcomes
What does 6CIT stand for?
6 item cognitive impairment test
What is the pathophysiology of vascular dementia?
Caused by multiple small cerebrovascular infarcts, affecting the white matter of the cerebral hemispheres, grey nuclei, thalamus and striatum ⇒ underperfusion and ischaemia ⇒ neuronal death ⇒ progressive loss of function
What are the symptoms of vascular dementia?
SLOWNESS
Seems to have slowness of thought, difficulty with planning and understanding, problems with concentration and problem solving rather than memory loss, as well as psychomotor retardation.
Mood disturbances - psychosis, delusions, hallucinations, paranoia
What are the 3 core symptoms of LBD?
- Visual hallucinations - like that question where the man was seeing zoo animals everywhere
- Fluctuating attention and concentration - impairments tend to be in attention and executive dysfunction, rather than memory
- Parkinsonism - movement
What is the pathophysiology of frontotemporal dementia?
Deposition of TDP43 and tau in the frontal and temporal lobes ⇒ neuronal damage and death in the frontal and temporal lobes ⇒ atrophy
What are the 2 types of FTD?
- Behavioural variant
- Mood changes, aggression, becoming more childlike
- Language variants
- Semantic dementia caused by isolated asymmetric left temporal lobe atrophy (lose the ability to identify words and know what things are called)
- Primary non-fluent aphasia (agrammatic, non-fluent speech)
What are the symptoms of FTD?
- Altered emotion responsiveness, apathy
- Disinhibition, impulsivity
- Progressive decline noted in interpersonal skills
- Changes in food preference, more childlike amusements
- Obsessions and rituals may also be noted
- Changes in personality, behaviour change followed by breakdown in attention and executive function (not paying bills for example) - impaired social conduct
- Progressive decline in the understanding of word meanings
- Speech may still be fluent, but there is difficulty in name-retrieval and use of less precise terms
- Are unable to determine the meanings of common words when asked
- This tends to develop into the inability to recognise objects, or familiar faces (prosopagnosia)
What is the pharmacological management of FTD?
- SSRIs for behaviour and disinhibition
- Benzodiazepines (lorazepam, diazepam) for behaviour and agitation
- Atypical antipsychotics for behaviour
What causes giant cell arteritis?
Primary - idiopathic immune process, leading to large vessel vasculitis
Secondary - drugs, infection, other immune conditions such as RA
What is the pathophysiology of GCA?
WBCs infiltrate into vessel walls of the extracranial branches of the carotid artery and opthalmic artery ⇒ granulomatous inflammation of the vessel walls
What are the RFs for giant cell arteritis?
Polymyalgia rheumatica, white, female, 50+
What are the signs and symptoms of GCA?
- Headache,unilaterally
- Blurred vision, diplopia, visual loss, amaurosis fugax
- Scalp tenderness
- Tongue or jaw claudication
- Symptoms of polymyalgia
- Weight loss, fever
What investigations are performed for GCA?
Bloods - raised ESR/CRP (ESR - first line)
Exam - absent temporal artery pulse
Temporal artery US - hypoechoic halo sign which means the vessel is swollen and the wall is thickened.
Temporal artery biopsy - multinucleated giant cells
Fundoscopy - papillodema
How is GCA managed?
Refer to rheumatology and ophthalmology
Corticosteroids - oral prednisolone, or IV methylprednisolone if visual changes
Weaning off can last for a year
What should patients on long term steroids be co-prescribed?
PPI, bisphosphonate
What is the pathophysiology of Huntington’s?
- Trinucleotide repeat disorder caused by an autosomal dominant mutation in huntingtin gene on chromosome 4
- CAG repeated at the N-terminal of the huntingtin gene
- This mutation results in abnormal Huntingtin proteins clustering together within neurons in the basal ganglia, leading to neuronal death.
- Results in destruction of the inhibitory pathway in the caudate nucleus and the putamen of the basal ganglia, which leads to the inability to control or prevent movement ⇒ chorea.
What are the pharmacological treatments for Huntington’s disease?
- Antipsychotics for psychotic symptoms (e.g. olanzapine)
- Benzodiazepines for behavioural symptoms (e.g. diazepam)
- Dopamine-depleting agents for chorea (e.g. tetrabenazine, risperidone)
- Antidepressants for psychiatric symptoms
What muscles does the radial nerve innervate?
Muscles involved – BEST – brachioradialis, extensors, supinator, triceps
How is a Schwannoma managed?
- If small and not causing any cranial nerve deficits - surveillance
- If large - stereotactic radio surgery/ radiotherapy
- if radiotherapy fails or tumour is large - resection
How is an acute attack of Meniere’s disease managed?
Prochlorperazine (pro because it’s the best)
Cyclizine
Is NPH responsive to levadopa?
Narp
How is NPH managed?
VP shunt
Repeated CSF taps if they can’t tolerate surgery for a VP shunt
What is the difference between NF1 and NF2?
- NF1
- Neurofibromas - tumours of the peripheral nerves - develop, which may compress other structures
- Chromosome 17
- NF2
- Tumours of Schwann cells - bilateral acoustic neuromas (tumors of the vestibulocochlear nerve or cranial nerve 8 (CN VIII) develop, often leading to hearing loss
- Chromosome 22
What is the mode of inheritance of NF?
Autosomal dominant
What are some signs and symptoms of NF1?
- 6+ cafe au lait spots
- Axillary/inguinal freckles
- Neurofibromas
- Optic nerve glioma
- Iris harmatoma / Lisch nodules
- Scoliosis
How id DKA managed, including the rate of insulin infusion?
- Clinically dehydrated but not in shock - give an initial intravenous bolus of 10 ml/kg 0.9% sodium chloride over 30 minutes (included in the defecit)
- Shock - give an initial intravenous bolus of 10 ml/kg 0.9% sodium chloride as soon as possible (not included in the defecit)
- Maintenance fluids as normal
- K+ should be in the fluids
- Fixed rate insulin infusion 0.1 unit/kg/hour - actrapid - short acting insulin
- Stop their normal short acting insulin, continue long acting
What bloods might be seen in DKA?
hyperglycaemia, acidosis and ketonaemia, raised creatinine (from dehydration), raised K+
What condition is associated with JIA?
Chronic anterior uveitis
Which drugs can cause Steven Johnson Syndrome
Allopurinol, lamotrigine, phenytoin, penicillin
If a child is having seizures, what is the first step in investigation?
Send for an EEG to determine the type of seizures and guide treatment
What are some complications of chickenpox?
Bacterial superinfection
Cerebellitis
Disseminated intravascular coagulation
Progressive disseminated disease
When is trauma focused CBT offered over EMDR?
NICE recommends that Trauma-focussed CBT should be offered first line to patients with PTSD,
presenting at least 1-month after the trauma (NICE recommend active monitoring in patients
who present within 1 month of a trauma)
EMDR is also used in PTSD, but is recommended in patients who have presented between 1 and 3
months after a non-combat related trauma who specifically prefer EMDR > trauma-focussed
CBT
What manic symptoms is likely to be absent in hypomania?
Grandiosity - this is a psychotic symptom and so would indicate mania
How often are clozapine levels monitored?
Clozapine requires differential white blood cell monitoring weekly for 18 weeks, then fortnightly for up to one year, and then monthly as part of the clozapine patient monitoring service
Which type of vaginal cancer is most common?
Metastatic - primary cancers are very rare. They tend to spread from the cervix or endometrium
How is CIN1 managed?
CINI: it will probably go away on it’s own, close surveillance with colposcopy and biopsy every 6 months is recommended
How is CINII-III and 1a cervical cancer managed?
LLETZ or cone biopsy (if slightly less advanced), or radical trachelectomy (if slightly more advanced but still contained within the cervix, removal of cervix, upper vagina and pelvic lymph nodes) - cone biopsy better for fertility, risks preterm birth in future pregnancies.
How is stage 1B and beyond cervical cancer managed?
- Stage 1B – 2A: Radical hysterectomy and removal of local lymph nodes with chemotherapy and radiotherapy
- Stage 2B – 4A: Chemotherapy and radiotherapy
- Stage 4B: Management may involve a combination of surgery, radiotherapy, chemotherapy and palliative care
What are some risk factors for placenta praevia?
Multiple pregnancy
(e.g twins- multiple placentas), smoking, intrauterine fibroids, maternal age >35
What is contraindicated for a pregnancy with vasa praevia?
Digital vaginal exam
How is asymptomatic bacturia managed in pregnancy?
Asymptomatic bacteriuria in a pregnant woman requires treatment due to risk of pyelonephritis, and
association with premature labour and ROM. However contamination of a first culture is possible and so
a second test should be performed to confirm.
What is the definition of polypharmacy?
Using 5 or more medications daily
What is the mechanism of hyperandrogenism in PCOS?
Insulin resistanceis a crucial part of PCOS. When someone is resistant to insulin, theirpancreashas to producemore insulinto get a response from the cells of the body. Insulin promotes the release ofandrogensfrom theovariesandadrenal glands. Therefore, higher levels of insulin result in higher levels ofandrogens
Which bacteria are most likely to cause reactive arthritis?
- Campylobacter, salmonella, shigella (post GI)
- Chlamydia (post STI)
Which joint is typically affected by reactive arthritis?
- Knee - hot, painful, swollen
What is reactive arthritis associated with?
Reiter’s triad - anterior uveitis, balanitis
* Keratoderma blenorrhagica (brown papules on the palntar surface of the feet)
How is reactive arthritis managed?
Initially treated as septic arthritis with antibiotics!
1 - NSAIDs
2 - Steroids - intraarticular if single joint, IV if multiple
3. Sulfasalazine
What are the 5 patterns of psoriatic arthritis?
- Oligoarthritis (<4) - most common
- Polyarthritis
- Spondylitic pattern
- DIP dominant
- Arthritis mutilans
What joints are most commonly affected in psoriatic arthritis?
- Oligoarthritis - fingers, toes, feet in an asymmetrical pattern
- Polyarthritis - similar to RA in a symmetrical pattern
- Spondylitic - sacroiliac joints
What are the sign and symptoms of psoriatic arthritis?
- Psoriatic plaques
- Nail symptoms - onycholysis, pitting
- Joint swelling and pain >30 minutes
What are the treatments for psoriatic arthritis?
Treat psoriasis
1. NSAIDs
2. Intraarticular corticosteroids
3. Methotrexate, sulfasalazine, lefunomide (leflunomide is preferred in advanced disease)
What investigations are common to all inflammatory arthritis?
- Bloods - anti-CCP, RF, ESR, CRP
- X-ray
What is the pathophysiology of anky spon?
- Main joints affected = sacroiliac joints and the joints of the vertebral column - tends to be symmetrical
- Inflammation in vertebra occurs in the corner and bone marrow oedema develops
- Fat is deposited in the corner of the vertebra as a result of oedema
- This encourages new bone formation and calcium deposition over time in the ligaments of the spine
- This fuses the spine and results in a question mark posture, where they cannot move their head or spine or neck
What changes would be seen on an x-ray for anky spon?
- In early disease, changes will only be visible on MRI
- Syndesmophytes (calcification of anteiror longitudinal ligaments, forming bony bridges between vertebra)
- Ankylosis
- Sclerosis
- Erosion
- Fusion of the sacroiliac joints
- Bamboo spine
How is anky spon managed?
- NSAIDs
- Steroids
No DMARDS! - Anti-TNF
- Secukinumab
Physiotherapy!!!
What are the rules surrounding steroids?
- DON’T –Make them aware that they will becomesteroid dependentafter 3 weeks of treatment and should not stop taking the steroids due to the risk ofadrenal crisisif steroids are abruptly withdrawn
- S–Sick Day Rules: Discuss increasing the steroid dose if they become unwell (“sick day rules”)
- T–Treatment Card: Provide asteroid treatment cardto alert others that they are steroid dependent in case they become unresponsive
- O–Osteoporosis prevention: Considerosteoporosisprophylaxis whilst on steroids withbisphosphonatesandcalcium and vitamin Dsupplements
- P–Proton pump inhibitor: Considergastric protectionwith aproton pump inhibitor(e.g. omeprazole)
Define semantic dementia (a type of FTD):
Semantic dementia (SD) designates a progressive cognitive and language deficit, primarily involving comprehension of words and related semantic processing. They lose the meanings of words.
Define non-fluent aphasia dementia (a type of FTD):
Difficulties speaking and may find talking more effortful. Although they know what they want to say, they may make mistakes in using the right words or grammar, and start talking in shorter sentences
What should methotrexate be co-prescribed with?
Folic acid 5mg on a different day to methotrexate
How are patients with psoriasis assessed for psoriatic arthritis?
Psoriasis Epidemiological Screening Tool (PEST)
When should primary care patients with suspected rheumatoid arthritis be urgently referred to rheumatology?
Small joints of the hands or feet are affected.
More than one joint is affected.
There has been a delay of 3 months or longer between the onset of symptoms and the person seeking medical advice
What are the medical streatments for osteoarthritis?
- Topical NSAID
- Oral NSAID
- Paracetamol or opioids for short term relief
- intraarticular steroid injection
What are the surgical treatments for OA?
- Arthroplasty - joint replacement but a last resort because replacements wear out - for uncontrolled pain, significant mobility impairment, pts wishes
- Fusion - usually ankle of foot when they wont tolerate replacement very well - reduces pain but big impact on mobility
What is usually seen on an hand x-ray from someone who has gout?
Punched-out erosions with overhanging edges
How is glandular fever diagnosed?
<12 - EBV serology
>12 clinical diagnosis, monospot test/Paul Bunnel test(you got glandular fever from kissing paul bunnel ew)
How can glandular fever and mumps be differentiated?
- Glandular fever causes hepatosplenomegaly - advise them not to do contact sports and avoid alcohol! (Glandular fever is the kissing disease, think of sex as a contact sport?)
How is measles investigated?
- Oral fluid sample
- Measles RNA - more appropriate for fisrt 48 hours
- Measles-specific IgM and IgG serology (ELISA) - more appropriate after 3 days
- Swabs
- Done if the oral fluid sample isn’t available - same 2 tests are done though
How is rubella diagnosed?
- Oral fluid sample
- Rubellaspecific IgM (ELISA)
What are the signs and symptoms of mumps?
- Fever
- Muscle aches
- Lethargy
- Reduced appetite
- Headache
- Dry mouth
- Parotid gland swelling
How is mumps diagnosed?
Saliva swab/blood sample ⇒ IgM antibodies to mumps virus / PCR testing
How is stubborn bacterial conjunctivitis managed?
Chloramphenicol or fusidic acid eye drops
How is allergic conjunctivitis managed?
- Antihistamines
- Mast cell stabilisers
What is the time difference between chronic and acute sinusitis?
- Chronic >12w
- Acute <12w
How is sinusitis treated?
- Conservative for 10 days as most cases resolve by themselves
- Phenoxymethylpenicillin if no improvement after 10 days
- If chronic, high dose nasal steroid spray for 14 days
What antibodies are tested for in pernicious anaemia, and which are most specific?
- Anti parietal cell
- Anti intrinsic factor - most specific (because pernicious anaemia is an intrinsic factor deficiency)
What are the stages of chronic peripheral artery disease?
Develops from intermittent claudication (walking small distances increases metabolic demands of the muscle, causign pain in te calf, thigh or buttock that abates after rest, as a result of the narrowing of the peripheral arteries) ⇒ rest pain (inadequate oxygen supply to allow it to function normally at rest) ⇒ night pain (when it gets so bad it happens at night because they lose gravity as a driver of circulation when they’re led down) ⇒ critical limb ischaemia (demands aren’t being met to keep tissue alive) ⇒ loss of limb
What surgeries might be offered for intermittent claudication and critical limb ischaemia?
- Endovascular angioplasty and stenting - inserting a catheter under Xray guidance, and inflating a balloon at the site of stenosis and then a stent to hold the artery open
- Endarterectomy– cutting the vessel open and removing the atheromatous plaque
- Bypass surgery– using a graft to bypass the blockage. Better patency and limb salvage but higher risk of morbidity and mortality
What surgeries might be offered for acute limb ischaemia?
- Endovascular thrombolysis– inserting a catheter through the arterial system to apply thrombolysis directly into the clot - streptokinase or alteplase
- Endovascular thrombectomy– inserting a catheter through the arterial system and removing the thrombus by aspiration or mechanical devices
- Amputation if it is not possible to restore blood flow
What is the first line and definitive investigation for proteinuria in pre-eclampsia?
First line - urinalysis
Definition - urine albumin creatinine ratio
What are the risk factors for BV?
- Multiple sexual partners (although it is not sexually transmitted)
- Inconsistent use of condoms
- Excessive vaginal cleaning (douching, use of cleaning products and vaginal washes)
- Recent antibiotics
- Smoking
- Pregnancy / hormonal changes
- COCP is protective
What are the risk factors for candidiasis?
- Increased oestrogen (higher in pregnancy and people taking the COCP, lower pre-puberty and post-menopause)
- Poorly controlled diabetes
- Immunosuppression (e.g. using corticosteroids)
- Broad-spectrum antibiotics
What kind of organism causes trichomoniasis?
A protist
What is syphilis?
Spirochete bacteria
What discharge might be seen in trichomoniasis?
Vaginal discharge - frothy, yellow-green, smells fishy (gonorrhoea might cause green discharge but it won’t be frothy and probs not fishy)F
How are genital warts managed?
- Patient applied therapy
- Podophyllotoxin - 1st line
- Imiquimod - 2nd line
- Cryotherapy - 1st line
What causes lymphogranuloma venereum?
Chlamydia trachomatis genovars/serovars L1, L2, or L3
Who is most at risk of lymphogranuloma venereum?
MSM
What are the signs and symptoms of lymphogranuloma venereum?
- A painless ulcer or sore on the penis, vagina or around the anus that develops into painful, unilateral, inguinal or femoral lymphadenopathy (often referred to as ‘inguinal syndrome’)
- Anal symptoms
- blood or pus from the anus on underwear or toilet paper
- pain in the anal area when pooing or having receptive anal sex
- constipation, painful straining ordiarrhoeawhen trying to poo
- a feeling of incomplete emptying after pooing
What test of cure is required for gonorrhoea?
- NAATs if asymptomatic
- MCS if symptomatic
What test is first line in children with global developmental delay?
Genetic karyotyping should be first line in any child with global developmental delay
What is the mode of inheritance of Noonan syndrome?
Autosomal dominant (Noonan and dominant both have an N in)
What causes William Syndrome?
Deletion of a small portion of a gene on chromosome 7 which encodes the elastin gene (William has 7 letters)
What are the key features of William syndrome?
Broad smile, starburst eyes, very social and trusting personality
How is William syndrome investigated?
Chromosomal microarray testing to identify genetic changes
