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2nd October [11th-17th] > Tuesday [12/10/2021] > Flashcards

Tuesday [12/10/2021] Flashcards

1
Q

Metabolic SE of antipsyhcotics

A

Metabolic side effects of antipsychotics include dysglycaemia, dyslipidaemia, and diabetes mellitus

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2
Q

Patient has JAK2 positive mutation, raised Hb, platelets and WBC, risk of developing? [1]

A

Stroke -> PCV.

pCV increased risk of thrombotic events

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3
Q

Mx of PCV [3] - !

A

aspirin
- reduces the risk of thrombotic events
venesection
- first-line treatment to keep the haemoglobin in the normal range
chemotherapy
- hydroxyurea - slight increased risk of secondary leukaemia
- phosphorus-32 therapy

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4
Q

Which drug should be given to all PCV patients? [1]

A

Asprin to reduce risk of thrombotic events

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5
Q

Prognosis of PCV [3]

A
  • thrombotic events are a significant cause of morbidity and mortality
  • 5-15% of patients progress to myelofibrosis
  • 5-15% of patients progress to acute leukaemia (risk increased with chemotherapy treatment)
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6
Q

What is the first-line Rx for depression? [1]

A

SSRIs like fluoxetine

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7
Q

pH in Trichomonas vaginalis [1]

A

Over 4.5

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8
Q

Urine sodium and urine osmolality in pre-renal uraemia [hypovolomiea] as cimpared to ATN [2]

A

Pre-renal uraemia (‘azotemia’):

  • Urine sodium < 20 mmol/L
  • Urine osmolality > 500 mOsm/kg

Acute tubular necrosis:

  • Urine sodium < 20 mmol/L > 40 mmol/L
  • Urine osmolality > 500 mOsm/kg < 350 mOsm/kg
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9
Q

A 55-year-old woman presented to her general practice with hearing loss and tinnitus for the past 3 weeks. She has also noticed several episodes of vertigo. This was associated with nausea in the past few days and several episodes of vomiting this week. She has not noticed any discharge from her ears and denied having otalgia. On examination, there is no erythema or swelling of her ears and no tenderness on palpation. Rinne tests are positive in both ears (air conduction > bone conduction). On Weber test, the sound lateralized to her right ear.

What type of hearing loss does she have?

A

Sensorineural hearing loss
Rinne result: Air conduction > bone conduction bilaterally
Weber result: Lateralises to unaffected ear

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10
Q

indications for labour [5]

A

prolonged pregnancy, e.g. 1-2 weeks after the estimated date of delivery
prelabour premature rupture of the membranes, where labour does not start
diabetic mother > 38 weeks
pre-eclampsia
rhesus incompatibility

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11
Q

How common is labour labour started artificially? [2]

A

Induction of labour describes a process where labour is started artificially. It happens in around 20% of pregnancies.

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12
Q

Interpretation of Bishop’s score [2]

A

a score of < 5 indicates that labour is unlikely to start without induction
a score of ≥ 8 indicates that the cervix is ripe, or ‘favourable’ - there is a high chance of spontaneous labour, or response to interventions made to induce labour

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13
Q

What does pH have to be for NG tube insertion? [1]

A

NG tubes safe to use if <5.5 on aspirate

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14
Q

First-line drug for GAD [1]

A

sertraline

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15
Q

Which imaging tool used to Dx anastomic leak? [1]

A

abdo CT

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16
Q

Features and Ix of polymyaglia rheumatica [4]

A
  • typically patient > 60 years old
  • usually rapid onset (e.g. < 1 month)
  • aching, morning stiffness in proximal limb muscles: weakness is not considered a symptom of polymyalgia rheumatica!
  • also mild polyarthralgia, lethargy, depression, low-grade fever, anorexia, night sweats

Investigations

  • raised inflammatory markers e.g. ESR > 40 mm/hr
  • note creatine kinase and EMG normal
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17
Q

Is weakness considered a Sx for PMR? [1]

A

No!, aching, morning stiffness in proximal limb muscles are Sx though

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18
Q

Ix for PMR

A

Investigations
raised inflammatory markers e.g. ESR > 40 mm/hr
note creatine kinase and EMG normal

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19
Q

Tx for PMR [2]

A

prednisolone e.g. 15mg/od
- patients typically respond dramatically to steroids, failure to do so should prompt consideration of an alternative diagnosis

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20
Q

WHAT IS RAMSEY HUNT SYNDROME? [1]

A

Ramsay Hunt syndrome (herpes zoster oticus) is caused by the reactivation of the varicella zoster virus in the geniculate ganglion of the seventh cranial nerve.

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21
Q

Features of Ramsey Hunt [4]

A

auricular pain is often the first feature
facial nerve palsy
vesicular rash around the ear
other features include vertigo and tinnitus

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22
Q

Mx of Ramsey Hunt syndrome [2]

A

Treatment of Ramsay Hunt syndrome consists of oral aciclovir and corticosteroids
- 7d acyclovir and oral pred for 5d for example

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23
Q

Features and Mx of HIT [3]

A

features include a greater than 50% reduction in platelets, thrombosis and skin allergy
address need for ongoing anticoagulation:
- direct thrombin inhibitor e.g. argatroban
- danaparoid

Heparin overdose may be reversed by protamine sulphate, although this only partially reverses the effect of LMWH.

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24
Q

how should lithium levels be measured on patients starting the drug? []

A
  • inadequate monitoring of patients taking lithium is common - NICE and the National Patient Safety Agency (NPSA) have issued guidance to try and address this. As a result it is often an exam hot topic
  • when checking lithium levels, the sample should be taken 12 hours post-dose
  • after starting lithium levels should be performed weekly and after each dose change until concentrations are stable
  • once established, lithium blood level should ‘normally’ be checked every 3 months
  • after a change in dose, lithium levels should be taken a week later and weekly until the levels are stable.
  • thyroid and renal function should be checked every 6 months
  • patients should be issued with an information booklet, alert card and record book
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25
Q

How is secondary hypothyroidism Ix? [1]

A

Secondary hypothyroidism is very rare and results in a low TSH and low T4. In these cases, pituitary insufficiency is most likely and therefore an MRI of the gland should be performed.

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26
Q

skin manifestations of SLE [4]

A

photosensitive ‘butterfly’ rash
discoid lupus
alopecia
livedo reticularis: net-like rash

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27
Q

You are asked to review a 76-year-old woman with metastatic bowel cancer. She was admitted four days prior with abdominal pain and has not opened her bowels for the last six days.

She is receiving diamorphine via a syringe driver. However, she is still having intermittent severe abdominal pain.

Which of the following medications should be added to her syringe driver?

A

Syringe drivers: respiratory secretions & bowel colic may be treated by hyoscine hydrobromide, hyoscine butylbromide, or glycopyrronium bromide

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28
Q

How often is Depo Provera given? [1]

A

Every 12w

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29
Q

A 59-year-old woman presents to the emergency department complaining of a three-day history of new-onset palpitations. She has no structural or ischaemic heart disease. Her heart rate is 120bpm, and she shows no signs haemodynamic compromise. Her ECG shows an irregularly irregular rhythm with the absence of p waves. The consultant recommends elective cardioversion for this patient. Which one of these management plans is the most appropriate for this patient?

A

Bisoprolol and oral anticoaulgant therapy for 3w and then electrical cardioversion:

For cardioversion of AF: patients must either be anticoagulated or have had symptoms for < 48 hours to reduce the risk of stroke.

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30
Q

Drugs causing lower zone fibrosis [4]

A

idiopathic pulmonary fibrosis
most connective tissue disorders (except ankylosing spondylitis) e.g. SLE
drug-induced: amiodarone, bleomycin, methotrexate
asbestosis

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31
Q

Sx of rheumatic fever [2]

A

The underlying diagnosis is rheumatic fever. This is supported by the recent sore throat, chorea (jerk, irregular movements) and polyarthralgia.

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32
Q

What causes rheumatic fever? [2]

A

Rheumatic fever develops following an immunological reaction to recent (2-6 weeks ago) Streptococcus pyogenes infection.

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33
Q

Causes of erythema rheumatica

A

antibiotics: oral penicillin V
anti-inflammatories: NSAIDs are first-line
treatment of any complications that develop e.g. heart failure

34
Q

Which contraception most likely to cause weight gai? [1]

A

Depo-provera

35
Q

Compare primary to secondary pneumothorax

A

A pneumothorax is termed primary if there is no underlying lung disease and secondary if there is.

36
Q

Recommendations for primary pneuothorax [3] - !

A
  • if the rim of air is < 2cm and the patient is not short of breath then discharge should be considered
  • otherwise, aspiration should be attempted
  • if this fails (defined as > 2 cm or still short of breath) then a chest drain should be inserted
37
Q

Secondary pneumothorax Ix [3] - !

A

Recommendations include:

  • if the patient is > 50 years old and the rim of air is > 2cm and/or the patient is short of breath then a chest drain should be inserted.
  • otherwise aspiration should be attempted if the rim of air is between 1-2cm. If aspiration fails (i.e. pneumothorax is still greater then 1cm) a chest drain should be inserted. All patients should be admitted for at least 24 hours
  • if the pneumothorax is less the 1cm then the BTS guidelines suggest giving oxygen and admitting for 24 hours
38
Q

Iatrogenic pneuothorax Mx [3]

A

less likelihood of recurrence than spontaneous pneumothorax
majority will resolve with observation, if treatment is required then aspiration should be used
ventilated patients need chest drains, as may some patients with COPD

39
Q

Smoking, flying, scuba diving advice for patients that have had a pnueothorax and being discharged [3]

A

Smoking
- patients should be advised to avoid smoking to reduce the risk of further episodes - the lifetime risk of developing a pneumothorax in healthy smoking men is around 10% compared with around 0.1% in non-smoking men

Fitness to fly
- absolute contraindication, the CAA suggest patients may travel 2 weeks after successful drainage if there is no residual air. The British Thoracic Society used to recommend not travelling by air for a period of 6 weeks but this has now been changed to 1 week post check x-ray

Scuba diving
- the BTS guidelines state: ‘Diving should be permanently avoided unless the patient has undergone bilateral surgical pleurectomy and has normal lung function and chest CT scan postoperatively.’

40
Q

Hypertrophic scar features [3]

A

Excessive amounts of collagen within a scar. Nodules may be present histologically containing randomly arranged fibrils within and parallel fibres on the surface. The tissue itself is confined to the extent of the wound itself and is usually the result of a full thickness dermal injury. They may go on to develop contractures.

41
Q

Keloid scar features [2]

A

Excessive amounts of collagen within a scar. Typically a keloid scar will pass beyond the boundaries of the original injury. They do not contain nodules and may occur following even trivial injury. They do not regress over time and may recur following removal.

42
Q

Durgs which impair wound healing [4]

A

Non steroidal anti inflammatory drugs
Steroids
Immunosupressive agents
Anti neoplastic drugs

43
Q

Dx of COPD, what is approriate first-line drug? [1]

A

a SABA or SAMA first-line for COPD

SABA = salbutamol
SAMA = ipratropium
44
Q

Best way of differentiating between primary and secondary adrenal failure? [1]

A

Skin hyperpigmentation

45
Q

MoA of why praimry but not secondary adrenal failure causes skin hyperpigmentation [2]

A

Primary adrenal failure is where the problem is located in the adrenal gland. As the adrenal gland isn’t functioning as normal it is secreting a smaller amount of cortisol than it should be. This leads to the pituitary gland responding to this drop in cortisol by secreting more ACTH. ACTH is derived from a larger precursor called pro-opiomelanocortin (POMC), which also happens to be a precursor for beta-endorphin (which isn’t important in this case) and melanocyte stimulating hormone (MST). MST, as the name suggests, stimulates melanocytes giving the hyperpigmentation that can be seen in primary adrenal failure.

This process is not seen in secondary adrenal insufficiency, as the underlying mechanism of this is hypopituitarism. This means that, as opposed to a lack of cortisol production as in primary disease, the problem is from a lack of ACTH. A lack of ACTH production means that there is also a lack of POMC, and hence a lack of MST.

46
Q

Features of both primary and secondary hypoadrnealism [4]

A

Muscle aches, orthostatic hypotension, hyponatraemia and weight loss can all be observed in both primary and secondary disease.

47
Q

Another name for hypoadrenalism [1]

A

Addison’s disease

48
Q

What therapy do patients with Addison’s disease need? [1]

A

Patients who have Addison’s disease are usually given both glucocorticoid and mineralocorticoid replacement therapy.

49
Q

Therpay for patients with Addison’s disease [2] - !

A

hydrocortisone: usually given in 2 or 3 divided doses. Patients typically require 20-30 mg per day, with the majority given in the first half of the day
fludrocortisone

50
Q

Patient education for Addison’s disease [4 - !]

A

emphasise the importance of not missing glucocorticoid doses
consider MedicAlert bracelets and steroid cards
patients should be provided with hydrocortisone for injection with needles and syringes to treat an adrenal crisis
discuss how to adjust the glucocorticoid dose during an intercurrent illness (see below)

51
Q

Mx of intercurrent illness in Addison’s disease [2]

A

in simple terms the glucocorticoid dose should be doubled, with the fludrocortisone dose staying the same
the Addison’s Clinical Advisory Panel have produced guidelines detailing particular scenarios - please see the CKS link for more details

52
Q

A 25-year-old man is referred to neurology by his GP. Over the last six months he has been experiencing neck pain and stiffness and arm weakness. He is normally fit and well and denies any history of trauma, bowel or bladder problems or erectile dysfunction. He drinks five pints of beer per week.

On examination, there is a small area of erythema with central blistering on his right elbow which he had not noticed previously. Pin-prick sensation is reduced in the C5-6 dermatomes bilaterally. Fine touch, proprioception and vibration sensation are intact throughout. Forearm flexion is weak bilaterally with reduced biceps tendon reflexes. Forearm extension is weak on the right with a brisk triceps reflex. He is alert and orientated. His cranial nerves are intact. His coordination and gait are normal.

What is the most likely diagnosis?

A

Syringomyelia classically presents with cape-like loss of pain and temperature sensation due to compression of the spinothalamic tract fibres decussating in the anterior white commissure of the spine

53
Q

What is syringomyelia [2]

A

Syringomyelia (‘syrinx’ for short) describes a collection of cerebrospinal fluid within the spinal cord.

54
Q

What is syringobulbia? [2]

A

Syringobulbia is a similar phenomenon in which there is a fluid-filled cavity within the medulla of the brainstem. This is often an extension of the syringomyelia but in rare cases can be an isolated finding.

55
Q

Causes of syringomyelia [4]

A

a Chiari malformation: strong association
trauma
tumours
idiopathic

56
Q

Classical presentatio of a syrins [2]

A

The classical presentation of a syrinx is a patient who has a ‘cape-like’ (neck and arms) loss of sensation to temperature but preservation of light touch, proprioception and vibration. Classic examples are of patients who accidentally burn their hands without realising. This is due to the crossing spinothalamic tracts in the anterior commissure of the spinal cord being the first tracts to be affected. Other symptoms and signs include spastic weakness (predominantly of the upper limbs), paraesthesia, neuropathic pain, upgoing plantars and bowel and bladder dysfunction. Scoliosis will occur over a matter of years if the syrinx is not treated. It may cause a Horner’s syndrome due to compression of the sympathetic chain, but this is rare.

57
Q

Ix and Mx for syringomyelia [2]

A

Investigation requires a full spine MRI with contrast to exclude a tumour or tethered cord. A brain MRI is also needed to exclude a Chiari malformation.

Treatment will be directed at treating the cause of the syrinx. In patients with a persistent or symptomatic syrinx, a shunt into the syrinx can be placed.

58
Q

How would syringobulbia present? [2]

A

Syringobulbia is a similar disorder to syringomyelia where a syrinx affects the brainstem. It causes cranial nerve abnormalities e.g. trigeminal pain and temperature sensation loss, nystagmus, dysphagia, palatal weakness and tongue atrophy.

59
Q

How would SACD present? [2]

A

Subacute combined degeneration of the cord (SACD) causes a lesion of the dorsal columns, then later the corticospinal tracts and spinothalamic tract. SACD occurs due to vitamin B12, vitamin E and copper deficiency. It causes loss of vibration and proprioception (later other sensory modalities), sensory gait ataxia, distal muscle weakness and dementia. SACD is more common in older adults with malabsorption or poor nutrition.

60
Q

Cause of SACD [3]

A

SACD occurs due to vitamin B12, vitamin E and copper deficiency.

61
Q

Features of Friedrich’s ataxia [3]

A

Friedreich’s ataxia is a genetic progressive neurodegenerative disorder. It causes degeneration of the corticospinal tracts, dorsal columns and spinocerebellar tracts, as well as hypertrophic cardiomyopathy and diabetes. Symptoms include ataxia, slurred speech, spasticity, dysphagia, limb sensory loss and vision and hearing loss. Symptoms are usually apparent by adolescence and the absence of ataxia makes Friedreich’s ataxia less likely.

62
Q

A 27-year-old female presents to her general practitioner complaining of vaginal itchiness and discharge. On examination, the doctor can observe an inflamed vulva and some white, thick vaginal discharge. The cervix looks normal and there is no pain on bimanual examination. A high vaginal swab shows a pH of 4.3.

She has a past medical history of asthma, well-controlled with salbutamol, and has no known allergies. Dx? [1]

A

White ‘curdy’ vaginal discharge with pH <4.5 is likely to be candidiasis

63
Q

Cause of candiadis [2]

A

Vaginal candidiasis (‘thrush’) is an extremely common condition which many women diagnose and treat themselves. Around 80% of cases of Candida albicans, with the remaining 20% being caused by other candida species.

64
Q

RFs for candiadis [4]

A

diabetes mellitus
drugs: antibiotics, steroids
pregnancy
immunosuppression: HIV

65
Q

Features of candidiasis [4]

A

‘cottage cheese’, non-offensive discharge
vulvitis: superficial dyspareunia, dysuria
itch
vulval erythema, fissuring, satellite lesions may be seen

66
Q

Ix for candidiasis [1]

A

a high vaginal swab is not routinely indicated if the clinical features are consistent with candidiasis

67
Q

Mx of candidiasis [4]

A

options include local or oral treatment
local treatments include clotrimazole pessary (e.g. clotrimazole 500mg PV stat)
oral treatments include itraconazole 200mg PO bd for 1 day or fluconazole 150mg PO stat
if pregnant then only local treatments (e.g. cream or pessaries) may be used - oral treatments are contraindicated

68
Q

Recurrent vaginal candidiasis Mx [4]

A

BASHH define recurrent vaginal candidiasis as 4 or more episodes per year
compliance with previous treatment should be checked
confirm the diagnosis of candidiasis
- high vaginal swab for microscopy and culture
- consider a blood glucose test to exclude diabetes
exclude differential diagnoses such as lichen sclerosus
consider the use of an induction-maintenance regime
- induction: oral fluconazole every 3 days for 3 doses
- maintenance: oral fluconazole weekly for 6 months

69
Q

A 67-year-old male presents to the emergency department complaining of new-onset pain in his left groin. On examination, a large, warm, non-reducible mass located inferolateral to the pubic tubercle can be observed. It is accompanied by erythema of the overlying skin. When asked, he admits to vomiting twice and passing stools with blood mixed in them once. He looks in pain and sweaty. He has a past medical history of peptic ulcer disease, managed with omeprazole.

Which one of the following is the most likely diagnosis?

A

Stangulated femoral hernia

70
Q

Features of incracerated inguinal hernia [2]

A

Incarcerated inguinal hernias are non-reducible masses superior and medial to the pubic tubercle. They do not cause symptoms of strangulation.

71
Q

Features of stnagulated inguinal hernia [2]

A

A strangulated inguinal hernia would present with similar symptoms such as systemic upset, pain, erythema, vomiting, and bloody stools. But the mass would be superior and medial to the pubic tubercle rather than inferolateral.

72
Q

What are femoral hernias? [2]

A

Femoral hernias occur when a section of the bowel or any other part of the abdominal viscera pass into the femoral canal. The canal is usually a densely packed area of the anterior thigh, however, it is a potential space which can become occupied by herniated contents via the femoral ring.

73
Q

Features of inguinal hernias [4]

A

A lump within the groin, that is usually mildly painful;
It is important to distinguish femoral hernias, which are inferolateral to the pubic tubercle, from inguinal hernias which are superlateral to the pubic tubercle;
Typically non-reducible, although can be reducible in a minority of cases;
Given the small size of the femoral ring, a cough impulse is often absent.

74
Q

Dx of inguinal hernias [3]

A

Much less common than inguinal hernias (only 5% of abdominal hernias are femoral);
More common in women (M:F 1:3);
The effects of increased abdominal pressure in pregnancy, mean that femoral hernias are more common in multiparous women compare to nulliparous women.

75
Q

Dx of inguinal hernias [5]

A 
Lymphadenopathy;
Abscess;
Femoral artery aneurysm;
Hydrocoele or varicoele in males;
Lipoma;
Inguinal hernia.
76
Q

Cx of inguinal hernias [4]

A

Incarceration, where the herniated tissue cannot be reduced;
Strangulation, which can follow on from incarceration, and is a surgical emergency that requires urgent management (see below). These hernias will be tender and likely non-reducible, and may also present with a systemically unwell patient. The risk of strangulation is much higher with femoral hernias than inguinal hernias and increases as the time from diagnosis rises;
Bowel obstruction, again a surgical emergency;
Bowel ischaemia and resection due to the above, which may lead to significant morbidity and mortality for the patient.

77
Q

Mx of inguinal hernias [4]

A

Refer both men and women with equal urgency;
Surgical repair is a necessity, given the risk of strangulation, and can be carried out either laparoscopically or via a laparotomy;
Hernia support belts/trusses should not be used for femoral hernias, again due to the risk of strangulation;
In an emergency situation, a laparotomy may be the only option.

78
Q

Which autoantibodies most associated with Sjogren’s? [1]

A

Anti-Ro

79
Q

What is there a marked increase in in Sjogren’s? [1]

A

Lymphoid malignancy [40-60-fold]

80
Q

Features of Sjogren’s syndrome [8]

A 
dry eyes: keratoconjunctivitis sicca
dry mouth
vaginal dryness
arthralgia
Raynaud's, myalgia
sensory polyneuropathy
recurrent episodes of parotitis
renal tubular acidosis (usually subclinical)
81
Q

Ix for Sjogren’s syndrome [8]

A

rheumatoid factor (RF) positive in nearly 50% of patients
ANA positive in 70%
anti-Ro (SSA) antibodies in 70% of patients with PSS
anti-La (SSB) antibodies in 30% of patients with PSS
Schirmer’s test: filter paper near conjunctival sac to measure tear formation
histology: focal lymphocytic infiltration
also: hypergammaglobulinaemia, low C4

82
Q

Mx of Sjogren’s

A

artificial saliva and tears

pilocarpine may stimulate saliva production

2nd October [11th-17th] (4 decks)

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