Y3 Exam 1 Flashcards
What is the ICD10 classification of mild depression?
What is the ICD10 classification of moderate depression?
What is the ICD10 classification of severe depression?
Mild depression, need 2 of the general criteria PLUS 1 additional sympotms
Moderate depression, need 2 of the general criteria PLUS 3 additional symptoms
Severe depression, need all 3 of the general criteria PLUS 5 additonal symptoms
General criteria for depression:
- Low mood for most of the day almost everyday for 2+ weeks
- Loss of interest or pleasure (anhedonia)
- Decreased energy (fatigue)
Additonal symptoms:
- Loss of confidence
- Feelings of guilt
- Suicidal ideation
- Decreased concentration
- Agitation/ psychomotor retardation
- Sleep disturbance
- Change in appetite
List some symptoms of anorexia (7)
Lanugo hair
Cold intolerance
Blue hands / feet
Amenorrhoea
Dry skin
Hypotension
Weakness / fatigue
List some features of nephrotic syndrome: (4)
List some features of nephritis syndrome: (3)
Nephrotic syndrome:
• proteinuria (+++)
• oedema
• hypoalbuminaemia
• hyperlipidaemia
Nephritic syndrome:
• haematuria
• hypertension
• proteinuira (+)
What is the definition of epilepsy?
State the difference between generalised and partial (focal) seizures:
State whether the following types of epilepsy are generalised or partial:
a) tonic-clonic
b) simple partial
c) complex partial
d) absence seizures
e) myoclonic seizures
f) secondary generalised
g) tonic seizures
h) atonic seizures
i) clonic seizures
Epilepsy - More than 1 unprovoked seizure
Generalised seizures: electrical activity spreads across both hemispheres of brain
Partial (focal) seizures: electrical activity only involves one hemisphere/ lobe
- *a) tonic-clonic:** generalised seizure
- *b) simple partial:** partial seizure
- *c) complex partial:** partial seizure
- *d) absence seizures:** generalised seizure
- *e) myoclonic seizure:** generalised seizure
- *f) secondary generalised:** partial seizure
- *g) tonic seizure:** generalised seizure
- *h) atonic seizure:** generalised seizure
- *i) clonic seizure:** generalised seizure
What are the 7 phases that anaethetists go through to manage a patient?
~ Note which ones are the 4 phases of anaesthesia
1) Pre-operative care/ planning
2) Preparation
* 3) Induction*
* 4) Maintenance*
* 5) Emergence (waking patient up)*
* 6) Recovery*
7) Post-operative care
What are the 2 mechanisms underlying addiction?
~ State whether they underpin physical/ psychological dependence
- Tolerance - physical dependence
- Activation of the reward pathway - psychological dependence
What screening tool is used to assess the likelihood of anorexia nervosa?
A score of what would suggest an eating disorder?
SCOFF questionairre
2+
What is calculated alongside the ASA grade to risk stratify the patient before surgery?
~ a score of what makes them a high risk patient?
How is a patients exercise tolerance graded? (what unit is used?)
~ What score would the following exercise tolerances be given:
a) walking around the house
b) walk 100-200m on flat
c) strenuous exercise
Cardiac risk index - score 2+ = high risk patient!
METs
a) 2 METs
b) 4 METs
c) 9 METs
(Eg, diabetes, renal failure, ischaemic heart disease, congestive heart failure etc)
What is a pleural effusion?
What is the difference between exudate & transudate?
List lung causes of an exudate (3) & transduate (1):
Pleural effusion = fluid in the pleural cavity
Exudate: fluid contains 3g+ of protein - caused by inflammation
• Lung cancer
• Pneumonia
• TB
Transudate: fluid contains less than 3g of protein - caused by fluid shifts
• Congestive heart failure
There are 2 extremes of delirum. What are they called? List some symptoms seen in each: (3, 3)
Hyperactive delirium:
→ Aggression/ aggitation
→ Hallucinations
→ Restlessness
Hypoactive delirium:
→ Sleepiness/ fatigue
→ Withdrawn
→ Memory problems (temporary dementia)
What type of hallucinations are common in lewy body dementia?
Visual hallucinations:
→ animals in the house
→ faces in the wallpaper
What is the gold standard investigation for suspected vesico-uteric reflux in children?
What investigation is used to look for any kidney scarring/ function of the kidney?
What investigation is used to look at the structure (size & shape) of the kidney?
MCUG (micturicting urogram)
DMSA
US KUB
What part of the GIT does coeliacs disease affect & what is the main histological finding seen?
List some clinical features seen in coeliac disease: (6)
What condition is closely associated with coeliac disease?
Small bowel (esp jejenum) - villous atrophy
- Failure to thrive (in children)
- Diarrhoea
- Weight loss
- Fatigue
- Dermatitis herpetiformis (itchy rash, usually on abdomen)
- Malabsorption
Type 1 diabetes (as well as other autoimmune conditions)
What condition is indicated if a woman presents with recurrent miscarriages & a history of VTE events?
What is the treatment of this condition? (2)
Antiphospholipid syndrome
Aspirin & LMWH
What is the prophylaxis management of haemophilia?
How is an acute episode of bleeding treated? (3)
Replacement of clotting factors via IV transfusions (VIII - A, IX - B)
1) Infusions of affected clotting factor (VIII or IX)
2) Desmopressin (DDAVP) - to stimulate VWF release
3) Tranexamic acid - reduces the rate of fibrinolysis so that clot remains for longer
What drug class is used for the treatment of Alzheimers disease & Lewy Body dementia?
Give an example of a medication from this class.
Acetylcholinesterase inhibitors
Donepezil
The Philadelphia chromosome is associated with what haematological condition?
The philadelphia chromosome (a mix of 2 chromosomes) results in what oncogenic gene?
~ What is the translocation of the gene?
Chronic myeloid leukaemia
BCR-ABL gene
~ t(9;22)
Regarding sections from the MHA below, state a) how long they are valid for, b) who is able to use them, c) whether they include assessment/ treatment
Emergency detention certificate
Short-term detention certificate
Compulsary treatment order
Emergency detention certificate:
• Valid for 72h
• Fully registered doctor (FY2 onwards) + consent from a MHO (if available)
• ONLY detention
Short-term detention certificate:
• Valid for 28d
• Approved mental health doctor (psychiatrist!!) + MHO consent
• Detention & treatment
Compulsary treatment order:
• Valid for 6m - but can be renewed!
• MHO applies to Tribunal with 2 supporting medical reports from a AMP (psychiatrist) & GP (otherwise 2x AMPs)
• Detention & treatment
Amyotrophic lateral sclerosis is a type of what disease?
List some features of this condition: (4)
What gene mutation is associated with this condition?
What is the treatment of this condition?
What type of penetrance does the disease have? - What does this mean for family members with the gene?
Motor neurone disease
ONLY motor symptoms!!!!!!
• Progressive muscle weakness (LMN)
• Muscle wasting (LMN)
• Hyper-reflexia (UMN)
• Spasticity (UMN)
SOD gene
NO TREATMENT
Incomplete penetrance:
~ People with the gene don’t always develop the disease so offspring may/ may not be affected
~ Environmental factors ‘switch’ the gene on - nobody knows how/ why
What is Immune Thrombocytopenic Purpura (ITP)?
What blood abnormality does it result in?
What is the 1st line treatment for ITP?
If this doesn’t work, what do you add to the treatment?
Autoimmune attack of platelets (antibodies are made against platelets)
Results in thrombocytopenia (low platelet count)
1st line treatment: steroids
If steroids don’t work, add in IV IgG (immunoglobulins)
Give 2 examples of:
a) obstructive lung diseases
b) restrictive lung diseases
Would you expect an FEV1:FVC ratio to be < or > 75% in each?
Obstructive lung diseases: FEV1:FVC < 75%
• COPD (permanent airway obstruction)
• Asthma (reversible airway obstruction)
Restrictive lung diseases: FEV1:FVC > 75%
• Pulmonary fibrosis (interstitial lung disease)
• Sarcoidosis
What are the key clinical features in lewy body dementia? (3)
Fluctuating confusion throughout the day
Visual hallucinations
Parkinsonism symptoms (poor mobility, tremor)
List some features of a pleural effusion: (3)
List 2 findings seen on a chest xray:
What other investigation would you do in a pleural effusion to determine the cause?
What is the treatment of a small effusion/ large effusion?
What is the name of an infected pleural effusion?
- SOB
- Reduced breath sounds
- Dullness to prescussion over the effusion
Xray findings:
• Blunting of the costophrenic angles
• Fluid in the lung fissures
Pleural fluid aspirate - to determine exudate VS transudate cause
- *Treatment:**
- Small effusion:* conservative management
- Large effusion:* chest drain
Infected pleural effusion = empyema
What is the definition of psychosis?
What 2 clinical signs fall under pschosis?
The inability to distinguish between symptoms of delusion, hallucination and disordered thinking from reality (aka, lack of insight)
Hallucinations
Delusions
List the positive & negative symptoms of schizophrenia: (3, 3)
Having more of which type of symptoms indicates a better prognosis?
How long do symptoms need to be present for an ICD-10 diagnosis?
Positive symptoms: - better prognosis!
• Hallucinations
• Delusions
• Disordered thinking
Negative symptoms:
• Anhedonia
• Lack of emotions (emotional blunting)
• Apathy (lack of motivation)
Schizophrenia = symptoms present for 1 month +
Describe what nociceptive pain is:
Describe what neuropathic pain is:
Note whether they have a protective function or not.
Nociceptive pain = pain when there is tissue injury or illness (eg when you cut yourself)
~ has a protective function (the pain causes you to stop whatever is causing the pain)
Neuropathic pain = pain caused by nervous system damage / abnormality
~ no protective function, often occurs long after there has been trauma!
Regarding fluids, (colloid & crystalloid’s):
1) give an example of each type commonly used in hospital
2) describe the size of the molecules they contain & the consequence of this on fluid compartments within the body
3) state a contraindiction in each type
- *1) Colloid**: fluid containing starch/ gelatin
- *Crystalloid**: plasmalyte/ hartmans/ dextrose/ 0.9%NaCl
- *2) Colloid:** large molecules → more fluid is retained in the blood vessels
- *Crystalloid:** small molecules → some fluid remains in blood vessels & some moves into the tissues/ cells
- *3)** Colloid: the large molecules can cause kidney damage (so cannot be used in patients with renal failure)
- *Crystalloid:** 0.9%NaCl has a high Na conc so can cause hypernatraemia
Germline mutations:
• occur in what cells?
• can mutations be passed on to offspring?
Somatic mutations (non-germline):
• occur in what cells?
• can mutations be passed on to offspring?
Germline:
• mutations occur in egg/ sperm
• mutations are passed to offspring - offspring will have the mutation in every cell within their body!
Somatic:
• mutations occur in any cell of the body except egg/ sperm
• mutations are not passed to offspring
What is the treatment of mild-moderate Alzheimers disease? (Drug & drug class)
~ Name a common S/E of this.
What is the treatment of severe Alzheimers disease/ if previous treatment has failed?
What is the treatment of Vascular dementia?
What is the treatment of Lewy-Body dementia? (Drug & drug class)
~ Name a common S/E of this.
What is the treatment of Fronto-temporal dementia?
Anticholinesterase inhibitors: donepezil
S/E = GI upset (nausea, vomiting, diarrhoea)
Memantine
Management of underlying vascular risk factors
Anticholinesterase inhibitors: donepezil
S/E = GI upset (nausea, vomiting, diarrhoea)
No current treatment..
Explain the difference in absorption of drugs between younger & geriatric patients:
• amount of absorption
• rate of absorption
Name the exception (drug) to this!!!
- Amount of drug absorption is the SAME
- Rate of drug absorption is SLOWER in geriatric patients compared with younger people → time of onset of drug action is delayed
LEVODOPA is absorbed quicker in older people!!!
List some features of Crohn’s: (NESTS) +2
→ NO blood/ mucus (uncommon)
→ Entire GI tract
→ Skip lesions on endoscopy
→ Terminal ileum most affected & Transmural thickness of inflammation
→ Smoking = risk factor
→ Weight loss
→ Structures/ fistulas
What is the mode of inheritance of Myotonic dystrophy?
~ What is the repeated gene?
Explain what anticipation is:
List some symptoms/ signs of Myotonic dystophy: (6)
Autosomal dominant
~ CTG repeats
Anticipation: Successive generations inherit more CTG repeats in the gene → earlier onset & increased severity of the disease
• Distal muscle weakness/ stiffness (diaphragm/ face)
• Saggy face (due to muscle weakness)
• Bilateral ptosis
• Bilateral cataracts
• Frontal balding
• Difficulty letting go after shaking someones hand
What are the 1st rank symptoms of Schizophrenia? (ABCD)
A - Auditory Hallucinations
B - Broadcasting of Thought
C - Controlled Thought (delusions of control)
D - Delusional Perception
Having a H.pylori infection increases the risk of what condition?
How is H.pylori infection treated & how long for?
What is Barretts oesophagus & what causes it?
Barretts oesophagus increases the risk of what?
What is the a) prevention & b) treatment of Barretts oesophagus?
Stomach cancer (MALT)
Triple therapy for 7 days:
~ PPI (eg omeprazole)
~ 2x antibiotics
A premalignant change from squamous to columnar epithelium in the lower oesophagus - caused by persistent reflux (GORD)
Adenocarcinoma
Prevention: PPI’s (eg omeprazole)
Treatment: ablation of dysplastic cells
What immunological mechanism is responsible for type 2 hypersensitivity reactions?
Give 2 examples of conditions that this occurs in:
Auto-antibody mediated receptor activation
Haemolytic disease of the newborn
Transfusion reactions
If a woman is *Rh- and is carrying a Rh+ baby and there is no intervention, what will happen during delivery/ when there is mixing of blood?
Why does this happen?
When should this be checked for during pregnancy?
What can be given as prophylaxis for this?
*Rh = rhesus
The women will start developing anti-D antibodies after any sensitising event (commonly giving birth)
If someone is rhesus negative, they don’t have the D antigen on their RBC’s so if their blood comes into contact with someone that is rhesus positive then their blood will start producing antibodies against the foreign antigens.
Rh status of mother & baby is checked at the booking appointment (week 10)
If mother is negative & baby is positive, prophylaxis = anti D injection at 28 weeks gestation PLUS immediately after any sensitising events (eg birth/ trauma)
Name the condition described:
“Episodes of binge eating with a sense of loss of control, followed by purging behaviour” - BMI less than 17.5
Anorexia nervosa: binge purge subtype
A 19 year old student presents to his GP with a three month history of hearing a voice commenting on what he is doing and making derogatory comments about him. It has recently started telling him to do things. He has started to believe that his flatmates are against him and wish to harm him. He uses no illicit drugs.
What is the most likely diagnosis?
Schizophrenia
Anti-CCP is specific for what condition?
Rheumatoid arthritis
An extradural haemorrhage is commonly caused by a tear in which artery?
A # in which part of the skull usually causes this tear?
Middle meningeal artery
A # of the pterion - the pterion is weakest part of the skull & lies above the middle meningeal artery
What are the 3 core symptoms of depression?
- Low mood (for more than half of the day, 2+ weeks)
- Anhedonia
- Low energy levels
List some common symptoms of asthma: (3)
List some common symptoms of COPD: (5)
~ state the biggest risk factor!!
Asthma:
• Wheeze
• Cough (worse at night)
• SOB
COPD:
• Progressive SOB
• Cough
• Sputum production
• Wheeze
• Recurrent resp infections
Risk factor: SMOKING
Anti-CCP is specific for what condition?
Rheumatoid arthritis
What are the 2 main joints affected in ankylosing spondylitis?
What gene is associated with the condition?
What is the main presenting symptom?
~ Describe this
List 2 common xray findings seen in ankylosing spondylitis:
What is the 1st line medical treatment? - what is used in acute flares?
- Sacroiliac joint
- vertebrae
HLA B27
Lower back pain & stiffness
~ gradual onset (months)
~ worse at rest & in the morning/ night
~ improves with movement
Bamboo spine, squaring of the vertebral bodies
1st line treatment: NSAIDs (no known drugs modify disease course!)
• flares: steroids
Germline mutations:
• occur in what cells?
• can mutations be passed on to offspring?
Somatic mutations (non-germline):
• occur in what cells?
• can mutations be passed on to offspring?
Germline:
• mutations occur in egg/ sperm
• mutations are passed to offspring - offspring will have the mutation in every cell within their body!
Somatic:
• mutations occur in any cell of the body except egg/ sperm
• mutations are not passed to offspring
There are 2 types of immunity: innate & adaptive:
1) Which one is activated in a primary/ secondary infection?
2) Which one is rapid & non-specific/ slow onset & very specific?
3) Which one provides ‘short’/ ‘long’ term immunity?
4) Which one involves phagocytes & the complement system?
5) Which one invovles antibodies and cellular immunity (provided by T cells)?
1) Primary infection = innate
* *Secondary** infection = adaptive
2) Rapid & non specific = innate
* *Slow & very specific** = adaptive
3) Short term immunity = innate
* *Long term immunity** = adaptive
4) Phagocytes & complement = innate
5) Antibody production & cellular immunity = adaptive
What is the mode of inheritance of Huntington’s Disease?
~ What is the repeated gene?
Explain what anticipation is:
List some symptoms/ signs of huntingtons: (4)
What type of penetrance does the disease have? - What does this mean for family members with the gene?
Autosomal dominant
~ CAG gene repeats
Anticipation: Successive generations inherit more CAG repeats in the gene → earlier onset & increased severity of the disease
- Chorea (involuntary, abnormal movements)
- Dementia (poor memory/ cognitive function)
- Personality change
- Depression/ psychosis etc
Full penetrant - all family members with the gene will develop the disease at some point
What does SCID stand for?
Which immune cells are affected in SCID?
What are the 2 treatment options for SCID?
Severe combined immunodeficiency
Development of B cells & T cells is affected producing dysfunctional B & T cells
1st line = stem cell transplant
If not available: gene therapy
Explain urge incontinence:
• state the commonest cause
What are the treatments of urge incontinence?
• Non-pharmacolgical
• Pharmacological
The sudden need to urinate without warning
• overactive/ irritated bladder (detrusor muscle is over stimulated!)
- *Non-pharmacolgical:** Bladder retraining
- *Pharmacological:** Antimuscarinics** (eg Oxybutinin)
Antimuscarinics act to block activation of the detrusor muscle
List some clinical features seen in haemophilia: (5)
Haemarthrosis (bleeding into the joints)
Muscle haematoma
CNS bleeding
Prolonged bleeding after surgery/ trauma
Menorrhagia
List 3 screening tools used to identify an alcohol problem:
CAGE - score of 2+ indicates alcohol problem
AUDIT
FAST
Explain the effects that the below changes in body composition in the elderly have on the drug effects:
a) increased adipose tissue
→ volume of distribution
→ duration of action/ half life
b) reduced body water
→ volume of distribution
→ serum concentration
→ duration of action
c) reduced albumin
→ serum concentration
→ effect of drug
a) Increased adipose tissue
→ increased volume of distribution of fat soluble drugs
→ fat soluble drugs will have longer 1/2 life & duration of action!
b) Reduced body water
→ lower volume of distribution of water soluble drugs
→ higher serum concentration
→ reduced duration of action
c) Reduced albumin
→ reduced amount of drug will be bound to albumin (as there is less of it)
→ higher serum concentration of active drug
→ bigger (stronger) effect of drug produced
Between which meningeal layers does a subarachnoid haemorrhage occur?
Between the arachnoid mater & pia mater
What is the acute management of a manic episode? - give an example
What is the chronic management of bipolar disorder?
Antipsychotic (eg, Olanzapine)
Lithium (or sodium valproate)
+ antipsychotic (eg olanzapine) - if uncontrolled with lithium
A patient with delirium does not have capacity. - T/F
Capacity is decision specific. - T/F
False, some patients may still have capacity
True, a patient may not have capacity for more complex decisions but may retain capacity for basic decisions
What are 2 serious side effects of MAOI’s? - How can these be avoided?
1) Hypertensive crisis (cheese reaction)
~ avoid tyramine rich foods as they cause huge increase in BP
~ eg, beer, wine, cheese
2) Serotonin syndrome
~ occurs when MAOI’s are taken alongisde drugs that increase serotonin (eg SSRI’s)
~ wait 2 weeks after stopping SSRI before starting MAOI
What are the 2 main joints affected in ankylosing spondylitis?
What gene is associated with the condition?
What is the main presenting symptom?
~ Describe this
List 2 common xray findings seen in ankylosing spondylitis:
What is the 1st line medical treatment? - what is used in acute flares?
- Sacroiliac joint
- vertebrae
HLA B27
Lower back pain & stiffness
~ gradual onset (months)
~ worse at rest & in the morning/ night
~ improves with movement
Bamboo spine, squaring of the vertebral bodies
1st line treatment: NSAIDs (no known drugs modify disease course!)
• flares: steroids
What is the management of tension headaches?
Simple analgesia: NSAIDs / paracetemol
An elderly man has been admitted to hospital with acute onset disorientation, visual hallucinations and agitation. He has no psychiatric history and lives alone and requires no support.
What is the most likely diagnosis?
Delirium
What type of dementia is most common in the under 65’s age group?
Alcohol related brain damage (ARBD)
The body compostion changes with age. In regards to the following, state what you would expect in older people, compared to young:
a) muscle mass
b) adipose tissue (fat)
c) % body water
d) albumin
e) permeability of the BBB
a) Reduced muscle mass
b) Increased adipose tissue
c) Reduced body water %
d) Reduced albumin
e) Increased permeability of BBB
What is the difference between mania and hypomania?
For a diagnosis of either, how long do symptoms need to be present for?
Mania: Elated/ irritable mood PLUS:
• psychotic features (halluctination/ delusions)
• impacts on ADL
Hypomania: Elated/ irritable mood PLUS:
• NO psychotic features
• NO impact on ADL
Diagnosis requires symptoms for 1 week+
Now-a-days most medications aren’t stopped before surgery, even if patients are NBM…!
List 3 medications that would never be stopped before a surgery:
List 2 medications that may be stopped before a surgery:
Never stop:
• Inhalers
• Anti-anginals (GTN)
• Anti-epileptics
Sometimes may stop:
• Diabetic meds
• Anti-coagulants
What is the ASA grading system used for in anaesthetics?
Describe each ASA grade 1-6:
ASA used to identify how healthy the patient is in order to stratify the risk of surgery on the patient
ASA1: Healthy patient, non-smoker
ASA2: Mild systemic disturbance/ smoker/ obesity (eg, well controlled diabetes/ hypertension)
ASA3: Severe systemic disturbance (eg, poorly controlled diabetes/ hypertension)
ASA4: Life threatening disease (eg, recent MI/ sepsis)
ASA5: Moribund patient (unlikely to survive the surgery)
ASA6: Organ retrieval (patient is brain dead)
What are the cancerous cells in chronic lymphocytic leukaemia?
List some symptoms/ signs of CLL: (4)
What autoimmune condition is associated with CLL?
What cell would be seen on a blood film?
What is the management of CLL? - is it curable?
Differentiated lymphoid cells (B & T lypmhocytes)
- COMMONLY ASYMPTOMATIC !!!!
- Non-tender lymphadenopathy
- Hepatosplenomegaly
- B symptoms
Warm autoimmune haemolytic anaemia
Smudge cells
NOT CURABLE - if no symptoms, don’t treat!
(Otherwise chemotherapy)
List some extrinsic causes of urinary incontinence: (5)
- Immobility issues - unable to get to toilet
- Diuretics - increase volume of urine
- Constipation
- Confusion - may be unaware of needing toilet
- Painkillers - can cause constipation
A bacterial growth of what suggests a UTI?
105
In the RAT approach to pain management, what does R, A, T stand for?
How would a patient describe nociceptive pain?
How would a patient describe neuropathic pain?
- *R** - recognise pain
- *A** - assess pain type/ severity
- *T** - treat pain
Nociceptive pain:
• Sharp/ dull pain
• Well localised (patient can point to location of pain)
Neuropathic pain:
• Burning/ shooting pain
• Pins & needles
• Numbnesss
Describe what you might see in the following seizures:
a) Tonic-clonic seizure
b) Myoclonic seizure
c) Absence seizure
d) Atonic seizure
Tonic-clonic seizure: Muscles stiffen (go rigid = tonic) before generalised jerking of limbs (clonic)
Myoclonic seizure: Sudden jerking of one limb - patient may be conscious!
Absence seizure: Patient ‘pauses’ for a few seconds before restarting activity - patient often has no recollection
Atonic seizure: Muscles suddenly loose all tone - patient falls over
What is a common presentation of a cluster headache? (6)
Male with sudden onset, severe pain, behind one eye
Associated with:
~ watery, bloodshot eye
~ lacrimation
~ ptosis
~ miosis
~ runny nose (rhinorrhea)
What type of pain will the WHO pain ladder be successful at helping?
What is the treatment for the other type of pain? (name 2 examples of drugs used)
Nociceptive pain = use WHO pain ladder
Neuropathic pain - WHO pain ladder doesn’t work
~ amitriptylline
~ gabapentin
~ duloxetine
What type of headache is associated with autonomic symptoms? (Ptosis, miosis, lacrimation, nasal congestion)
Cluster headache
What immunological mechanism is responsible for type 3 hypersensitivity reactions?
Give an example of a disease that is caused by type 3 hypersensitivity.
Immune complex deposition
SLE
What are the 3 main criteria of PTSD according to ICD-10? - list some symptoms that fall under each one
What is the management of sub-clinical PTSD?
What is the management of moderate+ PTSD?
~ if this doesn’t work, what medication can be used?
1) Hyper-arousal
~ persistent anxiety
~ poor concentration
~ emotional numbing
2) Flashbacks
~ intense flashbacks at night/ during day
3) Avoidance
~ activities that remind patient of trauma are avoided
Subclinical: Watch & wait approach
Moderate: Trauma focused CBT - SSRI’s
When should an ADR be reported to the yellow card scheme? (3)
- Any ADR seen in a new drug
- Any ADR in children
- Any serious ADR, even if the ADR is already known about (eg neutropenia/ agranulocytosis etc)
What is the treatment of von Willebrand disease?
List 2 contraindictations to the use of DDAVP:
There is no day-to-day treatment. Treatment is given after a bleed or in preparation for surgery
1) VWF concentrate IV
2) Desmopressin - stimulates the release of VWF
3) Tranexamic acid - inhibits fibrinolysis (clot breakdown)
Contraindictations: young children, people with high cardiovascular risk
What chromosome is associated with chronic myeloid leukaemia? - what are the consequences of this?
What is the gene translocation?
What is the 1st line management of CML?
Philadelphia chromosome ⇒ BCR-ABL gene (oncogene)
t (9;22)
Tyrosine kinase inhibitors (inhibit BCR-ABL!)
~ eg Imatinib
What is often the first clinical feature seen in vascular dementia?
Aphasia (problems with communication)
* Memory is often spared until advanced disease
TRUE/ FALSE:
- Blood pressure normally goes up under anaesthesia.
- End tidal CO2 measures how much CO2 the patient breathes in.
- There are 5 pieces of monitoring that must be present before a GA is given.
- Only some patients require airway management whilst under anaesthesia.
False - anaesthetics commonly make BP fall
False - the amount of CO2 breathed out
True - BP, SATs, ECG, end tidal CO2, airway pressure
False - every patient will require some degree of airway management
A bacterial growth of what suggests a UTI?
105
What is Osteoarthritis - what does it usually present with?
~ what makes it worse/ better?
List the 4 commonest joints affected:
List 2 common signs that are seen in the hands:
What things are used in the management?
Mechanical wear & tear - presents with joint pain & stiffness
~ worse at night & upon activity, better with rest
- Hips
- Knee
- DIPs (of hands)
- MCP joint at base of thumb
- Haberdens nodes (DIP joints)
- Bouchards nodes (PIP joints)
- Physiotherapy (mobilising joint)
- Weight loss
- Paracetemol & topical NSAIDs ⇒ oral NSAIDs
- Intra-articular steroid injections
What is the management of mild- moderate depression?
What is the management of moderate- severe depression?
What do you do next if the 1st medical managent of severe depression fails?
~ If this fails, then what?
~ What do you add in next?
What is the management of severe treatment resistant depression?
~ If patient doesn’t want this, what medical management is available?
Mild-moderate: • Group CBT
Moderate-severe: • CBT PLUS SSRI (sertraline)
Add in a 2nd SSRI
~ Swap one of the SSRI’s for an SNRI
~ Use these along with lithium
** Review after 2 weeks
ECT (electro convulsive therapy)
~ Monoamine oxidase inhibitors (MAOIs)
What is a tension pneumothorax?
~ what is the cause?
List some signs of a tension pneumothorax: (4)
What is the initial management?
What is the definitive management?
Tension pneumothorax: air enters the pleural space through a one way valve - during inspiration, air moves into pleural space, during expiration air cannot leave
~ Caused by trauma to the chest
- SOB
- Tracheal deviation away from side of pneumorthorax
- Reduced air entry on affected side
- Resonant to percussion on affected side
- *Management:**
- Initial*: insert a large bore cannula into the 2nd intercostal space in the midclavicular line
- Definitive*: Chest drain
Joint pain/ stiffness that is worse in the morning & improves with exercise indicates:
a) mechanical cause
b) inflammatory cause
Inflammatory cause
Which electrolyte imbalance is seen in anorexia nervosa?
Hypokalaemia (low K)
What cells are cancerous in myeloproliferative disorders? - where in the body are these cancerous cells found? (before mets)
List some clinical signs/ symptoms of chronic myeloid leukaemia (a myeloproliferative disorder) (4) - what is the cancerous cell?
What chromosome is associated with CML? - what are the consequences of this?
What is the 1st line management of CML?
Differentiated cells of myeloid origin
~ found in bone marrow
• Anaemia (→ pancytopenia)
• Massive splenomegaly
• HIGH WCC
• Gout
~ Cancerous cell = neutrophils
Philadelphia chromosome ⇒ BCR-ABL gene (oncogene)
Tyrosine kinase inhibitors (inhibit BCR-ABL!)
What condition is indicated if a woman presents with recurrent miscarriages & a history of VTE events?
What is the treatment of this condition? (2)
Antiphospholipid syndrome
Aspirin & LMWH
What are the 3 criteria needed for a diagnosis of learning difficulty?
What are the 3 main causes of learning difficulty?
1) Intellectual impairment (IQ < 70)
2) Social/ adaptive dysfunction
(eg deficits in communication/ self-care, social skills etc)
3) Onset before 18y (whilst brain is still developing)
1) Head injury
2) Chromosomal abnormalities (eg Downs)
3) Congenital abnormalities (eg infection/ abnormal brain development)
Explain what tolerance (in regards to addiction) means:
Name the 2 types of tolerance & explain the physiological process behind each type:
How can tolerance result in dependence?
Tolerance: Reduced responsiveness to a drug caused by the body adapting to previous physiological effects of the drug
~ body tries to maintain homeostasis
Dispositional tolerance
~ less drug reaches the drug receptors
Pharmacodynamic tolerance
~ drug has less action on the drug receptors
Tolerance = body physiologically adapts each time drug is taken → stopping drug causes withdrawal symtpoms which are often unpleasant → drug is repeatedly taken to avoid withdrawal symptoms
What is graft vs host disease?
How can the risk of GVHD be minimised?
Rejection of a transplant caused by the donor’s T cells attacking the recipant’s antigens !!
Immunosuppression!
• steroids
• cyclosporin/ rapamycin
Anaphylaxis is what type of hypersensitivity reaction?
This type of reaction is mediated by what?
Type 1 hypersensitivity reaction
IgE mediated mast cell degranulation
What cells are cancerous in acute myeloid leukaemia? - where in the body are these cancerous cells found? (before mets)
List some clinical signs/ symptoms of AML: (4)
What is the definitive investigation of AML?
~ List 2 things that would be seen on this
What is the treatment of AML?
Undifferentiated, myeloid progenitor cells
~ found in the bone marrow
- Pancytopenia
- Gum hypertrophy
- Hepatosplenomegaly
- Petechiae & abnormal bleeding (caused by low platelets)
Bone marrow biopsy
• > 20% blast cells
• auer rods
Chemotherapy +/- stem cell transplant
What antibodies are present in coeliac disease?
What type of Ig are these antibodies?
When testing for these antibodies, what do you also need to test for to avoid a false negative result?
Anti-tissue transglutaminase (anti-TTG) & anti-endomysial (anti-EMA)
IgA antibodies
Total IgA levels - some people are IgA deficient so their total IgA will be low, even if they have coeliacs
Where are most drugs excreted in the body?
Explain the differences in drug excretion in older people & the effect this has on drug action:
Kidneys
Reduced kidney function = less excretion of the drug → drug has a longer action in the body
What are hypersensitivity reactions?
Exaggerated immune responses that cause damage to tissues/ blood
Name the condition described:
“Episodes of binge eating with a sense of loss of control, followed by purging behaviour” - normal BMI
Bulimia nervosa
List some clincial features seen in someone with bulimia nervosa (6)
Swollen parotid glands
Poor dentition (from the acid in the vomit)
Mouth sores
Eosophageal tears → haematemesis
Heart burn
Cuts on knuckles from induced vomiting (Russell’s sign)
List 4 risk factors for Hodkins lymphoma:
What is the key presenting symptom?
What is the diagnostic test/ investigation?
~ What is a key finding in this?
What is the staging used in all lymphoma’s? - describe the stages
→ Smoking
→ Epstein barr virus
→ HIV
→ Immunosuppression
Lymphadenopathy - non-tender, alcohol causes pain in lymph nodes
Lymph node biopsy
~ Reed sternberg cells
Ann Arbor Staging:
Stage 1: Only 1 lymph node group affected
Stage 2: Several lymph nodes affected but on the same side of diaphragm
Stage 3: Several lymph nodes affected but on different sides of diaphragm
Stage 4: Organ invovlement (eg, lungs/ liver)
Define what dementia is:
Dementia is a syndrome (a collection of different symptoms) associated with an progressive decline in brain functioning
Name the condition described:
“Episodes of binge eating with a sense of loss of control, followed by purging behaviour” - BMI less than 17.5
Anorexia nervosa: binge purge subtype
What are the main features of myeloma? (CRAB)
→ HyperCalcaemia
→ Renal failure
→ Anaemia
→ Bone disease
What class of antidepressant’s are lethal in overdose?
Give an example of a drug in this class
TCA’s - amitriptyline
What 3 things are included in the triad of anaesthesia? (targets of drug action)
- Analgesia
- Hypnosis
- Relaxation (of muscles)
What is the 1st line treatment of generalised seizures?
What is the 1st line treatment of partial (focal) seizures?
What is the treatment of absence seizures?
Generalised seizures: Sodium valproate (lamotrigine for females)
Partial seizures: Lamotrigine
Absence seizures: Ethosuximide
What are the cancerous cells in myeloma & what do they produce? - explain what these are..
List some signs/ symptoms of myeloma: (4)
Name the definitive investigation of myeloma:
What would be seen on a bone marrow biopsy? - state what would qualify as myeloma
Plasma cells - produce paraproteins
Paraproteins = identical immunoglobulins (usually IgG) produced by a (cancerous) clonal population of plasma cells
- Hypercalcaemia
- Renal failure
- Anaemia
- Lytic bone disease/ pain
Serum protein electrophoresis
Bone marrow biopsy: high plasma cells
~ plasma cells >10% = myeloma
~ plasma cells < 10% = MGUS
Lynch syndrome (HNPCC) is caused by mutations in what?
What mode of inheritance is seen in Lynch syndrome?
What are the 3 commonest cancers associated with the condition?
DNA mismatch repair genes
Autosomal dominant
** Colon cancer ** - commonest in distal colon
• Endometrial
• Ovarian
Skin prick testing is used to test for what type of hypersensitivity reaction?
Patch testing is used to test for what type of hypersensitivity reaction?
Skin prick testing = hypersensitivity I
Patch testing = hypersensitivity IV
List the distinguishing features that differentiate IgA nephropathy from post-streptococcal glomerulonephritis: (2)
IgA Nephropathy:
~ 1-2 days post URTI
~ Renal biopsy: IgA immune complex deposits in the glomerulus
Post-strep GN:
~ 1-3 weeks post URTI (usually strep throat)
~ Renal biopsy: IgG immune complex deposits in the glomerulus
Name the reversible neurological condition commonly seen in alcoholics:
~ What causes this condition?
List the triad of presenting features seen in this condition:
What is the treatment of it?
If left untreated, what can it progress into?
Wernicke’s encephalopathy
~ Thiamine (B1) deficiency
1) Ataxia (problems with coorindation, balance & speech)
2) Confusion
3) Opthalmoplegia/ nystagmus
Treatment: IV thiamine (usually given as pabrinex)
Korsakoff’s syndrome (irreversible brain damage)
Name the main neurones involved in the reward pathway & state which NT they release
How is activation of the reward pathway involved in addiction?
VTA neurones → nucleus accumbens → pre-frontal cortex
~ release dopamine
Release of dopamine creates feeling of pleasure → psychological cravings of this feeling then occur which result in dependence
** VTA = Ventral tegmental area
How many days supply of controlled drugs are given at any time?
Up to 30 day supply
What is found within the subarachnoid space?
CSF
How long must diarrhoea persist for to be referred to as chronic diarrhoea?
More than 4 weeks
List some patient factors that an anaesthetist would aim to optimise in their pre-operative assessment: (6)
- Diabetes control
- Hypertension control
- COPD
- Epilepsy
- Heart failure
- Lifestyle: weight, exercise tolerance, smoking cessation
What drug class is used for the treatment of Alzheimers disease & Lewy Body dementia?
Give an example of a medication from this class.
Acetylcholinesterase inhibitors
Donepezil
Status epilepticus is pronounced after a generalised seizure has been ongoing for how long?
What is the 1st line management of status epilepticus?
~ when should it be given?
What is the 2nd line management of status epilepticus?
What is the 3rd line management of status epilepticus?
5 minutes
1st line: Buccal midazolam or IV lorazepam
~ given at 5 minutes
~ repeat again at 10 minutes if still ongoing
2nd line: Sodium valproate
3rd line: Anaesthesia and intubation (propofol)
What are ‘neologisms’? - what condition might they be featured in?
Neologisms = made up words - indicates a thought disorder
~ common in Schizophrenia
What other mental health disorders are associated with eating disorders? (3)
OCD, anxiety, perfectionism
What cells does HIV destroy?
What are the 3 ways that HIV can be tested for in someone?
What 2 things are used to monitor a HIV infection? (below what num. would be abnormal/ end stage disease?)
CD4 T helper cells
1) Antibody blood test - may appear negative until 3 months post exposure
2) PCR: p24 antigen - detects the HIV antigen in the blood
2) PCR: HIV RNA - detects the quantitiy of HIV in the blood (used to measure viral load)
Monitoring:
1) CD4 count
~ below 500 cells/mm3 = abnormal (deficient)
~ below 200 cells/mm3 = end stage disease (AIDs)
2) Viral load
Tuberous Sclerosis is a genetic condition in which hamartomas form throughout the body (benign tumours composed of multiple cell types).
What is the mode of inheritance?
What are the classic triad of features seen in Tuberous Sclerosis?
List some skin lesions seen in this condition: (3)
Autosomal dominant
- Epilepsy
- Learning difficulties
- Skin lesions
- Ash leaf spots
- Shagreen patches
- Angiofibromas (looks like acne on nose, cheeks, chin)
You are working in A&E and a patient is hypotensive. What do you do to increase the BP?
How much of this would you give and over what time?
IV fluid resuscitation
500ml saline or plasmalyte bolus over 15 mins
What are the common symptoms of a migraine? (5)
Unilateral, throbbing headache that’s aggravated by movement
Photophobia (light makes it worse)
Phonophobia (loud noises make it worse)
Nausea / vomiting
+/- Aura
If someone presents with a thunderclap headache, what is the most likely diagnosis?
Subarachnoid haemorrhage
How long must diarrhoea persist for to be referred to as chronic diarrhoea?
More than 4 weeks
What is the typical presentation of someone with an extradural haemorrhage? (symptoms)
Head trauma +/- unconsciousness followed by lucid period (as the blood is pooling)
Progressive headache
Nausea / vomiting
Decreasing GCS
How is Binge Eating Disorder different from Bulimia Nervosa?
What is an effective treatment in Binge Eating Disorder?
In Binge Eating Disorder, patient’s don’t purge themselves after eating
Treatment BED: CBT
What genetic mode of inheritance is seen in haemophilia A & B?
Which sex is haemophilia more common in?
X linked recessive inheritance!
Males
Which antibodies are tested for in SLE? (3)
List some common symptoms seen in SLE: (6)
What is the 1st line treatment of SLE?
What is used to treat an SLE flare?
- Anti-nuclear antibodies (ANA)
- Anti-double stranded DNA (anti-dsDNA)
- Anti-smith
- Fatigue
- Weight loss
- Photosensitive malar rash
- Joint & muscle pain
- Mouth ulcers
- Hair loss
- *Treatment:** NSAIDs & hydroxychloroquine
- Flares:* steroids (commonly prednisolone)
What is the mode of inheritance of Myotonic dystrophy?
~ What is the repeated gene?
Explain what anticipation is:
List some symptoms/ signs of Myotonic dystophy: (6)
Autosomal dominant
~ CTG repeats
Anticipation: Successive generations inherit more CTG repeats in the gene → earlier onset & increased severity of the disease
• Distal muscle weakness/ stiffness (diaphragm/ face)
• Saggy face (due to muscle weakness)
• Bilateral ptosis
• Bilateral cataracts
• Frontal balding
• Difficulty letting go after shaking someones hand
Amyotrophic lateral sclerosis is a type of what disease?
List some features of this condition: (4)
What gene mutation is associated with this condition?
What is the treatment of this condition?
What type of penetrance does the disease have? - What does this mean for family members with the gene?
Motor neurone disease
ONLY motor symptoms!!!!!!
• Progressive muscle weakness (LMN)
• Muscle wasting (LMN)
• Hyper-reflexia (UMN)
• Spasticity (UMN)
SOD gene
NO TREATMENT
Incomplete penetrance:
~ People with the gene don’t always develop the disease so offspring may/ may not be affected
~ Environmental factors ‘switch’ the gene on - nobody knows how/ why
How is Binge Eating Disorder different from Bulimia Nervosa?
What is an effective treatment in Binge Eating Disorder?
In Binge Eating Disorder, patient’s don’t purge themselves after eating
Treatment BED: CBT
When would baby blues typically present?
When would postnatal depression typically present?
Baby blues: Within 2 weeks of delivery
Postnatal depression: several weeks after delivery up to 1y
What other mental health disorders are associated with eating disorders? (3)
OCD, anxiety, perfectionism
What is the commonest blood cancer of children?
What blood cell line does this cancer arise from?
List some symptoms/ signs of this cancer: (4)
What is the definitive investigation? What will be seen on this?
What is the treatment of this cancer?
Acute lymphoblastic leukaemia
Lymphoid progenitor cells (undifferentiated)
- Child with a limp
- Bone/ joint pain
- Exertional SOB
- Pancytopenia
Bone marrow biopsy - blast cells
Prolonged course of chemotherapy
List some reasons to intubate a patient: (4)
- Protection from aspiration
- Muscle relaxation is needed for the operation
- Shared airway (the surgery invovles the airways areas)
- Need for tight CO2 control
List some characteristics seen in Borderline Personality Disorder: (5)
What treatment options are available for personality disorders? (2)
- Impulsive behaviour
- Inability to control emotions
- Unstable relationships
- Self harm
- Feelings of paranoia/ anxiety
Treatment options:
• CBT
• Antipsychotics/ antidepressants/ mood stabilisers - to treat underlying mental health condition!
What is the difference between generalised anxiety disorder & phobic anxiety disorders?
What is agoraphobia?
What is the available treatment of GAD?
GAD - anxiety symptoms occur all the time & are not restricted to certain circumstances
Phobias - anxiety symptoms only occur in particular circumstances
Agoraphobia: A fear of crowded spaces
1) Counselling
2) SSRI’s (sometimes TCA’s)
What are the key clinical features in lewy body dementia? (3)
Fluctuating confusion throughout the day
Visual hallucinations
Parkinsonism symptoms (poor mobility, tremor)
Name the drug classes used in each of the 3 steps of the WHO pain ladder. Give an example of a drug in each class.
Explain how to use the WHO pain ladder.
Step 1: NSAIDs & paracetemol
~ Aspirin, Ibuprofen, Diclofenac
Step 2: Mild opioids (codeine/ tramadol) +/- NSAIDs/ paracetemol
Step 3: Strong opiods (morphine/ fentanyl) +/- NSAIDs/ paracetemol
Start with step 1, if pain not tolerated, add in mild opioid. If not tolerated, swap mild opioid fo strong one with NSAID/ paracetemol still
What is an extradural haemorrhage?
A collection of blood between the skull and the dura mater
Describe the meaning of frailty:
List the 5 decompensated frailty syndromes:
Increased susceptibility to environmental stress that the body isn’t able to physiologically deal with (eg catching a pneumonia/ falling)
1) Falls
2) Immobility
3) Delirium
4) Incontinence
5) Susceptibility to S/E of medications (eg, confusion with coediene, hypotensions with antidepressants)
Explain neuropathic bladder (aka underactive bladder):
• state the commonest cause
• what type of incontinence can it result in?
What is the treatment of a neuropathic bladder?
Underactive bladder: bladder no longer detects when it contains urine (detrusor muscle doesn’t contract)
• commonest cause = long term catheterisation
• results in overflow incontinence
Treatment: catheterisation!
List some common side effects of antimuscarinics in the elderly: (5)
- dry mouth
- constipation
- confusion/ delirium
- falls
- urinary retention
How long does a migraine attack usually last for?
4 - 72h
Joint pain/ stiffness that is worse in the morning & improves with exercise indicates:
a) mechanical cause
b) inflammatory cause
Inflammatory cause
What drug class is used as the 1st line treatment to manage an acute migraine attack?
Give an example of a commonly used drug from this class.
Triptans
Sumatriptan
What is Neurofibromatosis Type 1 (NF1)?
What mode of inheritance is seen in NF1?
List some common symptoms/ signs of NF1: (5)
A genetic condition that causes cancers to grow along the nerves (often benign but can turn malignant)
Autosomal dominant
• Cafe au lait spots (coffee colour patches on the skin) - see below
• Axilliary freckling
• Neurofibromas (small nodular tumours on the skin)
• Brown patches on the iris
• Learning difficulties/ epilepsy
List some common drugs that cause ADR’s in the elderly: (8)
_1) Anti-cholinergics
2) Sedatives (eg benzodiazepines)_
- Opioids
- Anti-psychotics
- NSAIDs
- Diuretics
- Anti-hypertensives
- Antibiotics
What condition is associated with alcohol withdrawal?
~ How long after withdrawing alcohol does this usually present?
List some clinical features associated with this condition: (5)
What class of drugs are used to help prevent withdrawal symptoms? - Name the main drug used.
Delirium tremens
~ Presents 72h after stopping alcohol
- Confusion
- Hallucinations (visual & tactile (insects crawling under skin))
- Sweating
- Hypertension
- Seizures
Benzodiazepines (eg Chlordiazepoxide)
What would you expect to see in the blood results of a patient diagnosed with anorexia nervosa in regards to:
- K levels
- Cholesterol levels
- Sex hormone levels (FSH, LH, Oestrogen, Testosterone)
- GH levels
- Cortisol levels
- Hypokalaemia
- Hypercholesterolaemia
- Low sex hormones
- Raised GH
- Raised cortisol
TB usually presents with chronic, slowly progressive symptoms. List some: (6)
What is the management of acute TB? (RIPE)
~ state the common side effects
- Cough +/- haemoptysis
- Fever/ night sweats
- Weight loss
- Fatigue
- Erythema nodosum (nodules on shins)
- Lymphaddenopathy
Management of acute TB:
R: Rifampicin (6 months)
S/E: red/ orange tears/ urine (secretions)
I: Isoniazid (6 months)
S/E: peripheral neuropathy
P: Pyrazinamide (2 months)
S/E: gout (causes high uric acid levels!)
E: Ethambutol (2 months)
S/E: colour blindness
Name the condition described:
“Episodes of binge eating with a sense of loss of control, followed by purging behaviour” - normal BMI
Bulimia nervosa
Medications that are associated with dependence which have the potential to be abused are classed as what types of drug?
Controlled drugs
Name the test used to differentiate between IBD & IBS:
What criteria is used to assess severity of UC?
Name the 1st line medication used to induce
a) remission
b) maintenance of Crohn’s
Name the 1st line medication used to induce
a) remission
b) maintenance of UC
Faecal calprotectin
Truelove & Witts criteria
Crohn’s:
Remission: Steroids (eg, prednisolone)
Maintenance: Azathioprine (immunosuppressant drug)
UC:
Remission: Aminosalicylate (5ASA) - eg mesalazine
Maintenance: Aminosalicylate (5ASA) - eg mesalazine
What type of hallucinations are common in lewy body dementia?
Visual hallucinations:
→ animals in the house
→ faces in the wallpaper
What is often the first clinical feature seen in vascular dementia?
Aphasia (problems with communication)
* Memory is often spared until advanced disease
What is an autologous transplant?
What is an allogeneic transplant?
What is a syngeneic transplant?
What is an xenogeneic transplant?
What type of transplant has the highest risk of rejection?
Autologous transplant: tissue from the same person
Allogeneic transplant: tissue from another member of the same species (eg, human - human)
Syngeneic transplant: tissue from an identical twin
Xenogeneic transplant: tissue from a different species
Xeogeneic transplant has the biggest risk of rejection as it is tissue from another species
What are the 2 commonest causes of a subarachnoid haemorrhage?
Ruptured aneurysm, commonly in the cirle of willis
Severe head injury
What is the management of Schizophrenia? - Name the drug class & 2 examples
What are some common contraindictations of atypical antipsychotics?
What can also be given if patient is aggitated in an acute episode of Schizophrenia?
What medication is used in treatment resistant Schizophrenia?
~ Name an important S/E of this
Atypical antipsychotics - eg olanzapine/ risperidone**
Atypical’s:
• Weight gain & hyperlipidaemia/ hypercholesterolaemia (olanzapine)
• Hyperprolactinaemia (risperidone)
Aggitation: Benzodiazepam, eg lorazepam
Clozapine - agranulocytosis (weekly blood tests needed)
** CBT may aslo be used
What screening tool is used to assess the likelihood of anorexia nervosa?
A score of what would suggest an eating disorder?
SCOFF questionairre
2+
Describe the location & level of support provided in each level 1-3 of the organ system support:
Level 1 care: medical ward based care
Level 2 care: HDU - offers single organ support (eg heart failure)
Level 3 care: ICU - offers multiple organ support
Describe a cluster headache.
How long do they usually last for?
Sudden onset, unilateral pain behind one eye
Typically last between 15 mins - 3 hours
A 39 year old woman presents with a complaint that she is fearful that something bad may happen to her. This fear occurs where-ever she goes and she cannot describe what might happen. She also complains of pains in her chest, a tremor and sweating at times.
What is the most likely diagnosis?
Generalised anxiety disorder
What is the abnormality that results in polycythaemia vera?
What mutation is associated with polycythaemia vera?
List some clinical signs/ symptoms of this condition: (5)
What is the management of this condition?
Proliferation of RBC’s
JAK2 mutation
- Red face (plethora)
- Vascular occlusion (DVT/ PE/ Stroke)
- Splenomegaly
- Headaches
- Itchy, especially after hot bath
Management: venesection (to prevent hyperviscosity of blood) & aspirin
Which electrolyte abnormality can blood transfusions cause?
Why does this happen?
Hypocalcaemia
When blood is donated, it’s mixed with sodium citrate to prevent it from coagulating. → The citrate in the blood can bind to the patient’s circulating calcium resulting in a decreased amount of free calcium = symptoms of hypocalcaemia
Someone with autism may have defecits in what 3 things?
What does the management of autism involve?
What congenital condition is autism commonly seen in?
1) Social interaction
2) Communiation
3) Behaviour
Management: MDT team, no medications
Down syndrome
Regarding pO2 & pCO2, what would be seen on a blood gas in:
a) type 1 respiratory failure
b) type 2 respiratory failure
Type 1 resp failure: low O2, normal CO2
Type 2 resp failure: low O2, high CO2 - respiraoty acidosis
IV salbutamol can cause what electrolyte abnormality? - what monitoring is needed to identify this?
Which of the following would be used in:
a) moderate asthma attack
b) severe asthma attack
c) life threatening asthma attack
- IV aminophylline
- Nebulised salbutamol
- IV magnesium sulphate
- Nebulised ipratropium bromide
- IV salbutamol
- Intubation
Salbutamol causes K to move from serum into cells = hypokalaemia
~need to monitor serum K
Moderate asthma attack:
• Nebulised salbutamol
• Nebulised ipratropium bromide
Severe asthma attack:
• IV aminophylline
• IV salbutamol
Life threatening attack:
• IV magnesium sulphate
• Intubation
What are some common triggers of trigeminal neuralgia? (5)
Cold
Wind
Chewing
Talking
Touching face
Where are most drugs metabolised in the body?
Explain the differences in drug metabolism in older people:
What effect does this have on serum conc. of drug?
How does this affect the onset & effect of pro-drugs? (drugs that are activated by the liver into their active form)
Liver metabolises most drugs!
Drug metabolism
→ liver works slower in older people SO metabolism of drugs is also slower
→ reduced 1st pass metabolsim
Effect on drugs action:
Reduced 1st pass metabolism = more drug in circulation that can have an affect (as it is being removed at a slower rate)
Pro-drugs
Less active form of the drug in circulation so ONSET = delayed, EFFECT = weaker (as there is less active drug)
List some features of nephrotic syndrome: (4)
List some features of nephritis syndrome: (3)
Nephrotic syndrome:
• proteinuria (+++)
• oedema
• hypoalbuminaemia
• hyperlipidaemia
Nephritic syndrome:
• haematuria
• hypertension
• proteinuira (+)
What’s the difference between hallucinations & delusions?
Hallucinations are seeing/ hearing things not related to an external stimulus
~ Can affect any of the 5 senses (touch, smell, taste, hearing, sight)
Delusions are fixed, firm beliefs that are outwith the patients cultural beliefs
~ Patients will believe delusions are true, even if shown evidence against them
What is the mode of inheritance of Huntington’s Disease?
~ What is the repeated gene?
Explain what anticipation is:
List some symptoms/ signs of huntingtons: (4)
What type of penetrance does the disease have? - What does this mean for family members with the gene?
Autosomal dominant
~ CAG gene repeats
Anticipation: Successive generations inherit more CAG repeats in the gene → earlier onset & increased severity of the disease
- Chorea (involuntary, abnormal movements)
- Dementia (poor memory/ cognitive function)
- Personality change
- Depression/ psychosis etc
Full penetrant - all family members with the gene will develop the disease at some point
Regarding pO2 & pCO2, what would be seen on a blood gas in:
a) type 1 respiratory failure
b) type 2 respiratory failure
Type 1 resp failure: low O2, normal CO2
Type 2 resp failure: low O2, high CO2 - respiraoty acidosis
What is Neurofibromatosis Type 1 (NF1)?
What mode of inheritance is seen in NF1?
List some common symptoms/ signs of NF1: (5)
A genetic condition that causes cancers to grow along the nerves (often benign but can turn malignant)
Autosomal dominant
• Cafe au lait spots (coffee colour patches on the skin) - see below
• Axilliary freckling
• Neurofibromas (small nodular tumours on the skin)
• Brown patches on the iris
• Learning difficulties/ epilepsy
If a patient presents with “the worst headache they’ve ever had”, what diagnosis is this suggestive of?
Subarachnoid haemorrhage
Commonly presents with a thunderclap headache
What abnormality is seen in haemophilia A?
What abnormality is seen in haemophilia B?
What is the mode of inheritance of haemophilia?
What tests would you do to diagnose haemophilia and what results would you expect in haemophilia? (3)
Haemophilia A: deficiency of clotting factor VIII
Haemophilia B: deficiency of clotting factor IX
X linked recessive
1) Clotting factor tests - to look at levels of factors VIII & IX (low VIII in haemophila A & low IX in haemophilia B)
2) Blood test APTT*: prolonged
3) Blood test prothrombin: normal
* APTT = blood test that measures time taken for blood to clot
What area of the brain is responsible for memory storage & is usually atrophied in Alzheimers?
~ What lobe(s) are affected in Alzheimers?
What lobe(s) are affected in Frontotemporal dementia?
Hippocampus
~ Parietal lobe & temporal lobe
Frontal lobe & temporal lobe
Lynch syndrome (HNPCC) is caused by mutations in what?
What mode of inheritance is seen in Lynch syndrome?
What are the 3 commonest cancers associated with the condition?
DNA mismatch repair genes
Autosomal dominant
** Colon cancer ** - commonest in distal colon
• Endometrial
• Ovarian
What is lactate a marker of?
Is a high or low lactate good?
Hypoperfusion (reduced O2 reaching the tissues)
LOW lactate - the higher the lactate, the more tissues are without O2!
What is the 1st line medication used to treat trigeminal neurlagia?
This medication is also used in the treatment of what?
Carbamazepine
Epilepsy!
What is the function of haptoglobin?
It transports free haemoglobin in the bood → reticuloendothelial system to be recycled
What is an unliscenced drug?
What is an ‘off label’ drug?
Unliscenced drug: the drug is used in other countries but has not been approved in the UK (or it is being used in a different form to what it is liscened as, eg powdered tablet for children instead of the tablet)
- *Off label drug:** the drug is liscenced by the MRHA but not for the treatment of the condition you are prescribing for
- or* it is being used in a different age group to that listed on the liscence
What is sarcoidosis?
State the ‘buzzword’ features of sarcoidosis: (6)
What results would be seen on:
a) blood tests (3)
b) chest xray
Sarcoidosis: a granulatomas inflammatory condition that can affect the whole body (commonest in young, black females)
Features:
• SOB
• Dry cough
• Erythmema nodosum (nodules on shins)
• Mediastinal lymphadenopathy
• Fatigue & weightloss
Bloods:
• Raised serum ACE (screening tool)
• Hypercalcaemia
• Raised CRP
Imaging:
• Chest xray: hilar lymphadenopathy
An 8 year old boy is referred with behavioural problems to the child Psychiatry Department. He is always active at home and moves from task to task. He finds it difficult to concentrate to read or watch TV. He often puts himself into dangerous situations like climbing onto high roofs. His performance at school is poor where he is distractible and causes distractions to others.
What is the most likely diagnosis?
ADHD
List the 3 main features of delirium:
1) Fluctuating consciousness
~ hypoactive
~ hyperactive
~ disrupted REM sleep
2) Change in cognition
~ confusion
~ memory impairment
3) Acute onset
If a UTI is suspected in older, hospitalised patients, what test should be done to confirm the UTI?
~ Explain why this is done
Urine sample should be sent for analysis - DO NOT DO URINE DIP
Most older people have asymptomatic bacteriurea which will indicate infection on a urine dip so need to send the sample for analysis!
What is the gold standard investigation to confirm a diagnosis of sarcoidosis & what would this show?
What other investigations would you do? (2)
What is the treatment of sarcoidosis if:
a) patient is asymptomatic
b) patient has symptoms
Biopsy of mediastinal lymph nodes: non-caseating granulomas with epitheloid cells
Bloods (raised serum ACE & CRP, hypercalcaemia) + chest xray
Treatment:
a) None - commonly self resolves
b) 1st line = oral steroids for 6-24m PLUS bisphosphonates (to protect their bones)
~ 2nd line = methotrexate
~ 3rd line = lung transplant
List some symptoms of anorexia (7)
Lanugo hair
Cold intolerance
Blue hands / feet
Amenorrhoea
Dry skin
Hypotension
Weakness / fatigue
Regarding sections from the MHA below, state a) how long they are valid for, b) who is able to use them, c) whether they include assessment/ treatment
Emergency detention certificate
Short-term detention certificate
Compulsary treatment order
Emergency detention certificate:
• Valid for 72h
• Fully registered doctor (FY2 onwards) + consent from a MHO (if available)
• ONLY detention
Short-term detention certificate:
• Valid for 28d
• Approved mental health doctor (psychiatrist!!) + MHO consent
• Detention & treatment
Compulsary treatment order:
• Valid for 6m - but can be renewed!
• MHO applies to Tribunal with 2 supporting medical reports from a AMP (psychiatrist) & GP (otherwise 2x AMPs)
• Detention & treatment
What are the aims of HIV treatment?
What does HIV treatment involve?
~ when is it started?
Aims of treatment:
• normal CD4 count
• undetectable viral load
HIV treatment: cART
Treatment involves a combination of 3 of the below:
• Protease inhibitors
• Integrase inhibitors
• Nucleoside reverse transcriptase inhibitors (NRTIs)
• NNRTIs
~ treatment is started as soon as infection is confirmed regardless of their CD4/ viral load count!
What drug class are extrapyramidal side effects associated with?
List some common ones: (4)
Typical antipsychotics
• Akathisia (restlessness)
• Parkinsonism features (bradykinesia, tremor, rigidity)
• Dystonia (involuntary muscle twitching)
• Tardive dyskinesia (involuntary facial movements)
What is a subdural haematoma?
Damage to which blood vessels cause a subdural haematoma?
A collection of blood between the dura mater and arachnoid mater
Tear in the bridging veins between the cortex and dura mater
What is the maximum score of a GCS?
Explain each point in the GCS: (6 5 4, MOVE)
~ Eyes
~ Verbal response
~ Motor response
15/15
Motor response:
6 = Obeys commands
5 = Localised to pain
4 = Normal flexion
3 = Abnormal flexion
2 = Extends
1 = Nothing
Verbal response:
5 = Orientated
4 = Confused conversation
3 = Inappropriate words
2 = Incomprehensible sounds
1 = Nothing
Eyes:
4 = Spontaneously opens
3 = Opens to speech
2 = Opens to pain
1 = Nothing
Tuberous Sclerosis is a genetic condition in which hamartomas form throughout the body (benign tumours composed of multiple cell types).
What is the mode of inheritance?
What are the classic triad of features seen in Tuberous Sclerosis?
List some skin lesions seen in this condition: (3)
Autosomal dominant
- Epilepsy
- Learning difficulties
- Skin lesions
- Ash leaf spots
- Shagreen patches
- Angiofibromas (looks like acne on nose, cheeks, chin)
Which electrolyte imbalance is seen in anorexia nervosa?
Hypokalaemia (low K)
What is the first presenting symptom of:
a) Alzheimers dementia
b) Vascular dementia
c) Lewy-body dementia
d) Fronto-temporal dementia
a) Alzheimers: Loss of recent memory
b) Vascular: Step wise decrease in ADL (language affected first)
c) Lewy-body: Fluctuating confusion & visual hallucinations (+ parkinsonism symptoms)
d) Fronto-temporal: Personality change
Name the drug classes used in each of the 3 steps of the WHO pain ladder. Give an example of a drug in each class.
Explain how to use the WHO pain ladder.
Both weak & strong opioids have the potential to cause addiciton. T/F?
When moving down the pain ladder, paracetemol should be stopped before NSAIDs. T/F?
Step 1: NSAIDs & paracetemol
~ Aspirin, Ibuprofen, Diclofenac
Step 2: Mild opioids (codeine/ tramadol) +/- NSAIDs/ paracetemol
Step 3: Strong opiods (morphine/ fentanyl) +/- NSAIDs/ paracetemol
Start with step 1, if pain not tolerated, add in mild opioid. If not tolerated, swap mild opioid fo strong one with NSAID/ paracetemol still
TRUE
FALSE - stop NSAIDs first due to their side effects
Define what dementia is:
Dementia is a syndrome (a collection of different symptoms) associated with an progressive decline in brain functioning
Explain stress incontinence:
What are the treatments of stress incontinence?
• Non-pharmacolgical
• Pharmacological
• Surgical
Stress incontinence occurs when abdominal pressure is increased, eg coughing/ jumping
- *Non-pharmacolgical:** physiotherapy (pelvic floor exercises)
- *Pharmacological:** oestrogen pessary/ duloxetine (SSRI)
- *Surgical**: Colposuspension
What is delirium?
What is a screening tool for delirium?
What is the management of delirium? (5)
An acute confusional state
4AT
Non-pharmacological management !!!!!
~ Stop/ treat any precipitating factors (eg medications, infection)
~ Mobilise patient asap
~ Make patient familiar with their surroundings
~ Normalise sleep-wake cycle
~ Discharge from hospital ASAP
What is the textbook cause of an extradural haematoma?
Trauma to the head, eg car crash/baseball bat to the head
What are the 6 components of sepsis 6?
~ state the order you would do these in
(take 3, give 3)
1) Give O2 if sats are below 94%
2) Take blood cultures
3) Give IV antibiotics
4) Fluid challenge (give IV fluids)
5) Measure blood lactate
6) Measure urine output
What are common signs of raised ICP? (4)
Headache that is worse in the morning & when bending over/coughing
Headache that is relieved by lying down
Papillodema
Vomiting
Cancers within the bone marrow can cause what result on a FBC?
Why can this occur?
Pancytopenia
Occurs when the cancerous occupy most of the space within the bone marrow - normal blood cells are unable to develop!
What condition would the following indicate:
A patient presents with a 2 day history of haemoptysis. Blood results show a raised urea & creatinine.
Goodpasture Syndrome (anti-glomerular basement membrane disease)
~ glomerulonephritis (AKI)
~ pulmonary haemorrhage (haemoptysis)
Explain what FEV1 & FVC are:
FEV1:FVC < 75% indicates what type of respiratory disease?
FEV1:FVC > 75% indicates what type of respiratory disease?
FEV1: Forced expiratory volume in 1 second
~ the amount of air exhaled in1s.
~ it measures how easily air flows out of the lungs
FVC: Forced vital capacity
~ the total amount of air that someone can exhale after a full inhilation
~ it measures the lung capacity of the patient
FEV1:FVC < 75% = obstructive lung disease
~ FEV1 is reduced whereas FVC may be normal
FEV1:FVC > 75% = restrictive lung disease
~ both FEV1 & FVC are reduced so the ratio is normal/ high!
Explain urinary retention with overflow:
• state the commonest cause in males!
What are the treatments of overflow incontinence?
• Non-pharmacolgical
• Pharmacological
• Surgical
Stenosed urethra causing blockage of urinary flow
• benign prostatic hyperplasia
- *Nonpharmacolgical**-: suprapubic catheterisation (last resort)
- *Pharmacological**: Alpha blockers or anti-androgens
- *Surgical**: TURP (trans-urethral resection of prostate)
What are the 5 standard things that the anaesthetic machine monitors?
- ECG
- SATs
- BP
- End tidal CO2
- Airway pressure
In a centrifuge, what 3 components will blood separate into?
Name some cells that will be found in each component.
Plasma
→ Clotting factors
→ Albumin (& other proteins)
→ Antibodies
Buffy coat
→ Platelets
→ WBC’s (leucocytes)
Red blood cells
What are the 2 core features of OCD?
What is the 1st line treatment of OCD?
What is the 2nd line treatment?
What is the last treatment option if the above 2 don’t work?
1) Recurrent, obsessive thoughts
2) Compulsive acts (eg they can’t stop themselves from doing something)
1st line: CBT
2nd line: SSRI’s (fluoxetine)
Psychosurgery
What is a pneumothorax?
What is the 1st line investigation?
~ If a pneumothorax is too small to be seen, what other investigation can be done?
What is the management:
a) no SOB/ < 2cm
b) SOB / > 2cm
c) unstable patients/ failure of b) twice
Air inside the pleural space separates the lung from the chest wall
- *Investigations:**
1) Erect chest xray
2) CT thorax - *Management:**
a) no treatment - should self resolve (advise follow up 2 - 4 weeks)
b) aspiration of air → reassessment
c) chest drain
What would you expect to see in the blood results of a patient diagnosed with anorexia nervosa in regards to:
- K levels
- Cholesterol levels
- Sex hormone levels (FSH, LH, Oestrogen, Testosterone)
- GH levels
- Cortisol levels
- Hypokalaemia
- Hypercholesterolaemia
- Low sex hormones
- Raised GH
- Raised cortisol
List some common presentations of von Willebrand disease: (5)
→ nose bleeds
→ menorrhagia
→ bleeding gums when brushing teeth
→ prolonged, heavy bleeding during surgery/ trauma
→ easy bruising
What is the management of an acute cluster headache attack?
100% oxygen through a mask
What is a type 4 hypersensitivity reaction?
Give 2 examples of conditions that are caused by type 4 hypersensitivity reactions:
Delayed hypersensitivity reaction, mediated by T cells
Autoimmune conditions:
Rheumatoid arthritis
Type 1 Diabetes
List some features of UC: (CLOSEUP)
→ Continuous inflammation
→ Limited to colon & rectum
→ Only superficial mucosa affected
→ Smoking is protective
→ Excrete blood & mucus
→ Use aminosalicylates (1st line treatment)
→ Primary scleorising cholangitis
What is the typical presentation of a subdural haematoma? (5)
Older person had a fall days-weeks ago
Progressive headache
Nausea / vomiting
Confusion
Reduced GCS
What type of dementia is most common in the under 65’s age group?
Alcohol related brain damage (ARBD)
Refeeding syndrome can occur in people who havent eaten for how many days?
What happens to K, phosphate & Mg2+ if food is reintroduced too fast to someone with anorexia?
What are 3 common symptoms/ signs seen in refeeding syndrome?
5+ days
Levels fall resulting in depletion of all 3 electrolytes!
- Arrhythmia’s
- Confusion
- Death
What is the management of all personality disorders?
CBT
Regarding the triad of anaesthetic medications, state what they are:
From the anaesthetic drug classes below, state what part of the triad above they predominantly act upon:
a) Opiates
b) GA
c) LA
d) Muscle relaxants
• Hypnosis
• Analgesia
• Relaxation
a) Opiates: analgesia
b) GA: hyponosis
c) LA: analgesia
d) Muscle relaxants: relaxation
