Zero To Finals Flashcards
Gram positive cocci
Staphylococcus
Streptococcus
Enterococcus
Gram positive rods
Corny mike’s list of basic cars
Corneybacteria Mycobacteria Listeria Bacillus Nocardia
Gram positive anaerobes
CLAP Clostridium Lactobaccilus Actinomyces Propionibacterium
Abx inhibit cell wall synthesis
With beta-lactam ring (penicillin, carbapenem, cephalosporin)
Without beta-lactam ring
(Vancomycin, teicoplanin)
Abx inhibiting folic acid metabolism
Sulfamethoxazole and Trimethoprim block formation of folic acid
Co-trimoxazole is a combination of the two
Abx inhibit protein synthesis (target ribosome)
Macrolides (erythromycin, clarithromycin, azithromycin)
Clindamycin
Tetracyclines
Chloramphenicol
Unusual chest infection organisms
Moraxella catarrhalis (in immunicompromised with chronic Lung disease) Pseudomonas auerginosa (CF) Staphylococcus aureus (CF)
Most common UTI bacteria
E. coli
Gram -ve, anaerobic, rod shaped
Chest infection 1st line
Amoxicillin
UTI 1st line
Trimethoprim
Nitrofurantoin
UTI in pregnancy
7d abx
1st Nitrofurantoin (do not give in 3rd trimester - haemolytic anaemia)
2nd amoxicillin
trimethoprim (do not give in 1st or anti-epileptics as has ANTI FOLATE effect)
Cellulitis and golden crust?
Staph aureus infection
Cellulitis tx 1st line
Flucloxacillin
Centor criteria
<3 not bacterial tonsilitis
Fever >38*C
Tonsillar exudates
Absence of cough
Tender lymph nodes
Bacterial tobsilitis 1st line
Penicilin V /phenoxymethylpenicillin 10days
Otitis media 1st line
Amoxicilin
But (erythronycin, clarithromycin if penicillin Allergy)
Sinusitis management
Pencilin V/ phenoxymethylpenicillin 5days
No improvement after 10 days: 2 weeks of high dose steroid nasal spray
No improvement after 10 days + likely bacterial cause: Abx
Septic arthritis tx
1st flucloxacillin + rifampicin
2nd vancomycin + rifampicin (joint replacement or penicillin allergy)
Influenza treatment
Oral oseltamivir 75mg 2x day for 5 days
Or
Inhaled zanamivir 10mg 2x day for 5 days
(Treatment must start within 48h of symptoms)
Same drugs but 1x day for 10 days in PEP
Gram negative diplococcus
Gonorrhoea
Neisseria meningitidis
Bacterial meningitis in adults
Neisseria meningitidis, strep pneumoniae
Neonates: group B strep
Lumbar puncture in babies
<1 month with fever
1-3 month fever and unwell
<1 year unexplained fever and serious ilness
Kernig’s test
Pt on back, flexing hip and straightening knee - meninges stretch and -> resistance or pain
Brudzinski’s test
Pt flat on the back, chin to chest -> if meningitis then pt flexes hips
Community meningitis 1st line
Benzylpeniclinin IM/IV stat
300mg <1y
600mg 1-9y
1200mg >10y
Meningitis hospital tx
<3m cefotaxime + amoxicillin
>3m ceftriaxone
+ Dexamethasone to prevent hearing loss and neuro damage 4x/4 days
Lumbar puncture results
Bacterial - cloudy
Viral / normal - clear
Bacteria release proteins and use up glucose
Viruses don’t use glucose and release little protein
Neutrophils released for bacteria and lymphocytes released for viruses
High WBC for both
TB staining
Ziehl Neelsen stain turns bacteria bright red and background blue
TB grows acid-fast bacilli (rod shaped)
BCG vaccine
Intradermal infection of life attenuated TB
- works against complicated TB
- not as effective for pulmonary TB
Mantoux test
Injecting tuberculin into intradermal space
Check after 72h, >5mm is positive (previous vaccination, latent, or active TB)
Interferon gamma release assays
Confirms latent TB disease
Pts at risk of TB reactivation (w latent TB) tx
Isoniazid and rifampicin 3m
Isoniazid 6m
Acute TB tx
Rifampicin 6m
Isoniazid 6m
Pyrazinamide 2m
Ethambutol 2m
Isoniazid side effects and tx
Peripheral neuropathy
- Pyridoxine (B6)
Rifampicin se
Red discolourstion of urnie and tears
Induces p450 so reduces effect of contraceptive pill
Pyrazinamide se
Hyperuricaemia (high uric acid and gout)
Ethambutol se
Colour blindness and reduced visual acuity
PCP in hiv
Co-trimoxazole prophylaxis in CD4 <200
PEP
<72h
Truvada (emtricitabine/ tenofovir) and Raltegravir 28days
Uncomplicated malaria treatment
Malarone
Quinine sulphate
Doxycycline
IV tx for complicated malaria
Artesunate and quinine dihydrochloride
Antimalarials
Malarone (2d/during/1week)
Mefloquine (2w/during/4week) - psychotic episodes and seizures
Doxycycline (2w/during/4week) - Abx so thrush, diarrhoea
OA risk factors
Obesity Age Trauma Female Family history
OA X-ray
Loss of joint space
Osteophytes
Subarticular sclerosis
Subchondral cysts
OA symptoms
Pain and stiffness worsened by activity
OA signs
Haberdens nodes DIP
Bouchards nodes PIP
Squaring of the thumb
OA management
Weight loss, physio
Paracetamol + topical NSAID
Add oral NSAID + PPI
Add codeine / morphine
RA genetics
HLA DR4 - RF positive pt
HLA DR1 - often present in RA
Antibodies in RA
RF
anti CCP
RA presentation
Symmetrical polyarthritis MCP and PIP joints Atlantoaxial subluxation Pain, swelling, stiffness Pain worse after rest, improves with activity
Signs in the hands RA
Boggy feeling Z shaped thumb Swan beck deformity Boutonnières deformity (flexor digitorum superficialis works) Ulnar deviation
Felty’s syndrome
RA, neutropenia, splenomegaly
DAS 28
Disease activity score
Swollen joints
Tender joints
ESR/CRP result
RA DMARDs
1st mono: methotrexate, leflunomide, sulfasalazine, hydroxychloroquine
2nd: 2 drugs
3rd: methotrexate + biological therapy (TNF inhibitor - adalimumab, infliximab, etanercept)
4rd: methotrexate + rituximab
Methotrexate SEs
Pulmonary fibrosis
Leflunomide se
Hypertension and peripheral neuropathy
Sulfasalazine se
Male infertility (reduced sperm count)
Hydroxychloroquine se
Nightmares and reduced visual acuity
Anti TNF se
Reactivation of TB and hep B
Rituximab
Night sweats and thrombocytopenia
Psoriatic arthritis signs
Nail pitting Psoriasis plaques on skin Onycholysis- nail separates from nail bed Dactylitis Conjunctivitis Pencil in cup appearance
Chlamydia vs
Gonorrhoea ->
Chlamydia -> Reactive arthritis
Gonorrhoea -> gonococcal septic arthritis
Reactive arthritis
Conjunctivitis, arthritis, balanitis
Seronegative spondyliarthropathy
HLA B27 gene
Ankylosing spondylitis
Reactive arthritis
Psoriatic arthritis
AS features
Sacroiliac and vertebral pain and stiffness
Vertebral fractures
Pain worse at night
Morning stiffness, gets better throughout the day
Stiffness worse with rest and better with movement
AS associations
Anaemia Anterior uveitis Aortitis Heart block Pulmonary fibrosis
X ray changes in AS
Bamboo spine Squaring of vertebral bodies Subchondral sclerosis Fusion of joints Syndesmophytes
AS treatment
Nsaids 2-4weeks then change if no improvement
Steroids
Anti TNF (etanercept)
Monoclonal antibody against TNF (infliximab, adalimumab)
SLE signs
Photosensitive malar rash
Worse with sunlight
SLE investigations
C3 and C4 decreased in active disease
CRP and ESR raised in active inflammation
Increased PCR in lupus nephritis
SLE antibodies
ANA
anti ds DNA (increased with disease activity)
Anti Smith
specific to SLE
Sensitivity
How many/% ill people had positive result
Specificity
What % of healthy people had negative result
Anti centromere
Limited cutaneous systemic sclerosis
Anti Ro and Anti La
Sjorgen’s syndrome
Anti Scl 70
Systemic sclerosis
Anti Jo 1
Polymyositis
SLE treatment
NSAIDs
Steroids (prednisolone)
Hydroxychloroquine (mild SLE 1st line)
Biological therapies: rituximab, belimumab
Systemic sclerosis
Hardening of the skin
Fibrotic connective tissue disease
Limited cutaneous systemic sclerosis antibodies
Anti Scl 70
Anti centromere
Limited cutaneous systemic sclerosis features
Calcinosis Raynuaurd phenomenon Esophageal dysmotility Sclerodactyly Telangectasia
Diffuse cutaneous systemic sclerosis antibodies
Anti Scl 70
Diffuse cutaneous systemic sclerosis symptoms
CREST
+ CV problems
+ lung problems
+ kidney problems
Polymyalgia rheumatica
2 weeks of Bilateral shoulder pain, pelvic girdle pain Worse with movement Wakes up from sleep At least 45min stiffness in the morning
Polymyalgia rheumatica tx
15mg prednisolone /day Until symptoms settle (3-4 weeks) Then 12.5mg for 3 weeks 10mg for 4-6 weeks Reduce by 1mg every 4-8 weeks
Giant cell arteritis risk
Vision loss
Temporal artery biopsy findings in giant cell arteritis
Multinucleated giant cells
Also investigations: raised ESR, CRP, hypoechoic halo on duplex ultrasound
Giant cell arteritis tx
40-60mg prednisolone/day
also 75mg aspirin daily
Polymyositis and /dermatomyositis
+ diagnosis
+tx
Chronic muscle inflammation /+ skin involvement
Raised CK
Corticosteroids
DermatoMyositis signs
Gottron lesions (knuckle hardening)
Photosensitive rash on the back and neck
Calcium deposits in subcut tissue
Polymyositis antibodies
Anti Jo 1
Dermatomyositis antibodies
Anti Mi 2
ANA
Antiphospholipid syndrome antibodies
Lupus anticoagulant
Anticardioliptin antibodies
Anti beta 2 glycoprotein I antibodies
Libmann-Sacks endocarditis
Non bacterial endocarditis with vegetations on mitral valve,
SLE and antiphospholipid association
Livedo reticularis
Purple lace like rash with mottled appearance to the skin
Sjorgen’s Syndrome
Autoimmune condition affecting exocrine glands
-dry mucous membranes, dry mouth, eyes, vagina
Secondary Sjorgen’s
When condition is related to SLE or rheumatoid arthritis
Sjorgen’s antibodies
Anti Ro
Anti La
Schirmer test
Tears should travel 15mm in healthy adult
10mm is significant
Sjorgen’s syndrome tx
Artificial saliva, tears
Vaginal lubricants
Hydroxychloroquine stops disease progression
Vasculitis markers
ESR and CRP raised
Anti neutrophil cytoplasmic antibody ANCA
pANCA
peri Nuclear anti-neutrophil cytoplasmic
Anti-PR3
Microscopic polyangitis, churg-Strauss
cANCA
Wegener’s granulomatosis
Vasculitis treatment
Steroids,
Immunosuppressants (cyclophosphamide, methrotrexate, azathioprine)
Henoch Schonlein Purpura
IgA Vasculitis Purpuric rash in lower limbs and buttocks - purpura - joint pain - abdominal pain - renal involvement
Wegener’s polyangitis
Respiratory track and kidney involvement
Epistaxis
Hearing loss and sinusitis
Saddle shaped nose due to perforated septum
Kawasaki disease (medium vessel Vasculitis)
CRASH AND BURN Conjunctivitis Rash Adenopathy /Lymphadenopathy Strawberry tongue Hands and feet skin peeling
Fever >5d
Kawasaki disease complication
Coronary artery aneurysm
Behcet disease gene
HLA B51 (prognostic of severe disease)
Behcet disease features
Oral and genital ulcers
+ skin inflammation, uveitis, muscle stiffness, GI ulceration, veins - Budd chiari syndrome, DVT, pulmonary artery aneurysm)
Pathergy test
For Behcet disease
Tests for skin hypersensitivity
Skin subcut abrasion, reviewed 24-48h later, >5mm weal is positive
Behçet’s disease tx
Colchicine for inflammation
Immunosuppressant azathioprine
Topical (bethamethasone) and systemic (prednisolone) steroids
Gout aspirate features
No bacteria
Needle shaped crystals
Negative birefringent
Monosodium urate
Gout X ray
Sclerotic boarders with overhanging edges
Punched out erosions
Gouty throphi
Subcut deposits of uric acid
Gout mx
Acute: NSAID, colchicine, steroid
Colchicine se
Diarrhoea
-given in pts who can’t use NSAID
Gout prophylaxis
Allopurinol, reduces uric acid levels
Pseudogout
Calcium pyrophosphate crystals / chondrocalcinosis
Pseudogout joint aspirate
No bacteria
Calcium pyrophospahte crystals
Rhomboid shaped
Positive birefringent
Pseudogout on X ray
Chondrocalcinosis
Pseudogout tx
NSAID, colchicine, steroids
+- joint washout
Risk factors for osteoporosis
Old age Female Low BMI Low activity/ mobility Alcohol and smoking Rheumatoid arthritis Long term corticosteroid use Post menopause (oestrogen is protective)
FRAX tool
Prediction of fragility fracture in 10years
Age, BMI, smoking, alcohol, co-morbidities, family history
Osteoporosis tx
Bisphosphonates (upright, empty stomach, 30 min before eating)
- alendronate 75mg/week
- risedronate 35mg/week
- zolendronic acid 5mg/ year IV
Osteomalacia
Defect in bone mineralisation due to insufficient vit D
If in children before growth plate close - rickets
Osteomalacia pathology
Low vit D
causes low Ca and PO4
2* hyperparathyroidism
Reabsorption of Ca from bones (causing soft bones)
Investigation for vit D
<25 - vit D deficiency
25-50 insufficient
>75 optimal
Osteomalacia tx
Vit D
- 000 1x weekly (6w)
- 000 2x weekly (7w)
- 000 daily (10w)
Maintenance 800 daily
Paget’s disease
Excessive bone turnover (formation and reabsorption due to increased osteoblast and osteoclast activity)
Forms high density sclerotic and low density lytic patches.
Paget’s disease biochemistry
Raised ALP
Normal Ca
Normal PO4
Paget’s X ray
Cotton wool skull
V shaped defect in long bones
Paget’s disease treatment
Bisphosphonates
+ vit D and Ca supplementation on bisphosphonates
NSAIDs for pain
ABCD2 score
48h risk of stroke post TIA Age >60 (1) BP >140/90 (1) Clinical features - dysphasia (1), +weakness (2) Durstion >60min (2), 10-60min (1) Diabetes (1)
Stroke management
Aspirin 300mg/ day for 2 weeks
Thrombolysis with alteplase within 4.5h (after CT)
TIA mx
Aspirin 300mg
+ secondsry prevention:
Clopidogrel 75mg 1x or dypiridamole 200mg 2x
Atorvastatin 80mg
Crescendo TIA follow up
Within 24h specialist assessment
ABCD2 >3 24h assessment, otherwise 1 week assessment
GCS
Eyes: none, Pain, speech, spont
Verbal: None, sounds, words, confused, orientalned
Motor: none, Extends, abnormal flexion, flexion, localises Pain, obeys commands
Subdural haemorrhage location
Bridging veins
Between dura and arachnoid
Subdural haemorrhage on CT
crescent shape
Crosses cranial sutures
Subdural haemorrhage risk factors
Elderly and alcoholic
Extradural haemorrhage location
Middle menigeal artery
Temporal/parietal region
Assoc w fx of temporal bone
Extradural haemorrhage CT
Biconvex
Does not cross cranial sutures
Extradural haemorrhage hx
Young pt
Ongoing headache
Period of improvement and rapid decline in consciousness
Subarachnoid haemorrhage location
Pia matter and arachnoid membrane
Subarachnoid haemorrhage vessel
Cerebral aneurysm rupture
Subarachnoid haemorrhage hx
Occipital headache (strenous activity) Thunderclap headache Neck stiffness Photophobia Hit on the back of head
Subarachnoid headache associations
Cocaine use Sickle cell anaemia Alcohol Smoking HTN
Ix in subarachnoid haemorrhage
CT hyperattenuation
CSF red cell count and xantochromia
Subarachnoid haemorrhage mx
Coiling or clipping of the aneurysm
Nimodipine for vasospasm
Lumbar puncture and shunt to treat hydrocephalus
CN VI palsy in MS
Internuclear ophthalmoplegia
Conjugate lateral gaze disorder
MS lumbar puncture
Oligoclonal bands
Optic neuritis features
Central scotoma
Pain
Reduced colour vision
RAPD
MS relapse treatment
Methylprednisolone 500mg PO 1x for 5 days
Or 1g IV daily 3-5d
Lower motor neurone disease
Muscle wasting
Reduced tone
Fasciculations
Reduced reflexes
Upper motor neurone disease
Increased tone
Brisk reflexes
Upgoing plantars
Management of motor neurone disease
Riluzole
Parkinson’s triad
Resting tremor
Rigidity
Bradykinesia
Parkinson’s features
Ansomnia Shuffling gait Hypomimia Asymmetrical tremor 4-6hz Worse at rest Improves with movement No change with alcohol
Levodopa
Synthetic dopamine
Peripheral decarboxylase inhibitors
Benserazide
Carbidopa
Too high dopamine se
Dskinesia (excessive motor activity)
Dystonia
Abnormal postures and exaggerated movements
Chorea
Abnormal involuntary movements (jerking and random)
Athetosis
Involuntary twisting in hands feet fingers
COMT inhibitor
Inhibits levodopa metabolism in body and brain
Slows levodopa breakdown
Dopamine agonists
SE pulmonary fibrosis
Bromocryptine
Pergolide
Carbergoline
MAO B Inhibitors
Block enzyme breaking down dopamine neurotransmitter
Selegiline
Rasagiline
Benign essential tremor tx
Propanolol (non selective beta blocker)
Primidone (anti epileptic)
Tonic clinic seizure
Prolonged post ictal Loss of consciousness Confused Drowsy Incontinence
Focal seizures characteristics
Hearing speech memory
Deja vu
Autopilot (strange things, don’t remember)
Hallucinations
Focal seizure location
Temporal
Infantile spasms
West syndrome
full body spasms
Tx prednisolone and vigabatrin
Seizure treatment
(Everything but focal)
Sodium valproate
Lamotrigine/carbamazepine
Focal
Lamotrigine/carbamazepine
Sodium valproate/levetiracetam
Absence Seizure tx
Sodium valproate or Ethosuximide
Carbamazepine se
Agranulocytosis P450 inducer (eg cocp)
Phenytoin se
Folate and vit D deficiency
Osteomalacia
Megaloblastic anaemia
Status epileptic is mx in community
Buccal midazolam
Rectal diazepam
Status epilepticus mx in hospital
O2 Check blood glucose IV access IV lorazepam 4mg (repeat after 10min) IV phenobarbital or phenytoin
Trigeminal neuralgia tx
Carbamazepine
Neuropathic pain tx
(1 at a time, if doesn’t work switch, try all 4) Amitryptyline Duloxetine Gabapentin Pregabalin
Bell’s palsy tx
Prednisolone (start within 72h)
50mg for 10days
60mg for 5 days and 5days reducing regime (10a day)
Ramsay Hunt Syndrome
Herpes zoster virus
72h prednisolone, acyclovir
Bilateral acoustic neuromas association
Neurofibromatosis type 2
Acoustic neuroma symptoms
Hearing loss
Tinnitus
Balance problems
Bromocriptine
Block prolactin secreting tumours
Somatostatin analogue (ocreotide)
Block growth hormone secreting tumours
Huntingtons genetics
AD On chromosome 4 Trinuckeotide repeat disorder mutation in HTT gene Anticipation
What is anticipation
Successive generation have more repeats of the gene
- earlier onset age
- increased severity of disease
Drugs to manage huntingtons symptoms
Antipsychotic (olanzapine)
Benzodiazepines (diazepam)
Dopamine depleting (tetrabenazine)
Myasthenia gravis antibodies
Acetylcholine receptor antibodies 85%
Muscle specific kinase antibodies 10% (make up the receptor)
LRP4 abs (5%)
Edrophonium test
IV 10mg of endrophonium chloride / neostigmine
Stops breakdown of acetylcholine and relieves weakness
Atropine 0.6mg IV to reverse
Myasthenia gravis treatment
Acetylcholinedterase inhibitors (neostigmine, pyridostigmine)
Or monoclonal:
Rituximab, eculizumab
Myasthenic crisis tx
IVIG
Plasma exchange
Lambert Eaton associations
Small cell lung cancer
Proximal muscles affected
Diplopia, ptosis, dysphagia
Lambert Eaton treatment
Amifampridine - allows more Ach to be released in junction synapses
Charcot Marie tooth genetics
AD
Charcot Marie tooth characteristics
High foot arch/ pes cavus Inverted champagne bottle legs Loss of ankle dorsiflexion Weak hands Reduced muscle tone Peripheral neuropathy
Gillian barre triggers
-affects PNS
Clampylobacter jejuni
CMV
EBV
Gullain barre ix
CSF raised protein
Nerve conduction reduced
NF1 genetics
AD
chromosome 17
NF1 diagnostic criteria
Cafe au lait (6 spots >15mm) Relative with NF1 Axillary/inguinal freckles Bony dysplasia, bowing of bones Iris hamartomas Neurofibromatomas Glioma of optic nerve
NF2
Chromosome 22
AD
—> leads to development of Schwannomas and acoustic neuromas
NF 2 associations
Bilateral acoustic neuromas
Tuberous sclerosis genetics
TSC1 gene chromosome 9 - hamartin
TSC2 gene chromosome 16 - tuberin
Hamartin and tuberin control cell growth
Skin signs of tuberous sclerosis
Ash leaf spots Shagreen patches Angiofibromas Cafe au lait Poliosis \+ epilepsy and developmental delay
Migraine acute and long term management
Acute: paracetamol, sumatriptan 50mg, nsaid, metoclopramide for vomiting
Long: propanolol, topiramate (teratogenic, cleft lip and palate), amitriptyline
Migraine around menstruation tx
NSAIDs
Or
Frovatriptan
Zolmitriptan
Cluster headache acute and long term mx
Acute: high flow O2, sumatriptan 6mg subcut
Long term: veramapil, lithium, prednisolone
Glaucoma
Optic nerve damage due to rise in intraocular pressure
IOP
10-21mmHg
Start treatment in >24mmHg
Risk factor for glaucoma
Black ethnic
Age
Myopia/ near sight
Glaucoma tx
Latanoprost
Timolol
Dorzolamide
Brimonidine
Latanoprost
Prostaglandin analogue eye drops
Increase uveoscleral outflow
Eyelash growth
Eyelid and iris pigmentation
Timolol
B blocker
Reduce aqueous humour production
Dorzolamide
carbonic anhydrase inhibitor
Reduce aqueous humour production
Brimonidine
Sympathomimetic
Reduce aqueous fluid production and increase uveoscleral flow
Medications precipitating close/acute angle glaucoma
Noradrenalin
Oxybutynin
Solifenacin
Amitryptyline
Close angle glaucoma immediate management
Lie on the back
Pilocarpine eye drop (pupil contatriction)
Acetazolamide PO 500mg (carbonic anhydrase, reduces aqueous humour production)
Close angle glaucoma 2* care
Pilocarpine Acetazolamide Hyperosmotics (mannitol, glycerol) Timolol Dorzolamide Brimonidine
Age Related Macular Degeneration presentation
Reduced visual acuity Wavy appearance of straight lines Worsening of central vision -drusen -scotoma -amsler grid
Dry AMD tx
Lifestyle
Stop smoking
Control BP
Wet AMD
anti VEGF injected into vitreous chamber (ranibizumab, bevacizumab, pegaptanib)
Diabetic retinopathy pathophysiology
Blot haemorrhage
Hard exudates
Cotton wool spots
Micro aneurysm
Small bulges in blood vessels due to weakness
Venous beading
Walls of vessels no longer straight, string of beads or sausages
Cotton wool spots
Nerve fibre damage - white fluffy patches
Retinopathy management
Laser photocoagulation
Anti VEGF ranibizumab, bevacizumab
Silver wiring/ copper wiring
Walls of arterioles are thickened and sclerosed
Av Nicking
Arterioles compress veins when they cross over
Cataract
Lens of the eye becomes cloudy and opaque
Cataracts presentation
Worsening vision
Change in colour vision (colours more brown/yellow)
Starburts around lights
Loss of red reflex
Dilated pupil
Horner adie
Raised icp
3rd nerve palsy
Anticholinergics
Constricted pupil
Horner syndrome
Argyll Robertson pupil
Opiate
Nicotine
3rd CN palsy (oculomotor)
Ptosis
Dilated pupil
Down and out
Horner syndrome
Ptosis
Miosis
Anhidrosis
+ enophthalmos/ sunken eye
Anhidrosis - pre ganglionic
- Face anhidrosis
Cervical rib
Pancoast tumour
Trauma
Anhidrosis central
- Face arm trunk Syringomyelia Stroke MS Swelling (tumour)
Post ganglionic Anhidrosis
No Anhidrosis
Carotid aneurysm
Carotid artery dissection
Cavernous sinus thrombosis
Holmes Aldie pupil
dilated pupil, slow to react to light, slow dilatation
Holmes aldie syndrome
Holmes aldie pupil
Ankle and knee reflexes absent
Test for Horner syndrome
Cocaine (stops noradrenaline reuptake) - normal dilates, affected no reaction
Adrenaline eye drop - will dilate affected pupil but no reaction in normal
Hordeolum externum
stye
Gland of zeis/ moll infection at base of eyelashes
Hordeolum internum
Meibomian glands infection, pointing inwards towards the eyeball
Chalazion
Mebomian gland blockage and swelling
Hot compress and analgesia
Chloramphenicol if acutely inflamed
Trichiasis
Inward growth of eyelashes
Preorbital cellulitis
Infection of eyelid and skin in front of the ortbital septum
Orbital cellulitis
Infection around the eyeball involving tissues behind the orbital septum
- pain on movememt
- proptosis
- reduced vision
- abnormal pupil reactions
Episcleritis vs scleritis
Episcleritis painless
Scleritis painful
Conjunctivitis mx
Cool water eye cleaning
Chloramphenicol and fusidic acid drops
Neonatal conjunctivitis
Gonococcal infection
Anterior uveitis genetics
HLA B27
Ankylosing spondylitis
IBD
reactive arthritis
Anterior uveitis mx
Steroid (oral topical Iv)
Immunosuppressants (dmard and TNF inhibitor)
Cycloplegic-mydriatic - dilate pupil to reduce pain (cyclopentolate, atropine)
Corneal abrasion in contact lenses
Pseudomonas infection
Corneal abrasion complication
Herpes keratitis (antiviral treatment)
Corneal abrasion /herpes keratitis diagnosis
Fluorescein stain - ulcer /abrasion
Keratitis
Inflammation of the cornea
Bacterial keratitis causes
Pseudomonas or staphylococcus
Viral keratitis
Herpes simplex keratitis
Herpes keratitis fluorescein
Dendritic corneal ulcer
Herpes keratitis tx
Acyclovir (topical or oral)
Ganciclovir eye gel
Sensorineural hearing loss caused by drugs
Loop diuretics (furosemide) Aminoglucoside antibiotics (gentamicin) Chemotherapy drugs (cisplatin)
Causes of prebyscusis
(Sensorineural hearing loss) Loss of hair cells in cochlea Loss of neurons in cochlea Reduced endolymph Atrophy of stria
Sensorineural hearing loss tx
Cochlear implants
Sudden sensorineural hearing loss
Over 72h
Loss of 30 decibels in 3 consecutive frequencies
Sudden sensorineural hearing loss tx
Steroids (oral, intratympanic)
Eustachian tube dysfunction mx
Valsava manouvre (blow closed nose)
Decongestant nasal spray
Surgery (grommet, ballon dilatation)
Otosclerosis
Remodelling of small bones of middle ear - bone hardening
AD pattern
Onset <40yo
Conductive hearing loss
Hearing loss at low frequencies
Otosclerosis
Conductive hearing loss mx in otosclerosis
Hearing aids
Surgery - stapedectomy or stapedotomy
Bacterial cause of otitis media
Step pneumoniae
Other:
Hem influenza
Moraxella catarrhalis
Staphylococcus aureus
Otitis media tx
Amoxicillin 5-7d
Clarithromycin (in penicillin allergic)
Erythromycin (in pregnant and allergic to penicillin)
Otitis externa bacterial causes
Pseudomonas auerginosa
Staph aureus
Otitis externa hearing loss
Conductive
Pseudomonas auerginosa
Gram -ve aerobic rod shaped bacteria
Colonises in lungs in CF
Tx with aminoglycosides (gentamicin), quinolones (ciprofloxacin)
Otitis externa tx
Mild: acetic acid 2% Moderate: topical abx + steroid - neomycin, dexamethasone, acetic acid -neomycin and bethamethasone - gentamicin and hydrocortisone - ciprofloxacin and dexamethasone Severe: oral abx flucloxacillin or clarithromycin
Ototoxic drugs
Aminoglycosides (gentamicin and neomycin)
Toxic if get past tympanic membrane
Must exclude perforated tympanic membrane
Fungal otitis externa tx
Clotrimazole ear drops
Malignant otitis externa findings
Granulation tissue
Malignant otitis externa tx
Admission
Imaging
IV abx
Methods of removing ear wax
Ear drops (olive oil, sodium bicarbonate 5%)
Ear irrigation
Microsuction
Primary tinnitus
Occurs with sensorineural hearing loss
BPPV
Calcium carbonate crystals displaced into aemicircular canals
Labirynthitis vs vestibular neuronitis
Labirynthitis causes hearing loss
Posterior circulation infarction symptoms
Vertigo
Ataxia
Diplopia
CN or limb symptoms
Cerebellar examination
Dysdiadochokinesia Ataxic gait Nystagmus Intention tremor Speech Heel to shin
Head impulse test
Shaking head left or right
Asking pt to keep looking at doctors nose
If saccades, PERIPHERAL vertigo
Nystagmus test
Quick look right to left (repeat)
Unilateral horizontal: PERIPHERAL cause
Bilateral vertical: CENTRAL cause
Central vertigo treatment
Referral, CT MRI
Peripheral vertigo tx
Prochlorperazine
Antihistamine
Meniere disease Tx
Betahistine
Vestibular migraine tx
Triptans
Propanolol/ topiramate/ amitryptyline long term
BPPV symptoms
Vertigo attacks 20-60 sec
asymptomatic in between
Over several weeks
No tinnitus or hearing loss
Vestibular neuronitis
Vestibular nerve inflammation
Inner ear parts
Semicircular canals
Vestibule
Cochlea
Semicircular canals role
Detect head rotation
Otolith organs role
Detect gravity and linear acceleration
Labirynthitis LOSS of hearing
Neuronitis NO loss of hearing
Tinnitus and hearing loss - Labirynthitis or Menieres disease
Nausea and balance - vestibular neuronitis
Vestibular neuritis and Labirynthitis treatment
Prochlorperazine
Antihistamines (cyclizine, promethazine)
Meningitis complication
Hearing loss
Meniere disease triad
Hearing loss Vertigo Tinnitus - unilateral - symptoms 20min-couple hours - low frequency sensorineural hearing loss
Cholesteatoma
Squamous epithelial cells abnormal collection in middle ear
Choelsteatoma presentstion
Foul discharge
Unilateral conductive hearing loss
Nosebleed management
Nasal packing (tampons or inflatable packs)
Nasal cautery with silver nitrate
Then 4x day for 10 days - naseptin nasal cream (chlorhexidine, neomycin)
Naseptin components and contraindication
Chlorhexidine and neomycin
Cd: peanut or soya allergy
Acute sinusitis
If symptoms not impoving after 10d
High dose nasal spray 14d (momethasone 200mcg 2x daily)
Delayed abx prescription if not improved after 7d (phenoxymethylpenicilline)
Nasal polyps unilateral
Concern for malignancy, specialist referral
Samter’S triad
Nasal polyps, asthma, aspirin intolerance/allergy
Nasal polyps apperance
Pale grey/yellow growth on mucosal wall
Apnoea assessment
Epworth sleepiness scale
Tonsilits bacterial cause and tx
Group A step (streptococcus pyogenes)
- penicillin V / phenoxymethylpenicillin
Or strep pneumonia Other causes: Haemophilius ibfluenza Moraxella catarhhalis Staphylococcus aureus
Centor criteria - probability of bacterial tonsilitis
3 or more (40-60%) Fever 38*C Tonsilar exudates Absence of cough Lymphadenopathy
FeverPAIN score
4-5 score (62-65%)
- Fever in previous 24h
- Pus on tonsilitis
- Attend within 3 days of symptoms
- Inflamed tobsils (severely inflamed)
- No cough or coryza
When to prescirbe abx?
Centor >= 3
FeverPAIN >= 4
Tonsilitis tx
Penicillin V 10 day Course
Or
Clarithromycin for penicillin allergy
Peritonsillar abscess cause
Strep pyogenes (group A Strep)
Staph aureus
Haemophilius influenzae
Quinsy treatment
Co amoxiclav
Incision and drainage
Tonsilectomy indications
7 tonsilitis in 1y
5 tonsilitis in 2y
3 tonsilitis in 3y
Post tonsilectomy bleeding management
Hydrogen peroxide gargle
Adrenalin soaked swab
Re - surgery
Thyroid lump
Moves with swallowing
Thyroglossal cyst
Movement when sticking tongue out
Bronchial cyst
Transluminates with light
Anterior triangle
EBV and abx
Maculopapular rash in response to amoxicilin and cefalosporin
Hodgkin lymphoma node biopsy
Reed Sternberg cell
Thyroglossal cyst
Mobile
Non tender
Soft
Fluctuant
Lipoma
Mobile
Soft
Painless
No skin change
Branchial cyst
Round Soft Cystic swelling Transluminate with light Anterior to SCM
Glossitis causes
Iron deficiency
B12, folate deficiency
Coeliac disease
Oral candidiasis treatment
Miconazole gel
Nystatin suspension
Fluconazole tablets
Leuko and erythroplakia
Leuko - white patches
Erythro - red lesions
Precancerous changes, increasing risk of squamous cell carcinoma
Aphthous ulcers treatment
Topical:
Choline salicylate
Benzydamine
Lidocaine
Topical corticosteroids - severe:
Hydrocortisone buccal tablets
Bethamethasone soluble tablets
Beclomethasone inhaler spray
VTE prophylaxis in hip/knee
LMWH 28d post hip, 14d post knee replacement
Or aspirin, rivaroxaban, stockings
Prostethic joint infection organizm
Staphylococcus aureus
Children fracture types
Salter Harris ONLY in children
Greenstick
Buckle fracture
Cancers that metastasise to the bone
PoRTaBLe Prostate Renal Thyroid Breast Lung
FRAX tool
Measures pt’s risk of fragility fracture over 10 years
Tx for preventing fragility fractures
Calcium and vit D
Bisphosphonates (alendronic Acid) - alternstive with monoclonal ab Denosumab-
Bisphosphonates side effects
Osteonecrosis of jaw or external auditory canal
Reflux and oesophageal erosion
Atypical fractures
Non displaced intra capsular fx tx
Internal fixation
Displaced intra capsular fx tx
Hemiarthroplasty - elderly, co morbidities, mobility issues
Total hip replacement - young, walk independently
Extra capsular fx
Intertrochanteric fx
Subtrochanteric fx
Intertrochanteric fx tx
Dynamic hip screw
Subtrochanteric fx tx
Intramedullary nail
Hip fx presentation
Shortened, abducted, externally rotated leg
Disruption of Shenton line
NOF fx
Acute limb ischaemia
PULSELESS limb
Acute compartment syndrome
Pain - disproportionate, worsened by passive movememt Paraesthesia Pale High pressure Paralysis
Osteomyelitis
Inflammation of bone and bone marrow due to bacterial infection
Most common cause of osteomyelitis
Staph aureus
Acute osteomyelitis treatment
6 weeks of flucloxacillin
with rifampicin/fusidic acid added for first 2 weeks
Clindamycin if penicillin allergy
Vancomycin or teicoplanin if MRSA
Most common bone cancer
Osteosarcoma
Kaposi sarcoma cause
HHV 8
Most common sarcoma metastasis
Lungs
Sciatic nerve roots
L4 - S3
Exits pelvis through greater sciatic foramen
Then divided into tibial and common peroneal nerve
Thomas test
Flexibility of hip flexors (eg iliopsoas muscle group)
Long term back ache tx
Duloxetine
Amitryptyline
Cauda equina
Compression of cauda equina nerve roots L3-S5
Cervical cancer Red flag
IMB
PCB
Primary amenorrhoea
Not starting period by 13yo when no other pubertal development
Not starting period by 15yo when there are other signs of puberty
Normal puberty dates/events
Girls 8-14 with Breast buds then pubic hair
Boys 9-15
Hypogonadotrophic hypogonadism
LH and FSH deficiency so no stimulation for ovaries to produce sex hormones
Causes of hypogonadotrophic hypogonadism
Hypopituitarism CF Delay in growth and development Growth hormone deficiency Hypothyroidism Cushing Hyperprolactinemia Kallman syndrome
Kallman syndrome
Hypogonadotrophic hypogonadism
Ansomnia
Hypergonadotrophic hypogonadism
Gonads fail to respond to gonadotropins (LH FSH)
Hypergonadotrophic hypogonadism
Previous gonads damage (torsion, cancer, mumps)
Congenital absence of ovaries
Turner syndrome XO
Congenital adrenal hyperplasia symptoms
FEMALE with: Tall Facial hair Primary ammenorhoea Deep voice Early puberty
Androgen insensitivity syndrome
Males
Male sexual characteristics do not develop
Results in female phenotype, female external genitalia, absent uterus/vagina/fallopian tubes/ovaries
GH deficiency screening
ILGF low = low GH
Hypogonadotrophic hypogonadism tx
(Eg hypopituitarism or Kallman syndrome)
Treat with pulsatile GnRH (induce menstruation and ovulation)
Replacement sex hormones (cocp - induce menstruation)
Secondary amenorrhoea
No menstruation >3m if previous regular periods
No menstruation 6-12m if previous irregular
Pituitary causes of secondary amenorrhoea
Pituitary tumour (prolactinoma) Pituitary failure (Sheehan syndrome)
Drugs to reduce prolactin production
Bromocriptine
Cabergoline
Dopamine agonists (cabergoline bromocriptine)
Treat hyperprolactinemja
Parkinson’s
Acromegaly
Primary ovarian failure bloods
High FSH
PCOS bloods
High LH
High LH:FSH ratio
Raised testosterone conditions
PCOS
Androgen insensitivity syndrome
Congenital adrenal hyperplasia
Reducing osteoporosis risk in pts with amenorrhoea
Vit D and Calcium
Hormone replacement therapy
PMS
Symptoms during luteal phase
These are progesterone induced
PMS mx
Healthy lifestyle
COCP (drospirenone)
SSRI
CBT
Physical symptoms of PMS tx
Brest swelling
Water retention
Bloating
- spironolactone
Cyclical breast pain tx
Danazole, tamoxifen
Menorrhagia
Heavy menstrual bleeding (>80ml)
Menorrhagia mx (no contraception)
Tranexamic acid - if no pain (antifibrynolytic reduced bleed)
Mefenamic acid - pain (NSAID reduce bleed and pain)
Menirrhagia mx contraception
Mirena coil IUS
COCP
Cyclical oral progestogens (norethistone 5mg 3x daily days 5-26)
Fibroid
Benign tumour of uterus smooth muscle
They grow in response to oestrogen
Fibroid types
Intramural
Submucosal
Subserosal
Pedunculated
Fibroids <3cm mx
IUS mirena
NSAID/ tranexamic acid
COCP
Cyclical legal progestogens
Surgical options for fibroids <3cm
Endometrial ablation
Resection during hysteroscopy
Hysterectomy
Fibroids >3cm mx
Referral to Gynae NSAID/ tranexamic acid Mirena coil IUS COCP cyclical progestagen
Uterine artery embolisation
Myomectomy
Hysterectomy
How to reduce fibroid size?
GnRH agonist before surgery
Goserelin (Zoladex)
Leuprorelin (Prostap)
Induce ovulation-like state
Uterine artery embolisation
Blockage of arterial supply to fibroids causes them to shrink
Malignant change of fibroid
Leiomyosarcoma
Red degeneration
Ischaemia and necrosis if fibroid due to disrupted blood supply (occurs in larger fibroids >5cm)
Fibroid enlarges quickly in 2nd and 3rd trimester and outgrows it’s blood supply so it dies
Red degeneration hx
Severe abdominal pain Low grade fever Tachycardia Vomiting \+history of fibroids Tx: test fluid analgesia
Endometriosis
Ectopic endometrial tissue outside the uterus
Endometrioma
Lump of endometrial tissue outside uterus
- in ovaries these are called chocolate cysts
- within the myometrium: adenomyosis
Risk factors for adenomyosis
Multiparous
Later reproductive years
Adenomyosis symptoms
Dysmenorrhea
Menorhhoagia
Dyspareunia
Gold standard ix for endometriosis and adenomyosis
Endometriosis - laparoscopy
Adenomyosis - hysterectomy with histological examination
Adenomyosis tx
Same as endometriosis and heavy menstrual bleeding
Premature menopause
Before age of 40
Result of premature ovarian insufficiency - lack of ovarian follicular function
- Low oestrogen and progesterone
- LH and FSH High
Lack of oestrogen risks
Osteoporosis Pelvic organ prolapse Urinary incontinence CVD Stroke
Symptoms of lack of oestrogen
Hot flashes Low mood PMS irregular and heavy/light period Low libido Joint pains Vaginal dryness
When can menopause be diagnosed?
12 months with no periods in women >45yo
When to do FSH blood tests?
<40 yo with suspected menopause
40-45yo with symptoms or change in menstruation
Contraception and menopause
For 2 years after LMP of <50yo
For 1 year after LMP >50yo
Depo - Provera (progesterone depot injection) SE
Weight gain
Reduced bone density / osteoporosis
UNSUITABLE in >45yo
Progesterone with low risk of DVT
Norethisterone
Levonorgestrel
Primenopausal symptoms management
HRT
Tibolone (steroid hormone, continuous combined HRT)
Clonidine (agonist of alpha-adrenergic and imidazoline receptors)
Testosterone for low libido
Vaginal oestrogen or moisturiser
Premature ovarian insufficiency
Menopause <40yo
Hypergonadotrophic hypogonadism
Diagnosis of premature ovarian insufficiency
FSH raised >25/30 on 2 samples with 4 weeks apart
HRT under 50yo
Does not increase risk of breast cancer
Increased risk of VTE, but this is reduced by transdermal patch
Why progesterone must be added to contraception?
Must be given to women with uterus as it prevents endometrial hyperplasia secondary to unopposed oestrogen
Continuous or cyclical HRT
if still have periods must go on cyclical HRT with cyclical progesterone and regular breakthrough bleeds
If no periods for >12months go on continuous combined HRT
Non hormonal menopause tx
Lifestyle changes CBT SSRI Clonidine (agonist of alpha adrenergic) Venlafaxine (SNRI) Gabapentin
Clonidine
Lowers BP and HR
Alpha 2 adrenergic receptor agonists
Used to prevent vasomotor symptoms
SE dry mouth, headaches, dizziness, fatigue
Alternative remedies for menopause
Black cohosh - cause liver damage Dong quai - causes bleeding disorders Red clover - oestrogenic side effects Primrose oil - clotting disorders and seizures Ginseng- mood and sleep benefit
HRT risks (worse in older women and longer use)
Breast cancer
VTE
Stroke
Coronary artery disease
HRT risks that do not apply
To women <50yo
No risk of endometrial cancer if no uterus
No risk of breast cancer and CVD if oestrogen-only HRT
Choosing HRT formulation
1) local or systemic symptoms (topical or systemic tx)
2) uterus - combined HRT, no uterus - continuous oestrogen only HRT
3) perimenopausal - cyclical HRT, postmenopausal- continuous HRT
Cyclical progesterone use
10-14 days per month
Continuous progesterone HRT
When no period in 24months <50yo or 12 months >50yo
Progestogens definition
Chemicals that target progesterone receptors
Progesterone
Hormone naturally produced in the body
Progestin
Synthetic progesterone
Progestogen classes
C19 peogestogen derived from testosterone (norethisterone, levonorgestrel, desogestrel) - help with reduced libido
C21 progestogen derived from progesterone (dydrogesterone, medroxyprogesterone) - help with mood and acne
Best way of delivering oestrogen in HRT?
Patches, reduced VTE risk
Best way of providing progesterone in HRT?
Intrauterine device
Added benefit of contraception and treating heavy period
No progestogenic side effects or risk of breast cancer or CVD
Tibolone
Synthetic steroid
Oestrogen and progesterone receptors
Continuous combined HRT
Help with reduced libido
HRT and surgery
Stop 4 weeks before major surgery
HRT and oestrogen contraceptive
Oestrogen SE
Bloating
Breast swelling
Headache
Leg cramps
Progesterone se
Mood swings Bloating Fluid retention Acne Weight gain
Rotterdam criteria for PCOS
Anovulation
Hyperandrogenism (hirsuitisn or acne)
PCOS
Drugs causing hirsuitism
Phenytoin Cyclosporin Corticosteroids Testosterone Anabolic steroids
Pelvic ultrasound in PCOS
String of pearls - 12 or more follicles in the ovary
Ovary >10cm3
Impaired fasting glucose
6.1-6.9
Impaired glucose tolerance (at OGGT 2h)
7.8-11.1
Diabetes OGTY 2h
> 11.1
Drugs to induce fertility/ovulation
Clomifene
Metformin/letrozole