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Key concepts Flashcards

1
Q

Beck’s Triad

Found in Cardiac Tamponade

A

Fall in BP

Rise in JVP

Muffled heart sounds

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2
Q

Eating Disorders

  • Atypical (most common)
  • Binge Eating
  • Bulimia
  • Anorexia (least common; 10% mortality; 20% suicide risk)

Diagnosis:person’s history, suggestive clinical features, and supported, where possible, by corroboration from a relative or friend

Management:

  • clear agreement between primary and secondary care about responsibility for monitoring
  • Monitoring ongoing level of risk to the person’s mental and physical health and managing complications —
  • Placing an alert in the person’s prescribing record
  • ECG monitoring to people with an eating disorder who are taking medication that can compromise cardiac functioning for example drugs that may cause electrolyte imbalance, bradycardia, hypokalaemia, or a prolonged QT interval.
  • Adults - 1st line CBT-ED, Maudsley Anorexia Nervosa Treatment (MANTRA); Children - 1st line Familt therapy, 2nd line CBT
  • Giving advice on contraceptive use and pregnancy to women (LARC - implants and IUS recommended - not Depot) Ensuring the person and their family/carers have access to information and support.
A

Referral criteria for Anorexia: -

  • BMI <13
  • CVS instability,
  • hypothermia
  • metabolic and electrolyte imbalance
  • oncurrent infection, overall ill health or abnormal blood tests.
  • reduced muscle power
  • risk of refeeding syndrome.
  • lack of support at home.
  • acute mental health risk — risk of suicide attempt/ DSH
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3
Q

Pemberton Sign

Signs of Superior Vena Cava Obstruction e.g in lung cancer, thyroid goitre

A

Neck + facial erythema and oedema

More pronounced on elevation of the arms over the head

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4
Q

Erythema Nodosum

Auto-immune T III reaction

A

Behcet,

Sarcoid,

IBD,

Streptococcal infect,

TB,

OCP,

Other drugs

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5
Q

Quadrantanopia

Lesion is on the opposite Parietal or Temporal site

A

PITS

Parietal - Inferior

Temporal - Superior

Visual field om opposite side is affected

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6
Q

Polymyalgia Rheumatica (PMR)

A
  • > 50 years-old
  • at least 2 weeks of bilateral shoulder and/or pelvic girdle pain

and

  • stiffness lasting for at least 45 minutes after waking or periods of rest
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7
Q

Fibromyalgia

A

11 tender points in the body - 9/11 points should be positive

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8
Q

Ischemic stroke

A
  • Aspirin 300 mg daily for 2 weeks

then,

  • clopidogrel 75 mg daily long-term (life-long if Stroke with AF - give Warfarin)
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9
Q

Neuropathic Pain Mx

A

Amitriptyline, Duloxetine, Gabapentin or Pregabalin

Switch drugs - don’t add

Tramadol - rescue therapy for exacerbations

Topical Capsaicin- FRUIT Extract for localised neuropathic pain

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10
Q

Ovarian mass/ lump

Most common

Benign - Follicular cyst

Malignant - Serous Adenocarcinoma

A

Types:

Germ cell tumours

  • Yolk Sac tumours (endodermal sinus tumour)- S_A_C Schiller Duval bodies, raised AFP, children
  • Dysgerminomas: DysGERMANoma - German flag (Raised LDH and HCG)
  • Teratoma - TERROR toma - monster - all kinds of tissues

Sex cord stromal tumour

  • Fibroma (Meig’s Syn)
  • Sertoli Leydig tumour: Virilisation due yo raised Androgens, Reinke Crystals (LeDIG for Crystals!)
  • Granulosa Theca Call Tumour = Raised Estrogen, Call-Exner bodies (Gran Exner)

Others

  • Brenner tumour (Bladder like)
  • Krukenberg: metastasises from gut to ovary
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11
Q

Vomiting in neonate

A

Duodenal atresia - within few hours of birth (double bubble sign)

Meconium ileus - 24 - 48 hrs after birth

Necrotising enterocolitis - after 2 weeks, premature

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12
Q

Screening programmes in NHS -1

  1. Antenatal - diabetes (preconception, 28 weeks, anaemia at 16 weeks incl Hbinopathy, infection (HIV, Hep B and syphilis), FASP (10 -20 weeks; scan +/- blood tests), diabetic eye screen of T1DM and T2DM
  2. Neonatal: NIPE (72 hrs; eye, heart, hips, testes); heel prick/ blood spot (5 - 8 days; 9 disease - SCD, CF, CHT, PKU, MCAACD, MSUD, IVA1, GA1, HCU); Hearing (6-8 weeks; OAER/ AABR)
  3. Chlamydia - opportunistic; men and women <25 years, urine or swabs for females
  4. Cervical - cervical smear, 25-49 yrs women 3 yearly then 50-64 yrs 5 yearly
A

Screening programmes in NHS -2

  1. Breast - Mammogram; 47-73 yrs women (50 - 70 yrs); 3 yearly
  2. Bowel - FOB, 2 yrly; men and women 60 - 74 yrs
  3. Aortic Aneurysm - Ultrasound for men at 65 years
  4. Diabetes Eye screening - annual all T1 and T2 DM
  5. No screening for Prostate/ Ovarian Ca
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13
Q

Respiratory infections and common pathogens

A

Common cold - rhinovirus

Flu - influenza virus

Epiglottis - Haemophilus influenza B (HiB)

Bronchiolitis - Respiratory syncytial virus

Croup - parainfluenza virus

Bonchiectasis exarcebations - Hib

Pneumonia

  • post flu: staphylococcus aureus
  • community-acquired pneumonia: mycoplasma
  • atypical pneumonia - Mycoplasma (flu-like, precedes dry cough & complications - haemolytic anaemia erythema multiforme); Legionella (A/C spread, lymphopaenia, hyponatraemia, and deranged LFT); Pneumocystis jiroveci in HIV+ (few chest signs - hilar interstitial infiltration and exertional dyspnoea). Mycobaterium TB - Cough, night sweats and weight loss, Klebsiella - apical and cavitating, associated with Alcohol misuse
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14
Q

Antipsychotic Drugs - Typical (old)

  • Haloperidol
  • Chlorpromazine

Side Effects:

Extra- Pyramidal e.g. Parkinsonisim, Tardive dyskinesia

Acute dystonia e.g. oculogyric crisis

Thromboembolism

Hyperprolactinaemia

A

Antipsychotic - Atypical (New drugs)

Quetiapine, Risperidone, Olanzapine, Clozapine

Side Effects: • Weight gain • Agranulocytosis • Hyperprolactinaemia • Stroke & thrombolembolism in elderly, amisulpride, aripiprazole

Clozapine causes:

agranulocytosis (1%), neutropaenia (3%), reduced seizure threshold - can induce seizures in up to 3% of patients, constipation, myocarditis: a baseline ECG should be taken before starting treatment, hypersalivation

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15
Q

School exclusions

A
  • Measles: 4 days
  • Mumps & Rubella: 5 days
  • Chicken Pox: Till all the lesions have crusted
  • Scarlet fever: 24 hrs after abx
  • Whooping cough: 48 hrs after abx
  • Impetigo: 48 hrs after starting abx or after crusting
  • Diarrhoea: 48 hrs after recovery
  • Hand foot and mouth, head lice: No exclusion
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16
Q

Ecstasy poisoning

Ecstasy aka MDMA, aka 3,4-Methylenedioxymethamphetamine

c/f: • Hyperthermia • Agitation, anxiety, confusion, ataxia • tachycardia, hypertension • hyponatremia • rhabdomyolysis

A

Supportive

Dantrolene for hyperthermia

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17
Q

Key features of atypical pneumonia

Mycoplasma A - dry cough, flu, auto-haemolytic anaemia, erythema multiforme

Klebsiella - Alcoholism, red-currant jelly sputum, cavitating in upper lobe

Legionella - AC, travel hx, lymphopenia, low sodium, abnormal LFT

Pneumocystis jiroveci - HIV +

Chlamydia psittaci - Birds, parrots

Tuberculosis (TB) - weight loss, fever, night sweat, cough with sputum

A

Treatment of atypical pneumonia

Mycoplasma - erythromycin

Klebsiella - erythromycin

Legionella - erythromycin

Pneumocystis jiroveci - co-tromoxazole

Chlamydia psittaci - erythromycin

TB - RIPE for 4/12, then RI for 2/12

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18
Q

Angina

breathlessness on exertion

Causes: Ishaemia, valvular ds (AS), HTN, HOCM

Types: Stable or Unstable

Referral to Specialist: if no relief on BB + CCB, worsening symps, unstable angina

A

Mx:

  1. Quit smoking,
  2. Cardioprotective diet,
  3. physical activity within limitation
  4. healthy weight
  5. alcohol use within limits
  6. Anti-anginal medication: sublingual GTN for rapid relief or before activity that triggers, beta blocker or calcium channel blocker - singly first, them switch to other, then combine, long acting nitrates - isosorbide, nicorandil, ivabradine, ranolazine - third drug while awaiting specialist review and cardiac revascularisation
  7. secondary protection = aspirin 75 mg, ACE inhibitor, statin, control of HTN +/- DM
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19
Q

Contraindications to COC use

4 point scale

UKMEC 1: no restriction

UKMEC 2: benefits outweigh the risks

UKMEC 3: risks outweigh benefits

UKMEC 4: unacceptable health risk

A

Relative contraindications to COC (UKMEC3)

> 35 years and smoking <15 cigarettes/day

BMI > 35 kg/m^2*

family hx of VTE disease in first degree relatives < 45 years

controlled hypertension

immobility e.g. wheel chair use

carrier of known gene mutations of breast cancer (e.g. BRCA1/BRCA2)

current gallbladder disease

Absolute contraindications to COC use (UKMEC4)

> 35 years and smoking <>5 cigarettes/day

Liver ds - cirrhosis, malignancy

migraine with aura

history of thromboembolic disease or thrombogenic mutation

history of stroke or ischaemic heart disease

breast feeding < 6 weeks post-partum

uncontrolled hypertension

current breast cancer

major surgery with prolonged immobilisation

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20
Q

Aspirin use in pregnancy

A
  • Mother age above 40 years & first pregnancy
  • FHx of eclampsia
  • BMI above 35
  • 10 yrs age between pregnancies
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21
Q

Types of Hypersensitivity reactions

A

A - Allergen, Atopy, Asthma, Allergic rhinitis, Anaphylaxis - IgE, basophils & mast cells - Rapid (<30’) - TYPE I

C - Cytotoxic - Complement mediated (csmooth deposition) activated by IgG/ IgM - GoodPasture’s, Myasthenia, AHA, Graves’, Intravascular reaction, Blood transfusion reaction - TYPE 2

I - Immunecomplex mediated, Ag and IgG & IgM form complexes (lumpi + bumpi) deposits, Tissue Damage RA, Erythema nodosum - Post streptococcal GN, SLE - TYPE 3

D - Delayed Cytotoxic - cell mediated, CD8 + killer cells - Lymphocyte, T-cells; 48-72 hrs later - Diabetes, dermatitis, Tuberculin test (Mantoux’s), contact dermatitis, graft - TYPE 4

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22
Q

Medical conditions notifiable to DVLA

Group 1 - car and motorcycles

Group 2 - lorries, heavy vehicles, buses

  • diabetes taking insulin
  • syncope (fainting) and sudden dizziness, Meniere’s disease - till symptoms in control
  • heart conditions (including AF and pacemakers eg implanted defibrillator
  • sleep apnoea
  • epilepsy
  • strokes & TIA
  • glaucoma
A

hypertension: drive unless treatment causes unacceptable side effects, no need to notify DVLA - if Group 2 driver disqualified from driving if resting SBP consistently >180 mmHg or DBP > 100 mm Hg

angioplasty (elective) - 1 week off driving

CABG - 4 weeks off driving

acute coronary syndrome- 4 weeks off driving - 1 week if successfully treated by angioplasty

angina - driving must cease if symptoms occur at rest/at the wheel

pacemaker insertion - 1 week off driving

implantable cardioverter-defibrillator (ICD) - if implanted for sustained ventricular arrhythmia - stop driving for 6 months; if implanted prophylactically then cease driving for 1 month. Having an ICD results in a permanent bar for Group 2 drivers

successful catheter ablation for an arrhythmia - 2 days off driving

aortic aneurysm of 6cm or more - notify DVLA. Licensing will be permitted subject to annual review; an aortic diameter of 6.5 cm or more disqualifies patients from driving

heart transplant: do not drive for 6 weeks, no need to notify DVLA

1st seizure: 6 mth no driving, with established epilepsy till fit free for 12 months

Multiple TIA’s - 3 mth no driving

Stroke: 1/12 no driving

Craniotomy: 1 yaer of driving

Pituitary tumour - 6 mth off driving

Narcolepsy/ cataplexy: stop driivng on diagnosis

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23
Q

Drug Causes of Pernicious Anaemia

Auto-immune

Severe Vit B12 deficiency

A

PPI

H2 receptor antagonist

Metformin

Colchicine

Nitrous Oxide

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24
Q

Immunisation for those born before 2020

2 mth: 6 in 1, rotavirus, PCV, Men B

3 mth: 6 in 1, rotavirus

4 mth: 6 in 1, PCV, Men B

12 - 15 mth: MMR, Hib/MenC, Men B, PCV

3 - 4 yrs: pre-school 4 in 1 (DTP, polio), MMR

2 - 11 yrs: annual flu (LAIV - fluenz tetra; live)

12 - 13 yrs: HPV x 2 dose 6-24 mth apart

14 yrs: pre-university (DT, polio), Men ACWY

Pertussis: Pregnancy 28 - 32 weeks

A

Immunisation for those born after 2020

2 mth: 6 in 1, rotavirus, Men B

3 mth: 6 in 1, rotavirus, PCV

4 mth: 6 in 1, PCV, Men B

12 - 15 mth: MMR, Hib/MenC, Men B, PCV

3 - 4 yrs: pre-school 4 in 1 (DTP, polio), MMR

2 - 11 yrs: annual flu (LAIV - fluenz tetra; live)

12 - 13 yrs: HPV x 2 dose 6-24 mth apart

14 yrs: pre-university (DT, polio), Men ACWY

Pertussis: Pregnancy 28 - 32 weeks

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25
Q

Benzylpenicillin Dose in suspected Meningitis

A

< 1 year - 300 mg im/iv

1 - 10 years - 600 mg im/iv

>10 years - 1200 mg im/iv

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26
Q

Febrile convulsions in Children

Lasts 3 - 6 mins; tonic-clonic

May be simple (recovers in 10’, no recurrence in 24 hrs) or complex (lasts > 15’, recurs in <24 hrs, focal s/s)

d/d: epilepsy, hypoglycaemia, brain injury, apnoea, rigors, syncope, meningitis, encephalitis

referral criteria: < 18 mths old; first seizure, diagnostic uncertainty, complex seizures, parental anxiety, recently taken abx

A

Febrile convulsions

Treatment

  • Midazolam buccal/ rectal diazepam
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27
Q

Diagnosing Diabetes

  • Fasting glucose >7.0 mmol/ l
  • Random or After oral 75 gm glucose > 11.1 mmol/ l
  • done once in symptomatic patient and x 2 in asymptomatic
  • HbA1C > 48 mmol/l
A

Impaired Fasting Glucose: FBS 6.1 - 7 mmol/ l

Impaired Glucose Tolerance: FBS < 7.0 mmol/l and OGTT 2-hour > 7.8 and above

Pre-diabetes: HbA1 C 42 - 47 mmol/ l

Diabetes: 48 mmol/ l

Blood Sugar Control targets

On metformin alone 48 mmol/ l

On insulin or combined drug producung hypoglycaemia 53 mmol/l

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28
Q

2 WW - Referral Criteria

https://www.nice.org.uk/guidance/ng12/resources/suspected-cancer-recognition-and-referral-pdf-1837268071621

  • Suspected Oral Ca: Unexplained oral ulceration >3weeks; Lump on lip or in mouth, ?erythroplakia (red or red+white patch), Erythroleukoplakia; Persistent unexplained neck lump
  • Suspected Laryngeal Ca: >=45 years PLUS Persistent unexplained hoarseness/ Unexplained neck lump
  • Suspected ENT Ca: unilateral symptoms or unilatetal nasal polyp
  • Suspected Lung Ca: chest X-ray findings that suggest lung cancer OR =>40years AND unexplained haemoptysis

URGENT CXR criteria (=>40 yrs over AND =>2 or more of unexplained symptoms, or if they have ever smoked and have 1 or more of the unexplained symptoms: cough, fatigue, SOB, chest pain, weight loss, appetite loss, finger clubbing

  • Suspected Breast Ca: Aged =>30 years AND Unexplained breast/ axillary lump +/- pain; Aged =>50 years AND Unilateral discharge, retraction, other concerning changes like skin changes
  • Suspected Oesophageal Ca: Dysphagia in >= 55 yrs PLUS weight loss AND upper abdominal mass, pain +/- reflux
  • Suspected Stomach Ca: Dysphagia AND Aged >=55 with weight loss and upper abdo pain, reflux, dyspepsia
  • Suspected Pancreatic Ca: Aged >=40 + jaundice OR Aged >=60 with weight loss and diarrhoea, back pain, abdo pain, nausea, vomiting, constipation, new diabetes
A

2 WW - Referral Criteria

  • Suspected Colorectal Ca: Aged >=40 PLUS Unexplained weight loss + abdo pain; Aged <50 AND Rectal bleeding, abdo pain, change in bowel habit, weight loss, IDA; Aged >=50 PLUS Unexplained rectal bleeding; Aged >=60 PLUS Iron deficiency anaemia/ Changed in bowel habit, Any age AND FOBT +ve or Rectal/abdominal mass
  • Suspected Anal Ca: Unexplained anal mass or Unexplained anal ulceration

Suspected Ovarian Ca: Ascites, Pelvic or abdo mass, USS suggestive ovarian cancer and raised Ca 125

Suspected Endometrial Ca: Aged >=55 with PMB or increased ET

Suspected Cervical Ca: On examination, appearance of cervix consistent with cervical cancer

Suspected Vulval Ca: Unexplained vulval lump, ulceration or bleeding

Suspected Vaginal Ca: Unexplained palpable mass in entrance to vagina

Suspected Prostate Ca: Feels malignant on DRE; PSA over age-specific range

Suspected Bladder Ca: >=45 AND Unexplained visible haematuria without UTI or after successful treatment of UTI or >=60 AND Unexplained non-visible haematuria AND dysuria with raised serum WCC

Suspected Renal Ca: Aged >=45 + unexplained visible haematuria without UTI or after successful treatment of UTI

Suspected Testicular Ca: Non-painful enlargement/change in shape or texture of testis

Suspected Penile Ca: Penile mass/ulcer with STI excluded or STI treated

Suspected Melanoma: Major features scoring 2 points each with change in size, irregular shape, irregular colour. Minor features of the lesions (scoring 1 point each): largest diameter 7 mm or more, inflammation, oozing, change in sensation.

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29
Q

Tests in Upper Limb

Hoffman’s sign - sign of UMN dysfunction due to degenratice cervical myopathy.

(Hoffman)-Tinel’s sign (wrist): paraesthesia on tapping at wrist in medial nerve distribution in carpal tunnel syndrome:

Phalen’s sign: Forced dorsiflexion of wrists in carpal tunnel syndrome

Finkelstein’s test: De Quervain’s tenosynovitis (gamer’s wrist or berry thumb) - pulls the thumb of the patient in ulnar deviation and longitudinal traction - pain over lateral styloid process.

Mill’s test: Lateral epicondilytis (tennis elbow)

Forced extension of the wrist with a supinated and extended forearm: Medial epicondilytis (Golfer’s elbow)

A

Tinel test (ankle) tapping in front and behind medial malleolus to check for compression/ damagetp ant tibial and post tibial nerve respectively.

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30
Q

Mental Health Act (supercedes Mental Health Capacity Act)

Sectioning to admit/ treat > 16 yrs old not agreed voluntarily and at risk to self and others (under influence of alcohol/ drugs excluded)
Section 2

admit for assessment for up to 28 days, not renewable; applied to by AMHP or NR on the recommendation of 2 doctors, one ‘approved’ under Section 12(2) of the Mental Health Act (usually a consultant psychiatrist); treatment can be given against a patient’s wishes
Section 3

admit for treatment for up to 6 months, can be renewed, AMHP along with 2 doctors, both have seen the patient <24 hours; treatment can be given against a patient’s wishes
Section 4

72 hour assessment order in emergency, when delays with section 2; a GP and an AMHP or NR; changed to a section 2 upon arrival at hospital
Section 5(2)

voluntary patient in hospital - legally detained by a doctor, for 72 hours
Section 5(4)

allows a nurse to detain a patient who is voluntarily in hospital, for 6 hours

A

Section 17a

Supervised Community Treatment Order (CTO); used to recall a patient to hospital for treatment if they do not comply with conditions of the order in the community.
Section 135

a court order to allow police to break into property to remove a person to Safety
Section 136

someone found in a public place who appears to have a mental disorder can be taken by the police to a Place of Safety; can only be used for up to 24 hours, whilst a Mental Health Act assessment is arranged

31
Q

Functional Somatic Disorders

Somatisation disorder

multiple physical SYMPTOMS since 2 years, patient refuses to accept reassurance or negative test results

Hypochondriasis
persistent belief in the presence of an underlying serious DISEASE, e.g. cancer; patient refuses to accept reassurance or negative test results

Conversion disorder

involves loss of motor/ sensory function, the patient doesn’t consciously feign/ seek material gain

A

Dissociative disorder

‘separating off’ memories from normal consciousness, dissociative identity disorder (DID) is the new term for multiple personality disorder; intentional production of physical or psychological symptom. Has psychiatric symptoms of amnesia, fugue, stupor

Factitious disorder - patient feigns illness, Munchausen’s syndrome - describes the intentional production of symptoms, for example self poisoning

Malingering patient seek material gain by pretending to be ill

32
Q

Drugs that can cause agranulocytosis

A

Antipsychotics (predominantly Clozapine)

Antiepileptics

Antithyroid Drugs (Carbimazole)

Antibiotics (Penicillin, Chloramphenicol and Co-Trimoxazole)

Cytotoxic Drugs

Gold

NSAIDs (Naproxen, Indomethacin)

Allopurinol

Mirtazapine

33
Q

Delusions

A
  • *Othello syndrome** - belief that partner is committing infidelity despite no evidence.
  • *De Clerambault syndrome (erotomania)**, - believes that a person of a higher social/ professional standing is in love with them.
  • *Ekbom syndrome** is also known as delusional parasitosis and is the belief that they are infected with parasites or have ‘bugs’ under their skin.
  • *Capgras delusion** - belief that friends/ family members have been replaced by an identical looking imposter.
34
Q

Drugs causing hyponatraemia

A

Diuretics (especially thiazides),

SSRIs

Antipsychotics - haloperidol

NSAID

Carbamazepine.

35
Q

Autosomal Dominant Conditions -1

achondroplasia

acute intermittent porphyria

adult polycystic kidney disease

antithrombin III deficiency

benign congenital hypotonia

Charcot-Marie-Tooth disease

cleft hand

cleidocranial dysostosis

diaphyseal aclasis

dysplastic naevi syndrome

Ehlers-Danlos syndrome (EDS)

fascioscapulohumeral muscular dystrophy

familial hypocalciuric hypercalcaemia

familial medullary thyroid carcinoma

familial triglyceridaemia

Gilbert’s disease

Hayley-Hayley disease

hereditary pancreatitis

hereditary haemorrhagic telangiectasia

Holt-Oram syndrome

hereditary elliptocytosis

hypertrophic cardiomyopathy

hereditary spherocytosis

Huntington’s disease

idiopathic hypoparathyroidism

medullary adenocarcinoma of the thyroid

mucosal neuroma

Machado-Joseph disease

oculopharyngeal muscular dystrophy

intestinal polyposis

A

Autosomal Dominant Conditions - 2

Marfan’s syndrome

myotonia congenita

multiple epiphyseal dysplasia

marble bone disease

neurofibromatosis

osteogenesis imperfecta type I - mild disease

osteogenesis imperfecta type IV - moderately severe disease

Noonan’s syndrome

osteogenesis imperfecta

retinoblastoma

Peutz-Jegher’s syndrome

protein C deficiency

Sipple’s syndrome

Sturge-Weber syndrome

tuberous sclerosis

Treacher-Collins syndrome

variegate porphyria

von Hippel-Lindau syndrome

von Willebrand’s disease (congenital deficiency of von Willebrand’s factor )

Wermer’s syndrome

Marfan’s syndrome

myotonia congenita

multiple epiphyseal dysplasia

marble bone disease

neurofibromatosis

osteogenesis imperfecta type I - mild disease

osteogenesis imperfecta type IV - moderately severe disease

Noonan’s syndrome

osteogenesis imperfecta

retinoblastoma

Peutz-Jegher’s syndrome

protein C deficiency

Sipple’s syndrome

Sturge-Weber syndrome

tuberous sclerosis

Treacher-Collins syndrome

variegate porphyria

von Hippel-Lindau syndrome

von Willebrand’s disease (congenital deficiency of von Willebrand’s factor )

Wermer’s syndrome

36
Q

Autosomal Recessive - 1

oculocutaneous albinism

5 alpha reductase deficiency

abetalipoproteinaemia

alkaptonuria

alpha -1 - antitrypsin deficiency

apo C-II deficiency

Bartter’s syndrome

cystinosis

cystinuria

Bloom’s syndrome

Crigler-Najjar syndrome

congenital adrenal hyperplasia

factor XI deficiency

familial amaurotic idiocy

cystic fibrosis

Dubin-Johnson syndrome

galactosaemia

Gaucher’s disease (GD)

hereditary haemochromatosis (HH)

homocystinuria

infantile polycystic kidney disease

Laron type dwarfism

A

Autosomal Recessive - 2

microcephaly (autosomal recessive)

ochronosis

osteogenesis imperfecta type II - perinatal lethal

Kugelberg-Welander disease

Hurler syndrome

polyglandular autoimmune syndrome I

limb girdle dystrophy

methaemoglobinaemia

Pendred’s syndrome

Laurence-Moon-Biedl syndrome

marble bone disease

pseudoxanthoma elasticum

Prader-Willi syndrome

phenylketonuria

Refsum’s disease

Smith-Lemli-Opitz syndrome

spinal muscular atrophy

Rotor’s syndrome

severe combined immunodeficiency disease

sickle cell anaemia

Tay-Sachs disease

thalassaemia

vitamin D dependent rickets type I

Werdnig-Hoffman disease

Wilson’s disease

xeroderma pigmentosum

Zellweger syndrome

37
Q

X linked Recessive

adrenoleukodystrophy

Alport’s syndrome

Becker muscular dystrophy

colour blindness

Duchenne muscular dystrophy

glucose-6-phosphate dehydrogenase deficiency

haemophilia

idiopathic hypoparathyroidism

Lesch-Nyhan syndrome

severe combined immunodeficiency disease

X-linked ichthyosis

X-linked agammaglobulinaemia of Bruton

A
38
Q

Causes of Neonatal Jaundice

First 24 hrs:

Causes of jaundice in the first 24 hrs

rhesus haemolytic disease

ABO haemolytic disease

hereditary spherocytosis

glucose-6-phosphodehydrogenase deficiency

Day 2 - 14

Physiological jaundice

A

Causes of Neonatal Jaundice

Prolonged jaundice

  • biliary atresia
  • hypothyroidism
  • galactosaemia
  • urinary tract infection
  • breast milk jaundice
  • congenital infections e.g. CMV, toxoplasmosis
39
Q

Gross Development Milestones

A
  • 3 mths: Little/ no head lag on being pulled to sit, lying on abdomen with good head control, Held sitting, lumbar curve
  • 6 mths: Lying on abdomen, arms extended, lying on back, lifts and grasps feet, pulls self to sitting, held sitting, back straight, rolls front to back
  • 7-8 mths: Sits without support (Refer at 12 months)
  • 9 mths: Pulls to standing, crawls
  • 12 mths: Cruises, walks with one hand held
  • 13-15 mths: Walks unsupported (refer at 18 months)
  • 18 mths: Squats to pick up a toy
  • 2 yrs: Runs, walks upstairs and downstairs holding on to rail
  • 3 yrs: Rides a tricycle using pedals, walks up stairs without holding on to rail
  • 4 yrs: Hops on one leg
40
Q

Speech Milestones

A
  • 3 mths: Quietens to parents voice, turns towards sound, squeals
  • 6 mths: Double syllables ‘adah’, ‘erleh’
  • 9 mths: ‘mama’ and ‘dada’, nderstands ‘no’
  • 12 mths: Knows and responds to own name
  • 12-15 mths: Knows about 2-6 words (Refer at 18 months), understands simple commands - ‘give it to mummy’
  • 2 yrs: Combine two words, points to parts of the body
  • 2½ yrs: Vocabulary of 200 words
  • 3 yrs: Talks in short sentences (e.g. 3-5 words), asks ‘what’ and ‘who’ questions, identifies colours, counts to 10 (little appreciation of numbers though)
  • 4 yrs: Asks ‘why’, ‘when’ and ‘how’ questions
41
Q

Strokes

A
  • Anterior cerebral artery: Opposite side hemiparesis, sensory loss, LL > UL
  • Middle cerebral artery: Opposite side hemiparesis, sensory loss, UL > LL, Opposite side homonymous hemianopia, Aphasia
  • Posterior cerebral artery: Opposite side homonymous hemianopia with macular sparing, visual agnosia
  • Weber’s syndrome (branches of the posterior cerebral artery that supply the midbrain): Same side CN III palsy, weakness of upper and lower extremity
  • Posterior inferior cerebellar artery (lateral medullary syndrome, Wallenberg syndrome): Ipsilateral facial pain and temperature loss, Contralateral: limb/torso pain and temperature loss, Ataxia, nystagmus
  • Anterior inferior cerebellar artery (lateral pontine syndrome): Symptoms are similar to Wallenberg’s (see above), but: Ipsilateral: facial paralysis and deafness
  • Retinal/ophthalmic artery: Amaurosis fugax
  • Basilar artery: ‘Locked-in’ syndrome
42
Q

Poisoning Management

Paracetamol: Activated charcoal if < 1 hour ago, N-acetylcysteine (NAC), liver transplantation

Salicylate: urinary alkalinization with IV bicarbonate, haemodialysis

Opioid/opiates: Naloxone

Benzodiazepines: Mainly supportive only, Flumazenil - risk of seizures only used with severe/ iatrogenic overdoses.

Tricyclic antidepressants: IV bicarbonate - reduces risk of seizures and arrhythmias in severe toxicity; for arrhythmias - class 1a (e.g. Quinidine) and class Ic antiarrhythmics (e.g. Flecainide) are contraindicated as they prolong depolarisation; Class III drugs such as amiodarone should be avoided as they prolong the QT interval. Response to lignocaine is variable and it should be emphasized that correction of acidosis is the first line in management of tricyclic induced arrhythmias; dialysis is ineffective in removing tricyclics

Lithium: for mild-moderate toxicity volume resuscitation with normal saline, haemodialysis needed when severe, sodium bicarbonate is sometimes used - increasing the alkalinity of urine, promotes lithium excretion

Warfarin: Vitamin K, prothrombin complex

Heparin: Protamine sulphate

Beta-blockers: If bradycardic then atropine, in resistant cases glucagon may be used

A

Poisoning Management

Ethylene glycol: ethanol -used for many years, works by competing with ethylene glycol for the enzyme alcohol dehydrogenase - this limits the formation of toxic metabolites (e.g. Glycoaldehyde and glycolic acid) which are responsible for the haemodynamic/metabolic features of poisoning, fomepizole, an inhibitor of alcohol dehydrogenase, is now used first-line in preference to ethanol, haemodialysis also has a role in refractory cases

Methanol poisoning: Fomepizole or ethanol, haemodialysis

Organophosphate insecticides: atropine the role of pralidoxime is still unclear - meta-analyses to date have failed to show any clear benefit

Digoxin: Digoxin-specific antibody fragments

IronDesferrioxamine, a chelating agent

Lead: Dimercaprol, calcium edetate

Carbon monoxide: 100% oxygen, hyperbaric oxygen

Cyanide: Hydroxocobalamin; also combination of amyl nitrite, sodium nitrite, and sodium thiosulfate

43
Q

Causes of Dysphagia

A

Extrinsic

  • Mediastinal masses
  • Cervical spondylosis

Oesophageal wall

  • Achalasia
  • Diffuse oesophageal spasm
  • Hypertensive lower oesophageal sphincter

Intrinsic

  • Tumours
  • Strictures
  • Oesophageal web
  • Schatzki rings

Neurological

  • CVA
  • Parkinson’s disease
  • Multiple Sclerosis
  • Brainstem pathology
  • Myasthenia Gravis
44
Q

Contraindication to thrombolysis after MI

Thrombolysis done with streptokinase

A
  • Any bleeding/ trauma/ operation/ dental extraction
  • Coma
  • Pericarditidis
  • Pulmonary cavitation
  • Pancreatitis
  • Peptic Ulcer
  • Oesophageal varices
  • Endocarditis
  • Severe HTN
  • Aortic aneurysm/ Aortic dissection
  • Coagulation defect
  • Bacterial endocarditis
  • Bleeding disorders
45
Q

Learning Difficulty Classification

Based on IQ

A
  • Mild IQ 50-69
  • Moderate IQ 35 - 49
  • Severe IQ 20 - 34
  • Profound. IQ <20
46
Q

Classification of Obesity

Based on BMI

A
  • Normal BMI 18.5 - 24.9
  • Overweight BMI 25 - 29.9
  • Obesity Grade 1 BMI 30 - 34.9
  • Obesity Grade 2 BMI 35 - 39.9
  • Obesity Grade 3. BMI > 40
47
Q

Causes of Hyperprolactinaemia

A
  • Physiological - pregnancy, puerperium, excessive exercise
  • Endocrine - Hypothyroidism, Cushing’s syndrome
  • Metabolic - Chronic Renal Failure
  • Tumours - Pituitary adenomas
  • Traumatic - Head Injury, brain surgery
  • Drugs - Risperidone, Metoclopromide, Domperidone, Tricyclic Antidepressant
48
Q

Autoimmune Disease Association with MHC Antigens

https://www.immunopaedia.org.za/immunology/advanced/10-antibody-mediated-autoimmune-diseases/

Addison’s disease DR3 RR 6

Ankylosing spondylitis B27 RR 70 - 100

Behcet’s syndrome B51 RR 3–6

Celiac disease. DR3, DQA1*0501, DQβ1*0201 RR > 200

Congenital adrenal hyperplasia. B47 RR 15

Dermatitis herpetiformis. DR3 RR 15–18

Goodpasture syndrome DR2 RR 16–20

Graves’ disease DR3 RR 4

A

Autoimmune Disease Association with MHC Antigens

Hashimoto’s disease. DR11 RR 3

Hereditary hemochromatosis A3/B14 RR 90

Insulin-dependent diabetes mellitus B35, Cw04 RR 1–3

Idiopathic membranous glomerulonephritis DR3 RR 12

Multiple sclerosis. DR2, DQ6 RR 5–12

Myasthenia gravis DR3 RR 10

Narcolepsy DR2, DQβ1*0602. RR 130

Psoriasis vulgaris. Cw613

Pemphigus vulgaris. DRβ1*0402-DQβ1*0302 RR 14–21

DRβ1*1401-DQβ1*0503

Rheumatoid arthritis. DR4 RR 4–10

Systemic lupus erythematosus DR3 RR 3–6

Sarcoidosis DRβ1*1101 RR 1.5–3.6

49
Q

Autoimmune Disease and AutoAntibody

https://youtu.be/bXecMhv-ZzE

Systemic Antibodies:

Antinuclear Antibodies (ANA) - SLE

Antineutrophil Cytoplasmic Antibodies (ANCA) - Vasculitis affecting lungs and kidneys (Wegener’s, polyangitis, polyarteritis)

Anti-Double Stranded DNA (anti-dsDNA): SLE

Anticentromere Antibodies (ACA): Limited scleroderma (CREST syndrome)

Antihistone Antibodies: Drug induced SLE

Cyclic Citrullinated Peptide Antibodies (CCP) - Rheumatoid Arthritis

Extractable Nuclear Antigen Antibodies e.g., anti-SS-A (Ro) and anti-SS-B (La) - in Sjogren’s syndrome, anti-RNP (ribonucleic proteins) like anti-Jo-1 (anti-tRNA synthetase in polymyositis/ dermatomyositis), anti-Sm, anti -Scl-70 (also called anti-DNA Topoisomerase 1 - found in diffuse scleroderma), Anti PM1 in polymyositis, Anti C-anca in Wegener’s ds, Anti U1RNP in Mixed connective tissue ds

Rheumatoid Factor (RF) also called Anti IgG - in Rheumatoid Arthritis.

A

Organ-specific autoantibodies

Clotting (coagulation) system

  • Cardiolipin Antibodies
  • Beta-2 Glycoprotein 1 Antibodies - Antiphospholipid Syndrome
  • Glycoprotein IIb/IIIa: Immune thrombocytopenic purpura
  • Antiphospholipid Antibodies (APA)
  • Lupus anticoagulants (LA)

Endocrine/metabolic system

  • Islet Autoantibodies in Diabetes
  • Anti-glutamate debarboxylase - T1DM

Gastrointestinal tract

  • Anti-Tissue Transglutaminase (anti-tTG), Anti-Gliadin Antibodies (AGA) & Anti-endomysial - Coeliac disease (there is deficiency og IgA in 3% of patients)
  • Intrinsic Factor Antibodies
  • Parietal Cell Antibodies

Thyroid

  • Anti-Thyroid Peroxidase, TSH receptor antibodies - Graves Disease
  • Anti-microsomal & Anti-thyroglobulin - Hashimoto’s disease

Liver

  • Smooth Muscle Antibodies (SMA) and F-actin Antibody - Autoimmune Hepatitis
  • Antimitochondrial Antibodies (AMA) and AMA M2 - Primary Biliary Cirrhosis
  • Liver Kidney Microsome Type 1 Antibodies (anti-LKM-1)
  • Kidney*
  • Anti-Glomerular Basement Membrane (GBM) - Goodpasture’s Syndrome
  • Muscles*
  • Acetylcholine Receptor (AChR) Antibodies - Myasthenia gravis
  • Skin*
  • Anti-Desmoglein - Pemphigus Vulgaris
50
Q

Drugs affecting coagulation

Anti-platelet

Anti coagulants

Thrombolytics

A

Anti-platelets

  • Aspirin - inhibits COX1 and so inhibit thromboxane release
  • Clopidogrel, ticagrelor, prasugrel, ticlopidine - Inhibit P2Y12 receptors for ADP binding
  • Abciximab, eptifibatide, tirofimab -GPIIb/IIIa inhibitors (prevent fibrinogen cross-linking - can be given iv
  • Dipyridamole, cilostazole -Phosphodiesterase inhibitors - raise cAMP and promote vasodilation

Anti-coagulants

  • Heparin - inactivates both Xa and thrombin formation by binding to antithrombin IIIa
  • Enoxaparin, dalteparin (LMWH) - accelerate inactivation of Xa by binding to antithrombin III a
  • Fondaparinux - directly accelerates inactivation of Xa
  • Apixaban, rivaroxaban - bind to active site of Xa and prevent conversion of prothrombin to thrombin- oral
  • Argatroban, dapigatran - univalent binding (Xa receptor), direct thrombin inhibitor
  • Bivalirudin, desirudin - bivalent binding (Xa and prothrombin exosite receptor), direct thrombin inhibitor
  • Warfarin - reduces activation of II, VII, IX & X through inhibition of Vit K epoxide reductase, INR, narrow therapeutic index, antidote vit K

Thrombolytics

Alteplase, Reteplase, Tenecteplase

Urokinase, Streptokinase

Antidotes: Protamine sulphate, Vit K, aminocaproic acid, tranexamic acid

51
Q

Side/ Adverse effects of Drugs

Antibiotics:

Amoxicillin: diarrohoea, nausea, non allergic rash

Azithromycin - hearing loss and tinnitus

Doxicycline - photosensitivity, skin rash - DRESS, Stevens Johnson Syndrome

Gentamicin: nephrotoxicity (acute tubular necrosis), ototoxicity (irreversible auditory or vestibular nerve damage)

Macrolides like clarithromycin, erythromycin: prolongation of the QT interval, GI side-effects, Nausea is less common with clarithromycin than erythromycin, cholestatic jaundice: risk may be reduced if erythromycin stearate is used, P450 inhibitor (see below)

Metronidazole: metallic taste, nausea, disulfiram like reaction

Mefloquine: Neuropsychiatric

Proguanil:

Quninine:

Chloroquin:

Isoniazid: Peripheral neuropathy, headache

Rifampicin: orange urine, p450 inducer

Ethambutol: Optic neuritis

Pyrizinamide:

CVS:

Amiodarone: corneal deposits, photosensitivity (grey slate), hypo - and hyperthyroidism, pulmonary fibrosis, deranged LFT, peripheral nephropathy, low K (pre rx tests - CX`R, LFT, U &E, TFT; after 6/12 TFT & LFT)

Verapamil: Ca Channel Blocker (CCB) - Heart failure, constipation, hypotension, bradycardia, flushing, heart block if when given with Beta blocker (BB)

Diltiazem: Ca Channel Blocker (CCB - Hypotension, bradycardia, heart failure, ankle swelling, Caution with heart failure or BB

Amlodipine, Nifidepine, Felodipine (CCB) - Flushing, headache, ankle swelling, gingival hyperplasia, diarrhoea

Beta blockers - bisoprolol: peripheral coldness due to vasoconstriction, hypotension and bronchospasm, erectile dysfunction

Digoxin: Yellow/ Orange vision

Bendroflumethiazide:

Beta blockers - bisoprolol: peripheral coldness due to vasoconstriction, hypotension and bronchospasm

CNS

Lithium: increased thirst, polyuria, metallic taste, fine tremor, weight gain

Mirtazapine - shows noradrenergic and serotonergic activity -drowsiness, increased appetite, dry mouth, or constipation, agitation, aggression and forgetfulness - not to use mirtazapine with buspirone, fentanyl lithium tryptophan, St. John’s wort, or migraine/pain medicines (triptans, tramadol), best to stop drinking alcohol

Sodium Valproate: hair loss, nausea, diarrhoea, weight gain, drowsiness, suicidal thoughts, inhibits P450

Phenytoin - Gingival hyperplasia

Phenobarbital

Sodium Valproate

Carbamazepine

Ethosuximide

Hormonal

Tamoxifen: Hot flushes, Amenorrhoea, PV bleeding, Endometrial Ca, Alopecia, cataracts, VTE (Raloxifene - less endometrial Ca)

Goserelin: hot flashes (flushing), dizziness, headache, increased sweating, increased or decreased sexual interest, impotence, fewer erections than usual, trouble sleeping, nausea, breast swelling or tenderness, vaginal dryness/itching/discharge, hair loss, mental/mood changes (such as depression, mood swings, hallucinations)

injection site reactions (pain, bruising, bleeding, redness, or swelling), bone pain, diarrhea, constipation, sleep problems (insomnia), acne, or skin rash or itching

Sildenafil (Viagra): Blue vision, nasal congestion, flushing, GI side - Other drugs - tadalfil, vardenafil

A

(contd)

ACE inhibitors: hypotension, renal dysfunction, dry cough

Angiotensin II Receptor Blockers

Clopidogrel: GI symptoms, bleeding

Sulfasalazine (DMARD) - oligospermia, Stevens-Johnson syndrome, pneumonitis / lung fibrosis, myelosuppression, Heinz body anaemia, megaloblastic anaemia, may colour tears → stained contact lense

Methotrexate: Myelosuppression, Liver cirrhosis, Pneumonitis

Leflunomide: Liver impairment, Interstitial lung disease, Hypertension

Hydroxychloroquine: Retinopathy, Corneal deposits

Prednisolone: Cushingoid features, Osteoporosis, Impaired glucose tolerance, Hypertension, Cataracts

Cyclosporin: gingival hyperplasia

Azathioprine - bone marrow depression, nausea/vomiting, pancreatitis, increased risk of non-melanoma skin cancer

Gold: Proteinuria

Penicillamine: Proteinuria, Exacerbation of myasthenia gravis

Etanercept: Demyelination, Reactivation of tuberculosis

Infliximab: Reactivation of tuberculosis

Adalimumab: Reactivation of tuberculosis

Rituximab: Infusion reactions are common

NSAIDs (e.g. naproxen, ibuprofen): Bronchospasm in asthmatics, Dyspepsia/peptic ulceration

Cimedidine

Ranitidine

Ondansteron

Alpha-1 antagonists e.g. tamsulosin, alfuzosin - dizziness, postural hypotension, dry mouth, depression

5- alpha reductase inhibitor - Finasteride: erectile dysfunction, reduced libido, ejaculation problems, gynaecomastia

Isoretinoin: dry skin, hair loss, hyperlipidaemia,

52
Q

Causes of Clubbling

A

Respiratory - Lung cancer, abscess, bronchiectasis, empyema, Interstitial lung disease,fibrosing alveolitis, cystic fibrosis

Cardiac - atrial myxoma, congenital heart disease, infective endocarditis

GI - Inflammatory bowel disease, Coeliac disease, Primary Biliary Cirrhosis, GI myxoma

Miscellaneous - pregnancy, familial, thyroid acropachy, congenital

53
Q

NYHA Classification of Heart failure

A

Class 1 - No limitation of physical activity, comfortable with physical activity

Class 2 - Slight limitation of physical activity, comfortable at rest, symptom with ordinary activity

Class 3 - Marked limitation of physical activity, comfortable at rest, symptom with less than ordinary activity

Class 4 - Inability to do any physical activity without symptoms

54
Q

P450 System of Drug Metabolism

Inducers: enhance metabolism and clearance, reduce effectiveness

Inhibitors: Delay metabolism, increase therapeutic conc, increase side/ adverse effects

CYP 1A2 - AcetAminophen

CYP 2E1 - Alcohol

CYP 2C9 - Warfarin

CYP 2D6 - CVS drugs

CYP 3A4 - most common

A

P450 Inducers: P450 Inhibitors

Carbamazepine Valproate

Rifampicin Ketoconazole

Alcohol Isoniazid

Phenytoin Sulphonamide

Griseofulvin Chloramphenicol

Phenobarbital Amiodarone

Sulphonylureas Erythromycin

Quinidine

Grapefruit Juice

CRAP GPS induces rage

VK IS CA EQG

55
Q

Clinical Tests for MSK conditions

Lachman - Anterior Cruciate Liament Injury

Finkelstein

Trendelenburg

McMurray

Babinsky

Faber

Thomson’s - achilles tendon rupture

Barlow

Ortolani

Tinel

A
56
Q

Clinical Scores

APGAR: assesses health of newborn at birth - (Appearance, Pulse, Grimace, Activity, Respiration)

CHA2DS2-VaSC: risk of stroke in AF patients. CHF, HTN, Age (65-74 & >75), Diabetes, Stroke/TIA, Vascular ds, sex

HAS BLED: risk of bleeding in patients of AF on anticoagulant. HTN, abnormal LFT/ RFT, Stroke, bleeding, labile INR, elderly, drugs (NSAID, aspirin, clopidogrel) or alcohol use > 8 units/ week

NYHA: Severity of heart failure (1 - 4 increasing severity)

CURB 65: Risk scoring for pneumonia severity for inpatient/ outpatient Rx, Confusion, urea > 19mg/dl (7 mmol/l), RR >30, BP <90/60 for site of care, severity of pneumonia & choice of abx

Glasgow Coma Scale:

Wells Score for DVT

Wells Score for PE

Child Pugh Score: Assesses severity of liver cirrhosis

DAS 28: Disease Activity Score in RA

Ranson Criteria: For Acute Pancreatitis (G-A-L-L/ E-T-O-H - Glucose, Age > 55, Leucocytes, LFT; Electrolytes - low Ca, Third spacing - raised urea, hypovolemia, Oxygen low, Haematocrit

IPSS: Intenational Protate Symptom Score

Gleason Score - Prognosis in Prostate Ca

Waterlow Score: Risk of developing pressure sore

FRAX: estimation of 10 year of developinh osteoporosis related fracture

A

Epworth: Assess obstructive sleep apnoea

MMSE (Mini mental state examination), assess cognitive impairment

AMTS: Abbreviated Mental Test Score to rapidly assess elderly patients for the possibility of dementia.

HAD: Hospital anxiety & Depression scale, assess severity of anxiety depressionPatient Health Questionnaire, assess severity of depression

GAD - 7: Screening generalised anxiety disorder

PHQ-9: Patient Health Questionnaire to assess severity of depression

Edinburgh Postnatal Depression Scale: Screen for PND

SCOFF: To detect Eating disorder and aid treatment

AUDIT: Alcohol misuse screening

CAGE: Alcohol misuse screening

FAST: Alcohol misuse screening

57
Q

Conversion of Opiate Dose

A

Oral morphine to Subcutaneous morphine - Divide by 2

Oral morphine to Subcutaneous diamorphine - Divide by 3

Oral oxycodone to Subcutaneous diamorphine - Divide by 1.5

Oral codeine to Oral morphine - Divide dose by by 10

Oral tramadol to Oral morphine - Divide by 10

Oral morphine to Oral oxycodone - Divide by 1.5-2

Transdermal fentanyl 12 mcg patch = 30 mg oral morphine/ d

Transdermal buprenorphine 10 mag patch = 24 mg oral morphine/d

58
Q

Paraneoplastic syndromes

Paraneoplastic syndromes - group of rare disorders triggered by abnormal immune system response to neoplasm.

Happens when cancer-fighting antibodies or white blood cells (known as T cells) mistakenly attack normal cells in the nervous system

Progressive neurological damage.

No cures

Stage of cancer at diagnosis determines outcome.

A

Gastric Ca - Acanthosis Nigricans

Lung Ca

Small Cell - Hyponatraemia(SIADH); SVC syndrome, Eaton Lambert Syn, Cushing syn (inc ACTH), carcinoid (flushing&diarrhoea)

Squamous cell - Hypercalcaemia (PTH rp), Horner’s syn (ptosis, miosis & anhydrosis), Pancoast’s tumour - T1&2 nerve, shoulder pain & ulnar nv pain)

Large Cell - SVC syn, gynaecomastia

Adenoca - Pulmonary osteoarthropathy,

Breast Ca -

Ovarian Ca -

Lympatic system Ca - Hodgkin’s disease (PCD)

Testicular cancer (brainstem and limbic encephalitis),

Neuroblastoma (opsoclonus–myoclonus).

59
Q

Strokes

80% ischaemic

20% haemorrhagic

A

Anterior cerebral artery: Contralateral hemiparesis and sensory loss, lower extremity > upper

Middle cerebral artery: Contralateral hemiparesis and sensory loss, upper extremity > lower
Contralateral homonymous hemianopia, Aphasia

Posterior cerebral artery: Contralateral homonymous hemianopia with macular sparing,Visual agnosia

Weber’s syndrome (branches of the posterior cerebral artery that supply the midbrain): Ipsilateral CN III palsy
Contralateral weakness of upper and lower extremity

Posterior inferior cerebellar artery (lateral medullary syndrome, Wallenberg syndrome): Ipsilateral: facial pain and temperature loss, Contralateral: limb/torso pain and temperature loss, Ataxia, nystagmus

Anterior inferior cerebellar artery (lateral pontine syndrome): Symptoms are similar to Wallenberg’s (see above), but:
Ipsilateral: facial paralysis and deafness

Retinal/ophthalmic artery: Amaurosis fugax

Basilar artery: ‘Locked-in’ syndrome

60
Q

Delusions

A

Capgras - belief that friends/ family members have been replaced by an identical looking imposter

Othello - belief that partner is committing infidelity

Cotard - belief that insides are rotting as one is deceased

De Clerambault (erotomania), belief that a person of a higher social/ professional standing is in love with them

Ekbom - belief that they are infected with parasites or have ‘bugs’ under their skin - delusional parasitosis

61
Q

NICE Traffic light system for disease in children

  1. Colour
  2. Activity
  3. Respiration
  4. Hydration & Circulation
  5. Others
A

Green – low risk

Amber – intermediate risk

Red – high risk

Colour

(of skin, lips or tongue)

• Normal colour

Activity

• Responds

normally to

social cues

Content/smiles

Stays awake

or awakens

quickly

Strong normal

cry/not crying

• Pallor reported by parent/carer

social cues

No smile

Wakes only with prolonged

stimulation

Decreased activity

  • Pale/mottled/ashen/ blue
  • Not responding normally to
  • No response to

social cues

Appears ill to a

healthcare

professional

Does not wake or if

roused does not

stay awake

Weak, high-pitched

or continuous cry

Respiratory

• Nasal flaring • Tachypnoea:

  • RR >50 breaths/
    minute, age 6–12 months
  • RR >40 breaths/ minute, age >12 months

Oxygen saturation ≤95% in air

Crackles in the chest

Grunting

Tachypnoea:

RR >60

breaths/minute

Moderate or severe

chest indrawing

Circulation and hydration

Normal skin and eyes

Moist mucous membranes

Tachycardia:
- >160beats/minute,

age <12 months
- >150beats/minute, age 12–24 months - >140beats/minute,

age 2–5 years

CRT ≥3 seconds

Dry mucous membranes

Poor feeding in infants

Reduced urine output

• Reduced skin turgor

Other

• None of the amber or red symptoms or signs

Age 3–6 months, temperature ≥39°C

Fever for ≥5 days

Rigors

Swelling of a limb or joint

Non-weight bearing limb/not

using an extremity

Age <3 months, temperature

≥38°C*

Non-blanching rash

Bulging fontanelle

Neck stiffness

Status epilepticus

Focal neurological

signs

Focal seizures

CRT, capillary refill time; RR, respiratory rate
* Some vaccinations have been found to induce fever in children aged under 3 months This traffic light table should be used in conjunction with the recommendations in the NICE guideline on fever in under 5s.

62
Q

Causes of Mydriasis

Large pupil

  • 3rd nerve palsy
  • Holmes-Adie pupil
  • Traumatic iridoplegia
  • Phaeochromocytoma
  • Congenital
  • Drugs: topical - tropicamide, atropine; sympathomimetic drugs: amphetamines, cocaine, anticholinergic drugs: tricyclic antidepressants

Anisocoria - unequal pupils, sympathetic palsy - cortical, pre- and post ganglionic

Small pupil: Horner’s syndrome, Argyll Robertson,

A

Pupillary conditions

Marcus Gunn - both pupils dilate to swinging light

Argyll Robertson

Holmes Adie

Horner’s

Acute angle closure glaucoma Primary open angle glaucoma

63
Q

Heart Failure

ability of the heart to maintain the circulation of blood is impaired as a result of a structural or functional impairment

symptoms - SOB, fluid retention, and fatigue

signs: SOB, basal crepitations, and peripheral oedema, reduced/ preserved ejection fraction.

New York Heart Association (NYHA) functional classification.

most common underlying cause is coronary artery disease.

Complications - arrhythmias, depression, cachexia, CKD, sexual dysfunction, and sudden cardiac death.

Prognosis: 50% of people with heart failure die within 5 years of diagnosis, and about 40% of people admitted to hospital with heart failure die or are readmitted within 1 year. High levels of NT‑proBNP carry a poor prognosis

Ix:

NT‑proBNP level above 2,000 ng/litre (236 pmol/litre) - specialist assessment and transthoracic echocardiography < < 2 weeks.

NT‑proBNP level between 400 and 2,000 ng/litre (47 to 236 pmol/litre) - specialist referral and transthoracic echocardiography < 6 weeks.

Arrange 12-lead ECG for all

A

Management

A loop diuretic may - for symptom relief while awaiting specialist assessment.

To relieve symptoms of fluid overload, a diuretic should be prescribed.

To reduce morbidity and mortality - angiotensin-converting enzyme (ACE) inhibitor and a beta-blocker should be prescribed. One drug should be introduced at a time, adding the second drug once the person is stable on the first drug.

If symptomatic despite optimal treatment with an ACE-inhibitor and beta-blocker - arrange specialist referral

heart failure with preserved ejection fraction - a low to medium dose diuretic should be prescribed and specialist referral

antiplatelet drug and statin should be considered.

Comorbidities and precipitating factors should be managed.

Screening for depression or anxiety should be undertaken.

Supervised exercise-based rehabilitation programme should be offered.

Appropriate vaccinations .

Self-care advice

Nutritional status - assess.

Follow-up and advanced care planning should be offered, if appropriate.

Women of child-bearing age should be given advice about contraception and pregnancy.

64
Q

Antidepressants

Act by improving the levels of Serotonin, Dopamine, & Norepinephrine at synaptic junctions

A

Categories of Antidepressants

  • SSRI (Selective Serotononin Reuptake Inhibitors) - fluoxetine (1st choice - in young <30, Citalopram in elderly), Sertraline (in presence of Heart Conditions, in post natal depression)
  • SNRI (Serotonin and Norepinephrine Uptake) Inhibitors: Duloxetine, Venlafaxine
  • TCI (Tricyclic Inhibitor Antidepressants): Amitrptiline, Desipramine, imipramine
  • MAOI (Monoamine Oxidase Inhibitor): Selegeline, phenelzine, Isocarboxazid
  • NDRI (Norepinephrine and Dopamine Reupdake Inhibitors): Bupropion
  • Tetracyclics - Mirtazapine; stops neurotransmitters from binding to receptors
  • (SARI) Serotonin Antagonist and reuptake inhibitors; Nefaxodone, trazodone
65
Q

Acute Coronary syndrome

Non STEMI

STEMI

https://youtu.be/TBG9Jw3yd9I

A

NSTEMI - Subendocardial infarct - ST depression

STEMI - Transmural infarct - ST elevation

Anteroseptal - Left anterior descending - V1-V4

Inferior - Right coronary - II, II, aVF

Anterolateral - Left ant descending/ left circumflex - V4-V6, I, aVL

Lateral - Left Circumflex - 1, aVL, +/- V5-6

Posterior - left circumflex, right coronary - Tall R waves in V1-2

T/t - initial M-O-N-A: Morphine, Oxygen if sats < 94%, Nitrates, Aspirin

then, PCI within 90%, if not possible then Thrombolysis (TPA, streptokinase, tenecteplase, ateleptase)

Long term: A-B-A-S (ACE inhibitor, Beta blocker, Aspirin+Clopidogrel, Statin)

No driving for 4 weeks after MI, No driving for 1 week after successful PCI

66
Q

Diet

  • Cardiovascular diseases
  • Coronary artery disease,
  • Hypertension
  • Heart attacks
  • Stroke.
  • Diabetics
  • GI diseases - Crohn’s disease, ulcerative colitis and celiac disease
A

Cardioprotective diet:

Anti-Diabetic diet: high fibre, high glycaemic index

Crohn’s ds: Gluten and diary free diet

IBS: low sugar, low fibre (only soluble sugar), low fat, FODMAP (fermentable oligo, di-, mono-

67
Q

Drug Side effects

Causing impaired glucose tolerance: thiazide diuretics typical antipsychotics, goserelin

Causing hypoglycaemia: Beta blockers, disopramide, pentamidine, quinine, sulphonylurea, sulphonamide, salicylates

Drugs causing hyperlipaemia: hyperlipidaemia: thiazide diuretics, beta adrenergic blockers, anabolic steroids, prednisolone, estrogens, androgens, immunosuppressive, antineoplastic, atypical antipsychotics, HIV protease inhibitors, amiodarone, cyclosporin, olanzapine

Drugs causing hyponatraemia: ACEI, Heparin, Diuretics, Antidepressants, antipsychotics, carbamazepine

Causing hyperprolactinaemia: haloperidol and chlorpromazine, atypical antipsychotics

Causing gynaecomastia: D-I-S-C-O-S Digoxin, Isoniazid, Spironolactone, Cimetidine, Oestrogen, Stilboesterol Finasteride, antipsychotics, alcohol, keoconazole, methadone

Causing erectile dysfunction: S-T-O-P SSRI, Thioridazine, Methyldopa, Propanolol

Causing osteoporosis: steroids, alcohol, antiepileptic, lithium, cytotoxic drugs, cyclosporin

A

Drugs causing psychosis: steroids,

Causing long QT: Citalopram, low K, haloperidol and chlorpromazine

Drugs causing bradycardia: beta blockers, clonidine, lithium, opiates, phenytoin, neostigminr, TCA, phenylpropanolamine, lidocaine, mexiletene, beta blockers, amiodarone, sotalol, ticagrelor

Drugs causing bronchospasm: NSAID, aspirin

Drugs causing erythema nodosum: streptococcal infections, sarcoidosis, inflammatory bowel disease and drugs (penicillins, sulphonamides, oral contraceptive pill)

Worsening Psoriasis: Alcohol, lithium, beta blockers, NSAIDs, antimalarials (chloroquine and hydroxychloroquine), ACE inhibitors, infliximab, withdrawal of systemic steroid

Causing hair loss: Isoretinoin, ACEI, lithium, heparin, allopurinol, antidepressants, chemotherapy drugs

Causing SLE: Hydralazine, Minocycline, Methadone, Procainamide, Chlorpromazine, Quinidine

Causing gout: diuretics: thiazides, furosemide, ciclosporin, alcohol, cytotoxic agents, pyrazinamide, aspirin

Causing Interstitial pulmonatry fibrosis: methotrexate, sulfasalzine

68
Q

Myocardical Infarction

https://youtu.be/TBG9Jw3yd9I

A
  • Anteroseptal - V1-V4: Left anterior descending
  • Inferior - II, III, aVF: Right coronary
  • Anterolateral - V4-6, I, aVL: Left anterior descending or left circumflex
  • Lateral - I, aVL +/- V5-6: Left circumflex
  • Posterior - Tall R waves V1-2: Usually left circumflex, also right coronary
  • Septal = V1-2
  • Anterior = V2-5
  • Extensive anterior / anterolateral = V1-6, I + aVL
69
Q

Heart Block

https://youtu.be/d8b3VeT77IE

A
70
Q

COC preparations

A

Ethinylestradiol 20 microgramsDesogestrel 150 microgramsGedarel® 20/150

Ethinylestradiol 20 microgramsDesogestrel 150 microgramsMercilon®

Ethinylestradiol 20 microgramsGestodene 75 microgramsFemodette®

Ethinylestradiol 20 microgramsGestodene 75 microgramsMillinette® 20/75

Ethinylestradiol 20 microgramsGestodene 75 microgramsSunya® 20/75

Ethinylestradiol 20 microgramsNorethisterone acetate 1 mgLoestrin® 20

Ethinylestradiol 30 microgramsDesogestrel 150 microgramsGedarel® 30/150

Ethinylestradiol 30 microgramsDesogestrel 150 microgramsMarvelon®

Ethinylestradiol 30 microgramsDrospirenone 3 mgYasmin®

Ethinylestradiol 30 microgramsGestodene 75 microgramsFemodene®

Ethinylestradiol 30 microgramsGestodene 75 microgramsKatya® 30/75

Ethinylestradiol 30 microgramsGestodene 75 microgramsMillinette® 30/75

Ethinylestradiol 30 microgramsLevonorgestrel 150 microgramsLevest®

Ethinylestradiol 30 microgramsLevonorgestrel 150 microgramsMicrogynon® 30

Ethinylestradiol 30 microgramsLevonorgestrel 150 microgramsOvranette®

Ethinylestradiol 30 microgramsLevonorgestrel 150 microgramsRigevidon®

Ethinylestradiol 30 microgramsNorethisterone acetate 1.5 mgLoestrin® 30

Ethinylestradiol 35 microgramsNorgestimate 250 microgramsCilest®

Ethinylestradiol 35 microgramsNorethisterone 500 microgramsBrevinor®

Ethinylestradiol 35 microgramsNorethisterone 1 mgNorimin®

Mestranol 50 microgramsNorethisterone 1 mgNorinyl-1®

Ethinylestradiol 30 microgramsGestodene 75 microgramsFemodene® ED

Ethinylestradiol 30 microgramsLevonorgestrel 150 microgramsMicrogynon® 30 ED

Estradiol (as hemihydrate) 1.5 mgNomegestrol acetate 2.5 mgZoely®

71
Q

PE and ECG

A
  • Sinus tachycardia (44%) – the most common abnormality
  • Complete or incomplete RBBB (18%) – associated with increased mortality
  • Right ventricular strain pattern (34%)– T wave inversions in the right precordial leads (V1-4) ± the inferior leads (II, III, aVF).
  • Right axis deviation – seen in 16% of patients. Extreme right axis deviation may occur, with axis between zero and -90 degrees, giving the appearance of left axis deviation (“pseudo left axis”).
  • Dominant R wave in V1 – a manifestation of acute right ventricular dilatation.
  • Right atrial enlargement (P pulmonale) 9% – peaked P wave in lead II > 2.5 mm in height.
  • SI QIII TIII pattern (20%) – deep S wave in lead I, Q wave in III, inverted T wave in III. This “classic” finding is neither sensitive nor specific for pulmonary embolism
  • Clockwise rotation – shift of the R/S transition point towards V6 with a persistent S wave in V6 (“pulmonary disease pattern”), implying rotation of the heart due to right ventricular dilatation.
  • Atrial tachyarrhythmias (8%) – AF, flutter, atrial tachycardia.
  • Non-specific ST segment and T wave changes, including ST elevation and depression (50%)
  • Simultaneous T wave inversions in the inferior (II, III, aVF) and right precordial leads (V1-4) is the most specific finding in favour of PE
72
Q

Rashes

Childhood

chicken pox (VZ virus)- macular, papular vesicular and scabbing - head to trunk

Measles (Measles virus): koplik’s - grains of salt, blotchy maculopapular rash

mumps (mumps virus): parotid swelling and earache

rubella (rubella virus): pink maculopapular suboccipital and postauricular

Erythema infectiosum (parvo virus): ‘Slapped-cheek’ rash, proximal arms - extensor

Scarlet fever (Grp A Strep): ‘Strawberry’ tongue, Rash - fine punctate erythema sparing mouth - perioral pallor

Hand, foot and mouth disease - sore throat, feverVesicles in the mouth and on the palms and soles of the feet

A
73
Q

Leukaemias

A

ALL: children ~ 10, myeloperoxidase neg, LN enlargement, fatigue and flu like,, immature lymphocytes, cytarabine for t/t

CML: Middle age ~40, myeloid chain ,defect mature neutrophils, philadelphia chromosome, Imatinib for t/t

AML: Middle age ~50, pancytopaenia, immature neutrophils, myeloperoxidase +, Auer bodies, ATRA and Vit A

CLL: Elderly ~80, mature lymphocytosis, LNs enlarged, weight loss, night sweats No Rx

**bank (74 decks)

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