Core Conditions Flashcards

Question

Fibrosing Alviolitis

Answer 1

**Definition:** Progressive idiopathic pulmonary fibrosis **Aetiology:** Idiopathic **Associations:** Autoimmune Coeliac Disease Ulcerative Colitis Renal Tubular Acidosis **Clinical Features:** SoB Cyanosis Clubbing Bilateral fine inspiratory crackles Signs of respiratory failure, pulmonary HPT, RHF **Investigations:** CXR - reticulonodular shadowing HiRes CT Spirometry - restrictive pattern with reduced gas transfer Bronchoalveolar lavage - hypercellular Transbronchial biopsy **Management:** O2 Steroids Immunosuppression Single lung transplant **Complications:** Respiratory Failure Median survival 5 years

Answer 2

**Definition:** Pain caused by gallbladder contraction against a gallstone stuck in the neck or the cystic duct **Clinical Features:** Pain in the RUQ / Epigastrium - with radiation around costal margins to back Sweaty Pale Tachycardia Nausea / Vomiting Patients often writhe around with pain, rather than sitting still Attacks lasts \< 6hrs Examination is otherwise normal **Investigations:** FCB, U&Es, LFTs CRP, Urine Dipstix USS gall bladder **Management:** Analgesia Nil by mouth Laprascopic Cholecystectomy

Answer 3

**Definition:** Abnormal condition of the mind resulting in a loss of touch with reality **Aetiology:** Schizophrenia Schizoaffective disorder Bi-polar PTSD Drugs - alcohol, cannibis, meth **Clinical Features:** Schizophrenia: First Rank Symptoms - auditory hallucinations, thought withdrawal, thought insertion, thought broadcasting, delusions, externally controlled emotions, somatic passivity and feelings **Investigations:** Clinical based on first rank symptoms **Management:** Neuroleptics - (SE) Dopamine Antagonists (eg. Chlorpromazine, Haloperidol) Atypical (eg. clozapine, risperidone, olanzaoine) less extrapyramidal SE Psychosocial suppport and education

Answer 4

**Incidence:** 1 / 10000 per year Median Age at Presentation 50 **Risk Factors:** M:F = 1:2 FH Acute Sunburn, esp. childhood Number of pigmented moles Previous Melanoma **Features:** Irregular pigment and edge Increasing size in adult life Occurs in young adults **Types:** Superficial Spreading Nodular **Sites:** Males - back Females - leg Can occur anywhere on the body **Management:** Excise with wide margins - \>1cm

Answer 5

**Definition:** A disruption of conduction in the His / Purkinje system, either left or right. This causes the 'blocked' ventricle to receive the conduction impulse later. **Aetiology:** RBBB - congenital heart disease, cor pulmonale, PE, MI, cardiomyopathy, hyperkalaemia, normal LBBB - AS, HPT, acute MI, severe coronary disease, cardiomyopathy **Clinical Features:** **Investigations:** RBBB ECG - 'RSR' in v2 & slurred S in v5, v6 LBBB ECG - 'RSR' in I, AVL, v4-v6 & slurred S in v1, v2 **Management:** Pacing in symptomatic patients

Answer 6

**Aetiology:** Infective Endocarditis in IV drug users Chronic Lung Disease Pulmonary HPT Dilatation of Right Ventricle Carcinoid Syndrome **Clinical Features:** Exersional SoB GI upset due to congestion Elevated JVP with giant V wave Pulsatile Hepatomegaly Peripheral Oedema Ascites Pleural effusions Right Ventricular Impulse at Left Sternal Edge **Heart Sounds** Pansystolic Murmur at lower left sternal edge, louder in inspiration **Investigations:** **Management:** Medical: treat right ventricular failure Surgical: resection in infective EC valve repair or replacement

Answer 7

**Definition:** Commonest condition in childhood with E. Coli causing 95% of cases. **Clinical Features:** Fever Poor Feeding Irritability Offensive Urine Vomiting **Investigations:** Dipstix - leukocytes, blood, protein, nitrites Clean Catch Sample - microscopy & culture **Management:** \>3 months and not systemically unwell - treat at home with 3/7 Trimethoprim PO Recurrent UTI - Trimethoprim low dose OD **Further Investigations:** _Performed if UTI \< 6months or recurrent \>6months_ USS - to detect structural abnormalities of kidneys or obstruction DMSA - radio-isotope to give detailed anatomy of kidneys, shows renal scarring. Should be delayed by 2-3 months as recent infection affects validity. Micturating Cysto-urethragram - detects reflux from bladder to ureters (vesico-ureteric reflux VUR)

Answer 8

**Definition:** Circulatory failure resulting in inadequate organ perfusion. Generally systolic BP **Aetiology:** _Pump Failure_ Primary: Cardiogenic Shock Secondary: PE, tension pneumothorax, cardiac tamponade _Peripheral Circulation Failure_ **Hypovolaemia** Bleeding: trauma, AAA, ruptured ectopic Fluid Loss: Vomiting, diarrhoea, burns, 'third spacing' **Anaphylaxis** **Sepsis** **Neurogenic** **Endocrine Failure:** Addison's, Hypothyroidism **Iatrogenic:** Drugs e.g. anaesthetics, antiHPT **Clinical Features:** Pallor Inc. Pulse Red. Capillary Return Air Hunger Oliguria **Investigations:** ABC approach Simple: ECG, dipstix and culture, BM Bloods: FBC, CRP, U&Es, TFTs, LFTs and clotting, Glucose, ABG + lactate, Cultures, X-Match Radiology: CXR, ?echo, USS, abdo CT **Management:** ABC Raise Foot of Bed IV Access x2 Fluids Stat! Identify Cause Investigations as Above Catheterise

Answer 9

**Aetiology:** Mitral Valve Prolapse Rheumatic Fever IHD Dilated Cardiomyopathy Infective Endocarditis **Clinical Features:** Palpitations Exertional SoB Fatigue Cardiac Failure Apex – laterally displaced, hyperdynamic, systolic thrill **Heart Sounds** Soft 1st heart sound Loud pan-systolic @ apex with radiation to axilla 3rd heart sound **Investigations:** CXR Echo Cardiac Catheterisation **Management:** Medical: ``` Symptom management (ACEi, Diruretics) Endocarditis Prophylaxis ``` Surgical: Valve replacement

Answer 10

**Definition:** The protrusion of a viscus through the walls of it’s containing cavity into an abnormal position **Aetiology:** _Congenital hernias_ _Groin Hernias (most common 75%)_ Inguinal - direct, enter inguinal canal through transversalis and emerge at superficial inguinal ring - indirect, enter inguinal canal through deep ring and often protrude into scrotum **Arise SUPERIOR & MEDIAL to pubic tubercle** Femoral - emerge through femoral canal, normally contains only fat & lymph nodes. More prone to strangulation due to sharp edge of lacunar ligament **Arise INFERIOR & LATERAL to pubic tubercle**

Answer 11

Definition: 1st - Prolonged PR interval Mobitz 1 - Progressive elongation of PR until missed Mobitz 2- Missed QRS without PR elongation 2:1 or 3:1 - Every 2nd or 3rd P conducts 3rd - No association of P waves & QRS Aetiology: IHD Cardiac Surgery Dilated Cardiomyopathy Drugs Clinical Features: 1st - Usually asymptomatic Mobitz 1 - Usually asymptomatic Mobitz 2 - Usually asymptomatic 2:1 or 3:1 - Asymptomatic or syncope, dizziness, HF, fatigue, lethargy 3rd - Asymptomatic or syncope, dizziness, HF, fatigue, lethargy Investigations: Management: 1st - Surveillance and v.rarely pacing Mobitz 1 - Pacing if symptomatic (v.rare) Mobitz 2- Pacing if symptomatic (v.rare) 2:1 or 3:1 - Pacing if symptomatic and consider without symptoms as can progress to 3rd degree 3rd - Rule out reversible causes (K, Mg, Ca), sepsis, other illness and bradycardic drugs

Answer 12

**Aetiology:** Rheumatic Fever Marfan’s Syphilis Connective Tissue Disorders Aortic Dissection HPT **Clinical Features:** Can be asymptomatic Palpitations Angina LVF Collapsing Pulse Pistol Shot Femorals Wide Pulse Pressure **Heart Sounds** Apex – displaced, diffuse, hyperdynamic Soft, high-pitched early diastolic Left sternal edge Possible systolic aortic flow murmur Visible Carotid or Head Nodding **Investigations:** **Management:** Medical: Nifedipine may prolong time before replacement Surgical: Valve replacement at the onset of ventricular dysfunction

Answer 13

**Definition:** Someone who becomes acutely ill and in whom symptoms and signs are chiefly related to the abdomen. **Aetiology:** _Clinical Syndromes That Usually Require Laparotomy:_ Rupture of an organ – spleen, aorta, ectopic pregnancy Peritonitis – perforation of ulcer, diverticulum, appendix, bowel or gall bladder _Syndromes That May Not Require Laparotomy:_ Local Peritonitis – diverticulitis, cholecystitis, salpingitis or appendicitis Colic - **Clinical Features:** Rupture of an organ – shock, swelling, trauma Peritonitis – prostration, shock, lying still, +ve cough test, tenderness +- rebound/percussion, rigid abdomen, guarding, absent bowel sounds Local Peritonitis – Colic – waxing & waning pain, restlessness **Investigations:** FBC U&Es Amylase LFTs CRP Urinalysis ABG (mesenteric ischaemia) CXR (gas under diaphragm) AbdoCT / USS **Management:** ABC approach Fluid Resus Pain relief Nil by mouth Find & treat cause

Answer 14

**Definition:** Normal Range 2.12-2.65 mmol/L Always check corrected calcium as hypoalbuminaemia may give falsely low serum calcium. **Aetiology:** Vit D deficiency Hypoparathyroid Acute pancreatitis Alkalosis Alcoholism **Clinical Features:** spasm of hands and feet, twitching, tingling perioral, fatigue, depression, dry skin, coarse hair Hyperreflexia, tetany, Trosseau's, Chvosek's _Worrying Features_ Reduced GCS, chest pain, palpitations, low BP, abnormal ECG **Investigations:** ECG - prolonged QT, ST abnormalities, arrhythmias **Management:** Calcium Gluconate ?Vit D

Answer 15

**Definition:** Obstructive jaundice arising in the biliary tree **Aetiology:** _Main_ Gallstones Pancreatic Cancer _Other_ Cholangiocarcinoma Chronic Pancreatitis Enlarged lymph nodes in the porta-hepatitis **Clinical Features:** Yellow appearance of skin + mucous membranes (above 50 micromol/l) Dark urine Pale stools Pruritis Weight loss - due to inability to absorb fat **Investigations:** FBC U&E LFT - increased alk phos Clotting USS - gallbladder/biliary tree - is a stone or a tumour causing obstruction? Chest X-ray **Management:** _Gallstone_ Laproscopic cholycystectomy + Laproscopic common bile duct exploration or ERCP with stone extraction + Laproscopic Cholycystectomy _Pancreatic Cancer_ CT should be carried out too assess resectability If it looks favourable then an endoscopic USS should be done: Allow a closer look at head of pancreas Allows cytology sample to be taken If the endoscopic USS also suggests favourobility then Whipple’s should be done If at surgery it’s decided the tumour is not removable, a biliary bypass should still be done If the tumour is not treatable then a stent should be fitted via ERCP to provide symptomatic relief

Answer 16

**Definition:** Acute necrotizing hepatitis leading to cell destruction; There are three types of acute liver failure: 1. Hyperacute or fulminant liver failure – encephalopathy develops 2. Acute liver failure – encephalopathy develops 2-4/52 3. Subacute liver failure – encephalopathy develops 4-8/52 **Aetiology:** viral hepatitis, infection, drugs, toxins, alcohol, ischaemia, complications of pregnancy, malignancy **Clinical Features:** Lethargy, weakness, nausea, anorexia, sleep disturbance, Jaundice, fever, fetor hepaticus, encephalopathy, cerebral oedema leading to bradycardia, hypertension, tachypnea **Investigations:** Liver Screen to identify cause Poor prognostic indicators include: ⇑bilirubin, severe hyponatraemia, rising lactate, acidosis, rapid ⇓ transaminases, renal failure **Management:** Supportive in ITU, Liver Tx **Complications:** Renal failure, coagulopathy, respiratory failure, sepsis, circulatory failure, hypoglycaemia, pancreatitis

Answer 17

**Definition:** Recurrent headaches associated with visual and GI disturbance. **Aetiology:** Caused by the vasodilation and oedema of blood vessels and the release of vasoactive substances. **Clinical Features:** _Prodrome:_ Teichopsia (flashes) Jagged Lines Unilateral Patchy Scotoma Lasts 15-60 mins Headache (hemicranial or generalized) N&V Irritable Preferance for the dark Sleeping _Other Patterns:_ Migraine without aura Hemiplegic Migraine **Investigations:** Clinical **Management:** Avoid Precipitating Factors _During Attack:_ Paracetamol Antiemetics Sumatripan (5HT agonist) Ergotamine _Prophylaxis:_ Pizotifen, Methylsergitide (5HT antagonist) Propanolol Amitriptyline (low-dose)

Answer 18

**Definition:** A fall in systolic blood pressure of at least 20mm Hg and diastolic blood pressure of at least 10 mm Hg when a person assumes a standing position. **Aetiology:** The symptom is caused by blood pooling in the lower extremities upon a change in body position and reduction in venous return causing reduced cardiac output. Hypovolaemia Addison's Atherosclerosis **Clinical Features:** Dizziness Euphoria or dysphoria Bodily dissociation Distortions in hearing Lightheadedness Nausea Headache Blurred or dimmed vision Seizures **Investigations:** **Management:**

Answer 19

**Incidence:** 1 / 1000 per year M:F 1.3:1.0 **Risk Factors:** Skin Types 1&2 Sunburn in childhood Immunosuppression Old Age **Site:** Upper 2/3 of face **Features:** Pearly papule with telangectasia Eroded centre Slowly increasing in size **Management:** Surgical Excision Mohs Curettage & Cautery Cryotherapy Photodynamic Therapy Topical 5-fluouracil Superficial Radiotherapy **Prognosis:** Excellent - rarely local recurrence 50% 2nd BCC at 5 years Does not metastasize

Answer 20

**Definition:** A state of abnormally elevated or agitated mood **Aetiology:** Physical - genetic, reduced 5HT, hormonal, CNS abnormalities Psychological - maternal deprivation, learned helplessness Social - stressful life events, sexual abuse in childhood **Clinical Features:** Elevated mood, fast, pressured speech, flight of ideas, grandiose ideation, insomnia, disinhibition, increased libido, excessive drinking / spending **Investigations:** Rule out intoxication **Management:** Acute - Lithium, Neuroleptics (eg Haloperidol) Prophylaxis - Lithium (monitor closely U&Es, TFTs), Carbamazepine, Valproate Psychotherapy / CBT Social

Answer 21

**Definition:** Systematic disease with chronic, symmetrical polyarthritis, synovitis and non-articular features 1-3% of population Presents at all ages Commonly presents 30-50 years F \> M before menopause Familial or sporadic HLA-DR4 in 50-70% **Aetiology:** Unexplained T Cell Activation Presence of rheumatoid factors **Clinical Features:** Slow onset but progressive Symmetrical peripheral polyarthritis Joint pain & morning stiffness Eased by gentle activity Joints warm and tender Limitation of movement and deformity Joint effusion Muscle-wasting Lethargy, malaise Non-articular features **Investigations:** Anaemia ⇑ inflammatory markers Rh factors in 70% Xray – erosions **Management:** Explain diagnosis and reassure MDT approach _NSAIDs & Analgesics_ DMARDs Sulphasalazine Methotrexate Leflunomide Anti-TNF Drugs: Entanercept Infliximab Adalimumab Corticosteroids Less commonly used: Gold Penicillamine Hydroxychloroquine Azathioprine Ciclosporin Anikinra Joint Replacment / other surgery **Non-articular Manifestations of RA:** Hands: Nail fold lesions of vasculitis Tenosynovitis Tendon sheath swelling Carpal tunnel syndrome Arms: Bursitis / nodules Eyes: Scleritis Scleromalacia Dry - Sjögren’s Syndrome Mouth: Dry – Sjögren’s Syndrome Neck: Lymphadenopathy Atlanto-axial subluxation Rarely causing cervical cord compression Lungs: Pleural Effusion Fibrosing Alviolitis Caplan’s Syndrome Small Airway Disease Nodules Heart: Pericarditis Splenomegaly Renal: Amyloidosis Lower Limb: Ulcers Oedema Sensorimotor Polyneuropathy Anaemia

Answer 22

**Definition:** caused by a reentrant rhythm in either the right or left atrium. Typically initiated by a premature electrical impulse arising in the atria. **Aetiology:** IHD, Rheumatic heart disease, Thyrotoxicosis, Cardiomyopathy, W-P-W Syndrome, Pneumonia, ASD, Pericarditis, PE **Clinical Features:** Asymptomatic, reduced exercise tolerance, palpitations, HF, embolic events, completely irregular pulse **Investigations:** ECG - Sawtooth flutter waves between QRSs **Management:** Electrical Cardioversion Class III Antiarrythmics (K) - Amioderone, Sotalol

Answer 23

**Definition:** SIRS + suspected infection Severe Sepsis - sepsis + signs or organ hypoperfusion Septic Shock - persistant hypotension despite fluid challenge **Aetiology:** Pneumonia, cellulitis, gangrene, endocarditis, perforation, UTI, pyelonephritis, wound infection, bowel leak **Clinical Features:** Symptoms of infection plus low BP, tachy, warm peripheries, low JVP, reduced GCS, oliguria **Investigations:** Determine severity using 'sepsis 6' protocol **Management:** Follow algorithm Briefly: 1. Give 15LO2 2. Take blood cultures 3. Give IV Abx (according to suspected source) 4. Give IV fluids 5. Take lactate & Hb 6. Take urine for fluid balance (catherterise)

Answer 24

**Definition:** Uncoordinated rapid continuous activation of atria from multiple foci. Fortunately only some of these are conducted to the ventricles due to the AV node. Three Types Paroxysmal Persistent \>48 hours Permanent **Aetiology:** IHD, Rheumatic heart disease, Thyrotoxicosis, Cardiomyopathy, W-P-W Syndrome, Pneumonia, ASD, Pericarditis, PE **Clinical Features:** Spectrum - Asymptomatic \> Palpitations \> Dyspnoea \> Chest Pain \> Heart Failure \> Syncope **Investigations:** ECG - irregularly irregular QRS, no P waves, irregular baseline Rate may be fast, normal or slow **Management: (three principles)** Rate Control (if fast) - ß-blockers, Ca-blockers, Digoxin Rhythm Control - ß-blockers, Flecanide (Na), Amioderone (K) Stroke Prevention - Warfarin or Dabigatran/Rivaroxaban CHA2Ds2VASc risk stratification for use of anti-coagulation Consider DC Cardioversion

Answer 25

**Definition:** Inflammation of the pancreas, acute or chronic **Aetiology:** Alcohol Gall Stones Trauma ERCP Drugs - azathioprine, steroids, oral contraceptive Infection - mumos, coxsackie, klebsiella Metabolic - hypercalcaemia, hyperlipidaemia, renal failure Other - hypothermia, malnutrition, scorpion bite **Clinical Features:** abdo pain radiating to back, N&V, anorexia, abdo tenderness & guarding, Grey-Turner sign, basal crackles **Investigations:** Abdo Xray inc. neutrophils U&Es - renal failure Calcium & glucose Amylase elevated ABG - hypoxia & acidosis LFTs USS - gallstones CT **Management:** GLASCOW SCORE ABC Analgesia ERCP HDU

Answer 26

**Definition:** Common disorder characterized by red, scaly plaques. 2% of the population. M=F **Aetiology:** T-cell driven Genetic Environmental Triggers: Infection Drugs e.g. Lithium UV light Alcohol Stress **Clinical Features:** _Chronic Plaque Psoriasis:_ Purplish / red scaly plaques, particularly on extensor surfaces Scalp Involvement Can occur in areas of skin trauma (Köbner Phenomenon) 50% Associated with nail changes _Flexural Psoriasis:_ Occurs in older patients Patches in groin, natal cleft, submammary _Guttate Psoriasis:_ Raindrop lesions on trunk Occurs in children / young adults 2 weeks post strep sore throat **Management:** Education & Explanation Avoid irritants Topical steroids Calcipotriol (vit D analogue) Coal tar Phototherapy (PUVA) Methotrexate if severe

Answer 27

**Definition:** Fluid accumulation in the air spaces and paranchyma of the lungs. **Aetiology:** Cardiogenic - LVF, IHD Non-cadiogenic - HPT crisis, upper airway obstruction **Clinical Features:** dyspnoea, orthopnoea, PND, frothy sputum raised JVP, tachypnoea, fine crackles, wheeze, pitting, cold hands & feet **Investigations:** FBC - anaemia, infection, MI CRP - infection U&Es - BNP ?ABG ECG - exclude arrhythmias, STEMI, may show prev IHD CXR - cardiomegaly, oedema Echo - poor LVF **Management:** O2 Furosemide Analgesia ?nitrates

Answer 28

**Definition:** Diarrhoea with N&V +/- abdo pain. **Aetiology:** Usually due to viruses (inc. Norovirus) but other infectious agent important - Shigella, Campylobacter **Clinical Features:** Diarrhoea, N&V, abdo pain, fever, sweating **Investigations:** Stool culture WCC inc. CRP inc. **Management:** Fluid replacement Antiemetics Discuss with Micro

Answer 29

**Definition:** Inflammatory bowel disease, affecting the colon only **Aetiology:** Mucosal inflammation of colon (transmural in crohn’s) **Clinical Features:** Weight loss Bloody diarrhoea Fever Colicky abdominal pain Tenesmus Constipation Tender abdomen Distension Abdominal mass _Extra-gastrointestinal signs_ Erythema nodosum Pyoderma gangrenosum Ankylosing Spondylitis Episcleritis Primary Sclerosing Cholangitis **Investigations:** • Bloods o FBC – anaemia o CRP & ESR – disease severity o Antibodies – p Anca • Stool sample o Blood o Microscopy, Culture & Sensitivity • Abdominal X-ray – signs of toxic megacolon • Colonoscopy + Biopsy - diagnosis **Management:** Local – topical steroids in proctitis Systemic o Corticosteroids – Budesonide (induction of remission) o Mesalazine – induction & maintinence of remission o Azothiaprine – no response to steroids or \>2 use of steroids in 1yr o Infliximab – use when no response to azothiaprine (induction of remission) Surgery o Ileal pouch anal anastomoses (removal of colon)

Answer 30

**Definition:** Swelling of the thyroid gland, may be associated with hypo / hyperthyroidism **Aetiology:** _Aetiology in Euthyroid Patient:_ Simple non-toxic goitre - Iodine Deficiency - Treated Grave’s disease - Puberty Solitary Nodule - Thyroid adenoma - Thyroid cyst - Thyroid carcinoma _Aetiology in a Hypothyroid Patient:_ Hashimoto’s Thyroiditis Radioiodine-treated Grave’s _Aetiology in a Hyperthyroid Patient:_ Grave’s Disease Toxic Multinodular Goitre **Clinical Features:** Neck swelling and features of hyper / hypothyroidism **Management:** Treat cause

Answer 31

**Definition:** **Aetiology:** **Clinical Features:** **Investigations:** **Management:**

Answer 32

**Definition:** Cell degeneration in the substantia nigra. Loss of dopamine in the extrapyramidal nuclei Combination of tremor, rigidity and akinesia Increases with age, 1:200 over 70 Less prevalent in smokers **Aetiology:** Idiopathic Drug-induced eg. phenothiazides (chlorpromazine), antipsychotics MPTP (illegal synthetic opiate) Encephalitis lethargica **Clinical Features:** Tremor (pill-rolling) Micrographia Rigidity Cogwheeling Bradykinesia Falls Mask-like face Reduced blinking Festinant Poor arm swing Monotonous speech Normal power Brisk reflexes Downgoing plantars Cognitive function initially preserved, late dementia sometimes occurs **Investigations:** Clinical diagnosis **Management:** Levodopa plus decarboxylase inhibitor eg. Sinemet or Madopar (slow to reduce SE) Dopaminergic agonists eg. bromocriptine Selegeline - monoamine oxidase B inhibitor Neurosurgery (occasional for intractable tremor) Physiotherapy Physical aids _SE of levodopa:_ short - term: N&V Confusion Visual hallucinations Chorea _long-term:_ End-of-dose dyskinesia On-off syndrome Chorea Dystonic movements

Answer 33

**Definition:** Major cause of LRTI in children, most will have been infected by 2-3 years. Causes bronchiolitis **Aetiology:** **Clinical Features:** Flu-like illness, may lead to severe respiratory symptoms in some cases. **Investigations:** May do fluoroscopy **Management:** Supportive - fluids, O2, nebulsed saline

Answer 34

**Definition:** Two abnormal circuits produce this arrythmia, both passing through the AV node. AVNRT - atrio-ventricular node re-entrant tachycardia (passes through and near to AV node) AVRT - atrio-ventricular re-entrant tachycardia (electrical 'hole' in AV septum. This conducts the signal more rapidly - pre-excitation and shows as a delta wave on ECG **Aetiology:** Exertion Caffeine Alcohol ß₂-agonists Congenital - W-P-W **Clinical Features:** Palpitations Chest Pain SoB Syncope Polyuria Rapid Regular Pulse 140-280bpm **Investigations:** ECG - narrow complex tachycardia, P waves may be within or after the QRS **Management:** Vagotonic Manoeuvres Carotid Sinus Massage Occular Pressure Valsalva Manoeuvre Adenoseine (avoid in asthma) Prophylaxis Accessory Pathway Ablation

Answer 35

**Definition:** Aperistalsis in the oesophagus and failure of relaxation on the lower oesophageal sphincter. **Aetiology:** Unknown **Clinical Features:** Long history of dysphagia for both solids and liquids Regurgitation Severe retrosternal pain, particularly in younger patients **Investigations:** Barium Swallow - dilatation, aperistalsis, beak deformity Gastroscopy to exclude malignancy Oesophageal monometry - aperistalsis & failure of LOS to relax CXR - dilated oesophagus with fluid level behind heart and no fundal gas shadow **Management:** Symptom relief Dilatation or division of LOS Botox or Ca-blockers also used

Answer 36

**Definition:** Multiple plaques of demyelination in the brain and spinal cord disseminated in time and place 60-100 in 100 000 UK **Aetiology:** HLA linked ?viral infection ?dietary antigens **Clinical Features:** Optic - unilateral blurred vision, occular pain, optic neuritis, optic atrophy Brainstem - double vision, vertigo, facial numbness, weakness, dysphagia, pyramidal, nystagmus, ataxia, CN defects, internuclear opthalmoplegia Spinal Cord - difficult walking, sensory, Lhermitte's Sign, GU, spastic paraparesis, inc tone, weakness, brisk reflexes, up-going plantars, sensory level Others - epilepsy, trigeminal neuralgia, tonic spasms of hand, organic psychosis, dementia **Investigations:** Clinical diagnosis two neurological events separated in time and neurological location MRI brain & spinal cord - plaques CSF - oligoclonal bands in 80% & raised mononuclear cell count **Management:** Aimed at reducing frequency & intensity of relapses, long-term not affected. Corticosteroids ß interferon Physio Occupational Therapy SALT Counselling **Prognosis:** From grave disability to mild & benign

Answer 37

**Definition:** Normal Range 3.5-5.3 mmol/L **Aetiology:** _Decreased Excretion:_ Renal Failure Drugs - spironolactone, ACEi, NSAIDs, Heparin Addison's Acidosis _Increased Intake:_ KCl administration Blood Transfusion **Clinical Features:** Arrhythmias Hypotension / bradycardia if severe Kussmaul breathing (associated acidosis) Widened QRS / tented T waves **Investigations:** ECG monitoring **Management:** Calcium Resonium Dialysis Treat Cause

Answer 38

**Definition:** Air in the pleural space leading to lung deflation **Aetiology:** Spontaneous (primary or secondary to lung disease) Chest trauma Ventilation **Clinical Features:** Pleuritic Chest Pain SoB **Investigations:** CXR - lung markings not extending to the peripheries **Management:** If bilateral or haemodynamically unstable - chest drain _Primary_ + \>2cm &/or SoB - aspirate (drain & admit if fails) _Primary_ with no SoB or Secondary + \>2cm - chest drain & admit Secondary

Answer 39

**Definition:** Ventricular Fibrillation - Irregular rhythm with irregular QRS voltage and width. Not compatible with life. Broad Complex Tachycardia - VT until proven otherwise **Aetiology:** Shock MI **Clinical Features:** VF - LOC BCT - Palpitations, dizziness, syncope, angina **Investigations:** ECG VT - Irregular rhythm with irregular QRS voltage and width ECG BCT - wide QRS, usually rapid \>180bpm **Management:** VF - DC shock immediately BCT - If haemodynamically stable try amioderone / lignocaine If unstable DC shock as can progress to VF

Answer 40

**Definition:** Pain & disability associated with joint space narrowing and altered cartilage osteophyte formation. **Aetiology:** Primary - Idiopathic Secondary - trauma, chondrocalcinosis, haemochromatosis, acromegaly, haemophillia, AVN, sickle cell **Clinical Features:** Joint pain / swelling / instability Morning Stiffness Joint effusion & crepitus Bony Swelling Muscle Wasting Limitation of movement & loss of function **Investigations:** Inflammatory markers not elevated No autoantibodies Xrays abnormal if severe damage MRI can show early cartilage changes Arthroscopy – early fissuring and cartilage surface erosion **Management:** Treat symptoms and disability, not xrays! Explain diagnosis and reassure Weight loss and exercise Hydrotherapy Heat / massage Analgesia Patients often use complimentary medicine Joint replacements / other surgery **Clinical Subsets:** _Nodal OA_ Familial F \>\> M Develops in late middle age Poly articular involvement of the hand Heberden’s Nodes Generally good long-term functional outcome Predisposes to OA of the knee, hip and spine Xray – marginal osteophyte & joint space loss _Erosive OA_ Rare DIP & PIP joints Poor functional outcome Xray – marked subchondral cysts May develop in to rheumatoid arthritis _Generalised OA_ May occur in combination with nodal OA Hands, knees, first MTP joints and hips Familial F \> M May be autoimmune Large joint OA Knees & Hips _Crystal-associated OA (Chondrocalcinosis)_ Calcium Phosphate Crystal Deposition Knees and wrists commonly affected Xray – may show calcification in the cartilage

Answer 41

**Definition:** Variable combinations of fast & slow supraventricular rhythms. **Aetiology:** Ischaemia Infarction Degenerative Disease **Clinical Features:** Variable combinations of fast & slow supraventricular rhythms. **Investigations:** ECG - long interval between P waves \>2 seconds **Management:** Permanent Pacemaker Antiarrhythmics to reduce tachys Anticoagulation

Answer 42

**Clinical Features:** Hot, tender area of confluent erythema Often on lower leg Can affect face Caused by streptococci **Risk Factors:** DM **Management:** Oral / IV Abx

Answer 43

**Definition:** Reversible airway obstruction +/- wheeze, dyspnoea & cough. Leading chronic disease of childhood. **Aetiology:** FH, bottle fed, atopy, pollution Triggers - dust, pollen, animals, exercise, smoke **Clinical Features:** Wheeze SoB Cough **Investigations:** PEFR CXR **Management:** Chronic- Step 1 - occasional ß2-agonist via spacer Step 2 - regular inhaled steroid Step 3 - review diagnosis, check inhaler technique. Add LABA or aminophylline Step 4 - refer to specialist & increase inhaled steroid Step 5 - Prednisolone

Answer 44

**Definition:** Syndrome characterized by chronic hyperglycaemia due to relative insulin deficiency or resistance or both. _WHO Classification_ Type 1: β cell destruction usually leading to absolute insulin deficiency Autoimmune or idiopathic Type 2: Variable combination of insulin resistance and defects in insulin secretion **Aetiology:** Autoimmune Idiopathic Genetic Endocrine problems (e.g. Cushing's) Pancreatic trauma or disease Drug-induced - corticosteroids, thiazides **Clinical Features:** _Due to hyperglycaemia_ Thirst Polyuria Weight loss Ketoacidosis ⇓ Energy Visual Blurring Candida Infections _Due to Complications_ Skin infections Retinopathy - haemorrhages, exudates etc... Polyneuropathy - 'glove&stocking', autonomic Erectile Dysfunction Arterial Disease - atheroma, stroke, MI, PVD Renal Disease - glomerular sclerosis, pyelonephritis Charcot's Joints Diabetic Foot **Investigations:** _WHO Criteria For Diagnosis:_ HbA1c \>6.5% is diabetic HbA1c 6.0-6.4% is high risk of developing diabetes - lifestyle advice & yearly monitoring **Management:** Based on self-monitoring and management by the patient, helped and advised by specialists. Requires good education and understanding of disease by the patient, including: - Monitoring blood sugar - Self-injection of insulin - Managing hypoglycaemic events - How to recognize complications - When to contact specialists for help _Type I Drugs_ Insulin - fast, intermediate, long acting (pumps) _Type II Drugs _ Oral Hypoglycaemics: Biguanides - inc. insulin sensitivity (eg Metformin) Sulfonylureas - inc. insulin secretion (eg Gliclazide) Thiazolidinediones - inc. insuin sensitivity (eg Pioglitazone)

Answer 45

**Definition:** Inflammatory bowel disease which can affect anywhere from the mouth to the anus. It most commonly involves the terminal ileum, which can present as right iliac fossa pain. It affects patients between the ages of 18-30. **Aetiology:** Autoimmune attack against bowel wall. Causes full thickness infiltration and can therefore result in perforation, adhesions and fistula. It classically on colonscopy demonstrations skip lesions, which helps differentiate it from ulcerative colitis. **Clinical Features:** Fatigue Weight loss Fever Abdominal pain (classically RIF) Diarrhoea +/- blood Episcleritis Large joint arthropathy Tender abdomen Mass in RIF Episcleritis Erythema Nodosum Episcleritis Anal skin tags _Extra-intestinal Manifestations_ Erythema Nodosum Episcleritis Large joint arthritis / Ankylosing spondylitis Renal stones Primary sclerosing cholangitis **Investigations:** FBC – Anaemia CRP Antibodies - Anti-S cerevisiae antibodies (more common in crohns than UC) Stool sample – culture & microscopy Ilieo-colonoscopy + Biopsy – skip lesions, deep ulceration **Management:** Severe abdo pain, diarrhoea, bowel obstruction, or systemically unwell = admit Mesalazine – prophylactic therapy Budesonide – Fewer side effects than prednisolone, but may be less effective Antibiotics for septic disease _Immunomodulators_ Azothiaprine Methotrexate _Biologics_ Infliximab Elemental diet _Surgery_ _Maintaining remission_ Mesalazine – after surgery Azothiaprine Infliximab

Answer 46

**Definition:** Low bone mass & micro-architectural deterioration of bone. Mineralised normally but deficient in quantity & quality including structural integrity. **Aetiology:** Female, age, early menopause, smoking, FH, excess alcohol, nutrition, steroids, immunosuppression, endocrine disorders, RA, renal / liver failure **Clinical Features:** Back pain Weight loss Kyphosis Colles' # #NOF **Investigations:** Ca - ++, PO4 & alk phos normal XRAYs DXA - **Management:** Prevention Identification & monitoring patients at risk Diet rich in Ca & Vit D Exercise Stop smoking Reduce risk of falls Ca & Vit Supplements Bisphosphonates Raloxifene Parathyroid hormone Strontium Androgens in hypogonadal men

Answer 47

**Definition:** 'Blackouts' with multiple clinical pictures and causes. May or may not involve LOC Vasovagal Syncope: reflex bradycardia +/- vasodilation Cough Syncope: weakness + LOC after coughing Effort Syncope: on exercise, cardiac origin e.g. AS Micturition Syncope: mostly men, at night Carotid Sinus Syncope: carotid sinus hypersensitivity, headturning or shaving Epilepsy: most likely Grand Mal presenting with LOC Stokes-Adams Attacks: transient arrhythmias causing low cardiac output & LOC Others: hypoglycaemia, orthostatic hypotension, drop attacks, anxiety **Clinical Features:** LOC with possible associated symptoms e.g. nausea, pallor, sweating, visual disturbance **Investigations:** Collateral History CVS with sitting / standing BP Neuro BM ? 24hr ECG **Management:** Cause dependent

Answer 48

**Definition:** Increased menstrual blood loss for individual or change such as flooding, clots. **Aetiology:** IUCD Fibroids Endometriosis / Adenomyosis PID Polyps Hypothyroidism Dysfunctional Uterine Bleeding **Clinical Features:** As above **Investigations:** FBC TFTs Clotting USS Hysteroscopy Laproscopy **Management:** 1st Line - Mirena 2nd Line - Antifibrinolytics (Transexamic Acid), NSAIDs, COCP 3rd Line - oral prgesterone or injected pregesterone (Depo) Surgical - Ablation (if family complete)

Answer 49

**Definition:** Transient symptoms of myocardial ischaemia due to exertion which is relieved by rest. **Risk Factors:** Age, Male Sex, FH, Hyperlipidaemia, Smoking, HPT, DM, COX 2 inhibitors (celecoxib) Clinical Features: Central Chest Pain - heavy, tight, gripping, radiation to arms and jaw May be silent **Investigations:** Simple - ECG (normal or previous MI) - Exercise ECG (ST depression \>1mm which reverts to normal) Bloods - FBC, U&Es, TFTs Radiology - Angiogram - Thallium Scan **Management:** GTN ß-blocker or Ca-channel blocker, if not controlled.... Both ß-blocker & Ca-channel blocker (\*Nicorandil if not tolerated or cantraindicated\*) If not controlled..... Long-acting nitrate (isosorbide) or Nicorandil If not controlled...... Consider revascularisation

Answer 50

**Incidence:** 1 / 4000 per year **Risk Factors:** Skin Type 1&2 Chronic Sun Exposure Outdoor Work & Leisure Activities Immunosuppression Old Age Chronic Skin Ulceration Defects in DNA repair - xeroderma pigmentosum **Features:** Painful, firm, keratotic / eroded, indurated nodule Increasing size over months Sun exposed sites - scalp, ears, dorsa of hands, lower legs **Management:** Surgical Excision with 4mm margin **Prognosis:** More likely than BCC to recur or metastisize Worse: ear, lip, ulcers size \>2mm depth \>4mm poorly differentiated immunosuppressed

Answer 51

**Definition:** Endometrial glandular tissue beyond the uterine cavity **Aetiology:** Long-term IUCD or tampon use Retrograde menstrual flow **Clinical Features:** Pelvic pain at time of period Dysmenorrhoea Dyspareunia **Investigations:** PV exam MRI Laproscopy **Management:** Analgesia COCP or IUCD to stop ovulation so patches atrophy Excision

Answer 52

**Definition:** **Aetiology:** **Clinical Features:** **Investigations:** **Management:**

Answer 53

**Definition:** Steatosis \> Fibrosis \> Cirrhosis Degree of liver damage dependent on genetic factors and coexisting liver disease; women progress to cirrhosis faster **Cage Questionnaire:** * Have you ever felt the need to **_c_**ut down? * Have you ever felt **_a_**nnoyed by criticism of your drinking? * Have you ever felt **_g_**uilty about your drinnking? * Have you ever felt the need for an **_e_**ye-opener? **Clinical Features:** lethargy, splenomegaly, jaundice, leuconychia, telangiectasia, spider naevi, gynaecomastia, xanthelasma/xanthoma, Dupuytren’s, clubbing, dilated chest/abdo wall veins, excoriations, fetor hepaticus (breath of the dead), palmar erythema **Investigations:** FBC - ⇑MCV, ⇓Platelets LFTs - ⇑GGT, ⇑bilirubin Coag - ⇑PT Others: ⇑Albumin, ⇑cholesterol Liver Screen: ⇑IgA U&Es to check kidney function & provide baseline USS +- biopsy **Management:** Abstinence Nutrition Vitamin replacement Laxatives Liver Tx

Answer 54

**Definition:** Caseating granulomatous infection due to Mycobacterium tuberculosis in the lung TB is a notifiable disease and contact tracing is important **Patients at Risk:** Those from developing countries Immunosuppressed HIV / Steroids / malignancy Alcoholics / homeless / overcrowding **Clinical Features:** May be none Malaise & Lethargy Anorexia / Weight Loss Fever Cough Haemoptysis Pleural Effusion / Pneumonia / Fibrosis **Investigations:** CXR - affects upper zones mostly, +- calcification or cavitation Sputum Microscopy - Ziehl-Nielsen and culture Bronchial Lavarge / pleural biopsy **Management**: 6/12 of combination Abx, usually: Rifampicin & Isoniazaid + Pyrazinamide for 1st 2/12 Add Ethambutol if risk of resistance Compliance Vital

Answer 55

**Definition:** Can be either: Cholesterol stone - 75% Pigment stone - Mixed 90% are Radio-lucent (unable to see on X-ray) **Aetiology:** Female - 3x more common Age - 10% of over 50’s have gall stones Obesity Hyperlipidaemia Haemolytic anaemia Crohn’s Disease **Clinical Features:** _May Cause:_ **Gallbladder** Chronic cholecystitis Biliary colic Acute cholecystitis Mucocele **Common bile duct** Obstructive jaundice Cholangitis Pancreatitis **Gut** Gallstone ileus **Investigations:** Urinalysis, ECG, CXR to rule out other diseases FBC + CRP: infection LFTs: pattern of cholecystitis - ⇑ALP & ⇑GGT Amylase: pancreatitis U&Es: baseline USS to visualize stones ERCP **Management:** Usually surgical: cholecystectomy

Answer 56

**Definition:** Acute – inflamed weeping skin with vesicles Subacute – erythema, dry / flaky skin, crusted Chronic – lichinified skin **Aetiology:** 40% of population have an episode associated with atopy Atopic Individuals have a tendency to: Asthma Eczema Hay Fever Allergic Rhinitis Genetic Environmental – detergents, chemicals, infection, stress, animal fur, food **Clinical Features:** Itchy erythematous scaly patches Often flexural May be associated with nail pitting **Investigations:** May have raise IgE or eosinophils Patch Testing **Management:** Education & Explanation Avoid irritants Emollients Topical Steroids Abx Antihistamines Second-line Agents: UV Oral Steroids Ciclosporin / Azathioprine

Answer 57

**Definition:** Persistent low mood **Aetiology:** Physical - genetic, reduced 5HT, hormonal, CNS abnormalities Psychological - maternal deprivation, learned helplessness Social - stressful life events, sexual abuse in childhood **Clinical Features:** As you would expect plus hallucinations **Investigations:** Aimed at finding organic cause, endocrine, drugs etc **Management:** Stop depressing drugs Exercise SSRIs Venlafaxine ?TCAs, MAOIs, ECT Psychotherapy CBT Group / family support

Answer 58

Definition: Aetiology: Clinical Features: Investigations: Management:

Answer 59

**Definition:** Lung infection classified by site (lobar or bronchopneumonia) or by aetiology **Aetiology:** Bacterial - strep pneumoniae, mycoplasma pneumoniae Viral - Influenza A, Haemophilus Influenzae Opportunistic Infections Chemical (eg aspiration of vomit) Radiotherapy Allergic **Clinical Features:** Cough +/- purulent sputum Fever Pleuritic chest pain SoB **Investigations:** **CURB65** CXR ABG Blood & Sputum Culture Microbiology **Management:** MIld - amoxicillin 500mg TDS (or Clarythromycin) Moderate - IV amoxicillin 500mg TDS (or Claryth) Severe - IV cefuroxime 1.5g QDS & Clarythromycin Adjust according to C&S O2 Supportive - fluids etc **Complications:** Respiratory Failure - type 1 (low paO2, low/norm. PaCO2) Lung Abscess Empyema

Answer 60

**Definition:** Necrosis of hepatic parenchyma with connective tissue proliferation and nodular regeneration **Aetiology:** Alcoholism by far most common cause follwed by Hep c. Others - Hep B, PSC, PBC, Drugs, NAFLD, AA hep, Wilson's, Budd-Chiari **Clinical Features:** Related to underlying cause: lethargy, splenomegaly, jaundice, leuconychia, telangiectasia, spider naevi, gynaecomastia, xanthelasma/xanthoma, Dupuytren’s, clubbing, dilated chest/abdo wall veins, excoriations, fetor hepaticus (breath of the dead), palmar erythema **Investigations:** Aimed at finding cause: • LFTs • FBC • U&Es • Albumin • Coagulation • Biopsy **Management:** Treat underlying cause **Complications of Cirrhosis:** Malnutrition Hepatic Encephalopathy Ascites / Oedema Vitamin Deficiency Coagulopathy Impaired Immune System Varices Hepatorenal Syndrome Hepatocellular Carcinoma

Answer 61

**Definition:** A collection of fluid within the ovary, usually during childbearing age. Functional Cysts - follicular & corpus luteum (benign) Non-functional - chocolate (endometreosis), dermoid **Aetiology:** Idiopathic **Clinical Features:** Fullness / aching in lower abdo Urinary symptoms Systemic symptoms Disorders in menstruation **Investigations:** USS **Management:** 95% benign so analgesia Surgical excision

Answer 62

**Definition:** Heart is unable to maintain sufficient tissue perfusion despite adequate venous filling pressures. **Aetiology:** Left HF - ischaemic heart disease, HPT, mitral / aortic valve disease, cardiomyopathy Right HF - lung disease (cor pulmonale), PE, pulmonary HPT, L-R shunt, tricuspid regurgitation **Clinical Features:** Left HF - fatigue, exersional SoB, orthopnoea, PND, pulmonary oedema, tachy, enlarged heart, gallop rhythm, crackles Right HF - Tiredness, anorexia, nausea, GI upset, raised JVP, pitting oedema, pleural effusion, hepatomegaly, ascites, tricuspid regurgitation **Investigations:** BNP CXR ECG ECHO - LV ejection fraction Angiography **Management:** If ejection fraction preserved then control comorbidities. LV dysfunction: 1. ACEi (or ARB) + ß-blocker 2. Add in spironolactone or ARB or hydralazine 3. Consider CRT pacing and digoxin

Answer 63

**Definition:** _Barrett's Oesophagus_ - columnar epithelium with intestinal metaplasia replaces normal squamous mucosa _Oesophageal Carcinoma_ - 40% squamous, 60% adenocarcinoma _Achalasia_ - failure of relaxation of lower oesophageal sphincter **Aetiology:** _Barrett's Oesophagus_ - GORD _Oesophageal Carcinoma_ - Barrett's, smoking _Achalasia_ - **Clinical Features:** _Barrett's Oesophagu_s - _Oesophageal Carcinoma_ - dysphagia (solids-liquids), weight loss, anorexia, Virchow's _Achalasia_ - dysphagia (solids-liquids) **Investigations:** _Barrett's Oesophagus_ - Endoscopy _Oesophageal Carcinoma_ - Endoscopy, USS, CT _Achalasia_ - Barium Swallow (Rat's tail), endoscopy, manometry **Management:** _Barrett's Oesophagus_ - watchful waiting _Oesophageal Carcinoma_ - 10% 5 year survival, SCC (radio/chemo, surgery), Adeno (surgery, palliative, ablation, radio) _Achalasia_ - balloon dilatation, botox, Heller's sphinctotomy

Answer 64

**Definition:** Palpable lymph nodes **Aetiology:** Isolated infection - EBV, CMV, hepatitis, HIV, TB Malignancy - lymphoma, leukaemia, mets Autoimmune - SLE, rheumatoid Others - sarcoidosis, amyloidosis, drugs **Clinical Features:** Lump, usually in neck, axilla, groin Worrying Features - non-tender, \>3/52, \>1cm, hard, irregular, tethering, weight loss, night sweats, fatigue, absence of infection **Investigations:** Determine infective cause if possible, or biopsy if concerned. **Management:** Watchful waiting or biopsy

Answer 65

**Definition:** Stroke - a focal neurological deficit due to a vascular lesion lasting \>24 hours (if the patient survives) TIA - a focal neurological deficit lasting **Risk Factors:** HPT Smoking FH Hyperlipidaemia Afro-Caribbean High-dose OCP **Clinical Features:** _TIA_ Carotid System - visual loss, asphasia, hemiparesis, hemianopic visual loss Vertebrobasilar - diplopia, vertigo, vomiting, dysarthria, choking, ataxia, transient global ischaemia Evidence of embolic source - AF, carotid bruit, valvular heart disease, subclavian stenosis _Cerebral Infarction_ Initially flaccid, areflexic weakness followed by spastic tone, brisk reflexes and extensor plantars Dysphasia - most probably left hemisphere, expressive - Broca's area in frontal. Receptive - Wernicke's area in temporal-parietal Middle cerebral / internal carotid - hemiparesis, aphasia, hemianopic visual loss, dysarthria Posterior inf cerebellar - coma, vertigo, vomiting, dysphagia, choking, ataxia, contralateral loss of pain on face **Management:** Acute: CT Head to rule out haemorrhage ?Alteplase Aspirin Stroke unit ABCD2 - risk of stroke following TIA Find underlying cause - bloods, lipids, ECG, CXR, echo Chronic: SALT - swallowing assessment Physio - OT - Risk Factor Modification Anti HPT Aspirin (300mg initially) / Clopidogrel Anticoagulation - AF Surgery (internal carotid) **Prognosis:** 30-40% survival at 3 years 10% risk of further stroke within one year

Answer 66

**Definition:** Disorder of the neuromuscular junction **Aetiology:** Unknown - IgG antibodies to ACTH receptor leading to destruction. Thymic hyperplasia in 70%. Associated with: Thyroid disease RA Pernicious anaemia SLE **Clinical Features:** Weakness and fatigability of muscles: Proximal limb Extraoccular Speech Facial expression Mastication Ptosis Reflexes preserved but fatigable **Investigations:** Tensilon test Serum ACTH receptor antibodies (+ve in 90%) Mediastinal imaging for thymoma (CXR, CT, MRI) **Management:** Oral anticholinesterase eg. pyridostigmine Thymectomy (improves prognosis) Corticosteroids Azathioprine Plasmapheresis

Answer 67

Definition: Aetiology: Clinical Features: Investigations: Management:

Answer 68

**Definition:** Inflammation of the peritoneum, locally (eg appendicitis) or generalised. **Aetiology:** Rupture of abdominal viscus eg perforated duodenal ulcer, perforated appendix. **Clinical Features:** Sudden onset abdominal pain Shock Still patient **Investigations:** AXR - air under diaphragm Check amylase **Management:** Analgesia Surgery

Answer 69

**Definition:** Chronically high BP Stage 1 - \>140/90 in clinic & ABPM average \>135/85 Stage 2 - \>160/100 in clinic & ABPM average \>150/95 Severe - \>180 systolic or \>110 diasolic in clinic **Aetiology:** Primary - genetic, obesity, alcohol, sodium intake, stress Secondary Renal - diabetic nephropathy, renovascular disease, adult polycystic disease, chronic glomerulonephritis Secondary Endo - Conn's, adrenal hyperplasia, phaeochromocytoma, Cushing's, acromegaly Secondary CVS - coaectation of aorta Secondary Drugs - OCP, steroids, NSAIDs Secondary Pregnancy - 2nd half of pregnancy, pre-eclampsia **Clinical Features:** Usually asymptomatic Features of underlying cause Headaches Nose Bleeds Nocturia Elevated BP Renal Artery Bruit Radiofemoral Delay (coarctation) Left Ventricular Hypertrophy **Retinal Changes** Grade 1 - tortuosity of retinal arteries & 'silver wiring' Grade 2 - G1 + arteriovenous nipping Grade 3 - G2 + flame haemorrhages & soft "cotton wool" exudates Grade 4 - G3 + papilloedema **Investigations:** Simple - Urinalysis - casts, protein & red cells - ECG - LV hypertrophy & strain Bloods - Fasting BM & lipids - U&Es Radiology - CXR - Echo - LV hyoertrophy **Management:** Step 1 - ACEi (or ARB) Step 2 - Step 1 + Ca-channel Blocker Step 3 - Step 2 + Diuretic (thiazide-like) Step 4 - Consider Spironolactone or alpha-blocker or ß-blocker _\>55 years or black_ As above but start with Ca-channel Blocker Lifestyle - weight loss, alcohol reduction, salt restriction, exercise, low fat diet **Complications:** Cerebrovascular Disease Coronary Artery Disease Retinopathy Renal Disease

Answer 70

**Definition:** ACS is ischaemia of the myocardium and includes STEMI, NSTEMI and angina **Aetiology:** It is usually due to atherosclerotic disease of the coronary vessels Clinical Features: Chest Pain - severe, sudden, at rest, \>30mins Not relieved by GTN Sweating, SoB, N&V, Pale / grey, Tachy, HF, Hypotension, 'Silent' in 20% **Investigations:** Simple - ECG Bloods - FBC, U&Es, Trop T/I, Lipids Radiology - ?Angiography (see below) **Management:** O₂ if hypoxic Morphine + antiemetic GTN Aspirin 300mg and continue indefinitely Fondaparinux if low bleeding risk & angio \> 24 hours or LMWH if angio _NSTEMI & Unstable Angina_ GRACE score: Lowest Risk - Conservative Low Risk - 300mg loading then 12 months Clopidogrel Intermediate to Highest Risk - As above but also consider GPI (Tirofiban) or Bivalirudin plus Angiography +/- PCI within 96 hours _STEMI_ Cath lab for immediate PCI **Long-Term Drugs** Aspirin indefinitely Clopidogrel 300mg for 12 months ACEi ß-blocker Statins **Admin** Assess LVF Follow -up clinic Education Cardiac Rehab Lifestyle Modification

Answer 71

**Definition:** LRTI worse in smokers & COPD **Aetiology:** Viral but may be complicated by bacterial infection **Clinical Features:** Cough Wheeze Retrosternal discomfort Chest tightness **Investigations:** Rule out other or serious causes **Management:** Self limiting so supportive only 4-8 days

Answer 72

**Definition:** Chronic back pain caused by a small injury leading to spasm of the back muscles and pain. **Aetiology:** Disc rupture - young Vertebral # - old Soft tissue tear - low back strain **Clinical Features:** Pain, usually self limiting Red Flags - 50 years, trauma, CNS symptoms, infective symptoms, steroid use, bony tenderness **Investigations:** \>3/52 - routine bloods to find cause \>4/52 &/or trauma &/or Red Flag - imaging **Management:** Get on with your life within limits of pain Physio Analgesia Treat depression Education

Answer 73

**Definition:** Inflammatory disease of the blood vessel **Aetiology:** Vasculitis **Clinical Features:** Headache Pain on eating Visual disturbance Aching muscles Tenderness Pulseless or nodular vessel **Investigations:** ESR, CRP & Plts - raised Hb - low Biopsy diagnostic **Management:** Prednisolone Analgesia Urgent biopsy Speak to opthalmology

Answer 74

**Definition:** A condition in which free T4 is reduced due to different potential causes. **Aetiology:** Hashimoto’s - autoimmune Thyroid destruction Radioiodine-treated hyperthyroidism Thyroidectomy **Clinical Features:** Weight gain Lethargy Depression Patient feels cold Constipation Poor appetite Menstrual disturbances Myxoedema facies; thickened skin Brittle hair Periorbital puffiness Bradycardia Slow relaxing reflexes **Investigations:** Biochemistry Haemotology – macrocytosis, anaemia Anti-thyroid antibodies **Management:** Thyroxine Caution in cardiac disease Monitor TSH

Answer 75

**Definition:** Reduced Hb concentration (Normal Range 13M, 11.5F) **Aetiology:** Reduced production - aplastic, pernicious, iron deficiency Increased destruction - congenital, sickle cell, AA, DIC RBC loss - haemorrhage, menstruation **Clinical Features:** Fatigue SoB Exertional angina Palpitations Pallor Tachy Koilonychia Angular stomatits / glossitis **Investigations:** WCC may be low in bone marrow failure Reticulocytes - measures bone marrow activity Blood film - shows erythrocyte morphology **Management:** Treat underlying cause eg iron supplements

Answer 76

**Definition:** Upper airway obstruction which produces a high-pitched wheeze **Aetiology:** Infection (epiglottitis, abscess) Tumour Foreign Body Trauma Post-op Analphylaxis **Management:** ABC approach Anaesthetic & ENT urgently DO NOT LOOK IN MOUTH O2 Adrenaline Nebs (5mL of 1:1000) Look for signs of anaphylaxis Urgent portable CXR

Answer 77

**Definition:** Normal Range 3.5-5.3 mmol/L Determined by cellualr uptake, renal excretion and extra renal losses (GI) **Aetiology:** Renal - diuretics (thiazide & loop) Increased aldosterone - liver / heart failure, nephrotic syndrome, Cushing's, Conn's, ACTH tumours Steroids Renal Disease Dietary Deficiency GI Losses **Clinical Features:** Muscle paralysis if severe Arrhythmias in abnormal hearts Potentiation of Digoxin toxicity **Investigations:** ECG **Management:** K+ supplements K+- sparing drugs Treat underlying cause

Answer 78

**Definition:** Occur in 25-50% of surgical patients, and many none surgical patients. 65% of below knee DVTs are asymptomatic and rarely embolize to the lungs. **Risk Factors:** Age, pregnancy, synthetic oestrogen, surgery, prev. DVT, malignancy, obesity, immobility, thrombophillia **Clinical Features:** Calf warmth / swelling / tenderness / erythema Mild Fever Pitting Oedema **Investigations:** _Wells Score_ \>3 - High probability, treat as suspected DVT & USS 1-2 - Intermediate probability, treat as suspected DVT & USS 0 - Low probability, perform D-dimer.... If +ve treat as suspected DVT & USS If -ve DVT is reliably excluded **Management:** Enoxaparin and Warfarin for ~48 hours and stop Enoxaparin when INR = 2-3 Continue Warfarin for 3/12 post-op, 6/12 if no cause, lifelong if recurrent DVTs IVC filters may be considered later

Answer 79

**Definition:** Opacification of the lens by lens proteins **Aetiology:** Age Trauma Radiation Genetics Skin diseases Drug use Medications **Clinical Features:** Blurred vision **Investigations:** **Management:** Surgery

Answer 80

**Aetiology:** Congenital Rheumatic Fever Clacific **Clinical Features:** Often None Exertional angina, syncope, SoB Small volume, slow-rising pulse Sustained apex beat Systolic Thrill in aortic region Sudden Death **Heart Sounds** Ejection systolic murmur @ aortic area Radiation to carotids Ejection Click Soft 2nd heart sound **Investigations:** CXR Echo **Management:** Conservative: Avoid strenuous exercise Avoid vasodilators Medical: β-blocker for angina Surgical: Valve replacement (mandatory in symptomatic patients)

Answer 81

**Definition:** _Primary Hypoadrenalism (Addison’s)_ Destruction of adrenal cortex causing reduced production of glucocorticoid, mineralocorticoid and sex steroids. **Aetiology:** Common: Autoimmune disease ~90% TB Surgical removal Uncommon: Haemorrhage / infarction Meningococcal septicaemia Venography Malignancy Amyloid **Clinical Features:** Tiredness Debility N&V Anorexia / weight loss Abdo pain Diarrhoea Depression Menstrual disturbance Pigmentation – mouth, palmar creases Postural hypotension Dehydration Loss of body hair **Investigations:** Reduced 9am Cortisol Reduced Synacthen Test **Management:** Replacement of glucocorticoids and mineralocorticoids with oral hydrocortisone and fludrocortisone

Answer 82

**Definition:** Normal Range 2.12-2.65 mmol/L **Aetiology:** Hyperparathyroidism, malignancy, excess Vit D **Clinical Features:** Bones (pain / #), Stones (renal), Moans (depressed), Groans (abdo pain). Also: vomiting, const, weakness, thirst, polyuria, weight loss hypertension, arrhythmias, dehydrated, cachexia, bony tenderness _Worrying Features_ Reduced GCS, chest pain, palpitations, inc HR, low BP, abnormal ECG **Investigations:** ECG - short QT, arrhythmias CXR; Bone scan **Management:** Correct fluid deficit Furosemide Catheterisation Bisphosphonates

Answer 83

**Definition:** Wet or Dry subtypes which are retinal damage causing blindness in the centre of the visual field. **Aetiology:** Dry (nonexudative) form, cellular debris called drusen accumulates between the retina and the choroid, and the retina can become detached Wet (exudative) form, which is more severe, blood vessels grow up from the choroid behind the retina, and the retina can also become detached **Clinical Features:** Deterioration of central vision, loss of acuity but fields intact Pigment, fine exudate and bleeding at the macula Drusen **Investigations:** Opthalmoscopy **Management:** Laser photocoagulation Screenin initiated if Drusen are seen

Answer 84

**Definition:** Inflammation of the fallopian tubes or uterus, ovaries caused by infection. It may lead to adhesions and potentially infertility. **Aetiology:** 90% STI - usually chlamydia **Clinical Features:** Pain Fever Lower abdo muscle spasm Cervicitis with purulent, bloody discharge **Investigations:** Endocervical & urethral swabs Blood cultures **Management:** IV Abx (cefriaxone & doxycycline) Contact tracing

Answer 85

**Definition:** Normal Range 135-145 mmol/L Nearly always due to inadequate water intake **Aetiology:** Inadequate water intake plus: ADH deficiency (diabetes insipidus) Insensitivity to ADH (drugs, ATN) Osmotic Diuresis (diabetic coma, TPN) **Clinical Features:** Volume depletion Confusion / convulsions Fever Features of underlying cause **Investigations:** Plasma osmolality high Low urine osmolality indicates diabetes insipidus **Management:** Replace fluid Treat underlying cause

Answer 86

**Definition:** A displeasing feeling of fear and concern **Aetiology:** "biological vunerability" **Clinical Features:** GI - dry mouth, dysphagia, epigastric pain, diarrhoea Resp - chest constriction, difficulty inhaling, overbreathing CVS - palpitations, chest pain GU - frequency, erection failure, reduced libido Neuro - fatigue, blurred vision, dizziness, headache, poor sleep Psychological - Apprehension & fear, irritability, poor concentration, distractibility, restlessness, sensitivity to noise, depression, depersonalisation, derealisation **Investigations:** Clinical diagnosis **Management:** Reassurance, relaxation techniques, anxiety management, CBT SSRIs - citalopram, fluoxetine, sertraline ß-blockers for physical symptoms Short course of benzodiazepines - diazepam, temazepam

Answer 87

**Definition:** Inflammation of the gall bladder **Aetiology:** Caused by chemical irritation within an obstructed gallbladder. Often begins with simple Biliary Colic **Clinical Features:** Severe RUQ pain Fever Tachycardia Nausea / Vomiting Murphy’s sign +ve - ask patient to take deep breath pressing RUQ under costal margin **Patients tend to lay still & take shallow breaths as this is a local peritonitis** **Investigations:** WCC - increased USS - Gallbladder - thickened gallbladder Plain Abdominal X-ray - only show 10% of stones **Management:** IV Fluid resuscitation IV Antibiotics - Cefuroxime Keep patient NBM **Cholecystectomy** Time frame is controversial Increasingly surgeons carry out procedure early in the acute phase Some say it’s better to wait until 6-8 weeks later _80-90% of cases of acute cholecystitis will spontaneously resolve over 24-48hrs_

Answer 88

**Aetiology:** Compression of the median nerve as it passes depp to the flexor retinaculum. F\>M Idiopathic DM Hypothyroidism Pregnancy RA Obesity **Clinical Features:** Tingling or pain in thumb, index & middle fingers Worse at night Shake or flick wrist for relief Later: wasting of thenar eminence **Investigations:** Phalen's (inverted prayer for 1-2mins) Tinel's (tapping over tunnel) USS **Management:** Pain relief Splints at night Retinaculum division

Answer 89

**Definition:** Progressive degeneration of lower motor neurons and upper motor neurons of the cortex, cranial nerve nuclei and spinal cord. 2:100 000 pa Slight Male predominance **Clinical Patterns:** Progressive muscular atrophy – progressive weakness and wasting of arm and hand muscles Amyotrophic Lateral Sclerosis – progressive spastic tetraparesis or paraparesis with wasting and fasciculation Progressive Bulbar Palsy – degeneration of lower cranial nerve nuclei **Clinical Features:** Muscle Wasting Fasciculation Areflexia or hypereflexia Dysarthria Dysphagia Nasal Regurgitation of fluids Choking Bulbar & Pseudobulbar palsy Occular Movements not affected Cerebellar or extrapyramidal signs do not occur Dementia is unusual Sphincter function is usually preserved No sensory signs **Investigations:** Clinical diagnosis Electromyography (EMG) – denervation of muscles with preserved motor conduction velocity **Management:** Riluzole – sodium channel blocker slows progress Nothing affects outcome Relentlessly Progressive with death in 3 years