Internal med Flashcards
(125 cards)
1
Q
What are things to consider as part of initial management in patinets with COPD?
A
- smoking cessation advice: including offering nicotine replacement therapy, varenicline or bupropion
- annual influenza vaccination
- one-off pneumococcal vaccination
- Pulmonary rehabilitation to all people who view themselves as functionally disabled by COPD (usually Medical Research Council [MRC] grade 3 and above)
2
Q
Who is oral azithromycin prophylaxis useful for in COPD? 250mg 3 times a week
A
- Do not smoke and
- Have optimised non-pharmacological management and inhaled therapies, relevant vaccinations and (if appropriate) have been referred for pulmonary rehabilitation and continue to have 1 or more of the following, particularly if they have significant daily sputum production:
- Frequent (typically 4 or more per year) exacerbations with sputum production
- Prolonged exacerbations with sputum production
- Exacerbations resulting in hospitalisation.
3
Q
What are some congenital causes of QT prolongation?
A
- Jervell-Lange-Nielsen syndrome (includes deafness and is due to an abnormal potassium channel)
- Romano-Ward syndrome (no deafness)
4
Q
What are some medications that cause QT prolongation?
A
- amiodarone, sotalol, class 1a antiarrhythmic drugs
- tricyclic antidepressants, selective serotonin reuptake inhibitors (especially citalopram)
- methadone
- chloroquine
- terfenadine
- erythromycin
- haloperidol
- ondanestron
5
Q
What are some miscellanous organic causes of QT prolongation other than congenital and drugs?
A
- electrolyte: hypocalcaemia, hypokalaemia, hypomagnesaemia
- acute myocardial infarction
- myocarditis
- hypothermia
- subarachnoid haemorrhage
6
Q
What are the commonest bugs causing exacerbation of COPD?
A
Haemophilius influenzae
Strep pneumoniae
Moraxella catarrhalis
7
Q
Bug that causes chest infection and often affects younger patients, frequently those living in crowded accommodation. It is associated with a number of characteristic complications such as erythema multiforme and cold autoimmune hemolytic anemia.
A
Mycoplasma pneumoniae
8
Q
How do you differentiate typhoid from dengue and leptosperosis?
A
Dengue usually presents with fever and joint pains whilst leptospirosis follows a biphasic pattern of fever and headaches continuing with muscle and abdominal pain
Typhoid - erythematous rash on her trunk and back are known as rose spots which are irregular discrete spots measuring between 2-4mm. Non-productive cough, diarrhoea and constipation
9
Q
What is the organism that causes typhoid?
A
Salmonella typhi and Salmonella paratyphi
10
Q
A 25-year-old man with ulcerative colitis presents with new onset itching and fatigue. On examination you note that he is jaundiced and tender in the right upper quadrant with significant hepatomegaly. He reports that his ulcerative colitis is well controlled and he has not had a flare in over 6 months. However, he believes he has lost weight despite no change to his diet or exercise.
Which autoantibody tests would you expect to be positive?
A
p-ANCA
ulcerative colitis coupled with new clinical signs of hepatobiliary disease should make you think of primary sclerosing cholangitis.
11
Q
What are some of the complications associated with blood transfusion?
A
- Non-haemolytic febrile reaction
- Allergic reaction
- Anaphylaxis
- Infective
- transfusion-related acute lung injury (TRALI)
- transfusion-associated circulatory overload (TACO)
other: hyperkalaemia, iron overload, clotting
12
Q
what are the features of non-haemolytic febrile reaction? and management
A
Fever, chills
Thought to be caused by antibodies reacting with white cell fragments in the blood product and cytokines that have leaked from the blood cell during storage
Start paracetamol
13
Q
How do you differentiate chronic renal failure from AKI?
A
Best way to differentiate is renal ultrasound - most patients with CRF have bilateral small kidneys
hypocalcaemia (due to lack of vitamin D)
14
Q
What is the choice of antiplatelet therapy after NSTEMI?
A
DAPT:
1. Aspirin +
2.
if the patient is not taking an oral anticoagulant: prasugrel or ticagrelor
if taking an oral anticoagulant: clopidogrel
15
Q
How do you treat a man with UTI?
A
Trimethoprim or nitrofurantoin are both appropriate first-line antibiotics for suspected lower urinary tract infections. However, whilst a 3-day course is acceptable in women, men must be treated for 7 days and may need to be referred to a Urologist if they get a recurrence.
16
Q
What is the investigation of choice for suspected neoplastic spinal cord compression?
A
MRI whole spine
17
Q
What is the management for suspected neoplastic spinal cord compression?
A
High dose PO Dexamethasone
18
Q
What are the common side effects of 5-HT antagonists (ondensetron)?
A
constipation is common
prolonged QT interval
19
Q
What are the side effects of erythropoietin treatment?
A
- Accelerated hypertension potentially leading to encephalopathy and seizures (blood pressure increases in 25% of patients)
- Bone aches
- Flu-like symptoms
- Skin rashes, urticaria
- Pure red cell aplasia* (due to antibodies against erythropoietin)
- Raised PCV increases risk of thrombosis (e.g. Fistula)
- Iron deficiency 2nd to increased erythropoiesis
20
Q
What are some reasons patients do not respond to EPO treatment?
A
- iron deficiency
- inadequate dose
- concurrent infection/inflammation
- hyperparathyroid bone disease
- aluminium toxicity
21
Q
What are the causes of DCM?
A
alcohol
Coxsackie B virus
wet beri beri
doxorubicin
cocaine abuse, hemochromatosis, sarcoidosis, and pregnancy
22
Q
What are some live attenuated vaccines?
A
BCG MMR oral polio yellow fever oral typhoid
23
Q
A 40-year-old patient with HIV was assessed in the neurology clinic after reporting worsening clumsiness over the past month; he regularly falls into door frames and this is not something that he has experienced before.
On physical examination, the patient had an unsteady gait and dysdiadochokinesia. Cranial nerve testing and speech were normal, and the rest of the examination was unremarkable.
The patient underwent extensive investigation and his MRI scan was found to show multifocal non-enhancing lesions.
What is the likely diagnosis and causative organism?
A
The scenario above suggests that the patient has developed progressive multifocal leukoencephalopathy, which is a rare viral disease of the brain caused by the John Cunningham virus. The virus damages the nerves through demyelination and can become fatal if left untreated.
- Affects patients that are immunocompromised
- Ataxia , weakness, visual changes , disturbed speech
- Multifocal non-enhancing lesions
24
Q
What are some complications of meningitis?
A
- Sensorineural hearing loss
- Seizures
- focal neurological deficit
- Waterhouse- Friderichsen syndrome - adrenal insufficiency 2dary to adrenal haemorrhage
25
What are the potential risk factors for asystole?
- Complete heart block with broad complex QRS
- Recent asystole
- Mobitz type II AV block
- ventricular pause > 3 seconds
26
What is the most common inherited condition causing thrombophilia?
Factor V leiden
27
What is the INR target if on warfarin and VTE risk? ANd with recurrent VTE?
venous thromboembolism: target INR = 2.5, if recurrent 3.5
28
What is the INR target if on warfarin and has AF?
2.5
29
What are the fundamental INR action thresholds?
INR >5 = Vit K in some form or the other
Bleeding - IVI Vit K
Bleeding > 8 - stop warfarin + add Vit K
< 2 cover is required until patient is > 2 for 24hrs
30
What atypical pneumonia is associated with erythma multiforme?
Mycoplasma pneumoniae
31
When is warfarin stopped for surgery? and when is it restarted?
Usually stopped 5 days before planned surgery
Once the person's international normalized ration (INR) is less than 1.5 surgery can go ahead.
Warfarin is usually resumed at the normal dose on the evening of surgery or the next day if haemostasis is adequate.
32
What are some causes of hypervolaemic hyponatraemia?
Renal failure
Heart failure
Liver failure
Nephrotic syndrome
33
What are some causes of euvolaemic hyponatraemia?
- Syndrome of inappropriate ADH release (SIADH)
| - Hypothyroidism
34
What are the C450 inducers?
Reduce the concentration of drugs metabolised by the cytochrome P450
CRAPS out the drug
```
Carbamezapine
Rifampicin
Barbiturates
Phenytoin
St Johns Wort
```
35
What are some of the cytochrome P450 inducers?
Reduce the concentration of the drugs metabolised by the CP450 system
CRAPs out the drug
```
Carbamezapine
Rifampicin
bArbiturates
Phenytoin
St Johns Wort
```
36
What are some of the CP450 inhibitors?
Increase the concentration of drugs metabolised by the CP450 system
Some certain silly compounds annoyingly inhibit enzyme , Grrrrrrrr
```
Sodium valproate
Ciprofloxacin
Sulphonamide
Cimetidine/ Omeprazole
Antifungals, amiodarone
Isoniazid
Erythromycin/ clarithromycin
Grapefruit juice
```
37
What are some drugs that interact with CP450 inhibitors or inducers?
```
Warfarin
COCP
Theophylline
Corticosteroids
Tricyclics
Pethidine
Statins
```
38
What medications can induce cerebellar syndrome effects?
Phenytoin and Carbamezepine
39
what are the conditions required for diagnosis of graft vs host disorder?
Billingham's criteria:
1. transplanted tissue contains immunologically functioning cells
2. the recipient and donor are immunologically different
3. recipient is immunocompromised
40
what are the risk factors causing graft vs host disorder in patients recieving allogenic bone marrow transplant?
1. poorly matched donor and recipient
2. type of conditioning used prior to transplantation
3. gender disparity between donor and recipient
4. graft source - bone marrow/peripheral blood source higher risk than umbilical cord blood
41
what is the definition of acute Graft vs host disorder and what are the classical symptoms?
Is classically defined as onset is classically within 100 days of transplantation*
Symptoms:
- Painful maculopapular rash (often neck, palms and soles), which may progress to erythroderma or a toxic epidermal necrolysis-like syndrome
- Jaundice
- Watery or bloody diarrhoea
- Persistent nausea and vomiting
- Can also present as a culture-negative fever
42
what are the typical features of myxoedema coma?
It is a complication of longstanding untreated hypothyroidism precipitated by illness, stress and drugs.
```
confusion
hypothermia
non-pitting periorbital and leg oedema
reduced respiratory drive
pericardial effusions
anaemia
seizures
```
43
what are the common bacteiral organisms causing infective exacerbation of asthma?
1. haemophilus influenzae
2. streptococcus pneumoniae
3. moraxella catarrhalis
44
what is the triad seen in pharyngeal pouch?
1. dysphagia
2. aspiration pneumonia
3. halitosis
45
what is the monitoring required for statins?
1. liver impairment - 3 mths and then at 12 mths
| 2. myopathy
46
what causes pulsus paradoxus?
severe asthma
| cardiac tamponade
47
what is the cause of the 3rd heart sound and aetiology?
Caused by diastolic filling of the ventricle
heard in LV failure (dilated cardiomyopathy), constrictive pericarditis and mitral regurg
48
what are the symptoms of unstable patient with tachycardia?
1. shock - hypotension
2. syncope
3. myocardial ischaemia
4. HF
49
what are the features of boerhaaves syndrome?
- spontaneous rupture of the oesophagus
- sudden history of severe chest pain - complicates vomiting
Triad of - vomiting, thoracic pain, subcutaneous emphysema.
- Diagnosis - CT contrast swallow
50
what is the tx for boerhaave syndrome?
thoracotomy and lavage, if less than 12 hours after onset then primary repair is usually feasible, surgery delayed beyond 12 hours is best managed by insertion of a T tube to create a controlled fistula between oesophagus and skin.
51
what is the time threshold for fibrinolysis in MI?
12 hrs from onset of symptoms if PCI cannot be delivered within 120 mins
52
what cardiac marker is used to check for reinfarction?
CK-MB : most specific for cardiac muscles
| rises within 2-4hrs of an Mi and returns to normal in 72 hrs
53
what is the cause of persistent ST elevations 2 weeks after MI?
left ventricular aneurysm
54
what are some of the features of aortic regurgitation?
1. early diastolic murmur
2. collapsing pulse
3. wide pulse pressure
4. Quinke's sign (nailbed pulsation)
5. De musset's sign - head bodding
55
when sis adrenaline given in shockable rhythm?
after the third shock and another dose after 5 shocks
56
what are the features of MEN type 1 neoplasia?
3 Ps:
Parathyroid - hyperparathyroidism
pituitary
Pancreas - insulinoma, gastrinoma
MEN1 gene
57
what are the features of MEN type 2 neoplasia?
2 Ps:
Parathyroid
Pheochromocytoma
RET oncogene
58
what are the features of MEN type 3 neoplasia?
pheochromocytoma
RET oncogene
59
what are the contraindications to thrombolysis?
ABC SHIP
```
Aortic dissection
Bleeding
coag disorder
stroke < 3 mths
hypertension (severe)
intracranial neoplasm/ inur
pregnancy
```
60
what are some common side effect of amiodarone?
- persistent grey skin discolouration
- thyroid - both hypo and hyperthyroidism
- corneal deposits
- pulmonary fibrosis/pneumonitis
- photosensitivity
- bradycardia
- lengthens Qt interval
61
what drugs are associated with causing SIADH?
carbamazepine, sulfonlyureas, SSRi and tricyclics
62
what is the medical mx of SIADH?
fluid restrict and give demeclocycline
63
what is the management of type A aortic dissection?
surgical mx but blood pressue should be controlled to a target of 100-120 systolic
64
what is the management of type B aortic dissection?
conservative mx, bed rest and reduce blood pressue IV labetalol to prevent progression
65
what are the predisposing factors for sleep apnoea?
Obesity
macroglossia
large tonsils
marfan syndrome
66
what are the drugs that cause raised prolactin?
metaclopramide, domperidone
pheotiazine
haloperidol
SSRI , opioids
67
what are the features of kartegener syndrome?
"dextrocardia- situs inversus
bronchiectasis
recurrent sinusistis
subfertility"
68
A 67 year old female is admitted to hospital following a fracture to her left ankle. She has a history of coeliac disease and does not take any medications.
Her blood tests show a vitamin D level of 10 nmol/L, calcium level 2.16 mmol/L and ALP of 250 international units (IU).
What would be the most appropriate treatment regimen?
High dose vitamin D treatment and calcium supplementation
A vitamin D level of less than 25 nmol/L reflects deficiency and requires high dose treatment initially followed by maintenance treatment. If the patient is found to be hypocalcaemic, calcium supplementation should be advised.
69
when is surgery considered in patients with acute UC flare up?
Acute fulminant ulcerative colitis
Toxic megacolon who have little improvement after 48-72 hours of intravenous steroids
Symptoms worsening despite intravenous steroids
Panproctocolectomy with permanent end ilesotomy
70
what are the features of TCA overdose?
1. drowsiness + confusion
2. Arrhythmia - sodium channel blockage - QRS complex widening
3. seizures
4. vomiting
5. headache + flushing
6. dilated pupils
71
what are the features of TCA overdose on ECG?
1. sinus tachycardia
2. widening of QRS
3. prolongation of the QT interval
72
what is the mx of TCA
IV bicarbonate
- first-line therapy for hypotension or arrhythmias
- indications include widening of the QRS interval >100 msec or a ventricular arrhythmia
73
which drugs cause post-hepatic jaundice?
```
coamoxiclav
flucloxacillin
nitrofurantoin
steroids
sulfonylureas
```
74
what are the 2 week referral criteria for neck lumps?
1. unexplained hoarseness or voice changes associated with a goitre
2. lymphadenopathy associated with a thyroid lump
3. rapidly enlarging painless thyroid mass increasing in size over a period of weeks
4. child with thyroid nodule
75
what are some causes of cerebellar syndrome?
1. stroke
2. lyme disease
3. multiple sclerosis
4. trauma to the posterior fossa
5. alcoholism
6. drugs - phenytoin and carbamazepine
7. neoplastic causes - cerebropontine angle tumour and acoustic neuroma
76
what are the cautions with TCA usage?
- Contraindicated in those with previous heart disease (use sertraline instead)
- Can exacerbate schizophrenia
- May exacerbate long QT syndrome
- Use with caution in pregnancy and breastfeeding
- May alter blood sugar in T1 and T2 diabetes mellitus
- May precipitate urinary retention, so avoid in men with enlarged prostates
- Uses the Cytochrome P450 metabolic pathway, so avoid in those on other
CP450 medications or those with liver damage
77
what are some of the hereditary causes of colorectal cancer?
- Familial adenomatous polyposis
- Hereditary nonpolyposis colorectal cancer (Lynch Syndrome)
- Juvenile polyposis
- Peutz-Jeghers syndrome
78
what is the initial testing or screening test for acromegaly?
IGF-1
79
what is the next step investigation if IGF-1 in elevated in suspected acromegaly?
Growth hormone is measured following intake of oral glucose (Oral Glucose Tolerance Test) to see if growth hormone is inappropriately suppressed and to confirm the diagnosis of acromegaly.
Food intake - causes high glucose and subsequently low levels of GH
GH suppressed - acromegaly ruled out
GH not suppressed - confirmed acromegaly
80
what is the triad of felty syndrome?
1. rheumatoid arthritis
2. splenomegaly
3. neutropenia
81
what are the different antui-epileptics available and which types of epilepsy do they treat?
Lamotrigine, levetiracetam and valproate are good for all seizure types.
Carbamazepine, gabapentin and phenytoin are better for focal (including secondary generalised) seizures.
Ethosuximide is the drug of choice for absence seizures.
Carbamazepine may worsen myoclonic seizures.
82
what is the periopertaive mx of non-insulin dependent diabetics?
1. Hold all oral diabetic medication on the morning of the procedure.
2. If the patient is on insulin then switch to sliding scale infusion (restart when they can eat).
3. Restart all oral medication the morning after surgery.
83
what is the periopertaive mx of insulin dependent diabetics?
1. Put the patient as early on the theatre list as possible minimising the amount of time the patient is nil by mouth.
2. Stop any other insulin and begin sliding scale insulin infusion from when the patient is placed nil by mouth.
3. Continue infusion until patient is able to eat post-operatively.
4. Switch to normal insulin regimen around their first meal.
84
who are the patients who need urgent endoscopy when they present with dysphagia?
Patients who are over 55 or present with ALARMS signs should undergo urgent endoscopy within two weeks to investigate for cancer.
```
ALARMS signs :
Anaemia
Loss of weight
Anorexia
Recent onset of symptoms, Melaena/haematemesis
Swallowing difficulties (dysphagia).
```
An epigastric mass or persistent vomiting would also be indications for urgent endoscopy.
85
what is the mx of peritoneal dialysis peritonitis?
1. The peritoneal dialysis fluid should be sent for culture.
| 2. Management is with intraperitoneal and systemic antibiotics.
86
what meds are used for neuropathic pain?
1. gabapentin
2. pregabalin
3. amitryptyline
4. duloxetine
87
what are the features of digoxin on ECG?
```
Downsloping ST depression
T-wave changes (inversion)
Biphasic/flattened and shortened QT interval
Slight PR interval prolongation
Prominent U-waves
```
88
what is pellegra and what are the features of it?
It is caused by vitamin B3 deficiency
Dementia
Dermatitis
Diarrhoea
hairloss
phtosensitivity
glossitis
89
what are the features of hypocalcaemia?
```
S – Spasms (Trousseau's sign)
P – Perioral parasthaesia
A – Anxiety/Irritability
S – Seizures
M – Muscle tone increase (colic, dysphagia)
O– Orientation impairment (i.e. confusion)
D – Dermatitis
I – Impetigo herpetiformis
C – Chvostek's sign
```
90
what is howell-joly bodies a sign of?
hyposplenism
91
what are the features of dehydration that can be detected biochemically?
- disproportionate increase in urea compared to creatinine
- increased albumin
- increased haematocrit
- increased sodium
92
what are the factors that can cause increased prostate specific antigen?
- Acute urinary retention
- benign prostatic hypertrophy
- recent ejaculation
- PR examination
- urethral instrumentation
- UTI
- prostatitis
- prostate cancer
93
what is the diagnostic criteria for DKA?
- pH <7.3 and/or bicarbonate <15mmol/L.
- Blood glucose >11mmol/L or known diabetes mellitus.
- Ketonaemia >3mmol/L or significant ketonuria ++ on urine dipstick.
94
what is the cause of hyperthyroidism with a tender goitre?
Subacute (De Quervain's) thyroiditis
95
who do you start tx for osteoporosis?
1. Anyone with a BMD >-2.5 on DEXA
2. Anyone 75 or Over with a Fragility Fracture
3. Anyone on High Dose Corticosteroids (>7.5mg for >3months)
96
what are the sick day rules of diabetes?
1. Increase frequency of blood glucose monitoring to four hourly or more frequently
2. Encourage fluid intake aiming for at least 3 litres in 24hrs
3. If unable to take or struggling to eat may need sugary drinks to maintain carbohydrate intake
4. It is useful to educate patients so that they have a box of 'sick day supplies' that they can access if they become unwell
5. Access to a mobile phone has been shown to reduce progression of ketosis to diabetic ketoacidosis
if on insulin - do not stop taking it
97
what is the make up of pseudogout and gout crystals?
pseudogout - weakly-positively bifringent rhomboid shaped crystal made of calcium pyrophosphate dihydrate crystals
gouts - needle shaped negatively bifringent monosodium urate
98
what metabolic abnormality does cushings syndrome cause?
hypokalemic metabolic acidosis -
when the levels of cortisol are high - inactivate 11beta dehydrogenase is free to bind with the mineralocorticoid receptors. This causes increase in water and sodium retention, increased potassium excretion and increased hydrogen ions.
99
what are the features of anti-phospholipid syndrome?
Clots in the arteries and veins
Livedo reticularis
obstetric problems/miscarriages
Thrombocytopaenia
100
what are the drugs causing drug induced lupus?
Most common causes
procainamide
hydralazine
Less common causes
isoniazid
minocycline
phenytoin
101
what do you need to monitor for pts on hydroxychlorquine?
visual acuity
bull's eye retinopathy - may result in severe and permanent visual loss
baseline ophthalmological examination and annual screening is generally recommened
102
what causes avascular necrosis of the hip?
High dose steroid therapy
| previous hip fracture and dislocation
103
what are the poor prognostic factors of rheumatoid arthritis?
1. rheumatoid factor positive
2. anti-CCP antibodies
3. poor functional status at presentation
4. X-ray - early erosions
5. extra articular features - nodules
6. HLA DR4
7. insidious onset
104
what is used to monitor the tx of rheumatoid arthritis?
Combination of CRP and disease activity (DAS28)
105
what needs monitoring when on methotrexate?
Monitoring of FBC and LFTs is essential - risk of myelosuppression and liver cirrhosis
106
what are different antibodies present in systemic sclerosis?
anticentromere antibodies - limited cutaneous systemic sclerosis
diffuse cutaneous systemic sclerosis - scl-70 antibodies
ANA positive - 90%
RF positive - 30%
107
what are the features of pancreatic cancer?
Courvoisier sign: enlarged, nontender gallbladder and painless jaundice
Belt-shaped epigastric pain which may radiate to the back
Nausea
Trousseau syndrome: superficial thrombophlebitis
108
what is the secondary stroke prevention?
HALTSS
1. Hypertension: studies show there is no benefit in lowering the blood pressure acutely (as this may impair cerebral perfusion) unless there is malignant hypertension (systolic blood pressure >180 mmHg). Anti-hypertensive therapy should, however, be initiated 2 weeks post-stroke.
2. Antiplatelet therapy: patients should be administered Clopidogrel 75 mg once daily for long-term antiplatelet therapy. In patients with ischaemic stroke secondary to atrial fibrillation, however, warfarin (target INR 2-3. or a direct oral anticoagulant (such as Rivaroxaban or Apixiban) is initiated 2 weeks post-stroke.
3. Lipid-lowering therapy: patients should be prescribed high dose atorvastatin 20-80 mg once nightly (irrespective of cholesterol level this lowers the risk of repeat stroke).
4. Tobacco: offer smoking cessation support.
5. Sugar: patients should be screened for diabetes and managed appropriately.
6. Surgery: patients with ipsilateral carotid artery stenosis more than 50% should be referred for carotid endarterectomy.
109
what are the features of osteogenesis imperfecta?
Osteogenesis imperfecta is a genetic disorder varying in severity characterised by inadequate collagen formation in bones, leading to fragile bones which are prone to fractures. It is also commonly associated with eye, hearing and dental abnormalities.
```
BITE:
B = bones
I = eyes
T = teeth
E = ears
```
110
how do you differentiate short head vs long head bicep rupture?
History of severe pain and flexor weakness following strenuous action is highly suggestive of a bicep tendon injury. The large bulge in the anterior is the contracted body of the belly of the biceps muscle (called Popeye sign because it makes the arm look like the arm of the cartoon character Popeye the Sailor Man).
Short head - flexion is weak but supination is relatively preserved implies that the short head of biceps (which inserts into the radial tuberosity) has torn.
Long head - weakness on supination
111
what are the different types of surgery you can have for ulcerative colitis?
Divided based on presence of anus
1. In a loop ileostomy 2 bowel ends are visible. The patient is likely to have had an anterior resection (for high rectal cancer) with formation of a temporary loop ileostomy (to allow for healing of the distal anastomosis).
2. In an end ileostomy 1 end of bowel is visible. The patient may have had a sub-total colectomy with formation of a rectal stump and temporary end ileostomy. This may be done as an emergency for fulminant ulcerative colitis or C. diff colitis.
3. A patient with a colostomy and no anus is likely to have had an AP resection (for low rectal cancer).
4. A patient with a colostomy and an anus is likely to have had an emergency Hartmann's procedure. The stoma is temporary and can be reversed.
112
what is the 5 drug package for secondary mx post-MI? what else is part of the follow-up care package?
1. Aspirin 75mg OM
2. second anti-platelet (clopidogrel 75mg OD or ticagrelor 90mg OD)
3. Beta blocker (normally bisoprolol)
4. ACE-inhibitor (normally ramipril)
5. High dose statin (e.g. Atorvastatin 80mg ON)
All patients should have an ECHO performed to assess systolic function and any evidence of heart failure should be treated.
All patients should be referred to cardiac rehabilitation.
Patients who have been treated without angiography should be considered for ischaemia testing to assess for inducible ischaemia.
113
what is the bolam and boitho rules?
1. Standard of care is judged against an ordinary level from a doctor of that experience in those circumstances (Bolam)
2. Their actions must be sanctioned by a professional body of medical opinion (Bolam)
3. Those actions must stand up to logical scrutiny in court (Bolitho)
114
what are the false increases in troponin caused by?
```
Pericarditis
Myocarditis
Arrythmias
Defibrillation
Acute heart failure
Pulmonary embolus
Type A aortic dissection
Chronic kidney disease
Prolonged strenuous exercise
Sepsis
```
115
what are diagnostic investigations for multiple myeloma?
1. Serum and/or urine electrophoresis: this will show a paraprotein spike (typically IgG).
2. Serum free light chain essay (Bence Jones protein): in myeloma serum free light chain levels are high. This can be used in the 1-2% of patients with non-secretory multiple myeloma (i.e. those that are negative for serum/urine monoclonal protein on electrophoresis).
3. Tissue diagnosis typically by bone marrow aspirate and biopsy: myeloma is confirmed if there are >10% of plasma cells in the bone marrow.
116
which bloods can help detect the prognosis of multiple myeloma?
1. CRP (the higher the level, the worse the prognosis)
2. LDH (the higher the level, the worse the prognosis)
3. Beta-2 microglobulin (a very high over very low level confers poor prognosis)
4. FISH and cytogenetic analysis (this may also inform the type of treatment used)
117
what are the 5 extraarticular features of ankylosing spondylitis?
5 As
```
Anterior uveitis
aortic regurgitation
apical lung fibrosis
achilles tendonitis
amyloidosis
+ cauda equina syndrome
```
118
what are the features of ankylosing spondylitis?
SPINEACHES
```
Sausage digits
Psoriasis
Inflammatory back pain
NSAIDs good response
Enthesitis
Arthritis
Crohn's colitis, elevated CRP
HLA B27
eye (uveitis)
seronegative
```
119
when is surgical management of ectopic pregnancy advised?
Surgical management is recommended if the patient would be unable to attend follow-up or if the ectopic is advanced. An advanced ectopic is indicated if any of the following are present:
1. The patient is in a significant amount of pain
2. There is an adnexal mass of size ≥35mm
3. B-hCG levels are ≥5000IU/L
4. Ultrasound identifies a foetal heartbeat
120
what are the causes of hypoglycaemia?
```
EXPLAIN:
Exogenous drugs (typically sulfonylureas or insulin)
Pituitary insufficiency
Liver failure
Addison's disease
Islet cell tumours (insulinomas)
Non-pancreatic neoplasms
```
121
what is the cytotoxic drug associated with hypomagnesaemia?
cisplatin
122
what are the main side effects to look out for with mesalazine?
pancreatitis
| agrunolocytosis
123
what blood tests are part of the confusion screen?
1. FBC
2. U&E
3. LFt
4. Calcium
5. glucose
6. ESR/CRp
7. . TFT
8. Vitamin b12
9. folate
124
what is the treatment for cerebral toxoplasmosis?
sulfadiazine and pyrimethamine
125
what are the skin changes seen in varicose veins?
1. varicose eczema (also known as venous stasis)
2. haemosiderin deposition → hyperpigmentation
3. lipodermatosclerosis → hard/tight skin
4. atrophie blanche → hypopigmentation
