Learning Objectives Flashcards
(188 cards)
1
Q
What are hypertrophic and keloid scars and what is the difference?
A
Hypertrophic - exaggerated normal remodelling response, within wound margins, improves over time and responds to steroids and pressure
Keloid - extends beyong wound margins and progresses over time, more common with darker skin, less responsive to steroids and pressure
2
Q
What are the management options for dupuytrens contracture?
A
Nothing
Limited Fasciectomy
Radical Fasciectomy
Fasciotomy
Amputation
3
Q
What are some causes of dupuytrens contracture?
A
Alcohol
Congenital
Work
Epileptic drugs
Diabetes
4
Q
What are the main differential diagnoses for dysphagia?
A
Oesophageal cancer
Achalasia
Oesophageal Stricture
Stroke
Parkinsons
5
Q
What are the investigations for dysphagia?
A
Video swallow
Gastroscopy
Barium swallow
CT
Manometry
Endoscopic US
6
Q
What is the management for some differentials for dysphagia (pharyngeal pouch, oesopahgeal cancer, stricture, hiatus hernia, achalasia)?
A
Pharyngela Pouch - surgical repair
Cancer - surgery, adjuvant therapy
Stricture - surgical dilation, PPI, fundoplication
Hiatus Hernia - laporascopic repair
Achalasia - divide LOS, dilation
7
Q
What is the pathophysiology of aortic dissection?
A
Tear in the aortic intima - more commonly ascending aorta - leads to blood tracking between the intima and the media
8
Q
What are 5 risk factors associated with aortic dissection?
A
Hypertension
Aortic Aneurysm
Atherosclerosis
Male/increasing age
Collagen disorder - marfans, ehlers danlos
9
Q
What is the presentation of an aortic dissection?
A
Tearing pain radiating to the back +/- syncope
10
Q
What are the investigations and management for aortic dissection?
A
Investigations - BP different in each arm, D-dimer, CT
Management - analgesia, antihypertensives, beta blockers, surgery
11
Q
What is the pathophysiology and presentation of Marfan syndrome?
A
Pathophys - defect in fibrillin 1 gene, autosomal dominant, trouble producing elastin
Presentation - long bone excess growth, mitral valve prolapse, aortic regurg, joints lax, pectus carinatum (pigeon chest), scoliosis
12
Q
What is the investigation and management for Marfan syndrome?
A
Investigation - genetic testing, echo
Management - surgery, observation
13
Q
What are the common sites of berry aneurysm?
A
Posterior communicating and anteroir communicating arteires - branch points where vessels are weakest and are anastomosing
14
Q
What is a complication of berry aneurysm rupture and what is the treatment?
A
SAH - vasospasm few days later due to breakdown of blood products - treat with papaverine (vasodilation)
15
Q
What is thrombophilia and what may cause it?
A
Increased tendency of the blood to clot
Causes
- Factor V leiden
- Prothrombin mutation
- Protein C, S, antithrombin deficiency
- Antiphospholipid syndrome
16
Q
What are the most common presentations of thrombophilia?
A
DVT
PE
17
Q
What is the pathophysiology of vasculitis?
A
Inflammatory leucocytes in vein walls causing reactive damage and loss of vessel integrity - bleeding and downstream tissue ischaemia and necrosis
18
Q
What are the risk factors for vasculitis?
A
Smoking
HTN
Hypercholesterolaemia
Infection
19
Q
What is the pharmacological management for vasculitis?
A
Methotrexate
Prednisolone
Cyclophosphamide
20
Q
What are the classifications of vasculitis?
A
Large vessel
- Giant cell
- Takayasu
Medium vessel
- Polyarteritis
- Kawasaki
Small vessel
- ANCA
- Immune complex
- Good pastures
- IgA vasculitis
- Autoimmune - SLE
21
Q
What are the normal ranges of ABGs?
A
pH= 7.35-7.45
PaCO2= 35-45mmHg
PaO2=100 (>85)mmHg
HCO3= 22-30
SaO2 95-100%
22
Q
What is the acute management for raised ICP?
A
Maintain ICP at less than 20-25mmHg (dexamethasone, mannitol)
Avoid aggravating factors: obstruction of venous return (head position, agitation), respiratory problems (airway obstruction, hypoxia, hypercapnia), fever, sever hypertension, hyponatremia, anaemia, seizures
Sedation
Drainage of CSF
Osmotherapy with mannitol or hypertonic saline
23
Q
What are the risk factors for dementia?
A
Age
ApoE4 mutation
Head trauma
Smoking
Education
Vascular disease
Diabetes
Lewy body disease
24
Q
What are the featrues of Alzheimers?
A
Memory loss
Loss of social and occupational functioning
Diminished executive function
Speech and motor deficits
Personality change
Behaviour and psychological disturbance
25
What is the treatment for an ischaemic stroke?
Thrombolysis (tPA - ateplase) within 4 hours of symptom onset
Aspirin
Fibrinolytic therapy
Antiplatelet
Mechanical thrombectomy - clot retrieval
26
What are the causative agents of meningitis and their CSF features?
27
What are the signs and symptoms of meningitis?
Headache
Rash
Neck stiffness
Photophobia
Nausea and vomiting
Fever
28
What is required for diagnosis of MS?
More than one episode of demyelination or evidence of more than one lesion on MRI
29
What may be the first presentation of MS?
White middle aged woman - temporary visual or sensory loss (optic neuritis)
30
What are the common causes of abdominal distension?
Flatus
Faeces
Foetus
Fluid
Fat
Fing big tumour
31
What is the investigation for bowel obstruction?
CXR - free fluid under the diaphragm
Supine AXR - dilated loops of bowel
Erect AXR - air fluid levels (\>3 is abnormal)
32
What antigen is raised in colorectal cancer?
CEA - only of use if it is high on diagnosis to look at after treatment to see value dropping (may also be elevated normally in smokers)
33
What are the major risks of scope procedures and what anaesthetic method is used?
Perforation and haemorrhage
Sedation - propofol
34
What is a Hartmanns procedure?
Sigmoidectomy without anastomoses (colostomy bag) --\> can come back after ~3 months and assess for rejoining (can bring out a temporary ileostomy to reduce stress on recently joined anastomoses)
35
Patient presents with eye pain worse with movement and colour vision is dulled and there may be loss of vision. What is the likely pathology and how can this be tested?
Optic neuritis
Swinging light test - afferent pupillary defect
36
What are the causes of a hydrocoele?
Primary - idiopathic (bilateral)
Secondary - cancer, mumps, epidiymal orchitis, trauma
37
What are the tumour markers for testicular cancer?
LDH
Beta-hcg
alpha-fetoprotein
38
Where do the testicular lymph nodes drain?
Paraaortic nodes
39
What are some signs and symptoms for SBO?
Nausea and vomiting (fecalant material)
No flatus
Absolute constipation
Abdominal distension
40
What are the management steps for a SBO?
Fluid resuscitation
NGT
Surveillance - most resolve within 48 hours
Nutritional support
Surgery - division of adhesions
41
What are some causes of spinal cord compression?
Tumour
Abscess
Degeneration - disc prolapse, OP, spondylosis, canal stenosis
Infection
Haematoma
Developmental - syrinx (fluid filled cavity in spinal cord), cyst
42
What are the red flags of back pain?
Hx of cancer
Sciatica
Pain at rest
Pain not relieved by analgesia
Fatigue, night sweats, loss of weight/appetite
Age \< 20 or \> 50
Glucocorticoid use
IVDU
Rapid progression
\> 1 month duration
43
What is the cause of cervical myelopathy and how does a patient present?
Cause is usually cervical vertebrae degeneration and canal stenosis in the elderly
LMN signs in upper limbs and UMN signs in lower limbs with neck pain
44
What may be the presenting complaints of a patient experiencing cauda equina compression?
Urinary retention/trouble initiating urination or incontinence
Constipation and faecal incontinence
45
Where is a spinal malignancy most commonly found?
Thoracolumbar region - dual blood supply
46
Where is a spinal abscess usually found and how does one present?
Thoracolumbar region - dual blood supply
Pain, neurological deficit, fever, diaphoresis, fatigue
47
What are the presenting symptoms of perianal disease?
PR bleeding
Pain
Anal lumps/swellings
Itch
Discharge
48
What are some PAINFUL perianal conditions?
Anal fissure
Haemorrhoids (strangulated)
Haematoma
Abscess
Anal cancer
Proctalgia fugax
49
What are some PAINLESS perianal conditions?
Fistula
Skin tags
Haemorrhoids (1st, 2nd, 3rd degree)
Low rectal cancer
Rectal prolapse
Polyps
Warts
Pruritis ani
50
What are the investigations for perianal pathology?
DRE (contraindicated with pain)
Sigmoidioscopu
Proctoscopy
51
What are the management options for an anal fissure?
Topical analgesia
Stool softener (Coloxyl + Senna)
Sitz bath
Rectogesic ointment - GTN (vasodilation to promote healing)
Nifedipine
Botox injection to intersphincteric space
Lateral sphincterotomty
* More indicated in males
* May lead to flatus incontinence, especially in females
Fissurectomy
52
What are the management options for perianal abscess?
Drainage
Antibiotics
(Surgery)
53
What are the management options for haemorrhoids?
1st (internal) - High fibre diet (reduce constipation), injection sclerotherapy, phenol in almond oil
2nd (protrude on defecation) - Diet modification, rubber band ligation
3rd (usually protruding) - Haemorrhoidectomy
4th (strangulated, painful) - Analgesia and surgery
54
What are the management options for anal warts?
Improve hygeine
HPV vaccine
Local excision
(Chemoirradiation therapy)
55
What are the management options for pruritis ani?
Topical steroid
Antifungal
Oral antihistamine
Avoid excessive wiping
Excise skin tags
56
What are the management options for low rectal cancer?
Radiotherapy
Chemotherapy
Surgical removal
* Low anterior resection (high risk of faecal incontinence)
* Abdomino-perineal excision - removal of rectum and anus, permanent stoma
57
What are the management options for anal cancer?
Radiotherapy
Chemotherapy
Abdominoperineal resection - permanent stoma
58
What is this pathology, the presentation and management?
Orbital Cellulitis
Painful red eye, fever, malaise
Surgical drainage and IV antibiotics
59
What is this pathology and what is the presentation and management?
Pterygium
Impaired ocular appearance, vision loss
Treat with topical lubricants and surgery
60
What is this pathology and what is the management?
Subconjunctival haemorrhage
Self resolving
61
What is this pathology, the presentation and management?
Scleritis
Aching pain, impaird vision
Urgent referral to opthalmologist
62
What is this pathology and the management?
Foreign body
Removal via surgery
63
What is this pathology and the management?
Hyphaema
Usually occurs due to blunt trauma
Treat with topical steroids and cycloplegics
64
What is this pathology, the presentation and management?
Acute angle closure glaucoma
Painful unilateral red eye, worsening vision, sudden onset
Acetaxolamide, beta blocker, steroids, laser
65
Patient presents with flashes of light and blurred vision, what is the pathology?
Retinal detachment
66
What is this pathology and the management?
Keratoconus
Need hard contact lenses or corneal transplant
67
Patient presents with dull colour vision, blurred vision and glare, what is the likely pathology?
Cataract
Need lens transplant
68
Patient presents with sudden painless unilateral vision loss and this fundoscopy view, what is the pathology?
Central retinal artery occlusion
69
Patient presents with sudden painless unilateral vision loss and this fundoscopy view, what is the pathology?
Central retinal vein occlusion
70
Patient presents with rapid decrease in central vision, metamorphosphia and central scotoma, what is the pathology and treatment?
Wet macular degeneration - anti-VEGF injections every 4-6 weeks for life
71
Patient presents with a gradual decrease in central vision and central scotoma, what is the pathology and treatment?
Dry macular degeneration - vitamin supplementation
72
What are the common benign breast conditions and their presentations?
Fibrocystic - scar tissue, rubbery and firm
Fibroadenoma - small lumps
Mastitis - breast enlarged due to infection (more common when breastfeeding) - staph aureus - manage with flucloxacillin
Fat Necrosis - lumps when areas of fatty breast tissue are damaged
Calcification - non painful, non palpable
73
What are the pros and cons of investigations for breast disease (mammogram, US, FNA, core biopsy)
Mammogram: early screening to pick up small cancers, lots of lesions picked up that may have never been a problem, radiation exposure
US: doesn't pick up all calcification, non-invasive
FNA: can work out nature of lesion, quick and simple, brusing bleeding and infection, seeding risk (displace tumour cells)
Core Needle Biopsy - tissue type lesion, haematoma, not always feasible for lesion in tricky spot
74
What is key for home breast examinations?
Better to examine breasts after a period - hormone levels are low and breasts should be at their 'normal'
Look for even shaping and colour
Nipple changes, redness, rash, swelling, dimpling of skin --\> consult doctor
Roll over breast while lying down to feel for lumps
75
What are the most common type of renal stones and what are the risk factors?
Calcium Oxalate
Risks: dehydration, high sodium diet, fam hx, climate, anatomical abnormalities
76
What are the causes of kidney stone formation?
Hypercalcaemia - primary HPT, immobile, cancer, sarcoidosis
Uric Acid Lithiasis - gout, idiopathic, low urine output
Metabolic - cystinuria
Secondary Urolithiasis - infection, obstruction
77
What is the typical presentation with renal calculi?
Pain
Haematuria
Infection (fever)
78
What is the typical presentation with ureteric calculi?
Sudden onset of severe flank pain which may radiate to groin
79
What is the investigation for acute stone episodes?
FBE, U&E, creatinine
Serum calcium and uric acid
CMP
MSU
CT-KUB
80
What are the management options for kidney stones?
Pain relief
Hydration
Expulsive therapy - alpha blockers (relax ureter wall)
Lithotripsy - shock waves to break down stones
Nephrolithotomy - remove stone through kidney cortex
Endoscopic surgery
81
What is the presentation for obstructive pyonephrosis and what is the management?
Presentation - flank pain, unwell, febrile, urinary symptoms, sepsis
Management - IVABx, decompression, fluids
82
What are some strategies to prevent renal strone recurrence?
Hydration
Reduce dietary salt
Urinary alkalinisation
Thiazide diuretics/allopurinol
83
What are some causes of haematuria?
Renal - glomerulonephritis, cancer, trauma, calculus, infection
Ureter - TCC (transitional cell carcinoma), calculus
Bladder - TCC, cystitis (MOST COMMON CAUSE), calculus, trauma
Prostate - BPH, carcinoma, prostatitis
Urethra - structure, urethritis, trauma, carcinoma
84
What are some investigations for haematuria?
Urine
* Micro
* RBC
* Morphology
* Glomerular (upper tract bleeding - red cells look misshapen)/non-glomerular (red cells look untouched)
* Protein/casts (suggestive of renal parenchymal problem)
* Cytology
* Culture
Imaging
* US urinary tract
* CT urogram (not in people who can't tolerate contrast)
Endoscopy
* Cystoscopy (retrograde pyelogram)
* Ureteropyeloscopy (+/- biopsy)
85
What are some differentials for headache and their features?
Tension - late in day, occipitalis and frontalis muscle spasm
Migraine - photophobia, scintillating scotoma, aura
Meningitis - fever, neck stiffness
Encephalitis
Subdural Hematoma - elderly, alcoholics, anticoagulants
Tumour - morning headaches, seizures, neurological deficits
Trauma
Temporal Arteritis - unilateral, usually \> 50, visual disturbance, jaw claudication, scalp tenderness
Aneurysm (strong association b/w berry aneurysms and adult polycystic kidney disease - autosomal dominant - bicuspid aortic valve with aortic coarctation)
Sinusitis
Cluster headache
Glaucoma - unilateral, visual disturbance
86
What are common investigations used to diagnose SAH?
CT - within 12-24 hours, may be normal
LP - looking for bloodstained CSF that doesn't clear on 3 consecutive samples
Cerebral angiography
87
What is the early management for SAH?
Observation - BP, RR, HR (watching for coning and cushings triad - bradycardia, hypertenson and irregular resp rate)
Analgesia (avoid opioids)
Surgica Clipping
Endovascular coil embolization
88
What are some complications of SAH?
Vasospasm
Acute hydrocephalus
Rebleeding
89
What is normal ICP?
7-15mmHg (supine)
90
What are the signs of malignancy on mammogram and US for breast disease?
Mammogram - spiculated mass, irregular borders, microcalcification
US - hypoechoic, poster acoustic shadowing, taller than wide
91
What arethe prognostic and predictive features of breast carcinoma?
Prognostic
* Size
* Histology (ductal, lobular)
* Grade
* Margins
* Lymph invasion
Predictive
* PR and ER status (positive in low grade)
* HER2 status (positive in high grade)
92
What are the common causes of upper GI bleeding?
Peptic ulcer disease
Gastristis
Oesophageal varices
Mallory weiss tear
93
What are haematemesis and melena?
Hematemesis - bleeding in upper GIT, leading to vomiting of fresh blood
Melena - black stool due to processing of blood from upper GIT - proximal to ileocaecal valve
94
When is bleeding haemodynamically significant?
Blood loss \> 500mL
Resting tachycardia, HR \> 100bpm
Systolic BP \< 100mmHg
Orthostatic Hypotension - pulse increase of \> 20 bpm OR systolic pressure decrease of \> 20 mmHg
95
What are the risk factors, pathogenesis and clinical features, investigation and principles of management of adenocarcinoma?
Risks - older adult smokers, women, non-smokers
Pathogenesis - outer lung, EGFR/ALK mutations, most common non-small cell
Clinical - chest pain, haemoptysis, cough, B symptoms, SOB
Investigations - Hb, LFT, CXR, PET, sputum, bronchoscopy, FNA, tissue biopsy
96
What are the risk factors, pathogenesis and clinical features, investigation and principles of management of large cell carcinoma?
Risks - smoking
Pathogenesis - rapid growth, not common, any part of lung
Clinical - chest pain, SOB, cough, haemoptysis, B symptoms
Investigations - Hb, LFT, CXR, PET, sputum, bronchoscopy, FNA, tissue biopsy
Management - chemo, radiation, surgery
97
What are the risk factors, pathogenesis and clinical features, investigation and principles of management of small cell carcinoma?
Risks - adult smokers
Pathogenesis - most aggressive lung cancer, near bronchi, obstruction or distant mets on presentation
Clinical - cough, SOB, chest pain, haemoptysis, ADH syndrome, cyshingoid (hormone secretion), B symptoms
Investigations - Hb, LFT, CXR, PET, sputum, bronchoscopy, FNA, tissue biopsy
Management - chemotherapy (rapid response)
98
What are the risk factors, pathogenesis and clinical features, investigation and principles of management of squamous cell carcinoma?
Risks - men, smokers
Pathogenesis - cells lining airways, central
Clinical - chest pain, SOB, haemoptysis, B symptoms, cough
Investigations - Hb, LFT, CXR, PET, sputum, bronchoscopy, FNA, tissue biopsy
Management - surgery, chemotherapy, radiation
99
What are the patterns of injury following FOOSH and the best imaging for these?
Colles Fracture - distal radius, dinner fork deformity, AP and lateral wrist X-rays, extraarticular fracture, risk of median nerve damage
Smith Fracture - distal radius, palmar angulation (reverse colles), oblique wrist x-ray
Scaphoid fracture - risk of avascular necrosis of proximal scaphoid, image scaphoid (fat pad sign, terry thomas sign - scapholunate ligament disruption), CT may be better
100
What is the appropriate management for septic arthritis?
Joint washout
## Footnote
GP - vancomycin, clindamycin, cephalosporin, joint aspiration
GN - 3rd gen cephalosporin, joint aspiration, IV ciprofloxacin, gentamicin
MSSA - IV flucloxacillin then oral flucloxacillin (4 weeks)
MRSA - IV vancomycin, joint aspiration then oral clindamycin
101
What are the risk factors, presentation, investigations and treatment for epididymitis?
Risks - STI (chlamydia), e.coli, mumps, elderly, diabetic, immunosupressed
Presentation - pain, urethritis (discharge), dysuria, haematuria, unilateral swollen scrotum
Investigation - MSU, US
Treatment - analgesia, empiric Abx (trimethoprim, cephalexin, augmentin), epididimectomy
102
What are the risk factors, presentation, investigations and treatment for hydrocele?
Risks - idiopathic (bilateral), cancer, mumps, epididymal orchitis, trauma
Presentation - swollen scrotum
Investigations - US, tumour markers
Management - radical orchidectomy, PET, jabalay (evert tunica vaginalis)
103
What are the risk factors, presentation, investigations and treatment for varicocele?
Presentation - 'worms' left side when standing, pain
Management - surgical tie off of cremaster veins
104
What are the risk factors, presentation, investigations and treatment for fourniers gangrene?
Risks - infection of scrotum - necrotising fasciitis
Presentation - unilateral black scrotum
Management - debridement, graft, reimplant testes
(fatal if left alone)
105
What are the risk factors, presentation, investigations and treatment for testicular cancer?
Risk - 20-34, caucasion, trauma, hormones, atrophy, undescended testes
Presentation - painless lump, hydrocele, scrotal swelling (seminoma most common)
Investigation - US, tumour markers, CT, PET
Treatment - radical orchidectomy, BEP chemo (bleomycin, etoposide, cisplatin), radiotherapy (best for seminoma), lymph node dissection
106
What are the risk factors, presentation, investigations and treatment for lymphoma?
Presntation - unilateral testicular swelling, B symptoms
Investigations - US (hypoechoic lesion)
Management - orchiectomy, chemotherapy
107
What is the cause, drainaing site and treatment for penile cancer?
Squamous cell carcinoma
Drains to inguinal nodes
Penectomy (amputation) or radiotherapy
108
What are the risk factors, presentation, investigations and treatment for testicular torsion?
Risk - \< 25, neonate, trauma, undescended testi, cold weather
Presentation - acute severe pain, swelling, trauma, nausea and vomiting
Investigations - tender firm testicle, absent cremasteric reflex, urinalysis, US, doppler
Treatment - fixation, dartos pouch
109
What is myocarditis, how does a patient present and what is the treatment?
Myocardial inflammation due to viral infection - influenza, coxsackie, parvovirus, CMV, adenovirus, rubella, enterovirus, HCV
Presentation - chest pain, fatigue, arthralgia, peripheral oedema
Treatment - abx, steroids, diuretics, low salt diet, pacemaker
110
What is shock, why does it occur, how does it present and what is the management?
Inadequate organ perfusion nd oxygenation due to imbalance between supply and demand
Causes
* Cardiogenic (MI, arrhythmia, aortic stenosis, mitral regurg)
* Hypovolemic (haemorrhage, vomiting, diarrhoea, burns, dehydration)
* Obstructive (PE, tension pneumothorax, tamponade)
* Distributive (septic, anaphylactic, neurogenic)
Presentation - tachycardia, tachypnoea, hypotension, cold clammy skin, confusion, anxiety, low urine output, cyanosis, LOC
Management - DRSABCD, volume resus, vasopressors, rectify cause
111
What are some causes of sudden cardiac death?
Coronary heart disease
Congenital heart conditions
Cardiomyopathy
Valve disease
Arrhythmia - VF, VT, asystole, PEA
Previous MI
Trauma
Drugs
Long QT (greater than half the RR interval) - thiazide, macrolides, methadone, haloperidol, antihistamines
Cocaine
Aortic dissection
112
What are the types of cardiomyopathy and what is the most common?
**Dilated**
Hypertrophic
Restrictive
Arrhythmogenic
113
What are some of the signs of chronic liver disease?
Spider naevi: central arteriole with radiating small vessels, blanches, \>2 is abnormal, normally in SVC distribution
Splenomegaly
Jaundice: high bilirubin, sign of decompensation, can have isolated jaundice and high bilirubin (Gilberts, haemolytic disease (haemolysis))
Ascites: abdominal free fluid due to reduced oncotic pressure (low albumin production) and increased portal pressure
Caput Medusa: portal hypertension leading to umbilical anastomoses dilating
Clubbing: increased soft tissue of distal fingers and toes - maybe due to arterial hypoxaemia due to pulmonary AV shunt
Leuconychia: white flecks in the nail bed - due to low albumin or compression of capillary flow
Palmar Erythema: excessive oestrogens altering microvasculature
Dupuytrens Contracture: chronic liver disease (alcohol), manual labour, anti-epileptics, diabetes
Parotidomegaly: associated with alcoholism (fatty infiltrate due to alcohol toxicity and malnutrition)
Gynaecomastia: excessive oestrogen, spironolactone medication (K sparing diuretic)
Bruising: reduced production of clotting factors and platelets (thrombocytopenia)
Coagulopathy: reduced clotting factors, thrombocytopenia
114
What are some of the investigation findings associated with chronic liver disease?
LFT
* Low albumin
* Raised bilirubin
* AST \> ALT (cirrhosis)
Coagulopathy
* Prolonged INR (1.2-1.3)
* Low platelets (\<200) - possible portal HTN, folate or B12 deficiency, IPT
Ultrasound
* Cirrhotic shrunken liver
Fibro-scan
* Assess liver stiffness (\> 13kPa)
115
What is decompensated liver disease?
Decompensated alcohol related liver disease occurs when there is a deterioration in liverfunction in a patient with cirrhosis, which presents with jaundice, coagulopathy, ascites, and hepatic encephalopathy.
116
What are some causes of liver failure?
Autoimmune hepatitis
Primary biliary cirrhosis (autoimmune, women)
Primary sclerosing cholangitis (associated with IBD)
Haemochromatosis
Wilsons Disease - excess copper deposition in liver
NASH
Budd-chiari - hepatic venous outflow obstruction
HCC (hep B)
117
What are the key functions of the liver?
Synthesis of clotting factors (not factor 8 - produced in liver sinusoidal cells and endothelial cells outside of liver and circulates bound to Von Willebrand factor until an injury occurs)
Glucose homeostasis - gluconeogenesis, glycogen storage
Albumin synthesis
Conjugation and clearance of bilirubin
Ammonia metabolism and urea cycle
Drug metabolism and clearance
Immune - dealing with gut bacteria and products
118
What things increase the risk of breast cancer?
Early menarche
Late menopause
Nulliparus
No breastfeeding
Obesity
Genetics
119
What are the fertility issues with breast cancer treatment?
Premature ovarian failure or amenorrhoea with chemotherapy - need to consider fertility preservation
120
What endocrine therapy is available for breast cancer?
Tamoxifen (PR, ER)
Herceptin (HER2+ve)
121
What are the issues with surgical management of breast cancer?
Breast conservation surgery - risk of incomplete clearance
Consider double mastectomy and prophylactic oopherectomy
Lymph node clearance leading to lymphedema - chronic pain and loss of function
122
What are the types of anaemia and their causes?
Microcytic (\<80 MCV)
* **T**halassemia
* **A**naemia of chronic disease
* **I**ron deficiency (NSAIDs, stomach ulcer, colitis, piles, bowel cancer, menorrhagia, veganism, pregnancy, low iron diet)
* **L**ead poisoning
* **S**ideroblastic
Normocytic (80-100 MCV)
* **A**cute blood loss
* **B**one marrow failure
* **C**hronic disease (malignancy, rheumatological, coeliac)
* **D**estruction - haemolysis
* **E**PO low (chronic renal failure)
Macrocytic (\>100 MCV)
* **B**12/Folate low
* **A**lcoholism
* **L**iver failure
* **D**rugs (phenytoin)
* **H**ypothyroid
* **A**plastic (radiation, benzenes)
* **I**ncreased
* **R**eticulocytes
123
What is the pathology of pagets disease?
Disease that causes bones to grow too large and weak – usually in spine, pelvis, skull or leg - abnormal osteoclast activation
124
What is the pathology of avascular necrosis?
Cellular death of components of bone due to impaired blood supply – usually occurs at epiphysis of long bones, femoral head, femoral condyles, humeral head, scaphoid, talus
125
What is the pathology of osteomyelitis?
Infection of the bone/bone marrow usually via bacterial access to blood - Pyogenic bacteria most common
Can be isolated bacteraemia or associated with systemic sepsis
126
What is the pathology of septic arthritis?
Infection of a joint
* Staph aureus
* Strep pyogenes
* Haemophilus influenzae
* Knee most common site
127
What is the pathology of a lipoma?
Benign tumour composed of adipose tissue – most commonly occurring on trunk or proximal limbs
128
What is the pathology of an osteosarcoma?
Malignant mesenchymal tumour in which the tumour cells produce bone
129
What are some non-infective causes of fever?
Tumour - lymphoma, RCC, hepatoma, metastatic malignancy
Drugs (beta lactams, sulfonamides, quinidine, hydralazine, allopurinol, bleomycin, phenytoin, barbiturates)
Vasculitis (temporal arteritis)
SLE
Rheumatic fever
Sarcoidosis
IBS
Thromboembolic disease
Hyperthyroidism
Gout
Febrile neutropenia - chemotherapy, immunosuppression
130
What are the causes of post op fever?
Wind
* Pneumonia
* PE (day 5 post op)
* Atelectasis (early)
* More common in upper abdo surgery where breathing is more difficult due to pain
* Treatment - chest physio, antibiotics, CXR
Water
* UTI
* Catheter
* Alcohol withdrawal
Walking
* DVT
* Acute gout
Wonder Drugs
* Antimicrobials
* Heparin
Wound
* Sutures
* Cannula
* Injection sites
* Pressure ulcers
131
What are the main causes of lower urinary tract symptoms in men?
E.coli, klebsiella, proteus, providencia
IDC
Retention
Vesicouterine reflux
Renal tract obstruction - BPH, stones, stricture
Previous UTI
\>50
Instrumentation of renal tract
132
What are the main causes of lower urinary tract symptoms in women?
E.coli, staph saphrophyticus
Intercourse
Poor hygiene
Vesicouterine reflux
Recurrent UTI
Catheter
Retention
Spermicide use
Family history
Foreign body - stone, stitch
Post menopausal urogenital atrophy
133
What is the pathophysiology of BPH?
Hyperplasia of epithelial and stromal prostatic components, increased stromal : epithelial ratio. Over time can get bladder outlet obstruction. Increased epithelial tissue mostly in transition zone
134
What are the risk factors for BPH and what is the typical presentation?
Risks - age, family history
Symptoms - urinary retention, hesitancy, dribbling, weak stream, straining, intermittency
135
What is the treatment available for BPH?
5-alpha reductase inhibitor (reduce prostate growth)
Alpha blockers (reduce smooth muscle tone)
TURP
136
What is the difference between painful and painless urinary retention?
Acute urinary retention is usually painful and chronic urinary retention is often painless
Acute urinary retention generally presents as inability to pass urine and is typically associated with lower abdominal and or suprapubic discomfort
Chronic retention - bilateral hydronephrosis, bloating, overflow incontinence (first notice bed wetting)
137
What conditions can lead to osteoporosis?
Thyrotoxicosis
Primary hyperparathyroidism
Chronic liver or kidney disease
Hypercalciuria
Rheumatoid arthritis
Diabetes
Multiple myeloma
HIV
Mastocytosis
Immunosuppression
Osteogenesis imperfecta
138
What are some risk factors for osteoporosis?
Low exercise
Smoking
Poor nutrition - calcium/vitamin D deficiency
Prolonged amenorrhea
Post menopausal \<50
Excessive alcohol use (\> 2 units daily)
BMI \<20 or obesity
139
How is vitamin D deficiency related to osteoporosis?
Low vitamin D means there is no aid to absorb calcium, reduced calcium means that bone must be resorbed (osteoclasts) to maintain the extracellular calcium level
140
How are osteopaenia and osteoporosis diagnosed via bone density scanning?
Osteopenia - low bone density, DXA T-score 1-2.5
Osteoporosis - DXA T-score \< 2.5 due to reduced number of normally mineralised bone trabeculae
141
What is osteomalacia?
Defective bone mineralisation and fragility due to insufficient dietary calcium, vitamin D deficiency or resistance or due to increased renal loss of phosphate, DXA score can be in osteopenia or osteoporosis range (rickets in kids - wide ankles and wrists, short stature and bowed legs)
142
What are some preventative strategies for osteoporosis?
Weight bearing exercise
Diet rich in calcium and vitamin D
Weight loss
Smoking cessation
143
What are the therapeutic options for osteoporosis?
HRT: block osteoclast activation
Raloxifene (women only): agonist at oestrogen receptors in bone and CVS
Bisphosphonates - alendronate, risedronate, zoledronate: inhibit osteoclast formation and initiate osteoclast apoptosis, may cause jaw necrosis
Teriparatide: stimulates osteoblasts (PTH)
Denosumab: bind RANKL to prevent osteoclast action
Strontium: inhibit osteoclast formation and boost osteoblast activity, increase
144
What are some differentials for a patient presenting with haemoptysis, cough and SOB?
Lung cancer
PE
Pneumonia
TB
Bronchiectasis
Trauma
145
What are the respiratory causes of clubbing?
Idiopathic pulmonary fibrosis
Lung cancer
Bronchiectasis
Empyema
Cystic fibrosis
146
What is the prevalence of lung cancers (most to least common)?
Adenocarcinoma
Squamous cell
Large cell
Small cell
147
What is the typical presentation of lung cancer?
Cough
Change in voice
SOB
Haemoptysis
Chest Pain
Metastatic symptoms - bone pain, headaches
Lethargy
Weakness
Low weight and appetite
148
Why would there be a normal lactate in testicular tosion?
Strangulation or incarceration would cause lactate to be released - indicative of ischaemia - but due to blood supply being cut off, this is not released into the general circulation and is not picked up on routine testing
149
Where does a spigellian hernia occur?
Occurs at the lateral edge of rectus abdominus at arcuate line
150
What is the management for diverticulosis?
If recurrent episodes of diverticulitis and repeated administration of antibiotics, need to consider bowel resection or hartmanns to prevent recurrence of infection and irritation
151
What is COPD?
Irreversible airway inflammation and disruption of airflow
152
What are the risk factors for COPD?
Male
Indigenous
Smoking (active and passive)
Air pollution
Alpha-1 antitrypsin deficiency
Bronchial hyperresponsivness
Recurrent RTIs
153
What is the pathogenesis of COPD?
Noxious agents lead to airway inflammation, loss of elasticity and remodelling
Neutrophils, macrophages and CD8T cells cause an imbalance of proteinases - causing further lung damage
154
What is the pharmacologic management for COPD?
Smoking cessation: nicotine replacement, bupropion (antidepressant), varenicline (nicotinic receptor partial agonist)
Beta-2 agonists (SABA - salbutamol, LABA - salmeterol), SE: tremor, tachycardia
Anticholinergics: tiotropium, ipratropium (LAMA), SE: dry mouth
Inhaled corticosteroids: fluticasone
Influenza (annually) and pneumococcal (5 yearly) vaccines
155
What is the non-pharmacologic management for COPD?
Stop smoking: advice, willpower, counselling, courses
Pulmonary rehabilitation
Home oxygen therapy - 2-4L/min for 16hrs/day
Portable oxygen
156
What are the types of refractive error and what are they?
Myopia - short sighted, light focuses before the retina, cannot see things distant
Hyperopia - long sighted, light focuses behind the retina, cannot see things close up
Astigmatism - visual acuity lessened, football shaped cornea
Presbyopia - age 40, focal point of light starts to move behind the retina, need to hold things further away to focus on them, age related due to lack of flexibility of the lens
157
What is primary open angle glaucoma?
Progressive creeping peripheral visual field loss (central loss comes late), elevated intraocular pressure and extreme pain when acute.
Caused by neurodegenerative damage due to blochage of aqueous humour in the anterior chamber
158
What are the types of diabetic retinopathy?
Non-proliferative: aren't new vessels, mild, moderate and severe types, intra retinal and superficial bleeds (microaneurysms), exudative serous material leaking into macular region, can have intraocular injections to settle
Proliferative: new vessels forming, haemorrhage, treat with pan retinal photocoagulation - demand on the blood vessels is reduced to protect the retina
159
What is the likely pathology if a patient complains of fence posts bending in their vision?
Macular degeneration (process is metamorphopsia)
160
What are the types of macular degeneration?
Dry
Slowly progressing, little yellow spots in the retina (drusen) - waste material that collect under the retina (pigment epithelium not getting rid of waste material - early and intermediate MD) - drusen cause a bump in the retina causing a disruption in images, NO treatment (diet high in antioxidants is only recommendation for waste clearance)
Wet
Bleeding into the retinal tissue due to breakdown of barrier and blood vessels growing into the retina, treatable via injections of anti VEGF drugs (repetitive - every 4,6 or 8 weeks - intraocular injection for life), rapidly progressive
161
What is this pathology?
3rd cranial nerve palsy
Diplopia
Eyes turned down and out with ptosis
162
What is this pathology?
4th cranial nerve palsy
Eye raised and head tilt to try to overcome palsy
163
What is this pathology?
6th cranial nerve palsy
Cannot turn eye out when trying to look in that direction
Lateral rectus impaired
164
What are the features of a glioma?
Tumour arising from brain parenchyma
50% malignant astrocytomas
Signs - headache, visual loss, pain, weakness, numbness
165
What are the features of a meningioma?
Most common benign brain tumour
May cause no symptoms as there is no infiltration of brain tissue
Presentation - raised ICP, seizures, diplopoa
Radiation only known risk factor
166
What are the features of a pituitary adenoma?
Pituitary gland tumour causing bitemporal hemianopia (loss of vision on lateral sides of each eye)
May secrete hormones
Treat with hypophysectomy
167
What is parkinsons?
Loss of dopaminergic neurons in the substantia niagra in the basal ganglia and lewy bodies throughout the cortex causing a progressive decline in motor function
168
What is the presentation of parkinsons?
(usually asymmetrical to start with)
Resting tremor (4-6Hz)
Rigidity
Slow onset of anosmia
Bradykinesia
Postural instability
Hypophonia
Dysphagia
Stooped posture
Pedestal turning
Depression
Expressionless face
Dementia
Constipation
Fatigue
Shuffling gait
Micrographia
169
What is the treatment for parkinsons?
Levodopa/ carbidopa (prevents levodopa conversion outside brain - reduce emesis)
Bromocriptine (dopamine agonist)
Cabergoline (dopamine agonist)
Selegilline (MAO-B inhibitor, prevent dopamine reuptake)
Deep brain stimulation
170
What is primary angiitis and what is the presentation and differentials?
Vasculitis confined to the CNS
Presentation - prodrom, headache, cognitive impairment, stroke, seizures, TIA
Differentials - stroke, SLE, SAH, infection, systemic vasculitis
171
What are the red flags for headache?
Systemic illness
Neurologic signs
Onset sudden
Over 40-50
Prior headaches different
172
What movement is not possible with a median nerve dysfunction?
Thumb abduction
173
Why will a collateral ulnar ligament injury not heal without surgery?
Won't heal with splintage due to adductor aponeurosis overlying - which in injury ends up being under the ligament, so the ligament cannot heal back to normal position
174
What is a lung abscess and what are the risk factors?
Circumscribed collection of pus in the lung leading to cavity formation and air filled level of CXR
Risks -
Aspiration of gastric contents
Elderly
Reflux
Immunosuppression
Bronchial obstruction
Alcoholism
Malnourished
Klebsiella, pseudomonas
Most common in right lower lobe
Pre-existing lung damage - at risk of aspergillus
175
What is the presentation for lung abscess and how should it be investigated?
Fever, productive cough (putrid)
CXR - see cavitation with air fluid level
176
What is the treatment for a lung abscess?
Antimicrobials
Drainage
177
What are the common causes of community acquired pneumonia?
Strep pneumonia
Mycoplasma pneumoniae
Chlamydia
Legionella
Influenza
Adenovirus
Rhinovirus
178
What is the presentation of pneumonia?
Fever
Chills
Cough
Sputum
Dyspnoea
Myalgia
Arthralgia
Pleuritic pain
179
What is the treatment for community acquired penumonia?
Empirical Antibiotics
Macrolide – azithromycin/clarithromycin
Fluoroquinolone
Amoxicillin
Doxycycline
Oxygen
180
What are the main causes of hospital acquired pneumonia?
Gram negative bacilli – pseudomonas aeruginosa, E.coli, klebsiella, acinetobacter
181
What is the treatment for hospital acquired penumonia?
Penicillin
Macrolide
Doxycycline
182
What causes a pleural effusion and how does a patient present?
Causes
* Congestive heart failure
* Infection – pneumonia (gram positive most common)
* Malignancy
* Post surgery
Symptoms
* SOB
* Cough
* Pleuritic chest pain
* Fever and chills
* Tachypnoea
183
What is the treatment for a pleural effusion?
Chest physio
Fluid drainage (chest catheter)
Antibiotics
Diuretics
Cancer treatment
184
What is idiopathic fibrosis, causes, symptoms, investigations and management?
Fibrotic lung disease with no known cause that progresses over years - characterised by scar tissue formation within the lungs
Causes
* Cigarette smoking
* Environmental exposure
Presentation - SOB, cough
Investigations
* X-ray
* Spirometry (restrictive - low FVC, normal FEV1)
Management
* Lifestyle - smoking cessation
* Supplemental oxygen
* Antifibrotics (pirfenidone, nintedanib)
* Pulmonary rehab
* Lung transplant
185
What is bronchiectasis, causes, symptoms, investigations and management?
Chronic infection in small airways resulting in the lungs becoming damaged, scarred and dilated
Causes: Chronic airway infection (usually bacterial) – immune response results in chronic inflammation, pneumonia, COPD, smoking
Symptoms
* Productive cough
* Mucopurluent sputum
* Recurrent infections
* Fatigue
* Nasal inflammation
Investigations - sputum sample, CXR, CT (widening of airways)
Management - chest physio, inhaled bronchodilator, inhaled hyperosmolar agent, long term oral macrolide, inhaled antibiotic, lung transplant, ventilation (oxygen)
186
What is ARDS, causes, symptoms, investigations and management?
Acute respiratory distress syndrome – widespread inflammation in the lungs
Causes: pneumonia, sepsis, aspiration, trauma, smoke inhalation
Symptoms - SOB, hypoxia
Diagnosis: acute onset, bilateral CXR opacity, hypoxaemia, widespread consolidation
Management - low tidal volume plateau pressure limited mechanical ventilation
187
How do you get a malignant mesothelioma?
Asbestos - recurrent effusions, shrinking lung, 100% mortality
188
How does an appendectomy cause a hernia?
Damage to the iliohypogastric nerve at McBurnies point- damaging inguinal muscles resulting in lack of nerve supply to internal oblique and transversus abdominus muscles - resulting in weakness of anterior abdominal wall and risk of direct inguinal hernia
