M+M Flashcards
1
Q
Name three things to ask about in a suspected Bell’s palsy history?
A
- Is the forehead involved? If you can’t raise eyebrows it’s LMN (Bell’s) if you can its UMN (Stoke/TIA)
- Diabetes (increased risk)
- Limbs affected (rule out CVS)
- Other symptoms (migraine, partial seizure)
- History of nerve problems (rule out MS)
2
Q
How do you manage Bells palsy (2)
A
1 - Prednisolone for 10 days
2- Supportive (eye drops, tape eyes shut at night)
Should resolve fully in 6-12 months, may get worse initially
3
Q
Patient presents with an isolated foot drop and frequent stumbling. The is some numbness on the upper side of the foot. What is the expected diagnosis (and what nerve is involved)?
A
Common perineal nerve (foot drop)
4
Q
Patient presents with an isolated foot drop and frequent stumbling. The is some numbness on the upper side of the foot. What are the two main differentials and how would you distinguish?
A
1- Foot drop
2- L5 root compression
Distinguish as (2) will also see a loss of ankle reflex and possible back pain
5
Q
How would you manage an isolated common perioneal nerve palsy?
How long would it take to resolve?
A
Conservative (splinting, avoid kneeling, leg crossing and squatting)
Should resolve in 2-3 months
6
Q
Patient presents after a fracture of the humerus with a wrist drop, which nerve is involved and how should it be managed?
A
Radial nerve
Splint and see function return in 4 months
7
Q
Name 5 questions for red flags that must be asked in any back pain history?
A
1- Saddle anaestheisa, changes in urine/ bowel symptoms/ LL neuro symptoms - CES
2- Point tendereness - #
3- Night pain, weight loss, night sweats - Cancer
4- Fever or recent infection - STI
5- Problems with prostate - metastatic
6- Sudden onset (AAA)
8
Q
What 5 things should be `counselled on for a case of mechanical back pain?
A
1- Don’t avoid exercise and activity - stay active
2- Avoid rest
3- Posture
4- Adaptations at home and work
5- Short course low dose NSAIDS
6- Physio
7- 80% of people have an episode of low back pain at some point in their lives, 90% recover within 4 months
9
Q
What is the management of an acute episode of sciatica?
A
Most cases resolve in 6 weeks 1- Oral NSAIDS + physio 2- IM NSAIDS 3- Opioids 4- Manual therapy
10
Q
A patient presents with Mania, you suspect Bipolar disease but suggest (3) other differentials?
A
Substance induced mood disorder
Psychosis
Personality disorder
ADHD
11
Q
What is the definition of rapid cycling bipolar?
A
4 or more cycles of depression and mania within a year, with no asymptomatic episodes
12
Q
What is your management of bipolar disorder?
A
1- Educate about triggers, self help groups etc.
Drugs:
- Lithium (GOLD standard)
If acutely manic episode:
Quetiapine or Olanzapine
13
Q
How do you diagnose delirium?
A
Delirium must be diagnosed using either the CAM (Confusion assessment method) or 4AT tests
14
Q
What are the CAM criteria for delirium?
A
To be delirum must be:
1- Acute onset with fluctuating course
2- Show inattention (count back from 20 to 1)
3- Have EITHER (disorganized thinking) or (changed level of consciousness)
15
Q
What are the 4 questions and score of the 4AT test?
A
1- Alertness (Abnormal = 4)
2- AMT4 (Age, DOB, year and where. 2+ mistakes = 2)
3- Attention (Months backward). 7+=0, 7-=1, untestable=2)
4- Acute and fluctuating course (Y=4)
Any score over 4 shows possible delirium, then use CAM
16
Q
A patient has suspected delirium, but what are 3 other DDx’s?
A
Dementia Depression Bipolar Psychosis Stroke
17
Q
What investigations should be done if someone has a diagnosis of delirium? (3)
A
Hx and Obs
Urine dip
ECG
CXR
18
Q
Name 5 management steps for a patient with delirium.
A
Good communication Clock Familiar objects Avoid over/understimulation Side room Control lighting and temperature Maintain mobility TREAT UNDERLYING CAUSE
19
Q
If a patient has delirium, how does their prognosis change?
A
Worse if hypoactive compared to hyperactive
2-3x increase in mortality
20
Q
What are the key components of a dementia history? (5)
A
Onset duration Past strokes/ other neurological signs - Vascular HTN/ smoking - Vascular Flucuation - Lewy body Hallucinations - Lewy body Personality changes - Frontotemporal
21
Q
What treatment can be used for Alzheimer’s dementia? (3)
A
1- Supportive (OT, support groups, charities)
2- Donepezil, rivastigmine or galantamine (ACh inhibitors)
3- Memantine
22
Q
What is the mean survival from diagnosis for someone with Alzheimer’s dementia?
A
7 years
23
Q
What medicines are used to treat vasular dementia?
A
None
24
Q
What medicines can be used for Lewy Body Dementia?
A
Rivastigmine
25
Name three tools which could be used to measure cognitive function in a suspected dementia? (3)
ACE III (20-25 mins)
MoCA (10-15mins)
MMSE (15mins)
26
What are the DSM 5 criteria for depression?
Last month more days than not:
1- Down depressed or hopeless
2- Not enjoying normal activities and not getting pleasure
3- Three of SAGCLASS
27
Name 4 things which must be screened for in a depression history?
```
Mania
Psychosis
Suicide risk
Risk to others
Substance misuse
```
28
What investigations should be done for depression? (3)
Rule out hypothyroid
PHQ-9
FBC - Anemia etc.
29
What management should be offer for mild to moderate depression? (3)
Watchful waiting - see again in two weeks
Low intensity CBT
Relaxation therapy
(only offer meds if depression persists or other comorbid problems)
30
What is the first line management of depression in adults? (3)
Supportive
SSRI (Sertraline/ citalopram)
CBT
Review in 2 weeks
31
Name 5 side effects of SSRI's
```
GI upset/ nausea (resolves in 1-2 weeks)
Increased anxiety (resolves in 1-2 weeks)
Dry mouth
Drowsiness
Low sex drive
```
32
Which two common drugs should you try not to use with SSRI's?
Triptans (migraine)
| Aspirin (due to ulcer risk)
33
What is the second line medication for adults with depression?
Venlafaxine
| CI uncontrolled hypertension
34
Name 3 symptoms of SSRI withdrawal syndrome
```
Increased mood changes
Restlessness
Sleeping difficulty
GI (pain, cramping)
D+V
Paraesthesia, sweating, unsteadiness
```
35
What is the average length of a depressive episode?
6-8 months
(80% will have another episode in their lifetime)
(20% will become chronic)
36
What are the 5 ear symptoms you should always ask about in an ear history?
```
Ache (otalgia)
Discharge (Otorrhoea)
Hearing loss
Tinnitus
Dizziness
```
37
What are the 5 nose symptoms you should always ask about in an nosehistory?
```
Obstruction
Running nose (rhinorrhoea)
Loss of smell
Nose bleeds (epistaxis)
Facial pain
```
38
What are the 5 throat symptoms you should always ask about in a throat history?
```
Sore throat
Difficulty swallowing (dysphagia)
Pain on swallow (odynophagia)
Hoarse voice (dysphonia)
Regurgitation
```
39
Name 4 differentials for a conductive hearing loss
Wax/ foreign body
Infection
Trauma + perforation of tympanic membrane
Otoscleroisis
40
Name 4 differentials for a blocked nose
Septal deviation
Acute rhinosinusitis
Chronic rhinosinusitis
Chronic rhinosinusitis with polyps
41
Where is the most common site in the nose to bleed from?
Kiessllbach's plexus in little's area
42
What is first line management of epistaxis?
Nasal oinment (Naspetin or Bactoban)
43
Name two broad categories of seizures
Generalised
| Partial
44
Name three possible triggers for seizures?
Most idiopathic but sleep deprivation, alcohol, dehydration and not eating
45
Name two differentials for a seizure
Syncope
Non-epileptic attack disorder
Migraine
46
What investigations should be done following a first seizure?
Bloods (FBC, U+E) - looking for infection or metabolic disturbance
ECG
MRI (non urgent) to look for cause, only urgent if neurological signs
47
What is the first line management for an adult with generalised tonic-clonic seizures?
Valproate or lamotrigine (often better tolerated with less SE)
48
What is the first line management for partial (focal) seizures?
Carbamazepine or lamotrigine
49
What side effects should you council for antiepiletics?
Drowsiness and slowed cognition
Dizziness
RASH - Stephen Johnson Syndrome
50
Management of acute epilepsy is... (4)
ABCDE
Look for reversiable cause (bloods, glucose etc.)
IV Lorazepam or buccal midazolam
IV Phenytoin
51
In addition to a thorough before, during and after, what else should you ask about in a falls history?
Eyesight
Any problems with heart
Drugs
Any problems with blood pressure
52
What assessment tool can be used to calculate falls risk?
Tinetti Assessment Tool
| (0-28) anything below 19 is a high risk
53
What tool can be used to calculate 10 year fracture risk?
FRAX
54
What investigations should be performed following a fall? (5)
```
FBC (anaemia, infection)
Neuro exam (peripheral neuropathy)
ECG
Lying and standing blood pressure
Tinetti assessment tool
FRAX assessment tool
```
55
Name 5 symptoms of fibromyalgia
```
Pain
Unrefreshing sleep
Tired
Some morning stiffness
Paraesthesia
Felling of swollen joints
Headaches
Anxiety and depression
```
56
What 5 tests would you do to investigate a suspected fibromyalgia?
TFT- Rule out thyroid
ANA - Rule out lupus
FBC/ Iron studies - Anaemia can cause some symptoms
Vit D - Low can cause muscle pain and tiredness
Magnesium - low levels can lead to muscle cramps
57
What scoring tool could be used to assess fibromyalgia?
| What is the cut off score for fibromyalgia?
Widespread pain score (0-19)
| More than 7 with symptoms for 3 months and no cause = fibromyalgia
58
Name the first three lines of management for fibromyalgia?
1- Education and exercise (only one with evidence)
2- CBT
3- Paracetamol, weak opioids (not NSAIDS)
59
Name 5 features of compartment syndrome?
```
Pain (worse on stretching)
Pallor
Pulselessness
Paralysis
Parathesia
```
60
How should you manage compartment syndrome?
Measure pressure (if 30-40mmHg greater than systemic > Open fasiciotomy)
61
Which artery (and it's root artery) is most likely to be affected causing loss of blood supply to the femoral head in a #NOF?
Medial circumflex artery
| From deep femoral
62
What are the diagnosis criteria for GAD?
Excessive anxiety and worry
More days than not
Over a wide range of activities and events
Lasting over 6 months
63
Name 7 symptoms of anxiety
```
Restlessness, irritability
Difficulty concentrating
Easily fatigued
Sleep disturbance
Palpitations
Fast HR
Sweating, trembling
Dry mouth
SOB
Nausea
```
64
Name 5 possible differentials for someone presenting with anxiety?
```
GAD
Panic disorder (trigger)
PTSD
Phobia
Social phobia
Depression
```
65
What investigations should be done when suspecting GAD (4)
```
PHQ-9
FBC (anaemia)
TFT (thyroid)
Cortisol
B12
Folic acid
```
66
Name the first two (non-pharma) management steps for GAD
1- Educate (avoid caffeine, alcohol, illicit drugs, stimulants). Try breathing exercises and exercise
2- Low intensity psychological support, support or self help groups,
67
Name the post education/ support group management steps for GAD (2)
1) CBT
| 2) SSRI (Sertraline, escitalopram)
68
How would you explain GBS to a patient?
Guillian Barre
| An autoimmune disorder which attacks your nerves, and that causes this progressive neuropathy
69
What disease makes up 95% of Guillian Barre Syndrome cases?
AIDP (Acute inflammatory demyelinating polyradiculoneuropathy)
70
With a history of possible GBS, what key history questions should you ask? (3)
75% have preceding infection
More common if malignancy or post-partum
SOCRATES
71
A patient presents with possible GBS, what are your differentials? (3)
```
Encephalitis
Transverse myelitis (UMN)
Boutulism (descending)
Stroke
Myasthenia gravis
```
72
What is the single best investigation for GBS?
Nerve conduction studies
73
What three maininvestigations could be done for GBS?
Nerve conduction
Lumbar puncture (raised protein)
Antibodies to peripheral nerves
SPIROMETRY (most important determinant for need to admit to ICU)
74
What is management of GBS?
IVIG or plasma exchange
- Spirometry and consider ITU support
75
What is the prognosis of a patient with GBS?
80% walk unaided and fully recover in 6 months
76
Name 7 differentials for a headache?
```
Tension-type headache
Migraine
Cluster headache
Meningitis
SAH
Trigeminal neuralgia
Temporal arteritis
Raised ICP
Sinusitis
```
77
Name 4 common features of a tension type headache? (including negatives)
```
Bilateral
Feeling like pressing or tightening
No nausea, no aggravation by physical activity, light or noise
Often late in the day
Aggravated by stress
```
78
What investigations would you do for a tension headache (and all headaches)? (2)
Optic fundi
| Blood pressure
79
What management for a tension type headache?
Simple analgesics, avoid triggers
80
What is the classic presentation of a migraine? (6)
Unilateral
Pulsating/ throbbing headache in trigeminal nerve
Nausea is common
Lasts between 4-72 hours
Photophobia
Aura (normally visual) - last 5 mins to one hour.
81
What investigations should be done for a patient with migraine? (1)
Neurological exam
82
What percentage of migraines involve aura?
33%
83
What is the diagnosis criteria for migraine without aura?
Need 5 attacks with three of classic symptoms
84
What is the diagnosis criteria for migraine with aura?
Can diagnose with one episode if no other pathology suspected
85
Name 7 potential triggers for migraine?
Stress, louid noise, bright light, travel, cheese, chocolate, alcohol, missed meals, dehydration, lack of sleep, oral contraceptives
86
What is first/ second line treatment for an episode of migraine?
1st: Soluble paracetamol
2nd: Triptain (sumatriptan)
87
Name two drugs/ classes of drugs which can't be taken with Sumitriptan?
Citalopram
| COCP
88
Name two non-drug CI for sumitriptan
CHD
Uncontrolled HTN
Risk factors for CHD
89
Name the first and second line preventative measures for migraine and the criteria to use them
AVOID TRIGGERS
| 2) Propanolol - only if QoL affected or <2 episodes per month
90
Name the classic presentation features of cluster headache
Short painful attacks
30mins-3hrs
Around one eye
Occur a few times a day fpr months then remission period
Often begins with severe pain which wakes them up
Symptoms like red eye and ptosis
91
What is the acute management of a cluster headache? (2)
100% oxygen for 15 mins upto 5x per day
| Sumitriptan subcut
92
What is the preventative management of cluster headache?
Verapamil
93
Name 4 red flags in a headache history to screen for meningitis
```
Neck stiffness
Fever
Non-blanching rash
Seizures
Photophobia and vomitting also for migraine
```
94
What is your first investigations (3) to order in suspected meningitis?
LP, blood cultures, throat swab
95
Name your first two management steps for meningitis
ABCDE
| Broad spectrum AB's (treat as bacterial until proven otherwise)
96
What is your first investigation for suspected SAH?
CT head
| Neurosurgical consult
97
Name 5 possible features of trigeminal neuraliga
Pain in face
Electric shock sensation
Lasts a few seconds to ew mins
Exacerbated by touch or , cold or eating
98
What is the first line management of trigeminal neuralgia and how long do you treat for?
Carbamazepine (withdrawn one month after remission)
Surgical options available down the line but not curative
99
What patients classically experience temporal arteritis?
Over 50
| Presenting with headache, scalp pain, transient visual symptoms
100
What investigations should be performed in suspected temporal arteritis? (2)
ESR (<50mm/hr)
| Temporal artery biopsy
101
What is the management of temporal arteritis?
Prednisolone 40mg
| If visual symptoms admit and give IV
102
What classic features are associated with a headache due to raised ICP?
Transient visual obscuration
Worse in morning
Vomitting
Worse on coughing, straining or bending forward
103
What investigations should be done for suspected raised ICP? (2)
CT head
| Fundoscopy
104
How should raised ICP be managed? (1)
IV mannitol
105
A patient presents with headache, reporting seeing halo's around lights with pain in their eyebrow. You notice a red eye and a fixed dilated pupil, it has come on over a day. MLD?
Acute closed angle glaucoma
106
Name 5 common symptoms of acute angle closure glaucoma
```
Ocular pain
N/V
Halo's around lights
Blurred vision
Red eye (conjunctival injection)
```
107
What's your first investigation for acute closed angle glaucoma?
Check IOP (should be under 21mm/Hg)
108
How should you manage acute closed angle glaucoma? (4)
Topical Beta Blockers, steroids and pilocarpine
| IV Acetazolamide
109
Name 4 common features of sinusitis?
Facial pain
Exacerbated by leaning forward or coughing
Rhinorrhoea
Nasal congestion
Pain on percussion of frontal or temporal sinus
110
What is the management of sinusitis? (4)
Warm face packs, analgesia, saline nasal drops, antibiotics if bacterial
111
Name 5 key questions which should be asked in any lupus history?
```
Rashes (especially in sun)
Tiredness
Weight loss
Joint pain
Cold hands changing colour
Ulcers in the mouth
Muscle pains or aches
```
112
What is the most sensitive autoantibody for Lupus?
ANA
| Negative almost excludes SLE
113
What is the most specific autoantibody for Lupus?
Anti-Sm
| followed by Anti-dsDNA
114
Name 2 diseases commonly associated with Lupus
Anti-phospholipid syndrome
Thyroiditis
All other autoimmune conditions
115
Name 2 lifestyle suggestions for patients with lupus
Stay out of sun
| Encourage regular exercise
116
What is the first line treatment for Lupus (pharmacological) and how long does it take to work?
Hydroxychloroquine
| 6-12 weeks
117
What is second line Lupus treatment?
Add induction therapy
| Mycophenolate, cyclophosphamide, azathioprine
118
What does section 2 of the MHA allow?
Detained in hospital for 28 days for assessment and treatment if needed
119
Who can detain under MHA section 2?
GP can refer then two doctors (one specialist) must approve within 14 days
120
What does MHA section 3 allow?
Detained in hospital for 6 months for treatment
121
What does MHA section 4 allow?
Detained for emergency assessment for up to 72 hours
122
Who can approve MHA section 4?
Needs only one doctor (has to have seen in last 24 hours)
123
Can you treat under MHA section 4 and 5?
No
124
What does MHA section 5 allow?
Stopped from leaving hospital if needed
125
What two subsections MHA section 5 are there and who do they apply to?
5(2) - doctors
| 5(4) - nurse (mental health nurse)
126
What does an MHA section 135 allow?
Warrant to gain access to premises to remove patient to safety
127
What does an MHA section 136 allow?
Removal of a person from a public place for there/ other's safety
128
Name 6 symptoms of alcohol withdrawal
```
Shaking
Sweating
Headache
Confusion
Tremor
Hallucinations
Agitation
Ataxia
```
129
What investigations should be done when querying alcohol issues?
Blood alcohol
Gamma GT
Urine drug screen
130
How do you manage alcohol intoxication? (2)
Chlordiazepoxide for 5 days
| Thiamine to prevent Wernicke's
131
What 4 factors should always be asked about in an opthalmic SHx?
OCDS
| Occupation, carer?, driving, smoking/ alcohol
132
Name 3 risk factors for angle closure glaucoma?
Female
Hyperopia
Asian
133
Name 5 presenting symptoms of acute angle closure glaucoma?
```
Blurred vision
Halo's around lights
Painful
Red eye
Headache
Nausea and vomiting
```
134
How do you diagnose acute angle glaucoma (2)?
```
Goldmann tonometry (<21mmHg)
Gonioscopy (examination of anterior chamber angle)
```
135
Name 4 treatments for acute angle closure glaucoma?
Peripheral iridotomy
Drops:
-Carbonic anhydrase inhibitors, beta blockers, alpha agonists
136
Name 4 risk factors for central retinal artery occlusion
```
HTN
DM
CHD
PVD
Smoking
```
137
How does a patient with central retinal artery occlusion present (1)
Sudden painless loss of vision
138
What is seen in central retinal artery occlusion on fundoscopy?
Cherry red spot
139
How does retinal detachment present? (3)
Sudden loss/ deterioration of vision
May be floaters
Can be peripheral or central
Described as a curtain coming down
140
How should retinal detachment be treated? (1)
Urgent surgery
141
Name 3 risk factors for retinal detachment?
Myopia
Trauma
DM
AMD
142
How does orbital cellulitis present? (4)
```
Red swollen eye
Painful
Reduced vision
Opthalmoplegia
Systemic features like fever
```
143
What investigations should be done for orbital cellulitis (4)
CT or MRI of sinus and orbits
Conjunctival cultures
Blood cultures
FBC
144
Name 3 possible treatments for orbital cellulitis?
IV AB's
Nasal decongestants
Surgical drainage of absess and pressure relief
145
Name 3 presenting features of conjunctivitis?
Red eye
Itchy
Watery or purulent discharge
146
What is the most common viral pathogen which causes conjunctivitis?
Adenovirus
147
What is the most common bacterial pathogen which causes conjunctivitis?
Strep. pneumoniae
148
What is first line Tx for suspected viral conjunctivitis? (3)
Artificial tears
Topical steroids
Topical antiviral
149
Which agent is first line tx for bacterial conjunctivitis? (1)
Topical chloramphenicol
150
What are the DVLA minimum driving sight requirements? (1)
6/12 with both eyes open
151
A patient with dry AMD presents with sudden onset of blurred vision, what is most likely diagnosis?
Wet AMD
152
Name three fundoscopic features of dry AMD
Drusen
Geographic atrophy
Macular pigmentary changes
153
What is the classical presentation of dry AMD? (1)
Progressive loss of central vision
154
What investigations are routinely needed for CTS?
None
| Electroneurograhy is gold standard but not routinely needed
155
How long should it take CTS to resolve?
6 months
156
Name three management steps for CTS?
Splint/ simple analgesia (but not NSAIDS)
2nd: Corticosteroid injections
3rd: Surgery (refer if not change in 3 mths)
157
Which genetic mutation is associated with ankylosing spondylitis?
HLA-B27
158
Name three presenting features of ankylosing spondylitis (including age)?
Back pain which improves with exercise
Pain which wakes patient in early morning
Stiffness
Presents before age 30
159
Name two common associations with ank spond?
Peripheral enthesitis - Achillies tendonitis, plantar fascitis
Peripheral arthritis - Hip/ shoulder
Both affect around 1/3 of patients
160
Name three tests or investigations for ank spond?
Schobers test
Sacroilitis on x-ray < diagnostic
Bamboo spine on x-ray < late sign
161
How should ank spond be managed? (4)
Physio and exercise
NSAIDS
Steroid injections
Biologics and surgery if severe
162
What is the classical presentation of polymyalgia rheumatica?
Bilateral pain and morning stiffness of neck, shoulder and pelvic girdle
Only occurs in those age over 50
163
What investigations should be done for PMR? (1)
ESR (>40mm/hr)
| Note PMR is very similar to vasculitis
164
What disease is commonly associated with PMR?
Giant cell/ temporal artertis
165
What is the treatment for PMR (1)?
Steroids for 3 weeks then reducing over one year
166
In a patient with PMR what three symptoms would you ask about to screen for GCA?
Headache, visual disturbance, jaw claudication
167
How would you describe GCA to a patient?
Autoimmune, inflammation of the blood vessels
168
What is the classical presentation of GCA? (4)
Temporal headache, scalp tenderness, transient visual symptoms and unexplained facial pain
Usually in over 50
169
What investigations should be done for GCA? (2)
ESR (<50mm/hr)
| Temporal artery biopsy if unsure
170
How should GCA be managed? (3 points to note)
High dose steroids (pred)
If visual symptoms admit for IV steroid (methylpred)
Aspirin and PPI should also be given
171
Name some presenting features of Granulomatosis with Polyangitis (Wegners)? (3)
```
ENT+Lungs+Kidneys
Ulcers, sores, crusting of nose
Rhinorrhoea
Haemoptysis
Haematuria
Fever
Cough
Chest pain, joint pain, abdo pain
```
172
How do you diagnose Granulomatosis with Polyangitis (Wegners)? (3)
```
c-ANCA (80% sensitive)
ESR raised
U+E plus urinalysis
CT chest
FBC (anaemia)
```
173
How should you manage Granulomatosis with Polyangitis (Wegners)?
High dose steroid
| Can escalate do cyclophosphamide etc if needed
174
What is the difference between Eosinophillic Granulomatosis with polyangitis (Churg-Strauss) and Granulomatosis with Polyangitis (Wegners)?
Presence of eosinophils (asthma is the defining symptom)
| Eosinophillic has much more diffuse symptoms which can affect almost the whole body (diffuse vasculitis)
175
How do you investigate Eosinophillic Granulomatosis with polyangitis (Churg-Strauss)?
Urine dip (glomerulonephritis)
CXR (lung cavities)
p-ANCA (present in 40%)
176
What is pagets disease of the bone? How common is it? Where does it most commonly affect?
Uncontrolled bone turnover
Present in 5% of population but only 5% of these will have symptoms
Most commonly affects pelvis, lumbar spine, femur
177
What investigations should you do for Paget's disease of the bone? (2)
Isolated raised ALP is indicative
Xray- Osteolysis and excessive formation
Look out for blade of grass lesion and cotton wool pattern in skull
178
How should you manage Paget's disease of bone? (2)
Give patient bisphosphonates and ensure adequate calcium/ Vit D
179
How do you exacerbate lateral epicondylitis (tennis elbow)?
Extend wrist and supinate
| Tennis is throw up wrists and Turn over
180
How do you exacerbate medial epicondylitis (golfers elbow)?
Flex wrist and pronate
| Golfers is floppy wrists GO out
181
How should tennis/ golfers elbow be managed? How long will it take to resolve? (4)
Supportive - APRICE (Takes anything from a few weeks to a year)
Analgesia - NSAIDS
Protection- Avoid activities which may cause harm
Rest
Ice (for pain)
Compression - Not relevant
Elevation- Not relevant
182
How does adhesive capsulitis (frozen shoulder) present?
Reduced shoulder movements both actively and passively, can be bilateral in up to 20%
183
How long does an episode of adhesive capsulitis normally take to resolve?
6 months to 2 years
184
How should you treat adhesive capsulitis? (4)
NSAIDS
Physio
Oral steroids
IM Steroids
185
What is a classic history of an ACL tear? (4)
```
Twisting force to bent knee
Pain
Sensation of knee buckling and popping
Very rapid swelling
Can't continue activity
```
186
What is a classic history of a PCL injury? (3)
Hyperextension injury
Pain
Rapid swelling
Can continue activity
187
What is a classic history of an MCL/ LCL injury? (3)
Blow to lateral aspect of knee
Pain
Less likely to have swelling
188
What is a classic history of a meniscal injury?
Twisting MOI
Pain in joint line with stiffness
May have buckling, locking or catching
189
Following an ACL injury what are the treatment options? (2)
Wait for swelling to go down
Do physio
Surgery not for around 3 weeks (although not everyone will have surgery)
190
How long does a first episode of sciatica last?
Normally around 6 weeks
191
What management steps are there for sciatica?
NSAIDS
Physio
Steroid injections
192
What are the most common hip problems in 0-3 year olds (2)
Developmental dysplasia of the hip
| Haematological malignancy
193
What are the most common hip problems in 4-10 year olds (2)
Transient synovitis
| Perthe's disease
194
What are the most common hip problems in 11-16 year olds (2)
Slipped upper femoral epiphysis
| Osteosarcoma
195
Name 5 risk factors for osteoporosis?
```
Age
Female
Low body mass
Steroid therapy
Smoking
Immobility
FHx
```
196
Name 3 conditions associated with osteoporosis?
```
Early menopause
Inflammatory arthritis
Hyperthyroidism
IBD
COPD
Chronic liver disease
```
197
Who should have a FRAX risk assessment (3)
Women over 65
Men over 75
Those with risk factors
198
What should be done about a low risk FRAX score?
Lifestyle advice only
| Activity, strengthening and increase Ca and VitD intake
199
What should be done about a medium risk FRAX score?
Do DEXA scan to establish BMD then recalculate FRAX
200
What should be done about a highrisk FRAX score?
Start treatment
| Bisphosphonates plus Ca and Vit D
201
What is first line treatment in osteoporosis?
Bisphosphonates plus Ca and Vit D
202
What is second line treatment for osteoporosis in postmenopausal women?
Raloxifene or Denosumab
203
Name 7 features of Parkinsonism?
```
Gait changes (shuffling, festinating (can't stop))
Stooped posture
Bradykinesia
Rigidity
Resting tremor (fine and pill rolling)
Hypophonia (quiet voice)
Poverty of expression
Micrographia
Unilateral onset
```
204
What are the classical features of a benign essential tremor? (4)
Familial (70%)
Improves with alcohol
Bilateral
Action tremor (rare at rest)
205
What is the tx for benign essential tremor?
Propanolol
206
What investigations should be done for someone with potential PD? (1)
None routinely
Neurological exam
Refer to movement disorder team
207
How would you manage a patient with parkinson's disease newly diagnosed? (4)
Refer to movement disorder team
Patient should inform DVLA
Consider if OT assessments etc are required
1st Line:
- If QoL affected: Levodopa (with co-benaldopa)
- If QoL not affected/ young etc: Rasagiline (MAO-B inhibitor)
208
What prognosis for PD should be counselled to a patient?
Very variable (some little disability after 20 years, some may be severely disabled after 10 years)
209
Name 5 differentials for a tremor?
Parkinsonism < rest tremor
Benign essential < action, FHx, relieved by alcohol
Hyperthyroid < Always present, too hot, tachycardia and other thyroid symptoms
Drug induced < Action (Salbutamol, alcohol)
Cerebellar (ataxic) < Intention tremor with other cerebellar signs
210
Name one feature which would make you consider a diagnosis of drug induced PD as opposed to IPD?
Bilateral symptoms
| Temporal onset correlating
211
Name 3 RF's for schizophrenia?
```
FHx
Low birth weight
Social isolation
Abnormal family interactions
Abuse
Cannabis use
```
212
Name four first rank symptoms of schizophrenia?
Delusions (grandiose or persecutory)
Hallucinations (auditory most common)
Thought disorder (insertion, removal, broadcasting)
Lack of insight
213
Name 5 differentials for someone presenting with a schizophrenic type picture?
- Schizophrenia
- Substance induced psychosis
- Schizoaffective disorder (mood disorder with schizophrenia but criteria not fully met)
- Depression with psychosis (depression occurs first)
- Bipolar with psychosis (mood syx first)
- Organic psychosis (tumor etc)
214
What investigations should be done for a patient presenting with schizophrenia like symptoms? (3)
Drug and alcohol screen
Urine dip
Serological tests for syphilis
215
What is the criteria needed to diagnose schizophrenia?
Two positive symptoms, not attributable to any other cause for most of the time for one month or more
216
How should a patient with newly diagnosed schizophrenia be managed? (5)
Refer to psychiatry for support
Assess social circumstances and family relationships
Formally assess and document capacity
Consider whether admission is needed under MHA (S2 or 3)
1st Line: Atypical anti-psychotics (Olanzapine, quetiapine)
217
How long should a patient with schizophrenia be treated with antipyschotics?
1-2 years after event
| Close supervision for withdrawal
218
What is prognosis for a patient with schizophrenia?
80% will recover from first episode but most relapse
| 1 in 20 will go on to commit suicide
219
What is the definition of a TIA?
An acute focal disturbance of cerebral function lasting less than 24 hours
220
What percentage of strokes are caused by infarction?
85%
(10% inter-cerebral haemorrhage)
(5% subarchnoid haemorrhage)
221
Name 5 modifiable risk factors for stroke which any patient with stroke/ TIA should be counselled on?
```
HTN
Smoking
High cholesterol
Obesity (loose weight)
Alcohol
```
222
Name 3 stroke mimics
- Hypoglycemia - Whipples triad (BM<2.8, Syx's and resolution after glucose back to normal)
- Tumour
- Migraine
- Temporal arteritis
- Todd's palsy (post seizure)
223
Name 5 investigations which should be done in a suspected stroke?
```
CT head to rule out haemorrhage (needs to be immediately if considering for thrombolysis)
ECG!!! - AF
Carotid doppler
FBC - platelets
Blood glucose - stroke mimic
Lipids
INR
BP - reversible cause
```
224
What scoring system can be used to assess severity of a stroke?
NIHSS
| National institute of health stroke scale
225
What system can be used to classify stroke?
Oxford Stroke Classification (Bamford)
| Has three symptoms, strokes classified according to how much affected
226
What is the affected artery and Bamford criteria seen in a TACI? (3)
Total anterior infarct (15%):
- Middle (face/ arms) and anterior cerebral (leg) arteries
- All three Bamford criteria
- Worst prognosis
227
What is the affected artery and Bamford criteria seen in a PACI? (3)
Partial anterior infarct (25%)
- Most common
- Division of the middle cerebral artery
- 2/3 Bamford
- 1/3 die/ 1/3 disabled and 1/3 survive
228
What is the affected artery and Bamford criteria seen in a lacunar infarct?
Lacunar (25%)
- Arteries around internal capsule, thalamus, basal ganglia
- One of Bamford criteria
229
What is the affected artery and Bamford criteria seen in a posterior infarct?
Posterior infarct (25%)
- Vertebrobasillar arteries
- Either cerebellar issue, LOC or isolated homonymous hemianopia
230
How should you manage an acute stroke? (5A's)
The 5A's of immediate stroke management:
- ABCDE
- Assess eligibility for thrombolysis (4.5hrs, clear onset)
- Aspirin 300mg OD for 14 days
- Assess for cause (ECG, glucose etc.)
- Actively encourage early rehab (goal setting etc)
Carotid doppler
231
How should you manage an acute TIA? (4)
Start 300mg Aspirin
ABCD2 Score (0-7)
- If score if over 4 then assess in 24hrs to look for cause (carotid doppler, ECG etc.)
- If score is 3 or below then review in one week same as above
Carotid doppler
232
What is the long term management of a stroke or TIA? (5)
- Rehab
- Review and counsel on lifestyle factors
- Start on Statin
- Treat any risk factors such as HTN
If due to AF/ PAF:
- CHADSVASC to decide if starting LT anticoag
If not due to AF/PAF:
- Start on clopidogrel 14 days post event
233
How long after a stroke or TIA are you unable to drive , do the DVLA need informing?
```
1 month (or 1yr if group 2)
Normal drivers do not need to inform DVLA
```
234
You are about to take an Alcohol history, name the 8 key areas which should be discussed?
```
Thoughts (Do you feel you have a problem)
Who/ what/ where/ when/ why?
Screening - CAGE
Dependence (Withdrawal, tolerance, priority, craving)
RISK - Mood and suicide
Other psych history
Social history (OCDS)
Thoughts of quitting
```
235
How should metastatic spinal cord compression be treated?
ABCDE
Immediate MRI and surgical referral
Dextamethasone
Nursed flat with log rolling to protect spine
236
Name 3 differences you would see in RA and not OA on an examination?
```
Boggy joint swellings (as opposed to hard)
Symmetrical involvement (OA is uni)
Extra-articular manifestations (OA doesn't)
MCP and PIP (vs. DIP and Wrist in OA)
```
237
What are the components of an ABCD2 score?
```
Age > 60 = 1
Blood pressure > 140/90 = 1
Clinical features:
- Unilateral weakness = 2
- Speech disturbance only = 1
Duration of symptoms:
- > 60 mins = 2
- 10-59 mins = 1
- <10mins =0
Diabetes = 1
```
238
How do you investigate and monitor severity of RA?
DAS Score (0-28)
239
What is a major cause of morbidity with lupus and so needs to be regularly monitored for?
```
Lupus nephritis
(Do do regular urine dip)
```
240
Talk through radiograph interpretation (8
Plain radiograph of L/R XXX... Patient details
View and additional views- lateral view also
State the view, exposure, adequacy
Fractures - describe (open/ closed, simple/ comminuted, transverse etc.)
241
Comprehensive geriatric assessment
```
Physical health
Functional capacity
Polypharmacy
Social function
Financial status
Cognitive (MMSE) and Falls (Tinetti)
Screen for low mood and other mental health
```
242
What is a classic presentation of labrynthitis? (4)
- Room spinning (exacerbated by movement but not triggered by movement)
- Hearing loss/ tinnitus
- URTI infections commonly preceed or are concurrent
Rule out stroke, mengitis etc, ear pain is not present
243
What examination findings would be seen in viral labrynthitis? (3)
Abnormal head impulse test
Nystagmus
Fall to affected side when walking
244
What is the main distinction between BPPV and viral labyrinthitis? (1)
BPPV is trigger by positional changes
245
Management of viral labyrinthitis?
Self limiting - normally resolves in days to a few weeks
During acute episode - Lie down still
Prochlorperazine can be given for vertigo, nausea and vomiting
246
How should Myasthenia Gravis be managed?
1- Avoid tiredness/ stress etc for exertion
2- Pyridostigmine (encourages movement, lasts a few hours so multiple doses needed)
3- Add steroids
4- Add immunosuppresant
247
Name the 5 A's of things affected by Dementia?
```
Amnesia
Agnosia
Aphasia
Ataxia
ADL's
```
248
What should be asked about in an eating disorder history using the SCOFF acronym?
```
Sick (laxatives, smoking, exercise)
Control foods (ask diet)
One stone (weight loss)
Fat (perceptions)
Food dominate (most important thing in life)
```
249
Name 5 features of charcot marie tooth?
Group of inherited peripheral neuropathies (AD)
Progressive weakness, muscle wasting and sensory loss
Inverted champagne bottle and pes cavus
Tx- Physio and surgery for deformities
