medicine Flashcards
(107 cards)
1
Q
Treatment of Psoriasis treatment ladder according to NICE guidelines?
A
Regular emollients
1) 4 weeks corticosteroid OD + vit D analogue (calcipotriol) OD - use separately ie one in morning one in evening
2) 8 weeks vit D analogue BD
3) 4 weeks potent corticosteroid BD or coal tar preparation
2
Q
Classic signs/ symptoms of cataracts & risk factors?
A
- Gradual reduced vision
- Faded colour vision
- Halos around lights
- Deflect in red reflex
- RF: ageing, smoking, alcohol, DM, trauma, long term steroids, hypocalcaemia
3
Q
When to start acetylcysteine immediately in a paracetamol OD?
A
- Uncertainty about the time of OD
- Staggered OF
- Plasma paracetamol level is over the treatment line on the graph
- OD taken 8-36 hrs before presenting
4
Q
Who benefits from activated charcoal in the context of paracetamol OD?
A
Those presenting within 1 hour
5
Q
Asthmatic features/ features suggesting steroid responsiveness in COPD?
A
- Prev. diagnosis of asthma or atopy
- Higher blood eosinophil count
- Substantial variation in FEV1 over time (at least 400ml)
- Substantial diurnal variation in PEF (at least 20%)
6
Q
Indications of thrombectomy in acute ischaemic stroke + time frames?
A
ASAP in those who:
* were last known to be well up to 24 hrs prev.
* Have acute ischaemic stroke and confirmed occlusion of the proximal posterior circulation (ie basilar or posterior cerebral artery) as demonstrated by CTA or MRA- offer within 6 hrs of symptoms onset
* There is potential to salvage brain tissue as shown by imaging such as CT or MRI showing limited infarct core volume - within 6-24 hrs
* Confirmed occlusion of proximal anterior circulation- 6-24 hrs
7
Q
How to differentiate sigmoid and caecal volvulus?
A
Caecal:
* Signs/ symptoms of SBO- vomiting
* Any age
* Associated with adhesions, pregnancy
* Mx- usually surgery, R hemicolectomy
Sigmoidal:
* Signs of LBO- constipation, increasing abdo pain, nausea, bloating
* Associated with elder patients, chronic constipation, PD, schizo
* X-ray- large, dilated loop of colon, often with air-fluid levels + coffee bean sign
* Mx- rigid sigmoidoscopy with rectal tube insertion
8
Q
How to recognise subcutaneous emphysema on CXR?
A
Striations of pec major caused by air outlined the muscle- anterior chest wall affected- ginkgo leaf sign
9
Q
Name some complications of laparoscopic surgery
A
- General risks related to anaesthetic
- Vasovagal (bradycardia) in response to abdominal distention
- Extra-peritoneal gas insufflation- surgical emphysema
- Injury to GIT
- Injury to BVs- common iliacs, deep inferior epigastric artery
10
Q
Mx of DKA?
A
- IV fluids- they’ll be deplete by 5-8 litres- use isotonic saline initially. 1L over 1st hr, then 1 L over next 2 hrs, then again over next 2 hrs, then over next 4 hrs, then over next 4 hrs, then over next 6hrs
- Insulin infusion- 0.1 unit/ kg/ hr
- Consider ICU
- Once blood glucose < 15 mmol/L, 5% dextrose infusion can be added
- K may need to be added to replacement fluids as it can be low due to insulin treatment
- Continue long-acting insulins, stop short-acting insulins
11
Q
How does intermitted testicular torsion present & how should you treat it?
A
- Intermittent, sharp, excruciating testicular pain
- mx- prophylaxtic fixing- orchidopexy
12
Q
Name some drugs known to induce toxic epidermal necrolysis
A
- Phenytoin
- Sulphonamides
- Allopurinol
- Penicillins
- Carbamazepine
- NSAIDs
13
Q
How does PMR present?
A
- Typically age > 60
- Rapid onset <1 month
- Aching, morning stiffness in proximal limb muscles (not weakness)
- Mild polyarthralgia, lethargy, depression, low-grade fever, anorexia, night sweats,
- Raised ESR >40 (CK and EMG normal)
- Mx- prednisolone (if no response then consider alt. diagnosis)
14
Q
Features of LB dementia & how to differentiate from parkison’s disease?
A
- Progressive cognitive impairment
- Cognitive impairment before parkinsonism, both within 1 yr of each other
- Fluctuating cognition
- Early impairments in attention & executive function (c.f. AD where just memory loss)
- Visual hallucinations
- Parkinsonism
15
Q
Why does goserelin cause a transient increase in symptoms of prostatic cancer?
A
Initial increase in LH production prior to receptor down regulation
To avoid this, give flutamide, a synthetic antiandrogen, can preemptively attenuate the tumour flare through its antagonistic effects at androgen receptors
16
Q
When & how to treat hypocalcaemia?
A
- Severe hypocalcaemia requires treatment- eg carpopedal spasm, tetany, seizures, prolonged QT interval
- Required IV calcium replacement- give IV calcium gluconate 10ml of 10% solution over 10 mins
- ECG monitoring recommended
17
Q
ECG changes of hyperkalaemia?
A
- Tall tented T waves
- Small P waves
- Widened QRS
18
Q
Treatments for hyperkalaemia & how they work?
A
- Calcium gluconate- stabilise cardiac membrane & reduce ECG changes - doesn’t actually affect K level
- Combined insulin/ dextrose infusion & nebulised salbutamol to help drive K into icf from the ecf- reduces K levels in blood
- Stop drugs that increase K
- Help remove K from body eg calcium resonium (binding resins) or loop diuretics or in severe cases dialysis
19
Q
How does ascending cholangitis present?
A
- RUQ pain
- Fever
- Jaundice
- Obstructive features on LFTs
20
Q
What are the clinical consequences of alpha 1 antitrypsin deficiency & what is the mode of inheritance?
A
- Lungs- emphysema, mostly in lower lobes
- Liver- cirrhosis & hepatocellular carcinoma in adults, cholestasis in children
- Autosomal recessive
21
Q
Transmission of which type of infection is likely to occur following a platelet transfusion?
A
Bacterial- as platelet concentrates are generally stored at room temperature providing a more favourable environment for bacterial contamination than other blood products
22
Q
Treatment of infertility in PCOS?
A
Weight reduction if appropriate
Clomifene is used 1st line - lower risk compared to other treatments of ovarian hyperstimulation syndrome
Metformin is also used, combined with clomifene or alone, particularly in obese pts.
23
Q
What happens to the ECG in hyper and hypocalcaemia
A
Hyper- short QT interval
Hypo- long QT interval
24
Q
Which infection is strongly associated with the development of Guillain-Barre syndrome?
A
Campylobacter jejuni
-Immune mediated demyelination of the peripheral NS
25
Treatment of urge incontinence
1st line bladder retraining
Bladder stabilising drugs- antimuscarinics oxybutynine (IR), tolterodine (IR), darifenacin (OD)
If concerns about anticholinergic S/E in frail pts- mirabegron can be used
26
Treatment of stress incontinence
1st line is PFMT, 8 contractions 3x per day for min 3/12
Surgery- retropubic mid-urethral tape procedures
Duloxetine to women who decline surgical procedures - SNRI
27
Essential tremor- mode of inheritance & what makes it better or worse?
* Autosomal dominant
* Worse when arms outstretched
* Better by alcohol & propranolol
28
How does an EMG look for a pt with MG?
Diminished response to repetitive stimulation on EMG
29
How can molar pregnancy result in thyrotoxicosis?
* Very high beta HCG
* Biochemical structure of beta HCG is similar to LH, FSH and TSH
* Hence stimulates thyroid gland to produce thyroid homrones
* Resulting in S&S of thyrotoxicosis
* High T3/T4 causes negative feedback on pituitary gland to stop TSH secretion hence overall reduction in TSH
30
What is the most common cause of death in pts following MI?
Ventricular fibrillation leading to Cardiac Arrest
31
Mx of acute & chronic anal fissure?
* Soften stool- high fibre diet, high fluid intake, bulk-forming laxatives 1st line, if not tolerated try lactulose
* Lubricants such as petroleum jelly prior to defecation
* Topical anaesthetics
* Analgesia
* Chronic- topical GTN - if not effective after 8 weeks refer for surgery or botulinum toxin
32
What is the most common form of prostate cancer?
Adenocarcinoma
33
What is courvoisier's law?
Jaundice and enlarged smooth RUQ mass (gallbladder) - suspect malignancy of the biliary tree or pancreas
(distal biliary obsturction secondary to malignancy)
The cause is unlikely to be gallstones
34
What is the most common site for bile duct cancers?
At the bifurcation of the right and left hepatic ducts (Klatskin tumours)
Typically slow growing, invades locally & metastases to local LN before spreading to peritoneal cavity, lung & liver
35
Does cholecystitis present with jaundice?
Usually no- typically presents with RUQ pain and signs of inflammation (fever)
In Mirizzi syndrome, the stone can cause compression on the adjacent common hepatic duct if it is located in Hartmanns pouch (outpouching of the gallbladder wall at the junction with the cystic duct) or in the cystic duct itself
This causes obstructive jaundice even without stones present within the lumen of the common hepatic or common bile ducts
36
When is VBAC appropriate and when is it contraindicated?
Appropriate after a single CS at 37 weeks onwards (planned delivery)
Contraindicated in previous uterine rupture or classical CS scar (longitudinal incision in the upper segment of the uterus)
37
What is the most important risk factor for aortic dissection?
Hypertension
38
Side effects of thyroxine therapy?
* Hyperthyroidism
* Reduced bone mineral density- osteoporosis
* Worsening of angina
* AF
39
People with T2DM on insulin treatment should receive what?
As well as the correct insulin preparation, they should receive glucose and/or glucagon kit for treating hypoglycaemia
40
Hyperthyroid symptoms + ocular symptoms = ? how to treat?
Graves disease
Beta blocker to manage adrenergic symptoms (palpitations, tremor, anxiety) whilst awaiting specialist referral
Carbimazole can be considered too in primayr care if symptoms are not controlled with propanolol
Refer to secondary care
41
How to differentiate the 2 types of diabetes?
T1DM- low C peptide, as it is made in the pracreas along with insulin
In T2DM, where pts have increased insulin resistance they have normal or high C peptide levels due to increased insulin production
42
Define impaired glucose tolerance
Fasting glucose >/= 6.1, <7 IFG then needs to be investigated with OGTT to rule out DM.
OGTT 2 hr value >/= 7.8, < 11.1
43
Which oral steroid has the least amount of mineralcorticoid activity?
Dexamethasone
This is clinically relevant as there are some situations where it is important to combine high glucocorticoid (anti-inflammatory) activity with minimal mineralocorticoid (fluid-retention) effects. A good example is the use of dexamethsone for patients with raised intracranial pressure secondary to brain tumours.
44
What is 1st line for hypertension in diabetic Afro Caribbean 59 y/o?
ARB
NICE advises ACEi or ARB as a first line in all pts with diabetes, regardless of age.
NICE also recommends in patients of black African or African-Caribbean to use an ARB in preference to an ACE inhibitor.
45
Addison's disease mx?
Both glucocorticoid and mineralcorticoid replacement therapy
* Hydrocortisone 20-30mg- replaces cortisol
* Fludrocortisone- replaced aldosterone
Double doses of glucocorticoid during acute illness
Provide hydrocortisone injection rescue kit for adrenal crises
46
Most common cause of primary hyperaldosteronism?
Bilateral idiopathic adrenal hyperplasia
Ix- adrenal venous sampling
Mx- spironolactone
47
Typical presenting features of myxoedema coma?
Confusion and hypothermia
48
What medical conditions would mean a HbA1c result would be underestimating blood glucose levels?
Conditions where there is reduced RBC lifespan
* HS
* SCA
* G6PD deficiency
* Haemodialysis
49
List some specific features of graves' disease
* Eyes- exophthalmos, ophthalmoplegia
* Pretibial myxoedema
* Thyroid acropachy- triad of digital clubbing, soft tissue swelling of hands & feet, periosteal new bone formation
50
Features of prolactinoma?
* Headaches due to mass effect
* Amenorrhoea- prolactin prevents release of GnRH thus decreasing levels of LH & FSH
* Bitemporal SUPERIOR quadrantonopia- as the tumour grows upwards on the pituitary stalk compressing the optic chiasm from below, compresses the inferior fibres of the chiasm first hence superior visual quadrants are affected
51
Diagnostic criteria of DKA?
* pH<7.3 bicarb <15
* Blood glucose >11 or known DM
* Ketonaemia >3 or ++ urine dipstick
52
Features of a thyroid storm?
* Very high temp >38.5 C
* Tachycardia
* Confused and agitated
* N&V
* Htn
* HF
* abnormal LFTs/ jaundice
53
Treatment of thyroid storm?
* Paracetamol
* treat trigger
* BB IV propranolol
* Anti-thyroid drugs eg PTU
* Dexamethasone eg 4mg IV qds- blocks conversion of T4 to T3
54
Drug causes of gynaecomastia
* spironolactone (most common drug cause)
* cimetidine
* digoxin
* cannabis
* finasteride
* GnRH agonists e.g. goserelin, buserelin
* oestrogens, anabolic steroids
55
Most common cause of hypercalcaemia?
* Primary hyperPTH commonest cause in non-hospitalised pts
* Malignancy- commonest in hospitalised pts. Eg PTHrP from lung SCC, bone mets, myeloma
* Other causes- sarcoidosis, vit D intoxication, acromegaly, thyrotoxicosis, drugs such as thiazides, Addison's disease, dehydration
56
Any interactions to be aware of with thyroxine therapy?
Iron and calcium carbonate reduces the absorption of levothyroxine- give 4 hrs apart
57
Drug causes of galactorrhoea?
* Metaclopramide
* Domperidone
* Haloperidol
58
If T2DM pt develop cardiac risk or CHF, what drug should be introduced
SGLT2 inhibitors- empagliflozin, canagliflozin, dapagliflozin
58
If T2DM pt develop cardiac risk or CHF, what drug should be introduced
SGLT2 inhibitors- empagliflozin, canagliflozin, dapagliflozin
59
Symptoms of gastroparesis?
* Erratic blood glucose control
* Bloating
* N&V
* Early satiety
60
What acid-base imbalance is expected in Cushing's syndrome?
Hypokoalaemic metabolic alkalosis
61
What acid-base imbalance is expected in Cushing's syndrome?
Hypokoalaemic metabolic alkalosis
62
Define subclinical hypothyroidism
very mildly raised TSH but normal T3 and T4
63
Htn + muscle weakness = ?
Primary hyperaldosteronism
Bilateral adrenal hyperplasia is the most common cause
Muscle weakness due to hypoK
Would see alkalosis
64
Who gets referred for consideration of PT surgery?
Primary hyperparatyhroidism
* Sx of HyperCa (thirst, polyuria, constipation)
* End organ disease (renal calculi, fragility fractures or osteoporosis)
* Corrected serum Ca > 2.85
65
What does graves' disease show on radioactive iodine uptake test?
Increased homogenous uptake due to generalised overactivity of the whole thyroid gland
65
What does graves' disease show on radioactive iodine uptake test?
Increased homogenous uptake due to generalised overactivity of the whole thyroid gland
66
What is the main mechanism of action of sitagliptin?
DPP4 inhibitor
Reduces peripheral breakdown of incretins such as GLP-1
67
What is haemolytic uraemic syndrome?
Caused by E coli 0157, shiga toxin
Diarrhoea becomes bloody after 1-3 days
Triad of AKI, microangiopathic haemolytic anaemia, thrombocytopenia
Haemolysis, anaemia, thrombocytopenia, raised LDH, urea, creatinine
68
Pt with CLL suddenly unwell, what has happened?
Richter's transformation- CLL --> high grade lymphoma (Non-Hodgkins)
Sx- LN swelling, fever w/o infection, wt loss, night sweats, nausea, abdo pain
69
Pt with CLL suddenly unwell, what has happened?
Richter's transformation- CLL --> high grade lymphoma (Non-Hodgkins)
Sx- LN swelling, fever w/o infection, wt loss, night sweats, nausea, abdo pain
70
Treatment & dose for acute MS relapse?
Oral methylprednisolone 0.5g for 5 days
71
When using an inhaler, how long must you wait between doses?
Approx 30 seconds
72
1st line for absence seizures?
Ethosuximide
73
Sensorineural hearing loss + loss of corneal reflex = ?
Acoustic neuroma
Symptoms include vertigo, tinnitus and unilateral sensorineural hearing loss
Through invasion of the trigeminal nerve, patients may also present with an absent corneal reflex
74
Management of campylobacter
Usually self limiting
If severe/ immunocompromise- 1st line abx clarithromycin
Ciprofloxacin is alternative
75
What is Beck's triad?
* Hypotension
* Raised JP
* Muffled heart sounds
Cardiac tamponade
76
ECG changes in hypothermia
Jesus Its Bloody Frezing
J waves, irregular, bradycardia, first degree heart block
77
What is re-expansion pulmonary oedema & how can we prevent it?
* When a pleural effusion is drained too quickly, this is a complication
* May be preceded by onset of a cough or SoB
* If concerned clamp the chest drain and order urgent CXR
* To avoid re-expansion, clamp the drain tubing regularly if there is rapid fluid output- drain output should not exceed > 1L of fluid obver <6hr
78
When and what abx to prescribe in COPD exacerbation?
* Amoxicillin or doxycycline
* Erythromycin if pregnant
* Abx indicated if PURULENT sputum production or clinical signs of pneumonia
79
What are the cardinal signs of Meig's syndrome?
1. Benign ovarian tumour
2. Ascites
3. Pleural effusion
80
Do you give abx to pts with acute bronchitis?
* Give to systemically very unwell pts
* Pts with co-morbidities
* If CRP 20-100, delayed prescription of abx
* CRP>100 immediate prescription
* Usually doxycycline for 5 days
81
Which COPD pts should be considered for abx prophylaxis therapy? Which abx are used?
* >3 exacerbations requiring steroid therapy and at least 1 requiring hosp. admission in the last year
* Axithromycin (macrolide)
* Pts should not smoke, have optimised treatment
* Do EXG to exclude QTx prolongation as azithromycin can prolong QT
82
How to diagnose occupational asthma?
Serial measurements of peak expiratory flow are recommended at work and away from work.
83
How is obstructive sleep apnoea diagnosed?
Poysomnography (sleep studied) involves taking multiple measurements including an ECG, pulse oximetry, respiratory airflow, thoracoabdominal movement, and taking recordings of snoring
84
What are the most common causes of bilateral hilar lymphadenopathy & how can these be differentiated?
* TB- haemoptysis, productive cough
* Sarcoidosis- multi-system involvement, dry cough, erythema nodosum, polyarthralgia
85
Causes of cavitating lesions on CXR
* Squamous cell carcinoma
* Lung abscess
* TB
* PE
* RA
* Aspergillosis
* Wegener's granulomatosis
* Klebisella- cavitating pneumonia in upper lobes mainly in diabetics and alcoholics
86
Treatment of allergic bronchopulmonary aspergillosis
* Oral prednisolone
* 2nd line itraconazole
87
What would a CXR of bronchiectasis show?
May be normal or may show dilated bronchi with thickened walls (tram-track sign). An air-fluid level may be seen in severe cystic bronchiectasis.
88
Why is intubation a risk factor for aspiration pneumonia?
* Use of neuromuscular agents may lead to an impaired swallow
* Intubation itself can cause regurgitation
* Intubation may cause damage to the trachea/airway that can inadvertently increase the risk of gastric contents aspirating into the lung
89
What are the commonest sites affected by aspiration pneumonia?
* Right middle and lower lung lobes due to the larger calibre and more vertical orientation of the R main bronchus
90
What is the triangle of safety for chest drain insertion?
The triangle of safety for chest drain insertion involves the base of the axilla, lateral edge pectoralis major, 5th intercostal space and the anterior border of latissimus dorsi
91
Causes of respiratory alkalosis?
* anxiety leading to hyperventilation
* pulmonary embolism
* salicylate poisoning*
* CNS disorders: stroke, subarachnoid haemorrhage, encephalitis
* altitude
* pregnancy
92
What murmur is associated with Turner's syndrome?
Ejection systolic
Due to bicuspid aortic valve
93
Mx of testicular torsion?
Fixation of both testest to prevent torsion of the other
Emergency bilateral orchidopexy
94
Treatment of constipation in IBS
1st line ispaghula husk
Lactulose not recommended as it can increase gas production making symptoms worse
95
What are the classic features in acute liver failure?
1. Encephlopathy (impaired awareness, sleep alterations, reduced attention)
2. Jaundice
3. Coagulopathy (INR >1.5)
Most common cause is paracetamol OD or alcohol
96
What biopsy finding is consistent with gastric adenocarcinoma?
Signet ring cells
97
Hereditary Haemochromatosis mode of inheritance?
Autosomal recessive
98
RF for C diff?
* Abx- clindamycin or second and third generation cephalosporins
* PPIs
99
What do you think of with periumbilical lymph nodes
Gastric cancer
Sister mary joseph nodule
100
How to investigate/ diagnose UC?
Colonoscopy + biopsy
BUT for severe colitis- avoid colonoscopy due to risk of perforation- flexible sigmoidoscopy is preferred
Findings- inflammation confined to submucosa, pseudopolyps, crypt abscesses, depletion of goblet cells, red raw mucosa bleeds easily
101
Most affected bowel in Coeliacs?
Duodenum & jejunum
Ileum not affected unlike Crohn's
102
Mx of pituitary adenomas
Dopamine agonists- cabergoline, bromocriptine are 1st line
2nd line- trans sphenoidal surgery
103
Which COPD pts qualify for LTOT?
Stopped smoking and 2 ABG readings pO2<7.3
or pO2 7.3-7.8 AND secondary polycythaemia/ peripheral oedema/ pulmonary htn
104
Most common organism found on culture of ascitic fluid in SBP?
E Coli `
105
Which patients should be given abx prophylaxis for spontaneous bracterial peritonitis?
Pts who have had a previous episode of SBP
Patients with fluid protein < 15 and either child-pugh score of at least 9 or hepatorenal syndrome
Offer prophylactic ciprofloxacin or norfloxacin
