Medicine Flashcards
(191 cards)
1
Q
Treatment for Hepatic Encephalopathy
A
- Avoid sedeatives
- ITU, sat up at 20 degrees.
- Measure and correct electrolytes
- Consider Intubation amd NG tube if GCS drops low enough
- LACTULOSE and RIFAXIMIN can both help clear Nitrogen from body
2
Q
Prophylaxis for Oesophageal Varix
A
Propanolol
3
Q
Which ulcer type is relieved by eating
A
Duodenal.
Gastric is worsened as it stimulates acid to be released.
4
Q
Budd-Chiari Triad
A
Ascites, Abdominal Pain, Smooth Hepatomegaly
5
Q
Whats the difference between PBC and PSC
A
PBC = Auto-immune process mainly affecting the liver. PSC = Chronic process also impacting the gallbladder.
Both causes of acute liver failure, and both linked to UC.
6
Q
Causes of Erythema Nodosum
A
NODOSUM NO known cause Drugs Oral Contraceptive Pill Sarcoidosis UC and Crohns Microbes and Malignancies.
7
Q
Extra-Intestinal Manifestations of IBD
A
A PIE SAC
Apthous ulcers, Pyoderma gangrenosum, Iritis, Erythema nodosum, Sclerosing cholangitis, Arthritis, Clubbing
8
Q
How is Proctitis distinct from regular UC
A
Rectal bleeding and mucus discharge are present, but the patient’s stools are well formed and they are in good systemic health.
Very mild form of UC.
9
Q
How do you decide how to manage a UC flare?
A
Truelove and Witt Classification.
Low = Try and induce remission (Prednisolone, Mesalazine, Bone protection)
High = Emergency Colectomy
10
Q
How is UC remission maintained?
A
5-ASAs.
Mesalazine generally, as Sulfasalazine is linked with Agranular Cytosis (but still sometimes used).
Can give orally, as a suppository or as an enema.
11
Q
What are the two different “versions” of Crohn’s?
A
Fistula/Perforation and Fibrosis/Stricture. Just different reactions to the inflammation, believed to be genetic.
12
Q
Basics of Crohns Management?
A
- Flare ups: Prednisolone and Azathioprine. Remember Heparin as IBD leads to a pro-thrombotic state.
- Azathioprine then continued and used to manintain remission.
- Some patients may get away with simpler management, e.g. through smoking cessation, switching to an elemental diet, Loperamide for diarrhoea.
- Surgery is an option that should really only be reserved for complications.
- Infliximab is another last resort option.
13
Q
Define Malnourished
A
Loss of 5-10% of body weight over the last 3-6 months.
BMI is less than 18.5
14
Q
What drugs do you stop in AKI?
A
DAMN
Diuretics, ACE Inhibitors, Metformin, NSAIDs
15
Q
How do you distinguish IgA Nephropathy and Post-Strep Glomerulonephritis?
A
Both present as Nephritic Syndromes
IgA: Onset in days after URTI, affects young men, coca-cola urine.
PSGN: Onset isnt until weeks after URTI, proteinuria is much more prominant and associated with low compliment levels.
IgA may also have associated Abdominal Pain, Arthritis and a Palpable Purpuric Rash (in which case it is known as Henoch-Schonlein Purpura)
16
Q
Indications for Dyalisis in AKI
A
AEIOU
Acidosis, Electrolyte imbalances not settling, Intoxication (medications that need to be removed from the blood), Oedema, Uraemia
Options are limited to Haemodyalisis and Haemofiltration.
17
Q
Rough management for AKI
A
1) Treat Cause:
- Pre renal, give fluids
- Intra renal, take biopsy ad send to specilialists, probably for steds
- Post renal, catheter/nephrostomy/urological intervention.
2) Spot and Treat Complications:
- Fluid Balance
- Hyperkalaemia
- Acidosis
3) Spotting early the need for RRT:
- AEIOU
- Haemodialysis or Haemofiltration
18
Q
Immediate complications of starting a patient on RRT (e.g. in AKI)
A
- Infection risk (Sepsis and Endocarditis)
- Procedural hypotension
- Bleeds (requires anticoagulation)
- Altered nutrition and drug clearance
- “First Use Syndrome”, an anaphylactic type reaction seen in patients going through RRT for the first time
19
Q
Long term complications of being on RRT
A
- HUGE increase in CVD risk factors due to raised BP, calcium levels, vascular stiffness, inflammation, oxidative stress
- Protein-Calorie malnutrition.
- Renal Bone disease
- Infection
20
Q
Why is Uraemia serious in renal patients?
A
Can cause Pericarditis and Encephalopathy.
Causes T-cell dysfunction with an increase in Sepsis related mortality.
21
Q
Why does CKD cause bone disease?
A
1) Kidney loses ability to secrete phosphate, so PTH rises
2) Kidney loses ability to activate Vitamin D, so Calcium drops
22
Q
Antibiotic of choice for Staph Epidermidis
A
Vancomycin
23
Q
Rough management of CKD
A
1) Knowing when to refer to Nephrology (e.g. stage 4-5 CKD, ACR high enough, declining eGFR, poorly comtrolled BP…)
2) Slowing disease progression with ACEis, BM control, lifestyle
3) Managing complications
- Anaemia with Iron/B12/Folate/EPO
- Acidosis with Sodium Bicarb
- Oedema with Fluid restriction and LDs
- Renal Osteodystrophy with Vit D and Phosphate binders
- Restless leg syndrome with Gabapentin
4) Managing CVD Risk with ASPIRIN AND ATORVOSTATIN
5) Knowing when to plan for RRT (<12 months is safe)
24
Q
How do you manage Raynaud’s
A
Calcium Channel Blockers e.g. Amlodopine.
25
Broad management for Nephrotic Syndrome
- VTE Prophylaxis
- Symptomatic relief through Diuretics, Statins, Albumin
- Definitive management relies on cause, but often steroids.
Nephritic is similar but with focus on blood pressure control and without the statins and albumin.
26
Vasculitis Symptoms
General: Fever, Malaise, Headache, Fatigue, Weight Loss, Might Sweats.
Specific: Kidney dysfunction, Uveitis, Mononeuritis, Arthritis, Sinusitis, Nose bleeds, Rashes.
WATCH OUT FOR PULMONARY OEDEMA
27
Types of Diabetes Insipidus
- Cranial. Comes from Pituitary Gland failing to secrete ADH.
- Nephrogenic. Kidney stops responding to ADH.
- Drug Induced. Lithium
28
Common RA Extra-Articular Features
Main two are Lung Fibrosis and Rheumatoid Nodules.
Alao look out for Eye inflammation, Renal disease, Pericarditis and Pleuritis, Carpal Tunnel Syndrome.
29
Dactylitis Differential Diagnosis
- Rheumatoid: Psoriatic Arthritis, Ank Spon
| - Non Rheumatoid: Sarcoidosis, Sickle Cell, TB, Leprosy)
30
Presenting features of Psoriatic Arthritis
ROADS
Rheumatoid like pattern, Oligoarthritis, Arthritis Mutilans, Dactylitis, Spondylitis.
31
Symptoms of Fibromyalgia
Chronic and widespread pain with a heightened pain response to pressure.
Also commonly see excessive fatigue, sleep problems and memory dysfunction.
32
Management of Gout
Lifestyle advice = Lose weight, cut down on alcohol and red meat, avoid aspirin, avoid fasting.
Acute management = NSAIDs, Steroids, COLCHICINE
Alopurinol is used to maintain remission, dose must not be changed during a flare up.
33
Features of Behcet’s Disease
- Mouth sores
- Genital sores
- Arthritis
- Inflammation of the eye
34
What is the pathophysiology of Systemic Sclerosis and differentiate between the two types.
Path = Auto-Immune process causes Collagen build up causes Small artery occlusion causes Skin thickening.
Two types:
- Localised (mainly skin on the face and hands)
- Systemic (affects skin all over the body, including organs leading to CREST symptoms and organ damage)
35
How do you define and manage a severe Lupus flare
Definition = Lupus Nephritis, Pericardial Involvement, CNS Involvement or Haemolytic Anaemia.
Management = HD Steroids, Mycophenolate + Rituximab + Cyclophosphamide.
36
Maintenance Lupus therapy
- High Factor sun cream
- NSAIDs and Azathioprine or Methotrexate are used to maintain remission
- Hydroxychloroquine is best for joint and skin involvement
37
What are the common features of the seronegative spondyloarthropathies?
1) RF Negative
2) Associated with HLA-B27
3) Axial Skeleton involvement
4) Asymetrical Large Joint involvement
5) Dactylitis
6) Enthesitis
7) Extra-Articular Manifestations (e.g. Psoriasis, Iritis, Oral ulcers, Aortic valve incompetence and IBD)
38
Differential diagnosis for a single swollen joint
- Septic Arthritis
- Trauma
- Haemarthrosis
- Gout or Pseudogout
- Other bony or ligamentous pathology
39
What are the symptoms of GPA?
GPA is a condition characterised by inflammation of multiple blood and lymohatic vessels coupled with the formation of granuloma.
Symptoms = Nasal Bleeding/Crustiness/Deformity, Arthritis, Kidney dysfunction, Sight loss, Skin changes, Muscle pain, Blood in the stools and cough.
40
How do you manage GPA?
Infliximab and Steroids for induce remission
Azathioprine and Methotrexate for maintenance.
41
What are the common diabetic neuropathies?
Somatic:
- Distal Symmetrical Polymeuropathy (glove and stocking)
- Mononeuritis (either ulnar nerve or CN3 palsy)
- Diabetic Amyotrophy (quad muscle weakness)
Autonomic:
- Postural Hypotension
- Impotence
- Nocturnal Diarrhoea
- Urinary Retention
- Gastroperisis
42
What paraneoplastic syndromes are associated with Small Cell Lung Cancer?
ADH
ACTH (causing atypical features; hypertension, hyperglycaemia, hypokalaemia, alkalosis and weakness are more coomon than bufalo hump)
43
What paraneoplastic syndromes are associated with Squamous Cell Lung Cancer?
PTHrP (causing hypercalcaemia)
Clubbing
TSH (causing hyperthyroidism)
44
How do you distinguish Hypo and Hyper natraemia?
Hypo causes Nausea and Anorexia
Hyper causes Thirst.
Both can come in with mood symptoms such as confusion and irritability, and both can progress to seizures, coma, loss of consciousness.
45
What causes Hypernatraemia?
Fluid loss basically.
Diarrhoea, Vomiting, Burns, DI
46
What causes Hyponatraemia?
Either
- Increased Fluid (HRH, SIADH)
- Reduced Na (Addison’s, Diuretics, MDMA)
47
How do you treat hyponatraemia and what to look out for?
If Asymptomatic, fluid restriction.
If Symptomatic, SLOW rehydration with 0.9% Saline. Aim for rise in Na of no greater than 12 mmol/L/day. If rehydrate too fast can cause Central Pontine Myelinolysis.
Consider Furosemide.
48
Causes of Hypokalaemia?
- Thiazide, Indapamide or Loop Diuretic use.
- Diarrhoea and Vomiting.
- Cushings (or steroid use).
- Conn’s.
- Liquorice.
49
Management of DI
Cranial = Desmopressin
Nephrogenic = Treat underlying cause, give thiazide diuretics to reduce urine output,
50
What tests would you order for a fever in a returning traveller?
- FBC (with DWCC), LFTs, U&Es, possibly TFTs, CRP and ESR.
- 3x Thick and Thin blood film (MALARIA). Consider Malaria Antigen Rapid Diagnostic Test (MARDT)
- 2x Blood culture (TYPHOID)
- PCR for Dengue Virus and ELISA for Dengue Antigens
- Urinalysis and Stool culture (including parasite ovas and cysts) (always required as often blood cultures come back negative, so may need to culture typhoid before treatment)
- CXR (could be TB pr HIV)
- BLOOD BORNE VIRUS SCREEN!!! (HIV, Hep, CMV, EBV)
51
What are the features of severe Malaria?
- Paracitaemia above 10%
- Hypoglycaemia below 2.2
- ARDS
- Shock
- Anaemia below 80
- Haemoglobinuria
- DIC
- Spontaneous bleeding
- Impaired consciousness
- Seizures
- AKI
52
How do you cure Malaria?
P. Falciparum=
- Uncomplicated: Artemisin Combination Therapy
- Severe: Artesunate Regimen
Other forms=
- Chloroquine and Primaquine (one for blood one for liver)
53
How do you cure Typhoid?
IV Ceftriaxone + Oral Azithromycin
54
What are the causes of PUO?
The big 3:
- AI diseases
- Weird infections (abscesses, endocarditis, TB)
- Cancers (RCC, Leukaemia and Lymphoma)
The weird 3:
- Hyperthyroidism
- Medication
- VTE
55
How do you test for STIs?
Asymptomatic patients should be NAAT tested. This is usually done through First Pass Urine in men and Vulvo-Vaginal swab in women (as deep as possible, rubbed against vulva on the way out).
Any discharge, Charcoal swab which can test for Gonorhoea.
Any ulcer can be swabbed using a Green Swab.
WOMEN GET PREGNANCY TESTS.
56
What tests would you order in a suspected HIV patient?
- HIV test, to confirm.
- Viral load, to judge if contageous.
- CD4 count, to stage.
- Resistence profile, to begin targeting therapy.
- Hep and Syphylis serology, to look for co-morbidities.
- Normal bloods.
Consider TB screen, fungal cultures, Cryptococal antigen testing, Viral PCR.
57
Outline the rough management of a HIV patient?
Main thing = anti-retrovirals. Various kinds, but many complicated interactions with drugs such as asthma meds, OTCs and herbal remedies so must iron out what they cam and can’t take. Examples-
- CCR5 Antagonists
- Nucleoside and Non Nucleoside RTIs.
- Integrase Inhibitors.
- Protease Inhibitors.
- Pharmacokinetic Boosters (increases the effect of other drugs).
Furthermore, they will need prohylactic antibiotics depending on how low their CD4 count is-
- <200, Co-Trimoxazole OD, vs PCP
- <50, Azithromycin OW as well, vs Mycobacteria Avium
Vaccinations against-
- Hep B
- Pneumococcus
- Annual Flu vaccines
58
How do you diagnose and trest latent and active TB?
Latent:
- Diagnose through either the Mantoux (tuberculin slin test) or Interferon Gamma Release Assay (better for those whove had BCG vaccine). Neither can confirm nor deny TB.
- Manage with 3 months of Rifampicin and Isoniazid
Active:
- Diagnose with CXR, Sputum AFB smear and culture, NAAT.
- Manage with 2 month intense stage with RIPE, then 4 month relaxed stage with RI.
Always remember to check baseline LFTs and Visual Acuity first, give Pyridoxine to avoid nerve issues, give steroids if TB in awkward place.
59
What are you worried about if someone comes in with low Glucose + Mg + K + Phosphate?
How do you manage them?
Refeeding Syndrome.
Sudden reintroduction of food causes the body to secrete insulin, massive increase in synthesis which drains the blood of these ions, causing the symptoms of refeeding syndrome.
Treat with Pabrinex, Fluids, Vitamins and Minerals. If alcoholic consider Chlordiazepoxide and further thiamine deficiency issues.
60
How do you manage alcohol withdrawal?
Fluids, Pabrinex, Chlordiazepoxide, Consider additional Thiamine.
Aim is to avoid Wernicke’s becoming Korsakof
61
What medications are most commonly associated with falls in the elderly?
In order:
- Antidepressants
- Antipsychotics
- Sleeping pills (benzos, other sedatives)
- BP medication
- Anti-inflammatory drugs
- Opioids
- Diuretics
62
What are the 5 common causes of falls in the elderly?
1) Muscle weakness or balance issue.
2) Issues relating to their vision.
3) Long term medical conditions (e.g. Cardiac, Respiratory or Neuro)
4) Long term medications (antidepressants, antipsychotics, sedatives, BP)
5) Issues in their home enviroment.
A good broad approach to managing a falls patient is assessing and correcting these issues.
63
Distinctive features of delirium vs dementia
Acute, fluctuating change in ALERTNESS, CONSCIOUSNESS AMD ATTENTION. Causes Delusions that are short lived and fluctuating, and leads to fragmented sleep but not Sleep-Wake Reversal.
Remeber to always ask for a colateral history to help distinguish.
64
Broadly what are the causes of Delirium?
- Liver or Lung Failure
- Infection
- Metabolic disturbance
- Iatrogenic (either medication or post-op)
- Pain or Anxiety
- Urinary Retention or Complications
- Substance Intoxication or Withdrawal
65
Why is the anti-cholinergic burden a concern in older patients?
High anti-cholinergic scores are associated with blurry vision, urinary retention and constipation.
These are all things that can precipitate falls in the elderly.
66
3 main effects of Dementia?
- Impaired Cognition
- Impaired Memory
- Impaired Activities of Daily Living
67
Drugs used to treat Dementia?
Cholinesterase inhibitors: Neostigmine, Donepezil, Galantamine.
If vascular dementia is suspected, management of cardiac risk factors is essential.
68
How do you manage Stress and Urge incontinence?
In both cases lifestyle factors such as increasing fluid intake but reducing caffeine can be effective, as well as regular toileting and maintaining good bowel habits.
Stress:
1st = Pelvic Floor Muscle Training
2nd = Duloxetine
3rd = Tension Free Vag Tape, Intra-Mural Bulking, Artificial Sphincter.
Urge:
1st = Bladder Training
2nd = Oxybutinin
3rd = Botox Injections, PC Sacral Nerve Stimulation, Urinary Diversion bia Ileal Conduit.
69
What are the two common causes of faecal incontinence?
Constipation and Neurological dysfunction.
If a patient presents with faecal incontinence, important to check anything that could cause these two.
70
Describe a Vasovagal?
Comes on over a few seconds during which the patient may experience nausea, swetting and pallor. Unconscious period lasts about 2 minutes and nothing happens during it. Patient recovers rapidly.
Look out for causes, common ones include coughing, effort, micturition, or Carotid Sinus Stimulation from head turning or shaving.
71
Describe Epilepsy?
Commonly occur when lying down or asleep or due to obvious triggers such as TV. Patient may experience an aura with altered breathing, cyanosis. Quite prominent synptoms during, such as incontinence, jerking, cyanosis and tongue bitting. Patient feels off afterwards, postictal state of drowsiness, confusion, amnesia.
72
Describe a Stokes-Adams attack?
Transient arrythmia causing a temporary drop in CO, which is rapidly resolved on collapsing.
Little to no warning, perhaps palpitations. Patient will go pale with a slow, weak pulse during but will recover rapidly as CO increases again.
Can happen multiple times a day.
73
Causes of Constipation?
- General (poor diet, low fluid intake, old age, post-op)
- Anorectal Disease (cancer, fissures, prolapse)
- Bowel (obstruction, strictures, masses, diverticulitis)
- Endocrine (High Ca, Low K, Low Thyroid)
- Drugs (Opiates, TCAs, Iron, Furosemide)
- Neuromuscular (Diabetic neuropathy, injuries)
74
What are the 4 types of laxatives and give an example of each?
- Bulking agents e.g. Fybogel. Work by increasing the mass of stool and triggering peristalsis.
- Stimulants e.g. Senna. Increase gut motility.
- Stool softeners e.g. Arachis Oil Enemas.
- Osmotic Laxatives e.g. Macrogol or Lactulose. Work by producing a low pH diarrhoea which is easier to pass.
75
How do you diagnose Urge incontinence?
Complete emptying (stress is normally only small amounts) + Triggers followed by Urge + Urodynamic study.
76
Differentials for a stroke?
Seizure, Syncope, Sepsis.
Primary headache disorder, Space occupying lesion.
77
Reversible Causes of Cardiac Arrest
Hs and Ts
Hypothermia, Hypoxia, Hypovolaemia, Hyperkalaemia, Hypokalaemia, Hydrogen ions (acidosis), Hypoglycaemia.
Trauma, Tamponade, Thrombus (PE and MI), Tablets, Toxins, Tension Pneumothorax
78
Causes of non-resolving Pneumonia?
CHAOS
```
Complications (e.g. empyema, abscess)
Host (immunocompromised)
Antibiotic (inadequate dose, poor absorption)
Organism (resistance, unexpected)
Secondary diagnosis (PE, cancer)
```
79
What special test should be ordered in cases of pneumonia withnhigh Curb scores?
Atypical pneumonia screen (serology and urine for Legionella)
80
Causes of haemoptysis?
VICED
Vasculitis, Infection, Cancer, Embolus, Deranged coagulation.
81
What would you do if consolidation on CXR but could be TB or Pmeumonia?
Treat as pneumonia
Give antibiotics according to CURB 65
Lauch full investigations for TB
82
How does Usual Interstitial Pneumonia present?
4 Cs
Clubbing
Chest expansion (reduced)
Crepitations (fine, basal or axillary)
Cardiovascular involvement (due to pulmonary hypertension
83
What are the sub forms of ILD?
Usual Interstitial Pneumonia
Non-Specific Interstitial Pneumonia
Extrinsic Allergic Alveolitis
Sarcoidosis
84
What tests do you order in someone you suspect has ILD?
```
Plasma Auto Antibodies
Anti-GBM
ANCA p and c
ACE
IgG to Serum Precipitins
HIV
```
85
How do you distinguish between Sarcoidosis and TB?
Both involve granuloma at lungs and other tissues, both form granulomata.
However Sarcoidosis are non caseating TB are caseating
Require Histology.
86
How does Hypersensitivity Pneumonitis present?
With a trigger in the history. Often something organic like plant matter or pigeon faeces.
Acute Presentation = Shortly after exposure (4-8 hours, reversible, settles within 3 days)
Chronic Presentation = Months or more often Years into exposure (less reversible, worse prognosis).
87
Pharmacological options for Interstitial Lung Diseases?
PIRFENIDONE. Inhibits the growth factors responsible for ILD.
N-Acetylcysteine and Immunosuppresion may also play a role.
Other than that, remove trigger, stop smoking, transplant, oxygen, paliative.
88
Causes of Lung Fibrosis?
Upper Zone = CHARTS
Coal worker pmeumonitis, Hypersensitivity pmeumonitis, Ank Spon, TB, Sarcoidosis
Lower Zone = UIP, SLE, Amiodarone, Sulfasalazine, Methotrexate, Asbestos.
89
How do you manage Sarcoidosis?
Important to remeber that 50% of patients recover without treatment, and 50% of patients deteriorate and eventually require treatment.
That treatment usually involves Paracetemol and Ibuprofen (covers the majority of symptoms), but severe cases can reauire Azathioprine and Methotrexate.
90
Causes of Type 1 Resp Failure?
Anything causing a V/Q missmatch:
Pneumonia, Asthma, COPD, PE, ARDS, Oedema, Pulmonary Fibrosis.
91
Causes of Type 2 Resp Failure?
Anything causing more broad Alveolar Hypoventilation.
Think of it going down the resp pathway:
- Decreased central drive (sedation, opiates, rainstem disorders)
- Neuromuscular disease (spinal cord lesions, myasthenia gravis)
- Issues with the thoracic wall (obesity, scoliosis)
- Intrinsic lung disease (asthma, COPD, fibrosis)
Most common cause is IECOPD.
92
How do you manage respiratory failure?
- Treat cause
- Supportive care
- Oxygen is mainstay. Type 1 can safely be given high flow oxygen initially, Type 2 you have to be a bit more careful as may be IECOPD, 24% through a Venturi mask.
- Repeat ABGs every 20 minutes.
- If all fails, intubation and mechanical ventilation are options.
93
What is Acute Respiratory Distress Syndrome?
Acute onset, non-cardiogenic pulmonary oedema secondary to damage to the lung tissue causing a massive release of inflammatory mediators.
94
What causes ARDS?
Pulmonary = Pneumonia, Gastric aspiration, Inhalation, Direct injury, Vasculitis, Contusion.
Other = Shock, Sepsis, Haemorrhage, DIC, Pancreatitis, Liver failure, Head injury, Malaria, Burns, Heroin, Eclampsia.
95
Features of ARDS?
Cyanosis
High RR and HR
Peripheral Vasodilation
Bilateral inspiratory crackles
96
How do you diagnose ARDS?
1) Must be acute onset
2) Bilateral infiltrate on CXR
3) PULMONARY CAPILLARY WEDGE PRESSURE < 20 or Lack of CHF (basically need to prove pulmonary oedema isnt cardiogenic)
4) Hypoxaemia
97
How do you manage ARDS?
1) Treat cause and admit to ITU
2) Provide respiratory support, at least CPAP possibly NIV.
3) Provide circulatory support, either as a blood transfusion, conservative fluid management or with Donutamine.
4) Consider Nitric Oxide (pulmonary vasodilator) to manage Pulmonary hypertension.
5) Consider haemofiltration if kidney damage.
6) Consider enteral feeding
98
Benefits of Pulmonary Rehab?
```
Reduces symptoms.
Improves knowledge of the condition.
Increases muscle strength and endurance, and exercise tolerance.
Reduces length of hospital stays.
Improves function in day-day life.
Manages depression and anxiety.
```
99
What is involved in an asthma self care plan?
- A detailed explanation on what drugs to take normally.
- Information on how to spot an attack coming on and what to do.
- Often a 7 day course of steroids, used to manage an exacerbation but not an attack until they can get to the GP.
100
What is involved in a COPD rescue pack?
If you feel out of breath, use your reliever.
If you still feel out of breath, this is an exacerbation, use your Prednisolone.
If your sputum changes colour or increases in volume, take rescue antibiotics (normally Doxy or Amox)
If you have an increased chesty cough, keep calm and so your resp exercises.
101
What medications are available on the NHS for smoking cessation?
- NRT. Can come in the form of patches, lozenges, sprays, gums... Safe to combine two and safe in pregnancy.
- Varenicline, partial nicotine agonist, marginally more effective.
- Bupropion, nicotine re uptake inhibitor.
102
What cultures do you order for someone with suspected bacterial endocarditis?
3 sets, from different sites, at different times.
103
What investigations do you order in Endocarditis?
Bloods:
FBC, Us and Es, Rh F (raised in EC for some reason), Urine Analysis.
Cultures: 3 sets, @ 3 sites, @ 3 times.
Imaging:
CXR (oedema) and ECG (heart block)
TTE may show growths but TOE is gopd standard.
CT best.
104
Antibiotics for Endocarditis not on a new prosthetic valve?
FAG
Flucloxacillin, Ampicillin, Gentamicin
105
Antibiotics for Endocarditis on a new prosthetic valve?
Vancomycin, Gentamicin, Rifampicin.
106
Emergency therapy for thyrotoxic storm?
Beta blockers, Hydrocortisone, PROPYLTHIOURACIL
107
What UTI to give a pregnant or breastfeeding woman?
First Trimester: Nitrofurantoin
Third Trimester or Breast feeding: Trimethoprim
N before T in alphabet.
108
What changes do you make to STEMI management if patient is going for PCI?
Double Aspirin and Clopidogrel doses.
Will probably have Fondaparinux at 6PM every day after.
109
Broad management of ACS?
```
ROMANCE:
Reasure
Oxygen
Morphine
Aspirin
Nitrates
Clopidogrel
ECG and Enoxaparin
```
110
Crohn’s Disease endoscopic changes?
- Fat wrapping
- Fissures
- Narrowed Lumen
- Skip lesions
- Cobblestone
111
How does Sarcoidosis cause Hypercalcaemia?
- Macrophages start uncontrolably synthesising Vit D, increasing gut absorption.
- Increase in Bone turnover
112
What skin changes can Sarcoidosis cause?
- Erythema Nodosum
- Annular lesions
- Non-caseating Granulomata
113
How do you manage Sarcoidosis?
Initially, nothing. 50-80% spontaneously resolve.
Indications for management: Progressive pulmonary disease, organ involvement, peristemt hypercalcaemia, skin involvement, uveitis, hypersplenism.
Mx: Initially, P&I for symptoms. If not resolving, Methotrexate and Azathioprine are good.
114
Causes of bilateral hilar lymphadenopathy?
- Sarcoidosis
- TB
- Lymphoma
115
Causes of a massive Pleural Effusion?
- Lung cancer
- TB
- CCF (normally bilateral but not necesarily)
116
What are some examples of less common lung cancer paraneoplastic syndromes?
Acromegaly
Carcinoid syndrome
Hyperthyroidism
Gaenecomastia
117
Differential diagnosis for a cavitating lesion?
- TB
- Squamous Cell Carcinoma
- Bacterial pneumonia (esp. Pseudomonas)
118
What are the 3 public health measures to take in a suspected TB case?
- Notify public health
- Isolation
- Mantoux test those who have come into immediate contact with the patient (remember will false negative if patient is immunocompromised)
119
What are some COPD changes on X-Ray
- Increased lung volume
- Flattened diaphragm
- Loss of CP angle
- Widened inter-costal spaces
120
What oxygen therapy should you give a ECOPD patient?
Controlled Oxygen Therapy.
- Start at 24-28% through a Venturi mask.
- Aiming for Sats of between 88 and 92%
- Anytime you give oxygen, an ABG must be done within the hour. In these cases, look for a PaO2 above 8.0 and a rise in PaCO2 of no greater than 1.5
121
What interventions actually improve the long term outcome of COPD patients?
- SMOKING CESSATION (by far the biggest contributor)
- LTOT if necessary and capable
- Regular flu vaccines
- Lung Volume Reduction Surgery
122
When and how do you manage a high Lactate?
Manage if greater than 2.0
Admit to ITU, start giving fluids, Lactate should drop naturally.
123
Most common complications of Pneumonia?
Most common are Sepsis and AF.
Also remember Empyema, Abscess, Respiratory Failure, ARDS.
124
How do you judge if a patient needs a CTPA?
Using the Well's score?
Greater than 4, CTPA.
Less than 4, D-Dimer and re-evaluate.
125
How long should patients be on anti-coagulation post-PE?
Unprovoked = 3 months
Provoked = 6 months
Due to Malignancy = Lifelong
Definition of Unprovoked is DVT/PE arising in someone not on HRT or the COCP and who has none of the major risk factors for DVT/PE.
126
What ECG changes are seen in PE?
- Sinus Tachycardia
- RBBB
- Right Ventricular Strain
- Right Axis Deviation
- Right Atrial Enlargement
127
If leads 1 and 3 appear to be pointing at each other, what is suggested?
RAD
128
What does Hypogammaglobulinaemia cause?
Bronchiectasis
129
What are the CT findings in Bronchiectasis?
- Tram lines
- Signet ring sign
- Cystic lesion
- Air-fluid levels
- Dilated bronchi
130
How do you distinguish COPD from HF (say if someone comes in with a chronic productive cough)?
- Warm vs Cold extremities
- Purse lip breathing
- Inability to lie down in HF
131
What are some common complications for Sickle Cell Disease?
- Bone pain
- Acute Coronary Syndrome
- Aplastic crisis
- Arrhythmia
- Seizures
- Haemolytic anaemia
- Infection
- Bone marrow aplasia
- Hypersplenism
132
Why is pre-excited AF with WPW such a concern and how do you manage it?
Very likely to become VF and can't be managed through normal AF drugs.
Use Flecainide/Sotolol/Procainamide
133
How do you describe Psoriasis?
Silvery scaling on a red erythematous base
134
What can cause Polycythaemia?
Primary causes e.g. PRV
Secondary causes due to PHYSIOLOGICAL increased EPO production e.g. Altitude, COPD, CVD, Shunting, Smoking
Secondary causes due to PATHOLOGICAL increased EPO production e.g. RCC, Wilm's tumour, HCC, Adrenal tumours.
Apparent polycythaemia e.g. Dehydration, Burns, Stress
135
What can cause microcytic anaemia?
TICS
Thalasaemia, Iron deficiency, Chronic disease, Sideroblastic anaemia.
136
How do you easily differentiate between Migraines and Cluster headaches?
Migraines make people want to be very still and calm, Cluster headaches make people very agitated.
(can't use aura as not 100% reliable)
137
What are the differentials for a headache?
Primary Headache Disorder
Stroke
Hypertension
SOL
138
What is Amaurosis Fugax?
Painless, temporary loss of vision in one eye, described as "like a curtain coming down"
Caused by a TIA temporarily occluding the retinal artery, most patients will have cardiac risk factors and/or carotid artery stenosis.
139
How do you interpret a DEXA scan?
>0 = Better than average
0 to -1 = Worse than average but still okay
-1 to -2.5 = Osteopenia. Offer lifestyle advise.
-2.5 and down = Osteoperosis. Offer lifestyle advise, treatment with Bisphosphonates and repeat DEXA in two years.
140
Factors suggestive of Pseudogout?
Positively bifringent, rhomboid shaped crystals.
Calcium PyroPhosphate crystals.
Chondrocalcinosis.
141
What effects can a Pancoast tumour have on the surrounding structures?
- Can compress the sympathetic chain, causing Horner's
- The T1 nerve root, causing thenar wasting
- The SVC causing SCVOS
- The thoracic outlet causing thoracic outlet obstruction
- The recurrent laryngeal nerve causing Bovine voice
142
Triad of Grave's disease?
Eye disease
Skin disease (pre-tibial myxoedema)
Hyperthyroidism
143
Common causes of AF in a young person?
Rheumatic fever, Pneumonia, Thyroid dysfunction
144
Signs of Hypothyroidism?
```
BRADYCARDIC
Bradychardia
Reflexes relax slowly
Ataxia
Dry skin and hair
Yawning and sleepiness
Cold peripheries
Ascites
Round puffy face
Defeated demeanour
Immobile/ Ileus
CCF
```
Also, Goitre
145
What are the 4 questions to ask alcoholics?
CAGE
Cutting down
Annoyed at people mentioning their drinking
Guilt around drinking
Eye opener
/do you use alcohol to help you sleep
146
What drugs prolong QT interval
Citalopram and Erythromycin mostly
147
What do you give a Pneumonia patient to cover both typical and atypical causes?
Amoxicillin for Typical
Clarithromycin for Atypical
Test CRP again after 4 days, if not dropping ABs aren't working so must revisit.
148
What are the 3 syndromes associated with alcohol withdrawal?
Delirium Tremens = Psych symptoms, Sweating and Tremor. Treat with Pabrinex BD
Wernicke's Encephalopathy = Same + Nystagmus, Ataxia, Opthalmoplegia. Treat with higher doses of Pabrinex.
Korsokoff = Irreversible memory decline secondary to acute alcohol withdrawal.
149
Pathological changes seen in COPD?
Loss of ciliary function
Increased mucus production
Goblet cell hyperplasia
Oedema and thickening of the mucosa
150
Pathological changes seen in Asthma?
```
Bronchoconstriction
Mucus plugging
Mucosal swelling
Airway remodelling (SM hypertrophy and fibrosis)
Goblet cell hyperplasia
```
151
Give some causes of Left and Right Axis Deviation?
Both can be caused by WPW.
Left: Left ventricular hypertrophy, Inferior MI, Left anterior hemiblock, Ventricular hypertrophy.
Right: Right ventricular hypertrophy, Anterior MI, Left posterior hemiblock
152
What are some pathophysiology things that happen in asthma and COPD?
```
Asthma:
Goblet cell hyperplasia
Smooth muscle hyperplasia
Epithelial damage
Mucus plugging
```
COPD:
Mucus gland hyperplsia
Chronic inflammation amd fibrosis of small airways
Loss of cilial function
153
What is involved in a pneumonia follow up?
- H Influenza IgG
- Pneumococcal IgG
- Immunoglobins
- HIV Test
- CXR
154
What are 3 causes, organisms and management options in Bronchiectasis?
Causes:
- Infections (TB and whooping cough)
- HYPOGAMMAGLOBULINAEMIA
- Genetic mucociliary clearing defect (CF, Youngs, Kartageners)
Organisms:
- H Influenza
- PSEUDOMONAS
- Fungi
Management Options:
- Physiotherapy to clear mucus
- Flu vaccine to prevent infections
- Antibiotics to treat infections
155
What are some common presentations and complications of Cystic Fibrosis?
Presentations:
- Meconium Ileus
- Intestinal Malabsorption
- Recurrent Infections
- Screening
Complications:
- Infections
- Low Body Weight
- DIOS
- Diabetes
156
When do you drain a pleural effusion? Why dont you normally?
Drain if clearly an empyema (purulent aspirate or pH less than 7.2)
Dont normally because need to know how much protein is in it to work out cause. Exudate vs Transudate. If between 25 and 35g use Lights criteria which involves looking at serum protein and LDH levels and comparing.
157
What broadly causes Obstructive Sleep Apnoea?
Either
- Small Pharyngeal diameter (Obesity, large tonsils)
- Excessive Pharyngeal narrowing in sleep (Obesity, stroke, MND, muscle relaxants, age)
158
How do you manage OSA?
Diagnosis with sleep study (either limited or full polysomnography).
Conservative: Lose weight, sleep on side
Medical: Mandibular Advancement Devices
Surgical: Pharyngeal surgery
If all else fails, CPAP.
Dont drive while sleepy.
159
Someone comes in with what looks like Liver failure. What tests do you order?
- Hep and HIV screen
- Blood cultures
- Paracetemol
- Hepatic Vein Doppler USS
- Liver USS, CT
- Alpha 1 anti-trypsin levels
- Ceruloplasmin
- Feritin (haemachromatosis)
- Autoantibodies
CXR FOR ARDS!!
160
Broadly how do you manage acute liver failure?
Basics:
- Sit patient up at 20 degrees in ITU
- Consider intubation and NG tube if reallt unwell
- Catheter and Central venous catheter
- 10% IV Glucose, 1L over 12 hours
- Focus on finding and treating cause
Look out for and manage complications:
- Seizures (Phenytoin)
- Hepatorenal Syndrome (Dialysis)
- Cerebral Oedema (Manitol)
- Ascites (Fluid restrict and give Furosemide)
- Bleeding (Vit K and Platelets)
- Infection (Ceftriaxone)
- Encephalopathy (Rifaximin and Lactulose)
Get in touch with transplant center and calculate their Kings College Criteria
161
What scoring system do you use when assessing Stroke risk in a TIA patient?
ABCD2:
Age
BP
Clinical features
Diabetes Duration of Symptoms
162
What are the common extra articular manifestations of RA?
- Nodules
- Lung fibrosis
- Skin changes and Eye changes
163
How do you manage Psoriatic arthritis?
Methotrexate for the joint issues.
TNF Inhibitors for the Psoriasis.
164
How does hyper mobility syndrome present?
Pain in wide variety of small and large joints.
Patients will report something like “going over on their ankle” a lot, or a history of recurrent dislocations.
165
How do you manage CREST?
Skin irritation can be managed with NSAIDs.
Raynaud’s can be managed with Prostacyclins.
166
What are the complications of GCA?
Blindness secondary to occlusion of the retinal artery
Aortic dissection
Aortic aneurism
167
What are the features of polymyositis/dermatomyositis?
Both have symetrical, proximal muscle WEAKNESS and TENDERNESS.
May also have respiratory muscle weakness, fibrosis of the lungs, dysphagia and Raynaud’s.
Dermatomyositis also involves the skin, with features like photosensitivity, nail bed capillary dilation, macular rash on the back and shoulders.
168
What does Ank Spon affect?
- Spine and SI joint
- Eyes
- Skin (Psoriasis)
- Ribs (Costochondritis)
- Fingers (Dactylitis)
- Ligaments and Tendons (Enthesitis)
- Lungs (Fibrosis)
- Heart (Aortic valve inconpentence)
- Bones (Osteoperosis)
169
What tests can you order to distinguish between T1 and T2 DM?
- Auto-antibodies vs Islets of Langerhan cells
- Insulin levels
- Ketone levels
170
Aside from, diabetic retinopathy, what eye pathology are diabetics at risk of?
Cataracts and Glaucoma
171
Aside from the obvious 6, what complications are diabetics at risk of?
- Impotence
- Dry Skin
- UTIs
172
What are the stages of Diabetic Retinopathy and what do you see in them?
Non-Proliferative (Mild-Severe):
- Flame haemorrhages
- Cotton wool spots
- Macular oedema
- Microaneurysms
- Hard exudate
Proliferative:
- New blood vessels begining to form
- That are abnormal looking
173
What are some common diabetic neuropathies?
Somatic:
- Distal Symmetrical Polyneuropathy (glove and stocking)
- Minoneuritis (affects one nerve, due to compression, normally C3 or Ulna nerve)
- Diabetic Amyotrophy (weakness and wasting if the quadriceps muscles)
Autonomic:
- Postural hypotension
- Impotence
- Diarrhoea
- Urinary retention
- Gastroperesis
174
What causes diabetic feet?
Infections occur due to immunosuppression and neuropathy.
Ulcers form due to peripheral vascular disease.
Bone deformity occurs secondary to loss of proprioception, causing microtrauma, causing bone inflammation and subsequent remodelling, causing deformation of the joint.
175
What blood pressure should diabetics aim for?
130/80
176
What are the MoA of the common diabetic drugs?
Metformin reduces GNG and increases utilisation of glucose
Sulphonylureas increase insulin secretion
Pioglitazone increases insulin sensitivity
Acarbose stops intestinal enzymes digesting carbs
GLP 1 Agnosists and DDP4 inhibitors both serve to increase the efficacy of GLP1, which stimulates insulin release AND decreases glucagon release.
177
What causes hypos?
Commonly:
- Alcohol binges paired with not eating enough
- Insulin or Sulphonylureas overdose
Less commonly:
- Addisons
- Liver failure
- Insulinomas
Consider investigating these with LFTs, C Peptide levels, drug levels, Short Syncaten test...
178
How does someone in DKA present and how do you investigate them?
Symptoms to do with hyperglycaemia (like polydypsia and polyurea) + Symptoms to do with acidosis (abdo pain and hyperventilation)
Obviously order BMs but also consider CRP, Cultures, ECG and Troponin because DKA almost always has a root cause, usually infection or MI.
179
Outline the rough management of DKA?
1) Hydration. 2L in first hour, 6-9L total of 0.9% Saline
2) VRII
3) Once BMs get to 15, start them on dextrose to maintain this level
4) Consider NG tube IF EVIDENCE OF GASTROPERISIS
5) Look for and treat cause
6) HEPARIN. DKA IS A PRO-THROMBOTIC STATE.
7) Consider ITU
180
What are the two most common causes of hypercalcaemia?
Cancer (bone mets, lung cancer secreting PTH)
Sarcoidosis
Lithium
181
What are the symptoms of hypocalcaemia?
- Muscle tone increase and spasms (including Chvostek and Trousseau signs)
- Paraesthesia
- Confusion, anxiety, irritibleness and irationality (Es if you’re reading this its you lol)
- Seizures
PROLONGUED QT.
182
Causes of hypocalcaemia?
Renal osteodystrophy
Hypoparathyroidism
Pancreatitis
Vit D deficiency
183
How do you distinguish hyper and hyponatraemia?
Both make you feel a bit shit; Iritable, confused, tired. Both can eventually progress into coma and seizures.
Distinction is with HYPER patient will be very thirsty, while in HYPO they will feel nauseas/vomit.
184
Why do you rehydrate Hypernatraemia patients with 5% glucose?
Saline and Hartmans both contain lots of sodium
185
What causes hyponatraemia?
Dilusional = HRH
True = Addison’s, Hypothyroidism, SIADH
186
How do you manage hyponatraemia?
If not symptomatic or chronic: Fluid restriction should be enough.
If symptomatic or acute or patient is also dehydrated: Need to give Iv Na through 0.9% Saline. Be VERY careful to not increase it too much and cause CPM. Aim for a gradual increase of 12 mmol/L/day.
187
What causes hypokalaemia and how do you treat it?
- Loop Diuretics
- Thiazides
- Vomiting and Diarrhoea
- Cushings, Cons, Steroids
Treat with oral K and review if mild, IV K if severe (below 2.5)
188
How do you treat cranial Diabetes Insipidus?
Desmopressin
189
What is the full battery of Cushing’s tests?
- Morning plasma cortisol + 24 hour urinary free cortisol
- Plasma ACTH
- Us and Es (high Na low K)
- BMs (should be hyperglycaemic)
- BP
- MRI of the pituitary
- CT of the adrenals
- Chest XR
- Dexamethasone suppression test
190
How do you diagnose Acromegaly?
Serum IGF-1 levels OR Oral Glucose Tolerance Test
191
How would you manage Acromegaly?
- Somatostatin once theyve been diagnosed. Reduces effect of GH directly.
- Transphenoidal removal of pituitary adenoma is curative.
