Mixed Topics Flashcards
(219 cards)
1
Q
What does release of CCK lead to?
A
- GB squeezes
2. sphincter of Oddi relaxes
2
Q
Describe the pain in biliary colic
A
RUQ (and epigastric) pain that may radiate to the shoulder; “dull” pain
increases in severity over 15 minutes and then reaches a plateau (normally for less than 6 hours) until the gallstone dislodges and the pain subsides.
the pain starts several hours after a meal but may also be worse at night because it is easier for the gallstone to become lodged when lying flat.
3
Q
What are the histological features of UC, CD and Coealic disease?
A
UC: continuous distal disease, mucin depletion, basal plasmacytosis, diffuse mucosal atrophy, absence of granulomata, and anal sparing. crypt branching/spaarcity.
CD: transmural involvement with non-caseating granulomas. Significant inflammation in the colonic wall, widening of submucosa, and dense lymphoid aggregates in the submucosa. Cryptitis with morphological distortion of the crypts accompanied by inflammation and abundant lymphatic and plasma cells. lymphoid aggregates.
(intestinal biopsy is confirmative rather than diagnostic).
Coeliac: villous atrophy
4
Q
What are the layers of the skull/
A
- Skin
- aponeurosis
- Periosteum
- Bone / cranium
- Dura Mater (periosteal and meningeal layer)
- Arachnoid Mater
- Pia mater
- Brain (grey matter and white matter)
5
Q
What is Rigler’s triad?
A
Rigler triad of gallstone ileus, pneumobilia (air in the
biliary tract, low small bowel obstruction with distended
small bowel loops, and an impacted gallstone in the terminal ileum.
It is an unusual complication of cholecystolithiasis and chronic cholecystitis.
6
Q
What are the ECG features of WPW syndrome?
A
- short PR interval (<120ms)
- wider QRS (>110ms)
- delta waves (lead V1 +ve in type A, -ve in type B)
- you may also get ST-segment and T wave deflection in the direction opposite of the QRS.
7
Q
What are the A to J signs of liver failure?
A
· Asterixis · Bruising · Clubbing · Dupuytren's contracture · Erythema (palmar) · Fetor hepaticus (breath has a strong, musty smell) · Gynaecomastia · Hepatomegaly (in early cirrhosis) · Itching · Jaundice
8
Q
Do you get koilonychia in cirrhosis?
A
No - koilonychia (spooning of the nails) occurs in chronic iron deficiency
It is associated with Plummer-vinson syndrome - a disease characterised by the formation of oesophageal webs leading to dysphagia.
9
Q
Name the 5 organisms that cause bloody diarrhoea
A
There are 5 common organisms that cause bloody diarrhoea - the CHESS organisms · Campylobacter jejuni · Haemorrhagic E.coli (O157)** · Entamoeba histolytica · Salmonella · Shigella
**most common cause of travellers diarrhoea; can be found in Thailand.
10
Q
Name 3 conditions that pre-dispose you to SAH
A
- PKD (autosomal dominant condition with bilaterally enlarged kidneys, HTN and haematuria)
- Marfan’s syndrome
- Ehler Danlos syndrome
11
Q
What are the 6 Ps of acute limb ischamia?
A
- pale
- pulseless
- pallor
- power loss or paralysis
- paraesthesia
- perishingly cold
12
Q
Name UMN and LMN signs
A
UMN:
- spasticity/increased muscle tone
- hyperreflexia
- clonus
- Babinski’s sign
- NO muscle atrophy because LMN are still intact and supply the muscles with nutrients, however over time there will be a degree of muscle atrophy due to disuse
LMN:
- hypotonia
- hyporeflexia
- muscle atrophy
- Fasciculations (visible twitches in the muscle caused by damaged motor units firing spontaneous, uncoordinated APs
- Fibrillations (twitches of individual muscle fibres that can be observed using EMG but not by the naked eye)
13
Q
What are the ECG findings of a patient with a PE?
A
- sinus tachycardia
- S1Q3T3 ( dep S wave in lead 1, pathological Q wave in lead 3, inverted T wave in lead 3)
- right ventricular strain (RBBB, right axis deviation)
14
Q
Describe the gait of a patient with PD
A
- narrow based gait which is stooped and shuffling with reduced arm swing.
15
Q
Description of a BCC vs SCC
A
BCC: rolled, pearly edges
SCC:
16
Q
Summarise the criteria for MS Dx very briefly
A
Absence of alternative diagnosis
Dissemination in time (DIT)
Dissemination in space (DIS)
– but could definitely say “oligoclonal bands were present in the CSF but not the serum”
17
Q
Describe when you would see the following gaits:
- ataxic
- hemiplegic
- scissor gait
- choreiform
- shuffling
A
- Ataxic gait is cerebellar sign, seen in Wernicke’s encephalopathy.
- Hemiplegic is typically following a stroke
- Scissor gait characteristic of cerebral palsy
- Choreiform (dance like) typical of Huntington’s
- shuffling, narrow gait, stooped with reduced arm swing is characteristic of PD
18
Q
Describe when you would see the following gaits:
- ataxic
- hemiplegic
- scissor gait
- choreiform
- shuffling
A
- Ataxic gait is cerebellar sign, seen in Wernicke’s encephalopathy.
- Hemiplegic is typically following a stroke
- Scissor gait characteristic of cerebral palsy
- Choreiform (dance like) typical of Huntington’s
- shuffling, narrow gait, stooped with reduced arm swing is characteristic of PD
19
Q
Name the triad of Sx in PD as well as the 6Ms
A
Classical parkinsonism triad
Bradykinesia
Rigidity
Rest tremor
6Ms Monotonous, hypotonic speech Micrographia HypomiMesis (expressionless face) March a petit pas Misery → depression Memory loss → dementia
Motor: Tremor, Rigidity, Akinesia &
Bradykinesia, clumsiness, loss of postural reflexes,
falls, dystonia, cramps
Neuropsychiatric: Hallucinations, Anxiety,
Confusion, Stupor, Impulsivity, Depression,
Cognitive decline, Dementia, Paranoia,
Visuospatial dysfunction
Autonomic & Vegetative: Bladder, Bowel,
Hypotension, Impotence, Dysarthria,
Dysphagia, Drooling, Rash, Anosmia
Sleep: Restless Legs, REM Sleep disorder,
PLMD, Nightmares, Nocturia, Immobility, Pain
20
Q
What is the most common cause of Parkinsonism and what are some other causes?
A
- PD is the most common cause (due to loss of DA-ergic neurones is the substantia nigra )
- drug induced (e.g. antipsychotics and anti-emetics that lower DA levels)
- atypical Parkinsonism (e.g. multi-infarct Parkinson’s, where the symptoms are a result of one or more strokes in the striatum area, not due to neurodegenerative loss of dopaminergic neurones)
21
Q
Summarise fronto-temporal dementia:
A
- also known as Pick’s disease
- Personality change
- Disinhibition
- Overeating, preference for sweet foods
- Emotional blunting
- Relative preservation of memory
- Tauopathy (Pick bodies: Hyperphosphyorlated tau protein)
- 40-60yrs
- Also typically affects people younger than in other dementias
- ±FHx (although most are sporadic)
- Death within 5-10yrs
22
Q
Summarise the main features of Wernicke’s encephalopathy
A
ACE
- ataxia (due to cerebellar damage)
- confusion
- eye signs (ophthalmoplegia, nystagmus, diplopia, ptosis)
- alcoholism
- malnourishment
Wernicke-Korsakoff syndrome is collection of acute neurological signs arising from lack of vitamin B1 (thiamine).
Classically there us a triad of symptoms listed above. But only 10% of patients will present with all 3 symptoms
Alcoholism is the no. 1 cause of WKS because people with the condition generally have a poor diet. Alcohol also prevents vitamin B-1 absorption and storage.
23
Q
Which drugs worsen the Sx of myasthenia gravis?
A
- beta blockers
- lithium
- several Abx
- several antimalarials
24
Q
What are the BTS criteria for a severe asthma attack?
A
PEF <33% expected
<92% SpO2
PaO2 <8 kPa
25
What are the 4 subtypes of melanoma?
- superficial spreading (most common)
- nodular melanoma (second most common)
- acral lentiginous melanoma (soles of the feet and palms of the hands)
- Lentigo maligna melanoma (least common, arising from lentigo maligna usually on sun exposed skin)
26
What is Bowen's disease?
squamous cell carcinoma in situ (restricted to the epidermis).
It is a pre-malignant condition that appears as red-brown scaly patch most commonly on the arms, legs or trunk.
27
What are the indications for dialysis in AKI?
- refractory pulmonary oedema
- persistent hyperkalaemia
- severe metabolic acidosis
- uraemic complications (e.g. encephalopathy, pericarditis)
- Drug overdose by the BLAST drugs (barbiturates, lithium, alcohol, salicylates and Theophyllline)
28
Summarise the management of pneumothoraces
Primary <2 cm: reassurance, analgesia and discharge
Primary >2cm: aspiration (insert large-bore cannula into the 2nd ICS MCL, discharge if successful, insert chest drain and administer high flow oxygen if unsuccessful)
Secondary <2 cm: aspiration (insert chest drain if unsuccessful)
Secondary >2cm: insert chest drain
-> all secondary pneumothoraces require hospital admission and all patients should be given high flow oxygen
All pneuomothpraces require a follow up CXR to confirm complete resolution.
29
What surgical procedure can be considered in patients with recurrent pneumothoraces?
Surgical pleurectomy - removal of the pleura
30
What is Beck's triad of signs?
A triad of signs seen in cardiac tamponade
- muffled heart sounds
- raised JVP
- hypotension
31
What causes haemopericardium?
MI
Trauma
ruptured aneurysm
32
What are the conditions associated with erythema nodosum?
LOST BUSH
Leprosy, Lymphoma (non-Hodgkin's), Leukaemia
Oral contraceptive (and pregnancy)
Sarcoidosis, Sulphonamides (and penicillins)
TB, Toxoplasmosis
Behcet's disease
UC and Crohn's disease
Salmonella (and Yersinia) and Strep
Histoplasmosis
33
What conditions can cause bilateral hilar lymphadenopathy?
sarcoidosis
TB
lymphoma
34
Why do you get elevated Ca2+ in sarcoidosis?
What other marker is raised in sarcoidosis?
- granulomatous tissue is sarcoidosis produces ectopic 1a-hydroxylase
- this enzyme converts 25-hydroxy vitamin D3 to the active 1.25 dihidroxy vitamin D3 (calcitriol)
- this leads to excessive calcitriol production which in turn leads to increased serum Ca2+
Serum ACE levels will also be elevated in sarcoidosis and is often measured to aid the diagnosis.
35
What are the most common causative organisms in septic arthritis?
Streptococcus aureus
Neisseria gonorrhoeae (esp. in younger people)
Staphylococci
H. influenzae is a common cause in children.
E. coli can cause septic arthritis in the elderly and in IV drug users.
TB is a rare cause.
36
What are the main features of SVC syndrome?
What are some causes?
- SOB
- orthopnoea
- swollen face and arms
- plethora
- cough
- engorged neck and facial veins
Causes:
- lung tumours compressing SVC
- mediastinal lymphadenopathy (rarer)
- thymomas (rarer)
37
What is the test used to identify SVC syndrome?
Pemberton's test:
- ask patient to lift arms above head for 1 minute
- this leads to facial plethora, raised and non-pulsatile JVP and inspiratory stridor
38
How does closed angle glaucoma present?
Most commonly in the elderly
- painful red eye
- vomiting
- impaired vision
- perception of haloes around lights.
prompt Dx and Mx is important as it can lead to blindness!
39
Differentiate between IgA nephropathy and post-streptococcal glomerulonephritis
Both cause nephritic syndrome
IgA nephrophaty / Berger's disease
- 5-7 days post infection (pharyngitis)
- heavy proteinuria, abdominal pain, skin rashes, arthritis more common
Post-streptococcal glomerulonephritis
- 4-6 weeks post streptococcal infection (pharyngitis, cellulitis)
- HTN more common
40
```
What arteries and leads are affected in
- anterior
- lateral
- inferior
MI?
```
Anterior: LAD; V1-V4
Lateral: Circumflex; I, V5, V6, AVL
Inferior: RCA; leads II,III, AVF
41
What are signs of a STEMI on ECG? (3)
- ST-segment elevation > 1 mm in 2 contiguous limb leads OR > 2 mm in 2 contiguous chest leads; and
- Hyperacute T-waves
- new onset LBBB (always regard as new onset unless proven otherwise)
42
AF Mx >48h and <48h onset
Atrial fibrillation with onset <48 hours is typically managed with rhythm control (LMWH followed by flecainide if there is no structural heart disease, or amiodarone if there is structural heart disease).
Atrial fibrillation with onset >48 hours is typically managed with rate control (i.e. metoprolol or bisoprolol or verapamil, or digoxin if there are signs of heart failure) and anticoagulation.
43
What drugs are involved in the management of CHF? What drug class is contraindicated?
Mx of CHF:
- diuretics (reduce Na+ and water absorption leading to Sx relief and reduced mortality)
- ACEi (prevent adverse cardiac remodelling and have a positive effect on survival, ARBs, like candesartan, can be used if ACEi not tolerated)
- beta-blockers (used with caution because maintaining the sympathetic drive to the heart is vital for preserving cardiac function)
- spironolactone (K+ sparing diuretic which can further improve survival)
- digoxin (provides symptomatic relief but does not improve survival)
Vasodilators such as hydralazine and isosorbide dinitrite are sometimes used in afro-carribean patients with HF.
NSAIDs are CI'd because they can cause Na+ and water retention, peripheral vasoconstriction and can worsen HF. They are also nephrotoxic and could further decrease the function of hypo perfused kidneys in CHF.
44
Where do the different diuretics act?
Thiazide diuretics (e.g. bendroflumethiazide) act on Na+/Cl- transporters in the dct.
Loop diuretics (e.g. Furosemide) inhibitive Na+/K+/Cl- triple transporter in the thick ascending limb in the loop of Henle.
Potassium sparing diuretics (e.g. spironolactone) are aldosterone antagonists which inhibit aldosterone mediated sodium reabsorption in the collecting ducts.
Amiloride blocks sodium channels within the collecting tunnels and has a similar effect to spironolactone.
Osmotic diuretics are solutes that are freely filtered but poorly reabsorbed, so they remain in the filtrate and exert an osmotic pressure that holds water within the tubules thereby reducing water reabsorption.
Carbonic anhydrase inhibitors act on the pct to increase bicarbonate excretion, which in turn increases sodium excretion.
45
Adenosine is contraindicated in patients with PMHx of ..... because .......
Asthma
because it can cause bronchospasm.
You give them Verapamil 2.5 - 5 mg instead for SVT.
46
How long is xanthochromia present post SAH?
12h - 12 days after SAH onset
47
What Abx are used to treat c diff?
Vancomycin or metronidazole PO
48
What is the scoring system for the risk of developing pressure sores?
Waterlow
49
What is the GRACE score?
used for triaging patients with NSTEMI and unstable angina
50
What is the ABCD2 score?
used to asses the stroke risk in patients who have had a TIA
51
What are scoring systems for severity of pancreatitis?
Ranson
Glasgow (more commonly used in the UK than ranson)
52
What ist the Rockall score used for?
predict the risk of re-bleed and mortality in patients who have suffered an upper GI bleed.
53
What is Conn's syndrome?
aldosterone secreting adenoma
54
When are J waves seen on ECG?
hypothermia
55
What are the reversible causes of cardiac arrest?
4 H's and 4 T's
Hypoxia
Hypothermia
Hypovolaemia
Hypokalaemia / Hyperkalaemia
Toxic
Thromboembolic
Tension pneumothorax
Tamponade
56
X-ray features of osteoarthritis?
- loss of joint space
- subchondral scleorsis
- bone cysts
- osteophytes
Severity of radiological findings is not representative of disease severity - treatment should be based on patient and extent of disability.
57
Management of OA?
No disease modifying drugs available.
- education
- analgesia (NSAIDs)
- PT/OT/Hand therapy
- corticosteroid injections
- surgery
58
What is Felty's syndrome?
Splenomegaly and neutropenia in a patient with rheumatoid arthritis.
59
Summarise reactive arthritis
- sterile arthritis occurring 1-4 weeks post dysentery (shigella, salmonella, campylobacter, yersinia spp) or urethritis.
- acute asymmetrical lower limb arthritis.
May also present with other features such as:
- conjunctivitis
- enthesitis (whichmay result in plantar fasciitis or Archilles tendonitis)
- circinate balanitis (painless superficial ulceration of glans penis),
- keratoderma blenorrhagica (painless, red plaques on the soles and palmes),
- nail dystrophy
- mouth ulcers
- rarely, aortic incompetence.
Treatment with:
- NSAIDs
- local steroid injection
- treat any underlying infection
for Sx control
Individuals who develop recurrent attacks of
arthritis can be considered for therapy with sulfasalazine or methotrexate.
60
What is Reiter's disease?
Triad of conjunctivitis, arthritis and urethritis.
61
What x-ray finding makes pseudo gout more likely than gout?
chonedrocalcinosis
62
What cells are found in Hodgkin's lymphoma?
Reed Sternberg cells
63
How do you manage ankylosing spondylitis initially?
spine exercises and NSAIDs (unless CI'd)
64
What are the risk factors for developing osteoporosis?
- female sex
- smoking
- increasing age
- early menopause
- certain ethnicities (caucasian, asian)
- rheumatoid arhritis
- excess alcohol
- corticosteroid use
- hypogonadism
65
DEXA Scan T-Score and Z-Score and what do the values mean?
T-Score : compared to a young healthy adult
- 2.5 osteoporosis
- 1.5 to -2.5 osteopenia
1. 5 or higher is normal
Z-score: compared to a
66
What is the most specific antibody in SLE?
- anti-dsDNA (raised in 60% cases)
Other Abs are also raised (e.g. ANA and RF) but are not as specific.
67
What is the most specific antibody in SLE?
- anti-dsDNA (raised in 60% cases)
Other Abs are also raised (e.g. ANA and RF) but are not as specific.
68
Signs seen in acute angle closure glaucoma?
- fixed mid dilated pupil (i.e. mydriasis)
- general corneal haze (rather than specific infiltrates)
- the eye feels rock hard when (gently) palpated, and if measured, intraocular pressure will be markedly raised
69
What are the links between rheumatoid arthritis and pulmonary fibrosis?
PF can be an extra-articular manifestation of RA. It presents with SOB, dry cough and bibasal fine crackles.
PF can also be the SE of methotrexate, a DMARD commonly used in RA.
70
Management of acute / chronic gout?
Acute:
- NSAID (e.g. indomethacin, ibuprofen, naproxen, diclofenac)
- Colchicine (if NSAID is CI'd)
- steroids (e.g. prednisolone)
- 2nd line: IL-1 inhibitor
Chronic:
- allopurinol plus suppressive therapy
- febuxostat (xanthine oxidase inhibitor, reduces the production of uric acid)
- weight loss, avoid alcohol, avoid foods rich in purines.
https://bestpractice.bmj.com/topics/en-gb/13/treatment-algorithm
71
What is Henoch Schönlein purpura?
A small vessel vasculitis that usually occurs in children after an upper respiratory tract infection.
Manifestations:
- lower limb purpuric rash
- arthritis (ankles, knees and elbows most common)
- abdominal pain
- haematuria may occur due to underlying glomerulonephritis.
72
How do you manage bacterial meningitis in the community?
Give IM or IV Benzylpenicillin and arrange urgent hospital transfer for further antibiotic treatment.
Dexamethasone may be given in secondary care to reduce cerebral oedema.
73
What is Kernig's sign?
Seen in meningitis as it is a feature of meningeal irritation.
Pain on flexion of the hip and extension of the knee.
74
What is pyoderma gangrenous and what conditions is it associated with?
Pyoderma gangrenosum presents as a rapidly enlarging, very painful ulcer. It is one of a group of autoinflammatory disorders known as neutrophilic dermatoses.
described as e.g. "large irregular ulcer on left shin"
Associated with: IBD, rheumatoid arthritis, multiple myeloma and granulomatosis with polyangitis (Wegener's disease)
75
What is Kartagener's syndrome?
A combination of PCD (primary ciliary dyskinesia) and situs inversus.
76
What is the Ann Arbor scoring system?
Used for Hodgkin's and non-Hodgkin's Lymphoma
77
What is the Gleason scoring system for?
Prostate cancer
78
What is the Duke's scoring system used for?
Colorectal cancer
79
What is the Rai and Binet scoring system used for?
CLL (chronic lymphocytic Leukemia)
80
What is the Breslow score used for?
Melanoma
81
Summarise the European Pressure Ulcer Advisory Panel (EPUAP) grading system for pressure ulcers
Grade 1: intact skin with non-blanching erythema. May be painful or itchy.
Grade 2: partial thickness loss of dermis presenting as a shallow open ulcer with a red wound bed, without slough. May also present as an intact blister without bruising.
Grade 3: full thickness skin loss. Subcutaneous tissue may be visible but bone, tendon and muscle are not. Undermining and tunnelling may occur.
Grade 4: full thickness tissue loss with exposed bone, tendon and muscle. Slough or eschar may be present and undermining and tunnelling usually present.
82
Is encephalitis generally viral or bacterial? What are the most common pathogens?
Mostly viral.
```
Viral:
Herpes simplex (most common)
Coxsackie virus
EBV
varicella zoster virus
```
Other:
syphylis
toxoplasmosis
listeria
83
What zone enlarges in BPH?
periurethral zone of the prostate gland
84
What medications are used to treat urinary incontinence?
anticholinergics like Oxybutynin and Solifenacin
85
What are some causes of vitamin B12 deficiency?
- dietary deficiency
- pernicious anaemia (lack of intrinsic factor due to autoimmune atrophic gastritis)
- terminal ileal resection
- Crohn's disease
86
What are the Sx of vitamin B12 deficiency?
Anaemia Sx
- fatigue
- SOB
- pallor
```
Neurological Sx:
- paraestxesia
- peripheral neuropathy
- depression
- psychosis
(because vitamin B12 is required to maintain the integrity of the nervous system)
```
Presence of neurological Sx is distinctive of vitamin B12 deficiency anaemia.
87
What are the 4 main features of anti-phospholipid syndrome?
- thrombophilia (recurrent DVT/PE)
- livedo reticularis (mottled appearance of the skin)
- obstetric issues (recurrent miscarriage)
- thrombocytopenia
Can occur on its own or in association with SLE.
test for
- lupus anticoaulant
- anti-cardiolipin antibodies
88
What are rose spots associated with?
Typhoid fever
(they are little red spots that appear on the torso) of some patients with typhoid fever.
89
Name some signs of infective endocarditis
- New onset murmur (this + fever is IE until proven otherwise)
- fever
- tachycardia
- clubbing
- Osler's nodes
- Janeway lesions
- splinter haemorrhages
- Roth spots on the retina
90
What are the major risk factors for infective endocarditis?
- recent dental surgery (S. viridans entry)
| - IV drug use
91
What is the modified Glasgow score used for?
to predict the severity of acute pancreatitis and the resulting mortality.
A score of 3 or more indicates severe pancreatitis.
92
Alvarado system - what is it used for?
Dx of appendicits
93
What is the Glasgow-Blatchford score used for?
To assess whether patients with upper GI bleeds should be managed as outpatients or should receive urgent intervention.
94
Rockall score
Estimates the risk of re-bleeidng and mortality in patients with upper GI bleeds.
95
Child-Pugh score
used to predict the prognosis of patients with cirrhosis.
96
Name some causes of aortic regurgitation
- bicuspid aortic valve
- rheumatic fever
- infective endocarditis
97
What are the main clinical signs of AR?
collapsing (water hammer) pulse
wide pulse pressure
early diastolic murmur
Can lead to HF -> SOB, orthopnoea, cough productive of pink+frothy sputum
98
Breast cancer screening in the UK
women 50-71 every 3 years (mammography)
99
What are the sepsis 6?
IN
- high Flow oxygen (1)
- empirical IV antibiotics (3)
- IV fluid challenge (4)
OUT
- serum lactate and Hb (5)
- blood cultures (2)
- measure urine output (6)
100
How does Wilson's disease usually present?
In children and young adults with either:
- Sx of liver dysfunction (jaundice, easy bruising, variceal bleeding)
- neuropsychiatric dysfunction (personality change, dysarthria, dyskinesia)
101
Blood Parameters in Wilson's disease:
LOW serum caeruloplasmin
+
LOW serum copper
Wilson's disease leads to hepatitis and cirrhosis and therefore can also have raised liver enzymes (AST, ALT, ALP)
102
What are the different chambers in the eye?
Anterior segment of the eye:
Anterior chamber: between cornea and iris
Posterior chamber: between iris and lens
Posterior segment of the eye:
Vitreous chamber: between lens and back of the eye
103
What are the chambers in the eye filled with?
anterior segment of the eye (anterior + posterior chamber): aqueous humour
posterior segment (=vitreous chamber): vitreous humour
104
Summarise the flow of aqueous humour in the eye
- produces by the ciliary epithelium in the posterior chamber
- flows into the anterior chamber through a gap between the front of the lens and the back of the iris through the pupil to the anterior chamber.
- leaves the anterior chamber via the trabecular meshwork
- enters the canal of Schlemm
- leaves through the aqueous vein (which is a part of the episcleral venous system)
105
In what order do you replace hormones in hypopituitarism?
1. cortisol
2. thyroxine
3, Sex hormones
4. GH (if necessary)
Administering thyroxine in cortisol deficient patients can make them feel very unwell.
106
Components of Reiter's syndrome
conjunctivitis
urethritis
arthritis
(can't see, can't pee, can't climb a tree)
107
What is the classic triad in Behcet's?
uveitis
genital ulcers
oral ulcers
(can't see, can't pee, can't eat spicy)
108
What is the Ddx of raised JVP?
- tricuspid regurgitation
- constrictive pericarditis
- right HF
109
Systolic murmur DDx
- AS
- MR
- TR
- VSD (ventricular septal defect)
differentiate via location and where it radiates to (AS -> neck + slow rising pulse, MR-> axilla + hyperdynamic apex beat, TR -> raised JVP)
110
In IV drug users, which heart side is more likely to be affected by infective endocarditis?
right (because of the port of entry)
111
What is atrial flutter and how does it present on ECG?
- a type of AF
- saw tooth pattern on ECG and there may be variable block (of what is passing through the AV node) the block can be regular e.g. 2-to-1
112
What can cause VT?
ischaemia
electrolyte abnormalities
long QT
113
Summarise the Mx of SVT
1) vagal manœuvres
2) Adenosine (Verapamil in asthmatics)
3) DC cardioversion if evidence of haemodynamic compromise
114
Summarise the Mx of AF
Rhythm control:
<48h cardioversion
>48h 3-4 weeks anticoagulation, then cardiovert (to prevent stroke)
Rate control:
- beta blocker
- digoxin
Think of Causes and Complications!
115
Summarise the Mx of VT
- if no haemodynamic compromise: IV amiodarone
- look for and treat underlying cause
- ICD
- if pulseless VT: defibrillate
116
Voltage criteria of Hypertension / Left ventricular hypertrophy
- deep s-wave in V1V2
- tall R in V5/V6
S in V1 + R in V5 or V6 (whichever one is taller) >= 7
117
What is S3?
Is associated with ventricular filling
118
What is S1 and S2?
```
S1 = closing of the mitral/tricuspid valves
S2 = closing of the aortic/pulomary valves
```
119
Summarise the Mx of acute HF
- sit them up
- 60-100% oxygen
- furosemide (IV)
consider IV GTN infusion
treat the underlying cause
120
Ddx for bilateral hilar lymphadenopathy
infection: TB
inflammation: sarcoidosis
malignancy: lymphoma
121
What is trigeminal neuralgia? What condition is it associated with?
intense neuropathic pain affecting one or more branches of the trigeminal nerve.
Thought to be due to nerve compression but mechanism not yet understood.
typically presents with recurrent episodes of sharp, stabbing, facial pain which can last seconds to minutes.
It is associated with MS.
122
What can trigeminal neuralgia be triggered by?
skin contact
brushing teeth
shaving
123
When are granulocytes with absent granulation and hyposegmented nuclei found?
Myelodysplastic syndrome
124
What abnormality is seen on blood film in multiple myeloma?
Roleaux
125
When is Roleuax seen on blood film?
In patients with multiple myeloma
126
What are dacrocytes and when are they seen?
tear shaped cells
seen in myelofibrosis
127
What cells are seen in chronic lymphocytic leukemia
Smear cells
128
When are smear cells seen?
chronic lymphocytic leukaemia
129
What is the cushing reflex?
The body's response to raised ICP
- high BP
- bradycardia
- irregular breathing
130
Kussmauls sign
paradoxical rise in JVP on inspiration, which occurs in patients with impaired right ventricular filling (e.g. constrictive pericarditis or restrictive cardiomyopathy)
131
When might you see pathological Q-waves?
on an ECG of someone with an old infarct
132
What are the signs of opioid overdose? How is opioid OD treated?
- pinpoint pupils
- reduced conciousness
- respiratory depression
treated with naloxone.
133
What is naloxone?
It is a non-selective and competitive opioid receptor antagonist.
Used to treat opioid overdose.
134
Which drug is used to treat paracetamol OD?
N-acetylcysteine (NAC)
135
What is flumazenil and what is it used for?
It is an antidote for benzodiazepine overdose.
136
What are the signs of and how do you manage a benzodiazepine OD?
CNS depression
ataxia
slurred speech
treat with flumazenil
137
In drug overdose, when is haemodialysis indicated?
For drug ODs and toxins using the mnemonic SLIME:
```
Salicylates
Lithium
Isopropanol
Methanol
Ethylene glycol
```
138
What is activated charcoal used for?
Activated Charcoal is not a specific antidote for acute poisonings.
It is sometimes indicated in the overdose of medication such as salicylates and Paracetamol and works by reducing the absorption of drugs from the gut.
139
What are Rotterdam criteria?
2 of 3 must be present to make the diagnosis of PCOS
1. Presence of Multiple Ovarian cysts
2. Oligomenorrhoea or amenorrhoea
3. Clinical/biochemical signs of hyperandrogenism
140
How does aldosterone work and what does it do in the kidneys?
It increases blood Na+ and decreases blood K+.
It acts on the Na+/K+ pump of principal cells in the distal convoluted tubule. (increases Na+ reuptake and K+ excretion)
141
How frequently does gestational diabetes mellitus (GDM) occur?
in 2-5% of pregnancies
142
How frequent are thymus abnormalities in patients with myasthenia gravis?
2/3 have thyme hyperplasia
10-30% have thymoma
143
Summarise Wallenberg's lateral medullary syndrome
This would present with the mnemonic "DANVAH" which stands for Dysphagia, Ataxia(ipsilateral), Nystagmus(ipsilateral), Vertigo, Anaesthesia, Horners. *Note that the Anaesthesia consists of ipsilateral facial numbness but also contralateral loss of pain sensation on the body.
144
What is the most common cause of viral encephalitis?
HSV
145
What viruses cause encephalitis?
- HSV-1 and HSV-2
- arbovirus
- CMV
- EBV
- HIV
- measles
- mumps
- rabies
- west nile virus
- tick borne encephalitis
- Japanese B encephalitis
146
What is the mortality of untreated encephalitis?
70%
147
What are the signs and symptoms of encephalitis?
- confusion or bizarre encephalopathic behaviour
- decreased GCS or coma
- fever
- focal neurological signs
- headache
- seizure
- Hx of travel or animal bite
148
Name some non-viral causes of encephalitis
- any bacterial meningitis
- TB
- malaria
- listeria
- lyme disease
- legionella
- leptospirosis
- aspergillosis
- cryptococcus
- schistosomiasis
- typhus
149
Summarise the prognosis of Bell's Palsy
- 70% people make complete recovery
- 13% people have permanent impairment to a minor degree
- 16% people have permanent impairment to a major degree.
150
Dx of Bell's palsy
clinical Dx of exclusion
| if after 4-6 months the Sx don't go away, this suggests an alternative Dx
151
What is Bell's palsy?
acute unilateral facial (VII) nerve palsy of probable viral aetiology
152
Mx of Bell's Palsy
If within 72h of onset, give 60mg prednisolone for 5d and tail by 10mg
If onset >72h then you reassure and wait for the Sx to go away (+safety net!)
153
Which orgaanisme cause mastitis?
Aerobes:
- staph aureus
- streptococcus
- E. coli
Anaerobes:
- clostridium
Others:
- TB
- Bartonella henselae
154
How do you treat non-lactating mastitis?
co-amoxiclav for 10-14 days
155
What increases the risk of non-lactational mastitis?
smoking
156
RFs for duct ectasia
menopause
smoking
obesity
157
Key words for duct ectasia
Peri-areolar mass
Cheesy/thick discharge
50-60 y/o
158
Mx of duct ectasia
Conservative
| Abx and excision if necessary
159
How does duct ectasia affect your risk for breast cancer?
duct ectasia does not increase your risk of breast cancer
160
What is the most common type of breast cancer?
invasive ductal carcinoma
161
Key words for intraductal papilloma
Bloody/serous discharge
Solitary lump near nipple
Peri/post menopause
± tender and slow
30-50 yo
Rare benign fibroepithelial tumour formed from the lactiferous duct epithelium
162
Most common location for breast cancers
UOQ
163
Breast lump assessment when US and when mammogram?
>35 mammogram
| <35 US
164
Management of Wernicke's encephalopathy
Pabrinex
165
What is inside Pabrinex and what do you use if for
- mixture of B-vitamins incl. B1 (thiamine)
| e. g. for Wernicke's encephalopathy (treatment and prophylaxis)
166
What would you expect to see on an MRI of a person with encephalitis?
bilateral medial temporal lobe involvement on MRI is strongly supportive of a diagnosis of encephalitis.
167
What medications are used to treat neuropathic pain?
Gabapentin, Pregabalin, Amitriptyline and Duloxetine are commonly used to treat neuropathic pain.
168
What do you give in bradycardia following an MI?
Atropine
| particularly if complicated by hypotension
169
When do you give adenosine?
used for SVT including WPW
170
What can atropine be used for?
Cardio:
- post MI bradycardia
- Beta-blocker induced bradycardia
- intra-operative bradycardia
Neuro:
- Control of muscarinic side-effects of neostigmine in reversal of competitive neuromuscular block
- Treatment of poisoning by organophosphorus insecticide or nerve agent (in combination with pralidoxime chloride)
Gastro:
-Symptomatic relief of gastro-intestinal disorders characterised by smooth muscle spasm
Ophthalmology:
- cycloplegia
- anterior uveitis
171
What are the indications for the use of adrenaline?
- CPR
- acute hypotension
- anaphylaxis
- control of bradycardia in patients with arrhythmias after MI, if there is a risk of asystole or the patient is unstable and has failed to respond to atropine
- priapism (intracaavernosal injection)
172
How much adrenaline do you give in anaphylaxis?
500 micrograms IM
| you can repeat after 5 mins if there is no response
173
What are the indications for the use of flecainide?
- Supraventricular arrythmias
- ventricular arrythmias
Initiated under the direction of a hospital consultant
174
When are red cell casts seen on urinalysis?
- RBCs may be found in a cast either as the result of leakage of RBCs through the glomerular membrane or by bleeding into the tubules at any point along the nephron
- Red cell casts . . . are virtually diagnostic of some form of glomerulonephritis or vasculi- tis
175
What is salbutamol?
A short acting beta 2 receptor agonist
176
Migraine - when is sumatriptan used?
during an acute attack
177
Migraine - when is amitriptyline used?
migraine prevention
n.b. it may also help with Sx of depression if conservative management is not enough.
178
Migraine - when is tompiramate used?
- migraine prevention especially in asthmatics or other situations where Propranolol is contraindicated.
- linked to increased risk of congenital malformations following exposure during the first trimester of pregnancy and we do not know whether the patient is on any contraception.
- Importantly, patients with migraine should avoid the oral contraceptive pill especially if they have auras with their migraine as there is an increased risk of stroke.
- It would be prudent to recommend an implant, an injection, or an intrauterine form of contraception before considering Topiramate.
179
What is the first line treatment for stag horn calculi?
PCNL
percutaneous nephrolithotomy
(ESWL is not promising for staghorn calculi)
180
What is the initial management of TIA?
anti platelet therapy
and specialist referral
181
Is electrical or pharmacological cardioversion more effective?
electrical cardioversion is more effective than pharmacological (success ate 95% vs. 40-70%)
182
When is pharmacological cardioversion indicated?
if the patient is unsuitable for electrical cardioversion or if electrical cardioversion is not available.
183
What drugs can be used for pharmacological cardioversion?
```
amiodarone
sotalol
verapamil
digoxin
and a few others.
```
184
What is fast AF?
When the ventricular rate is >100 bpm.
185
Summarise achalasia
failure of the lower oesophageal sphincter to relax causing failure of oesophageal peristalsis.
This leads to the symptoms:
- dysphagia to solids and liquiuds
- heartburn
- food regurgitation
CXR shows wide mediastinum
Barium swallow shows: birds beak appearance (dilated oesophagus with a fluid level)
186
What system is used for determining if a liver transplant is needed after a paracetamol overdose?
King's college criteria
187
What are the common medications that cause folate deficiency?
```
Anticonvulsants - phenytoin, valproate
Metformin
Methotrexate
Trimethoprim
Sulfasalazine
```
188
What is the role of alpha-1-antitrypsin in the lungs?
protects lungs from damage
189
Summarise alpha-1-antitrypsin deficiency
- inherited disorder
- codominant inheritance
- causes increased risk of COPD, liver problems, skin problems (panniculitis) and vasculitis.
Symptoms may include shortness of breath and wheezing, repeated infections of the lungs and liver, yellow skin, feeling overly tired (fatigue), rapid heartbeat when standing, vision problems, and weight loss. However, some people with AATD do not have any problems.
190
What is the inheritance pattern of neurofibromatosis 1 and 2?
Autosomal dominant
191
Summarise sensitivity and specificity
Sensitivity: of those with the condition, how many test positive? (TP/TP+FN). A sensitive test is correctly able to identify those with the disease.
Specificity: of those who do not have the condition, how many test negative? ( TN/(TN+FP). A specific test is correctly able to identify those without the disease.
192
What are the most common risks of TURP?
- retrograde ejaculation (most common long-term complication can occur in up to 90% cases)
- urinary incontinence (urge, usually improves in weeks post op)
- erectile dysfunction (up o 10%, can be temporary or permanent)
- urethral strictures
- bleeding
- UTIs
- urinary retention
- the prostate becoming large again
- TURP syndrome (nausea, disorientation, dizziness, headache)
193
What is beri beri?
Vitamin b1 (thiamine) deficiency
194
What is Pellagra?
Niacin (vitamin b) deficiency
195
What is scurvy?
Vitamin C deficiency
196
What is rickets?
Skeletal disorder caused by a deficiency in vitamin D, calcium or phosphate.
197
What is pernicious anaemia
Vitamin B12 deficiency caused by autoantibodies against IF or parietal cells, causing issues with absorption.
198
How does amyloidosis usually present?
Amyloidosis usually presents with unexplained weight loss, fatigue, and oedema resistant to diuretic therapy.
199
What are the first line investigations to diagnose amyloidosis?
- serum immunofixation (shows presence of monoclonal antibodies)
- urine immunofixation (shows presence of monoclonal antibodies)
- immunoglobulin free light chain assay (abnormal kapp to lambda ratio)
- Bloods (FBC normal or anemic, ALP elevated, low albumin, low calcium)
- 24h urine collection ( increased protein)
200
Tissue biopsy in patients with amyloidosis
Confirmation of amyloid deposits in tissue is essential for diagnosis.
positive apple-green birefringence when biopsy specimen is stained with Congo red;
presence of clonal plasma cells in bone marrow biopsy
Other tissues that can be easily biopsied include subcutaneous fat (recommended), lip (minor salivary gland), rectum, temporal artery, or skin. If these studies are negative, biopsy of an affected organ (heart, liver, kidney, or nerve) should be performed
amyloid despots are always extracellular and appear amorphous
201
Well's score, when do you do a D-dimer, when do you do a CTPA?
<4 points d-dimer
| >4 points CTPA
202
Summarise the components of the Well's scoring system
3 points:
Clinical signs and symptoms of a deep vein thrombosis (DVT)
If no alternative diagnosis is more likely than a PE
1.5 points:
Tachycardia (heart rate >100 beats/minute)
If the patient has been immobile for more than 3 days or has had major surgery within the last month
If the patient has had a previous PE or DVT
1 point:
If the patient presents with haemoptysis
If there is an active malignancy
203
What is Mirizzi syndrome?
Occasionally, a large gallstone can become lodged in the cystic duct and compress or damage the common hepatic duct, resulting in biliary obstruction and jaundice.
(Erosion of a stone into the common bile duct produces a biliary fistula, another form of the Mirizzi syndrome.)
204
Summarise acute tubular necrosis
ATN is an intrinsic AKI that follows a condition of severe and persistent hypoperfusion or toxic injury of epithelial cells causing detachment of the basement membrane and tubular dysfunction.
205
Risk factors of ATN
- CKD
- DM
- chronic HTN
- advanced age
- sepsis
- low perfusion states
- major surgery
- exposure to nephrotoxic agents
- exposure to radiocontrast media
- exposure to endogenous toxins
206
Psoriasis and Eczema - which one is flexors and which one is extensors?
Psoriasis: scalp, elbows, and knees, but any part of the skin can be involved.
Eczema:
207
Name some nephrotoxic agents
- aminoglycosides (gentamicin, tobramycin)
- amphotericin B
- chemotherapeutic drugs (cisplatin, carboplatin, cyclophosphamide)
- NSAIDs
- cyclosporine modified
- penicillin abx (when used with other nephrotoxic drugs)
- radiocontrast dye
ATN occurs in 10% to 20% of patients receiving aminoglycosides
208
What are some causes of ventricular tachycardia?
- CAD
- electrolyte imbalances (e.g. low Mg2+)
- valvular disease
- long QT syndrome
209
Management of haemodynamically stable VT
IV amiodarone
210
Compare damage to Wernicke's and Broca's area
Damaged Wernicke's: inability to understand language , however patients are able to produce fluent, but non-sensical speech.
Damaged Broca's: inability to produce fluent speech despite intact understanding of language. (located in the frontal lobe of the dominant atmosphere)
211
What connects Broca's and Wernicke's area?
arcuate fasciculus
212
How do lesions in the arcuate fasciculus present?
intact language comprehension and fluent speech production however poor repetition
213
How do you initially manage hyperkalaemia?
10 mL 10% calcium gluconate (cardiac protection)
214
Immediate + Long term treatment in TIA
Immediate: 300 mg aspirin (+ assess urgently within 24 hours)
these patients should then continue taking antiplatelet medication (aspirin or clopidogrel) and be given medication for secondary prevention (anti-HTN, statins)
215
When should carotid endarterectomy be considered?
In >70% stenosis at the origin of the ICA
216
Why are nitrates a risk factor for GORD?
nitrates are smooth muscle relaxants which reduce contraction of the lower oesophageal sphincter thus increasing the risk of acid reflux.
217
What is the immediate management of acute limb ischaemia? What are definitive treatment options?
Immediate: IV heparin and referral to vascular surgery (heparin is preferred to aspirin in acute limb ischaemia); heparinisation should not be delayed by investigations.
Definitive: surgical embolectomy and thrombolysis
218
What class of medication is enoxaparin?
LMWH
219
What class of medication is apixaban?
DOAC
