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MLA Paper 2 A Flashcards

1
Q

first-line to manage secretions in a palliative care setting

A

Hyoscine hydrobromide

2nd line: glycopyrronium bromide

Conservative
–> avoid fluid overload
–> educate family patient not troubled by secretions

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2
Q

The typical presentation can include reduced conscious level, slow respiratory rate, myoclonic jerks, and pinpoint pupils.

What toxicity does this relate to:

A

MORPHINE

Mild-moderate renal impairment: oxycodone

Severe renal impairment: alfentanil, buprenorphine and fentanyl patch

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3
Q

Breast cancer: management

A

1. Pre-operative axillary USS
–> (-) then sentinel node biopsy
–> palpable then axillary node clearance
NOTE consequences
*lymphoedema
*functional arm impairment

**Mastectomy **
–> multifocal tumour
–> central tumour
–> large lesion in small breast
–> DCIS > 4cm
Radiotherapy
1. T3-T4 tumours
2. with 4 or more positive axillary nodes

Wide local excision
–> solitary lesion
–> peripheral tumour
–> small lesion in large breast
–> DCIS < 4cm
Radiotherapy
1. whole breast recommended!
2. reduce recurrence 2/3rd

Hormonal therapy: if tumour (+) for hormone receptors
1. PRE-menopausual –> TAMOXIFEN
2. POST-menopausal –> ANASTROZOLE

Biological therapy
1. Trastuzumab (Herceptin) (HER2 positive)
NOTE
–> cannot use if pmhx heart disorders!

Chemotherapy
–> downstage primary lesion or post surgery
–> FEC-D used

Tamoxifen: oestrogen receptor selective antagonism

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4
Q

Infantile spasms in a child are part of what syndrome

A

WEST SYNDROME

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5
Q

Low molecular weight heparin (LMWH) exerts its anticoagulant effect primarily through inhibition of

A

Factor Xa

enoXAparin, dalteparin

Bind to antithrombin III –> cause conformational change allowing it to bind to inhibit factor Xa

Prevents conversion of prothrombin to thrombin –> reducing blood clotting

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6
Q

Heparin overdose may be reversed by

A

protamine sulphate

only partially reverses the effect of LMWH

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7
Q

Peri-arrest rhythms - bradycardia management

A
  1. Atrophine (500mcg IV) up to 3mg MAX
  2. Transcutaneous pacing
  3. Isoprenaline / adrenaline infusion titrated to response

If risk of asystole then Transvenous pacing!
–> complete heart block w/ broad complex QRS
–> recent asystole
–> mobitz type II AV BLOCK
–> ventricular pause > 3 seconds

Adverse signs
–> SHOCK
–> syncope
–> myocardial ischaemia
–> heart failure

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8
Q

What criteria is used in consideration of liver transplantation for paracetamol overdose:

A

KINGS COLLEGE HOSPITAL critiera

  1. pH <7.3 (24hrs post ingestion)
    or ALL of the following:
  2. prothrombin time > 100 seconds
  3. creatinine > 300 umol/L
  4. Grade III or IV encephalopathy

HE
Grade 1: Irritability
Grade 2: Confusion, inappropriate behaviour
Grade 3: Incoherent, restless
Grade 4: Coma

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9
Q

WHAT can occur after acute mitral valve regurgitation due to myocardial infarction

A

Flash pulmonary oedema: frothy sputum, breathlessness and coarse bilateral lung crackles

Acute mitral regurgitation
–> systolic murmur
–> jets of blood directed back towards pulmonary veins
–> causes fluid congestion in lungs and flash oedeam

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10
Q

Metabolic acidosis w/ raised anion gap

CAUSES

A

MUDPILES

NOTES
–> diarrhoea = normal ion gap metabolic acidosis

M - Methanol (think moonshine)
U - Uraemia
D - DKA (or any cause of ketoacidosis e.g. alcohol, starvation)
P - Paraldehyde (if I remember correctly it’s a rectal anticonvulsant we give to babies, but I could be wrong)
I - Isoniazid (used in TB) or Iron (classically wee kids that get into their parents pills)
L - Lactic acidosis (e.g. from ischaemia)
E - Ethylene glycol (think antifreeze)
S - Salicylates (e.g. aspirin overdose, this causes a bit of a weird picture, they make you hyperventilate so you get respiratory alkalosis, but they separately increase

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11
Q

Causes of respiratory alkalosis

A

HYPERVENTILATION
–> CO2 lost

Note: COPD patients may chronically retain CO2 so metabolism will compensate –> therefore respiratory acidosis with metabolic compensation

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12
Q

The anion gap is calculated by:

A

(sodium + potassium) - (bicarbonate + chloride)

A normal anion gap is 8-14 mmol/L

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13
Q

Causes of a normal anion gap or hyperchloraemic metabolic acidosis

A
  • gastrointestinal bicarbonate loss: diarrhoea, ureterosigmoidostomy, fistula
  • renal tubular acidosis
  • drugs: e.g. acetazolamide
  • ammonium chloride injection
  • Addison’s disease
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14
Q

Which diabetic medication has been linked to Fournier’s gangrene:

A

SGLT-2 inhibitors

Mx = Early surgical debridement and ABx

Other adverse effects of SGLT-2 inhibitors
1. Normogylcaemic ketoacidosis
2. increased risk of lower limb amputation

Benefits
–> patients often lose weight

Examples: canaglifozin!

SGLT2 enhances the urinary excretion of glucose -> bacteria love the sugar you are peeing out

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15
Q

paediatric fluid requirements for non-neonates

A

100mL/24 hours for every kilogram from 0-10 kg
50 mL/24 hours for every kilogram from11-20kg
20 mL per every kilo there after

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16
Q

WHAT is recommended as empirical therapy for adults > 50 years with suspected bacterial meningitis

A

IV cefotaxime (or ceftriaxone) + amoxicillin (or ampicillin)

IM benzylpenecillin in interchange (GP land)

Signs
–> headache, neck stiffness
–> positive brudzinski sign
–> (erythematous maculopapular rash OE)

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17
Q

Menginitis: management

A
  1. ABCDE (GCS, seizures, papilloedema)
  2. IV-ACCESS
  3. IV ABx
    * (3months-50 years) –> CEFOTAXIME (or ceftriaxone)
    * (>50 years) –> CEFOTAXIME (cefotriaxone) + AMOXICILLIN (or ampicillin)
  4. IV dexamethasone (before or w/i first dose of Abx but no later than 12 hours !) avoid dex in septic shock
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18
Q

SIGMOID VOLVULUS mx

What is the most appropriate first line management for this condition?

A

If unruptured:
Decompression via rigid sigmoidoscopy and flatus tube insertion

Investigation: usually diagnosed on the abdominal film
* sigmoid volvulus: large bowel obstruction (large, dilated loop of colon, often with air-fluid levels) + coffee bean sign
* caecal volvulus: small bowel obstruction may be seen

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19
Q

Frontotemporal lobar degeneration: common features and types

and other causes of memory loss!

A
  1. Behavioural-variant frontotemporal dementia
    –> social disinhibition
    –> FHx
  2. Alzheimers
    –> more severe memory loss
  3. Dementia w/ Lewy bodies (2/4 of the following)
    –> hallucinations
    –> fluctuating consciousness
    –> REM sleep behaviour disorder
    –> Parkinsonism

Semantic dementia
–> fluent progressive aphasia (speech fluent but conveys little meaning)

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20
Q

Diagnosis and management

A

LYME DISEASE : spirochaete Borrelia Burgdorferi

Management of asymptomatic:
1. remove tick w/ tweezers , wash area after

Suspected / confirmed lyme disease
1. DOXYCYCLINE
a) Amoxicillin if allergic or pregnant
2. Disseminated disease –> CEFTRIAXONE

Note: Jarish-Herxheimer reaction post tx
–> fever, rash, tachycardia after first dose

3rd degree Heart block

Features: Early w/i 30 days
1. Erythema migrans (bulls eye rash)
2. Systemic: headache, lethargy, fever, arthralgia

Late features (after 30 days)
1. CVD –> 3rd degree heart block, peri-myocarditis
2. Neurological –> facial nerve palsy, radicular pain, meningitis

IX –> ELISA

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21
Q

Disseminated gonococcal infection triad

A
  1. tenosynovitis
  2. migratory polyarthritis
  3. dermatitis

TenDer Pol

gram negative diplococci Neisseria gonorrhoeae

Mx of Gonorrhoea
1. 1g of IM CEFTRIAXONE
2. after sensitivities then single dose oral ciprofloxacin 500mg should be given
OR
- oral cefixime 400mg (single dose) and oral azithromycin 2g (single dose)

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22
Q

Bacterial vaginosis vs Trichomonas

A
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23
Q

COPD management

A

Oral ABX prophylaxis –> Azithromycin (bewate long QT)

SABA –> salbutamol
LABA –> salmetoral or formoterol
SAMA –> ipatropium
LAMA –> tiotropium

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24
Q

When would long term oxygen therapy be offered to a patient with COPD

A

Offer LTOT to patients with a pO2 of < 7.3 kPa or to those with a pO2 of 7.3 - 8 kPa and one of the following:
* secondary polycythaemia
* peripheral oedema
* pulmonary hypertension

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25
Diagnosis and managment
IMPETIGO Caused: staph aureus or strep pyrogenes --> VERY CONTAGIOUS Management 1. Hydrogen peroxide 1% (low risk) 2. Topical ABx --> Fusidic acid --> OR topical mupirocin if resistant or MRSA Extensive disease 1. Oral Flucloxacillin or oral erythromycin if pen allergic School Exclusion --> until all lesions are crusted and healed --> OR 48hrs post Abx tx starting
26
Raised intracranial pressure management
**1. Head elevation to 30 degrees** **2. IV Mannitol** **3. Controlled hyperventilation** a) reduce pCO2 --> v.constriction of cerebral arteries --> reduced ICP **4. CSF removal** a) repeated LP b) ventriculoperitoneal shunt (hydrocephalus) c) drain from intraventricular monitor ## Footnote normal ICP = (7-15mmHg suprine) CCP = MAP - ICP Features - headache - vomiting - reduced consciousness - papilloedema - CUSHINGS TRIAD
27
Ulcerative colitis management
## Footnote Maintaining remission 1. Proctitis and proctosigmoiditis --> topical aminosalicylate (daily or intermittent) --> oral aminosalicyclate plus rectal aminosalicylate --> oral aminosalicylate by itself 2. Left sided and extensive ulcerative colitis --> low maintenance dose of oral aminosalicylate 3. Severe relapse or > = 2 exacerbations --> oral azathioprine or oral mercaptopurine
28
Hashimoto's thyroiditis
hypothyroidism + goitre + anti-TPO | associated w/ development of MALT lymphoma
29
anticoagulation for a patient with a mechanical heart valve
Warfarin ## Footnote AF = DOACs Anti-phospholipid syndrome = Warfarin Prosthetic valces = Warfarin
30
Minimal change disease: mx
75% cases are children! Management: 1. oral corticosteroids 2. Cyclophosphamide: steroid resistant cases
31
Indications for prescribing prednisolone in sarcoidosis:
P- Parenchymal lung disease U- Uveitis N- Neurological involvement C- Cardiac involvement H- Hypercalcaemia
32
Patients with chronic kidney disease and an ACR > 30 mg/mmol should be started on
ACE inhibitor
33
worsening flu-like symptoms and a dry cough. Erythema multiforme is noted on examination Stereotypical history of:
mycoplasma pneumonia Ix: mycoplasma serology positive cold agglutination test --> peripheral blood smear may show RBC agglutination Management: --> doxycycline or macrolide (e.g. erythromycin / clarithromycin)
34
Hypertension in diabetics management
ACE inhibitors/A2RBs are first-line regardless of age
35
Legionella pneumophilia is best diagnosed by the
urinary antigen test Legionella pneumophilia - severe pneumonia - hyponatraemia - deranged LFTs - recent travel hx turkey
36
The tremor seen in Parkinson's disease is
unilateral tremor that improves with voluntary movement I | cogwheel rigidity, bradykinesia, and tremor
37
causes of torsades de pointes
METHCATS ○ M - Methadone ○ C - Chloroquine/Citalopram ○ E - Erythromycin ○ A - amiodarone ○ T - Terfenadine ○ T - tricyclics ○ H - Haloperidol ○ S - Sotalol ## Footnote Patients can present with symptoms such as palpitations, tachycardia, chest pain, shortness of breath, hypotension and syncope.
38
Acute angle closure glaucoma: associated with hypermetropia or myopia?
Hypermetropia Farsighted people prepare well and can only be hit by surprises, like an acute closed angle glaucoma. Shortsighted people never plan and can be slowly hurt over time, like with open angle glaucoma
39
Decreasing vision over months with metamorphopsia and central scotoma should cause high suspicion of
wet age-related macular degeneration ## Footnote Metamorphopsia is a syndrome in which the shape of objects appears distorted.
40
The initial management of acute limb ischaemia includes
- analgesia (IV opioids) - IV heparin - vascular review ## Footnote Features - 1 or more of the 6 P's * pale * pulseless * painful * paralysed * paraesthetic * 'perishing with cold' Peripheral arterial disease: 1. intermittent claudication 2. critical limb ischaemia 3. acute limb-threatening ischaemia
41
Most common cause of endocarditis:
1. Staphylococcus aureus 2. Staphylococcus epidermidis if < 2 months post valve surgery 3. Strep viridans (poor dental hygiene) 4. Strep bovis (colorectal cancer)
42
Tuberculosis: drug side-effects
Rifampicin --> hepatitis, orange secretions --> flu like symptoms Isoniazid --> peripheral neuropathy (prevent with vitamin b6, pyridoxine) --> hepatitis, agranulocytosis Pyrazinamide --> hyperuricaemia causing gout --> arthralgia, myalgia --> hepatitis Ethambutol --> optic neuritis: check visual acuity before and during tx --> dose adjust in renal impairment
43
man presenting with dyspnoea, peripheral oedema and a positive Kussmaul's sign Features - SOB - R heart failure - pericardial knock: loud s3 - kussmaul sign positive
constrictive pericarditis | Kussmaul's sign (the raised JVP that doesn't fall with inspiration)
44
Management of spontaneous bacterial peritonitis
Features - fever - abdominal pain - ascites Diagnosis - paracentesis - e.coli ! Management - IV CEFOTAXIME Antibiotic prophylaxis is needed in patients who have had an episode of SBP --> ciprofloxacin
45
What is the most appropriate blood test monitoring for a patient started on statins:
LFTs at baseline, 3 months and 12 months
46
45 Male pc: 2 day hx retrosternal sharp chest pain, constant, worse on inspiration. Diagnosis and mx
ECG: widespread ST elevation and marked PR depression Causes: viral (coxsackie), TB, post MI, radiotherapy, malignancy, trauma, thyroid etc IX - ECG - Transthroacic echo - Bloods: inflammatory markers, troponin Mx 1. avoid strenuous activity until symptom resolution 2. combination NSAIDs and colcicine (taper dose)
47
Poorly controlled hypertension, already taking an ACE inhibitor
add a calcium channel blocker or a thiazide-like diuretic ## Footnote Amlodipine is the only CCB licensed for HR. Nifedipine should be avoided to risk of exacerbation. Thiazide like diuretic = indapamide
48
Pneumocystis jiroveci penumonia is treated with
co-trimoxazole, which is a mix of trimethoprim and sulfamethoxazole
49
THIS medication should be considered for the prevention of calcium stones
Potassium citrate Prevent kidney stones --> drink 3L of water --> add lemon juice to drinking water --> less than 6g salt intake --> potassium citrate
50
first-line treatments for painful diabetic neuropathy
Duloxetine ## Footnote first-line treatment: amitriptyline, duloxetine, gabapentin or pregabalin
51
THIS presents with flu-like symptoms, RUQ pain, tender hepatomegaly and deranged LFTs
Hepatitis A ## Footnote vaccine available
52
High-dose dexamethasone suppression test with an ectopic source of ACTH
Cortisol: not suppressed ACTH: not suppressed
53
can be used to treat symptomatic itch in PBC
Cholestyramine
54
Diagnosis, cause and management | Monomorphic punched out erosions (circular, depressed and ulcerated)
ECZEMA HERPETICUM Herpes simplex virus 1 or 2 LIFE THREATENING Admission for IV aciclovir
55
A patient is started on finasteride for the treatment of benign prostatic hyperplasia. How long should the patient be told that treatment may take to be effective?
Up to 6 months Finasteride works by inhibiting the conversion of testosterone into dihydrotestosterone which contributes prostate enlargement
56
NICE recognise any of the following criteria to diagnose AKI in adults:
* ↑ creatinine > 26µmol/L in 48 hours * ↑ creatinine > 50% in 7 days * ↓ urine output < 0.5ml/kg/hr for more than 6 hours
57
may be used in patients with stress incontinence who don't respond to pelvic floor muscle exercises and decline surgical intervention
Duloxetine
58
Inducing remission in Crohns
1. Glucocorticoids (oral, topical or IV) 2. alternatively budesonide Second line --> 5-ASA drugs (mesalazine) --> azathioprine (or methotrexate) or mercaptopurine may be added on (not as monotherapy) ## Footnote Refractory disease and fistulating Crohn's --> infliximab Isolated peri-anal disease - metronisazole
59
Maintaining remission in Crohn's
1. STOP SMOKING 2. Azathioprine or mercaptopurine (1st line)
60
Vitamin B12 replacement should always occur prior to folate replacement as folate replacement prior to B12, why?
can precipitate subacute combined degeneration of the spinal cord.
61
Diabetic ketoacidosis: once blood glucose is < 14 mmol/l an infusion of what should be started
10% dextrose should be started at 125 mls/hr in addition to the saline regime ## Footnote DKA resolution is defined as: * pH >7.3 and * blood ketones < 0.6 mmol/L and * bicarbonate > 15.0mmol/L
62

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