MRCP part 1 Flashcards
- (245 cards)
1
Q
What is associated with aortic regurgitation
A
Wide pulse pressure and collapsing pulse, and is caused by Ankylosing spondylitis - bicuspid aortic valve - connective tissue disease (RA / SLE) - calcific valve - rhematic fever
2
Q
What deficiency causes dilated cardiomyotpathy
A
Selenium
3
Q
Restrictive cardiomyopathy?
A
Thiamine deficiency
4
Q
Prominent V waves are visible on assessment of the JVP in patients with
A
tricuspid regurgitation
5
Q
Cannon A waves are seen in patients with
A
complete heart block
6
Q
Absent A waves are seen in patients with
A
atrial fibrillation
7
Q
Prominent x descent is commonly visualised in conditions such as
A
acute cardiac tamponade and constrictive pericarditis
8
Q
Dipyridamole
A
is a non-specific phosphodiesterase inhibitor and decreases cellular uptake of adenosine
9
Q
Ticagrelor
A
directly blocks P2Y12-receptors
10
Q
What drug cannot be prescribed with BB as it may cause complete heart block?
A
Non dihydropyridine calcium channel blockers (verapamil / dialtazem)
11
Q
if patient has stable angine
A
monotherapy: Non dihydropyridine calcium channel blockers (verapamil / dialtazem) OR BB
If patient is on BB or dihydropyridine calcium channel blockers (amlodipine / nifedipine) but is still symptomatic: add dihydropyridine calcium channel blockers (amlodipine / nifedipine) or BB
If patient is on monotherapy and cannot tolerate BB or DCCB, add:
ong-acting nitrate
ivabradine
ranolazine
12
Q
Complete heart block following a MI?
A
Right coronary artery was most likely the culprit
13
Q
Naxos disease
A
an autosomal recessive variant of ARVC
a triad of:
ARVC
Palmoplantar keratosis
Woolly hair
14
Q
CPVT (catchecolinergic polymorphic ventricular tachycardia)
A
Sudden cardiac death
Mutation in RYR2 receptor of myocardium
15
Q
Bioprosthetic aortic valve replacement
A
Only lifelong aspirin
recommended for patients aged >65 years or younger patients not wishing to take lifelong anticoagulation
16
Q
Falsely elevated BNP
A
Left ventricular hypertrophy
Ischaemia
Tachycardia
Right ventricular overload
Hypoxaemia (including pulmonary embolism)
GFR < 60 ml/min
Sepsis
COPD
Diabetes
Age > 70
Liver cirrhosis
17
Q
JVP waves
A
A: atrial contraction
C: closure of tricuspid valve
X descent: ventricular systole (causes -ve pressure in the atrium)
V: passive filling of atrium
Y descent: opening of tricuspid valve
18
Q
If patient is asthamtic and has SVT
A
Adenosine contarindicated. GIve verapamil
19
Q
Mechanical Heart valves target INR
A
Aortic: 3.0
Mitral: 3.5
20
Q
Bendroflumethiazide predisposes to
A
gout, NOT pseudogout
21
Q
What lowers BNP levels (abnormal)
A
Obesity
BB
ACE i
22
Q
Pulmonary hypertension is a
A
contraindication to pregnancy because it significantly increases the risk of maternal morbidity and mortality.
23
Q
patients who have had a permanent pacemaker inserted must not drive for
A
1 week following the procedure
24
Q
hypertension?
A
ACE i
NDCCB
Thiazide diuretics
K <4.5 = spironolactone
K >4.5 = AB / BB
25
Pulmonary hypertension
loud second heart sound
26
S1:
Loud S1- moderate MS
Soft S1- severe MS + MR
27
S2: (divided into A2 -> P2)
Loud S2- HTN
Soft S2- AS
Widely split- RBBB + deep inspiration
Fixed split- ASD
Reveresed split- LBBB + severe AS
28
Pulsus alternans
severe LVF
29
pulsus paradoxus (> 10 mmHg change in SBP)
Cardiac tamponade
30
Bisferians pulse (two systolic peaks)
Mixed aortic valve disease
31
For PDA
Prostaglandins keep patency of PDA
Ibuprofin / indomethacin close it as they block PGS
32
Cardiac tamponade
Electrical alternans
Pulsus paradoxus
Absent Y descent
Prominent X descent
33
type A - ascending aorta
IV labetalol + surgery
34
type B - descending aorta
IV labetalol
35
Persistent ST elevation following recent MI, no chest pain -
left ventricular aneurysm
36
first line investigation for stable chest pain of suspected coronary artery disease aetiology
Contrast-enhanced CT coronary angiogram
37
1-2 months old and cyanotic?
Tetralogy of fallot
38
< 1 month old and cyanotic
transposition of great arteries
39
1. < 20 weeks old HTN =
2. > 20 weeks old HTN (no proteinuria) =
3. > 20 weeks old HTN (+ proteinuria) =
1. Pre-existing HTN
2. Pregnancy induced HTN
3. Pre-eclampsia
40
centrally acting antihypertensive
Moxonidine
41
ST elevation + -ve T waves + syncope
Brugada syndrome (Mutation in SCN5A / myocardial sodium ion channel)
42
what medication has interaction with macrolides
statins
43
1. Medical mx of SVT=
2. Medical mx of VT=
1. adenosine. if contraindicated (asthma), then go for Verapamil
2. Amiodarone (VERAPAMIL CONTRAINDICATED IN VT)
44
Rhematic fever (Evidence of streptocooccal infection + 2 major OR 1 major + 2 minor)
Streptoccoccus pyogens
Evidence of streptococcal infection (2-4 weeks ago):
raised or rising streptococci antibodies
positive throat swab
Major (PASES):
PAN-carditis (peri + myo + endo carditis)
Arthritis
Sydenhams chorea
Erythema marginatum
Subcutanueous nodules
Minor (FAPIL):
Fever
Arthralgia
Prolonged PR interval
Increased CRP + ESR
Leukocytosis
What is seen:
Aschoff bodies
Anitschkow cells
Tx is Penicillin V + NSAIDS
45
Pulmonary HTN
acute vasodilator testing
If +ve = CCB
If -ve= sildenafil / -tan / treprostinil / iloprost
46
Viral myocarditis:
parvovirus B-19 + HPV-6
47
Eclampsia tx
MgSO4 -> watch for:
- RR (since it can cause respiratory depression, Ca gluconate 1st line tx for that)
- UO
- Reflexes
48
Infective endocarditis
Most common: Staphyloccous aureus
Poor dentition: Strep viridans (mitis / sanguinis)
IV drug use: MRSA
Colorectal cancer: Strep bovis (gallolyticus)
Recent prosthetic valves (<2 months): Strep epidermidis (after 2 months, it goes back to Staphyloccous aureus)
Culture negative causes:
prior antibiotic therapy
Coxiella burnetii
Bartonella
Brucella
HACEK: Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella)
49
S4 heart sound
P wave
50
S4:
AS
HTN
HOCM
51
S3:
NORMAL IN <30 y/o
Constirvitve pericarditis
LVF
MR
52
Prinzmetals angina (coronary vasospasm) tx?
DCCB
AVOID BB (unlike in other anginas as they can worsen spasm)
53
Glycoprotein IIb/IIIa receptor antagonists
Examples include;
abciximab
eptifibatide
tirofiban
54
Acute pericarditis sensitive + specific ECG findings?
Most sensitive: concave ST elevation
Most specific: PR depression
55
Aortic stensois. When to operate?
Symptomatic
Asymptomatic IF:
- Severe LV dysfunction
- Aortic valve gradient > 40 mmHg
56
what medicartion to avoid in HOCM
ACE i
57
two types of ischemic strokes
thrombotic and embolic
58
if there is prego woman + suspicoin of DVT / PE, we do:
Compression duplex doppler
CTPA increases risk of breast cancer in pregnancy
V/Q scan increases risk of childhood cancer
59
if an indication for anticoagulant exists (for example atrial fibrillation) in a patient with STABLE CVD
it is indicated that anticoagulant monotherapy is given WITHOUT the addition of antiplatelets
60
Post-acute coronary syndrome/percutaneous coronary intervention + A FIB?
DAPT + 1 anticoagulant (DOAC if not contraindicated) for 4 weeks - 6 months, then switched to 1 antiplatelet + 1 anticoagulant
61
if a patient on antiplatelets develops a VTE
Anticoagulation should be commenced
HOWEVER
ORBIT score should be calculated
- Those with a low risk of bleeding may continue antiplatelets.
- In patients with an intermediate or high risk of bleeding consideration should be given to stopping the antiplatelets
62
What's contraindicated in WPW
NDP-CCB
sotalol should be avoided if there is coexistent atrial fibrillation with WPW
63
heart failure patients with a LVEF < 35% who are still symptomatic on ACE-inhibitors & beta-blockers
Stop them and switch to ARNI (Sacubitril-valsartan)
64
long QT interval + deafness
Jervell-Lange-Nielsen syndrome (includes deafness and is due to an abnormal potassium channel)
65
thiazide diuretics cause
hyperglycemia
gout
hypokalmeia
66
what organism carries the best prognosis in infective endocarditis
Streptococcus viridans infection
67
For PFO
we use bubble contrast ECHO as it doesnt show up on normal ECHO. It is also done for patient who had embolic stroke to rule out paradoxical embolus
68
A FIB iNR
2.5
69
VTE target INR
2.5
If recurrent, 3.5
70
Digoxin and potassium levels
Digoxin causes hyperkalemia
HYPOkalemia can cause Digoxin toxicity
71
MAT tx
NDP-CCB
72
VT vs SVT
What favors VT:
Vagal manoeuvres- not responsive
Fusion complexes- yes
AV disassociation- yes
Duration- > 140 ms
Axis- LAD
73
S1 variable intensity
A fib
Complete heart block
74
What is the best diagnostic modality to show which patients will respond greatly to CRT? And what are the criteria?
1. ECG (LBBB) and ECHO (EF < 35%)
75
WPW tx
Amiodarone
Flecainide
sotalol (should be avoided if there is coexistent atrial fibrillation with WPW)
76
Aortic stenosis - most common cause:
younger patients < 65 years: bicuspid aortic valve
older patients > 65 years: calcification
77
If there is a high risk of cardioversion failure (e.g. Previous failure or AF recurrence) then it is recommend to
have at least 4 weeks amiodarone or sotalol prior to electrical cardioversion
78
for A fib < 48 hours, patients who have been successfully DC cardioverted
anticoagulation is unnecessary, UNLESS they have high CHADSVASC
79
for A fib > 48 hours
1. anticoagulation should be given for at least 3 weeks prior to cardioversion
OR
2. perform a transoesophageal echo (TOE) to exclude a left atrial appendage (LAA) thrombus. If excluded patients may be heparinised and cardioverted immediately.
80
for A fib < 48 hours
1. patients should be heparinised and cardioverted immediately
OR
2. amiodarone if structural heart disease, flecainide in those without structural heart disease
81
for A fib > 48 hours, patients who have been successfully DC cardioverted should
continue anticoagulation therapy for at least four weeks after the procedure and then reassess CHADSVASC
82
Pulsus alternans -
seen in left ventricular failure
83
diabetes + HTN?
ACE, regardless of age
84
why should isosorbide mononitrate be taken asymmetrical timings?
Due to tolerance and reduced efficacy
85
Long QT syndrome -
usually due to loss-of-function/blockage of K+ channels
86
Complete heart block following an inferior MI
Conservative management
but if hemodynamically unstable -> atropine
If atropine fails -> pacing
87
Complete heart block following a non-inferior MI
pacing
88
reversible direct thrombin inhibitors example:
bivalirudin + dabigatran
89
A phosphodiesterase inhibitor, such as sildenafil
its use is contraindicated following recent occurrences of either ischaemic or haemorrhagic strokes
90
tricagrelor side effect?
SOB
91
MUGA scans
for more accurate LVEF status
92
Takayasu arteritis
- systemic features of a vasculitis e.g. malaise, headache
- carotid bruit and tenderness
- aortic regurgitation (around 20%)
- upper and lower limb claudication on exertion
- unequal blood pressure in the upper limbs
93
PAH?
PAP > 20 mmHg
94
Unprovoked PE or risk factors (APS or cancer or
LIFELONG anticoagulation
95
Provoked PE
3 months anticoagulation
96
Recurrent PE
IVC filters
97
PE with hemodynamic instability
thrombolysis
98
Choice of anticoagulation in PE
General: DOAC
If contraindicated: LWMH followed by warfarin
If APS: LWMH followed by warfarin
99
if african / carrbiean and already taking DHP-CCB, second anti-HTN medication in line would be
ARB (preferred to ACEi)
100
First line management of acute pericarditis involves
combination of NSAID and colchicine
101
what medication is avoided in HOCM
nitrates
ACE-inhibitors
inotropes
102
HOCM management
Management
Amiodarone
Beta-blockers or verapamil for symptoms
Cardioverter defibrillator
Dual chamber pacemaker
Endocarditis prophylaxis*
103
Adenosine interactions
dipyridamole enhances effect
aminophylline reduces effect
104
The criteria for urgent valvular replacement in IE are as follows:
- Severe congestive cardiac failure
- Overwhelming sepsis despite antibiotic therapy (+/- perivalvular abscess, fistulae, perforation)
- Recurrent embolic episodes despite antibiotic therapy
- Pregnancy
105
All types of arrhtymias can happen post MI, from AF to VT to VF to AV block. For IWMI, what is the most common?
AV block
106
What is most useful for detecting re-infarction in the window of 4 to 10 days after the initial MI
CK-MB
107
In endocarditis, what in the ECG to monitor?
PR prolongation due to possible aortic root abcess
108
Cardiac resynchronisation therapy (CRT) is recommended as a treatment option for people with heart failure who have
- left ventricular dysfunction with an LVEF of 35% or less
- LBBB with a QRS duration > 130 msec
109
Electrical cardioversion is synchronised to the
R wave
110
HOCM poor prognostic factor
Wall thickness > 3 cm
111
type A WPW
left-sided pathway
RAD
dominant R wave in V1
112
Type B WPW
Right-sided pathway
LAD
No dominant R wave in V1
113
Atrial myxoma - commonest site =
left atrium
114
warfarin affects which clotting factors?
1972 (10 for 1)
115
Regular cannon waves
VT
AVNRT
116
Irregular cannon waves
complete heart block
117
gynaecomastia on spironolactone?
Switch to Eplerenone
118
Patient started in ACE i but gets sharp rise in creatinine?
MR angio of renal vessels
suspected diagnosis: renal artery stenosis (as ACEi exacerbate the situation)
In younger patients consider fibromuscular dysplasia (string on beads appearance)
119
Nephrotic syndrome
1. Proteinuria (> 3g/24hr) causing
2. Hypoalbuminaemia (< 30g/L) and
3. Oedema
Primary causes:
Minimal change disease
focal segmental glomerulosclerosis (FSGS) (association with HIV infection)
membranous nephropathy.
Secondary causes:
Diabetes mellitus
systemic lupus erythematosus (SLE)
amyloidosis
drugs (NSAIDs, gold therapy)
Loss of antithrombin-III -> predispose to thrombosis
Loss of thyroxine-binding globulin -> lowers the total, but not free, thyroxine levels
120
in CKD, anemia is caused by
high hepcidin levels
or
reduced erythropoetin production
121
Minimal change disease
Fusion of podocytes and effacement of foot processes
in young people more
NSAID use
Hodgkin's lymphoma
infectious mononucleosis.
Tx- corticosteroids -> cyclophosphamide
122
Rapidly progressive glomerulonephritis
Wegners granulomatosis / GPA (vasculitic rash or sinusitis)
(positive cANCA)
(crescentic glomerulonephritis on renal biopsy)
Goodpasture's syndrome (haemoptysis)
IgG deposits on renal biopsy
anti-GBM antibodies
123
what decreases calcium renal stones
thiazide diuretics
potassium citrate
124
what decreases uric acid stones
allopurinol
125
what decreases oxalate stones
Calcium carbonate
Colysteramine
Pyrodoxine
126
what decreases struvite stones (MAP)
Proteus mirabillus
trimethoprim
127
Renal stones
if < 5mm and asymptomatic: watchful waiting
5-10mm shockwave lithotripsy
10-20 mm shockwave lithotripsy OR ureteroscopy
> 20 mm percutaneous nephrolithotomy
128
Ureteric stones
< 10mm: shockwave lithotripsy +/- alpha blockers
10-20 mm: ureteroscopy
129
Bicalutamide
androgen receptor blocker
130
Membranous nephropathy
A/W:
Malignancy
anti-phospholipase A2 antibodies
Hep B
Gold
'spike and dome' appearance
mx:
ACE or ARB
IF NOT IMPROVED -> corticosteroid + cyclophosmaide
131
Mesangiocapillary glomerulonephritis (membranoproliferative)
type 1: cryoglobulinaemia, hepatitis C
type 2: partial lipodystrophy (low C3)
Tram track appearance
132
in prerenal kidney injury
urinary sodium is low, this is because not much sodium is being filtered due to redueced blood flow
Specific gravity is high
Although in ATN urinary sodium is high due to damaged tubulues that dont know how to reabosrb sodium
133
Stauffer syndrome
liver dysfunction arising due to underlying renal cell carcinoma WITHOUT liver metastasis
134
HSP
in children after an infection:
polyarthritis
IgA nephropathy
Rash on extensor surfaces and buttocks
135
peritonitis secondary to dialysis
most causative agents:
Staph epidermidis
Staph aureaus
tx: vancomycin (or teicoplanin) + ceftazidime added to dialysis fluid
136
Patients who have received an organ transplant are at risk of what skin cancer?
squamous cell carcinoma
137
alprot syndrome
Type IV collagen defect
BL SNHL
Progressive renal failure
Retinitis pigmentosa
Biopsy: splitting of lamina densa seen on electron microscopy
138
Renal transplant HLA matching
HLA-DR
139
ADPKD
PKD-1 (chromosome 16)
PKD-2 (chromosome 4)
screening is with US
Ultrasound diagnostic criteria (in patients with positive family history)
- two cysts, unilateral or bilateral, if aged < 30 years
- two cysts in both kidneys if aged 30-59 years
- four cysts in both kidneys if aged > 60 years
140
IgA nephropathy
associated with URTI 2 DAYS back
Mesangial hypercellularity
141
referral to a nephrologist:
a urinary albumin:creatinine ratio (ACR) of 70 mg/mmol or more, unless known to be caused by diabetes and already appropriately treated
a urinary ACR of 30 mg/mmol or more, together with persistent haematuria (two out of three dipstick tests show 1+ or more of blood) after exclusion of a urinary tract infection
consider referral to a nephrologist for people with an ACR between 3-29 mg/mmol who have persistent haematuria and other risk factors such as a declining eGFR, or cardiovascular disease
142
if ACR is between 3 and 70
if > 70
repeat sample
No need
143
tx of proteinuria
ACEi
SGLT2i
144
leriche syndrome
claudication
impotence (erectile dysfunction)
Weak distal pulses
aortiliac occlusive arterial disease
145
Wolfram's syndrome
DIDMOAD
DI
DM
Optic atrophy
Deafness
146
DI
Dx:
Urine osmolality < 300
Serum osmolality > 300
Water deprivation test
Desmopressin test (differentiates between nephrogenic and central)
Central DI (AVP-D)
Tx- desmopressin
Causes-
- Head injury
- Pituitary surgery
- Craniopharyngiomas
Nephrogenic DI (AVP-R)
Tx- thiazide diuretics
Causes-
- Genetic
- haemochromatosis
- Demeclocycline
- Lithium
- Hypercalcemia
- Hypokalemia
147
Renal transplant rejection
Hyperacute: IgG
Acute: IgE
148
MAHA
Primary:
- TTP (ADAMTS13 deficiency)
Fever + HA + thrombocytopenia + neurological sx + petechiae
Tx- plasma exchange
- Typical HUS (STEC)
HA + thrombocytopenia + AKI + bloody diarrhea
Dx- stool culture
Tx- supportive mx
- Atypical HUS (complement mediated)
HA + thrombocytopenia + AKI
Tx- eculizumab
Secondary:
- DIC
Low fibrinogen + high PT + high D-dimer
- HELLP
- Malignant HTN
- Drug-induced
- Autoimmune disorders
149
Alport syndrome
SNHL
Hematuria
X-linked dominant
150
Fanconi syndrome
The proximal convoluted tubule (PCT) fails to reabsorb essential substances, resulting in wasting of solutes in the urine
Glycosuria
Aminoaciduria
Hypophosphatemia (osteomalacia)
Hypercalciruai (stones)
Hypokalemia
151
Alcohol binging causes polyuria due to
Inhibition of ADH production
152
SLE most commmonly associated kidney disease
When do we start treating?
diffuse proliferative glomerulonephritis
Class III and above with steroids + MMF / Cyclophosphamide
153
Tubulointerstitial nephritis with uveitis
females
fever
weight loss
painful red eye
154
PSGN vs IgA
PSGN develops 1-2 weeks after URTI. IgA nephropathy develops 1-2 days after URTI
155
IgA is A/W
Associated conditions
alcoholic cirrhosis
coeliac disease/dermatitis herpetiformis
Henoch-Schonlein purpura
156
Adult PKD a/w
MVP
berry aneurysms
Hepatic cysts which manifest as hepatomegaly
Ovarian cysts
Diverticulosis
157
PKD1 gene
PKD2 gene
Chromosome 16
Chromosome 4
158
Renal artery stenosis
1. secondary to atherosclerosis (90%)
2. fibromuscular dysplasia (10%, young females)
Causes HTN
Worsens with ACE i
159
hypokalemia
HTN
Aldosterone high
Renin high
What are the differentials?
Renal artery stenosis
Bartter syndrome
Primary hyperaldosteronism
How to go through differentials?
Answer is RAS
This is because in PH, renin would be low
Whereas for barterr syndrome, it has normotension instead of HTN
160
Bartter syndrome
Gene defect in Na⁺-K⁺-2Cl⁻ cotransporter (NKCC2)
Works like furosamide
Impaired sodium reabsorption
Hypokalemia
Volume depletion -> increased renin -> increased aldosterone
161
cystinuria
autosomal recessive disorder characterised by the formation of recurrent renal stones
cystine, ornithine, lysine, arginine (mnemonic = COLA)
dx- cyanide-nitroprusside test
mx- hydration + D-penicillamine
162
BPH tx
moderate size -> alpha-1 antagonist
Enlarged size -> 5ARi
163
Renal transplant complications
Infectious:
CMV, dx PCR, tx Ganciclovir
Rejection:
Hyperacute- immediatley after due to ABO incompatabilty
Acute- first 6 months due to T cells
Chronic- after first 6 months due to vascualr changes
Technical:
Renal artery thrombosis- sudden oliguria
Renal vein thrombosis- tenderness over graft area + hematuria + oliguria
Renal artery stenosis- uncontrolled HTN + edema
164
Beckwith-Wiedemann syndrome is a inherited condition associated with
Wilm's tumour (nephroblastoma)
organomegaly
macroglossia
abdominal wall defects
neonatal hypoglycaemia.
165
CIN
occurs after 2-3 days after administration of contrast
Hold metformin for min of 48 hrs
Fluid resuscitation 12 hours pre- and post contrast administration (1 ml/kg/hr)
166
Ascitic fluid
Peritoneal fluid
Neutrophil count > 250
Neutrophil count > 100
167
Lupus nephritis
class I: normal kidney
class II: mesangial glomerulonephritis
class III: focal (and segmental) proliferative glomerulonephritis
class IV: diffuse proliferative glomerulonephritis (MOST SEVERE AND COMMON FORM)
class V: diffuse membranous glomerulonephritis
class VI: sclerosing glomerulonephritis
168
how long to wait before AV FISTULA can be used
takes 6-8 weeks
169
routine fluid maintenance
Sodium - 1mmol/kg
Potassium - 1 mmol/kg
Water - 30 ml/Kg
Glucose - 50-100g
170
Rhabdomyolysis
Causes:
- crush injuries
- strenuous exercise
- seizure
- collapse/coma
- drugs
- co-prescribed statins with macrolides or fibrates
Features
- AKI due to ATN
- CK > 5x ULON
- Hypocalcaemia
- Hyperphosphatemia
- Hyperkalaemia
- lactic acidosis (if prolonged unconciousness)
- Myoglobinuria: dark or reddish-brown colour
Mx- Aggressive IV Fluid Resuscitation
171
Vesicoureteric reflux (VUR)
Since childhood
Abnormal backflow of urine from the bladder into the ureter and kidney
Recurrent UTI
Mx- micturating cystourethrogram
172
Diabetic nephropathy
Stage 1- hyperfiltration
Stage 2- latent / silent phase microalbuminurea < 30 mg/day
Stage 3- microalbuminurea 30-300 mg/day (dipstick -ve)
Stage 4- microalbuminurea > 300 mg/day (dipstick +ve) + HTN
Stage 5- ESRD (need renal transplant)
173
nephrolithiasis pain mx
IM declofenac
174
after starting ACEi, how much percentage is acceptable for rise in creatininie
< 30%
175
In a dipstick
1. If there is proteinuria, it automatically rules out
2. if there are leukocytes with proteinuria and a current AKI
1. pre-renal and post renal
2. goes more with AIN than ATN
176
ARPKD
prenatal diagnosis
177
What is the appropriate type of diuretic to help prevent reaccumulation of ascites?
Spironolactone
178
Thin basement membrane disease
(benign familial haematuria)
autosomal dominant
characterised by persistent microscopic haematuria
179
Tolvaptan
Used for ADPKD
It is a vasopressin receptor 2 antagonist
180
FSGS A/W
HIV
Drug use
podocyte proliferation
181
Wat is co-prescribed with goserelin (Zoladex)
cyproterone acetate
182
AIN triad
Fever
Rash
Eosinophilia
183
plasma exchange complication
Hypocalcemia
184
Alfacalcidol
used in CKD as vitamin D analogue as it doesnt require activation by the kidneys (1-alpha-hydroxylase), and is used to treat hypocalcemia and secondary hyperparathyroidism
185
KDIGO (AKI)
1. serum creatine (SC)
2. Urine output (UO)
Stage 1
SCr: > 1.5 x baseline or > 26 mmol/L over 48 hrs
UO: < 0.5 ml/kg/hr over 6 - 12 hours
Stage 2
SCr: > 2 x baseline
UO: < 0.5 ml/kg/hr over > 12 hours
Stage 3
SCr: > 3 x baseline or > 353 mmol/L or need for RRT (dialysis)
UO: < 0.3 ml/kg/hr over > 24 hours or > 12 hours anuric
186
Calciphylaxis
intensely painful, purpuric patches with an area of black necrotic tissue
187
indications for renal replacement therapy in acute kidney injury - but all only if refractory to medical management:
1. Hyperkalaemia
2. Metabolic acidosis
3. Symptoms or complications of uraemia e.g. pericarditis or encephalopathy
4. Severe pulmonary oedema
188
Brain abcess tx
craniotomy for abscess debridement
IV 3rd-generation cephalosporin + metronidazole
Dexamethasone (intracranial pressure mx)
Caused if patient had
- Sinusitis
- Middle ear infection
- Embolic endocarditis event
188
Myasthenia gravis
muscles become progressively weaker during periods of activity and slowly improve after periods of rest:
Muscles involved:
Extraocular- diplopia (antibodies may be negative)
Face
Neck
Limb girdle
Dysphagia
A/W:
Thymoma
Thymic hyperpalsia
Autoimmune disorders
Dx:
Single fibre electromyography
Anti-acetylcholine receptor abs
Anti-muscle specific tyrosine kinase abs
CT thorax to r/o thymoma
Tx:
pyridostigmine
Myasthenic crisis:
- plasmapheresis
- IVIG
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toperamite
Migraine prophylaxis medication as well as anti-epileptic
May cause acute angle closure glaucoma (cycloplegia + steroids to tx)
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Facioscapulohumeral muscular dystrophy (FSHMD)
autosomal dominant form of muscular dystrophy
Features
facial muscles are involved first - difficulty closing eyes, smiling, blowing etc
weakness of the shoulder and upper arm muscles
abnormal prominence of the borders of the shoulder blades - 'winging'
lower limb: hip girdle weakness, foot drop
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Different hematomas
Epidural = trauma + lucid interval + middle meningeal artery
Subdural = gradual onset of fluctuating consciousness + alcoholics / elderly / anticoagulated patients who had trauma days back + crescent-shaped on CT + bridging veins
Subarachnoid = ruptured aneurysm + worst headache of their life
Intracerebral = HTN + charcot bouchard anuerysm + amyloid
Intraparenchymal = HTN + lenticulostriate arteries
Cephalohematoma = neonate + does not cross sutures.
Subgaleal = neonate + does cross sutures
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epilepsy
>= 2 unprovoked seizures > 24 hours apart
193
Seizure tx
Lamotrigine or levetiracetam for most
For absence seizure (petit mal),
ethosuximide
Avoid carbamazepine
194
Tx of raised ICP during hemorrhagic stroke
Bed at 30% elevation
Mannitol 0.25 - 1 g/kg IV (avoid if hypotensive or renal failure, if so, 3% hypertonic saline)
195
IF a patient has thunderclap headaches but normal neurological exam and no bleeding on CT brain, we need to still exclude SAH, how?
LP to be done
If CT done within the first 6 hours of symptom onset -> no need for LP to be done
If CT done after 6 hours of symptom onset -> LP to be done (AFTER 12 HRS OF INITIAL ONSET OF Sx)
195
How to avoid vasospasm during hemorrhage
nimodipine
196
Target BP for SAH
120 - 160 mmHg
197
degenerative cervical myelopathy
> 55 y/o
pain in neck
loss of motor function
loss of sensory function
loss of autonomic function
Dx- MRI cervical spine
tx- decompressive surgery
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Normal pressure hydrocephalus
Urinary incontinence + gait abnormality + dementia
Management
ventriculoperitoneal shunting
199
MND tx
Riluzole (used more in ALS)
Non invasive ventialtion (better)
200
BB antidote
Glucagon (prescribe insulin infusion alongside)
201
1. UMN involvement and signs
2. LMN involve and signs
3. Bulbar involve and signs
1. Brain to spinal cord (extensor plantars)
Hyperreflexia
Spastic
Positive or upgoing babinski / extensor plantars
Clonus
2. Spinal cord to muscles (absent ankle reflex)
Hyporeflexia
Flaccid
Fasciculations
Muscle atrophy
Weakness
Absent or downgoing babinski / flexor plantars
3. Cranial nerve IX to XII
Dysarthria
Dysphagia
Tongue fasciculations
Tongue atrophy
Absent gag reflex
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In terms of Motor Neuron Disease
1. UMN lesions only
2. LMN lesions only
3. UMN + LMN lesions
4. LMN + bulbar lesions
1. PLS
2. PMA + SMA
3. ALS (but initially LMN)
4. Progressive BP
203
Overall diseases
1. Only UMN
2. Only LMN
3. Mixed
1.
- PLS
- MS
- Hereditary Spastic Paraplegia (HSP)
- Stroke
2.
- GBS
- MG
- Diabetic neuropathy
- SMA
- PMA
3.
- ALS
- PBP
- Subacute combined degeneration of the cord (vitamin b12 deficiency)
- Frederich's ataxia
- Taboparesis (syphilis)
- Syringomyelia
204
Painful third nerve palsy =
Third nerve palsy (down and out + ptosis + dilated pupil) =
posterior communicating artery aneurysm
DM
Cavernous sinus thrombosis
temporal arteritis
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Cavernous sinus thrombosis
Affects CN III IV V1 V2 VI
infection thrombosis following sinusitis or dental infection
staph aureus
orbital pain
proptosis (protrusion)
chemosis (swelling)
Headache
loss of sensation of V1 / V2 dermatomes (forehead and nose)
Dx- MR venography
Tx- Ceftriaxone + Metronidazole / heparin / surgical drainage
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It is advised that pregnant women taking phenytoin should be given what?
vitamin K in the last month of pregnancy to prevent clotting disorders in the newborn
207
Epileptic medications and pregnancy
sodium valproate: associated with neural tube defects
phenytoin: associated with cleft palate
carbamazepine: often considered the least teratogenic of the older antiepileptics
lamotrigine: studies to date suggest the rate of congenital malformations may be low. The dose of lamotrigine may need to be increased in pregnancy
In breastfeeding it is ok to take antiepileptics
208
myotonic dystrophy
causes prolonged PR interval (heart block)
209
chorea
caudate nucleus
210
migraine tx
Triptan + NSAID
or
Triptan + Paracetamol
211
Migraine prophylaxis
Propanolol
Amitriptyline
Toperamate (avoid in childbearing age)
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Trigeminal neuralgia
pain syndrome characterised by severe unilateral electric like pain.
The vast majority of cases are idiopathic but compression of the trigeminal roots by tumours or vascular problems
Tx- carbamazepine
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Visual field defects:
1. Lesion at optic nerve
2. Lesion at optic chiasim
3. Lesion at right optic tract
4. Lesion at left optic tract
5. Lesion at right superior optic radiation
6. Lesion at right inferior optic radiation
7. Lesion at left superior optic radiation
8. Lesion at left inferior optic radiation
9. Lesion at right inferior + superior optic radiation
10. Lesion at left inferior + superior optic radiation
11. Peripheral vision loss
12. Blind spot at central vision
13. Unable to recognise faces
- PBI (parietal - baum's - inferior quadtrantinpoia)
- TMS (temporal - meyer's - superior quadtrantinpoia)
1. Monocular
(blind in one eye)
2. Bitemporal hemianopia
- Loss of temporal (lateral) visual fields in both eyes
- inferior chiasmal compression = pitutary adenoma)
- superior chiasmal compression = craniopharyngioma, more in children)
3. Left homonymous hemianopia
(Same side visual field loss in both eyes)
4. Right homonymous hemianopia
5. Left inferior homonymous quadrantanopia
- Contralateral parietal lobe pathology
6. Left superior homonymous quadrantanopia
- Contralateral temporal lobe pathology
7. Right inferior homonymous quadrantanopia
- Contralateral parietal lobe pathology
8. Right superior homonymous quadrantanopia
- Contralateral temporal lobe pathology
9. Left homonymous hemianopia
10. Right homonymous hemianopia
11. Tunnel vision
(Glucoma / retinitis pigmentosa)
12. Scotoma
(optic neuropathy)
13. Prosopagnosia
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Complete homonymous hemianopia + sensory/Motor symptoms or signs
Complete homonymous hemianopia no sensory/motor symptoms or signs
Large Parietal/Temporal lobe stroke usually MCA
Large Occipital lobe stroke usually PCA
215
Steven johnson syndrome
reaction to medication that starts with flu-like symptoms, followed by a painful rash that spreads and blisters
Medications:
- Allopurinol
- Anticonvulsants (phenytoin, phenobarbital, carbamazepine, lamotrigine)
216
Benedikt syndrome
lesion at
CN III (down and out)
Medial leminscus (contralateral loss of proprioception and vibration)
"medial midbrain lesion- PCA"
217
Weber's syndrome
lesion at
CN III (down and out)
corticospinal tract (contralateral hemiparesis)
corticobulbar tract (pseudobulbar palsy - UMN + exaggerated gag reflex + spastic tongue)
"medial midbrain lesion- PCA"
218
UMN + exagerrated gag reflx
pseudobulbar palsy
219
Wallenberg (lateral medullary syndrome)
Ipsilateral horner's syndrome (miosis ptosis anhydrosis)
Ipsilateral facial sensory loss of pain and temperature
contralateral sensory loss of pain and temperature
CN 9 + 10 (hoarseness + absent gag reflex etc)
Nystagmus vertigo
PICA
220
Anterior circulation of brain supplies
cerebral coretx (except poterior side)
ACA
MCA
PCA
221
Posterior circulation of brain supplies
posterior cerebral cortex + brainstem + cerebellum
222
MCA stroke
(usually embolic from carotid artery disease)
contralateral motor + sensory weakness in arm + face > legs
Left side
- Aphasia
- right homonymous hemianopia
Right side
- Hemineglect
223
ACA Stroke
contralateral motor + sensory weakness in legs > arm + face
Urinary incontinence
224
PCA stroke
(usually atherosclerosis from vertebral or basilar artery)
if occipital lobe
- Contralateral homonymous hemianopia with macular sparing
if thalamic lobe
- contralateral sensory loss
225
Lacunar stroke
A/W HTN
Caused by lipohylainosis
pure motor or pure sensory (all equal deficits) of face + arm + leg
226
dejerine rousyy syndrome
post lacunar (thalamus) stroke chronic burning pain on the contralateral side
227
venous sinus thrombosis
a type of stroke where there is a clot in the venous sinus causing:
- Gradual headache
- thunderclap headache
- sx of raised ICP
dx: MR or CT venography
Tx: heparin
228
Lambert-Eaton myasthenic syndrome
an antibody directed against presynaptic voltage-gated calcium channel
association with small cell lung cancer
repeated muscle contractions lead to increased muscle strength (in contrast to myasthenia gravis)
limb-girdle weakness (affects lower limbs first, then upper limbs)
hyporeflexia
autonomic symptoms
229
Erb-Duchenne paralysis
damage to C5,6 roots
winged scapula
230
Klumpke's paralysis
damage to T1
loss of intrinsic hand muscles
231
HSV encephalitis
aphasia
232
wernickie
broca
Conduction aphasia
global aphasia
forms- fluent + word salad
expressive- non-fluent
fluent + repetition is poor + aware of the errors they are making
may use gestures
233
ovarian cancer + cerebellar signs
anti-YO
234
Small cell lung cancer + cerebellar signs
anti-HU
235
Small cell lung cancer + upgoing weakness
LEMS
236
cancer + stiff person's syndrome or diffuse hypertonia
anti-GAD
237
narcolepsy
low levels of orexin (hypocretin),
daytime sleepiness
nighttime disturbed sleep pattern
A/W cataplexy (sudden loss of muscle tone often triggered by emotion)
238
Ovarian teratoma is associated with
Anti-NMDA receptor encephalitis
239
essential tremor tx
propanolol
primidone (IF ASTHMATIC)
240
subacute combined degeneration of the spinal cord, WHAT IS AFFECTED?
dorsal columns
lateral corticospinal tracts
241
Miller Fisher syndrome
variant of Guillain-Barre syndrome
associated with ophthalmoplegia,
The eye muscles are typically affected first
usually presents as a descending paralysis rather than ascending as seen in Guillain-Barre syndrome
anti-GQ1b antibodies are present in 90% of cases
Campylobacter jejuni
242
GBS
anti-GM1
Campylobacter jejuni
ascending paralysis
243
