My Go To Notes Flashcards

Question

Varicocele management

Answer 1

Adult Men Sub-clinical or grade I varicocele — no treatment Offer semen analysis if fertility is a concern. Grade Il or Ill asymptomatic varicocele and normal semen parameters — consider observing with semen analysis every 1-2 years if clinically appropriate. Grade Il or Ill symptomatic varicocele, or with abnormal semen parameters — refer to a urologist for possible surgery.

Answer 2

1.Endothermal ablation: using either radiofrequency ablation or endogenous laser treatment. 2.Foam sclerotherapy: irritant foam → inflammatory response → closure of the vein 3.Surgery: ligation and stripping

Answer 3

semen analysis needs to be performed twice following a vasectomy before a man can have unprotected sex (usually at 12 weeks and 16 weeks)

Answer 4

13. Referral of Burns to A&E: "Cool Scientists Find New Innovative Solution to Difficult Health Challanges" (unfortunately, no good mnemonic for this one ©) Complex, Circumferential deep dermal burns Steam burns Full thickness non-accidental Inhalation injuries Sepsis Trauma (crush injury, Fx, Head Injury, Penetrating) Deep dermal (all in paeds, >5% in adults) High risk areas (face, hands,feet, perineum,genitalia,flexural surface) Comorbidities

Answer 5

Venous ulcers: - medial malleolus -shallow and bluish -normal pulses -normal capillary refill R: compression bandage or stockings, wound care

Answer 6

Arterial ulcers: -lateral malleolus, dorsal side of toes and feet, tibia -deep, black necrotic -weak or absent pulses -prolonged capillary refill Rx: Wound care, Revascularization

Answer 7

Neuropathic ulcers: -under big toe, first metatarsal, heel -deep and punched out -painless/reduced sensations -HX of DM Rx: wound care, orthotics (special footwear), Glycemic control

Answer 8

• 8 h after a large meal of solids particularly containing protein (e.g. meat) or fatty foods • 6 hafter a light meal (e.g. non-fatty meal such as toast) • 6 h after ingestion of infant formula, non-human milk. • 4 h after ingestion of breast milk • 2 h after clear fluid intake (including water, pulp-free juice, complex carbohydrate beverages, and tea or coffee without milk) for adults • 1 h after clear fluid intake for infants and children

Answer 9

Clopidogrel = 7 days before Warfarin = 5 days before DOAC = 18 hours for prophylactic dose, 48 hours for therapeutic dose Unfractioned Heparin= 4 hours before a neuraxial block LMWH=12 hours for prophylactic dose, 24 hours for therapeutic dose Metformin= 48 hours before until 48 hours after a surgery that involves contrast injection. Herbal medication (e-g st john wort) = 2 weeks before

Answer 10

Managment: - if vitally stable with normal vitals and spo2 = give intercostal block (analgesia) - If vitally unstable = ABCD first, then analgesia - If laboured breathing and drowsy = Intubate first

Answer 11

19. scrotal swellings: Anterior and lateral surface of testis —> hydrocele Above and BEHIND testis —> epididymal cyst Superior surface of testis -> spermatocele

Answer 12

unexplained thyroid lump: urgent referral to endocrinologist to rule out cancer even if there are no constitutional symptoms of cancer. Papillary thyroid carcinoma > lymphatic metastasis-->cervical/supraclavicular lymphadenopathy Follicular thyroid carcinoma ->hematogenous spread ›metastasis to bone and organs. Medullary thyroid carcinoma --› parafollicular c-cells cancer, produces calcitonin, ass with MEN-2

Answer 13

thyroid nodule: painless neck lump -->first line investigation-->ultrasound If nodule >1cm then FNAC is to be done after ultrasound.

Answer 14

21.Colorectal cancer screening: - England And Northern Ireland ---> FIT every 2 years from 60-74 years of age - Scotland --> FIT every 2 years from 50-74 years of age - Wales --> FIT every 2 years from 55-74 years of age

Answer 15

-For routine screening as mentioned above -If any symptom or sign closely related to CRC, offer an FIT test to guide referral.

Answer 16

-signs and symptoms suggestive of CRC and FIT is +VE. -Unexplained rectal mass -Unexplained anal mass -Unexplained anal ulceration

Answer 17

The Type of surgery for CRC depending upon the gut segment involved and type of anastomosis is a repeatedly tested topic in the exam.

Answer 18

-> Right hemicolectomy and colon-colon anastomosis

Answer 19

Left hemicolectomy and colon-colon anastomosis

Answer 20

High ant.resection (sigmoid colon is removed along with adjacent lymph nodes) and colo-rectal anastomosis

Answer 21

4.Upper rectum->Ant.resection (total mesorectal excision-TME) and colo-rectal anastomosis.

Answer 22

5. Lower rectum-> Low Ant.resection (low TME) and colorectal anastomosis

Answer 23

6.Anal -> Abdominoperineal excision of rectum and permanent colostomy.

Answer 24

Stage 1: induction-> from conscious to unconscious Stage 2: excitement --> depression of inhibitory neurons > muscle spasms, tremors, irregular breathing. Stage 3: Surgical anesthesia--> unconsciousness, amnesia, analgesia, regular breathing (ideal for surgery) Stage 4: Medullary depression -> depression of cardiorespiratory center -> coma

Answer 25

Muscle relaxants: Suxamethonium: Depolarization induced muscle paralysis-›used for rapid sequence intubation and short procedure-->can't be reversed quickly S/E: malignant hyperthermia, hyperkalemia Rocuronium/Vecuronium/atracurium: non-depolarizing NM blockade -.> used for rapid sequence intubation and long procedures >can be reversed quickly with neostigmine or suggammadax. S/E-atracurium can cause seizure, rocuronium can cause prolonged paralysis.

Answer 26

General anesthetics: (watch this video on YouTube hereclick) Induction agents: Etomidate: Blocks GABA receptors and increase duration of cl - channel opening S/E-adrenal suppression, myoclonus Propofol: MOA same as above S/E-Hypotension, resp.depression Barbiturates: MOA same as above S/E-hypotension, respiratory depression Dexmedetomidine: blocks pre-synaptic a2 receptors and inhibits NE release S/E- hypotension, bradycardia

Answer 27

1. Ketamine: blocks NMDA-glutamate receptors S/E- tachycardia, HTN, delusions, hallucinations, vivid dreams that may last upto 24 hours 2. NO/Xenon gas/cyclopropane: MOA same as above S/E-dizziness, nausea and vomiting Inhalational agents (halothane, sevoflurane, isoflurane, desflurane): GABA+NMDA mediated inhibition S/E- Halothane is hepatotoxic and can cause arrythmias, sevoflurane is nephrotoxic, all of them can cause malignant hypothermia and hypotension.

Answer 28

1. Suxamethonium: Depolarization induced muscle paralysis-›used for rapid sequence intubation and short procedure -->can't be reversed quickly S/E: malignant hyperthermia, hyperkalemia 2. Rocuronium/Vecuronium/atracurium: non-depolarizing NM blockade-.> used for rapid sequence intubation and long procedures > can be reversed quickly with neostigmine or suggammadax. S/E- atracurium can cause seizure, rocuronium can cause prolonged paralysis.

Answer 29

-First line is Alfa-1 blockers e-g tamsulosin, doxazosin -5 a reductase inhibitors e-g Finasteride is 2'* line -TURP if above fails

Answer 30

Anal Fissures: Location: post. Midline (6'o clock), ant.midline (12'o clock)

Answer 31

Hemorrhoids: Internal- bleed External-painful Location: 3, 7. 11'o clock Rx: conservative, Rubber band ligation, hemorrhoidectomy

Answer 32

Good Wise Medics Check FBC G= Gallbladder disease, Glucose (DM- controlled) W=Wheelchair bound (Immobility) M= Mutations (BRCA1 & 2) C= Controlled Hypertension F= Family hx of thromboembolic disease in 1st degree relative <45 yr old B= BMI > 35 C= Cigarettes (>35 yr old smoking <15 cigarettes/day),

Answer 33

B= Breast Cancer, Breast Feeding <6 weeks A=Aura (migraine) D=DVT S= Stroke/TIA/IHD A=Antiphospholipid antibody syndrome U= Uncontrolled Hypertension and DM C= Cigarettes (>35 yr old smoking >15 cig/day), E= Emmobile (Immobile after major surgery)

Answer 34

L - lithium A - amiodarone M - methotrexate B - benzos A - aspirin S - sulphonamides T - tetracyclines + 3 C's: carbimazole, chloramphenicol, ciprofloxacin

Answer 35

27. ECV At 36 weeks in nulliparous At 37 weeks in multiparous

Answer 36

MARMAC M=Multiple pregnancy A= abnormal CTG R= Ruptured membranes M=major uterine anomaly A=Antepartum hemorrhage

Answer 37

Complications: PROM Pre term labor Placental abruption fetal distress cord strangulation

Answer 38

Causes: • Fetal hypoxia • Chorioamnionitis • Hyperthyroidism • Fetal or maternal anemia • Fetal tachyarrhythmia

Answer 39

Causes: • Prolonged cord compression • Cord prolapse • Epidural and spinal anaesthesia • Maternal seizures Rapid fetal descent

Answer 40

Variability can be categorized as either reassuring, non-reassuring or abnormal. 1.Reassuring: 5 - 25 bpm 2.Non-reassuring: • less than 5 bpm for between 30-50 minutes • more than 25 bpm for 15-25 minutes Abnormal: • less than 5 bpm for more than 50 minutes • more than 25 bpm for more than 25 minutes • sinusoidal

Answer 41

Variable decelerations -> Cord compression Early decelerations > Head compression Accelerations -> Okay! Late decelerations -> Placental Insufficiency

Answer 42

FVS (fetal varicella syndrome) features of FVS include skin scarring, eye defects (microphthalmia), limb hypoplasia, microcephaly and learning disabilities.

Answer 43

Risks to the mother 5 times greater risk of pneumonitis -Oral acyclovir (or valaciclovir) is now the first choice for PEP for pregnant women at any stage of pregnancy. -Antivirals should be given at day 7 to day 14 after exposure, not immediately. - VZIG as prophylaxis for newborn only given when exposure occurs 7 days before to 7 days after delivery. -VZIG is also recommended for those for whom oral antivirals are contraindicated.'

Answer 44

Treatment of chickenpox in pregnancy -Oral acyclovir if ≥ 20 weeks' gestation and presents within 24 hours of onset of the rash -if < 20 weeks, acyclovir should be avoided or 'considered with caution' (risks outweigh the benefits).

Answer 45

Triple Test Down syndrome 1.USG (nuchal translucency) Inc 2.B-HCG Inc 3.PAPP-A dec Edward and Patau same but HCG is dec

Answer 46

HIT = HCG, Inhibin A, Translucency = only ones that increase in Downs. HCG is low in both Edward's and Patau To distinguish between the two, you can use inhibin A which is: PIES = Patau Increase, Edwards stays same

Answer 47

Quadruple Test 'Downs UP, Edwards DOWN, Neural TUBE UP' AUHI: AFP, Unconjugated oestriol, hCG, Inhibin A Down's Syndrome: 'Downs UP' - AFP reduced uE3 reduced hCG increased , Inhibin A increased Edward's Syndrome: 'Edwards DOWN' - AFP reduced uE3 reduced hCG reduced Inhibin A normal Neural Tube Defects: 'Neural TUBE UP' - AFP incresed uE3 ,hCG ,Inhibin A normal Low Chance Result is < 1 in 150 High Chance Result is > 1 in 150

Answer 48

CVS 11-15 weeks Amniocentesis 15 to 20 weeks

Answer 49

cffDNA test (cell free fetal DNA- detected in mother's blood)

Answer 50

-In eclampsia an IV bolus of 4g over 5-10 minutes should be given followed by an infusion of 1g/ hour. - Treatment should continue for 24 hours after last seizure or delivery (around 40% of seizures occur post-partum)

Answer 51

Levels greater than 9mg/dl is considered toxicity Mild to Moderate: Flushing, nausea and vomiting, hypotension, muscle weakness, lethargy Moderate to severe: Areflexia is first sign (absent DTRs) Respiratory arrest cardiac arrythmias cardiac arrest Monitoring During MgSo4 treatment: Urine output RR DTRs Oxygen sat

Answer 52

IV calcium gluconate supportive care dialysis in severe cases

Answer 53

-Enzyme-inducing drugs may reduce the effectiveness of oral contraceptives (combined hormonal contraception, progestogen-only pills), transdermal patches, the vaginal ring, and progestogen-only implants, and an alternative contraceptive method is recommended. - Methods unaffected by enzyme-inducing drugs include medroxyprogesterone acetate injections or an intrauterine method (Cu IUD or the LNG-IUS).

Answer 54

- copper intrauterine device (Cu-IUD) is the preferred option if taking enzyme inducers i-e Crap GPs.

Answer 55

-Sodium valproate: associated with neural tube defects -Phenytoin: associated with cleft palate -Breast feeding is generally considered safe for mothers taking antiepileptics with the possible exception of the barbiturates

Answer 56

Mnemonic _MORE Metabolic Disease (DM) Obese (BMI >30) Relative (family history of neural tube defects) Epilepsy (Anti-epileptic drugs)

Answer 57

• Trimethoprim • Methotrexate • Phenytoin

Answer 58

Oral labetalol is now first-line following the 2010 NICE guidelines Oral nifedipine (e.g. if asthmatic) and hydralazine 2nd line

Answer 59

-A score of < 5 means spontaneous labour is likely - A score of ≥ 8 means spontaneous labour is unlikely -In between, use clinical judgment

Answer 60

-membrane sweeping -Vaginal dinoprostone (PGE2) -Misoprostol (PGE1)| - Amniotomy - IV oxytocin -Cervical ripening balloon

Answer 61

vaginal prostaglandins or oral misoprostol Mechanical methods such as a balloon catheter can be considered if the woman is at higher risk of hyperstimulation or has had a previous caesarean

Answer 62

Amniotomy and an intravenous oxytocin infusion

Answer 63

less than 500ml at 32-36 weeks and an amniotic fluid index (AFI) < 5th percentile. Potter's sequence: Bilateral renal agenesis > dec. UOP > Oligo > Pulmonary hypoplasia/ Contractures/limb and facial abnormalities

Answer 64

-Placenta less than 20 mm from cervical os is Low lying placenta -Placenta Covering the cervical os is placenta Previa

Answer 65

-USG at 32 weeks (majority will become normal) - if still low lying/previa, discuss and plan elective C-section and follow-up with another USG at 36 weeks -if still low lying/previa, Deliver by elective C-section at 36-37 weeks

Answer 66

women with the following should take aspirin 75-150mg daily from 12 weeks' gestation until the birth 1 or more high risk factors (G.HTN in Previous Pregnancy, Chronic HTN, CKD, DM type1&2, SLE/APS)| 2 or more moderate factors (Primiparous, 10 yr gap b/w pregnancies, BMI >35, Family hx of Pre-eclampsia)

Answer 67

Pregnant women are screened for anemia at: the booking visit (often done at 8-10 weeks), and at 28 weeks

Answer 68

СТРА causes increased risk of maternal breast cancer and V/Q scan causes increased risk of childhood cancers so decision should be taken after discussion with the patient, radiologist & Obs/Gyne.

Answer 69

1.Primary infection: 1st and 2nd trimester > oral acyclovir for 5 days, then oral acyclovir starting at 36 weeks until delivery Deliver via SVD if no active lesion 2. 3rd trimester>> oral acyclovir for 5 days, then oral acyclovir starting at 36 weeks until delivery Deliver via C-section Secondary infection: oral acyclovir starting at week 36 until delivery Deliver by SVD if no active lesion

Answer 70

Secondary infection: oral acyclovir starting at week 36 until delivery Deliver by SVD if no active lesion

Answer 71

DOC is ERYTHROMYCIN

Answer 72

-Urine leakage from vagina -Hx of pelvic surgery/radiation Tx: surgery

Answer 73

45.HRT: | Estrogen only HRT: for those who have undergone hysterectomy or have IUS in place. Sequential (cyclical) HRT: for perimenopausal (less than 12 months since last period). Usually shifted to continuous HRT after 1 year of use. Bleeding is common in first 6 months of use of Cyclical HRT. Continuous combined HRT: for postmenopausal with vasomotor symptoms.

Answer 74

46.Anti-thyroid drugs in pregnancy: PTU: Pre-conception 1st trimester, post-partum Carbimazole: 2nd & 3rd trimester Radio-iodine therapy: contraindicated in Thyroid Eye Disease, worsens Grave's ophthalmopathy, also contraindicated in pregnancy

Answer 75

A = Abruption previously B = Blood pressure (i.e. hypertension or pre-eclampsia) R = Ruptured membranes, either premature or prolonged U = Uterine injury (i.e. trauma to the abdomen) P = Polyhydramnios T = Twins or multiple gestation | = Infection in the uterus, especially chorioamnionitis 0 = Older age (i.e. aged over 35 years old) N = Narcotic use (i.e. cocaine and amphetamines, as well as smoking

Answer 76

-If > 34 weeks---> expectant management to extend the delivery till 37 weeks while monitoring for chorioamnionitis -Meanwhile give Oral Erythromycin for 10 days or until established labor whichever is sooner -Corticosteroids can be considered until week 35, Beyond that risks/benefits ratio. -Mgso4 If <32 weeks -Tocolytics are contraindicated

Answer 77

Appropriate when Gestational age is 37 weeks or more and only one previous c-section Contraindications: -Prev. Uterine rupture -Classic C-section incision

Answer 78

All pregnant women should take vit D 10 micrograms (400 IU) daily throughout pregnanc or adequate fetal exposure and maternal healti - If a woman is at risk of gestational diabetes, offer referral for an OGTT between 24+0 weeks and 28+0 weeks - Refer women over 20+0 weeks with a first episode of hypertension (BP 140/90 mmHg or higher) to secondary care to be seen within 24 hours. -First Anamoly scan offered between 11 to 14 weeks -2'* Anamoly scan offered between 18 to 21 weeks - Anti-D prophylaxis: 1" dose at 28 weeks, 2'* dose at 34 weeks - A urine culture during the first visit to detect asymptomatic bacteriuria, a urine dipstick is only 73% sensitive.

Answer 79

• If 1 pill missed in week 1, 2, 3 ...> Take the missed pill ASAP and continue rest of the pack, no further action needed If 2 missed pills in week 1 ...> Take the last missed pill, use extra protection for 7 day id consider emergency contraception if had unprotected sex within last 48 hours • If 2 missed pills in week 2 .. Take the last missed pill, use extra protection for 7 days •If 2 missed pills in week 3 ...> Take last missed pill, skip pill free interval, no extra protection needed

Answer 80

• If one missed pill < 3 hours continue as normal • If one missed pill > 3 hours Take the missed pill asap Extra protection for 48 hours • Rifampin and other Inducers may reduce effectiveness • Diarrhea and vomiting mean you have missed the pill

Answer 81

1.Morning after pill (LNG) --> 1 tablet x P.O within 72 hours 2. Ella one (ulipristal acetate) -> 1 tablet x P.O within 72-120 hours 3. Copper IUD ---> within 120 hours

Answer 82

-Give methotrexate, and check hCG levels on day 4 and day 7 post-treatment. If hCG level decrease by at least 15% between day 4 and day 7 ...> successful response to Tx. -Further weekly hCG measurement until a negative pregnancy test result -If inadequate reduction or rise in hCG levels, repeat dose of methotrexate or surgical management. - Avoid alcohol, vitamins containing folic acid, and sexual intercourse until hCG levels have completely resolved

Answer 83

Salpingectomy (if stable, contralateral tube normal or fertility not desired in future) Salpingostomy (if fertility is desired and contralateral tube is damaged or absent).

Answer 84

First-line investigation is trans-vaginal ultrasound - a normal endometrial thickness (< 4 mm) has a high negative predictive value Hysteroscopy with endometrial biopsy to confirm the dx. ** Smoking • Decreases risk of endometrial cancer ®

Answer 85

1. If doesn't need contraception Mefenamic acid 500mg tds Or Tranexamic acid 1 g tds 2. If need contraception Mirena 1ª line Cocp. 2'd line Long-acting progesterone (depo) 3ª line ** Norethisterone 5mg tds can be used for rapid control for short term. **

Answer 86

1. First-line medications Antihistamines: oral cyclizine or promethazine Phenothiazines: oral prochlorperazine or chlorpromazine Combination drug: doxylamine/pyridoxine: Second-line medications Oral ondansetron: Ondansetron during the first trimester is associated with a small increased risk of the baby having a cleft lip/palate. Oral metoclopramide or domperidone: metoclopramide may cause extrapyramidal side effects. It should therefore not be used for more than 5 days

Answer 87

-Less than 36 years old and not conceived after 1 year -Earlier referral (6 months) if over 36 years old, amenorrhea, previous abd. surgery, previous STI, varicocele, or two abnormal semen tests etc Tests: - Semen analysis - Day 21 Progesterone if consistently less than 16, refer to specialist, >30 is normal

Answer 88

Medical Mx: Missed miscarriage: 200 mg oral mifepristone and 48 hours later, 800 micrograms misoprostol (vaginal, oral or sublingual) unless the gestational sac has already been passed. Incomplete miscarriage: Use a single dose of Misoprostol 600 micrograms (vaginal, oral or sublingual). Surgical Mx: -D & Cor -D& E

Answer 89

Open your l's Cervical os is open in Incomplete and Inevitable miscarriage Cervical os is closed in threatened and missed miscarriage

Answer 90

Pre-menopausal If <35 yr old, small (<5cm) simple cyst with no Alarm signs - > Watch & wait > repeat US in 8-12 weeks -> If persistent, refer to gyne Post-menopausal All cysts regardless of size and type should be referred to gyne for assessment

Answer 91

55. POF: -FSH > 30 ON TWO SAMPLES TAKEN 4-6 WEEKS APART -ESTROADIOL <100

Answer 92

Investigations: 1.anticardiolipin, lupus anticoagulant 2. TSH, TPO 3.USG 4. Cytogenetic analysis 9f pregnancy tissue 5.parental blood karyotyping REFERRAL: 3 or more miscarriages <10 weeks Or 1 or more morphological normal fetal loss after 10 weeks

Answer 93

1" line for candidiasis -> Oral fluconazole 150mg single dose 2'* line > 500mg clotrimazole vaginal

Answer 94

4 or more episodes per year Ix: High vaginal swab Blood glucose to exclude DM Rx: Induction maintenance regime Oral fluconazole q 3 day for 3 doses Then Weekly for 6 months.

Answer 95

All pregnant women should take vit D 10 micrograms (400 IU) daily throughout pregnanc or adequate fetal exposure and maternal health - If a woman is at risk of gestational diabetes, offer referral for an OGTT between 24+0 weeks and 28+0 weeks - Refer women over 20+0 weeks with a first episode of hypertension (BP 140/90 mmHg or higher) to secondary care to be seen within 24 hours. -First Anamoly scan offered between 11 to 14 weeks -2'* Anamoly scan offered between 18 to 21 weeks - Anti-D prophylaxis: 1" dose at 28 weeks, 2'* dose at 34 weeks - A urine culture during the first visit to detect asymptomatic bacteriuria, a urine dipstick is only 73% sensitive.

Answer 96

Recurrent vaginal candidiasis: 4 or more episodes per year Ix: High vaginal swab Blood glucose to exclude DM Rx: Induction maintenance regime Oral fluconazole q 3 day for 3 doses Then Weekly for 6 months.

Answer 97

C-COCP A-Allopurinol P-Penicillines S-Sulphonamides I-Infections (HSV, Streptococcus) C-Cancer A-Autoimmune (SLE/Sarcoidosis) M-Mycoplasma

Answer 98

EM Major target rash with few blisters < 10 % of BSA involved with little or no mucosal involvement + few systemic symptoms

Answer 99

SJS Lots of blisters and sloughing 10-30% of BSA involved with extensive mucosal involvement + marked systemic symptoms managed in ITU/ICU

Answer 100

TEN SJS that involves >30 BSA

Answer 101

E- Enterocolitica (Yersinia) No - no cause (idiopathic) D - drugs (penicillins, sulphonamides) O - OCP S - sarcoidosis, streptococci U - Ulcers (IBD, Behcet's) M - maternity, malignancy, mycobacterium TB.

Answer 102

Rx= 1. Mild Dermatophyte: amorolfine 5% nail lacquer; 6 months for fingernails and 9 - 12 months for toenails 2. Extesnive Dermatophyte: oral terbinafine 6 weeks - 3 months for fingernail 3 - 6 months for toe-nail 3.Candida Nail infection Oral itraconazole weekly 3 months fingers 6 months toes

Answer 103

fir-tree/christmas tree appearance Rx: self-limiting 6 weeks

Answer 104

-may be precipitated by a streptococcal infection 2-4 weeks prior to the lesions appearing. Rx: Topical steroids

Answer 105

Hereditary = First degree relative affected Hemorrhagic= Epistaxis, Visceral Lesions (AVM in Gl, Lungs, Brain, Spine) Telangiectasia= On lips, mouth, fingers, nose

Answer 106

Bullous Impetigo • Oral Flucloxacillin • Oral erythromycin if Pen allergic **exclude from school until crusted and healed or 48 hours after antibiotic Tx**

Answer 107

Major Criteria: size change shape change color change Minor criteria: Diameter 7 or more inflammation oozing and bleeding Altered Sensation

Answer 108

Referral Criteria: each major criteria = 2 points each minor criteria =1 point 3 or more point = urgent 2-week referral Breslow thickness in mm Excision in cm <1. <1 1 to 2. 1-2 2 to 4 2-3 Greater than 4. 3

Answer 109

Causes: 1. Alcohol 2. INH 3. Carcinoid syndrome

Answer 110

Dermatitis Diarrhea Dementia Death

Answer 111

• HHV7 • Herald patch • Fir-tree appearance Self-limiting

Answer 112

Antibodies against hemidesmosomes>>>Bullous blisters in old age+ no oral lesions + Nikolski sign negative >>>Steroids

Answer 113

Pemphigus vulgaris: Antibodies against desmosomes (desomoglein-1)>>>Bullous Blisters in adults+ oral lesions+ Nikolski sign positive >>> Steroids

Answer 114

Stap scalded skin syndrome: Staphylococcal exfoliative toxin (against desmoglein-1) >>>Bullous Blisters in children, Nikolski sign positive >>>> IV Flucloxacillin or IV Cefazolin

Answer 115

Five. (5-FU) Doctors. (Diclofenac) In (Imiquimod) California. (Cryotherapy) Cure. (Curettage, cautery) Cancer. (Pre-malignant)

Answer 116

74. Triggers of psoriasis: TIPHADS Trauma Infection (HIV or Strep) Pregnancy Hypocalcemia Alcohol Drugs -(BLANQ) beta blockers, Lithium, ACEI, Nsaids, Quinines Stress

Answer 117

Step 1 Corticosteroids +Vit-D Step 2 Twice daily Vit-D Step 3 Twice Corticosteroids Step 4 phototherapy Step 5 non-biologics Step 6 Biologics For Face, genitals and flexural psoriasis NICE recommend offering a mild or moderate potency corticosteroid applied once or twice daily for a maximum of 2 weeks

Answer 118

76. Side Effects of isotretinoin: Dilantin D= dry eye, skin, mouth |= Intracranial hypertension L=Low mood A=absent (nothing) N= nose bleed T=Teratogenicity |= increased TGs N= Nothing

Answer 119

Predominant erythema/flushing: Topical brimonidine gel Mild-to-moderate papules and/or pustules Topical ivermectin is first-line (IMA) Alternatives include topical metronidazole or topical azelaic acid Moderate-to-severe papules and/or pustules Combination of topical ivermectin + oral doxycycline

Answer 120

78. Parkinson disease is associated with seborrhoic dermatitis

Answer 121

-If <20mm Remove Tumor with 4 mm margins -1f >20mm Remove tumor with 6 mm margins

Answer 122

SPANLOC Sulphonamide Penicillin Phenytoin Allopurinol NSAIDS Lamotrigine OCP Carbamazepine

Answer 123

G= Geographia (ingesting clay/soil) P= peri oral/anal dermatitis C= cognitive impairment A= Alopecia, acrodermatitis S= short stature H= Hypogonadism, Hepatosplenomegaly

Answer 124

1* Line - Emollients should be used liberally even if eczema has cleared 2a Line - Topical Steroids according to severity (Mild a Moderate â Potent) | 3" Line - Topical Calcineurin Inhibitors 4* Line - Wet Bandaging

Answer 125

-Clobetasol is the sole steroid which is very potent and started by specialist -all hydrocortisone steroids are mild except hydrocortisone butyrate 0.1% which is potent. -All 0.1% steroids are potent -All moderate steroids have a moderate strength (0.025 or 0.05)

Answer 126

84. Acute epiglottitis H.Influenza B Diagnosis: direct visualization by Anesthesia/ ENT lateral view neck x-ray >>>> Thumb sign Treatment: 02, airway management by Anesthesia/ENT IV antibiotics (Cefuroxime/ceftriaxone first line, alternative is Co-Amoxiclav) IV fluids

Answer 127

Autosomal - ADPKD D - Dystrophia myotonica O - Osteogenesis imperfecta M - Marfan syndrome I - Intermittent porphyria N - Neurofibromatosis type 1 A - Achondroplasia N - Neurofibromatosis type 2 T - Tuberous sclerosis Hunts - Huntington's disease, Hereditary spherocytosis, HNPCC, Hypokalemic periodic paralysis Vulnerable - VWD disease, VHL Syndrome Family - Familial hypercholesterolemia, Familial adenomatous polyposis,

Answer 128

P=PKUl A=AKU S=Sickle cell T=Thalassemia A=Ataxia telangiectasia C= Cystic fibrosis H= Hemochromatosis, Homocystinuria A=adrenal hyperplasia (CAH) W=Wilson A=Albinism| L=Lipid storage (Gaucher, Neimann pick, Tay Sach) Fried= Friedric ataxia, Fanconi anemia

Answer 129

-Occurs in 4-10 years old, most common type of epilepsy in childhood -Focal seizure affecting face and mouth when sleeping or waking up. may become tonic-clonic -most children outgrow by 16 years of age. Rx: not needed

Answer 130

GRASS C (sounds like grassy) -Grunting -RR > 70 -Apnea -Seriously unwell child -Sat <92% -Chest recessions. central cvanosis Consider referral if: -RR >60 -Trouble breastfeeding or inadequate oral fluid intake -clinical dehydration

Answer 131

Patau - Small head, eyes, slit lip, multiple (13) fingers. Edward - Small jaw hence low ears, rocker bottom feet, overlapping fingers (they form a shape of 8, hence 18) Noonan - short, no neck, flat chest, Pulm stenosis. Prader-Willi: Think of a predator with a floppy willy - no tone, no balls and fat. Pierre-Robin: Robbed - Robbed of a jaw, tongue (pulled behind) and a clean palate. Fragile X: Everything Huge - has the X factor - big brain, big face, big balls, big ears but is still daft.

Answer 132

William: Short, Bony, Friendly and SASsy.(Supravalvular AS, Hypercalcemia) Cri Du Chat: Cries so can't eat, hence small jaw and brains.

Answer 133

Management: Breast fed babies: Troublesome symptoms despite reassurance- Trial of Gaviscon Bottle fed: Reduce feed 150mlkg/24 hour First line is Feed thickener 1/2 weeks If no response -> alginate for 1/2 weeks If no response--> 4 weeks PPI If no response...> refer for endoscopy (NICE)

Answer 134

Overweight: BMI 91st centile Clinical obesity: BMI 98th centile Severe obesity: BMI 99.6th centile

Answer 135

should be referred for same-day ophthalmology/pediatric assessment.

Answer 136

S - Sore throat C - Circumoral pallor A - Antecubital fossa petechiae i-e. 'pastia lines' R - Rash: sandpaper texture L - Lymphadenopathy E - Erythrogenic toxin is responsible for scarlet appearance T - Tongue (strawberry)

Answer 137

94. Live attenuated vaccines: MMR's BOY CRIST is weak MMR BCG Oral polio Yellow fever Chickenpox Rotavirus (Cl in intussusception) Influenza (nasal) | Smallpox Typhoid **Flu and yellow fever vaccine is Cl in egg allergy** **DTP vaccine should be deferred in children with evolving neurological condition. **

Answer 138

Soft Systolic Short Sounds (S1 and S2) normal Symptomless Special tests normal (X-ray, EKCG) Standing/Sitting (vary with position)

Answer 139

C=congenital infections (cmv, toxo) | A= Atresia (biliary) | P=prematurity G=Galactosemia U=UTIl T=Thyroid (hypothyroidism)

Answer 140

STILL S=Salmon pink rash T=Temperature 40-41 °C |=Eye (uveitis) | L=Loss of appetite L=Loss of weight Diagnosis: Clinical ANA +ve RF-ve Treatment: - NSAIDS - Corticosteroids - DMARDS (methotrexate, Leflunomide) - Biologics (adalimumab, etanercept)

Answer 141

CREAM C=conjunctivitis R=Rash (maculopapular, desquamating, erythema) E=Edema of hands and feet A=Adenopathy (U/L cervical) M=Mucositis/glossitis/strawberry tongue Diagnosis: -Clinicall -Echo for CA aneurysm Treatment: -High dose aspirin -IVIG

Answer 142

• < 3 months: IV amoxicillin (or ampicillin) + IV cefotaxime/ceftriaxone • >3 months: IV cefotaxime/ceftriaxone • If Pen or Cephalosporins allergy ->Chloramphenicol • If presents to GP...>M benzylpenicillin • Steroids: if >3 months.> Add Steroids • IV fluids • Public health notification • Prophylaxis of contacts ->Ciprofloxacin

Answer 143

-Raised ICP (papilledema, FND, Bulging Fontanella) -Meningococcemia -Skin infection at puncture site -Coagulopathy/DIC

Answer 144

PINA Pregnancy Immunosuppression/immunotherapy with 3 months Neomycin allergy Another live vaccine in 4 wk

Answer 145

Anti-Jo-1 = Dermatomyositis (also associated w/ ILD) | Anti-Mi-2 = Polymyositis + Dermatomyositis Anti-SRP 2 = Polymyositis + Dermatomyositis (also associated w/ cardiac involvement)

Answer 146

103. Drug Induced Lupus 'SHIP MAP' S - Sulfasalazine H - Hydralazine I-Isoniazid P - Phenytoin M - Minocycline A - Anti-TNFa P - Procainamide

Answer 147

is a defect in collagen type IlI

Answer 148

105.Hyperuricemia Causes CAN'T LEAP Cyclosporine Aspirin (Low dose) Nicotinic acid Thiazides Loop diuretics Ethambutol Alcohol Pyrazinamide

Answer 149

Type 1 diabetes mellitus* Rheumatoid arthritis - in particular the DRB1 gene

Answer 150

Dermatitis herpetiformis Sjogren's syndrome Primary biliary cirrhosis

Answer 151

Narcolepsy Goodpasture's

Answer 152

Coeliac disease

Answer 153

Ankylosing spondylitis Reactive arthritis Acute anterior uveitis Psoriatic arthritis

Answer 154

Behcet's disease

Answer 155

Haemochromatosis

Answer 156

Behcet's disease

Answer 157

HLA-A3 Haemochromatosis HLA-B51 Behcet's disease HLA-B27 Ankylosing spondylitis Reactive arthritis Acute anterior uveitis Psoriatic arthritis HLA-DQ2/DQ8 Coeliac disease HLA-DR2 Narcolepsy Goodpasture's HLA-DR3 Dermatitis herpetiformis Sjogren's syndrome Primary biliary cirrhosis HLA-DR4 Type 1 diabetes mellitus* Rheumatoid arthritis - in particular the DRB1 gene

Answer 158

-Causes bull's eye retinopathy. -Baseline ophthalmological examination and annual screening is generally recommended. -Safe in pregnancy

Answer 159

-Dilation of the aortic sinuses (seen in 90%) which may lead to aortic aneurysm, aortic dissection , aortic regurgitation -Mitral valve prolapses (75%) -Lung: Repeated pneumothoraces

Answer 160

the treatment of choice is folinic acid

Answer 161

Findings in Osteoarthritis _LOSS Loss of joint space Osteophytes forming at joint margin Subchondral sclerosis Subchondral cysts Findings in Rheumatoid Arthritis_ LESS Loss of joint space Erosions (periarticular) Subluxation Soft Tissue Swelling

Answer 162

BITE Bones-fracture I (eye) - blue sclera Teeth- imperfections Ear-hearing loss (Otosclerosis)

Answer 163

SPAGLA SSRIs Antiepileptics Proton pump inhibitors Glitazones Long term heparin therapy Aromatase inhibitors e.g. anastrozole

Answer 164

Postmenopausal women, and men age 250, who are treated with oral glucocorticoic. if starting ≥7.5 mg/day prednisolone or equivalent for the next 3 months, start bone protective treatment at the same time don't wait for a DEXA scan before starting treatment oral bisphosphonates are used first-line e.g. alendronate or risedronate.

Answer 165

Most common osteoporotic fragility fractures SAND Spine Arm proper (i-e humerus) Neck of Femur Distal Radius

Answer 166

ass with Hep B +ve serology in 30% patients. P-ANCA in 20%

Answer 167

Is ass with Hep B +ve serology in 30% patients. P-ANCA in 20%

Answer 168

Pseudo WHIM P=Phosphate(hypophosphatemia) W=Wilson H=Hyperparathyroidism, I=Iron (Hemochromatosis) M=Mg (hypomagnesemia) Rx. NSAIDS, Oral/IM/Intra articular steroids

Answer 169

Treatment: Flare: Nsaids + colchicine + PP| until 2 days after symptoms settle Corticosteroids If taking allopurinol continue Chronic:(AFP) if UA >450 start Allopurinol 100mg OD first line Febuxostat 2nd line Pegloticase (if above don't work or CI) lifestyle

Answer 170

Multiple presentations: Symmetrical polyarthritis asymmetrical oligoarthritis Sacroiliitis DIP Arthritis mutilans (severe deformed joints with telescoping of bones) Pencil in cup deformity of MCP /DIP Joints on hand x-ray Treatment: Mild= NSAIDS moderate/severe= NSAIDS + methotrexate Monoclonal antibodies

Answer 171

NICE CKS says only refer if suspecting secondary causes or if unresponsive to Tx First line CCB e-g nifedipine 2nd line IV Prostacyclin (epoprostenol)

Answer 172

120.Felty'S Syndrome Triad of - RA - Splenomegaly - Neutropenia

Answer 173

Triad of - RA - Rheumatoid nodules in lungs - Pneumoconiosis

Answer 174

Diagnosis: -Joint aspiration -blood culture -imaging Treatment: -painkillers -Antibiotic, Flucloxacillin>>if pen Allergy -Clindamycin>> if MRSA -Vancomycin for 6 weeks -Arthrocentesis -Arthroscopic lavage -Most common location for septic arthritis is knee. -Prosthetic joint infection requires urgent ortho referral for surgical arthrocentesis + Joint washout ≤ debridement (this is followed by the ABx regime mentioned in the notes above) -The management for native septic arthritis of the hip j. is almost identical to that of prosthetic joint infection.

Answer 175

Sjogren syndrome is ass with increased risk of non-Hodgkin lymphoma. Hydroxychloroquine may be used to slow the progression of the disease.

Answer 176

SJS Tears (color change) Oligospermia Pneumonitis (fibrosis) Myelosuppression.

Answer 177

BANTS Biopsy showing multinucleated giant cells Age > 50 New onset temporal headache Temporal artery abnormality: tenderness or reduced pulsation (halo sign on ultrasound?) Serum ESR ≥ 50

Answer 178

if >7.5mg prednisolone for >3 months give Bisphosphonates for bone protection

Answer 179

Loading Dose = Cumulative Dose of 300 000 IU over 6-10 weeks Maintenance Dose = Cumulative Dose of 800-2000 IU daily 'Specific patient populations' for which Vit D supplementation is recommended by NICE: A - Age > 65 B - Breast feeding + pregnancy C - Children 6 months to 3 years old D - Dark skinned individuals E - Exposure to sunlight

Answer 180

Kocher's WIFE W =WBCs >12 I =inability to bear weight F =Fever >38.5°C E =ESR >40 The probabilities are calculated thus: O points = very low risk 1 point = 3% chance of septic arthritis 2 points = 40% chances 3 points = 93% chances 4 points = 99% chances

Answer 181

129.UL nerve root values: 3 Musketeers, 2 were assassinated , 5 rats, 4 mice, 2 unicorns

Answer 182

-Age < 20 years or > 50 years -History of previous malignancy -Night pain -History of trauma -Systemically unwell e.g. weight loss, fever

Answer 183

In case of foot drop, how to differentiate L5 lesion from peroneal nerve injury? Answer: Ankle inversion is spared in CPN lesion but not in L4,5 Weakness of eversion+ dorsiflexion = CPN injury Weakness of eversion+ dorsiflexion+ inversion = L4,5 lesion

Answer 184

Femoral - L2-L4 Obturator - L2-L4 Sciatic - L4-S3 Tibial - L4-S3 Common Peroneal - L4-S2 Superficial Peroneal - L4-S1 Deep Peroneal - L4-S1

Answer 185

In case of foot drop, how to differentiate L5 lesion from peroneal nerve injury? Answer: Ankle inversion is spared in CPN lesion but not in L4,5 Weakness of eversion+ dorsiflexion = CPN injury Weakness of eversion+ dorsiflexion+ inversion = L4,5 lesion

Answer 186

ERDOGAN (Named after a Turk and more common in Turkey (medtierranean) E - Erythema nodosum R - Rheumatology (HLA B51 association) D - diarrhea, DVT O - oral ulcers G - genital ulcers A - anterior uveitis, arthritis, abdominal pain N - neurological involvement (aseptic meningitis)

Answer 187

Giant cell Tumor= Soap bubble appearance Osteosarcoma= Sun-burst appearance, periosteal lifting with formation of Codman's triangle Ewing Sarcoma= Onion skin appearance

Answer 188

1. Median Nerve_ sensory loss on lateral 3 fingers, wasting of thenar eminence (Ape like hands), Hands of Benedict 2.Radial Nerve Wrist drop, sensory loss on the dorsum of hand between 1" and 2nd metacarpals. 3 Unar Nerve_ sensory loss on medial 1 and 8½fingers, Claw Hand, loss of adduction and abduction of fingers, Fremont sign. 4 Klumpke's Palsy_ Lower Brachial plexus injury (C8, T1), ulnar claw hand and sensory loss on 1 medial side of forearm +/- Horner syndrome 5. Erb's Palsy_ upper brachial plexus injury (C5, C6), waiter's tip position.

Answer 189

Achilles tendon Rupture: trauma, popping sensation > simmonds thompson test >> USG >> immediate referral to ortho

Answer 190

Adhesive capsulitis: DM >> restricted painful active and passive movements, ext. rotation is affected more >> nsaids, physio, steroids>> self-limiting in 6-18 months

Answer 191

Pain in the malleolar area plus one of following; 1) tenderness at lat.malleolar area 2) tenderness at med.malleolar area 3)unable to walk four weight bearing steps immediately after injury

Answer 192

Ankle Sprains: Low ankle sprain: Very common, inversion of foot >>ATFL injury >> Tx: PRICE High Ankle sprain : rare, external rotation of foot >> syndesmosis injury >> if no diastasis (widening of tibiofibular joint) then cast or orthosis, if diastasis then surgery

Answer 193

children 5-10 years, rotational force >> bulging of cortex >> splinting

Answer 194

children, fall on outstretched hand>> incomplete fx, bending of bone>> cast or splint

Answer 195

conservative Tx for 6 weeks including steroids and wrist splint, if fails then surgery (flexor retinaculum division)

Answer 196

Finkelstein's test-tenderness on radial styloid process on ulnar deviation of thumb >>nsaids, steroids, spica splint

Answer 197

lateral epicondylitis » pain worse with wrist extension>> nsaids, rest, physio, steroids »if fails surgery

Answer 198

medial epicondylitis>> pain worse on wrist flexion >> nsaids, rest, physio, steroids >> if fails surgery

Answer 199

short and externally rotated leg 1. Intracapsular: Non-displaced >>>internal fixation Displaced >>> THR or hemiarthroplasty 2 Exracapsualr: intertrochanteric >>> dynamic hip screw Subtrochanteric >>> intramedullary device

Answer 200

1.DDH: unequal skin folds and knee height discrepancy >>>> +ve Barlow and Ortolani maneuver >> USG if <4 months old, X-ray if >4 months old >>> Tx. Pelvic Harness 2. Transient Synovitis: 2-10 years old, ass with viral infection, similar to septic arthritis but milder and without systemic symptoms >>>supportive Tx 3. Leg Calves Perthes: 4-8 years old boys, avascular necrosis of femoral head >>> conservative Tx (Rest, nsaids, physio, regular x-ray) until 6 years of age if no widening of joint space >>> if flattening of femoral head or failure of conservative Tx then surgery. 4. Slipped capital femoral epiphysis: obese children 10-15 years, thigh or knee pain >>> loss of internal rotation of leg >>> urgent referral to ortho for stabilization 5. Osgood Schlatter disease: 10-14 years old, athlete, pain and tenderness at the tibial tuberosity below the knee (inflammation of tibial tubercle) >> rest, symptomatic Tx

Answer 201

1.ACL:twisting force applied to a bent knee >>> ant. drawer sign positive >>> PRICE, physio, braces, surgery if everything fails 2.PCL: caused by hyperextension of knee >>> post. Drawer sign positive >>>Tx same 3.MCL: caused by lateral force on the knee >>> valgus stress test positive >>> Tx same 4. LCL: caused by medial force on the knee >>> varus stress test positive >>> Tx same 5. Meniscal tear: Clicking and locking of knee >>> medial meniscal tear is more common than lateral due to it being less mobile >>> Macmurray and Thessaly Tests to differentiate b/w medial and lateral tear>>T same

Answer 202

PADI- Posterior: adducted internally rotated AABE: anterior abducted externally rotated Rx: closed reduction under sedation, open reduction if Fx, post-reduction x-ray/CT to confirm alignment, rest, immobilization and physio

Answer 203

back pain that becomes with walking or lying down and improves with sitting, or leaning forward . >>>MRI >>>laminectomy.

Answer 204

Assessing Risk : FRAX or fracture score is used to assess 10-year risk of a fragility fracture in women 265, men ≥75, and younger people with major risk factors FRAX: gives the risk in color form, green-orange-red -> orange or red is an indication for DEXA scan Qfracture: gives risk in percentage ->10% is an indication for DEXA scan

Answer 205

• >50-year-old with fragility fracture • <40-year-old with a major risk factor for fragility fracture • someone who is going to receive hormonal therapy for breast and prostate cancer

Answer 206

• T score ≥ -1= Normal bone density • T score between -1 and -2.5= Osteopenia>>>>>>Ca+ and Vit D supplements if low, weight bearing exercises • T score ≤ -2.5= Osteoporosis >>>>>Start bisphosphonates

Answer 207

• Adults aged ≥75 with history of fragility fracture • Postmenopausal women with fragility fracture • Patient on long term steroids (≥7.5mg prednisone or equivalent for 3 months)

Answer 208

• Osteoporosis patient on bisphosphonates ---> repeat Dexa scan every 3-5 years • Osteopenia patient > repeat Dexa scan every 2-3 years

Answer 209

7Fs Female Family history First born Fat baby >5kg Foot deformity (calcaneovalgus) Faulty presentation (breech) Fewer Liquid (oligohydramnios)

Answer 210

- Injury to the recurrent laryngeal nerve -> Hoarseness of voice - Injury to external (branch of superior) laryngeal nerve -> changes of the voice Pitch. (Decreased pitch) N.B. About 18% of Lung cancer patients experience hoarseness of voice due to compression of the recurrent laryngeal nerve. Also, a complication of thyroid surgery. U/L recurrent L.N. - Hoarseness B/L recurrent L.N. - Aphonia/Stridor U/L external L.N. - Dysphonia

Answer 211

Diagnosis: US <4.5 months X-ray >4.5 months Treatment: Spontaneous until 3-6 weeks Pelvic Harness 4-5 months Surgery for older children

Answer 212

(Thin sacks filled with synovial fluid) | 1. Suprapatellar bursitis ›localized pain just above the patella-->rest, painkillers 2. Prepatellar (b/want. surface of patella and skin) = Housemaid's knee (inability to flex knee and localized redness and pain over affected bursa. Tx with Rest. 3. Infrapatellar (Superficial and Deep): deep is sandwiched b/w patellar tendon and tibia = Jumper's Knee/clergyman's knee 4. Pes anserine bursitis: lower medial part of knee, it is common in overweight individuals.

Answer 213

-baker's cyst DDH -tenosynovitis achilles tendon rupture

Answer 214

suspecting bone Mets: Pain on lying down, dull, worsening Best INITIAL test: serum Calcium Most Appropriate (Screening test for Bone Mets if no neurological signs): Bone Scintigraphy Bone Radionuclide test If Neurological Signs: MRI Urgent

Answer 215

-Pain on initial 60° of abduction -> rotator cuff tear -Painful arc between 60-120° of abduction > subacromial impingement Rx: painkillers, physio, steroids

Answer 216

-Pain and tenderness in the anatomical snuff box area, Pain at the radial aspect of wrist on ulnar deviation •Fracture might be missed on the x-ray, either do CT/MRI to confirm or immobilize with cas and repeat the x-ray because the risk of avascular necrosis is high if left untreated

Answer 217

FOOSH >>›distal radial fx with dorsal displacement of distal fragment (dinner fork deformity) >>> closed reduction and immobilization for minimally displaced fx, surgery (ORIF) for severely displaced fx.

Answer 218

1.Smith's fracture: FOOSH >>> distal radial fracture with volar (ventral) displacement of distal fragment (garden spade deformity) >>>Tx same as for Colles' fx 2.Colles' fracture: FOOSH >>› distal radial fx with dorsal displacement of distal fragment (dinner fork deformity) >>> closed reduction and immobilization for minimally displaced fx, surgery (ORIF) for severely displaced fx.

Answer 219

Monteggia: FOOSH with forearm in pronated position--> fracture of proximal ulna with dislocation of proximal radioulnar joint >>>open reduction and internal fixation (ORIF) Galeazzi: FOOSH with forearm in hyperpronation--->fracture of distal radius with dislocation of distal radioulnar joint >>>>ORIF

Answer 220

bone pain, bowing of tibia, skull bossing >> raised ALP with normal ca+, Ph-, vit D and PTH levels >>> Bisphosphonates

Answer 221

ECG Criteria for STEMI: -ST-elevation in leads V2-V3 that is ≥ 2.5mm in men below 40 AND ≥2mm in men above 40 -ST-elevation in leads V2-V3 that is ≥ 1.5mm in women -ST-elevation in all other leads that is ≥1 mm. -New Onset LBBB Once diagnosis of STEMI is confirmed:

Answer 222

Give DAPT + Anticoagulants + PCI DAPT: Aspirin + Prasugrel (no bleeding risk) OR Aspirin + Clopidogrel (bleeding risk present. Anticoagulants: Unfractionated heparin/Bivalirudin PCI with radial access: Unfractionated heparin with bailout GPI. PCI with femoral access: Bivalirudin with bailout GPI. PCI: Consider radial over femoral arterial access Thrombus aspiration over mechanical thrombus extraction should be considered

Answer 223

Give DAPT + Anticoagulants + tPA tPA: Alteplase/Tenecteplase DAPT: Aspirin + ticagrelor (no bleeding risk) OR Aspirin + Clopidogrel (bleeding risk present) Anticoagulant: Unfractionated heparin/Bivalirudin **Do ECG after 60-90 minutes if resolution of ST-segment elevation by >50% then good If not, then PCI should be considered.

Answer 224

≤1.5% lowest risk 1.5 to 3 % low risk 3 to 6 % intermediate risk 6 to 9% high risk >9 % highest risk

Answer 225

If GRACE Score (≥3%) Step 1. Aspirin 300mg PO + Fondaparinux (cannot give if immediate angiography planned) Step 2 -Clinically Unstable: Immediate angiography -Stable (not bleeding): Angiography within 72 hours (with follow-on PCI if indicated) -Not on anticoagulation: Prasugrel/ticagrelor + Aspirin - Only give prasugrel once PCI intended -On previous Anticoagulation: Clopidogrel + Aspirin.

Answer 226

If GRACE Score (< 3%) Step 1. Aspirin 300mg PO + Fondaparinux Step 2. - Low Bleeding Risk: Ticagrelor + Aspirin - Higher Bleeding Risk: Clopidogrel + Aspirin

Answer 227

patients who have high-risk features such as fever > 38°C or elevated troponin should be managed as an inpatient Rx: Colchicine +NSAIDS

Answer 228

It should be avoided in asthmatics due to possible bronchospasm. Can also cause transient flushing.

Answer 229

works by blocking K+ channels. Monitoring: TFT, LFT, U&E, CXR prior to treatment TFT, LFT every 6 months

Answer 230

Prevention: Aspirin + statins + lifestyle to prevent ACS Acute Attacks: Sublingual GTN (not ISM) Long term Management: -First drug is BB if BB is Cl or not tolerated, Start with NDCCB (verapamil, diltiazem) -2nd drug is CCB (amlodipine) if first drug was BB -3rd drug is either Long-acting nitrates or Ivabradine (Dec HR by Blocking If Na current) or Nicorandil (coronary vasodilation + K+ blocker) | or Ranolazine (blocks late Na current, dec ca+ overload, dec 02 demand)

Answer 231

1. Refer to Hospital, if - Pain at rest (which may occur at night). - Pain on minimal exertion. - Angina that seems to be progressing rapidly despite increasing medical treatment.

Answer 232

2. Refer to cardiologist for Angiography with possible PCI if - Evidence of extensive ischemia on ECG - Angina persists despite maximum therapeutic doses of two drugs and lifestyle interventions.

Answer 233

if asymptomatic >>> observe 1. If symptomatic >>> valve replacement either by Surgery (young and low/intermediate risk for surgery) or Transcatheter AVR (high risk for surgery) 2. Balloon Valvoplasty if children without calcified AV if not fit for valve replacement

Answer 234

1.Valsalva >> dec. Preload >> dec MS, AS, AR, MR, VSD >> Inc. HOCM and MVP 2. Squatting>> Inc. Preload >> Inc.MS, AS, AR, MR, VSD >>Dec.HOCM, MVP 3. Handgrip >> Inc. Afterload >> Inc. AR, MR, VSD >> Dec. HOCM, MVP

Answer 235

-second most common cause of sudden cardiac death in the young after hypertrophic cardiomyopathy -the right ventricular myocardium is replaced by fatty and fibrofatty tissue

Answer 236

Management: 1. Rate control: B Blockers or Ca Channel blocker 2. Rhythm Control: is done in certain situations, can be pharmacological or electrical When Rhythm Control?? 1. First episode and < 48 hours onset 2. HF 3. Reversible Cause 4. Rate control but still symptomatic

Answer 237

1.RATE CONTROL FIRST 2. Anti coagulate for 3 weeks then cardioversion or TOE done to exclude thrombus --- once excluded - heparinize and cardiovert (electrical preferred) **If High risk of failure, pharmacological use of amiodarone for 4 weeks prior to electrical cardioversion** 3. Following Electrical Cardioversion - anticoag for 4 weeks initially then review by CHA2DS2VASC

Answer 238

Rhythm control OR Rate control 1. Heparinized and rhythm control (by Amiodarone /flecainide or DC shock) **Pt with risk of stroke, give anticoagulation life long.** After electrical cardioversion, if noted that AF was less then 48 hours then no need for further anticoagulation if Cha2ds2vasc is zero.

Answer 239

if CHA2DS2VASc Score 1 more in male or 2 or more in female

Answer 240

-Orbit score to asses bleeding risk (Orbit 4-7 is high risk for bleeding) -Echo to rule out valvular disease

Answer 241

Absolute indication for anticoagulation regardless of chadsvasc score Give Warfarin instead of DOAC in Valvular AF

Answer 242

Absolute indication for anticoagulation regardless of chadsvasc score Give Warfarin instead of DOAC in Valvular AF

Answer 243

First line is DOAC 2nd line is warfarin

Answer 244

first line BB if asthma CCB if HF Digoxin

Answer 245

After cardioversion sinus rhythm is maintained by either BB, Dronedarone, amiodarone OR Catheter ablation >>>anticoagulant should be given 4 weeks before, during and for 2 months after procedure if chadsvasc score is zero if chadsvasc 2 or more lifelong anticoagulation.

Answer 246

Exclude Hemorrhage beforehand and then if TIA+ AF= DOAC immediately, no need to change anything. Stroke+ AF = 2 weeks clopidogrel then stop clop and start the DOAC.

Answer 247

SCN5A mutation (myocardial Na+ channel defect) >>> Arrythmias Down sloping ST segment into negative T (V1-3), Rx: ICD

Answer 248

Primary prevention of stroke e-g AF =Anticoagulant monotherapy (DOAC) Stroke +AF = clopidogrel for 2 weeks then DOAC monotherapy TIA+ AF= DOAC from beginning DVT= If taking AP and got DVT, calculate ORBIT score and stop AP ⬇️ if Intermediate or high bleeding risk ⬇️ and give DOAC monotherapy for 3-6 months.

Answer 249

N- normal variant I- infarction P- pericarditis & myocarditis P- prinzmetal's Angina L- left ventricular aneurysm E- endocardiomyopathy (takotsubo) S- SAH (myocardial stunning)

Answer 250

A: Antiarrhythmics (e.g. Amiodarone, sotalol) M: Macrolides (e.g., erythromycin, clarithromycin) E: Electrolyte imbalances (e.g., hypokalemia, hypomagnesemia, hypocalcemia) D: Diuretics (due to electrolyte disturbances) I: Inherited (genetic conditions like Long QT Syndrome) C: CNS drugs (e.g., antipsychotics, antidepressants such as SSRIs) A: Anti-infectives (e.g., fluoroquinolones, antimalarials) T: Toxins and recreational drugs (e.g., cocaine, methadone) I: Ischemia (myocardial infarction) O: Overdose of medications (e.g., TCAs, certain antihistamines) N: Non-drug related conditions (e.g., hypothyroidism, bradycardia) | S: Sepsis (can cause electrolyte imbalances and organ dysfunction)

Answer 251

-Adenosine is Cl in asthma -Verapamil is Cl in VT

Answer 252

-Total cholesterol > 7.5 -Ml in first degree relatives before 60yo -MI in second degree relatives before 50yo

Answer 253

Ventricular ectopic can cause palpitations in alcoholics >>>reassure

Answer 254

• Persistent ST-elevation means LV aneurysm, confirm on echo • Inferior wall Mi causes AV block • Fibrinous pericarditis in 48 hours • Dressler pericarditis in 2-6 weeks • MR due to Papillary rupture More common with infero-posterior MI because anterior papillary muscle has dual supply from LAD and LCA and post. pappilary muscle has single supply from RCA •PDE5 inhibitors (e.g. sildenafil) may be used 6 months after a MI. They should however be avoided in patient prescribed either nitrates or nicorandil

Answer 255

DABS Dual antiplatelet ACEI/ARBs BB Statins

Answer 256

Ivabradine -can cause luminous phenomenon (enhanced brightness or flashes of light in peripheral vision) Nicorandil can cause flushing and skin, mucosal and eye ulceration.

Answer 257

1.Biological Short life Used in old patients >65 for aortic and >70 for mitral Lifelong anticoagulation not needed Warfarin for 3 months based on patient factors Lifelong low dose aspirin

Answer 258

Long lasting Require lifelong anticoagulation with Warfarin Aspirin only if additional indication like IHD Target INR 3 in aortic 3.5 in Mitral

Answer 259

"HIT VAST" H - Hemorrhagic stroke (any recent intracranial hemorrhage) I - Intracranial neoplasm (brain tumors) T - Trauma or surgery (within the last 3 months) V - Very recent bleeding (Gl or urinary bleeding in the past 21 days) A - Anticoagulants (recent use or high INR levels) S - Severe hypertension (uncontrolled high blood pressure) T - Thrombus (non-cardiac origin, like in aortic dissection)

Answer 260

for statins check LFTs at baseline, 3 months and 12 months . (Discontinue statins if ALT/AST 3x the upper limit)

Answer 261

-Major Criteria: JONES J- Joints (migratory arthritis) 0 - 0 shaped Heart (pancarditis) N - Nodules (painless, subcutaneous) E - Erythema marginatum S - Sydenham's chorea

Answer 262

1.Established CVD 2. 10- year CVD risk >10% 3. Type 1 DM (>40 yr old, >10 yr since diagnosis, Nephropathy) 4. CKD eGFR <60

Answer 263

DOSAGE: Primary prevention: Atorvastatin 20mg, Rosuvastatin 10mg Secondary prevention: Atorvastatin 80mg, Rosuvastatin 40mg Side effects: MYOPATHY Liver toxicity (check Liver enzymes at baseline, 3 months and 12 months) Inc. Risk of ICH Contraindications: Macrolides Pregnancy

Answer 264

•Pulsus paradoxus: severe asthma, cardiac tamponade •Slow-rising: aortic stenosis •Collapsing: Aortic regurgitation, patent ductus arteriosus •Pulsus alternans: severe LVF •Bisferiens pulse: double pulse' - two systolic peaks, mixed aortic valve disease •Jerky pulse: Hypertrophic obstructive cardiomyopathy*

Answer 265

180. Pulmonary embolism Investigations: 2-level PE Wells score Clinical DVT 3 PE #1 diagnosis 3 HR>100. 1.5 Immobilization/Surgery 1.5 Hx of DVT/PE 1.5 Hemoptysis. 1 Recent Cancer 1 >4 or equal PE likely Less than 4 PE Unlikely

Answer 266

>>1. if stable CTPA first line >> if +ve, treat as PE >> if -ve consider leg US if DVT suspected >>2. if massive PE with Hemodynamic instability >> TTE first line >> if +ve Confirm by CTPA if feasible >> if CTPA not feasible >>Treat as PE >>if Contrast allergy/ renal failure >> V/Q scan

Answer 267

D-dimer first line if elevated >> CTPA >> if CT +ve >>treat as PE >> if CT -ve >> PE unlikely consider alternative If not elevated >> PE unlikely >> consider alternative

Answer 268

ECG Findings: S1Q3T3 CXR Findings: Atelectasis(consolidation), Hampton's hump (wedge shaped infarct), Westmark sign (Dec. Pulmonary vascular markings) Management: Pulmonary Embolism Severity Index (PESI) score is used to identify patient with PE that are suitable for OPD treatment. -1. First line is DOAC (rivaroxaban, apixaban) -2. if above two not suitable >> LMWH followed by Dabigatran/edoxaban OR >> LMWH followed by Warfarin. -3. IF eGFR <15_ unfractioned Heparin OR LMWH followed by Warfarin -4. IF ANTIPHOSPHOLIPID SYNDROME >> LMWH followed by Warfarin -5. IF PREGNANCY: LMWH is first line -6. IF RECURRENT PE: IVC Filter

Answer 269

IF VTE PROVOKED: 3 MONTHS Tx IF VTE UNPROVOKED: 6 MONTHS Tx PE with hemodynamic instability: Thrombolysis is now recommended as the first-line treatment for massive PE where there is circulatory failure (e.g. hypotension)

Answer 270

Warfarin remains the only oral anticoagulant approved for patients with AF + mechanical prosthetic heart valves or moderate to severe mitral stenosis.

Answer 271

Decreased Na, K, Ca, Mg, Cl, BP Glucose, U.A Increased Ototoxicity

Answer 272

Empirical Antibiotic Regimen NVE indolent: Amoxicillin + Gentamicin NVE, severe/Sepsis: Vancomycin + Gentamicin PVE Vancomycin+Gentamicin+Rifamipicn Change after culture results accordingly

Answer 273

Major: B= Blood culture + on 2 separate occasions E= Echocardiography -shows vegetations Minor: T=Temperature> 38 C I=Immune phenomenon (Osler nodes, Roth spots, GMN, +ve RF) M=Microbiology not meeting major criteria E=Embolic phenomenon (Janeway lesions, splinter hemorrhages, septic emboli to brain, limbs, spleen, Gi) | E=Echocardiographic evidence not meeting major criteria R= Risk factors (CHD, IVDU, prosthetic valves) IE= 2 major or 1 major + 3 minor or 5 minor

Answer 274

177.Infective endocarditis NVE _ Stap. Aureus, Stap Epidermidis, S.Viridans PVE- First year Stap.Epidermidis, later Stap. Aureus/S.viridans Investigations: 3 blood cultures 6 hours apart in subacute/chronic presentation 2 blood cultures 1 hours apart in Acute IE with sepsis TTE first >> if negative and still suspecting lE >>TOE Bloods, CXR, ECG

Answer 275

176.HOCM Echo findings: MR SAM ASH -mitral regurgitation (MR) -systolic anterior motion (SAM) of the anterior mitral valve leaflet -asymmetric hypertrophy (ASH)

Answer 276

HOCM - Management: ABCDE Amiodarone Beta-blockers or verapamil for symptoms Cardioverter defibrillator Dual chamber pacemaker Endocarditis prophylaxis* Drugs to avoid: -Nitrates ACE-inhibitors -Inotropes

Answer 277

-Minor Citeria: FRAP F - Fever R-Raised ESR/CRP A - Arthralgia P - Prolonged PR 2 major criteria OR 1 major + 2 minor criteria Plus, evidence of preceding Streptococcal throat infection (Inc. ASO Titres or + throat culture or rapid antigen test)

Answer 278

. Liddle syndrome ENaC defect Inc.Na reabsorption >> Hypertension, hypokalemia

Answer 279

Initial Mx: I/M Benzathine PenicillinG (1.2 M units) single dose Secondary prevention: Long term antibiotic prophylaxis IM Benzathine Penicilin G every 4 weeks Duration of antibiotics prophylaxis: -Carditis with residual heart disease-until age 40 or lifelong -Carditis without residual heart disease-for 10 years or until age 25 which is longer -Rheumatic fever without carditis-for 5 years or until age 18 which is longer

Answer 280

Ivabradine -can cause luminous phenomenon (enhanced brightness or flashes of light in peripheral vision) Nicorandil can cause flushing and skin, mucosal and eye ulceration.

Answer 281

1st Drug 1.if < 55-yr old or type 2 DM: ACEI/ARB (A) 2 if >= 55-years-old or of black African or African-Caribbean origin: Calcium channel blocker (C) 2nd Drug 1. if already taking an ACE-I or ARB add a Calcium channel blocker or a thiazide-like Diuretic 2.if already taking a Calcium channel blocker add an ACE-i or ARB or a thiazide-like Diuretic if Black African or Caribbean ARBs preferred over ACEI 3rd drug if taking A+C add D if taking A+D add C if taking C+D add A 4th Drug Either add 4th drug or seek specialist advice after 3 drugs if potassium < 4.5 mmol/l add low-dose spironolactone if potassium > 4.5 mmol/l add an alpha- or beta-blocker Patients who fail to respond to step 4 measures should be referred to a specialist.

Answer 282

Target BP: Age <80 clinic 140/90 ABPM 135/85 Age>80 clinic 150/90. ABPM 145/85 Type I DM: Start Drug treatment at lower threshold of BP >130/80 if Albuminuria or 2 or more features of Metabolic syndrome.

Answer 283

173. Hypertension if Clinic BP >140/90 confirm by ABPM or HBPM Stage 1 Clinic >140/90, ABPM >135/85 treat according to age if >80 yr and BP <150/90 don't treat If <80 yr + one of the TERD-10 present lifestyle+drug if <60 yr and 10-y risk < 10% life style+ drug if <40 yr consider 2ndry causes and specialist referral

Answer 284

Stage 2 clinic >160/100 or ABPM >150/95 Treat with drug regardless of age Severe Hypertension clinic >=180/120 if >180/120 + End organ damage symptoms, refer to hospital for same day assessment and admission if >180/120 and no symptoms but end organ damage present on investigation, start treatment with oral Anti-HTN without confirming. if >180/120 with no symptoms and no end organ damage evidence on tests, confirm by repeating clinic BP within 7 days or consider ABPM/HBPM and clinic review in 7 days and decide management accordingly.

Answer 285

TERD-10 -Target organ damage -Established CVD -Renal disease -DM -10-yr CVD risk >10%

Answer 286

• 02 (Sat 94-98%)| • IV Furosemide • Vasodilators (nitrates)>> if HTN, Ischemia, AR/MR • if cardiogenic shock - Inotropes (dopamin,dobutamin)>>if BP <90/60 - Noradrenaline >>if Inotropes Fail - Mechanical Support >> Ventricular assist devices, Intra-aortic balloon Catheter pulsation. • if Resp failure >> CPAP • Routine HF medications such as BB and ACEI continue Stop BB if - Unstable/shock - HR <50 - 2nd or 3rd degree Heart block *Morphine not used routinely*

Answer 287

ECG: LAD: +ve QRS complex in lead-I and -ve QRS complex in lead-III (Left leaves) RAD: -ve QRS complex in lead-I and +ve QRS complex in lead-Ill (right reaches)

Answer 288

-Target BP in Type 1 DM is <140/90 if ACR is <70 <130/80 if ACR is ≥70 <150/90 regardless of ACR if >80 years old ACEI/ARBs are first line in DM ARBs preferred over ACEl in black African/Caribbeans

Answer 289

WILL CHOP W-Wolff-Parkinson-White syndrome* - right-sided accessory pathway I-inferior myocardial infarction L-left anterior hemiblock L-left bundle branch block C-Congenital: tricuspid atresia H-Hyperkalemia O-Obese people P-Primum ASD

Answer 290

CLAPP Right with me C-Chronic lung disease → cor pulmonale L-Lateral myocardial infarction A-ASD (ostium secundum) P-Pulmonary embolism P-Posterior hemiblock R-Right ventricular hypertrophy W-Wolff-Parkinson-White syndrome* - left-sided accessory pathway M-Minor-normal in infant < 1 years old

Answer 291

CLAPP Right with me C-Chronic lung disease → cor pulmonale L-Lateral myocardial infarction A-ASD (ostium secundum) P-Pulmonary embolism P-Posterior hemiblock R-Right ventricular hypertrophy W-Wolff-Parkinson-White syndrome* - left-sided accessory pathway M-Minor-normal in infant < 1 years old

Answer 292

Anteroseptal V1-V4 Left anterior descending Inferior: II, III, aVF Right coronary Anterolateral: V1-6, I, aVL Proximal LAD Lateral: I, aVL +/-V5-6 Left circumflex Posterior: V1-3 (reciprocal changes) Usually Left Circumflex, also RCA Posterior infarction is confirmed by ST elevation and Q waves in Posterior leads (V7-9)

Answer 293

-Down-sloping ST depression (reverse tick, 'scooped out) -flattened/inverted T waves -short QT interval -arrhythmias e.g. AV block, bradycardia

Answer 294

remember 'NIPPLES' as nipples are elevated N- normal variant I- infarction P- pericarditis & myocarditis P- prinzmetal's Angina L- left ventricular aneurysm E- endocardiomyopathy (takotsubo) S- SAH (myocardial stunning)

Answer 295

Peaked T-wave then ST depression then inverted T-wave then ST elevation

Answer 296

(If K+ dips, ST segment also dips) K-hypokalemia D-Digoxin l-Ischemia P-Post. Wall MI (V1-V3)

Answer 297

-pulmonary embolism -myocardial infarction (anterior or anteroseptal-less common than LBBB) -atrial septal defect (ostium secundum) -cardiomyopathy or myocarditis -right ventricular hypertrophy -chronically increased right ventricular pressure - e.g. cor pulmonale

Answer 298

A2 D2 H2 A= Ant.wall MIl A=Aortic stenosis D= Digoxin Toxicity D=Dilated Cardiomyopathy H= Hypertension H=Hyperkalemia

Answer 299

165. Causes of LBBB A2 D2 H2 A= Ant.wall MIl A=Aortic stenosis D= Digoxin Toxicity D=Dilated Cardiomyopathy H= Hypertension H=Hyperkalemia

Answer 300

S - Sarcoidosis I-IHD M - MD I - Idiopathic L - Lyme disease A - Aortic root pathology R - Rheumatic fever

Answer 301

164.ECG: bundle branch block LBBB: -Broad QRS complex: >120 ms (3 small squares) -Dominant S wave in V1. (W pattern) -Broad, monophasic R wave in lateral leads: 1, aVL, V5-V6. (M pattern) -Absence of Q waves in lateral leads.

Answer 302

RBBB: -QRS duration ≥120 milliseconds. -In lead V1 and V2, there is an RSR' (M pattern) -in Leads 1 and V6, the S wave is of greater duration than the R wave, or the S wave is greater than 40 milliseconds. (W pattern)

Answer 303

* One of the most common ways to remember the difference between LBBB and RBBB is WiLLiaM MaRRoW

Answer 304

In Hypokalemia, U have no Pot and no T, but a long PR and a long QT -U waves -Flat or absent T-wave -Long PR - Long QT

Answer 305

J' wave (Osborne waves) - small hump at the end of the QRS complex

Answer 306

-Down-sloping ST depression (reverse tick, 'scooped out) -flattened/inverted T waves -short QT interval -arrhythmias e.g. AV block, bradycardia

Answer 307

W-Wolff-Parkinson-White syndrome* - right-sided accessory pathway I-inferior myocardial infarction L-left anterior hemiblock L-left bundle branch block C-Congenital: tricuspid atresia H-Hyperkalemia O-Obese people P-Primum ASD

Answer 308

C-Chronic lung disease → cor pulmonale L-Lateral myocardial infarction A-ASD (ostium secundum) P-Pulmonary embolism P-Posterior hemiblock R-Right ventricular hypertrophy W-Wolff-Parkinson-White syndrome* - left-sided accessory pathway M-Minor-normal in infant < 1 years old

Answer 309

-Down-sloping ST depression (reverse tick, 'scooped out) -flattened/inverted T waves -short QT interval -arrhythmias e.g. AV block, bradycardia

Answer 310

1. Mild asthma exacerbation: PEFR >75% best or predicted NO features of acute severe asthma 2. Moderate acute asthma: PEFR 51-75% best or predicted No features of acute severe asthma 3. Acute severe asthma: PEFR <50% best or predicted Respiratory rate >25/min Heart rate >110/min Inability to complete sentences in one breath

Answer 311

Life-threatening asthma attack (A CHEST) -Arrhythmia/ Altered conscious level -Cyanosis, PaCO2 normal -Hypotension, Hypoxia (PaO2<8kPa, SpO2 <92%)| -Exhaustion -Silent chest -Threatening PEF < 33% best or predicted (in those >5yrs old)

Answer 312

Raised PaCO2 and/or needing high inflation pressures if ventilated.

Answer 313

0 - Oxygen, 15 L/min NRM, 94-98% S - Neb Salbutamol, 5 mg >> repeat after 15-30 mint H - Hydrocortisone/Prednisone 100 mg QDS, 40-50mg I - Ipratropium, 500 mcg >> repat after 4 hours (Remember: given before steroids) T - Theophylline loading IV 5 mg/kg, maintenance 0.5-0.7 mg/kg M - Mg sulphate 2g in 100ml NS over 20 mints E - Escalate care ECMO, intubation & ventilation ABGs if SpO2 <92% Admission if life-threatening, severe asthma that doesn't respond to Tx, Prev near fatal attack, comorbidities, pregnancy, night presentation, attack occurred while already on steroids.

Answer 314

>>Been stable on their discharge medication (i.e. no nebulizers or oxygen) for 12-24 hours >>Inhaler technique checked and recorded >>PEF >75% of best or predicted

Answer 315

when antibiotics?? -systemically unwell -Comorbidities -CRP 20-100 (delayed prescription), >100 (immediate) Rx: -Doxycycline is 1st line -if children or pregnant >> Amoxicillin

Answer 316

Investigation: Vitals, pulse Ox, ABG, CXR, ECG, FBC, U&E, Sputum Analysis, Blood culture if fever Admission if Arterial Pa02 <7 Kpa Arterial pH <7.35 Sat <90% Cyanosis Confusion Comorbidity Severe SOB Inability to cope at home worsening edema already on Home 02 therapy

Answer 317

-Controlled oxygen therapy to maintain Sp02 88-92% (start VM 28% at 4l/mint) -Nebulized salbutamol 2.5-5 mg -Nebulized Ipratropium 500 micrograms | -Prednisolone 30 mg -Antibiotic agent (if purulent sputum or clinical signs of Pneumonia) >> amoxicillin or clarithromycin or doxycycline

Answer 318

BiPaP Settings EPAP= 4-5 cm of H2O IPAP= 10 cm of H2O (RCP guidelines) 12-15 cm of H20 (BTS)| if NIV fails then Invasive ventilation Most common pathogen COPD + consolidation = Str. Pneumo COPD + NO consolidation = Hemophilus

Answer 319

M, S, Z form of gene patients who manifest disease are usually homozygous for ZZ genotype Alphabetical order! = M for normal, S for slow, and Z for very slow Treatment: -Bronchodilators, physiotherapy -IV A1AT| -Lung reduction surgery, lung transplant

Answer 320

is most common cancer in Asbestosis not mesothelioma.

Answer 321

If >17-year-old -FeNO and -Spirometry with Bronchodilator reversibility test (BDR) If 5-16-year-old -Spirometry with BDR -FeNO (if Spirometry +ve but BDR -ve )| If < 5-year-old clinical judgement

Answer 322

Step 1 Step 2 Step 3 Step 4 Step 5 Step 6 Step 7 Step 1 SABA Step 2 SABA+ low dose ICS Step 3 SABA+ICS+LTRA (LABA as per BTS) Step 4 SABA+ICS+LABA +/-LTRA Step 5 SABA + Low dose-ICS MART +- LTRA Step 6 SABA + Moderate dose-ICS MART +- LTRA Or SABA+LABA +Moderate dose ICS+-LTRA Step 7 SABA +LABA +- LTRA + one of the following - High does ICA -A trial of LAMA or theophylline -Seek Expert Advice Low dose ICS <400mcg Moderate ICS 400-800mcg High Dose ICS >800mcg

Answer 323

-SABA, 15-30 mints before Exercise -Low dose ICS, if not controlled with SABA OR >2 epi of ElA per week -if not improves, ADD either one of the following; LTRA, LABA, Na Cromoglycate, Theophylline

Answer 324

-Long-term antibiotic for prophylaxis is Azithromycin -Most common bug is H.Influenza followed by pseudomonas, klebsiella, str. pneumo -Flu vaccine and Pneumococcal vaccine should be given in bronchiectasis.

Answer 325

Cadmium; Coal; Cotton; Cement; Grains (Cereal); A1ATd; Smoking.

Answer 326

Offer LTOT if -Pa02 <7.3 -Pao2 7.3 - 8 plus one of the Ps Pulmonary HTN Peripheral Edema Polycythemia

Answer 327

-Stop smoking -yearly flu vaccine and one-off pneumococcal vaccine -Pulmonary rehabilitation if MRC dyspnea scale 3

Answer 328

Grading Severity based on FEV1 FEV1 > 80% Mild FEV1 50-79% Moderate FEV1 30-49% Severe FEV1 <30% Very severe

Answer 329

Step1 SABA OR SAMA Step 2 Depends on presence/absence of asthmatic features/ Steroid responsiveness: 1) Previous Asthma or Atopy II) Eosinophil =>300 IIl) Variation in FEV1 over time (at least 400ml)| IV) Diurnal variation in PEF (at least 20%) if no steroid responsiveness: LABA+LAMA switch SAMA to SABA if started on step 1 if steroid responsiveness: LABA+ICS if no response to above LABA+LAMA+ICS switch SAMA to SABA Step 3: Oral theophylline after trial of Short and long-acting dilators Reduce dose with FQ and macrolides Oral PDE-4 Inhibitors: Roflumilast if Severe COPD, FEV1 <50% and 2 or more exacerbations while on triple inhaled therapy Step 4: Offer LTOT if - Pa02 <7.3 - Pao2 7.3 - 8 plus one of the Ps Pulmonary HTN Peripheral Edema Polycythemia Step 5: oral prednisolone or nebulized saline

Answer 330

Long term Oral Prophylactic Antibiotics Criteria: -Not smoking, on optimal treatment and still gets Exacerbations --Ecg to exclude QT prolongation -Oral Azithromycin Standby Medications: short course of Oral steroids + Antibiotics (to be taken at home in case of exacerbation) COR PULMONALE LTOT Loop diuretics ACEI, CCB, BB, a-blockers NOT used IMPROVE SURVIVAL 1) cessation of smoking 2) LTOT 3) Lung reduction Surgery

Answer 331

Treatment: -drugs approved are Pirfenidone (antifibrotic agent) Nintedanib if FVC 50-80% -pulmonary rehabilitation -supplemental 02 and Lung Transplant

Answer 332

Alcoholics Diabetics Aspiration (e-g stroke patients) Rx Pip/Tazo OR Meropenems

Answer 333

PipTazo/Co-Amoxiclav/Ampiciline+sulbactam/Meropenems IV antibiotics for 4-6 weeks if failed percutaneous drainage if failed surgery

Answer 334

CXR Chest CT Bronchoscopy (BAL) EBUS Percutaneous Biopsy pleural Aspiration PET-CT (uses 18 FDG-fluorodeoxyglucose Tracer) |

Answer 335

1. »> SMALL CELL SIADH ACTH LAMBORT_EATON >>2. Squamous CELL PTHr-P Hypercalcemia Clubbing Hypertrophic Pulmonary Osteoarthropathy (HPOA) Ectopic TSH ›3. Adenocarcinoma Gynecomastia HPOA

Answer 336

Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for lung cancer if chest x-ray findings that suggest lung cancer OR aged 40 and over with unexplained hemoptysis

Answer 337

>>Smoking increases risk of lung ca by a factor of 10 >>Asbestos - increases risk of lung ca by a factor of 5 >>Smoking and asbestos are synergistic, i.e. a smoker with asbestos exposure has a 10 * 5 = 50 times increased risk Risk factors mnemonic- CANSAR (rhymes with Cancer) C= Cryptogenic fibrosing alveolitis, chromate A= Asbestos, arsenic N=Nickl S=Smoking A=Aromatic Hydrocarbons R=Radon

Answer 338

*An acronym for Amine Precursor Uptake Decarboxylase

Answer 339

SCLC >>worse prognosis Non-SCLC l)Adenocarcinoma >> most common overall and in non-smoker Il) Squamous >> most common cancer in smokers Il) Large cell IV)Alveolar >> not related to smoking V) bronchial adenoma >>carcinoid

Answer 340

Epworth Sleepiness Scale OR Multiple Sleep Latency Test (MSLT) Diagnostic Test: sleep studies (polysomnography)

Answer 341

Type 1 -V/Q mismatch -hypoxic >>>low Pao2 -PE, Pulm.Edema, Pneumonia, atelectasis

Answer 342

Type 2 -Alveolar hypoventilation - Hypercapnic >>low pa02, high pCO2 - Asthma -COPD -Low respiratory effort (opioids, morbid obesity, neuromuscular disorders etc)

Answer 343

1. Cavitation: Bilateral_Staph. Aureus Upper lobe_Klebsiella 2. Consolidation: Bilateral patchy_Mycoplasma Bibasal_ Legionella Unilateral lobar_ Strept.Pneumo 3. Shadowing: Peri-hilar_ Carinii Diffuse Extrinsic allergic alveolitis

Answer 344

-B-blockers -Aspirin -Nsaids

Answer 345

Investigation: CXR-PA view Contrast CT>> to investigate underlying cause USG guided pleural aspiration Diagnostic pleural aspirate: Protein >30 Exudative Protein<30 Transudative Protein 25-35 use lights criteria Lights Criteria: Protein Ratio LDH Ratio Serum LDH >0.5 >0.6 >2/3rd of UL of normal Serum LDH When Chest Tube? if Purulent/Cloudy/turbid = Chest Tube If clear but pH <7.2 = Chest Tube if Empyema= Chest tube + IV antibiotics Treatment: -Opioids for pain - Recurrent aspiration for recurrent PE -Pleurodesis for recurrent PE -Indwelling catheter

Answer 346

CURB-65 0-1 Home based care - low risk 2 or more admit for oral/IV antibiotics-Intermediate risk 3 or more consider ICU - high risk Rx: Amoxicillin if low risk, Macrolide/doxy if pen allergy Amoxicillin+ Macrolide in intermediate risk co-amoxiclav/ceftriaxone/pip Tazo + Macrolide in high risk Repeat chest X-ray at 6 weeks after clinical resolution to ensure that the consolidation has resolved.

Answer 347

CRP < 20 mg/L - do not routinely offer antibiotic therapy CRP 20 - 100 mg/L - consider a delayed antibiotic prescription CRP > 100 mg/L - offer antibiotic therapy

Answer 348

-B-blockers -Aspirin -Nsaids

Answer 349

NRT: to reduce withdrawal symptoms side effects include nausea vomiting headache and flulike symptoms Varenicline: Partial agonist at Nicotine receptors start 1 week before the target stop date of smoking 12 weeks course Side effects: nausea, headache, insomnia, abnormal dreams Cl: Pregnancy and breastfeeding Use with caution in depression and those with hx of self-harm bez it increases suicidal risk Unlicensed form available in UK (supply issue) Bupropion: NE and Dopa reuptake inhibitors 1-2 weeks before the target stop date CI; pregnancy, breastfeeding, epilepsy relatively Cl in eating disorders

Answer 350

1. if currently smoking OR 2.stopped smoking <2 weeks ago OR 3.CO reading =>7ppm refer to NHS stop smoking services 1. First line is non-pharmacological intervention CBT or Motivational interviewing or structured self-help and support). 2. if that doesn't work then nicotine patch applied during the day time and removed at night.

Answer 351

If Minimal or no symptoms (no significant chest pain, SOB or physiological abnormalities) >>>1. Conservative management regardless of size (watch and wait) 2. Primary spontaneous > review in OPD every 2-4 days 3. Secondary spontaneous >>Inpatient monitoring 4. Once stable >> review in OPD every 2-4 weeks if Symptomatic then next step is to determine high risk features if high risk features absent then -Conservative OR -Ambulatory device Or -Needle aspiration if high risk features present then -Chest tube

Answer 352

1.stop smoking 2,avoid flying for 2 weeks 3.avoid scuba diving permanently unless B/L surgical pleurectomy done.

Answer 353

-Hemodynamics compromise (suggesting a tension pneumothorax) -Significant hypoxia -Bilateral pneumothorax -Underlying lung disease - >50 years of age with significant smoking history -Hemothorax

Answer 354

if persistent air leak or failure of lung re-expansion after chest tube insertion or recurrent pneumothorax then VATS to allow mechanical or chemical; pleurodesis +/- bullectomy. Discharge advice: stop smoking avoid flying for 2 weeks avoid scuba diving permanently unless B/L surgical pleurectomy done.

Answer 355

C=crush, coma, collapse M=Mcardle (glycogen storage disease) E=Ecstasy S=Seizure S=Statins

Answer 356

-Nephritic syndrome - subepithelial 'humps' caused by lumpy immune complex deposits on electron microscopy. Put the STEP (STREP) carefully because there 'humps.

Answer 357

-nsaids -Rifampicin -Hodgkin lymphoma -thymoma -infectious mononucleosis

Answer 358

Long Hx of Frequency, urgency, suprapubic pain and tenderness >>>MSU culture negative »>. cystoscopy >>> Hunner ulcer Rx: 1st line >>bladder training and pelvic floor relaxation 2nd line>>. amitriptyline, gabapentin

Answer 359

K <2.5 IV KCL K>2.5 oral K supplements K <3 + ecg changes "U wave" IV KCL

Answer 360

1. sever >6.5 or ecg changes -IV CaCl or CaGluonate(10%) x 10ml| -IV Insulin (rapid-acting) 10 U in 50ml of 50% dextrose -Nebulized Salbutamol 5 mg -Furosemide IV 40-80mg -Kayexalate 30g rectally -Calcium resonium 15g qds PO, 30g rectally -Hemodialysis if persistent 2. if K+ >6 stop offending drugs e-g ACEI/ARBs low K diet

Answer 361

Tx: -Iv fluids -Blood Transfusion -Hemodialysis -Eculizumab (remember E-Coli-zumab) -Plasma exchange

Answer 362

Central causes: -- DIPCI D= DIDMOAD |=Infiltrative (Hemochromatosis, sacrcoidosis,histocytosis) P=Pituitary surgery, Post head trauma C=Craniopharyngioma |=|diopathic

Answer 363

Nephrogenic Causes: Gelitine G=Genetic (Aqp-2, ADH-receptors) E=electrolytes (Hypokalemia, Hypercalcemia) | Li=Lithium T=tubulointerstitial disease Ine=Demeclocycline

Answer 364

Ix: -water deprivation test Rx: NDI: - low salt/low protein diet first line -Thiazide 2nd line CDI: -Desmopressin Complications of DI include dehydration and seizures

Answer 365

-First line ACEI/ARBs -U&E should be checked before starting and after each dose change in ACEI/ARBs - A rise in creatinine of <30% or a fall in eGFR of <25% is normal after starting ACEI/ARBs -Furosemide can be used when eGFR is 30-45 ml/min|

Answer 366

CAGE Creatinine Age Gender Ethnicity Treatment: -Lifestyle low protein, Na, K, P -HTN >> ACEI/ARBs -Phosphate binders e-g sevelamer -Ca+ and Vit D supplement -Iron + Epo - Statins (primary prophylaxis of CVS disease) -Glucose control -Dialysis -Transplant

Answer 367

NARMAL — G= (Normal gap or Hyperchloremic) N - Normal anion gap, A -Acetazolamide, R- Renal tubular acidosis, M -aMmonium chloride injections, A -Addison disease L-loss of HCO3 from gut MUDPILES = (High Anion Gap) M- Methanol U- Uremia D- DKA P- Paracetamol I- INH, Iron, Isopropyl alcohol (antiseptic) L- Lactic acidosis E- Ethanol, Ethylene glycol (antifreeze in car batteries) S- Salicylates

Answer 368

MUDPILES = (High Anion Gap) M- Methanol U- Uremia D- DKA P- Paracetamol I- INH, Iron, Isopropyl alcohol (antiseptic) L- Lactic acidosis E- Ethanol, Ethylene glycol (antifreeze in car batteries) S- Salicylates

Answer 369

NARMAL — G= (Normal gap or Hyperchloremic) N - Normal anion gap, A -Acetazolamide, R- Renal tubular acidosis, M -aMmonium chloride injections, A -Addison disease L-loss of HCO3 from gut

Answer 370

X-linked dominant >>defect in gene for Collagen 4 it's like being on a plane (Alport, similar to airport) - > wearing the eye mask so you can't see ->the toilet is always crowded so you can't pee > and you've got them ear plugs in while you sleep SNHL -on EM thickening of GBM and splitting of lamina densa

Answer 371

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 Rx: Tolvaptan (Vasopressin V2 antagonist)

Answer 372

-Renal Transplant -AKI with ITU admission -AKI with no known cause -AKI with no response to Tx -AKI with complications -AKI stage 3 -CKD stage 4 or 5 -Vasculitis/GMN/TIN/Myeloma - Renal replacement therapy indicated (AEIOU)

Answer 373

223. ACUTE KIDNEY INJURY Pre-renal Renal Post-renal Ix: -U&E -U/A| -Renal US

Answer 374

Diagnostic Criteria: >> A rise in creatinine of 26 Umol/L or more within 48H >>A rise in creatinine of 50% or more in 7 days >>A reduction in UOP of <0.5ml/kg/Hr for more than 6 hours in adults (>8 hours in children) >>a fall in eGFR of 25% or more in 7 days in CHILDREN. AKI staging (KDIGO Criteria): Stage 1= A rise in creatinine 1.5-1.9 times of baseline OR a decrease in UOP of <0.5ml/kg/hr for =>6hours. Stage 2= A rise in creatinine 2-2.9 times of baselines OR a decrease in UOP of <0.5ml/kg/hr for =>12 hours. Stage 3= A rise in creatinine =>3 times of baselines OR a decrease in UOP of <0.3ml/kg/hr for =>24 hours Management: -maintain fluid balance (fluid challenge if pre-renal) -Stop DAAMN Drugs -Manage electrolytes esp. K+ -BP Mx -Hemodialysis if AEIOU

Answer 375

PAIN P= 6 P's, penicillin, Pain-killers (NSAIDS), Pee (furosemide), PPI, RifamPicine, AlloPurinol A= Autoimmune (sle, sarcoidosis, Sjogren) | I=Infections (viral, bacterial, fungal) N=Neoplasm (leukemia, lymphoma)

Answer 376

Investigation: -First line is barium swallow (to see where exactly the obstruction is) | -Followed by Endoscopy esp. if alarm features to exclude Cancer -Gold standard is manometry

Answer 377

Wilson's disease Viral hepatitis (usually A or B) Autoimmune Hepatitis, Acute fatty liver of pregnancy Paracetamol overdose Ethanol (alcohol) Budd-Chiari

Answer 378

Management: -ABCDE| -Two wide bore IV canula (16G) -Take blood for tests, grouping and matching -Start IV fluids and arrange 6 units of O-ve blood -If Variceal bleed suspected >> Terlipressin and prophylactic antibiotics

Answer 379

-If Hb <70 give blood transfusion -If active bleeding and Platelets <50K, give Platelet transfusion -If Fibrinogen <1 g/L or PT/APTT >1.5 times normal then give FFP -If active bleeding on warfarin, give PCC+ Vit K -Once stable, ENDOSCOPY -If non-variceal bleed on endoscopy, give IV PPI -if Variceal bleed >> band ligation for esophageal varices and N-butyl -2-cyanoacrylate in gastric varies -If still bleeding after endoscopy, repeat endoscopy or interventional radiology and surgery. -TIPS for Variceal bleed if above fails - Use Rockall Score after Endoscopy >> it tells percentage risk of rebleeding and mortality after endoscopy.

Answer 380

-Beer (3 different types; lager, cider, bitter) ordinary strength (1 Pint) = 2 U stronger strength (1 Pint) = 3 U -Wine (9% ABV in standard, 12% ABV in red/white) 1 small glass of wine (125ml) = 1 U 1 glass of red/white wine (175ml) = 2 U -Vodka, Whisky, Tequila, Spirit (40% ABV) 1 shot (25ml) = 1 U 1 bottle of vodka = 32 U

Answer 381

AST/ALT ratio >2 is suggestive of AH. Treatment: -Glucocorticoids (prednisone) if Maddrey's DF value is =>32. (Maddrey's discriminatory function is a prognostic tool used to assess the prognosis and severity of alcoholic hepatitis and determine the need for Corticosteroid Tx-It is Measured using PT and Bilirubin values) -Pentoxyphyline (poor evidence base) (anti-inflammatory action by inhibition of TNF-a and fibroblast proliferation)

Answer 382

Mnemonic: Mesalazine is A PIG, Sulfasalazine is SLAMI (sulfasalazine is a derivative of mesalazine just like slami is made from pig) A= Agranulocytosis P=Pancreatitis |=Interstitial nephritis G=GI upset S=Steven Johnson syndrome L=Lung fibrosis A=Aspermia/oligospermia M=Megaloblastic anemia, Heinz body anemia I=invalid (nothing ©)

Answer 383

SAAG >1.1g/L Acute Liver failure/ cirrhosis Mets RHF Cons.Pericarditis PV thrombosis Budd Chiari Myxoedema

Answer 384

Hypoalbuminemia TB Cancer pancreatitis biliary ascites bowel obstruction Serositis (SLE)

Answer 385

Management: -Low sodium diet -Fluid restriction if Na+ < 125 -Spironolactone +/- Furosemide -Therapeutic abdominal paracentesis with albumin cover -Prophylactic ciproflaxin or norfloxacin to prevent SBP if ascitic protein =<15g -TIPS

Answer 386

Risk factors: SMOG S=Smoking M=Male (7:1) O=Obesity G=GERD Managment: -Metaplasia is managed by High dose PPI + Lifestyle + Increased surveillance -If short segment metaplasia >>Endoscopy every 3-5 years -If long segment>> endoscopy every 2-3 years -Low grade dysplasia -confirm by repeat endoscopy and biopsy after 6 months (two endoscopies, Biopsies examined by two different pathologists) - radiofrequency ablation, followed by surveillance endoscopy every 6 months for 1 year then annually thereafter.

Answer 387

-High grade dysplasia - Endoscopic resection followed by any residual ablation on subsequent endoscopy - surveillance endoscopy every 3 months for 1 st year then every 6 months for 2nd year then annually thereafter.

Answer 388

Causes: -Primary (Inc. Bile acid production) -Coelic, Crohn's, ileal resection, SIBO, cholecystectomy Ix: SeHCAT- nuclear medicine test Rx: Cholestyramine

Answer 389

-Polycythemia (PRV) -Pregnancy -Pills (cocp)| -Procoagulant state (deficiency of protein C, S, ATIll)

Answer 390

Presentation Abd. Pain sudden sever Abd. Distension >> ascites Tender hepatomegaly Ix: Doppler US Treatment: -LMWH followed by warfarin -TIPS (in refractory ascites/variceal bleed) or PTA-percutaneous transluminal angioplasty (in segmental HVT) -Surgery >> portocaval or mesoatrial shunt

Answer 391

Becks Triade= Hypotension, distended jugular veins, muffled heart sounds PEKY P=Pulsus paradoxus E= Electrical alternans K= Kussmaul sign (more commonly ass with constrictive pericarditis) Y= Y-descent absent

Answer 392

Ix: -Urinary 5 HIAA -plasma chromogranin A y Treatment: -Somatostatin analogue >> OCTREOTIDE >> Blocks serotonin release -Cyproheptadine (antihistamine which blocks serotonin 5-HT2 receptor and relieves symptoms)

Answer 393

Treatment: First Episode -First line is oral vancomycin -2nd line is fidaxomicin -3rd line is high dose oral vancomycin +/- IV Metro

Answer 394

Recurrent infection -First line for reinfection within 12 weeks of resolution is fidaxomicin Reinfection after 12 weeks of symptom resolution >> Vancomycin or fidaxomicin Severe life threatening: (Hypotension, Toxic megacolon, ileus, CT-evidence of severe disease) -Oral vancomycin + IV metronidazole -Seek specialist opinion, surgery might be needed Other Rx options are -bezlotoxumab >> not cost effective and doesn't prevent recurrences -fecal microbiota transplant if =>2 previous episodes ISOLATION UNTILL 48 Hours AFTER DIARRHEA STOPS.

Answer 395

251. Coagulopathy of liver disease Il the clotting factors are low except factor VIll which is released by endothelial cells int lood and cleared by liver from the bloor Elevated factor VIll + decreased anticoagulant factor production by liver like protein C, S and ATIll leads to a paradoxical increased risk of thrombosis. So, in liver disease PT/APTT elevated but there is risk of both bleeding and thrombosis.

Answer 396

Type 1>ANA /SMA, children and adults Type 2> LKM1A, children Type 3 > soluble liver-kidney antigen, middle age adults Presentation -CLD -Acute hepatitis fever, jaundice, anorexia, tender hepatomegaly -Amenorrhea is common Ix: -ANA/SMA/LKM1A is present -LFT -elevated IgG levels RX: -Steroids and immunosuppressants -Liver transplant

Answer 397

Clinchers: -villous atrophy -crypt hyperplasia -intraepithelial lymphocytosis Investigations: -first line TTG IgA - If negative and still suspecting >> EM(endomysial) IgA or DGP (deamidated Gliadin peptide) lgA or IgG - if IgA deficient (TTG IgG and DGP IgG) - Endoscopy and Biopsy (reintroduce gluten 6 weeks before endoscopy) Treatment: -gluten free diet -management of any complication

Answer 398

Complications: complications can be remembered with A HOLES: Anemia, Hyposplenism, Osteomalacia / osteoporosis, Lactose intolerance, Enteropathy associated T cell lymphoma, Subfertility

Answer 399

254. Colorectal Cancer Genetics sporadic >>APC gene -HNPCC (lynch Syndrome>> DNA mismatch repair genes >>MSH2, MLH1) - FAP >>APC gene Amsterdam Criteria for HNPCC -3 family members with CRC -2 generation affected -1 case <50 yr old

Answer 400

F-FAP O-Osseous tumors R-Retinal pigmentation E-Epidermoid cysts S-Skull and mandibula tumors (repeat of O) T-Thyroid carcinoma

Answer 401

Associated with Episcleritis and ankylosing spondylitis >> Inc. Risk of small bowel cancer >>Smoking worsens the disease

Answer 402

Continuous, lead pipe on imaging , crypt abscess, no granuloma, superficial ulcers , psuedopolyps Associated with uveitis and PSC >>Increased risk of CRC >> smoking is protective

Answer 403

Investigations: -ESR, CRP and routine blood -Fecal calprotectin -X-ray and barium enema -MRI for perianal fistula -ASCA for Crohn's -P-ANCA for UC -Colonoscopy with ileoscopy -capsule endoscopy

Answer 404

Remission induction: -First line glucocorticoids -2nd line 5-ASA -Azathioprine/6-MP added to steroids or 5-ASA methotrexate is alternative. -Infliximab for refractory Crohn's and perianal disease -Oral metronidazole for isolated perianal disease

Answer 405

-First line Azathioprine/6-MP (check TPMT levels before starting) -Methotrexate 2nd line

Answer 406

-MRI to diagnose -Symptomatic perianal fistula >>oral metronidazole or ciprofloxacin - Infliximab assists closure and maintenance of closure -Fistulotomy for simple (low fistula) -Seton suture for complex (high fistula)

Answer 407

Perianal Abscess: -I & D and Antibiotics

Answer 408

Surgery in Crohn's: -Ileocaecal resection -Small segmental resection -Sricturoplasty

Answer 409

-Mild <4 stools/day, small amount of blood -Moderate 4-6 stools/day ,varibale amount of blood, no systemic upset -severe >6 bloody stools, systemic upset present

Answer 410

REMISSION INDUCTION: MILD-MODERATE PROCTITIS: -Rectal ASA -if no response in 4 weeks, oral ASA -if no response, topical or oral steroids PROCTOSIGMOIDOITIS, LEFT SIDED COLITIS: -Rectal ASA -if no response either add oral ASA or switch to oral ASA+ Topical Steroids -if no response oral ASA + oral steroids EXTENSIVE COLITIS: -Rectal ASA + oral ASA -if no response, High dose oral ASA + oral steroids

Answer 411

MAINTAINENCE TREATMENT; MILD_MODERATE: PROCTITIS AND PROCTOSIGMOIDITIS: -Rectal ASA alone OR -Rectal +oral ASA OR -Oral ASA alone LEFT-SIDED AND EXTENSIVE COLITIS: -Low dose oral ASA

Answer 412

SEVERE COLITIS: -IV Steroids -if no response in 72 hours, consider adding IV ciclosporin or Infliximab

Answer 413

SEVERE COLITIS OR 22 episodes in year -Azathioprine/6-MP first line -Methotrexate (2nd line)

Answer 414

SURGERY in UC: - Left Hemicolectomy OR -Proctocolectomy depending on extent of disease.

Answer 415

Hepatocellular picture means Significantly elevated AST and ALTs, normal or slightly raised ALP, PT decreased Albumin decreased Cholestatic Picture means disproportionately elevated ALP compared to AST, ALT PT and Albumin maybe abnormal

Answer 416

P- Paracetamol H- Halothane A- Alcohol N- Nitrofurantoin T- TB drugs - isoniazid, rifampicin, pyrazinamide A- Amiodarone S- Sodium valproate M- MAOls/Methyldopa S- Statins

Answer 417

For Cholestasis - FACTS F- Fibrates/F(ph)enothiazines A- Abx (Flucloxacillin, Co-Amoxiclav, Erythro) C-COCP T- Testosterones S- Steroids/Sulphonylureas Liver cirrhosis: Methotrexate Methyldopa aMiodarone

Answer 418

URGENT REFERRAL: -dysphagia -Upper abdominal mass consistent with stomach Ca. -Aged =>55 year + Weight loss + One of the following; either upper abdominal pain or reflux or dyspepsia

Answer 419

Dyspepsia Mx: -Review medications -Lifestyle -Trial of PPI for 1 month OR Test and Treat for Pylori -Pylori test include C-13 Urea breath test OR Stool antigen OR serology for initial diagnosis. -Triple therapy for 2 weeks - Repeat test usually non needed if symptoms resolved -if Repeat test needed >>do C-13 Urea breath test