OCHM Flashcards
1
Q
Inverted P waves in the inferior leads are associated with what?
A
Retrograde atrial conduction
This is common in junctional tachycardias (atria are contracting from the AV rather than SA node)
2
Q
Digoxin toxicity can be caused by which drugs and conditions?
A
Chronic cardiac failure
hypothyroidism
Amiodarone, verapamil, and quinidine
(digoxin dose should be reduced if any of the above drugs are started).
3
Q
Name some thiazide-like diuretics
A
Indapamide or chlortalidone
4
Q
When can’t you use CCBs in hypertension?
A
Heart failure
presence of oedema etc
5
Q
What is the treatment for hypertension in diabetes
A
SIGN guidelines aim for a systolic of less than 130 and a diastolic of less than 80 in diabetic patients. ACE inhibitors have been consistently found to significantly reduce complications in hypertensive patients with diabetes, particularly renal complications.
First line treatment for hypertension in diabetic patients is an ACE inhibitor in everyone except:
Women with child bearing potential: calcium channel blocker
Black patients: ACE inhibitor + calcium channel blocker
6
Q
If a supraventricular tachycardia is treated by carotid sinus massage, the Valsalva manoeuvre, or adenosine what does this tell you about its nature?
A
Narrow complex tachycardias originate from within the atria or the AV node.
- atrial fibrilation
- sinus tachycardia
- supraventricular tachycardia (atrial tachycardia, AVNRT, AVRT)
Carotid sinus massage, Valsalva manoeuvre, and adenosine transiently block the AV node. So if they work its most likely AVNRT (which most of the time it is).
7
Q
What causes a loud S1?
A
Mitral stenosis
Because the narrowed valve orifice limits ventricular filling, there is no gradual decrease in flow towards the end of systole, and so shut rapidly leading to a loud S1 (the “tapping apex)
NB: S1 is also loud if the diastolic filling time is shortened (short PR interval or tachycardia)
8
Q
What is the cause of a soft S1?
A
Prolonged PR interval or mitral incompetence
this prolonges the diastolic filling time
9
Q
Junctional tachycardias (AVRT or AVNRTs) common see what abnormality to P waves?
A
Inverted P waves (particularly in inferior leads II, III, and aVF) as the rhythm is set by the AV node and spread retrogradely through the atria from AV to SA.
10
Q
What does the right coronary artery supply in the heart?
A
The RCA supplies blood to the right ventricle and 23-35% of the blood to the left ventricle
In 90% of people, it supplies the AV node, in 60% the SA node, and in 85% of people it gives off the PDA, which supplies the inferior wall, ventricular septum, and posteromedial papillary muscle
11
Q
What is the most important thing to determine when reviewing someone with palpitations?
A
Whether they are shocked or not
12
Q
Which type of angina is exercise ECG used for?
A
Stable angina
Contraindicated in unstable.
13
Q
An anacrotic pulse indicates what?
A
Aortic stenosis
this is a slow rising pulse
14
Q
A bisiferens pulse indicates what?
A
Mixed aortic stenosis and aortic regurgitation
15
Q
A jerky pulse indicates what?
A
HOCM
16
Q
When is corneal arcus pathological?
A
In those under 60
(those over 60 its a normal finding)
Need to check renal, liver, and thyroid function to determine the cause of hyperlipidaemia before just assuming its because of poor lifestyle factors
17
Q
How do you diagnose Lone AF?
A
In patients under 65 and CHADSVASC of 0 perform an echocardiogram (So score 0 on for all risk factors)
This confirms if a structurally normal heart is present
If it is then you don’t need any antithrombotic therapy
18
Q
How does the mechanism of action of dabigatran differ to other DOACs?
A
Dibigatran = Direct inhibitor of thrombin
Rivaroxaban and apixaban = direct inhibitor of factor Xa
19
Q
In complete heart block what needs to be determined prior to treatment?
A
Width of the QRS
Tells you if escape rhythm is above or below bundle of his
Narrow and pulse 45-60 = usually haemodynamically stable and may respond to atropine
Wide and pulse <45 = usually haemodynamically unstable and more likely to need emergency pacing.
20
Q
Explain the role of furosemide in transfusions
A
Given in large transfusions as 10-40mg IV with alternate units to prevent TACO.
21
Q
What is Kussmaul’s sign?
A
A rise in JVP with inspiration
(Inspiration increases venous return however when you restrict this (pericardial effusion etc) the blood will back up causing a rise in JVP)
22
Q
What criteria do patients have to meet to be offered pill in the pocket therapy?
A
There is no history of left ventricular dysfunction, or valvular or ischaemic heart disease
There are infrequent symptomatic episodes of paroxysmal AF
Systolic BP >100mmHg and resting HR >70bpm
Patients can understand how and when to take the medication
23
Q
If patients arent suitable to Fleicanide for paroxysmal AF what are your alternatives?
A
Metoprolol (or other standard B-blocker) would be the first choice alternative
Sotalol would be next if suppression of symptoms has not been achieved
Amiodarone can be used if B-blockers have been unable to suppress paroxysms in those with poor left ventricular function.
24
Q
After a central venous pressure line is inserted an X-ray should be ordered to check the line.
What 2 features should you look for safe placement of the line?
A
There is no pneumothorax from the procedure
The tip is between the first and third sternocostal joints
25
What are Stokes-Adams attacks?
What is the treatment?
Transient bradycardias due to lack of conduction through the atrioventricular node causing decreased cardiac output and loss of consciousness
Emergency treatment involves continuous cardiac monitoring and transcutaneous pacing with the view to the placement of a definitive transvenous pacemaker, even if the patient is asymptomatic.
26
What constitutes a long QT interval?
QTc >420ms
27
How do you manage a hypertensive emergency?
Severe hypertension with end-organ damage
The aim is to stop ongoing damage.
IV labetalol with the aim of reducing the diastolic blood pressure by 10-15%
(if there is no evidence of end organ damage (encephalopathy, acute pulmonary oedema, acute MI, acute renal failure etc) then you can lower BP over a couple of days with oral therapy
28
What are the diagnostic criteria for SLE?
Diagnosis if 4 or more out of the following 11:
-Malar rash
- Discoid rash (ears, cheeks, scalp, forehead, chest)
- ---3 stage rash (erythema -> pigmented hyperkeratotic oedematous papules -> atrophic depressed lesions)
- Photosensitivity
- Oral ulcers (usually painless)
- Non-erosive arthritis
- ----Involving 2 or more peripheral joints (like RA)
- ----A reversible deforming arthropathy may occur due to capsular laxity (Jaccoud's arthropathy)
-Serositis (Pleuritis or pericarditis)
- Renal disorder
- ---Persistent proteinuria or cellular casts
-CNS disorder (seizures or psychosis)
- Haematological disorder
- --- Haemolytic anaemia w/ reticulocytosis, Leukopenia, Lymphopenia, Thrombocytopenia
- Immunological disorder
- --- Anti-dsDNA, Anti-Sm or Anti-phospholipid
-Antinuclear antibody (ANA)
29
When can you drive after an episode of loss of consciousness (syncope)?
Full investigation should be carried out to:
- find a cause
- risk stratify
Dont drive for 4 weeks if:
- No cause found but low risk
- High risk but cause found and treated
Don't drive for 6 months if:
-no cause found and high risk
30
When do you consider cardiac resynchronization therapy in heart failure?
If symptoms persist or even worsen, despite optimal medical therapy
There are various inclusion criteria including the left ventricular ejection fraction and the width of the QRS complex.
(Cardiac resynchronisation therapy is essentially a biventricular pacemaker which coordinates the action of the right and left ventricles)
31
When do you use aldosterone antagonists (spironolactone for heart failure)?
Moderate to severe heart failure (after you have tried B-blocker and ACEi)
Those who have suffered an MI within the last month.
(caution in those with K+ >4.5)
32
What are the signs that a tachycardic patient is unstable?
What do you need to do with these patients?
Chest pain
Signs of heart failure
Reduced conscious level
Systolic BP <90mmHg
This should prompt urgent electrical cardioversion under sedation or GA (forget about the rest of the pathway!)
Give 3 shocks
300mg IV amiodarone
Repeat shock
900mg amiodarone over 24hrs
33
What is the immediate management of a regular (rhythm) supraventricular tachycardia?
Carotid massage and vagal maneuvres
Adenosine 6mg IV
Adenosine 12mg IV
Adenosine 12mg IV
Seek expert help
(If the above hasn't worked its not AV node and probably atrial flutter -> B-blockers)
34
What is the immediate management of an irregular supraventricular tachycardia?
Probable AF
Control rate with B-blocker or diltiazem (asthmatic)
If in heart failure consider (amiodarone or digoxin)
Assess thromboembolic risk and consider anticoagulation
35
How do you treat a broad complex tachycardia?
Regular rhythm
- If VT or unknown rhythm
- ---Amiodarone 300mg IV over 20-60 mins then 900mg over 24hrs
- If known to be SVT with bundle branch block
- ---Treat as regular narrow complex tachycardia
Irregular rhythm
-SEEK EXPERT HELP
36
What are the legally required things to include in any documentation in patient notes?
Write name and designation and sign with bleep number
Write time and date of review
Write reason for review and who was present
37
If treatment of a pneumonia is not proving adequate what investigation needs to be done?
Re-image the chest with CXR
38
Any patient admitted with acute asthma should have what done before they leave?
BTS guidelines: "no patient should leave hospital without an up to date written personalised action plan"
This should include review of when and how to use inhalers
Any admission should also be followed up by an asthma specialist within 30 days
39
What is the initial management of acute severe asthma in adults?
Oxygen to maintain SpO2 94-98%
Salbutamol 5mg via an oxygen driven nebuliser
(5mg every hour)
Prednisolone tablets 40-50mg or IV hydrocortisone 100mg
CXR if pneumothorax or consolidation are suspected or patient requires mechanical ventilation
If life-threatening features:
- ICU
- Consider IV magnesium sulphate 1.2-2g infusion over 20 mins (unless already given)
- Give neb B2 agonist more frequently 15-30mins)
40
When can you discharge patients home after an acute asthma attack?
No single physiological parameter defines absolutely the timing of discharge from an admission with acute asthma.
Should be "stable" on their regular asthma therapy for 24hrs prior to discharge home
Peak flow readings should be up to >75% of predicted or best
41
When may asthmatics need to stay in hospital a bit longer after an acute attack?
May need to stay longer if:
- Significant symptoms
- Concerns about compliance
- Lives alone or socially isolated
- Psychological problems, physical or learning disability
- Previous history or near fatal or brittle asthma
- Exacerbation despite oral steroid therapy pre-presentation
- Presented at night
- Pregnant
42
What are the signs or worsening asthma control?
Patient feeling it is less controlled
History of waking at night with wheeze, cough, or chest pain
Increased use of bronchodilator therapy
Decreased effectiveness of bronchodilator therapy
Work days missed through asthma
Any change in exercise tolerance
43
What are the asthma management guidelines for adults?
Add short-acting beta 2 agonist inhaler (e.g. salbutamol) as required for infrequent wheezy episodes.
Add a regular low dose corticosteroid inhaler.
Add LABA inhaler (e.g. salmeterol). Continue the LABA only if the patient has a good response.
Consider a trial of an oral leukotriene receptor antagonist (i.e. montelukast), oral beta 2 agonist (i.e. oral salbutamol), oral theophylline or an inhaled LAMA (i.e. tiotropium).
Titrate inhaled corticosteroid up to “high dose”. Combine additional treatments from step 4. Refer to specialist.
Add oral steroids at the lowest dose possible to achieve good control.
44
What is the treatment of chronic asthma <5?
Add short-acting B2 agonist inhaler (e.g. salbutamol) PRN
Add corticosteriod inhaler (200-400mcg/day) or leukotriene antagonist (i.e. montelukast)
Add the other option from step 2.
Refer to paediatric respiratory specialist
45
What is the treatment of chronic asthma 5-12?
Add short-acting B2 agonist inhaler (e.g. salbutamol) PRN
Add corticosteriod inhaler (200-400mcg/day).
Add long-acting B2 agonist inhaler (e.g. salmeterol).
Continue salmeterol only if the patient has a good response. Titrate the corticosteriod inhaler up to 400mcg as needed. Consider adding leukotriene antagonist (i.e. montelukast) or modified release theophylline
Increase inhaled corticosteroid up to 800mcg/day as needed.
Referral to specialist. May require daily steroid tablets.
46
What is the definition of an asthma attack?
"Worsening cough, chest pain, breathlessness, or wheeze not relieved by a B2 agonist, resulting in breathlessness impairing speech, eating or sleep"
47
What are the criteria for starting BiPAP (NIV)?
What are the contraindications?
Respiratory acidosis (pH < 7.35 AND PaCO2 >6) despite adequate medical treatment.
The main contraindications are an untreated pneumothorax or any structural abnormality or pathology affecting the face, airway or GI tract.
Patients should have a chest xray prior to NIV to exclude pneumothorax where this does not cause a delay.
A plan should be in place in case the NIV fails so that everyone agrees whether the patient should proceed to intubuation and ventilation and ICU or whether palliative care is more appropriate.
48
What is the management of a pneumothorax?
If no SOB and there is a < 2cm rim of air on the chest xray then no treatment required as it will spontaneously resolve. Follow up in 2-4 weeks is recommended.
If SOB and/or there is a > 2cm rim of air on the chest xray then it will require aspiration and reassessment.
If aspiration fails twice it will require a chest drain.
Unstable patients or bilateral or secondary pneumothoraces generally require a chest drain.
49
What are the paraneoplastic features of small cell lung cancer?
ADH
ACTH - not typical, hypertension, hyperglycaemia, hypokalaemia, alkalosis and muscle weakness are more common than buffalo hump etc
Lambert-Eaton syndrome
SIADH
50
What are the paraneoplastic features of squamous cell lung cancer?
Parathyroid hormone-related protein (PTH-rp) secretion causing hypercalcaemia
Clubbing
Hypertrophic pulmonary osteoarthropathy (HPOA)
Hyperthyroidism due to ectopic TSH
51
What are the paraneoplastic features of adenocarcinoma?
Gynaecomastia
Hypertrophic pulmonary osteoarthropathy (HPOA)
52
What is the likely cause of low sats and low resp rate?
Need to check pupils
Opioids etc can cause respiratory depression
Shouldn't have low sats and low resp rate without something like this causing respiratory depression
53
When do you need to wean patients off a steroid course?
Patients who have had a course of steroids shorter than 3 weeks and of doses <40mg do not need gradual weaning, unless they have a history of repeated steroid use or previous adrenal suppression.
54
What is the criteria for Well's score PE?
Clinical signs and symptoms of DVT = 3
PE is most likely diagnosis = 3
HR >100 = 1.5
Immobilisation for 3 days or surgery in last 4 months = 1.5
Previously diagnosed PE/DVT = 1.5
Haemoptysis = 1
Malignancy w/ treatment w/in last 6 months or palliative = 1
(In general if HR <100 and RR <20 then probably another cause of chest pain and haemoptysis)
(0-4 points = D-dimer, >4 = CTPA)
55
What COPD treatment is a particular risk for toxicity?
Theophyllines (e.g. Aminophylline)
Aminophylline toxicity can occur due to its narrow therapeutic range
Look out for antibiotics like erythromycin or ciprofloxacin
56
What steps do you take if you have inserted a chest drain but it doesn't appear to be working (e.g. underwater drain is not bubbling or swinging)?
Flush 20ml of saline through the drain
- Maybe blocked
Consult resp physician about putting the drain on high volume/low-pressure suction
Remove the drain and replace with one further into the apex
-Do not advance anything half in and out of someone as you'll just introduce infection
57
How do you convert a steroid dose from prednisolone to hydrocortisone?
Prednisolone is 4 times the strength of hydrocortisone.
58
What is fluid accumulation in the pleural space in the setting of an infection known as?
Parapneumonic effusion
59
How do you determine if a pleural effusion is transudative or exudative?
Protein <25g/L = transudate
Protein >35g/L = exudate
Protein = 25-35 then use Light’s criteria:
- Pleural fluid protein / Serum protein >0.5
- Pleural fluid LDH / Serum LDH >0.6
- Pleural fluid LDH > 2/3 * Serum LDH Upper Limit of Normal
60
What is the treatment for COPD?
Grade severity:
- Stage 1, Mild = FEV1 80% or more predicted
- Stage 2, Moderate = FEV1 50-79% predicted
- Stage 3, Severe = FEV1 30-49% predicted
- Stage 4, V severe = FEV1 <30% predicted
General
-Stop smoking, exercise, nutrition and obesity, influenza and pneumococcal vaccine, pulmonary rehabilitation, palliative care
Mild/Moderate
-Inhaled LAMA (ipratropium) or B2 agonist
Severe
-Combination LABA and corticosteroids (e.g. Symbicort (budesonide and formoterol) or tiotropium)
If remain symptomatic
- Tiotropium + inhaled steroid + LABA
- Refer to specialist
- Consider steroid trial, home nebs, theophylline
61
When should LTOT be considered for COPD?
Clinically stable non-smokers with PaO2 <7.3Pa despite maximum medical treatment
-These values should be stable on two occasions >3 weeks apart
If PaO2 7.3-8.0 AND pulmonary hypertension (e.g. RVH, loud S2), or polycythaemia, or peripheral oedema, or nocturnal hypoxia
O2 can also be prescribed for terminally ill patients
62
What is the treatment for Hyperthyroidism?
First line:
- Carbimazole
- --Usually normal thyroid function in 4-8 weeks
- --Continue to maintain euthyroid function through:
- --------Titration block (adjust level to keep euthyroid)
- --------Block and replace (use levothyroxine too)
- --Can usually stop treatment in 18 months
Second line:
- Propylthiouracil
- --Small risk of severe hepatic reactions (deadly) so Carbimazole preferred
- --Used in a similar way to above
Third line:
- Radioactive iodine
- --Remission can take 6 months and patients can be left hypothyroid afterward and require levothyroxine replacement.
- --There are strict rules where the patient:
- -----Must not be pregnant and are not allowed to get pregnant within 6 months
- -----Must avoid close contact with children and pregnant women for 3 weeks (depending on the dose)
- -----Limit contact with anyone for several days after receiving the dose
Fourth line:
-Surgery
63
What 3 conditions should you always keep adrenal insufficiency (addison's) on your list?
Anyone on exogenous steroids for long enough to suppress the pituitary adrenal axis (>40mg for >3 weeks)
Patients with overwhelming sepsis
Metastatic cancer
(think of addison's in all with unexplained abdominal pain or vomiting)
64
Addison's is a tricky non-specific diagnosis to make.
What investigation findings can point to it as a possible cause?
Hyponatraemia
Hyperkalamia (differentiates from anorexia etc)
Hypoglycaemia (differentiates from DKA)
Also:
Hypercalcaemia
eosinophilia
anaemia
65
When should sulphonylureas be considered in type 2 diabetes?
Examples: Gliclazide
Consider as first line if:
- The patient is not overweight (BMI <25)
- The patient does not tolerate metformin (or it is contraindicated)
- A quick response to treatment is needed due to hyperglycaemic symptoms
They can be added as a second treatment if sugar control remains suboptimal on metformin alone
66
When should thiazolidinediones be considered in type 2 diabetes?
Examples: Pioglitazone
Can be added as a third-line treatment if control still needs improvement while on metformin and a sulphonylurea
They can also be considered as a second-line agent in place of a sulphonylurea if the patient has particular concerns over hypoglycaemic episodes
Notable Side Effects:
- Weight gain
- Fluid retention (avoid in heart failure)
- Anaemia
- Heart failure
- Extended use may increase the risk of bladder cancer
- Does NOT typically cause hypoglycaemia
67
Name 2 GLP-1 agonists
What do they do?
What are the side effects?
Exenatide and liraglutide
Decrease gastric emptying and increase satiety
-Therefore cause weight loss
Increase insulin secretion
S/Es
- nausea, vomiting, constipation etc
- pancreatitis (stimulate pancreas)
68
Name 2 DPP-4 inhibitors
What do they do?
What are the side effects?
Examples: sitagliptin etc
Gastric emptying decreased and glucagon release increased
S/Es
- similar to GLP-1 agonists
- URTI like symptoms
- --nausea, vomiting, constipation
- --pancreatitis
69
Describe the basic medical management of type 2 diabetes
NICE Guidelines 2015 (updated 2017):
-First line: metformin titrated from initially 500mg once daily as tolerated.
-Second line add: sulfonylurea, pioglitazone, DPP-4 inhibitor or SGLT-2 inhibitor. The decision should be based on individual factors and drug tolerance.
-Third line:
Triple therapy with metformin and two of the second line drugs combined, or;
Metformin plus insulin
SIGN Guidelines 2017 suggest the use of SGLT-2 inhibitors and GLP-1 inhibitors preferentially in patients with cardiovascular disease.
70
A patient is found to have subclinical hypothyroidism.
How do you manage them?
If TSH is greater than 10mU/L and FT4 is within the normal range
-Start treatment (even if asymptomatic) with LT4 if aged 70 years or younger
-In older people (especially those aged over 80 years) follow a 'watch and wait' strategy, generally avoiding hormonal treatment.
If TSH is between 4 and 10 mU/L and FT4 is within the normal range
- In people aged less than 65 years with symptoms suggestive of hypothyroidism, consider a trial of LT4 and assess response to treatment 3–4 months after TSH stabilises within the reference range
- ---If there is no improvement in symptoms, stop LT4.
- In older people (especially those aged over 80 years), follow a 'watch and wait' strategy, generally avoiding hormonal treatment.
- In asymptomatic people, observe and repeat thyroid function tests (TFTs) in 6 months.
71
In all the subclinical hypothyroidism malarky what might it be useful to check?
SCH is common, with 10% of those >55 having a raised TSH.
Maybe useful to check thyroid peroxidase antibodies (this suggests that the patient is at risk of an auto-immune thyroiditis
72
How do you initially manage DKA (the first hour)?
Immediate actions
- Confirm diagnosis (VBG -> pH <7.3, H+ >45, HCO3 <18)
- Check U+Es and laboratory blood glucose
- Check urine and blood ketones
- Confirm patient >16
- Record time of arrival
Management
- 1L NaCl 0.9% over 1hr (within 30 mins of admission)
- Insulin IV 6 units/hour (within 30 mins of admission)
73
When should you call a consultant/ senior clinician in DKA?
Cerebral oedema
- Start IV mannitol 100ml 20% over 20mins OR Dexamethasone 8mg
- CT head to confirm
- Consider ITU
Hypokalaemia on admission
Reduced conscious level
Severe DKA
-pH <7.1 OR HCO3 <5 OR H+ >80
74
What other investigations/ interventions should be considered in a DKA presentation?
Monitoring
-ECG, GCS, Catheter (if oliguric), NG tube (vomiting), central line, DVT prophylaxis
Investigations (what is the cause)
-blood cultures, MSSU, CXR
75
How do you manage DKA after the first hour?
1L Sodium Chloride 0.9% hour 2 + KCL
500mls/hour for hours 3-4 + KCL
Potassium
- Prescribe KCl in 500 ml Sodium Chloride 0.9% bag as:
- ----None if anuric or K+ > 5 mmol/L
- ----10 mmol if level 3.5-5 mmol/L
- ----20 mmol if level <3.5 mmol/L (tick box if measured)
Monitoring
- Check finger prick Blood Glucose hourly
- Lab Glucose, U&Es and HC03 every 2 hours
76
How do you alter DKA management if blood glucose falls <14mmol within the first 4 hours?
Commence Glucose 10% 500mls with 20 mmol KCl at 100ml/hour
Continue Sodium Chloride 0.9% at 400mls/hour + KCL (as per K+ table above) until end of hour 4
Reduce insulin to 3 units/hour
Maintain Blood Glucose >9 mmol/L and ≤14 mmol/L adjusting insulin rate as necessary
If Blood Glucose <9mmol/L adjust insulin to maintain level >9mmol/L and <14mmol/L
77
What drugs can be used in the immediate management of hyperthyroidism to reduce symptoms?
B-blockers (propanolol)
| -If contraindicated then CCB like diltiazem
78
What levels of a raised plasma prolactin will indicate different causes?
Normal >390
1000-5000mU/L may be any cause
>5000 likely due to a prolactinoma
10,000-100,000 due to macroadenoma (>10mm)
79
What is midodrine?
a1 sympathomimetic that causes vasoconstriction and is therefore useful in the treatment of orthostatic hypotension.
80
What is the definition of impaired fasting glucose and impaired glucose tolerance?
A fasting glucose greater than or equal to 6.1 but less than 7.0 mmol/l implies impaired fasting glucose (IFG)
Impaired glucose tolerance (IGT) is defined as fasting plasma glucose less than 7.0 mmol/l and OGTT 2-hour value greater than or equal to 7.8 mmol/l but less than 11.1 mmol/l
Diabetes UK suggests:
'People with IFG should then be offered an oral glucose tolerance test to rule out a diagnosis of diabetes. A result below 11.1 mmol/l but above 7.8 mmol/l indicates that the person doesn't have diabetes but does have IGT.'
81
What is the treatment for addison's patiens who are vomiting/ unwell and risking adrenal crisis?
Hydrocortisone 100mg IM STAT
82
What can cause a pseudo-Cushing's?
False results can be due to enzyme inducers such as phenytoin as they increase the hepatic breakdown of cortisol
Be careful of this before diagnosing someone as Cushing
83
What do you do with metformin when performing IV contrast studies?
Metformin can be continued in patients with normal renal function and no known co-morbidities associated with lactic acidosis until the time of the scan, but should then be withheld for 48hrs
In those with normal renal function but with co-morbidities, a reassessment of renal function prior to restarting the metformin is advised.
In those with pre-existing renal dysfunction, much more cautious reinstitution of the metformin is advised.
84
What skin condition is associated with Addison's disease?
Vitiligo (autoimmune)
85
What are the sick day rules for diabetes?
In general
- Increase frequency of blood tests (2-3 hourly)
- Measure ketones (especially if BM >13-14)
- Drink adequate amounts (200mL/h) of sugar-free fluids to flush out ketones
- If they cannot eat replace meals with 10g carbohydrate every 1-2hrs
- ---100ml coke/fruit juice, 1 scoop ice cream, 200mL milk, 3 glucose tablets
Additional insulin dose will depend on degree of ketonuria
- Trace or small amounts = additional 10% of total daily insulin dose
- Moderate to large ketonuria = 20%
86
What are the clinical of bulbar palsy?
Often slurred speech, nasal regurgitation of food, difficulty chewing, and choking on liquids
Signs include tongue fasciculation and absence of a gag reflex
87
What is oesophageal spasm?
Uncoordinated peristaltic contractions such as the "nutcracker oesophagus" where the distal contractions are of excessive amplitude and cause retrosternal chest pain and intermittent dysphagia
Chest pain and dysphagia during meals is the classic presentation.
88
What should you advise all patients taking bisphosphonates?
The most common reaction to bisphosphonates is irritation, inflammation, or ulceration of the oesophagus.
As a precaution, therefore, they should be taken 30min before food (usually breakfast) and the patient should not lie down for at least 30min after taking the medication.
89
When should a cardiac cause be sought in epigastric pain?
If it is associated with nausea and sweating
90
What are the ALARM symptoms for dysphagia?
```
Anaemia
Loss of weight
Anorexia
Recent onset (>55) of progressive symptoms
Melaena or haematemesis
Swallowing difficulties.
```
91
What are the basics of the management of acute liver failure?
Generally:
- Nutritional management, i.e. reduction in protein intake, while receiving the maximum tolerable (1.2g/24hrs)
- Reduction in the "nitrogenous load" -> lactulose
For acute encephalopathy, give lactulose 45mL PO followed by an hourly dose until there is a bowel movement; after this, the target is two to three soft bowel movements a day
For ascites:
-Spironolactone and salt restriction are first line
-Abdominal paracentesis can be used for symptomatic tense, refractory or recurrent ascites, but not before attempts are made to increase ammonia excretion
92
What does hypoalbuminaemia in liver failure cause?
increasing peritoneal fluid
peripheral fluid distribution
leuconychia
93
What serology is seen in auto-immune hepatitis?
Anti-smooth muscle in 70%
| Liver kidney microsomal type 1
94
What antacids can be used prior to endoscopy if suffering from dyspepsia?
alginate antacid (gaviscon etc)
95
What is the first line treatment for H. Pylori?
A PPI twice daily and amoxicillin 1 g twice daily and
Either clarithromycin 500 mg twice-daily or metronidazole 400 mg twice-daily.
If the person is allergic to penicillin, offer a 7-day triple therapy regimen of:
-A PPI twice daily and clarithromycin 500 mg twice daily and metronidazole 400 mg twice-daily.
If the person is allergic to penicillin and has had previous exposure to clarithromycin, offer a 7–10-day triple therapy regimen of:
-A PPI twice daily and metronidazole 400 mg twice-daily and levofloxacin 250 mg twice-daily.
96
What is the second line treatment for H. Pylori?
A four drug combination using either metronidazole or clarithromycin (whichever you didnt use first time) PLUS, bismuth, tetracycline and PPI
This is for 2 weeks
97
Describe the management for patients who come in on an acute alcohol binge
2 doses of vitamins B + C (i.e. Pabrinex ampoules I + II) 3 times daily
-This must be done before giving patient glucose in any form as any patients with potential thiamine deficiency can get Wernicke's
IV fluids such as 1L 5% glucose IV (AFTER Pabrinex)
Consider Benzodiazepines such as Diazepam, Lorazepam or Chlordiazepoxide according to CIWA-Ar score
Omeprazole for any gastritis
Pancreatin 10,000U
-pancreatic enzyme supplement
Vitamin B compound strong 2 tablets PO
-reasonable in acute setting if the patient is low risk and a good idea in almost all patients on discharge
98
What aspirate pH is safe to start NG feeding?
0-5.5 can safely start feeding
99
When should you refer someone with iron deficiency anaemia?
Urgently refer within 2 weeks if they are:
- Aged 60 years or over.
- Aged under 50 years and present with rectal bleeding.
Refer to gastroenterology:
- All men and postmenopausal women with iron deficiency anaemia unless they have overt non-gastrointestinal bleeding.
- Men with a haemoglobin (Hb) level less than 120 g/L and postmenopausal women with an Hb level less than 100 g/L should be investigated more urgently, as lower levels of Hb suggest more serious disease.
100
What risk stratifying scores are used in upper GI bleeds?
Rockall score
- Pre-endoscopy and Complete score (includes endoscopy result
- Can be used to determine who needs scoping
Glasgow-Blatchford Bleeding Score (GBS)
- Better than rockall for low risk patients
- Can help determine who needs admitted to hospital or treated as outpatient
- Doesn't rely on endoscopy result for full score
101
What is included in the Rockall score?
Age
- <60 = 0
- 60-79 = 1
- 80 or more = 2
Shock
- No shock = 0
- Tachycardia (>100bpm) = 1
- Hypotension (sys <100) = 2
Comorbidity
- No major comorbidity = 0
- Any comorbidity except below = 1
- Renal failure, liver failure or disseminated malignancy = 2
Endoscopy result
102
How does refeeding syndrome occur?
In prologned starvation, the lack of dietary carcohydrate means insulin secretion is reduced.
As fat and protein stores are preferentially catabolized for energy, there is a loss of intracellular electrolytes, especially phosphate
When food becomes available again, a shift from fat back to carbohydrate metabolism and the resultant rise in insulin stimulate cellular uptake of phosphate
103
Describe the WHO performance status grading
0 = Fully active, able to carry on all pre-disease performance without restriction
1 = Resticted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature (e.g. light house work, office work)
2 = Ambulatory and capable of all selfcare but unable to carry out any work activities. Up and about more than 50% of waking hours
3 = Capable of only limited selfcare, confined to bed or chair more than 50% of waking hours
4 = completely disabled. Cannot carry on any selfcare. Totally confined to bed or chair
5 = Dead
(less than 3 months prognosis for Stage 3)
104
What are the criteria for IBS?
ABC for more than 6 months:
Abdominal pain or discomfort
Bloating
Change in bowels (as long as no red flags)
-unintentional weight loss
-rectal bleeding
-FHx of bowel or ovarian cancer
-Change in bowels to looser motions >6 weeks in those over 60 years
105
A patient starts ACEi and 2 weeks later has bloods for renal function.
What is an acceptable change in renal function to continue dose?
If fall in eGFR is <25% and the rise in serum creatinine is <30%, then the results can be rechecked within 2 weeks without altering dose.
If larger fall need to check other causes of renal failure (hypovolaemia, other drug side effects)
If no other cause can be found then stop ACEi and start alternative.
106
What is a "delayed nephrogram"?
Failure for contrast to drain in a normal time on imaging:
- Obstructive uropathy (most common cause)
- renal artery stenosis/ vein thrombosis
- extrinsic compression
IV urogram is taken 20 min after the injection of contrast dye. Immediately following this infucion, the contrast should be promptly taken up by a normal kidney and would create a distinct outline (nephrogram) on the initial 1mm film.
A well demarcated kidney on a 20 min film (delayed nephrogram) is a sensitive indicator of ureteral obstruction
If the obstruction is acute the delay is usually only for a few minutes, whilst in long standing obstruction, the uptake of contrast by the kidney can be 1h or longer, leading to a persistently dense nephrogram.
107
What is the treatment for renal colic?
Acutely
- 75mg diclofenac IM + either metoclopramide, cyclizine or prochlorperazine
- (reduce dose of metoclopramide in hepatic or renal impairment)
If no hospital admission needed:
- prescribe oral or rectal of the above drugs
- plenty of fluids
- seive urine through nylon stocking, coffee filter etc to get stone for lab analysis
- hospital appointment within 7 days for diagnosis and assessing the likelihood of stone passing
108
When do you admit patients with renal colic?
The person is in shock or has fever or other signs of systemic infection.
The person is at increased risk of acute kidney injury, for example if there is a solitary or transplanted kidney, pre-existing chronic kidney disease, or bilateral obstructing stones are suspected.
The person is pregnant.
The person is dehydrated and cannot take oral fluids due to vomiting.
There is uncertainty about the diagnosis.
There is no response to symptomatic treatment within 1 hour (or sooner depending on clinical judgement), or there is a rapid recurrence of severe pain.
109
What management is required after relieving urinary retention?
IV fluids
Monitor U+Es (Na and Bicarbonate)
Post-obstructive diuresis can cause up to 1L of fluid loss within the first hour. Therefore essential to provide concurrent rehydration therapy to avoid immediate dehydration. Sodium and Bicarbonate also last in large quantities.
110
What is the definition of metabolic syndrome?
Central obesity or BMI > 30kg/m2 plus 2 of the following:
- Triglycerides >1.7mmol/L
- HDL <1.3mmol/L
- BP >130/85mmHg
- Fasting glucose >5.6mmol/L
111
How do you differentiate nephritic and nephrotic syndrome?
Nephrotic
- BP = Normal/Mild increase
- Urine = Proteinuria >3.5g/day
- GFR = Normal/Mild decrease
Nephritic
- BP = Moderate/Severe increase
- Haematuria (mild-macroscopic)
- GFR = Moderate/Severe decrease
112
What are the common primary and secondary causes of Nephritic syndrome?
Primary:
- IgA nephropathy
- Mesangiocapillary GN
```
Secondary
-Post-streptococcal (Proliferative glomerulonephritis)
-Vasculitis
-SLE (other classes of nephritis)
Anti-GMB disease
-Cryoglobulinaemia
```
113
What are the 3 pathological categories of rapidly progressive glomerulonephritis?
Immune complex disease (45% of cases)
-post-infectious, SLE, IgA/HSP
```
Pauci-immune disease (50% of cases)
(80-90% ANCA +ve)
-Granulomatosis with polyangiitis (c-ANCA +ve)
-Microscopic polyangiitis (pANCA +ve)
-Churg-Strauss syndrome
```
Anti-GBM disease (3% cases)
-Goodpasture's disease
114
What are the common primary and secondary causes of nephrotic syndrome?
Primary
- Membranous
- Minimal change
- Focal Segmental Glomerulosclerosis
- Mesangiocapillary GN
Secondary
- Diabetes
- SLE (class V nephritis)
- Amyloid
- Hepatitis B/C
115
What are the causes of renovascualr disease?
>50 most likely atherosclerosis
In the young most likely due to fibromuscular dysplasia
-Presents gradually with resistant hypertension
116
What is the definition of nephrotic syndrome?
Proteinuria >3.5g/24h (ACR >250mg/mmol)
Hypoalbuminaemia (<25g/L, usually much lower)
Oedema
(severe hyperlipidaemia (total cholesterol >10mmol/L) is often present)
117
What risk assessment tool can be used in neutropenia?
Multinational Association for Supportive Care in Cancer (MASCC score)
If the total score is 21 or more, risk of septic complications is low (?home care):
- Solid tumour or lymphoma with no previous fungal infection = 4
- Outpatient status at onset of fever (not needing admission) = 3
- Age <60 = 2
- Burden of illness
- ---Mild/no symptoms = 5
- ---Moderate symptoms = 3
- ---Severe symptoms = 0
- No hypertension (systolic BP>90mmHg) = 5
- No COPD = 4
- No dehydration = 3
118
How do you treat DIC?
Treat underlying cause
Replace platelets if <50x10^9/L)
Cryoprecipitate to replace fibrinogen (fibrinogen levels correlate with severity)
FFP to replace coagulation factors
Consider protein C in severe sepsis or multi organ failure
119
In patients with CKD when can you assume anaemia is due to the CKD and not another cause?
If their eGFR is <60mL/min, anaemia can be assumed to be due to the CKD.
If it is higher then other causes need to be explored
120
When do you carry out routine screening for osteoporosis in CKD?
Stage 4 and 5 CKD (eGFR <30mL/min), but not before
121
How do you differentiate iron deficiency anaemia from anaemia of CKD (anaemia of chronic disease)?
Serum ferritin levels are used to detect iron deficiency anemia in those with CKD
-levels <100ml/L are diagnostic in those with stage 5 CKD and are highly suggestive in stages 3 and 4.
122
How does membranous nephropathy present?
This type of glomerular damage is associated with autoimmune conditions such as RA, as well as some of the drugs used to treat them.
It tends to present in adults with nephrotic syndrome
123
What are the most worrying clinical features in a patient receiving a blood transfusion?
Fever
Hypotension
(sepsis or haemolytic reaction)
124
What are the features of allergic reactions during transfusion? How do you treat?
Pruritis and urticaria
Transfusion can be slowed with the addition of chlorphenamine 10mg IM/IV and close monitoring
125
What investigations should be done in macrocytic anaemia?
TFTs
LFTs
Reticulocytes
Vit B12 and Folate levels
126
What investigations should be carried out in normocytic anaemia?
Examination of the rest of the blood count including platelets along with renal function
127
What investigations should be carried out in microcytic anaemia?
Iron deficiency:
- Low serum iron and ferritin
- Raised total iron-binding capacity and transferrin
If no iron deficiency investigate GI tract.
Other rarer causes:
- Hb elecrophoresis (thalassaemia or sickle cell)
- HbA2 level (High in B-thalassaemia minor)
128
How do you manage patients who's INR >5 but they are not bleeding?
Patients with an international normalized ratio (INR) > 5·0 but who are not bleeding should have 1–2 doses of warfarin withheld and their maintenance dose should be reduced. The cause of the elevated INR should be investigated
129
How do you manage patients who's INR 8 or more but they are asymptomatic?
Asymptomatic patients with an INR of ≥ 8·0 should receive 1–5 mg of oral vitamin K (1B). The INR should be rechecked the following day in case an additional dose of vitamin K is required.
130
How do you manage patients who have a high INR prior to surgery?
For surgery that requires reversal of warfarin and that can be delayed 6–12 h, the INR can be corrected by giving intravenous vitamin K.
For surgery that requires reversal of warfarin and which cannot be delayed for vitamin K to have time to take effect, the INR can be corrected by giving PCC and intravenous vitamin K.
PCC should not be used to enable elective or non‐urgent surgery
131
How do you manage patients on warfarin who are having major bleeding?
Emergency anticoagulation reversal in major bleeding should be with 25–50 U/kg four‐factor PCC and 5 mg intravenous vitamin K.
Recombinant factor VIIa is not recommended for emergency anticoagulation reversal (1B).
Fresh frozen plasma produces suboptimal anticoagulation reversal and should only be used if PCC is not available (
132
What are megaloblasts described as on blood film?
Hypersegmented polymorphs
133
How do you treat folate deficiency?
Folic adic 5mg/day PO for 4 months PLUS B12
NEVER treat without b12 unless the patient is known to have a normal B12 level
134
What is MGUS?
Monoclonal Gammopathy of Uncertain Significance (MGUS)
It is very common to find a monoclonal protein in the serum of those over 50 years old
However, in the absence of CRAB (signs) and if the concentration is <30g/L it is described as an asymptomatic plasma cell dyscrasia and labeled MGUS.
135
At what ages do the different leukemias present?
ALL Cellmates have Common Ambitions
Under 5 and over 45 – acute lymphoblastic leukaemia (ALL)
Over 55 – chronic lymphocytic leukaemia (CeLLmates)
Over 65 – chronic myeloid leukaemia (CoMmon)
Over 75 – acute myeloid leukaemia (AMbitions)
136
What translocations are associated with ALL?
It is associated with the t(15:17) translocation in 30% children with ALL and the Philadelphia chromosome (t(9:22) translocation) in 30% of adults with ALL.
137
What are the 3 clinical phases of CML?
Chronic myeloid leukaemia has three typical phases: the chronic phase, the accelerated phase and the blast phase.
- The chronic phase can last around 5 years, is often asymptomatic and patients are diagnosed incidentally with a raised white cell count.
- The accelerated phase occurs where the abnormal blast cells take up a high proportion of the cells in the bone marrow and blood (10-20%). In the accelerated phase patients become more symptomatic, develop anaemia and thrombocytopenia and become immunocompromised.
- The blast phase follows the accelerated phase and involves an even high proportion of blast cells and blood (>30%). This phase has severe symptoms and pancytopenia. It is often fatal.
138
What are the key giveaways of ALL?
Acute lymphoblastic leukaemia: Most common leukaemia in children. Associated with Down syndrome.
139
What are the key giveaways of CLL?
Chronic lymphocytic leukaemia: Most common leukaemia in adults overall. Associated with warm haemolytic anaemia, Richter’s transformation into lymphoma and smudge / smear cells.
140
What are the key giveaways of CML?
Chronic myeloid leukaemia: Has three phases including a 5 year “asymptomatic chronic phase”. Associated with the Philadelphia chromosome.
141
What are the key giveaways of AML?
Acute myeloid leukaemia: Most common acute adult leukaemia. It can be the result of a transformation from a myeloproliferative disorder. Associated with auer rods.
142
Why can lower levels of Hb be tolerated in sickle cell?
In sickle cell disease, the oxygen dissociation curve is shifted to the right, indicating that the Hb has a lower affinity for oxygen and can, therefore, more easily release it to the tissues.
As a result, lower levels of Hb can be well tolerated.
143
What is the Schilling test?
It is used in megaloblastic macrocytic anaemias to determine whether a low serum vitamin B12 level is due to reduced absorption at the terminal ileum or to decreased secretion of intrinsic factor.
It tests the ability to absorb B12
144
What is Ham's test?
Used to test for paroxysmal nocturnal hemoglobinuria (PNH) in which acidified serum activates an alternative complement pathway, which induces lysis of erythrocytes
Bit out of date now as the new gold standard is flow cytometry
(PNH causes a chronic intravascular haemolysis with pancytopenia and an increased risk of thrombosis)
145
What investigations are suggestive of anti-phospholipid syndrome?
Serology
- Anti-cardiolipin
- lupus anticoagulant
Thrombocytopenia
Paradoxically prolonged aPTT
146
What is the most common sign of heparin-induced thrombocytopenia (HIT)?
Venous thrombosis
Platelet count falls >30%, although not usually enough for bleeding to occur.
The most common symptom is enlargement of a pre-existing blood clot or the development of a new one.
antibodies against heparin cause platelet activation and subsequent thrombosis
Careful monitoring of symptoms and FBC is required in first 7-10 days of treatment
147
How do you manage suspected HIT?
Heparin treatment needs to be stopped immediately.
Treatment with non-heparin anticoagulant started
- Danaparoid
- Argatroban
Warfarin is started and non-heparin anticoagulant stopped once INR is stable
Warfarin continued for 3 months if thrombotic event HIT or 4 weeks if no thrombotic event.
148
Why is LMWH usually started initially with warfarin therapy?
Warfarin is a vitamin K antagonist
The level of protein S is dependent on vitamin K activity and, because it acts as a co-factor for protein C, there is a reduction in the breakdown of factors Va and VIIIa.
This causes the clotting cascade to favour the formation of clots and produces a transient prothrombotic state.
To cover this period, LMWH is started as an anti-coagulant and can be discontinued once the warfarin has been through its prothrombotic state and the INR is within target range.
149
What is the best route of administration for opioid in a sickle cell crisis?
Subcutaneously
Although absorption is slightly unpredictable, it is the safest for the short- and long- term health of the patient.
Sites should be varied between the abdomen and upper arms and legs
150
What is hypersplenism?
Hypersplenism is pancytopenia caused by splenomegaly.
When a spleen in large enough, it causes sequestration of all blood groups passing through its system and thus reduced counts. It does not exist on its own but as a secondary process to almost any cause of splenomegaly
151
What do you do if there is any doubt about whether a dose of warfarin has been given?
No further doses should be given on that occasion and an INR should be taken the next day.
152
Which virus can cause a retinitis with reduced vision and floaters?
Human Herpes Virus 5 = Cytomegalovirus
Can lead to blindness without treatment with ganciclovir
153
What are the prophylactic antimalarial medications?
Proguanil and atovaquone (Malarone)
- Taken daily 2 days before, during and 1 week after being in endemic area
- Most expensive (around £1 per tablet)
- Best side effect profile
Mefloquine
- Taken once weekly 2 weeks before, during and 4 weeks after being in endemic area
- Can cause bad dreams and rarely psychotic disorders or seizures
Doxycycline
- Taken daily 2 days before, during and 4 weeks after being in endemic area
- Broad spectrum antibiotic therefore it causes side effects like diarrhoea and thrush
- Makes patients sensitive to the sun causing a rash and sunburn
154
What is the treatment for severe or complicated malaria?
Artesunate
- Parenteral artesunate is used treat severe or complicated malaria.
- Intravenous artesunate can cause haemolysis and follow-up blood tests are required.
Quinine
-Quinine may be used initially to treat severe or complicated malaria if artesunate is unavailable.
155
What is the treatment for uncomplicated falciparum malaria?
Artemisinin combination therapy (ACT)
-ACT may be used to treat uncomplicated malaria and is the preferred treatment for mixed infection.
Atovaquone-proguanil
-Atovaquone-proguanil may be used to treat uncomplicated falciparum malaria if ACT is unavailable.
Quinine plus doxycycline
- A combination of quinine plus doxycycline may be used to treat uncomplicated falciparum malaria if ACT is unavailable.
- Doxycycline should not be given to children younger than 12 years of age.
156
What is the treatment of uncomplicated NON-falciparum malaria?
Chloroquine
-Chloroquine may be used to treat uncomplicated P. malariae, P. ovale and P. knowlesi and most cases of P. vivax malaria but use depends upon patterns of resistance and tolerance.
157
What treatment is required for the eradication of hypnozoites in malaria?
What needs to be done before starting this treatment?
Primaquine
Primaquine is the only currently effective drug for the eradication of hypnozoites (dormant parasites which persist in the liver after treatment of P. vivax and P. ovale).
Screening for G6PD deficiency is essential before treatment with primaquine is started as it can cause haemolysis in G6PD deficient individuals, which can be fatal. It is contraindicated in pregnancy and breastfeeding.
158
What are the clinical features of typhoid?
In the early stages, it typically features a headache and a slow rising fever, but with a relative bradycardia
As the illness progresses, hepatosplenomegaly and green "pea-soup" diarrhea commonly occur
Intestinal haemorrhage/perforation and neurological complications can occur.
159
What symptoms predominate in dengue fever?
Headache,
Rash (malaria doesn't cause a rash!)
Myalgia
Arthralgia
160
Cholestasis can be caused by which antibiotic?
Flucloxacillin
This drug-induced cholestasis usually presents with a painless jaundice 2-6 weeks after use but can occur up to 3 weeks after the drug has been stopped.
161
Which antibiotic is particularly associated with erythroderma (red man syndrome)?
Vancomycin
Anaphylactoid reaction due to vacnomycin induced mast cell degranulation and release of histamine
This is usually associated with a rapid infusion rate and results in pruritus and an erythematous rash over the face neck, and upper torso
Symptoms usually disappear shortly after discontinuation of the infusion
162
How do you differentiate oral hairy leukoplakia and candida?
Oral hairy leukoplakia cannot be removed, whereas when Candida is removed it leaves sore red patches.
163
What sensory testing can you examine in the hand?
Autogenous zones:
o Median nerve = volar aspect of index finger
o Ulna nerve = volar aspect of little finger
o Radial nerve = over 1st dorsal interosseous muscle (dorsum of 1st web space)
Superficial branch of median nerve
- Over thenar eminence.
- Discriminates between a high or low median nerve lesion.
Dermatomes -
- C6 = thumb & index finger;
- C7 = middle finger;
- C8 = ring & little fingers.
164
What is Froment's sign?
Paper placed between thumb and index finger
Examiner pulls the paper to provide resistance
In normal adductor policis (ulnar nerve function paper won't slip)
Deep branch of ulnar nerve C8-T1
165
What is Wartenburg's sign?
Involuntary abduction of the 5th digit (little finger) caused by unopposed action of the extensor digiti minimi
166
How do you test the function of the anterior interosseus nerve?
loss of precise pinch (unable to make 'OK' sign, instead make a square) due to loss of FPL & FDP to index finger.
167
How do you test the function of the posterior interosseous nerve?
Wrist dorsiflexion results in radial deviation (since ECU
| supplied by PIN, but brachioradialis & ECRL are supplied by the Radial nerve)
168
What are the features of idiopathic intracranial hypertension (pseudotumour cerebri)?
Think of this in those presenting as if with a mass (headache, raised ICP and papilloedema) when none is found.
Typical patients are obese women with narrowed visual fields, blurred vision +/- diplopia, VI nerve palsy, and an enlarged blind spot, papilloedema usually present
Consciousness and cognition are preserved
169
What are the features of a cerebellar lesion?
DASHING
```
Dysdiadochokinesis
Dysmetria (past pointing)
Ataxia
Slurred speech (dysarthria)
Hypotonia
Intention tremor
Nystagmus
Gait abnormality
```
170
How do you perform brudinski's sign?
Ask the patient to lift their head from the bed
| If the legs also raise it's positive
171
How do you perform Finkelstein's test?
Place the thumb in a closed fist and tilt your hand towards the little finger
172
What are the characteristics of a trochlear nerve palsy (CN IV)?
Patients usually tilt away from the side of the lesion in order to reduce their diplopia
The diplopia is worse on downward gaze and gaze away from the affected muscle
The trochlear nerve has 3 roles: intorsion, depression, and abduction of the globe
It is most commonly disturbed by head trauma but can be affected in microvasculopathies such as diabetes
173
How do you clinically differentiate a extradural and subdural bleed?
Extradural bleed = lucid interval where consciousness holds steady for several days after the initial insult before the rising ICP takes its toll.
Subdural bleed = fluctuating levels of consciousness (may be many weeks)
174
How do you test the tibialis posterior?
Ask the patient to point their toes and place the soles of their feet together
175
What should be performed prior to surgery in any patient on sodium valproate?
Clotting profile
Due to its effects on the liver
176
What medication is used after a stroke and TIA?
For the first 2 weeks after a vascular event (stroke/ TIA), aspirin 300mg is used
Thereafter:
Stroke -> clopidogrel
TIA -> aspirin and dipyridamole
-Dipyridamole may be used alone if aspirin not tolerated or contraindicated
177
When should EEGs be used?
NICE guidelines state that an EEG should not be performed (due to possible false positives). An EEG should only be used to support a diagnosis of epilepsy in those in whom the history is suggestive.
(i.e. dont do one if it looks like syncope but you want to rule out seizure activity)
178
What are the risk factors for Non-Epilleptiform Attack Disorder?
```
Female
Young adult
Those with family members who have seizures
Depression or anxiety
Childhood sexual abuse
```
179
What is Devic's syndrome?
Neuromyelitis optics (NMO)
An MS varient with transverse myelitis, optic atrophy and NMO-IgG antibodies
180
What is teichopsia?
A transient visual sensation of flashing lights/ colours before a migraine
181
When should the emergency services be contacted during a seizure in the community?
If seizures develop into status epilepticus
-Seizure lasts >30 mins or asecond fit starts before the person has regained consciousness
If there is a high risk of recurrence
If it is a first fit
If there is difficulty monitoring the individual's condition.
182
What are the characteristics of cerebellar speech?
Slurred and staccato
183
What speech pattern would indicate pseudobulbar palsy?
Slow, indistinct and effortful
184
What are the characteristics of Broca's dysphasia?
Inferior frontal gyrus lesion
(inferolateral frontal lobe)
Expressive dysphasia
- Non-fluent speech
- Normal comprehension
- Good repetition
185
What are the characteristics of Wernicke's dysphasia?
Superior temporal gyrus lesion
Receptive dysphasia
- Fluent speech
- Abnormal comprehension
- Good repetition
186
What are the characteristics of Conduction dysphasia?
Arcuate fasciculus lesion
Associative dysphasia
- Fluent speech
- Abnormal comprehension
- Poor repetition
187
What does the tibial nerve supply?
Sensory branch to the sole of the foot and a motor branch to the hamstrings, tibialis posterior, gastrocnemius, flexor digitorum longus, and the small muscles of the foot
188
How do you diagnose carcinomatous meningitis?
Imagins may show the suggestion of meningeal uptake (MRI) but the best way to detect malignant cells in the meninges is via a lumbar puncture.
189
What are the differentials for multiple discrete ring-enhancing lesions on a brain CT?
Metastases (most commonly from lung, kidney, breast, melanoma, and colon)
Demylination
Multiple infarcts
```
HIV +ve = lymphoma
long term immunosuppression = abscesses
-Toxoplasmosis
-Cryptococcosis
-Cysticercosis
```
190
What is the definition of mononeuritis multiplex?
2 or more peripheral nerves are compromised
Associated with diabetes, some vasculitides, and rheumatoid arthritis
191
What is a Total anterior circulation stroke (TACS)?
All of the following:
- Higher dysfunction (decreased level of consciousness, dysphasia, visuospatial)
- Homonymous hemianopia
- Motor/ sensory deficit (>2/3 face/ arm/ leg)
192
What is Partial anterior circulation stroke (PACS)?
Any 2 of:
- Higher dysfunction
- Homonymous hemianopia
- Motor/ sensory deficit (>2/3 face/arm/leg)
OR
- Higher dysfunction alone or
- Limited motor sensory deficit
193
What is a posterior circulation stroke (POCS)?
Any of the following:
- Cranial nerve palsy and CL motor/ sensory deficit
- Bilateral motor sensory deficit
- Conjugate eye movement problems
- Cerebellar dysfunction
- Isolated homonymous hemianopia
194
What is a lacunar infarct (LACS)
Any of the following (all affecting >2/3 face/arm/leg)
- Pure sensory deficit
- Pure motor deficit
- Sensorimotor deficit
- Ataxic hemiparesis
The patient must not have new dysphasia, visuospatial problem, proprioceptive loss, any vertebrobasilar features.
195
What is the definition of Wernicke's encephalopathy?
Ophthalmoplegia
- Nystagmus,
- Lateral rectus or conjugate gaze palsies
Ataxic gait
Global confusion
196
how do you treat Wernicke's?
In any patient with one or more of the three symptoms of Wernicke's and no other cause more likely start treatment
2 pairs of thiamine ampoules IV in 50-100mL 0.9% saline over 30min three times a day for 3-7 days before converting to oral thiamine
197
When should you consider alcohol withdrawal in an inpatient?
Classically presents between 10 and 72hrs after admission with hypotension, tachycardia, and visual/ tactile hallucinations
198
In most cases, anti-epileptic treatment does not start until after a second seizure. However, NICE highlights four situations in which it should be started after the first seizure.
What are they?
The individual has a neurological deficit
The EEG shows unequivocal epileptiform activity
The individual considers risk of further seizures unacceptable
Imagins shows a structural abnormality
199
What is urinary alkinization?
This uses bicarbonate to produce urine with a pH between 7.5 and 8.
This can enhance elimination of weak acids such as cocaine, TCAs and salicylates
200
What is the treatment of Benign Paroxysmal Positional Vertigo?
Displaced otoconia can be relocated by the Epley manoeuvre (requires someone else) or Brandt-Daroff exercises (can be done alone) and provide a cure in up to 80-90% of cases
201
Someone has a TIA
How do you predict their risk of having a subsequent stroke?
ABCD2 score
```
Age >60 = 1
BP >140/90mmHg = 1
Clinical features
-Speech disturbance without unilateral weakness = 1
-Unilateral weakness = 2
Duration
-10-59 mins = 1
- >60 = 2
Diabetes = 1
```
Score 3 or below -> aspirin 300mg daily starting immediately and specialist assessment within 7 days
Score 4 or more -> aspirin 300mg daily starting immediately and specialist assessment within 24hrs
202
how do you calculate serum osmolality?
2 x (Na + K) + Ur + glucose
203
Name the SLE autoantibodies
```
dsDNA (60% sensitivity but highly specific)
antihistone Ab (Drug-induced SLE 100%)
Antiphospholipid Ab (e.g. anti-cardiolipin Ab)
```
Anti-extractable nuclear antigen (ENA) antibodies
- Anti-Ro (SSA)
- Anti-La (SSB)
- Anti-Sm (20-30%)
- Anti-RNP (ribonucleoprotein)
204
Describe the long term management of osteoarthritis
First line:
- Education, advice, information access
- Strengthening exercise, Aerobic fitness training
- Weight loss if overweight/ obese
Second line:
- Paracetamol
- Topical NSAIDs
Third line:
- Meds:
- ---Capsaicin
- ---Oral NSAIDs including COX-2 inhibitors
- ---Opioids
- ---Intra-articular corticosteroid injections
- Surgery
- ---Joint arthroplasty
- Other
- ---Supports and braces
- ---Shock absorbing shoes or insoles
- ---TENS
- ---Local heat and cold
- ---Manual therapy (manipulation and stretching)
205
What is the immediate management of an acutely hot, swollen joint?
Aspiration first
- Appearance of fluid instantly useful
- ---Pus -> orthopaedics for washout
- ---Otherwise -> fluid analysis and IV antibiotics
If prosthetic joint -> dont aspirate, straight to orthopaedics
USS can be used to localise difficult effusions
206
What are the "yellow flags" for development of chronic pain?
Belief that pain and activity are harmful
Depression
Time off work, or claims for compensation
Problems or dissatisfaction at work
Extended rest (and other sickness behaviours)
Social withdrawal
Overprotective family or lack of support
Inappropriate expectations of treatment (e.g. low active participation in treatment)
207
What is Felty's syndrome?
Rheumatoid arthritis
Decreased WCC (neutropenia)
Splenomegaly (+/- hypersplenism, causing anaemia and thrombocytopenia)
also: recurrent infections, skin ulcers, and lymphadenopathy
208
What is the treatment for an acute attack of gout?
First line:
-High dose, fast acting NSAIDs (indometacin)
If contraindicated (peptic ulcer disease etc) -> colchicine (caution in those with renal impairment, takes longer to work compared to NSAIDs)
Don't start allopurinol for a 2-4 weeks
Continue allopurinol if already on it
209
What is the diagnostic criteria for RA?
Score 6 or more out of 10 diagnostic
Joint involvement:
- 1 large joint = 0
- 2-10 large joints = 1
- 1-3 small joints = 2
- 4-10 small joints = 3
- >10 joints (at least 1 small) = 5
Serology
- None positive = 0
- Low RF or low anti-CCP
- High RF or high anti-CCP
Acute phase reactants (at least 1 result needed)
- Normal CRP and ESR = 0
- Abnormal CRP or ESR = 1
Duration of symptoms
- <6 weeks = 0
- 6 or more = 1
210
When do you initiate biologics in RA?
DAS-28 >5.1 (should be aiming for <3) and tried at least 2 different DMARDs
1st line = TNFa inhibitors
- Infliximab/ etanercept/ adalimumab etc
- Usually used in combination with methotrexate
B cell depletion = Rituximab (CD20)
-Used again in combination with methotrexate where TNFa has failed
IL-1 and IL-6 inhibition
-Tocilizumab (IL-6) in combination with methotrexate
Disruption of T cell function
-Abatacept
211
What are the diagnostic criteria for PMR?
Age >50 years with symptoms >2 weeks
Bilateral aching of neck, shoulders, and /or pelvic girdle
Morning stiffness >45 mins
Evidence of an acute phase response (ESR)
Exclusion criteria:
- Active infection
- Active cancer
- Active giant cell arteritis
(NOTE: no weakness and CK will not be raised differentiating from myositis/myopathies)
212
How do the doses of prednisolone differ for PMR and GCA?
PMR = 15mg daily
GCA
- Visual symptoms = 60mg
- No visual symptoms = 40-60mg
213
What are the differentials in an asymmetrical oligoarthropathy?
Crystal
Reactive
Psoriatic
Spondyloarthropathies
214
What are the HLA-B27 associated diseases?
```
Ankylosing spondylitis (88%)
Acute anterior uveitits (50-60%)
Reactive arthritis (60-85%)
Enteric Arthropathy (50-60%)
Psoriatic arthritis (60-70%)
```
215
What are the signs of lithium toxicity?
What needs to be monitored?
A therapeutic lithium level can cause:
- Fine tremor
- GI upset
Toxicity:
-ataxia, blurred vision, coarse tremor, dizziness, muscle twitching, tinnitus, polyuria
Monitoring
-TFTs and renal function
216
What is the risk of a AAA rupture each year?
```
<5.5cm = 1% risk of rupture each year
>6cm = 25% risk each year
```
(Operative mortality is around 5% to put into context ->, therefore, the benefit outweighs risk about >5.5cm AAA)
217
What is the most important thing to remember to examine in someone with intermittent claudication?
Feel for expansile mass in abdomen (must rule out AAA which can interfere with leg vasculature causing claudication)
218
What are the criteria included in the Alvarado score?
Sign's
- Right lower quadrant tenderness = 2
- Elevated temperature = 1
- Rebound tenderness = 1
Symptoms
- Migration of pain to right lower quadrant = 1
- Anorexia = 1
- Nausea or vomiting = 1
Lab values
- Leukocytosis >10,000 = 2
- Leukocyte left shift (WCC 75% neutrophils) = 1
219
What are the borders fo the femoral canal?
Anterior border = inguinal ligament
Posterior border = pectineal ligament
Medial border = lacunar ligament
Lateral border = femoral vein
220
What are the differentials of Femoral hernias?
```
Inguinal hernia
Saphena varix
Enlarged Cloquet's node
Lipoma
Femoral aneurysm
Psoas abscess
```
221
What is a Spigelian hernia?
Occur through the linea semilunaris at the lateral edge of the rectus sheath, below and lateral to the umbilicus.
222
What drug can increase chance of bladder functioning when planning TWOC?
a-blocker
223
What is Prehn's sign?
Relief of severe pain when positioning the scrotum
Should always raise the suspicion of torsion and prompt urgent surgical review.
224
What is the most sensitive way to differentiate testicular torsion and acute epididymo-orchitis?
Cremasteric reflex
-Stroking the superior medial thigh causes elevation of the ipsilateral testicle
In patients with a torsion, it is absent; in those with epidiymo-orchitis, it is present.
225
What agent is best used in rapid sequence induction?
Suxamethonium
RSI requires a fast-acting depolarising neuromuscular blocking agent to prevent aspiration in those who have not been prepared by NBM
226
What anaesthetic agent causes malignant hyperpyrexia in particular?
What is the treatment?
Suxamethonium
Dantrolene
227
What is the most worrying feature of a hernia?
Pain
Not moving bowels = obstruction which needs to obviously be sorted but isn't immediately acute
Pain, however, means strangulation which is an emergency because the bowel is ischaemic.
228
What is Portsmouth sign?
Where the blood pressure markers on the NEWS (look like seagulls) are being rapidly engulfed by the rising pulse rate ("cliffs")
-Basically looks like the seagulls are flying into the clliffs
This is a poor prognostic sign where pulse is higher than heart rate and should worry any doctor more than say a rise in temperature.
It suggests a deteriorating cardiac output and thus end-organ instability
229
What drug can be used for intermittent claudication?
Cilostazol
-A selective adenosine monophosphate (AMP) phosphodiesterase inhibitor that acts as on arterial vasodilator and has anti-platelet activity.
230
What do you do with aspirin prior to surgery?
Aspirin needs to be stopped 5-7 days before an operation to prevent complications with haemostasis perioperatively such as haematoma formation.
231
What investigation is required in diverticulitis?
Erect CXR and USS can detect perforation, free fluid and collections
CT with contrast is gold standard
Colonoscopy should be avoided in acute attack
232
How is diverticulitis graded?
Stage 1 = Pericolic or mesenteric abscess = surgery rarely needed (fluids only and antibiotics)
Stage 2 = Walled off or pelvic abscess = may resolve without surgery
Stage 3 = Generalised purulent peritonitis = Surgery required
Stage 4 = Generalised faecal peritonitis = Surgery required
233
What do you use to unblock a non-depolarising neuromuscular blocking agent?
Neostigmine
Anticholinesterase which will increase the amount of acetylcysteine at the neuromuscular junction.
It is given with glycopyrronium to minimise its muscarinic side effects (such as the buildup of secretions)
234
When should mesenteric adenitis be considered?
Abdominal pain where other causes (appendicitis, ectopic, etc etc) have been excluded and there is a history of recent corzyal illness and palpable lymph nodes.
235
What are the risk factors for cholycystitis in the absence of gallstones?
Diabetes
Time on HDU or ICU
Recent serious illness
236
What are the contraindications to the use of compression stockings?
Need to be wary in unstable cardiac failure and peripheral arterial disease:
No evidence of acute heart failure and an ABPI > 0.8 = safe to use high-pressure compression
-High-pressure stockings used for ulcers rather than anti-VTE disease stockings or bandages
Those with an ABPI >5.0 but <0.8 should use low-pressure compression
-Most stockings are in this category
Those with an ABPI <0.5 or evidence of acute heart failure should be managed with leg elevation and no compression
237
What is required in splenectomy patients?
Vaccinations:
- HiB, pneumococcal, and meningococcal C
- Should happen 14 days before elective procedures
- Pneumococcal every 3-5 years
Penicillin V 500mg BD as continual prophylaxis against encapsulated bacteria
238
How do you convert from oral codeine or tramadol to oral morphine?
Divide by 10
239
How do you convert oral morphine to oral oxycodone?
What is the advantage of oxycodone compared to morphine?
Divide by 1.5-2
Generally, oxycodone causes less sedation, vomiting, and pruritis but more constipation compared to morphine.
240
What oral morphine dose is equivalent to 12mcg fentanyl and 10mcg Buprenorphine patch?
(good for renal impairment)
12mcg fentanyl patch = 30mg oral morphine
10mcg Buprenorphine patch = 30mg oral morphine
241
How do you convert oral morphine to SC morphine and SC diamorphine?
Oral morphine to SC morphine = divide by 2
| Oral morphine to SC diamorphine = divide by 3
242
How do you convert oral oxycodone to SC diamorphine??
Divide by 1.5
243
Why is SC diamorphine prefered to SC morphine?
Diamorphine has greater solubility when compared with morphine. This means that larger doses can be put into the syringe driver should they be required.
244
What features of a sigmoid volvulus suggest that laparotomy is needed?
Blood stained effluent and devitalised mucosa on sigmoidoscopy and a leucocytosis or pyrexia
245
What electrolyte needs to be monitored in heparin therapy?
Potassium
Heparin can inhibit aldosterone secretion and cause hyperkalaemia.
Patients with DM, chronic renal failure, acidosis, and raised potassium, or who are taking potassium-sparing drugs are more susceptible.
Baseline and regular measurement of potassium should be checked in those at risk (see above) or those receiving therapy for more than 7 days.
246
Ischaemic limbs are either embolic (30%) or thrombotic (60%). How do the treatments differ?
Embolic = embolectomy
Thrombotic = bypass or angioplasty
Amputation as last resort
247
What are the two common forms of pre-operative bowel prep?
Sodium Picosulphate with magnesium oxide (Picolax)
Phosphate enema
Those who use Picolax believe that the bowel should be emptied before the operation whilst others believe that the use of this preparation instead of a phosphate enema increases the risk of an anastomotic leak due to the spill of bowel contents
248
What are the criteria in the Glasgow-Imrie Criteria for Severity of Acute Pancreatitis?
```
PaO₂ <59.3 mmHg (7.9 kPa)
Age >55 years
WBC >15 x 10³/µL (10⁹/L)
Calcium <8 mg/dL (2 mmol/L)
BUN >44.8 mg/dL (serum urea >16 mmol/L)
LDH >600 IU/L
Albumin <3.2 g/dL (32 g/L)
Glucose >180 mg/dL (10 mmol/L)
```
249
What are the features of anti-phospholipid syndrome?
CLOTS
Coagulation defect
Livedo reticularis
Obstetric (recurrent miscarriage)
Thrombocytopenia
250
When is it safest to place or remove an epidural catheter?
Should be 10-12hrs after the last dose of LMWH thromboprophylaxis. If the patient is receiving a treatment dose of LMWH, this time should be extended to 24hrs.
Following removal, subsequent LMWH should be given no sooner than 4hr. These precautions reduce the chances of developing spinal haematomas.
251
A patient is on regular MR morphine with a breakthrough dose. Recently pain is much worse and they are maxing out their PRN morphine.
How do you adjust their daily regime to make them more comfortable?
The amount of PRN liquid taken daily should be added to the amount of MR daily.
-This tells you the total daily dose (TDD) they are taking each day to control their pain at the moment.
The new MR dose should be the new TDD divided by 2
-This will be taken twice daily
The new breakthrough (PRN) dose is usually taken as liquid and will be the TDD divided by 6
252
What is Ethilon suture material?
Polyamide monofilament used to close skin wounds.
| Non-absorbable
253
Name some common absorbable sutures
Dexon and Vicryl
-These are synthetic braided materials that are more suited to closing subcutaneous fat
Monocryl and PDS
-These are reasonable alternatives to non-absorbable materials for both transcutaneous subcuticular sutures
254
What characteristic rash is seen in Lyme disease?
Erythema chronicum migrans
255
How do you treat hypokalamia?
If potassium is >2.5mmol/L and asymptomatic, it can be treated with oral supplements
-Sando-K 2 tabs/8h
If K+ <2.5 or there are symptoms, treatment should be IV at no more than 20mmol/h and not more concentrated then 40mmol/L
256
Give an example of a recommended 24hr maintenance fluid regimen.
2L of 5% glucose (each containing 30mmol sodium) + 1L of 0.9% saline supplemented over the 24hr period with an additional 60mmol potassium.
This is for your average 60kg patient
257
What are the clinical features of osteomalacia?
Bone pain
Waddling gait (indicating proximal myopathy)
Fractures
Vitamin D deficiency (lives inside, poor diet, malapsorption)
