PACES ALL Flashcards

Question

Fine vs coarse creps? Vesicular vs bronchial breathing?

Answer 1

FINE (inspiratory) – pulmonary oedema (HF), interstitial lung disease (pul fibrosis) * Best heard at base of lungs COARSE (insp & exp) – bronchiectasis, COPD (chronic bronchitis), pneumonia * No specific area of lungs louder Vesicular - inspiratory \> expiratory Bronchial - inspiratory = expiratory

Answer 2

RFs: HTN, DM, Smoking, FHx IHD, Hypercholesterolaemia **Stable angina** - chest pain on exertion relieved by rest * Path - mismatch in O2 supply and demand to the myocardium * Ix: CT-angiogram * Mx: * B-blockers - reduces HR req for activity --\> reduced likelihood of mismatch in O2 supply & demand * GTN spray - reduce myocardial preload + reduces strain * RF modification --\> reduced risk of progression **Acute coronary syndrome** - Sx caused by sudden reduced BF to the myocardium * Dx: * _ST-elevation_ = STEMI * _Troponin raised_ = NSTEMI (+ dynamic T-wave inversion, ST depression) * Unstable angina pectoris (pain at rest) = ischemia NOT infarct * Generic ACS Mx - MONA BASH * ALL immediate: * 5-10mg Morphine IV + Nitrates (GTN spray) * Dual antiplatelet therapy (DAPT) - 300mg Aspirin STAT + 300mg Clopidogrel STAT (or 180mg PO Ticagrelor) * ALL long-term: * Continue DAPT * 1 year: _75mg_ OD Aspirin + _75mg_ OD Clopidogrel (or 90mg BD Ticagrelor) * \>1yr - **_75_**mg OD Aspirin * B-blocker (1.25-10mg Bisoprolol OD) * ACEi (1.25-10mg Ramipril OD) * Statin (80mg Atorvastatin OD) * STEMI Mx: establish coronary reperfusion ASAP * Sx \<12hrs: **_PCI_** BUT if no PCI within 2hrs Dx --\> thrombolysis (e.g. tPA - tissue plasminogen activator) * Sx \>12hrs: invasive coronary angiography ± PCI if needed * PCI: * If having PCI give **_Prasugrel_** (instead of Clopi/Ticagrelor) * PCI accessed via radial (or femoral) artery, guidewire passed via X-ray guidance into the affected coronary artery AND **_IV unfractionated heparin_** during the procedure --\> stent inserted impregnated with an anti-proliferative agent (e.g. Tacrolimus - to prevent adverse tissue reaction) --\> takes longer for endothelialization of stent so DAPT needed for 1yr * If PCI with stents inserted --\> DAPT 12 months * NSTEMI Mx: * 2.5mg SC Fondaparinux (direct factor 10a inhibitor) * Risk stratify - GRACE criteria (& others) * High risk = invasive coronary angiography (within 48-72hrs) Complications: **FAP** (failure, arrhythmias, pericarditis) * Heart failure, arrhythmias (incl. VF) * Pericarditis * _Early_ - positional chest pain day after MI --\> give NSAIDs * _Late_ - **Dressler's syndrome** - immune response @6wks (fever, pleuritic chest pain, pericarditis/pericardial effusion)

Answer 3

**Def:** pumping of blood by heart insufficient to meet the demands of the body Causes: * RVF: * Acute: MI, inf endocarditis, PE * Chr: Cor pulmonale, LVF * LVF: * Acute: ischaemic/hypertensive CMO, valvular HD * Chr: MI, inf endocarditis **Pathophysiology:** * **RHF** - right side of the heart pumps deoxygenated blood from the body to the lungs to be reperfused - if the RH is not pumping effectively you get the fluid collection in the peripheries = _PERIPHERAL OEDEMA_ * **LHF** - left side of the heart pumps oxygenated blood from the lungs to the body - if the LH is not pumping effectively you pooling of blood in the lungs = _PULMONARY OEDEMA_ * Reduced CO --\> shock, tachycardia, AKI * CO = SV\*HR * Ejection fraction = SV/End-diastolic Volume **Categories:** * HF w/ _preserved ejection fraction_ (left ventricular \>50%) = inadequate filling of ventricles during diastole (from ventricular stiffness) * Causes of ventricular stiffness: * Volume overload (valve regurg) * Pressure overload (HTN) * Decreased distensibility (constrictive pericarditis) * HF w/ _reduced ejection fraction_ (left ventricular \<40%) = inadequate emptying of ventricles during systoles (from outflow obstruction/impaired contractility) * Causes of outflow obstruction/impaired contractility: * MI, Cardiomyopathy, Arrythmia NYHA classification: * 1 - no limitation on activity * 2 - comfortable at rest but dyspnoea on ordinary activity * 3 - marked limitation on ordinary activity * 4 - dyspnoea at rest **Ix:** * Bedside: _ECG_ - detects if anything precipitating HF (arrhythmia/ischaemic event) * Bloods: _ABG_ (if resp compromise from pul oedema), _troponin_ (ACS), _BNP_ (HF screening) * Imaging: _CXR_ (visualise pul oedema, cardiomegaly), _ECHO_ (valvular abn/regional wall mov abn) **Mx:** MON BA (out of MONA BASH) * Immediate: * Sit the patient up (reduce venous return to heart --\> less strain) * O2 15L/min NRM * Medical: * **IV furosemide** (loop diuretic) - remove excess fluid + venous dilation (reduce preload) * _Nitrates_ (GTN/Isosobide Mononitrate) AND _Morphine_ - reduce preload on the heart * Long-term: * Reduced ejection fraction - prognostic benefit: * **B-blocker** (bisoprolol) - reduce strain on heart, do not give acutely if severe HF as will kill them * **ACEi** - reduce strain on heart * After the above if LVEF \<35% & Sx --\> mineralocorticoid antagonist e.g. _spironolactone_ * 3rd line - by specialist: Sacubitril/Valsartan (entresto), Ivabradine & CRT * **SGLT2 inhibitors** (dapagliflozin) * RF modification - poor glycaemic control/high cholesterol * Sx (diuretics) Complications: * Reduced CO (SV\*HR) --\> shock, tachycardia, AKI * Congestion --\> pulmonary oedema + peripheral oedema

Answer 4

**Def:** _regular_ narrow-complex tachycardia with no p-waves + supraventricular origin **Junctional types:** * AVNRT - local re-entry circuit within AV node * AVRT - re-entry circuit between atria and ventricles --\> after SVT **termination = _delta wave_ = WPW syndrome:** * Assoc w/ HOCM * Avoid _digoxin, verapamil, amiodarone_ (reduce conduction down SAN --\> worsen retrograde conduction --\> risk of VT) * Can use B-blocker/flecainide instead **Case example:** 23yrs, 1-hr palpitations + SoB, 2 similar episodes prev following alcohol, this time severe chest pain **Mx:** * Unstable tachycardia (\<90 BP/chest pain/acute heart failure) --\> synchronised DC Cardioversion * _Vagal manoeuvres_ (increase parasympathetic stim via vagus nerve to slow conduction via AV node) * Valsalva manoeuvre (blow out through nose while pinching + shut mouth) - breath through 50ml syringe * **Adenosine** 6mg --\> 12 mg --\> 12mg * NOTE: if adenosine CI (e.g. asthma) --\> _VERAPAMIL_ (rate-limiting CCB) * Other: * IV B-blocker/amiodarone/digoxin * Synchronised DC Cardioversion

Answer 5

Key murmurs: * **AS** = ejection _systolic_ + *radiates to carotids, slow rising pulse*, narrow pulse pressure, heaving apex beat * Sound: Wooooshhh * Severe AS - absent/soft 2nd heart sound, _reversed splitting of 2nd HS_, heaving apex beat * A longer murmur is worse (small space for blood to pass through = takes longer) * **MS** = mid-diastolic + *LLP, malar flush, AF, loud/palpable S1 "tapping" apex*, _pul HTN_ (loud P2 - pul thrill) * Sound: Wooosh de (loud S1) de (early diastolic snap) * **AR** = early diastolic + *sitting forward (LLSE), collapsing pulse*, wide pulse pressure, displaced apex * Sound: de woooshhhh * Severe AR --\> **Austin-flint murmur** = 'Rumbling _mid-diastolic_ murmur' * Best heard at apex, caused by blood flowing back through aortic valve and over mitral valve * Shorter murmur is worse (quicker to flow back through large hole) * **MR** = pan-_systolic_ + *radiates to left axilla, AF*, displaced thrusting apex, LVF/pul HTN * Sound: Woooooshhh (holosystolic) * NOTE: same pattern for pulmonary & tricuspid (pul stenosis & tricuspid regurgitation = systolic) * TR - pulsatile liver * PS - radiates to back, assoc w/ Noonan's (AD, webbed neck, wide-spaced eyes etc.) Accentuation manoeuvres: * R-sided murmurs (tricuspid + pulmonary) --\> louder on **_IN_**spiration = blood goes **_IN_** to right-side of heart * L-sided murmurs (aortic + mitral) --\> louder on **_EX_**piration = blood **_EX_**its left-side of heart * **AS** radiates to the carotids + louder on leaning forward + listen on right sternal edge * **MS** louder on turning to the left, **MR** radiates to axilla Causes: * **AS** (stenosis/sclerosis): _senile calcification_ (aortic valve) * **MR**: * Acute: - _IHD_ (papillary-muscle dysfunction post-MI), _Infective endocarditis_, cardiomyopathy, RHD * Chronic - myxomatous degeration * **AR**: * Acute (_infective endocarditis_, aortic dissection) * Chronic (_CTD_, RHD, HTN, congenital) * **MS**: _rheumatic heart disease_ (RHD) Left vs Right valve abn: * Left = more common as higher pressure system, more likely in damaged valves, commonly _Strep Viridans_ * Right = more common in IV drug users --\> tricuspid valve is first valve reached, commonly _S. aureus_ Management: * AS: * C: 6-monthly ECHO, exercise-stress test if asymptomatic * M: RF optimisation (statins, HTN, DM), HF Sx (diuretics, ACEi) * S: Based on severity/comorbid - **STS-PROM** (surgical risk calc) * If severe AS: * Medically fit (req midline sternotomy & cardiopul bypass) = _Surgical aortic valve replacement (SAVR)_ * Not fit = _Transcatheter aortic valve replacement (TAVR)_ * Acutely Sx/cardiogenic shock = _Balloon valvuloplasty_ * M**_R_**: * M: * ACEi ± B-blockers (as HTN worsens MR) * *Tx AF & anti-coagulate* * *Diuretic* (if refractory to surgery) * S: for acute MR (post-MI, chordae tendinae rupture), asymptomatic LVEF \<60%, symptomatic LVEF \>30% * Valve **_R**_epair \> _**R_**eplacement * A**_R_**: * M: asym + **_R_**eassurance (good prog) * Unfit for surgery/waiting - ACEi & vasodilators (e.g. hydralazine) * S: acute/Sx/severe = surgery * Valve **_R**_eplacement \> _**R_**epair * **_M_**S: * C: asymptomatic - **_M_**onitor * M: * *AF Tx, anti-coagulate & diuretics* (if Sx/severe) * S: Sx/severe - can do balloon valvuloplasty/replacement * Valvuloplasty = lateral thoracotomy scar * Do not do percutaneously if persistent left atrial thrombus/rigid calcified valve --\> need open heart surgery (CABG, concurrent severe MS) Complications of prosthetic heart valves: **FIBAT** * Failure * Infection * Bleeding - MAHA * Anaemia * Thromboembolic phenomena

Answer 6

* Inferior – right coronary artery (2,3, aVF foot) * Anterior – left anterior descending artery (V1-2) * Lateral – circumflex artery (1 ,aVL, V5/6) * **Posterior** - ST depression in V2-4, abnormal R wave in V2

Answer 7

**Def:** rapid, chaotic, and ineffective atrial electrical conduction * ECG def: irregularly irregular narrow complex tachycardia with no p waves **Causes:** idiopathic, cardio (**IHD**, valvular disease, cardiomyopathy), resp (PE, pneumonia), hyperthyroidism, alcohol **Ix:** ECG (absence of p-waves, irregularly irreg rhythm) **Mx:** * Haemodynamically unstable (≤90 BP, chest pain, acute HF) --\> DC Cardioversion OR * Rate control --\> **B-blocker** (bisoprolol) OR rate-limiting CCB (verapamil - asthma) OR * Rhythm control - ONLY if clear reversible cause * Sx onset **\<48hrs** --\> **DC/chemical cardioversion** (amiodarone/flecanide) * NOTE: IV heparin started prior to cardioversion * Sx onset \>48hrs --\> _anticoagulate for 3wks_ --\> elective cardioversion (also anticoag for 4wks after) AND * Stroke risk - CHADS-Vasc Vs Orbit/HAS-BLED score --\> DOAC (Apixaban) * If metallic heart valve --\> warfarin INR 3-3.5 * Otherwise DOAC * NOTE: if incidental non-symptomatic AF - normal rate, no other RFs, CHA2DS2-VASc 0 --\> anticoagulation not recommended * **C**HF, **H**TN, **A**ge ≥75rs (2), **D**M, **S**troke (2), **V**ascular disease, **A**ge 65-74, **S**ex - female * Score 1 - consider; ≥2 - DOAC/Warfarin needed * Lifetime risk = annual risk x estimated years of life left (up to 80 yrs e.g. if 60 then x annual risk by 20)

Answer 8

Def: infection of heart valves (typically mitral/aortic or _tricuspid in IVDU_) RFs: bacteraemia (long-term lines, IVDU, dental work), abn valves (prosthetic, RHD), prev endocarditis, VSD, piercings Presentation: low-grade fevers, night sweats * Exam: * Splenomegaly * _Splinter haemorrhages_, osler's nodes, Janeway lesions, petechiae, Roth spots (eyes) * Chronic = clubbing (rare, mostly acute now) **Ix:** * Urine dip - haematuria * _Serial BCs_ (x3 but start empirical abx), ESR * _Transoesophageal Echo_ (TOE - vegetations) **Dx: _DUKE’S CRITERIA_** (2 major OR 1 major + 3 minor OR 5 minor): * Major**: +ve BC** (typical organism), **new regurg murmur/veg on echo** * Minor: RF, fever (\>38), embolic (vascular) phenomena, immune phenomena, +ve BC (another organism) * **Mx**: IV abx for 6wks – fluclox/vanc/gent **Acute** in structurally normal heart – In IV drug user the first valve met is tricuspid valve, commonly _S. aureus_ (also most common cause in _prosthetic valve endocarditis_) **Subacute** in structurally abn heart – mitral & aortic valves more commonly affected as high pressure system, more likely damaged valves, commonly _Strep Viridans_ (overall most common cause of endocarditis)

Answer 9

3rd = rapid ventricular filling = _volume overload_ e.g. **HF** (reduced EF/systolic) * KEN...TU.CKY (deee. de.de) 4th = atrial contraction against stiff ventricles = _pressure overload_ e.g. **longstanding AS** & other causes of left ventricular hypertrophy (HTN heart disease**,** HOCM, HF with preserved EF/diastolic) * TE.NE..SSEE (de.de.deee)

Answer 10

1. HF so severe pressure insufficient to perfuse brain & heart alone --\> 100% death if untreated 2. Treat with inotrope - dobutamine/dopamine --\> increase perfusion of coronary arteries (saves 1/10) 3. Temporary external pacing --\> permanent pacemaker Q: cold peripheries & low UO

Answer 11

* Apex beat displaced by dilation = exam finding – caused by fluid overload * LVH = ECG Dx (peaked R-waves, ST depression and T-wave inversion in lateral leads) – caused by pressure overload e.g. HTN

Answer 12

Indications: * Left main-stem disease * 2+ vessel disease * Failure of medical Mx * Concomitant (aortic) valvular replacement Grafts: * Great saphenous vein * Internal thoracic (mammary) artery - NOW the most commonly used Meds post-CABG: * DAPT - aspirin + ticagrelor (for 12 months then just aspirin) ± specialist opinion * Cardio-selective beta-blocker (bisoprolol) * ACEi (or ARB)

Answer 13

Pericarditis Causes: * Viral (most common) * MI (can be Dressler's syndrome) * TB (constrictive) * Uraemia (CKD where urea high --\> pericarditis) = indication for haemodialysis (HUMP) * Hydralazine (AI pericarditis) * NOTE: also causes _drug-induced lupus_ * SLE, RF, radiation Presentation: * Pleuritic chest pain, worse lying flat * Exam: pericardial rub - "creaking/scratching" * Tip - put on all-fours, put stethoscope on sternal edge, hold inspiration Ix: * ECG: ST elevation widespread * Only slightly raised/normal troponin Mx: **_colchicine (3 months)_** + NSAIDs (ibuprofen, max 2wks)

Answer 14

JVP + hepatojugular pressure (RUQ), rockstar hand **PQRST:** * **P**ul HTN/PE/Pericarditis/Pericardial effusion/PS * **Q**uantity of fluid (fluid overloaded) * **R**HF * **S**VC obstruction * **T**amponade/TR

Answer 15

**VT** or SVT w/ aberrancy * SVT \>200bpm, also often irregular * VT more likely if LAD * Acutely treat any broad complex tachy as VT until proven otherwise Presentation: _palpitations, light-headed, chest pain_, syncope, seizure * Tachycardia, LVF * ACS most common cause * **_NEVER IGNORE palpitations & light-headedness_** Ix: ECG - regular broad complex tachycardia * U&E (Mg, Ca, K), TFTs, Troponins Mx: * Unstable tachycardia (BP \<90, chest pain, acute cardiac failure) = _DC cardioversion_ * Stable: * IV amiodarone, b-blocker --\> prepare for DC cardioversion

Answer 16

Presentation: swollen face and neck and distended veins on her chest in background of cancer Mx: dexamethasone to reduce tumour swelling * Insert EV stent if stridor (after intubation and steroids)

Answer 17

Innitial: A-E * If unstable - 500mcg IV atropine (/5mins up to 3mg) * Also considered unstable if: * Recent asystole \>3s/Mobitz T2 AV block/3rd degree heart block * Caution in acute MI, C/I if heart transplant * If persistent --\> transcutaneous pacing + analgesia/sedation (very painful) * If can't be achieved properly --\> IV isoprenaline/adrenaline (specialist help) * Arrange transvenous pacing (temporary if recent asystole \>3s/Mobitz T2 AV block/3rd degree heart block)

Answer 18

Causes: * MI/IHD (MOST COMMON) * Inf (RHD, IE) * Drugs (digoxin) * Metabolic (hyperkalaemia) * Infiltration of conducting system (e.g. sarcoidosis) * Degeneration of conducting system Types: * First Degree AV block - fixed prolonged PR interval (\> 0.2 s) - _ASYMPTOMATIC_ * Second degree AV block: * Mobitz TI (Wenckebach) - progressively prolonged PR interval --\> P-wave NOT followed by a QRS complex = 'going, going, gone' * _Normally asymptomatic_ * Mobitz Type II - intermittently P wave NOT followed by a QRS * May be regular pattern of P waves not followed by QRS (e.g. 2:1 or 3:1) * Can cause: * Stokes-Adams Attacks (syncope caused by ventricular asystole) * Dizziness, palps, chest pain, HF * Complete AV heart block - no relationship between P waves and QRS complexes * Presentation as in Mobitz T2 Ix: ECG * Bloods: TFTs, Digoxin, cardiac enzymes (troponin, CK, BNP) * CXR (cardiac enlargement, pulmonary oedema) * Echo (wall motion abn, aortic valve disease, vegitations) Mx: * Acute block - if clinical deterioration: * IV atropine * Consider temporary transcutaneous pacing * Chronic block: * 1st degree monitored * Permanent pacemaker in: * Symptomatic Mobitz T1 * Advanced Mobitz T2 * Complete heart block Complications: asystole, cardiac arrest, HF, surgical complications of pacemaker insertion

Answer 19

Types: * Implantable Cardioverter Defibrillator (ICD, has a thicker end) * Single-chamber pacemaker (right ventricle) * Used in permanent AF (no organised atrial contraction so atrial lead not required to sense contraction) * Rarely can have atrial lead only - if SA disease in young with good AV conduction * Dual-chamber pacemaker (right atrium & ventricle) * Can have ICD dual-chamber pacemaker * Used in paroxysmal AF/all other scenarios (there is sometimes organised atrial contraction - this is sensed by the atrial lead) * Cardiac Resynchronisation Therapy/Biventricular pacemaker (right ventricle, left ventricle ± right atrial lead) * Can have ICD biventricular pacemaker When to use each type: * Atrial lead only → Sino-atrial disease in young people with good AV node conduction * RV lead only → Pacing whilst in _permanent atrial fibrillation_ * Dual-lead → All other scenarios (paroxysmal AF, bradycardia) * CRT → LV dysfunction + broad QRS --\> _end-stage HF_ * Indications for ICD: * Primary prevention = **@risk of serious ventricular arrhythmia** * Familial cardiac conditions (hypertrophic cardiomyopathy, long QT) * Previous surgical repair of congenital HD * Previous MI + LVEF \<35% + HF Sx * Secondary prevention = **had previous serious ventricular arrhythmia _wo/ treatable cause_** * Cardiac arrest from VT/VT * Spontaneous sustained VT AND: * Syncope/haemodynamic compromise OR * LVEF \<35% + sign HF Sx (NYHA 3+) * NOTE: VT/VF from STEMI has treatable cause (open occluded vessel) Complications: * Surgical complications - infection, bleeding, damage to underlying structures * Displacement (of lead) * Pacemaker syndrome (if ventricular lead with no atrial) --\> AV node conducts in retrograde direction = mitral/tricuspid regurge + HF Sx

Answer 20

Pros: no bypass required, no large scars Cons: higher risk of stroke compared to open replacement

Answer 21

**Pulsus paradoxus** - greater than the normal (10 mmHg) fall in systolic blood pressure during inspiration → faint or absent pulse in inspiration * severe asthma, cardiac tamponade **Slow-rising/plateau** * AS **Collapsing** * AR, PDA * hyperkinetic states (anaemia, thyrotoxic, fever, exercise/pregnancy) **Pulsus alternans** - regular alternation of the force of the arterial pulse * severe LVF **Bisferiens pulse** - 'double pulse' - two systolic peaks * Mixed aortic valve disease * HOCM (also causes 'Jerky' pulse)

Answer 22

Pulsus paradoxus - BP variation between inspiration & expiration (≥10) Beck's triad (50%): * Raised JVP * Muffled heart sounds * Hypotension Mx: * IV fluids (RV filling depends on venous pressure & effusion is constricting) * Echo --\> refer to cardiology for pericardiocentesis * Coagulation profile (to prep for pericardiocentesis)

Answer 23

Young + very high BP --\> must be _secondary HTN_ (causes: endo - Conn's, Phaeo; coarctation of Aorta (CoA), renal artery stenosis, chronic renal failure) **CoA** - tissue restricting flow across aortic arch * Murmur across the coarctation = _left infrascapular area_ (due to turbulent BF) * Lower body underdeveloped vs upper (97% men going to gym) * Assoc: **_Turner's_** (+ Marfan's, Ehlers-Danlos) * Short stature, webbed neck, wide-spaced eyes, lack of other secondary sexual characteristics, shield-like chest, short 4th metacarpals/tarsals * Advice: avoid extreme isometric exercises e.g. weight-lifting --\> risk of _aortic dissection_ * How do you Dx dissection? CT aortogram w/ contrast

Answer 24

* Not palpable * Double pulsation * Obliterated when pressure applied at base of neck * Rises with hepatojugular reflux * Height changes with respiration

Answer 25

* Midline sternotomy + leg scar = CABG * Midline sternotomy (no leg scar) = Valve replacement most likely (rarely can be CABG without vein graft) * Left subclavicular -\> pacemaker, debfibrillator, resynchronisation device * L shaped scars under either breast -\> L/R Thoracotomy

Answer 26

Cause of hepatic decompensation in CLD: * _Hypokalaemia_ * _Constipation_ (given lactulose in hospital) * Alcohol * GI bleed (lots of protein (Hb) enters the bowel --\>liver can't cope) * HCC Decompensated CLD --\> **_Ascites_, jaundice & encephalopathy** * Severely scarred liver (cirrhosis) in CLD --\> back pressure on portal vein --\> **PORTAL HTN** = _splenomegaly, ascites, varices_ - caput medusae, oesophageal & rectal Ix: * **_Serum Ascites Albumin Gradient (SAAG)_** - serum albumin conc vs ascites conc - 11.1g/L * **\<11.1g/L = exudative cause** - peritonitis (infection), peritoneal malignancy OR n_ephrotic syndrome_ (pee out albumin so low serum albumin) * Otherwise = **transudative cause** - cirrhosis, renal failure, HF * \>250 neutrophils = **spontaneous bacterial peritonitis (SBP)** --\> Tazocin/3rd gen cephalosporin * If protein conc \<15g/L give prophylactic oral ciprofloxacin Mx: * **Paracentesis** (ascitic drain) --\> _post-paracentesis circulatory dysfunction_ (drops BP) SO if \>5L drained give human albumin solution (HAS) 8g/L drained * **Spironolactone** (2nd line - Furosemide) - to prevent fluid accumulation * (Salt restrict) * **Hepatic encephalopathy** (liver not dealing with toxins) - give **_Lactulose + Rifaximin_** to prevent * **Coagulopathy** - OGD (check for varices) + vit K (needed for clotting)

Answer 27

**Functions of the liver --\> failure:** * Albumin (plasma oncotic pressure) --\> **oedema** * Bilirubin metabolism --\> **jaundice** * Clotting factors --\> **coagulopathy** * Detoxification --\> **encephalopathy** **Causes:** * **Common** - alcoholic liver disease, viral hepatitis, NASH (non-alcoholic steatohepatitis) * **Less common** - AI hepatitis, PSC/PBC, HF, alpha1-antitrypsin def, haemochromatosis, Wilson's disease Presentation: * Spider naevi (≥5, SVC distribution, flush inside to out), palmar erythema, gynecomastia, Dupuytren's contracture (alcoholic liver disease), clubbing * Specific signs: * Needle marks/tattoos - hep C * Parotid swelling - alcohol-related liver disease * Bronzed complexion/insulin injection signs - haemochromatosis * Obesity/DM - non-alcoholic fatty liver disease * Xanthelasma - cholestatic disorder Ix: * Alcohol history * Hep B/C serology * Ferritin, transferrin, A1AT, ceruloplasmin (Wilson's) * Ig, auto-abs (ANA in AI hep, AMA in PBC) Important complication = **_VARICES_** * Normal venous return: GI tract --_hepatic portal vein_ --\> liver --\> _hepatic vein_ --\> systemic circulation * Physiological hepatosystemic anastomoses (connection of portal vein to systemic circulation) sites - oesophagus, spleen, umbilicus, rectum * MEMORY AID: **BUTT, GUT, CAPUT** * Pathological process: * In the case of cirrhosis - nodules impede flow of blood through the liver to the hepatic vein --\> reducing blood flow to the systemic circulation * Backflow of blood to the hepatic portal vein = increased --\> backflow to hepatosystemic anastomoses: * Oesophagus --\> **Oesophageal varices** * Spleen --\> **Splenomegaly** * Umbilicus --\> **Caput Medusae** * Only from portal HTN if running from below umbilicus up * Rectum --\> **Rectal varices** Score for prognosis & need for liver transplant = **Child-pugh score** (A = 5-6; B = 7-9; C = 10-15 --\> C is most severe)

Answer 28

**Pre-hepatic** - unconjugated bilirubin comes from breakdown of RBCs * _Haemolysis_ related-causes (excess prod) - AIHA, SCD, G6PD def, malaria * Ix: * Bloods: excess unconjugated bilirubin (exceeds capacity of liver to conjugate it) * Urine: normal (unconjugated bilirubin is insoluble) * Stool: normal as liver functioning normally **Hepatic** - bilirubin absorbed into liver --\> conjugated --\> excreted via biliary tract into duodenum * _Liver disease_ related-causes - cirrhosis, hepatitis, Gilbert's syndrome, drugs * Ix: * Bloods: high unconjugated (liver less able to conjugate quickly) & conjugated bilirubin (leakage of conjugated bilirubin into circulation) * Urine: dark (leaked conjugated bilirubin is soluble) * Stool: slightly pale (reduced conjugated bilirubin to GI tract) **Post-hepatic** - conjugated bilirubin --\> soluble urobilingogen (yellow): 1) Absorbed into circulation --\> excreted via kidneys 2) Remaining --oxidised--\> stercobilin (brown) * _Biliary disease_ related-causes (prevent bile outflow) - gallstones, head of pancreas tumour, cholangiocarcinoma, PSC/PBC * Ix: * Bloods: high conjugated bilirubin (backlog as obstruction at biliary tree so can't reach duodenum and instead leaks into blood) * Urine: dark (leaked conjugated bilirubin is soluble) * Stool: very pale (no conjugated bilirubin reaches GI tract --\> no stercobilin generated)

Answer 29

**IBD** * **Crohn's disease** * **Sx:** **RIF pain** (terminal ileum), failure to thrive (incl. between attacks) * **Distribution:** _mouth to anus_ (esp. terminal ileum), skip lesions * **Histology:** transmural, non-caseating granuloma (also in sarcoidosis) * **Ix:** * OGD/colonoscopy/capsule endoscopy * Gastografin follow-through * **Mx:** * Induction: * **Steroids** (induce remission) * 5-ASA (mesalazine) * Maintenance: * Steroid-sparing agents (methotrexate, azathioprine, mercaptopurine) * Biologics e.g. Anti-TNF (infliximab) * **Complications:** strictures, obstruction, fistulae * **Ulcerative colitis** * **Sx:** **gen. abdo pain**, **PR blood** & mucus * **Distribution:** ONLY _rectum & colon_, continuous * **Histology:** mucosa & submucosa, mucosal ulcers, crypt abscesses * **Ix:** * Flexible sigmoidoscopy/colonoscopy * **Mx:** * Induction: * **5-ASA** * Steroids * Maintenance: * **5-ASA** (mesalazine) * Steroid-sparing agents (azathioprine) * Biologics (infliximab) * Surgery (proctocolectomy, IJ pouch) * **Complications:** toxic megacolon, colonic carcinoma, PSC * Extra-intestinal signs of IBD - A PIE SAC * Aphthous ulcers (crohn's) * Pyoderma gangrenosum * Iritis, uveitis, episcleritis (Crohn's) * Erythema nodosum * Sclerosing cholangitis (PSC in UC) * Arthritis * Clubbing fingers (CD \> UC) * _Truelove & Witts'_ severity index = severity criteria for IBD **Coeliac disease** * **Def:** inflammatory response to gluten (immune reaction to gliadin) * DQ2/8 (on HLA typing) * **Sx:** abdo Sx (**_steatorrhoea_**, diarrhoea, bloating), failure to thrive * Exam: blistering rash on both knees. aphthous mouth ulcers * Assoc: T1DM * **Distribution:** duodenum * **Histology:** **_subtotal villous atrophy with crypt hyperplasia_** * **Ix:** (maintain normal diet - eat gluten for 6wks before testing) * Haematinics - macrocytic anaemia, low Fe, B12/folate * Serological testing: * Screening: **Anti-TTG** & _total IgA_ (check for selective IgA def in case this caused false '-ve' anti-tTg abs) * If weakly +ve --\> _anti-endomysial abs_ (more sensitive & specific) * OGD & **duodenal biopsy** * Histology: _sub-total villous atrophy with crypt hyperplasia_ * **Mx:** gluten avoidance **Irritable bowel syndrome** - Dx of exclusion * **Sx:** bloating, related to stress, diarrhoea/constipation, relieved by defecation * **"Pellet-like stools"** * **Ix:** **_faecal calprotectin_** (an inflammatory marker of GI tract = less likely to be IBS, more likely IBD) * Mx: dietary changes, stress Mx, anti-spasmodics, probiotics, laxatives/loperamide, anti-depressants

Answer 30

**Reason to do AXR:** worried about bowel obstruction (small/large bowel) **Small bowel obstruction** on AXR: * valvulae conniventes (from one wall to other) * Central to image * \>3cm distension * _Causes:_ **adhesions** (surgery, sepsis), hernia, neoplasm, volvulus, IBD **Large bowel obstruction** on AXR: * Haustra (Not full width of bowel) * Outsides of image * \>6cm distension * _Causes:_ **neoplasm,** diverticular disease, volvulus, faecal impaction _NOTE:_ 3/6/9 rule = upper limits of normal for bowel (small = 3cm, large = 6cm, caecum = 9cm) **Volvulus signs** (twisting of loop of bowel on mesentery --\> balloon animal): * **Coffee bean sign** - sigmoid volvulus (large bowel just before rectum) * **Embryo sign** - caecal volvulus (large bowel just after small bowel)

Answer 31

IBD (also pyoderma gangrenosum), Sarcoidosis TB Meds (OCP, sulphonamides, aspirin/NSAIDs)

Answer 32

* **PSC** - intrahepatic & extrahepatic (horrible & progressive disease, obstructive jaundice) * **Associations:** _UC_ (10% but 80% PSC have UC), _Cholangiocarcinoma_ * **Ix:** MRCP, pANCA * 'Beads on string' on ERCP * **Tx:** supportive, liver transplant * **PBC** - intrahepatic only (benign condition - middle-aged female, intractable itching) * **Associations:** _AI diseases_ (RA, Sjogren's, hypothyroidism) * **Sicca syndrome** (70%) - dry eyes & mouth (like Sjogren's syndrome) * Fat malabsorption w/ steatorrhoea (incl vitamins ADEK): * Low vit D can cause _osteomalacia & proximal myopathy_ *e.g. difficulty climbing stairs & pain in lower back* * Low vit K can cause coagulopathy * **Ix:** _anti-mitochondrial Ab (AMA)_, high cholesterol * **Tx:** ursodeoxycholic acid (prognostic benefit)

Answer 33

**Hepatomegaly causes:** * _Hepatitis (infective and non-infective)_ * _Hepatocellular carcinoma/hepatic mets_ * Wilson’s disease, Haemochromatosis * Primary biliary cirrhosis * Leukaemia, Myeloma, haemolytic anaemia * Glandular fever * Tricuspid regurgitation **Splenomegaly causes:** * _Portal HTN secondary to liver cirrhosis_ * Splenic mets * Haemolytic anaemia, Congestive HF, Glandular fever **Large kidney causes:** * Bilaterally enlarged: _polycystic kidney disease, amyloidosis_ * Unilaterally enlarged: _renal tumour_

Answer 34

**Blood supply** * **Coeliac axis** - oesophagus, stomach, start of small intestine * **Superior mesenteric artery (SMA)** - most of the small intestines up to 2/3 transverse colon * **Inferior mesenteric artery (IMA)** - from 2/3 along transverse colon down to rectym * NOTE: area 2/3 along transverse colon @splenic flexure = **_WATERSHED ZONE_** (limited supply from superior & inferior mesenteric arteries) --\> _vulnerable to ischaemia!!_ **__Mesenteric ischemia** * **Acute** - occlusion of SMA by thrombus/embolus * **Sx:** severe abdo pain, normal abdo exam, shock * **Ix:** * _AXR_ (gasless abdo) * _VBG_ (lactic acidosis) * **CT abdo with contrast** (if suspect mesenteric ischaemia)/**CT angiogram** (if LA) * If not primary surgery --\> followed by _mesenteric angiography_ (Dx non-occlusive mesenteric ischaemia) * Mx: resus + CCOT + NBM * Empirical abx * Bypass ± bowel resection * Heparin post-op * **Chronic** - narrowing of SMA by atherosclerosis (stable angina of bowel) * **Sx:** colicky post-prandial abdo pain (more work for bowel to do --\> pain, just like in stable angina & exercise) * Ix: as above * Mx: medical optimisation + bypass (angioplasty + stent if not suitable for surgery) **Ischemic colitis** * Occlusion of inferior mesenteric artery (IMA) by thrombus/embolus * **Sx:** abdo pain, PR bleeding * **Ix:** sigmoidoscopy/colonoscopy * Mx: seek GI & surgical input (can develop chr ulcerating IC) * Mild - conservative (IV abx, fluids, bowel rest, DM control) * Prophylactic LMWH * Segmental resection + stoma

Answer 35

GOR(D) * external **G**enitalia * hernial **O**rificies * digital **R**ectal Ideally nipples to knees but in this case, I will do nipples to the groin due to possible patient discomfort

Answer 36

RFs: * Immune dysregulation (thyroiditis, T1DM, UC, Coeliac, RA) * Genetic predisposition: * For T1 AIH - HLA-DR3/4 * For T2 AIH - HLA-DQB1/DRB1 Ix: * Anti-smooth muscle Ab (SMA), ANA * T1: Anti-soluble liver antigen or liver/pancreas (SLA/LP), pANCA * T2: anti-LKM1 Mx: high-dose prednisolone + long-term azathioprine Complications: * Cirrhosis in 40%, relapse high if stop IS

Answer 37

**Spleen (vs kidney):** * Moves down with inspiration * You can’t get above it * Has a notch * Dull to percussion & not ballotable

Answer 38

Presentation: peripheral neuropathy, cerebellar, Wernicke's, gout, parotitis, Dupuytren's contracture Bloods: AST \> ALT (2:1) Decompensated Mx: * _Discrimination function_ calculated (PT/INR + bilirubin): * \<32/Inf/upper GI bleed --\> no steroids * Otherwise --\> steroids

Answer 39

**Blatchford score** Variceal bleed * Massive haemorrhage --\> balloon tamponade * A-E assessment --\> IV fluids, blood transfusion * F1 Essentials: * 2x large bore cannula * VBG * G&S/X-match * Bleep the bleed reg * Drugs with prognostic benefit: * IV Terlipressin (ADH analogue --\> vasoconstriction)/Somatostatin (used for same reason) * Prophylactic abx - Ceftriaxone/Norfloxacin (abx) * Intervention (discuss with on-call bleed registrar) --\> endoscopic band ligation

Answer 40

Dysphagia - difficulty swallowing * vs Odynophagia - painful swallowing * vs Globus sensation - lump in throat, no pain Oropharyngeal - difficulty initiating swallowing (± cough, choking, aspirating, _regurgitation_) - pressure in throat * Oral: * mastication (CN 5,7,11) e.g. CVA * Low saliva e.g. Sjogren's syndrome * Pharyngeal: * Neuromuscular - CVA, Myasthenia Gravis, Parkinson's * Upper oesophageal sphincter - decreased relaxation Oesophageal - difficulty after swallowing - pressure in chest * Solids & liquids - motor * Intermittent: oesophageal dysmotility * Progressive (solids --\> both): achalasia ("birds beak"), systemic sclerosis * Solids only - obstructive * Non-progressive: lower oesophageal rings/webs, oesophagitis * Progressive: stricture, cancer Ix: * Barium swallow - if a possible proximal oesophageal lesion * Upper endoscopy ± biopsy * If affects solids & liquids --\> manometry

Answer 41

RFs: * H. pylori exposure * Aspirin/NSAID use Types: * Gastric - pain worsened by meal (pain 30m-1hr after meal), loose weight, vomiting, assoc w/ _NSAIDs_ * Duodenal - MORE COMMON, pain relieved by meal (pain 2-3hrs after meal), assoc w/ _H. pylori_, worse by stress/at night --\> radiates to back, put weight on, malaena * Gastroduodenal artery - runs posterior to 1st/2nd parts of duodenum --\> likely cause of bleeding in PUD Presentation: * Chr/recurrent upper abdo pain - related to eating & nocturnal * Can be severe/radiate to back in Duodenal ulcers if ulcers penetrates pancreas * Pointing sign on exam - show where pain is with 1-finger * NOTE: 'Coffee grounds' vomiting = upper GI bleed (mostly due to PUD \> gastric erosions) Ix: * **OGD endoscopy** = gold-standard * Immediately if dyspepsia + upper GI bleed * Within 2wks if ≥55yrs + weight loss + dyspepsia/reflux/upper abdo pain --\> exclude malignancy * Repeat within 6-8wks to ensure ulcer healing/rule out malignancy * **H. pylori stool antigen**/breath test (2wk wash out period after PPI or 4wks after abx, retest 6-8wks after starting Tx) * Bloods - FBC Mx: consider **STOPPING NSAIDs** * Active bleed: * Urgent evaluation (A-E + **Blatchford score**) + blood transfusion * **OGD endoscopy** (Dx & Tx) --\> high-dose IV PPI afterwards (continue oral PPI for 6wks) * **Rockall score** (for risk of rebleed/death) --\> if re-bleed --\> repeat endoscopy & Tx endoscopically/emergency surgery * If H. pylori +ve: * **H. pylori eradication - triple therapy for 7 days** (**PPI** + 2 abx = **Amox** + **clari**/metro) --\> retest 6-8wks after starting Tx (leave washout 2wks after PPI, 4wks after abx) * If pen allergic --\> PPI + Clari + Metro * If long-term NSAID/aspirin use: * Consider stopping NSAIDs/aspirin * Ulcer healing Tx - full-dose PPI/H2 antagonist for 8wks --\> H. pylori eradication afterwards * If H. pylori -ve: treat underlying cause + PPI (4-8wks, 2nd line = H2 antagonist) * If recurrent/refractory ulcers --\> long-term PPI/H2 antagonist

Answer 42

Dx: haemochromatosis * Risk of HCC (hepatocellular carcinoma) Classification: * Hereditary - AR, gene on chr6 (carried by 1:10 Europeans) * Secondary e.g. from frequent blood transfusions (SCD) Presentation - from Fe-deposition in various tissues: * Arthritis (esp hands), bronze DM (tan), cirrhosis * Hypogonadism (accumulates in testis) * Dilated cardiomyopathy (accumulates in heart) * XR - chondrocalcinosis is assoc w/ pseudogout & haemochromatosis Ix: * Blood iron profile: * **TF saturation high** (\>55% men, \>50% women) * Ferritin normal/slightly high (\>500) * Low TIBC (as all transferrin saturated) Mx: * **Venesection** (until transferrin saturation normal) * **Desferrioxamine** (iron chelator to prevent recurring) * Monitoring ; TF saturation \<50% & serum ferritin \<50ug/l

Answer 43

**Ischaemic liver** **Massive paracetamol overdose** Very rarely: fulminant hepatitis (B/C) Weird causes of slightly raised ALT: Addison's coeliac, anorexia

Answer 44

Dx: Wilson's disease (AR) * Neuropsych issues + liver involvement (no increased risk of HCC unlike haemochromatosis) * Basal ganglia degeneration - movement disorders, dysarthria Ix: * Conservative: * Urinalysis - elevated urinary copper * _Kayser-Fleischer rings_ on slit-lamp exam * Bloods: hepatic bloods, **reduced serum ceruloplasmin** * Genetic testing (trinucleotide repeat) - condition appears earlier & earlier each generation Mx: **chelation w/ penicillamine**

Answer 45

Dx: GORD * Decreased lower oesophageal sphincter (LOS) pressure: * Drugs - nitrates, CCBs (smooth muscle relaxation) * Alcohol, smoking * Hiatus hernia Presentation: RFs (above), heartburn (worse lying down/at night), reflux incl bitter taste in mouth (after meals) Ix: * 8wk PPI trial * If dyspepsia consider _OGD_ for: **anaemia, weight loss, dysphagia, \>55yrs** * Oesophageal pH study (\<4 for \>4% of time = GORD) Mx: * Conservative: weight loss, smoking cessation, head of bed elevation/avoid eating late at night, reduce alcohol * Medical: * **Standard-dose PPI** (20mg omeprazole) - continued long-term (if Sx continue after stopping/erosive oesophagitis/Barrett's oesophagus) * H2 antagonist (e.g. cimetidine) * Surgery (only if PPIs work but don't want long-term medical Tx) e.g. laparoscopic fundoplication Complication: Barrett's oesophagus --\> oesophageal adenocarcinoma

Answer 46

Gastrinoma (pancreatic islet-cell tumour) * Multiple peptic ulcers & relapses * _Diarrhoea_ * NOTE: can be good for OSCE - PUD presentation + diarrhoea ZE syndrome - is one cause of poorly healing gastric ulcers, others: * Crohn's, gastric Ca * Bisphosphonates * TB, CMV

Answer 47

Def: tears of the squamous lining of the distal anal canal * \<6 weeks = acute, ≥6wks = chronic * 90% @posterior midline RFs: constipation, IBD, STIs (HIV, syphilis, herpes) Presentation: painful, bright red, rectal bleeding Ix: PR exam Mx: * Acute \<1wk: * Soften stool - high-fibre diet + high fluid intake, fybogel (2nd - lactulose) * Lubricants (for passing stool), topical anaesthetic, analgesia * Chronic: maintain above + topical GTN * After 8wks (if above not effective) --\> GI referral for sphincterotomy (or botulinum toxin)

Answer 48

**Portal hypertension** - increase in the pressure within portal vein, which carries blood from the digestive organs to the liver * Hepatic venous pressure gradient (HPVG) = gold standard for assessing severity and a pressure **\> 5mmg** Causes: * Pre-hepatic – Portal/splenic vein thrombosis, congenital atresia of portal vein * Hepatic – Cirrhosis, Schistosomiasis, hepatic mets * Post-hepatic – Budd-Chiari Syndrome, Veno-occlusive disease, constrictive pericarditis

Answer 49

Presentation: rectal bleeding & perianal pain Grading: * 1 - prominent BVs (no prolapse) * 2 - prolapse on bearing down + _spontaneous reduction_ * 3 - _manual reduction_ * 4 - _can't be manually reduced_ Ix: * Bedside: Anoscopic exam, stool (occult haem) * Bloods: FBC * Imaging: Colonoscopy/flex sigmoidoscopy Mx: * Conservative - fibre, fluids * Medical = **G1** - topical CS * Surgical: * **G2/3**: band ligation * **G4**: surgical haemorrhoidectomy

Answer 50

Sx: confusion, altered GCS, headaches, seizures, encephalopathic Ix: fluid status, U&E, paired osmolalities (urine, serum) **Fluid status:** * **HYPO**volaemic (dehydrated) - _WASTING_ (diarrhoea/vomiting, diuretics) --\> **IV fluids** * **EU**volaemic (normal) - _ENDOCRINE_ (SIADH, hypothyroidism, Addison's) --\> **fluid restrict + Tx underlying cause** * **HYPER**volaemic (fluid overload) - _FAILURE_ (liver, renal, heart) --\> **fluid restrict + Tx underlying cause** **Urine Na:** * \<20 mmol/L --\> hypovolaemia (increased Na reabsorption in kidneys --\> increasing H20 retention --\> reducing urine Na) * \>20 mmol/L --\> SIADH (BUT if on diuretics, urine Na can't be interpreted) --\> fluid restrict Na corrected too fast (\>10) = osmotic demyelination syndrome (central pontine myelinolysis) --\> pseudo-bulbar palsy, paraparesis, locked-in syndrome

Answer 51

Areas involved: 1. Dietary intake 2. Absorption in GI tract 3. Adrenals & kidneys - regulate serum K concentration **_HYPO_**kalaemia: * Poor dietary intake, vomiting/diarrhoea * Diuretics - loop/thiazide (block channels causing K reabsorption) * Hyperadrenalism (Conn's, bilateral adrenal hyperplasia, Cushing's) * Conn's/BAH - excess aldosterone - NOTE: Aldosterone promotes reabsorption Na, _excretion K_ * Cushing's = excess cortisol --\> off-target effect on mineralocorticoid receptors --\> mimics aldosterone **_HYPER_**kalaemia: * false = HAEMOLYSIS --\> repeat sample * Kidney failure e.g. on dialysis (kidneys = main route to remove K) * Anti-HTN/diuretics * ACEi/ARB - reduce kidney hyperfiltration, mainly a risk if CKD * K⁺-sparing diuretics e.g. spironolactone/amiloride * Addison's disease (failure - can't produce enough cortisol/aldosterone) * NOTE: appearance on ECG = **tented T-waves**, broad QRS, prolonged PR interval **Hyperkalaemia Tx:** * **Protect heart** - **IV 10-30ml _10% Ca Gluconate_** (repeat /15m, x5 MAX) * **Reduce K⁺:** * 1st line - **_10U Actrapid_** (insulin \> drive K into cells) **AND _100mL 20% glucose_** (to prevent hypo) * 2nd line - 5mg Salbutamol NEB (b-agonist) * **Ix cause:** drug chart, U&E (kidney funct), short SynACTHen test (Addison's)

Answer 52

**Hormone production:** * **Parathyroid gland** - PTH --\> _INCREASE Ca_: * Bone resorption * GI absorption * Kidney - decreased excretion, increases 1alpha-hydroxylation (vitD activation) * Vit D₃aka cholecalciferol (UV)/ergocalciferol (diet) * In **Liver** --\> 25-OH(D) aka calcidiol * In **Kidney** + _1alpha-hydroxylase_ --\> 1,25-OH₂(D) aka Calcitriol (activated vitD) --\> _INCREASE Ca_ * GI absorption * Kidney - decreased excretion **HYPERcalcemia** * **Sx:** * Stones - urinary tract calculi * Bones - fractures * (Abdo) moans - dyspepsia * Thrones - polyuria, constipation * (Psych) overtones - depression, psychosis * Ix - check **_PTH_**: * **Low** - _hypercalcemia of malignancy_ (PTH axis is functioning normally) - bone mets, PTHrP (released by lung SCC), myeloma (CRAB) * **Normal/high** - _primary hyperparathyroidism_ (as if serum Ca high, PTH should be low) - adenoma, hyperplasia, MEN 1&2 * Other: * Fluid status, ECG (short QT), protein electrophoresis, 24hr urinary Ca (familial hypocalciuric hypercalcemia) * Bloods - bone profile (Ca, PO4), U&E * Imaging: CXR * Mx: * IMMEDIATE = **aggressive IV 0.9% fluid resus** (4-6L over 24krs), repeat Ca * Tx underlying cause: * Parathyroid adenoma - minimally invasive surgery (subtotal/total parathyroidectomy) * Malig - **Zalendronate**/Pamidronate (inhibit osteoclast activity), slow infusion * Other: * If bone mets --\> _bisphosphonates_ * If renal failure --\> Cinacalcet (reduce PTH) * Recheck serum Ca @day 2 --\> 4 **HYPOcalcaemia** * Causes: * Hypoparathyroidism (PO4 high, PTH low) * Pseudohypoparathyroidism (PO4 high, PTH high) = PTH resistance * CKD (high PO4, PTH high, ALP high) * Vit D def (rickets/osteomalacia, low/normal PO4, high PTH, high ALP) * Hypomagnesaemia (low/normal PO4, low/normal PTH, normal ALP) * Presentation: * Peri-oral numbness, digital paraesthesia, dermatitis * +ve _Trousseau's_ (BP cuff 20 over SBP for 3mins --\> salt bae hand), _Chovstek signs_ (tap over the masseter muscle in the inferior pre-auricular area) * Laryngospasm (wheeze, dysphagia, muscle cramps) * Confusion, seizures, prolonged QT * Ix: serum Ca, PO4, Mg, PTH, U&E, Vit D * Mx: PO/IV replacement of Ca

Answer 53

* Primary - PTH secretion from primary parathyroid tumour/ectopic secretion from another tumour (high Ca, high PTH) * Secondary - PT hyperplasia to maintain control of hypocalcemia, normally from CKD (low Ca, high PTH, normal -ve feedback) * CKD --\> bone profile, parathyroid hormone lvl every 3-6 months * Tertiary - prolonged secondary, becomes irrepressible by serum Ca lvls. Mostly kidney transplant patients (high Ca, very high PTH)

Answer 54

Presentation: polyuria, polydipsia, dehydration * Ketosis - malaise, vomiting * FHx, other endo disorders * If known DM: * Previous DM control (hyp/hyper) * Micro/macrovascular complications * Diabetic eye disease (Dx & Tx) RFs: overweight, FHx (DM), PMHx (GDM), PCOS, HTN, dyslipidemia, CVD Criteria for Dx (repeat test needed for Dx): * Fasting plasma glucose of ≥7.0 (normal ≤6) * OGTT (BM 2hours after 75g glucose-load)/ Sx + random plasma glucose of ≥11.1mmol/l (normal \<7.8) * HbA1c ≥48mmol/mol (≥6.5%) - not for young/T1DM, acutely ill, haem disease, preg, iatrogenic T1DM Mx: **_exogenous insulin_** to avoid DKA & long-term complications * Diet - lower fat, higher carbs = counting carbs (adjust insulin around diet rather than limiting eating) * Diabetic specialist nurse - EDUCATE: * Self-adjust dose - **_D_**AFNE course for T1DM (*D for DM*) * Fingerprick glucose * Calorie intake & carb counting * Phone support * Don't stop insulin during acute illness, maintain calorie intake * Insulin regimens: * 1st line - **Basal-bolus regimen** * Basal (background) - BD insulin detemir (or Levemir/Lantus/Tresiba) as basal insulin * Bolus (before meals) - analogue rapid-acting insulin e.g. insulin Lispro (Humalog)/Aspart (Novorapid)/Neutral (Actrapid) * Other: * BD biphasic (premixed insulin, hypos common) e.g. Novomix, Humulin M3, Humalog Mix * OD before bed long-acting (for T2DM) * NOTE: intermediate-acting insulin e.g. Humulin I, Insulatard T2DM Mx: * 1st line - Lifestyle changes - **_D_**ESMOND course for T2DM (*D for DM*), dietician input, self-BM monitoring (individual HbA1c target \<6.5) * HbA1c targets: * No hypoglycaemics - 48mmol/mol * Hypoglycaemics - 53mmol/mol * Escalate Tx - 58mmol/mol * Medication: * 2nd - **Metformin** (SEs: diarrhoea, LA - avoid if eGFR \<30) * 3rd - ADD **Sulphonylurea e.g. Gliclazide** (SEs: hypoglycaemia, weight gain) * 4th - ADD other DM med: * **Pioglitazone** (SEs: hypoglycaemia, weight gain, oedema, fractures in elderly) * C/I in HF, bladder cancer * **SGLT-2 inhibitor e.g. Empagliflozin** (SEs: Hypoglycaemia, weight loss, UTI) * Not recommended in impaired renal funct * **DPP-4 inhibitor e.g. Linagliptin** (APPROVED FOR USE IN **_CKD_**, weight neutral) * **GLP-1 analogues e.g. Exenatide/Liraglutide** (SE: weight loss - useful if BMI \>35; vomiting) * Not recommended in impaired renal funct * 5th - If on triple therapy & not providing control --\> commence **_insulin_** * CVD risk Mx - anti-HTN, anti-lipid, QRISK-3 score * Diabetic nephropathy Mx: * **Monitor albumin-creatinine ratio (ACR)** * Consider _ACEi/ARB_ early * Diabetic neuropathy Mx: * Annual Sx review (erectile dysfunction, autonomic neuropathy - orthostatic hypotension, gastroparesis, bladder emptying difficulties) * Annual foot screen + specialist foot Mx, monitor for diabetic foot/ulcers ± amputation * Diabetic retinopathy: retinal screen annually (age ≥12yrs) * Background: need to tighten control * Venodilation, microaneurysms (dots), hard exudates (lipid deposits) * Tx: tighten glycaemic control, refer if near macula * Pre-proliferative (mild) - _soft exudates_ (cotton wool spots e.g. infarcts) * Proliferative - _neovascularization_ (+ floaters, reduced acuity) * Tx: **pan-retinal photocoagulation** * Diabetic maculopathy - hard exudates, oedema (+ blurred vision, reduced acuity) * Tx: **intravitreal triamcinolone acetonide** decreases macula oedema * NOTE: Pre-diabetic --\> refer to diabetes prevention programme (DPP) Diabetes complications: * Microvascular: * Eye - diabetic retinopathy (± cataracts, glaucoma) * Kidney - diabetic nephropathy * Neuropathy - damage to PNS --\> diabetic neuropathy (peripheral neuropathy - glove & stockings distribution) --\> diabetic ulcers/gangrene * Macrovascular: * Brain - stroke/TIA/cog impairment * Heart - coronary heart disease * Extremities - PVD, diabetic ulcers/gangrene

Answer 55

Insulin: * High level of insulin --\> reduces serum BM (pushes into surrounding tissues & hepatic glucose store) * Low level of insulin --\> switches off ketone production Pathophysiology: * HHS = complication of T2DM * In HHS have enough insulin to switch of ketone production but not enough to reduce BM lvls * High glucose - osmotically active --\> polyuria --\> dehydration HHS criteria: * Hypovolaemia * Glucose \>30mmol/L * NO ketonaemia * Serum osmolality \>320mOsmol/kg Mx: REHYDRATE = **IV 0.9% NaCl (3-6L by 12hrs, deficit 110-220mL/kg)** * Targets: * Reduce **Na** by less than _10mmol/L/day_ (otherwise risk osmotic demyelination syndrome) * Reduce **BM** by over _5mmol/L/hr_ * NOTE: if targets not met by 0.9% saline --\> 0.45% instead * If fluid alone are not enough --\> **0.05 units/kg/hr fixed-rate insulin infusion**

Answer 56

**Criteria:** * True hyponatraemia * High urine osmolality * Clinically euvolemic * Dx of exclusion (9am cortisol + TFTs must be normal) **Causes:** * Malig (small cell lung cancer, breast cancer) * CNS disorders (encephalitis, abscess) * Chest disease (pneumonia, TB) * Drugs (opiates, _SSRIs_, carbamazepine)

Answer 57

**Sx:** hypernatremia (lethargy, thirst, irritable, confusion, coma, fits), polyuria, urine plasma osmolality \<2 (very dilute) **Types:** * Central (lack of ADH prod in hypothalamus) – pituitary surgery, irradiation, trauma, infarction * Nephrogenic (resistance to ADH effects) – hypercalcaemia, hypokalaemia, meds (lithium) **Ix:** rule out DDx (BM, review drugs, K/Ca lvls) * U&E, Ca, BM, serum & urine osmolarities * Dx: 2-step fluid deprivation test = give **desmopressin (DDAVP):** * Normal/primary polydipsia --\> urine concentrates on fluid deprivation (\>600) * Cranial DI - giving desmopressin allows ADH prod --\> urine conc * Nephrogenic DI: urine never concentrates * NOTE: DI excluded if urine to plasma (U: P) osmolarity ratio \>2:1 * _Cranial MRI_ - if suspect cranial DI NOTE: Fluid deprivation test process: * Baseline urine osmolality * Fluid deprivation for 8hrs, take urine osmolality * Give desmopressin, wait 8hrs, take urine osmolality Tx: * Nephrogenic DI --\> fluids (+ monitor UO) + **thiazide diuretics** (hydrochlorothiazide - weird/does not make sense) * Central DI --\> fluids + **desmopressin**

Answer 58

**Hypothyroidism:** * Causes: * _Primary:_ * **Hashimoto's thyroiditis** - most common hypothyroidism * Goitre, AI disease (vitiligo, pernicious anaemia, T1DM, Addison's) * Elderly females * May be initial ‘Hashitoxicosis’ * +++ Autoantibody titres * _Antithyroid peroxidase (TPO) & antithyroglobulin (TG)_ * **Atrophic AI thyroiditis** * No goitre, anti-TPO/TSH * Iodine def, meds (carbimazole, lithium), thyroid surgery * _Secondary:_ pituitary gland fails to produce TSH * Tumour, vascular (Sheehan syndrome), radiation, inf * Ix: * Bedside: ECG (pericardial effusion, ischaemia) * Bloods: FBC, U&E, TFTs, Lipids, Prolactin, Anti-TPO/TG * Imaging: CXR (effusions, HF) * Mx: thyroid replacement therapy (levothyroxine) * Monitor with serum TSH, careful with dose in elderly (prone to IHD) * Myxoedema coma - A-E & active warming, T3 slow IV, hydrocortisone IV * Associated complications: * Cardiac - HF * Serous effusions (pleural, peritoneal, pericardial, joint) * Neuro - carpal tunnel, proximal myopathy, cerebellar dysfunction, myxedema coma * Systemic - dyslipidemia, anaemia **Hyperthyroidism:** * Presentation: * Weight loss, increased appetite * Heat intolerance, tremor, sweating, palpitations * Mood (anxious, irritable) * Bowel habit (diarrhoea), menses (oligomenorrhoea) * Goitre * Eye Sx (watering, gritty, red) * Other AI disease (vitiligo) * Signs: * Lid lag (eyes) * Palmar erythema * Brisk reflexes * Sinus tachy/AF * Ix: TSH low, T3/4 high, TPO (may be raised), anti-TSHr ab (in Graves), technetium 99m uptake scan (diffuse/reduced) * Causes: * High-uptake: * **Graves’ disease**: MOST COMMON, autoantibodies ++ (_anti-TSH-R ab_), * Eye signs: proptosis --\> exophthalmos, diplopia, visual loss * Peripheral signs: pretibial myxoedema, thyroid acropatchy, onycholysis, bruit over thyroid * **Toxic multinodular goitre aka Plummer's disease:** hot nodules, _painless_ * Toxic adenoma: 5%, single ‘hot nodule’ on isotope scan (1 area of uptake) * Low-uptake: * **Subacute De Quervains (viral) thyroiditis**: self-limiting post-viral painful goiter. Initially hyperthyroid, then hypothyroid * Tx: NSAIDs * Postpartum thyroiditis (like De Quervain’s but postpartum) * Mx: * Conservative: lifestyle changes, corneal lubricants * **Medical:** * Sx relief – _B-blockers_ * Antithyroid meds - _Carbimazole_ (or propylthiouracil) * SEs: rashes, agranulocytosis - monitor * _Radioiodine:_ * acts slowly, effective, best Tx for toxic multinodular goitre * Risk of permanent hypothyroidism (10%) * CI in preg/lactating women * **Surgical:** _subtotal thyroidectomy_ (in large goitre/relapse) * Monitoring with TFTs annually * **Thyroid storm:** acute state of shock, pyrexia, confusion, vomiting * HDU/ITU support * _Propylthiouracil_ 600mg --\> 200mg QDS * Stable iodine (Lugol's iodine) ≥1hr later * Propranolol, dexamethasone & IV fluids

Answer 59

**Cushing's** #HighCortisol * Causes: * ACTH-dependent: * **_Pituitary_ tumour** (85%) = “Cushing’s disease” * _Ectopic_ ACTH-prod tumour (5%) - SCLC/carcinoid tumour * ACTH-independent: * _Adrenal_ tumour (10%) * _Iatrogenic_ steroid use * Presentation: * Thin skin, easy bruising, proximal myopathy, obesity (moon face, buffalo hump), other (hirsutism, acne) * Exam: vertical abdo striae * HTN, DM, osteoporosis (back/bone pain) * Ix: * Exclude pseudo-Cushing's - depression, alcohol excess, chr inf (no muscle weakness) * Confirm Dx: **low-dose dex suppression test** - fail to suppress cortisol in all * Overnight dexamethasone suppression test (1g @11pm) OR * 48hr low-dose 0.5mg/6h PO dexamethasone supression test OR * 24-hr urinary free cortisol (test x3 as low sensitivity) * **Plasma ACTH measured**: * High - _CRH test_ identifies if pituitary or ectopic * Could also do bilateral inferior petrosal sinus sampling --\> if no mass --\> CT contrast CAP for ectopic * Low - adrenal tumour --\> _CT/MRI adrenal glands_ --\> if nothing --\> adrenal vein sampling * Mx: treat underlying disease e.g. _withhold steroids_ or surgical removal of the lesion * Cushing's disease (pituitary tumour) --\> **trans-sphenoidal hypophysectomy** (complications - DI, hypopituitarism) * 2nd - _pituitary radiotherapy_ (also used if still high cortisol post-surgery) --\> progressive anterior pituitary failure * Metyrapone & ketoconazole - sometimes before/after surgery * 3rd - laparoscopic bilateral adrenalectomy in refractory (but require lifelong glucocorticoid/mineralocorticoid replacement + risk of Nelson's syndrome (increased skin pigment from high ACTH **Hypoadrenalism** * Causes: * AI: **Addison's disease** (\>70%) * Malig: **mets** (lung, breast. kidney) * Inf: **TB** (\>10%), HIV (CMV adrenalitis), Fungal * Infiltration: granulomatous disease, hemochromatosis, amyloidosis * Iatrogenic: ketoconazole, rifampicin, phenytoin, bilateral adrenalectomy * Congenital: congenital adrenal hyperplasia (late-onset) * Presentation: * Anorexia/weight loss, fatigue/weakness, postural dizziness, reduced libido, sweating * N&V, diarrhoea, salt craving * Signs: hyperpigmentation in skin creases/lip/mouth, vitiligo, sparse axillary/pubic hair * Ix: * Bedside - postural hypotension, IGRA (TB inf) * Bloods - FBC, **U&E** (↑ K⁺, ↓ Na⁺), **low glucose**, serum Ca, AI/auto-ab screen, plasma renin & aldosterone, **short snACTHen 250mcg IM test** (not Addison's if 30min cortisol _rises \>550nmol/L_ * Imaging: CXR (past TB), adrenal CT (for TB/mets) * Mx: * Addisonina crisis: Tx underlying cause, ICU input & alert bracelet * Ppt factors: inf, trauma, surgery, missed steroid doses * Ix: _Cortisol, ACTH_, U&E * Mx: **IV hydrocortisone + IV fluids ± fludrocortisone (if primary adrenal lesion)** * Monitor BM ± IV dextrose * Bloods, urine, sputum culture ± abx * Chronic: hydrocortisone + fludrocortisone (Na homeostasis), _education_ (compliance, increase steroid dose if ppt factors, follow-up **Hyperaldosteronism** (incl. Conn's) * Primary (HTN, ↑ Na+ ↓ K+): * **Conn's -** aldosterone-secreting adrenal adenoma * _Bilateral adrenal hyperplasia_ * Secondary - decreased renal perfusion (high renin --\> Na reabsorption --\> HTN) - RAS, HF, liver failure * Ix: **aldosterone-renin ratio** (ARR), CT/MRI adrenals, adrenal vein sampling * Conn's is very high (high aldosterone, low renin) VS BAH has both high (high aldosterone, high renin) * Mx: spironolactone, unilateral adrenalectomy (for Conn's) ****_PH_**aeochromocytoma** #HighCatecholamines * Cause: adrenal medulla tumour --\>↑ catecholamines (adrenaline/NA) * Presentation: episodic headache, sweating, tachycardia, hypertension, arrhythmias, death if untreated * 10% exta-adrenal, 10% bilateral, 10% malignant * Ix: ECG (LVF, increased ST seg, VT), **24hr urinary metanephrines**, abdo CT/MRI * Mx: specialist endo centre - alpha blockade = **_PH_**enoxybenzamine then beta-blockade --\> then surgery when BP controlled (after 4-6wks)

Answer 60

DDx: * Anaemia - PUD, altered bowel habit? occult blood loss? * Thyroid disease - thyroiditis? * DM - polyuria, polydipsia, weight loss * Adrenal insufficiency * Primary hyperparathyroidism - constipation, urinary stones, abdo pain, depression * Hypopituitarism * Anxiety & depression - sleep disturbances, poor appetite, recent stress Ix: * FBC, U&E, LFTs, CRP, bone profile, HbA1c, TFTs, haematinics * CXR

Answer 61

**Normal glucose transport:** diet --\> blood --insulin--\> hepatic glucose store --GH, Cortisol, Adrenaline, Glucagon--\> blood * During starvating - GH, Cortisol, Adrenaline, Glucagon make sure there is enough glucose in the blood BUT liver also produces ketones * Ketones can cross BBB providing an alternative source of fuel for the brain when low glucose * Pancreatic beta cells --\> insulin prod --\> reduces glucose (high glucose has--\> feedback on pancreatic beta cells --\> produce more insulin) * High insulin (associated with high glucose) --\> -ve feedback on ketone prod **In insulin deficiency** - high glucose but unable to produce insulin + no -ve feedback on ketone prod --\> _high glucose, high ketones_ * High glucose - osmotically active (moves along concentration gradient into urine --\> pulling more water with it) --\> POLYURIA --\> DEHYDRATION * High ketones - acidic (metabolic acidosis) --\> enzyme dysfunction --\> COMA & DEATH DKA Ix: * Bedside - urine dip, ECG, continuous cardiac monitoring * Bloods - VBG, FBC, U&E, BC, BM * Imaging - possibly CXR DKA Dx: * BM: ≥11mmol/L * Ketones: ≥3mmol/L (serum) OR ≥2+ (urine) * Acidaemia: pH \<7.3 OR Bicarb \<15mmol (ketoacidosis) DKA Mx: A-E assessment * **IV FLUIDS** (rehydrate) * Bolus --\> 1L over 1hr --\> 2hr --\> 3hr --\> 4hr * Add _40mmol KCL_ to fluids after bolus * **0.1 U/kg/hr fixed-rate INSULIN** **infusion** (reduce ketones) * If BM \<14 --\> start _125ml/hr 10% dextrose_ * Insulin infusion continues until ketones normalise (not BM) * NOTE: follow local trust guidelines for DKA Tx as varies slightly between trusts Monitor - BM, ketones, VBG (K conc) * Hourly targets: * Fall in BM ≥3 * Fall in ketones ≥0.5 * Rise in HCO3 ≥3 * Continue until: blood ketones \<0.6, pH \>7.3, HCO3 \>18

Answer 62

Cause: macroadenoma in anterior pituitary Presentation: coarse facial features * Skin (acanthosis nigricans - thick & dark in creases), sweating, carpal tunnel syndrome (bilateral) * Arthropathy, sleep apnoea, reduced sexual functioning, visual field defects (bitemporal hemianopia) * Assoc: DM, HTN, MEN type 1 (15%) Ix: * Bedside: CN VI palsy, urine dip (glucose), ECG (cardiomyopathy) * Bloods: **elevated IGF-1**, GH lvl during OGTT (not suppressed in acromegaly) * Imaging: MRI brain (macroadenoma), sleep studies, colonoscopy (screening), visual field testing (driving) Mx: * Transsphenoidal hypophysectomy (curative) * Medical: somatostatin analogue (octreotide) * External pituitary radiotherapy (long-term 5-10yrs) Complications: * General: HTN, DM, carpal tunnel syndrome, sleep apnoea, colorectal cancer, LVH/cardiomyopathy/IHD * Anterior pituitary hypofunction: hypogonadism * Local compressive: bitemporal hemianopia

Answer 63

* Conservative measures * Medical (none proven to provide sustainable weight loss) * Orlistat (gut lipase inhibitor, SEs: profound flatus, diarrhoea) * Surgical – bariatric surgery (BMI \>40 OR \>35 w/ comorbidity assoc w/ obesity) * Needs extensive screening + commitment to long-term follow-up

Answer 64

Causes: * Prolactinoma (macroprolactinoma \>6000) * Adenoma (non-funct pituitary adenoma 1000-5000, from compression & DA lvls) * DA antagonist (metoclopramide, anti-psychotics, methyldopa) * Hypothyroidism (increased TRH stimulates prolactin prod) * Physiological (pregnancy, breastfeeding) Presentation: irreg periods, decreased libido, galactorrhoea * Bilateral hemianopia Ix: * Bedside - pregnancy test, visual fields assessment * Bloods - serum prolactin, TFTs, U&E * Imaging - pituitary MRI Mx: * Asymptomatic pre-menopausal/post-menopausal with microadenoma - observation * Symptomatic pre-menopausal/macroadenoma post-menopausal/male: * **Dopamine agonist** (Cabergoline/Bromocriptine), 2nd line - COCP (not if want pregnancy) * Trans-sphenoidal surgery (if visual Sx/pressure effects refractory to medical Tx) * Follow-up: monitor prolactin, check visual fields

Answer 65

DDx: * Thyrotoxicosis - heat intolerance, palpitations, SoB, mood (irritable/anxious), bowel habit, menses, goitre, exophthalmos, recent pregnancy * GI-related conditions (IBD, upper GI pathology, coeliac disease, chr pancreatitis) - dysphagia, vomiting, regurgitation, abdo pain, altered bowel habit * Eating disorders (Anorexia nervosa) - reduced eating, compulsive exercise * Systemic conditions (malignancy) - FLAWS Ix: * FBC, U&E, CRP, LFTs, fasting BM, bone profile, TFTs, anti-TTG, IgA levels, haematinics * CXR

Answer 66

Diffuse: Graves' disease, Hashimoto's thyroiditis, De Quervain's thyroiditis Nodular: Multinodular goitre, adenoma, carcinoma

Answer 67

Classic = 6Ps: pain, pallor, perishingly cold, pulseless, paraesthesia, paralysis (BUT these tend to be more associated with PVD than compartment syndrome) Typical presentation: tightness in compartment + acute disproportionate pain (worse on stretching) after _trauma_: * Acute is following fracture, soft tissue/reperfusion/thermal injury * Chronic (pain on exercise) often in long-distance runners * Other early sign = paraesthesia * Late signs: pallor, pulseless, paralysis RFs: Trauma, bleeding disorder (haemophilia), compartment support (tight cast/wrappings), burns, intense muscular activity (long distance runner) Ix: * Compartment differential pressure measurement - within 20-30mmHg = fasciotomy needed * +/- serum CK, urine myoglobin (rhabdomyolysis) Acute Mx: dressing release + morphine * 2nd line = complete fasciotomy (open all 4 compartments of lower leg) * 3rd line = amputation * If rhabdomyolysis —\> hydration +/- Na bicarbonate (urine alkalisation) +/- haemodialysis (metabolic acidosis) Chronic Mx: limit exercise + NSAIDs * 2nd line = fasciotomy

Answer 68

NO HIVE: * **N**odules - _rheumatoid nodules_ (25%) * **O**steoporosis (worse by steroids & immobilisation) * **H**eart & haem - pericarditis, _anaemia_, Felty's syndrome (RA + splenomegaly + neutropenia) * **I**nterstitial - _pul fibrosis_ (& pleural effusions, Caplan's syndrome - nodules from RA + pneumoconiosis), interstitial nephritis (nephrotic syndrome) * **V**asculitis (high titre RF) * _Peripheral neuropathy_ presenting as mono-neuritis multiplex * Other neuro: carpal tunnel, cervical myelopathy * Splinter haemorrhages, cutaneous ulcers, distal gangrene * **E**ye pathologies - _secondary sjogren's syndrome_ (dry eyes, mouth & cough), episcleritis

Answer 69

Def: AI process causing **synovial joint inflammation (synovitis)** with destruction of peri-articular structures Presentation: joint pain @rest, swelling & stiffness in morning * Exam: * Symmetrical swelling w/ DIP sparing * Muscle wasting, ulnar deviation, volar subluxation @MCPs * Swan-neck & Boutonnieres’ & Z-thumb deformities * NOTE: if nail changes/extensor rash = psoriatic arthritis * Extra-articular manifestations of RA = **NO HIVE**: * **N**odules - rheumatoid nodules (25%) * **O**steoporosis (worse by steroids & immobilisation) * **H**eart & **H**aem - pericarditis, anaemia, Felty's syndrome (RA + splenomegaly + neutropenia) * **I**nterstitial: * _Pul fibrosis_ (& pleural effusions, Caplan's syndrome - nodules from RA + pneumoconiosis) * Interstitial nephritis (nephrotic syndrome) * **V**asculitis (high titre RF) * _Peripheral neuropathy_ presenting as mono-neuritis multiplex * Other neuro: _carpal tunnel_, cervical myelopathy * Splinter haemorrhages, cutaneous ulcers, distal gangrene * **E**ye pathologies - _secondary sjogren's syndrome_ (dry eyes, mouth & cough), episcleritis Ix: anti-RF/CCP, ESR/CRP, X-rays Mx: * Create an end target e.g., remission * 1st - Monotherapy with conventional DMARD (methotrexate/sulfasalazine) + bridging pred until Sx resolved * Target met? * Yes = keep drug regime + lifestyle changes (stay active, healthy diet, weight loss if appropriate, alcohol/smoking) * No = titrate cDMARD/trial alternative cDMARD ± dual therapy * Target met? * Yes = keep drug regime + lifestyle changes * No = biological agents if DAS28 score \>5.1 (severe burden of disease)

Answer 70

Pathogenesis - loss of cartilage + bone remodelling --\> inflammation & osteophytes Presentation: pain worse with activity, crepitus + reduced RoM * Hands - DIP & PIP swelling = Heberden’s (DIP) & Bouchard’s nodules (PIP) * Common site = base of the thumb (1st carpometacarpal joint) * Weight-bearing joints affected e.g. knees * NOTE: midline knee scar = total knee replacement --\> fixed flexion deformity post-replacement Ix: XR (2 views e.g. AP & lateral) * LOSS: **L**oss of joint space, **O**steophytes, **S**ubchondral sclerosis, **S**ubchondral cysts Mx: * Conservative – physio, exercise, weight loss * Medical: * Analgesia (paracetamol --\> topical NSAID --\> oral NSAID/opioid) * IA CS injection * Surgical – arthroplasty (e.g. TJR)

Answer 71

Signs: * Extensor plaques with scales (scalp + behind ears) * Nails - pitting, hyperkeratosis, onycholysis * Other forms: guttate (drop-like), Koebner phenomenon Types: * Mono/oligoarthritis * Spondylitis (back) * Asymmetrical polyarthritis (incl DIP-specific) * Arthritis mutilans * Rheumatoid-like Criteria name: CASPAR criteria - established inflame arthritis/enthesitis + ≥3 of options Mx: * Conservative: * Psoriasis - precipitant avoidance (alcohol, smoking, stress, B-blockers) * Exercise & physio for arthritis * Medical: * Psoriasis: * Topical Tx: * Topical steroids (hydrocortisone 2.5%/betamethasone 0.05%) * Calcipotriol * PUVA = Psoralen + UVA phototherapy * Arthritis = Methotrexate, anti-TNFs

Answer 72

0 to -2.5 DEXA: * Conservative - exercise, reduce alcohol, balanced diet, Tx underlying causes * Repeat DEXA @2yrs * 1st line - Bisphosphonates PO (e.g. alendronic acid) --\> if not tolerate can trial Denosumab/Raloxifene/Teriparatide * Vit D + Ca replacement (if inadequate sunlight/intake exposure) * Review Tx every 3-5yrs NOTE: * If premature menopause --\> discuss HRT * If on high-dose CS (≥7.5mg OD for ≥3 months) --\> consider bisphosphonates for bone protection Osteonecrosis of the jaw

Answer 73

Presentation - hot swollen joint with reduced range of motion Mx: needle aspiration before abx --\> fluids for 3Cs & G (cells, culture, crystals, gram stain) --\> empirical IV abx (based on aspiration) * S. aureus is most common * NOTE: if prosthetic joint - biofilm can be created - early (\<3m post-surgery)/delayed (\>3m) --\> more complicated, coag neg staph more common

Answer 74

Rules = **Ottawa rules** - for what ankle fractures qualify for an X-ray * Ankle XR: * Pain over malleolar zone * Tenderness along distal 6cm of the posterior edge of tibia/fibula * Inability to weight bear * Foot XR: * Pain over midfoot zone * Tenderness at base of 5th metatarsal/navicular bone * Inability to weight bear Classification = Weber classification - location of the fibula fracture in relation to the Syndesmosis (Distal Tibiofibula Syndesmosis - ligament between tibia & fibula) * Normal * A - fracture distal to the syndesmosis * B - fracture @level of the syndesmosis * C - Fracture above the syndesmosis * If also affecting the medial malleolus = bimalleolar fracture Ix: AP, lateral & oblique ankle X-ray * CT (distal tibia & hindfoot) - comminuted fracture * MRI - ankle ligaments & tendons Mx: depends on _Weber classification_ & level of _displacement_ * No to all Ottawa rules = conservative Mx: RICE – rest, immobilisation, compression, elevation * Unimalleolar: * No evidence of ligamentous injury on X-ray --\> _discharge w/ cast + fracture clinic follow-up X-rays_ * Evidence = UNSTABLE * Bimalleolar/unstable --\> _closed reduction (if joint dislocated on X-ray) --\> refer for surgical fixation_

Answer 75

**NoF anatomy - blood supply:** * Deep femoral artery (the main branch of the femoral artery) - gives rise to: * Medial & lateral circumflex femoral arteries - gives rise to: * Retinacular arteries - progress superiorly up to the head of the femur * Artery of ligamentum teres - only a very small component of perfusion of the head/neck of the femur * NOTE: retrograde blood supply from distal to proximal **NOF anatomy - joint capsule** (ligaments surrounding the head of the femur and acetabulum): * Intracapsular - fracture within the joint capsule (proximal to the trochanteric line) - high risk of blood supply compromise as retinacular vessels sheared --\> Avascular Necrosis (AVN) * Extracapsular - fracture outside the joint capsule (distal to the trochanteric line) - less risk of blood supply compromise **RFs**: elderly, freq falls, osteoporosis, high impact trauma, post-menopausal women **Presentation:** externally rotated + shortened leg * Typically old, frail, osteoporosis/malacia **Ix:** * Examine joints above & below, NV exam of lower limb * FBC, U&E, LFTs, CRP, G&S (if NoF - need surgery) * Hip XR --\> CT/MRI (if normal X-ray but high suspicion) * NOTE: NoF fracture Xrays: **_Shenton line_** - if not smooth = likely fracture * **NoF fracture types - based on location:** * Sub-capital (slightly below the head) * Transcervical * Basicervical * Intertrochanteric * Subtrochanteric * **Garden classification - level of displacement:** * Stage 1 - incomplete (not all the way through the bone) * Stage 2 - complete (but fracture components intact) * Stage 3 - complete with _some displacement_ * Stage 4 - complete with _significant displacement_ Mx: * Conservative - analgesia * Medical - bisphosphonates (bone protection) + Vit D + DEXA * Surgical: * Subtrochanteric - internal fixation = _femoral nail_ * Intertrochanteric – internal fixation = _dynamic hip screw (DHS)_ * Intracapsular: * Undisplaced (Garden I&II) – cannulated hip screw or DHS * Displaced (Garden III & IV) - higher risk of AVN: * \<55yrs – reduction & fixation w/ screws * \>65yrs – replace: * Fit = _THR_ (HoF & acetabulum replaced) * Independent, mobile with ≤1 stick, no cognitive impairment * Not fit = _hemiarthroplasty_ (just HoF replaced)

Answer 76

**Types:** * Colles' fracture - common in A&E, fall on an outstretched hand --\> fracture of distal radius, displaced dorsaly (dorsum of the wrist) * Smith fracture - fall on flexed wrist, displaced in a palmar direction (palm of the wrist) * NOTE: displaced in the direction that is facing upwards (e.g. in Colles' the dorsal aspect is facing the sky; in Smith's the palmar aspect is facing the sky) **Mx:** * Check neurovascular intact * Imaging (visualise fracture) * _Reduction_ under haematoma block \> _Hold_ (e.g. cast) \> _Rehabilitate_ * NOTE: Smith's fracture is often more complicated --\> surgical intervention

Answer 77

* Joint erosion * Periarticular osteopenia * Ulnar deviation * Z-thumb * Swan neck

Answer 78

**MSK X-RAY APPROACH:** * NOTE: likely knee or hip x-ray in the exam General: * Name, DoB ±PC * XR - date & time, views (AP/lateral), area of body, rotation, penetration (**_R_**I_P_E) * NOTE: always do _≥2 views_, compare to _previous X-rays_, look at imaging for _joints above and below_ **ABCS** approach: **A**lignment & joint space, **B**one texture, **C**ortices, **S**oft tissues * **Alignment & joint space:** * Changes suggest --\> fracture, subluxation (still touch) or dislocation * Displacement - describe the position of fragment distal to fracture site described * Joint space: * Narrowing due to cartilage loss/calcification (chondrocalcinosis)/new bone (osteophytes) * Subchondral sclerosis is increased bone density along joint lines (OA) * **Bone texture** - altered density (subchondral cyst - increased density, OA)/disruption (blurry - osteomyelitis) in trabeculae (inside of bone)/cortex (outer coating) * **Cortices** - trace around outside of each bone * Step = possible pathology: * Fracture * Bony destruction - inf or tumour (primary/secondary) * Periosteal reaction (new bone in response to injury/stimuli, appears as pale bone on the outside) - can be only sign of stress/healing fracture, mild osteomyelitis, tumour) * Soft tissues - swelling, foreign bodies (lipohaemarthrosis caused by fracture), effusions **DESCRIBE A FRACTURE:** Where - what bone? location (proximal, middle, distal OR epiphysis, metaphysis, diaphysis)? Does it involve articular surface (intra/extra-articular)? **Types:** _1. Simple vs Compound:_ * **Simple**: _closed_ fracture i.e. only bone involved * **Compound:** _open_ fracture i.e. bone exposed to the external environment - (↑risk of infection → ↑fracture non-union) Open fractures are emergencies and require urgent management with: * IV antibiotics * Tetanus prophylaxis * Wound debridement _2. Subtype:_ * Complete (all the way through the bone) * **Transverse:** perpendicular to long axis of bone * **Oblique:** tangential to long axis of bone * **Spiral:** oblique and rotating around the shaft * Comminuted: \> 2 fragments --\> CT to further assess * Impacted: broken ends of bone are jammed together by the force of injury, fracture line is indistinct * Linear: parallel to axis of the bone * Avulsion: bone attached to tendon/ligament is pulled away from main bone * Incomplete (not whole cortex, most common in children): * Greenstick: bone bends and cracks, occurs \< 10yrs * Salter-Harris: growth plate involvement Displacement - describe the position of distal fragment to body (anterior/posterior) * Angulation: change in bone axis (varus/valgus, dorsal/palmar, radial/ulna) * Translation: movement of fractured bones away from each other (% of bone width) OVERALL: 1) _Type_ (simple/compound \> subtype) 2) _Relevant region, side and name of bone_ 3) _Displacement_ (& angulation, translation) * Example: Simple oblique fracture of the proximal right tibia with posterior displacement

Answer 79

Meniscal injury - tenderness over joint line (+ McMurray's) Gout/pseudogout - swollen, erythematous, tender joint OA - pain, crepitus, limited RoM Ligament injury based on special tests/mov

Answer 80

Swan neck deformity - PIP hyperextension, DIP flexion Boutonniere's deformity - PIP flexion, DIP hyperextension Other signs of RA: Z-thumb, ulnar deviation

Answer 81

Def: hypertrophy & contracture of palmar aponeurosis (fascia retinaculum) Causes: * Idiopathic, age, trauma, familial (AD) * _Alcoholic liver disease_ * _Epilepsy & anti-epileptics_ (e.g. phenytoin)

Answer 82

CMCs --\> MCPs --\> PIPs --\> DIPs Carpal bones: **S**ome **L**overs **T**ry **P**ositions **T**hat **T**hey **C**an't **H**andle * Base of wrist (radial to ulnar): **S**caphoid, **L**unate, **T**riquetrum, **P**isiform * CMCs (radial to ulnar): **T**rapezium (trapezi"thumb"), **T**rapezoid, **C**apitate, **H**amate

Answer 83

Look at Shenton's line (inferior pubic rami) = NoF fracture

Answer 84

Presentation: 1st MTP joint, monoarticular (can be poly) Ix: Bloods (FBC, CRP, Urate), X-ray (errosive) Mx: * Acute: * NSAIDs * Colchicine * Oral Pred (5 days), steroid joint injection * Chronic: * Dietary advice - low purine, weight loss * Xanthine oxidase inhibitor e.g. allopurinol/febuxostat * Consider - uricosuric agents e.g. sulphinpyrazone, probenicid, benzbromarone * (NOTE: Rasburicase - tumour lysis syndromes)

Answer 85

Axial spondylitis Ix: * Spinal exam: _Schober's test_ - gross restriction \<3cm (should be 8-10cm) * X-ray: * Sacroiliitis * Sclerosis * Erosive damage * Widening joint space * (Fusion) * MRI scan whole spine & sacroiliac joints - detect pre-radiographic axial spondylitis * Sacroiliitis * Shiny corners (Romanus lesions) Mx: * Analgesics + NSAIDs * TNF-alpha blocker (or IL-17 blocker)

Answer 86

Def: multisystem disease - inflammation, vascular abn, fibrosis Presentation: digital ulcers, tight skin around hands/mouth Subsets: * Limited cutaneous SS (CREST) - skin changes limited to forearm/calf/distal/peri-oral area * Diffuse cutaneous SS - more extensive, upper arms, legs, trunk Presentation: * Swelling of hands & feet, Reynaud's phenomenon, skin thickening * Heartburn/reflux/dysphagia, bloating * Arthralgia/myalgia * Dyspnoea & dry crackles (pul fibrosis, pul HTN) * Scleroderma renal crisis (renal failure, marked HTN) Ix: * Bedside: ECG, urine dip, pulmonary function tests (pul fibrosis) * Bloods: * FBC, U&E, LFTs, CRP/ESR, * Abs: ANA (also in SLE, AI hep), **anti-centromere** (limited cutaneous), **SCL-70 aka topoisomerase** (diffuse cutaneous) * Imaging: CXR, Echo, barium swallow Mx: * Specialist MDT * Conservative: smoking cessation, **emollients**, avoid cold/gloves (Raynaud's), physio, OT * Medical: * CCB (nifedipine) for Raynaud's * Omeprazole, prokinetic (domperidone) for GI Sx * Analgesia (for joint pain) * ACEi (for HTN) * **Steroids + IS** (methotrexate) --\> if diffuse disease/complications (pul fibrosis) * Scleroderma renal crisis - ACEi + renal dialysis/transplant

Answer 87

GCA is most common primary vasculitis **Presentation:** headache, scalp pain/tenderness, aching & stiffness, jaw/limb claudication * Loss of vision - can have amaurosis fugax, blindness if vision not treated within hrs * Commonly associated with polymyalgia rheumatica (PMR) **Ix:** * ESR & CRP * USS temporal artery --\> bilateral temporal artery biopsies - up to 2wks after high-dose steroids **Mx:** prednisolone, if visual Sx consider IV methylprednisolone * If persistent active/relapsing - IL-6 receptor blocker (Tocilizumab)

Answer 88

Def: inflammatory rheumatological condition Presentation: muscle aches and joint stiffness (takes 2-3hrs to loosen up in the morning) * Profile: elderly woman (\>70yrs) * Difficult to rise from seated/prone position * Shoulder/hip stiffness & bursitis * muscle tenderness & oligoarthritis Associated with **GCA** (15-20% have GCA; 40-60% GCA have PMR) * GCA is most common primary vasculitis * Can have amaurosis fugax, blindness if vision not treated within hrs * Ix: _bilateral temporal artery biopsies_ - up to 2wks after high-dose _steroids_ Dx: clinical + **ESR, CRP**, FBC (to rule out haem disorders) Mx: prednisolone + osteoporosis prevention (Ca, Vit D, Bisphosphonates) * Other: methotrexate + folic acid

Answer 89

Tenosynovitis def: * Involves extrinsic tendons of hand & wrist & corresponding retinacular sheath * Characterised as tendon irritation manifesting as pain --\> progress to catching and locking when tendon gliding fails. RFs: insulin-dep DM, pregnancy/lactation, dom-hand involvement Presentation: location over retinacular sheat, pain increases with motion, * **Trigger finger:** * _Painful popping_ on finger flexion/extension (catching of flexor tendon) * Palpable nodule @level of metacarpal head in palm * **De Quervain's disease:** * Pain, tenderness, swelling localised to _radial wrist_ (1-2cm proximal to radial styloid) * Worse on thumb mov/ulnar deviation * Finkelstein test (thumb in hand + ulnar deviation --\> pain) * **Intersection syndrome:** * Pain & swelling _4cm proximal to wrist joint_ ± redness/palpable crepitus * Much worse on resisted wrist extension * Extensor pollicis longus: * Thumb IP mov --\> pain @Lister's tubercle * Extensor carpi ulnaris: * Ulnar wrist pain * Worse with extension/ulnar deviation against resistance * Flexor carpi radialis: * Pain @palmar wrist crease over scaphoid tubercle + along tendon ± localised swelling/ganglion cyst * Worse with resisted wrist flexion, radial deviation Ix: **high-res USS** Mx: * NSAID ±splinting * CS injection (sheath/compartment): flexor tendon sheath (trigger finger), 1st dorsal compartment (De Quervain's disease) * Surgery (surgical release of compartment)

Answer 90

DDx: degenerative, infective, inflammatory, traumatic, congenital Ix: 2 views = AP & lateral views + imaging of joints above and below as well Mx: conservative, medical, surgical

Answer 91

**Schober's test:** gross restriction \<3cm = _Ankylosing Spondylitis_ (fusion of sacro-iliac & lower spine) * Mark midline between dimples of venus & 10cm above --\> ask to touch toes --\> measure distance between 2-points * Should increase by 8-10 **Sciatic stretch test:** pain in thigh & buttocks = _sciatica_ (L3-S3 nerve root irritation) * Patient supine, straight leg raise while ankle dorsiflexion **Femoral nerve test:** pain in thigh & buttocks = _L2-4 nerve root irritation_ * Patient prone, extend hip

Answer 92

**RFs:** * Exposure to high-intensity global UV radiation * Treatment w/ lipid-lowering agents, D-penicillamine (Tx for RA) * HIV, prev inf/vaccine **Presentation:** * Overall: insidious/acute symmetrical muscle weakness of proximal arm & leg --\> difficulty getting out of chair/climbing stairs * **Dermatomyositis** - _acute_, proximal muscle weakness + **rash**: * _Heliotropic rash_ (purple discolouration of upper-eyelids) * _Gottron's papules_ (erythema over knuckles) * **Polymyositis** - _subacute_, proximal muscle weakness, no rash * **Inclusion body myositis (IBM)** - _slowly_, proximal & **distal** muscle weakness + muscle atrophy (_quadriceps, distal wrist & finger flexor)_ * Assoc: * **ILD** - in 10% patients with dermatomyositis/polymyositis * Malignancy (ovarian, pancreatic, NH lymphoma, lung, bladder) * AI disease **Ix:** * Bloods: CK, ANA/myositis ab panel (anti-Jo-1) * Imaging: MRI of involved muscle, electromyogram (EMG), muscle biopsy Mx: * Induction: **CS** (PO/IV) ± IVIg * Maintenance: **IS** (methotrexate/azathioprine) ± IVIg

Answer 93

Def: chronic pain syndrome diagnosed by the presence of widespread body pain ≥ 3 months Presentation: * RFs: AI rheum condition (RA, SLE), female * Chronic widespread body pain * Diffuse tenderness on physical exam * Fatigue, memory problems, sleep & mood disturbance Ix: clinical Dx * To exclude other causes: FBC, TFT, ESR/CRP, vit-D, Ab-testing (RF, anti-CCP, ANA) Mx: * 1st - TCA e.g. amitryptiline * Non-pharm: education, exercise, CBT ± referral to psych

Answer 94

**Def:** slowly progressive hyperplasia of periurethral (transition) zone of prostate gland --\> urinary outflow obstruction * Common - occuring primarily in elderly men **Sx:** lower urinary tract symptoms (FUND HIPS) **Ix:** urinalysis (UTI), PSA (cancer) ± US/CT (abdo/pelvis)/cystoscopy **Mx:** * Acute retention = _CATHETERISE_ * Conservative - watchful waiting * Medical: * _Alpha-blocker_ (relax sm muscle around prostatic urethra) e.g. **tamsulosin** * _5-alpha-reductase inhibitor_ (reduce conversion of testosterone --\> dihydrotestosterone - reducing androgenic stimulation of prostate) e.g. **finasteride** * Surgical: **TURP** (transurethral resection of the prostate - shave extra prostate), open prostatectomy * NOTE: TURP not curative - will continue to grow

Answer 95

**Def:** crystal deposition within the urinary tract **Presentation:** severe loin to groin pain (ureteric colic - starts around back and moves towards groin) **Stone types:** * **Ca oxalate (80%)** * Mg Ammonium Phosphate (struvite) - likely **_staghorn calculi_** * Associated with **_proteus mirabilis_** inf * Urate * Cysteine **Ix:** * Bedside - urine dip (microscopic haematuria) * Bloods - U&E (post-renal AKI) * Imaging - gold standard **_non-contrast CT KUB_** (kidneys, ureters, bladder) * Contrast is excreted by kidneys - looking for bright white light of Ca --\> if you give contrast it will mask the finding Mx: * Infected & obstructed = **pyonephrosis** --\> URGENT decompression via **_NEPHROSTOMY_** (or retrograde w/ JJ stent) * Opening between kidney & skin w/ nephrostomy bag for external collection * Nephro (kidney) stomy (opening) * \<5mm (on CT) - allow spontaneous passing, retain stone for analysis * \>5mm (on CT): * **Ureteroscopic lithotripsy** - endoscope into ureter & using mechanical force/laser to destroy stone * Uretero (through ureter) scopic (camera) Litho (stone) tripsy (crush) * **Extracorporeal shockwave lithotripsy** - external USS to destroy stone * Extra (outside) corporeal (body) shockwave (USS) Lithtripsy (crushing stone) * **Percutaneous nephrolithotomy** - ONLY if stone in kidney (e.g. staghorn calculi), extract stone through skin in back * Percutaneous (through skin) Nephro (kidney) lith (stone) otomy (cutting) When to ADMIT: * Pain not controlled * Significantly impaired renal function * Single kidney * Pyrexia/sepsis * Stone \>5mm If managed at home: * High fluid intake + return if pain worsening/develop temperature * OPA in 4 weeks with CT-KUB on arrival --\> if stone still present need lithotripsy/nephrolithotomy

Answer 96

**DDx:** * _Testicular torsion_ - EMERGENCY & TIME-URGENT * Elevated testis, loss of cremasteric reflex, very tender * Tx: bilateral orchidopexy (orchidectomy - if necrotic) * **Can you feel above swelling?** * YES - **swelling separate from testis?** * YES - _Epididymal cyst_ OR _Varicocele_ * NO - **Tender?** * YES - _Epididymo-orchitis_ * NO - _Hydrocele_ OR _Tumour_ * NO - _Inguinal hernia_

Answer 97

Epidemiology & mets: * Mets to para-aortic LNs * Most common malignancy in males 20-40yrs Ix: * Blood testicular tumour markers: alpha-fetoprotein, beta-hCG, LDH (necrosis, others secreted by tumour itself) * Testicular US --\> CT-CAP for staging (would likely do orchidectomy before CT) * Urine dip (look for infection) --\> culture Mx: * **Orchidectomy** – take _inguinal_ approach (scrotal approach risks mets and inguinal is coming out the same way the testicle drops) - only time would not do this first is when respiratory compromise then would do chemo first * **BEP chemotherapy** follow-up = very good response typically * Very good prognosis - good/intermediate prognosis groups have \>90% 5-yr survival

Answer 98

**Def:** collection of fluid in tunica vaginalis **Ix:** US, testicular tumour markers (AFP & bHCG - secreted by tumour, LDH - necrosis), urine culture (inf) **Causes:** idiopathic, inf, trauma, tumour

Answer 99

Def: distended veins of pampiniform plexus Key points: * More common on left (the way left testicular vein drains into left renal vein) * Assoc w/ infertility, renal cancer * Swelling may reduce when lying down

Answer 100

Most common = transitional cell carcinoma (urothelial) Presentation: * Painless visible haematuria (or asymptomatic non-visible haematuria) * Irrigative LUTS (urgency, suprapubic pain) * Recurrent UTIs * Pain, weight loss, lymphoedema Ix: * Initial: * Urine dip (blood, leucocytes) * MC&S (use MSU - RBCs & WBCs, no bacterial growth) * Bloods - FBC * **Flexible cystoscopy** (lower urinary tract) + **CT-urogram** (upper urinary track if visible haematuria --\> if non-visible low-risk use _US_) * Dx & staging = **_Transurethral Bladder Tumour Resection (TURBT)_** - resects full tumour + histology * Intravesical therapy: * Bacillus Calmette-Guerin (BCG) instilled into bladder --\> reduces superficial bladder cancer recurrence (causes immune response to remaining tumour cells, same substance as in BCG vaccine) * Mitomycin - cytotoxic chemo agent Mx: 2wk wait urology * Muscle invasive = cystectomy (young people) or radiotherapy/chemotherapy (older) * Superficial = surveillance cystoscopies, intravesical chemo * Mets = systemic therapy

Answer 101

Presentation: _HTN_, abdo discomfort, blood in urine, FHx of IC haemorrhage * Cysts in kidneys prod renin --\> HTN * Space occupying masses in abdo (renal/liver cysts) * Can bleed into cysts --\> blood in urine Associations: * Hepatic cysts * **Berry aneurysms --\> risk of ICH** * Mitral valve prolapse Family screening - renal USS

Answer 102

Presentation: sudden-onset pain, high fixed position, absent cremasteric reflex Tx: bilateral orchidopexy (both sides as increased risk of torsion in the other side)

Answer 103

**Paraphimosis def:** unable to pull back the foreskin **Causes:** tight foreskin (phimosis), a complication of urinary catheter (always remember to replace foreskin after withdrawing for catheter insertion) **Pathophysiology:** constrictive effect of foreskin --\> oedema of distal penis --\> ischaemia/necrosis (if severe) **Mx:** UROLOGICAL EMERGENCY - must be reduced ASAP * Reduce with - Lubricating jelly OR dextrose-soaked gauze * If difficult - needle used to make small holes in penis --\> drainage of oedema

Answer 104

Ix: * PR exam, PSA * FBC, U&E, LFTs * Transrectal ultrasound (TRUS)-guided needle biopsy * Gleason score = PC grading * TNM staging * Multiparametric MRI Mx: surgery/radiotherapy * Radial prostatectomy ± LN dissection * External beam radiotherapy/brachytherapy * Androgen-deprivation therapy (ADT)

Answer 105

Stress-incontinence (leak on laugh/cough): * Pelvic muscle exercises * Pseudoephedrine (2nd - Duloxetine) * Retropubic suspension/colposuspension Urge-incontinence (preceded by the urge to pass urine): * Bladder retraining * Anticholinergic e.g. Oxybutynin (not if \>80yrs), Tolterodine Overactive bladder syndrome (urge but not incontinence - increased freq + nocturia): same as urge incontinence

Answer 106

Identify a problem and deal with it as going along... * Airway - patent? look, listen and feel --\> head tilt + chin lift, jaw thrust, airway adjunct * Breathing - RR, O2 Sats (\>94% - scale 1, 88-92% - scale 2 if COPD), resp exam, ABG --\> Oxygen (15L/min O2 non-rebreather mask) * Circulation - HR, BP, CRT, cardio exam --\> IV fluids * Disability - BM, pupils (PEARL - pupils equal and reactive to light), GCS/AVPU, abdo/neuro exam * Exposure - assess everything but not all at the same time --\> calf tenderness, bleeding, bruising, rashes etc. NOTE: if put in intervention say to examiner I would reassess previous steps e.g. A&B if gave IV fluids are there any changes

Answer 107

**Def:** Acute confusional state caused by a physical condition **Causes:** U PINCHES ME * **Urinary retention** * **Pain** * **Infections** * Nutrition * **Constipation** * **Hydration** * Endo & electrolytes * Stroke * **Medications** & alcohol * Environmental **Delirium screen:** - FBC, U&E, LFT, glucose, BC, _Ca, TFTs, B12/folate_ - Urine dip + MC&S - CXR, possibly CT-head **Management:** Tx cause * Conservative: lighting, clocks, 1:1 nursing, adequate hydration, laxatives, involve family/carers * SOS (risk to themselves/others): * Lorazepam (PO/IM/IV) * Haloperidol (PO/IM) - be careful if Parkinson's --\> worsens Sx

Answer 108

Circle of Willis - perfuses brain * **Cerebral arteries** - anterior, middle, posterior (all bordering the circle) * **ACA** - supplies _anterior & medial brain_ (frontal lobe + medial motor & somatosensory cortices) --\> *behavioural changes, weakness legs \> arms, mild sensory defect* * **MCA** - supplies the _lateral brain_ (lateral motor & somatosensory cortices, language - Broca & Wernicke's, optic tracts) --\> *weakness face \> arms \> legs, aphasia (expressive/receptive), hemisensory defect, homonymous hemianopia* * **PCA** - supplies _inferior & posterior brain_ (affecting visual cortex and tracts) --\> *homonymous hemianopia, visual agnosia/prosopagnosia* * Major arteries giving rise to the circle of Willis: * **Vert****ebral artery** (from the spine) * **Internal carotid artery** (gives rise to A & M cerebral arteries)

Answer 109

Outer layers of the brain: * Skull \> dura mater (adherent to inside of skull) \> arachnoid mater \> pia mater \> brain parenchyma Types: * **Extradural** haemorrhage- bleed between dura mater & skull * Most common = skull fracture of pterion (temple) --\> trauma to **_middle meningeal artery_** * Hx: clear trauma --\> transient LoC --\> _lucid interval_ --\> ongoing headache --\> reduced consciousness * **Convex (EGG) appearance on CT-head** as blood sealed in by dura ± soft-tissue oedema outside skull (trauma site) * Mx: A-E approach, refer to neurosurgery * Monitor GCS = deterioration * **Subdural** haemorrhage - bleed between dura & arachnoid mater * Tearing of _bridging veins_ going from outer surface of brain to dura mater * Common in _elderly + alcoholics_ (both have cerebral atrophy) * Types: **both concave (SICKLE) appearance on CT-head** * Acute - assoc w/ trauma + blood _white (hyperdense)_ on CT-head * Chronic - little/no Hx of head trauma e.g. fall several weeks ago and then not been normal since (elderly) + _dark (hypodense)_ blood on CT-head * Reduced consciousness, if severe = focal neurology (esp. if midline shift) * Mx: A-E, neurosurgery referral * Monitor GCS, reverse Warfarin * **Subarachnoid** haemorrhage - between arachnoid & pia matter * Caused by an aneurysm (berry) or trauma * Presentation: sudden-onset worst headache ever, photophobia, neck stiffness * LP 12hrs after Sx-onset (xanthochromia) * Mx: A-E approach * Monitor GCS and neuro obs * Discuss with neurosurgery * Other – fluids, monitor Na, **_nimodipine_** * Complications: * Vasospasm – presents like a stroke * Hyponatraemia – can be SIADH * Rebleed - coil ASAP if possible

Answer 110

Types: * **Tension** - band-like, front of forehead, causes: dehydration, stress * **Cluster** - intense pain behind/around eye (worse @night + lacrimation & ptosis during attack), daily clusters for 4-6wks then nothing for months, M\>F * Mx: 100% O2 + nasal triptans * **Migraine** - intense/throbbing, focal, aura, photophobia * Triggers: alcohol, chocolate, cheese, oestrogens (OCP) * Mx: * Acute - simple analgesia, dark room + **_Triptans_** (take as soon as Sx start) * Prevent - trigger avoidance + **propranolol**/ **topiramate** (anticonvulsant, terratogenic) /**amitriptytline** (TCA) * **Meningitis** - generalised, moves down neck, neck stiffness + fever + rash (meningococcal) * Ix: CT-head, LP (type of meningitis), BC (causative organism) * Mx: * Suspected in primary care - **IM/IV Benzypenicillin** * Secondary care - **IV Ceftriaxone** _± Amoxicillin_ (infants/\>50yrs) * If could be encephalitis (seizure/behavioural) - _IV Aciclovir_ * **SAH** - sudden-onset, worst headache ever ± neck stiffness, can get preceding sentinel bleed (minor), assoc w/ PCKD (Berry aneurysm in Circle of Willis)/Marfan's * Ix: non-contrast CT --\> LP for xanthochromia (after 12hrs) * Mx: nimodipine (CCB, give every 4hrs, reduces vasospasm in cerebral arteries) * **Giant cell (temporal) arteritis** - vasculitis --\> scalp tenderness, jaw claudication, vision loss, assoc w/ polymyalgia rheumatica (\>50yrs) * Ix: ESR, temporal artery biopsy * Mx: **high-dose Prednisolone** (to prevent blindness, do not wait for biopsy) * **Trigeminal neuralgia** - electric shock-like pain on _touching_ face (extremely tender) * Divisions of trigeminal nerve (V2&3) * Ix: MRI brain * Mx: Carbamazepine (for pain), neurology referral * **Raised ICP** - worse at night/on waking/coughing/straining ± N&V, visual disturbances * Mx: osmotic diuresis - mannitol/hypertonic saline * **Cerebral Venous Sinus Thrombosis** (VTE in the brain) - papilloedema, 6th nerve palsy, _seizures, Cushing's reflex_ (HTN, bradycardia, Cheyne-Stokes breathing) * Ix: MRI w/ MR venography * Mx: LMWH * **Idiopathic intracranial HTN (IIH)** - Obese, female, papilloedema, postural headache worse with straining, assoc w/ OCP * Ix: visual field testing, fundoscopy, MRI brain, LP (≥25 opening pressure) * Mx: _acetazolamide_ (carbonic anhydrase inh), weight loss, LPs + VP/LP shunt, ophthalmology follow-up

Answer 111

Def: better to use cardiovascular accident (CVA) * Stroke ≥24hrs, TIA ≤24hrs Presentation: * Pyramidal weakness (flexors stronger than extensors in upper limb, opposite in lower limb), hypertonia, hyperreflexia * Hemiplegic/scissor gait --\> circumduction * TIA: _Amaurosis Fugax_ (black curtain) * If ≥2 in 1wk = high risk of stroke --\> ADMIT * Aspirin 300mg + secondary prevention (as for stroke) DDx: * Cerebral lesion - 80% ischaemic, 20% haemorrhagic (reduced GCS & raised ICP) * Neoplastic - SOL * Rare: syphilis, Todd's paralysis (post-ictal), migraine, MS, cerebral abscess, rheumatological (arteritis) Classification: **Bamford aka Oxford** * **Total anterior circulation stroke:** hemiplegia, homonymous hemianopia, higher cortical dysfunction * **Partial anterior circulation stroke:** 2/3 * **Lacunar circulation stroke:** hemi-motor OR hemi-sensory stroke only * **Posterior stroke:** cranial nerve problems, eye-movement disorder, cerebella presentation * Weber's & Wallenberg's (lateral medullary syndrome = posterior cerebellar artery infarct) **Ix:** * BEFORE Tx = **CT-head** - 80% strokes ischaemic, 20% haemorrhagic (wrong Tx will make it much worse) --\> haemorrhage has an area of hyperdense (white) bleeding * After initial Mx --\> **identify cause:** * ****Structural heart defect - _echocardiogram_ * AF - _ambulatory ECG_ (24hr tape if no obv sign of AF as outpatient) * Carotid atherosclerosis - _carotid doppler_ --\> carotid artery stenosis (70-99%) = carotid endarterectomy Mx: A-E approach + URGENTLY contact stroke team --\> dedicated stroke unit, if ischaemic: * **Immediately:** * **Aspirin 300mg** OD + _STOP_ anticoagulants (high risk of haemorrhagic transformation in first 2wks) * \<4.5hrs since Sx onset: **thrombolysis** (Alteplase = tPA) * C/I: any sign of active bleeding, very high BP, recent surgery, raised ICP * \>4.5hrs since Sx onset: conservative Mx: * BM - keep controlled \<11 (sliding scale insulin) * NG tube (nutrition) * **MDT** - dietician, SALT, PT/OT * \< 6hrs (sometimes up to 24hrs, depending on size, area, damage) --\> thrombectomy (neurosurgery) * **After 2wks:** * STOP aspirin --\> start **clopidogrel 75mg OD** + consider _anticoagulation_ (e.g. if AF) - DOAC/Warfarin * Manage vascular RFs (DM, HTN, QRISK etc.)

Answer 112

**Def:** a neurodegenerative disease of **dopaminergic neurones** of substantia nigra (part of basal ganglia in the midbrain) **Cardinal Sx** (from extrapyramidal involuntary dysfunction)**:** _resting tremor_, _rigidity_ (cogwheeling due to superimposed tremor), _bradykinesia, postural instability_ + insomnia, hypomimia (mask face), depression, autonomic dysfunction DDx: * Benign essential tremor - bilateral, postural, FHx, alcohol improves it (in 50%) * Drug-induced (anti-psychotic, metoclopramide) - _drug chart_ * **MSA** (multisystem atrophy) incl Shy-Drager (autonomic) - _cerebellar signs_ * **PSP** (progressive supranuclear palsy) - _loss of downward gaze_ * **LBD** (Lewy body dementia) - _visual hallucinations_ * _Normal-pressure hydrocephalus_ - gait disturbance, cognitive impairment, impaired bladder control * Other: * Corticobasal degeneration - single-arm signs, alien limb syndrome (myoclonus) * Wilson's disease (copper) - motor **Ix:** clinical Dx --\> dopaminergic agent trial ± MRI scan/DAT scan **Mx:** problem = lack of dopamine in substantia nigra --\> aim of Tx is to increase dopamine here * **Dopamine agonist** (cross BBB): * Good for younger patients to reduce time on levodopa (as get very sensitised) * Types: * **Non-ergot -** _ropinirole, pramipexole_ - avoid below SEs = 1st line but still get **dopamine dysregulation syndrome** (hypersexuality & gambling) * _SC Apomorphine_ for advanced disease * Ergot - cabergoline, bromocriptine --\> retroperitoneal/pulmonary fibrosis * '**L-DOPA (levodopa)** _AND_ **peripheral DOPA-decarboxylase enzyme (Carbidopa)**' = Sinemet/Medapar * Relevant physiology: * Substantia nigra contains dopaminergic neurones with _DOPA decarboxylase_ (converts L-DOPA --\> dopamine) - not happening as normal in Parkinson's * Peripheral DOPA-decarboxylase in body * Chemoreceptor trigger zone (CTZ) --\> triggers nausea & vomiting * Drug explanation: * If give L-DOPA by itself it will be broken down by peripheral DOPA-decarboxylase into dopamine - this can't cross BBB to reach substantia nigra but can reach CTZ --\> nausea/vomiting * Instead, give L-DOPA with peripheral DOPA-decarboxylase inhibitor to allow more L-DOPA to cross BBB to reach dopaminergic neurones in substantial nigra to be converted to dopamine (some still reaches CTZ --\> SE of nausea/vomiting) * Other SEs: dyskinesia, on-off phenomena, postural hypotension * Amantadine - for dyskinesia secondary to levodopa * COMT inhibitors e.g. entacapone for tailing off betw/ doses of levodopa Complications: * Falls, cognitive impairment, depression * Drool (SALT/glycopyrronium) * Meds SEs (e.g. vomiting)

Answer 113

**Corticospinal tract = voluntary motor pathway for body:** 1. Cortex - primary motor cortex (posterior frontal cortex) 2. Medulla - tracts from PMC converge and **cross over** = _pyramids_ 3. Spinal cord - UMN synapases with LMN 4. Peripheral nerves - LMN innervates muscle **UMN lesions** * Causes (anything affecting brain itself): stroke, SOL, MND, MS * Signs: hypertonia, hyperreflexia, spasticity (velocity/direction-dependent), upgoing plantars, pronator drift * NOTE: increased tone/reflexes as -ve feedback loop from the brain is removed **LMN lesions** * Causes (affect peripheral nerves): MND, trauma, polio, GBS * Signs: hypotonia, hyporeflexia, muscle atrophy, fasciculations, fibrillations * NOTE: reduced tone/reflexes because no nerve supply

Answer 114

**SUMMARY:** * **Normal gait cycle:** 1) heel strike 2) foot flat 3) mid stance 4) heel off 5) toe-off * **Antalgic gait** - limping due to pain e.g. osteoarthritis, inflammatory joint disease, fracture, sciatica * **Hemi/Diplegic gait** - uni/bilateral circumduction of leg - CNS lesion (bilateral is called a 'scissoring gait') * **Parkinsonian gait** - shuffling gait, no arm swing - Parkinson's/DLB/Antipsychotics * **Ataxic gait** - wide/broad-based stance & imbalance - Cerebellar/Vestibular/Sensory neuropathy * NOTE: can't do _tandem walk_ * **Neuropathic gait** - high-step gait (from foot drop) - motor neuropathy e.g. L5 radiculopathy (e.g. herniated disc), common peroneal neuropathy, MS, Charcot-Marie-Tooth disease * Can't walk on _heels_ * **Myopathic gait** - waddling/Trendelenburg gait (hip sways to one/both sides - hip abductor muscles weak) - muscular dystrophy/myopathy * **Choreiform gait** - involuntary movements - Basal ganglia disease e.g. Parkinson's meds, Huntington's, Wilson's, Cerebral Palsy * **Stomping gait** - sensory neuropathy (loss of proprioception & vibration sense = dorsal column disease) * _Vibration_ --\> _proprioception_ (Romberg's +ve) --\> _light touch_ (in order lost) * Causes: SACD (subacute combined degen cord - B12), Friedrich's ataxia, Tabes/taboparesis & tabes dorsalis (syphilis), * _Marche à petit pas_ - small steps = normal pressure hydrocephalus **IN-DEPTH:** **Normal gait cycle:** 1) heel strike 2) foot flat 3) mid stance 4) heel off 5) toe off **Antalgic gait** - _limping due to pain_ * Causes: osteoarthritis, inflammatory joint disease, lower limb fracture, nerve entrapment (sciatica) **Hemiplegic gait** - _unilateral circumduction of leg_ to prevent dragging foot * CNS lesion --\> unilateral weakness & spasticity (spastic flexion of upper limb vs extension of lower limb) * Causes - UMN lesion: * Unilateral cerebral lesion e.g. stroke, SOL, trauma, MS * Hemisection of spinal cord (trauma) **Diplegic gait** - _bilateral circumduction of legs_ (scissoring gait_)_ * CNS lesion as above but bilateral clinical findings - spasticity worse in lower limbs vs upper limbs ± hyperreflexia, clonus, Babinski +ve, reduced power, sensory level if spinal cord pathology * Causes: * Spinal cord lesion e.g. prolapsed intervertebral disc, spinal spondylosis, spinal tumour/infarct, transverse myelitis * Bilateral brain lesion - cerebral palsy, MS, bilateral brain infarcts, midline tumour (paraspinal meningioma) * MND - if also LMN findings (wasting, fasciculations) **Parkinsonian gait** - _shuffling gait_ * Loss of dopaminergic neurones in substantia nigra of basal ganglia --\> extrapyramidal dysregulation = _rigidity, bradykinesia_, resting tremor, postural instability * Features of parkinsonian gait: * Initiation - slow to start walking * Step length - _shuffling gait_ (short steps) & festinant gait (progressively smaller steps) * Arm swing - reduced (early feature) * Posture - flexed trunk & neck = _stooped_ * Turning - postural instability * Causes: Parkinson's, Dementia w/ LBs, Parkinson's plus syndromes (Multisystem atrophy & progressive supranuclear palsy), drug-induced (antipsychotics/emetics) **Ataxic gait** - _wide/broad-based stance_ (to maintain balance) * Assoc w/: * Midline _cerebellar_ disease (alcoholism/B12 def, MS, cerebellar stroke) - **DANISH** (dysdiadokokinesia, ataxia, nystagmus, intention tremor, slurred speech, hypotonia) * _Vestibular_ disease (labyrinthitis, Meniere's, acoustic neuroma) - vertigo, N&V * _Sensory_ ataxia (peripheral neuropathy e.g. DM) - +ve Romberg's, impaired proprioception, impaired vibration sense, lack of other cerebellar signs * Features of ataxic gaint: * Stance - broad-based ataxic gait * Stability - staggering, slow, unsteady --\> veer towards side of lesion * Turning - very difficult **Neuropathic gait** - _high-step gait (from foot drop)_ * Weakness in muscles of distal limb (foot dorsiflexors) - damage to peripheral nerves providing motor innervation --\> foot drop & dragging toes --\> knee & hip flex excessively to compensate * Other features: peripheral vascular disease, peripheral sensory impairment, reduced/absent reflexes * Causes: motor neuropathy * Isolated common peroneal nerve palsy (trauma/compression) * L5 radiculopathy (disc prolapse) * Generalised polyneuropathy involving multiple nerves (DM, MND, Charcot-Marie Tooth disease) **Myopathic gait** - _waddling/Trendelenburg_ gait (hip sways to one/both sides) * Weakness of hip abductors --\> can't stabilise pelvis --\> tilts down towards unsupported side * Assoc features: hard to stand from seat/squat/lying without arms, +ve trendelenburg's sign (stand on one leg - if the hip on the side of the raised leg drops = +ve) * Causes: muscular dystrophy, myopathy (e.g. in hyperthyroidism, Cushing's, acromegaly, Polymyalgia rheumatica) **Choreiform gait** - _involuntary movements_ * Oro-facial dyskinesia (grimacing/lip-smacking) & choreic mov of upper/lower limbs = dance-like/writhing @rest/mov * Causes: Basal ganglia disease * Huntington's, Sydenham's chorea, Cerebal palsy (Choreiform type), WIlson's disease, Dopaminergic meds (e.g. Parkinson's)

Answer 115

MAVIS: * MS - eye (RAPD, INO), spastic paraparesis, catheterised * Alcohol - peripheral neuropathy, liver signs * Vascular (thromboembolic/haemorrhagic) * Inherited (Friedrich's ataxia) * SOL * Other: hypothyroidism & paraneoplastic syndrome

Answer 116

Def: evidence of damage to CNS that is separated in time & space Key features: * Profile: young, female (catheter & walking aid/wheelchair), eye & cerebellar signs * Initial: * Ipsilateral visual disturbance - greying/blurring ± pain on eye mov/loss of red colours * Sensory phenomena - wetness/burning, uncomfortable band around the chest * Lhermitte's sign - electric shock down neck and along spine & may radiate along limbs * Uthoff's - neuro Sx worsen with increased temperature (hoff = hot) * UMN Sx: hyperreflexia, hypertonia, pyramidal pattern (arm flexors stronger, leg extensors stronger) * Dorsal column disease - reduced vibration, proprioception, Romberg's +ve * Eyes: * Internuclear ophthalmoplegia * Adduction paralysis and abduction nystagmus * From lesion in **_medial longitudinal fasciculus_** * Optic nerve damage: * Colour & visual acuity loss, RAPD * Central scotoma (central blindspot), optic atrophy * CN palsy (most commonly 6th - as longest) * Cerebellar signs (imbalance, can't tandem walk) DDx: * Cervical spondylosis - wo/ UMN signs but no cerebellar signs * Subacute combined degeneration of the cord (SACD) - dorsal columns & cerebellar - if low B12 * Neuromyelitis optica aka Devic's disease (IgG against aquaporin-4 channel) - optic neuritis & transverse myelitis but no cerebellar Sx Clinical courses/patterns: * **Relapsing-remitting** - steady decline + strong flair * Primary progressive - steady decline without attacks * Secondary progressive - initial relapsing-remitting becoming primary progressive * Marburg variant - very severe, rapidly progressive Ix: * Bedside: * Fundoscopy (optic neuritis), full functional assessment (physio, OT) * Nerve conduction studies - visual evoked potentials (VEPs) - if single nerve lesion, delayed response * Bloods - B12 (SACD), TFTs * Imaging: * MRI (T2) head (lesions disseminated in time & space) - **McDonald's criteria** * Periventricular white matter lesions * LP: IgG oligoclonal bands, high protein Mx: * **Acute relapse:** _high-dose methylprednisolone_ (shortens acute attack) e.g. optic neuritis (painful eye mov + reduced visual acuity) * **Long-term -** MDT approach (physio, OT, SALT) * Mobility - mobility aids, physio, OT * Spasticity --\> Baclofen/Gabapentin (Dantrolene if CKD) * Bowel (laxatives) & bladder (oxybutynin, LT catheter) * Fatigue --\> Amantadine * Oscillopsia (visual jumping when actually still) --\> Gabapentin * Emotional lability --\> Amitriptyline Poor prognostic features: * Brainstem/cerebellar disease at onset * \>40yrs at onset * Primary progressive MS (no resolution

Answer 117

Def: Acute presentation of thiamine (B1) def Triad: confusion, ataxia, nystagmus Complication = Korsakoff syndrome (chronic & permanent memory problems) Delirium tremens: confusion, _visual hallucinations_, tachycardia, pyrexia

Answer 118

Rigidity (in Parkinson's disease) = increased muscle tone, that is _not_ velocity or direction-dependent * In Parkinson's get Cogwheeling = rigidity overlayed by tremor Spasticity (in Stroke) = increased muscle tone, that is _velocity or direction-dependent_ * Flexors/extensors become imbalanced in strength - certain directions have increased muscle tone (not all) AND worse stiffness if move arm more quickly

Answer 119

**Types:** * **Alzheimer's disease** * Progressive decline in cognitive function * Tx: _Acetylcholinesterase inhibitors_ (Donepezil)/NMDA receptor antagonists (Memantine) * **Vascular dementia** * A stepwise decline in cognitive function * Background of vascular disease (IHD, PVD) * **Dementia with Lewy Bodies** * Triad - _dementia, hallucinations, parkinsonism_ * Balance - Parkinsonism = dopamine def vs hallucinations = dopamine excess * **Frontotemporal** - personality changes, early onset * **Depressive pseudodementia** - disinterested, low mood

Answer 120

ALL: involve MDT for full functional assessment (physio & OT) UMN: * Imaging (brain ± spinal cord) * CSF (LP) * Brain biopsy LMN: * Nerve conduction studies & electromyography (NCS & EMG) * Bloods (metabolic, abs) * Muscle/nerve biopsy

Answer 121

Nerve innovations: * S1,2 - buckle my shoe - ankle jerk (Achilles tendon) * L3,4 - kick the door - knee jerk (patellar tendon) * C5,6 - pick up sticks - biceps, brachioradialis reflex * C7,8 - lay them straight - triceps reflex

Answer 122

Presentation: mixed UMN/LMN (no sensory deficits, no eye involvement) * UMN in lower limbs (spasticity, hyperreflexia, upgoing plantars) * LMN in upper limbs (hypotonia, hyporeflexia, _fasciculations_, wasting) * Bulbar/pseudo-bulbar tongue/speech (**tongue fasciculations**, palatal paralysis, nasal speech) * NORMAL SENSORY EXAM DDx mixed signs: * Dual pathology (stroke + peripheral neuropathy) * Conus medullaris lesion - painful, assoc with traumatic spinal injury/higher up mets) * B12 def (subacute combined degen of spinal cord) = cofactor in myelination (as is folate) Types: * **Amyotrophic lateral sclerosis** (60%) - classic (UMN & LMN) * Progressive Bulbar Palsy (30%) - CN 9-12 --\> dysarthria (speech), dysphagia (swallowing) * Primary Lateral Sclerosis - pure UMN onset * Progressive Muscular Atrophy - pure LMN onset, 'flail limb' appearance Dx: clinical, exclude other causes * EMG/NCS (nerve conduction study) - chronic nerve root denervation * Imaging - MRI (cervical, thoracic, lumbar spine) - exclude other causes Mx: no cure - MDT approach * Conservative - SALT (swallowing), physio & OT * Sx-control: * Quinine - muscle cramp * Anticholinergics e.g. hyoscine patches - drooling * Exercise & nutrition * Prognostic: * Riluzole - glutamate antagonist (extend life expectancy by 3-5 months) * NIV - if respiratory muscles no longer functioning Complications: resp compromise, frontal lobe dementia (2%)

Answer 123

* 1 flicker * 2 is moves with gravity removed * **3 is movement against gravity** * 4 is reduced power against resistance * 5 is normal

Answer 124

**Monro-Kellie Doctrine:** skull is a closed box, the sum of volumes of brain, CSF & IC blood is constant - increase in one should cause a decrease in one/both of others * In brain there is little wiggle-room, the only weak point is the foramen magnum --\> herniation = coning --\> death **Causes:** IC haemorrhage (IC blood), tumour, (brain vol), cerebral oedema (CSF) **Signs:** * Acute (pressure on brainstem): **_CUSHING'S TRIAD_** (HTN, bradycardia, irregular breathing) + reduced GCS * Chronic: long-term headache Mx: * **Conservative:** sit up, hyperventilated (if intubated --\> reduce pCO2 --\> reduce vasodilation in brain) * **Medical:** mannitol (osmotic diuretic), hypertonic saline --\> both draw fluid out of brain --\> reduce ICP * **URGENT neurosurgical inpu**t --\> Burr hole surgery

Answer 125

Def: compression of Cauda Equina (nerve fibres below L1-2) Sx: **can you feel it while you urinate/when you tug on catheter?** * Severe back pain * Saddle anaesthesia (numb around the anus) * Bladder/bowel dysfunction (urinary retention, faecal incontinence) * Lower limb weakness * Reduced anal tone (on PR exam) Causes: _large disc herniation_, cancer, trauma, abscess, haematoma * NOTE: if likely mets e.g. background of prostate cancer --\> 16mg Dexamethasone (reduces swelling) Ix: urgent MRI scan (+ PR exam) Mx: * In normal disc herniation (above cauda equina): * Get the patient to keep moving (or muscles will seize up) * Analgesia - PR Diclofenac (neuropathic pain) + Diazepam * In cauda equina --\> _urgent referral to neurosurgery for decompression/laminectomy_

Answer 126

Meningitis: * Presentation: headache, fever, photophobia, neck stiffness * Causes: * Bacterial – **N. meningitides, S. pneumo** (TB; neonates/elderly – GBS/Listeria/E.coli) – Listeria also more common in _alcoholics_ * Viral – enterovirus (Coxsackie, echovirus), mumps, HSV2 * Fungal – cryptococcus neoformans (chr) * Ix: A-E, **BC**, CT head, **LP** (CT first, if raised ICP --\> LP would cause coning) * Kernig sign - flex knee & hip to 90 degrees --\> extend knee (painful & limited extension) * Brudzinski sign - raise head while flat --\> hip & knee flexion * Mx: bacterial – **IV ceftriaxone** ± amoxicillin (Listeria - neonate/elderly) * **IM BenPen** for possible meningococcal infection (rash) in GP setting before sending to the hospital * Viral – supportive (self-limiting) * Altered consciousness (encephalitis?) --\> add _IV acyclovir_ Encephalitis: * Presentation: headache, fever, seizures, drowsiness, confusion (viral _HSV1_ affects temporal lobes --\> affecting consciousness) * Ix: BC, CT head, LP * Mx: **IV acyclovir** ± anti-convulsants

Answer 127

Dark matter middle (cell bodies = synapses) --\> white matter on the outside (neurone tracts) Sensory pathways (ascending - goes up): * **_Dorsal columns_** (posterior) - **fine touch, vibration, proprioception** * Sensory receptors - _1st order neurone_ up spinal column along ipsilateral side * At the **medulla oblongata** - synapses with _2nd order neurone_ that crosses the midline (decussation) * At the **thalamus** synapses with _3rd order neurone_ to the **Primary Somatosensory cortex** * **_Spinothalamic tracts_** (anterior) - **pain & temperature** * **Nociceptors** (pain) - _1st order neurone_ to **Substantia Gelatinosa** within grey matter of spinal cord * Synapses with _2nd order neurone_ & immediately crosses midline (decussation) to ascend spinothalamic tract * *NOTE: spinothalamic tracts decussate at the level the neurone enters the spinal cord* * At the **thalamus** synapses with _3rd order neurone_ to the **Primary Somatosensory cortex** * (Spinocerebellar tracts (lateral) - proprioceptive info to cerebellum) Motor pathways (descending - goes down): * **_Corticospinal tracts_** (anterior = trunk, neck, shoulders; _lateral - limbs_) - **voluntary motor control** (from primary motor cortex) * From the **Primary Motor Cortex** - _UMN_ goes to the **Medulla** and crosses over (decussation) * At the **anterior horn** for each spinal level synapses with _LMN_--\> muscle * NOTE: at any spinal level will be LMNs exiting the spine and UMNs that travel down further before synapsing with their respective LMN * SO *cord pathology above the level of Cauda Equina --\> some UMN & LMN signs*

Answer 128

Def: tendency to have recurrent, unprovoked seizures * Seizure = episodes of abnormal uncoordinated excessive brain activity * Provoked seizures = consequence of inf/drugs * Unprovoked = epilepsy Types: * **Generalised** (whole brain): * Tonic-clonic, Tonic, Atonic, Myoclonic --\> Tx: _Na Valproate_ (AVOID in girls/women of childbearing age) * Absence --\> Tx: _Ethosuximide_/Na Valproate * **Focal** - aware (conscious) OR impaired awareness (impaired consciousness) * Tx: _Lamotrigine_ Status epilepticus = \>5mins/repeated seizures without full recovery in between * 1st - IV lorazepam 4mg --\> repeat * 2nd - phenytoin infusion * 3rd - general anaesthesia * If no IV access --\> rectal diazepam/buccal midazolam

Answer 129

RFs: atherosclerosis, hypotension, aortic aneurysm, aortic dissection Ix: * Traumatic - CT-spine (bony injury/fracture) * Non-traumatic - MRI spine (soft tissue injury) Mx: spinal immobilisation, manage in tertiary neurosurgical centre

Answer 130

HTN, bradycardia, Cheyne-Stokes breathing Indicates raised ICP (likely form herniation through foramen magnum) Urgent referral to tertiary neurosurgical centre

Answer 131

Berry aneurysm (85%) LP in 12hrs for xanthochromia (yellow from bilirubin in CSF - RBC breakdown) Nimodipine

Answer 132

Hammertoes - bilateral, symmetrical, distal wasting of small muscles of feet * Advanced = dorsal guttering from distal wasting, wasting of _extensor digitorum brevis at inferior border of lateral malleolus_ * Similar can be seen in the hands = wasting of _first dorsal interosseus_ Sign of **Charcot-Marie-Tooth disease** aka hereditary motor & sensory neuropathy (HMSN)/peroneal muscular atrophy (PMA) * Hx ankle sprains & scoliosis * Motor & sensory losses (sensory milder) = classic peripheral neuropathy * LMN pattern of weakness: * Motor loss in anterolateral compartments of legs (ankle dorsiflexion & toe extension) * Absent reflexes (plantar reflexes show no response) * Sensory loss in _glove & stocking distribution_ bilaterally * Pes cavus ± palpable common peroneal nerve, thickened nerves @medial malleolus * High stepping (foot drop) & ataxic gait * Test for foot drop = _heel walking_ What do I need to check for? NO scars over fibula (would indicate peroneal nerve damage from trauma e.g. car accident) DDx: * _Common peroneal nerve palsy_ (inversion of foot normal) * Sensory peripheral neuropathy: B12-def (SACD), Alcohol, DM, Hypothyroid (vitiligo?), HIV, drugs * Motor peripheral neuropathy: lead poisoning Types: * **Type 1** - demyelination, AD * Type 2 - axonal, AD/AR * Type 3 - demyelination, AR & presents as infant Ix: full functional assessment, FHx, _nerve conduction studies_, genetic testing Mx: * Physio, walking aids with ankle & foot supports (e.g. foot splint)

Answer 133

Hand muscle wasting - _dorsal guttering_ = first to be affected in ulnar lesions * First dorsal interosseous (next to thumb) = ulnar nerve * Abductor policies brevis (thenar eminence) = median nerve * Weakness of both - suspect T1 radiculopathy * NOTE: ulnar nerve innervates most of the intrinsic muscles of hand except median nerve serves **LOAF**: 2 radial **L**umbricals, **O**pponenes pollicis, **A**bductor pollicis brevis & **F**lexor pollicis brevis **Ulnar nerve palsy** = _claw hand_ @rest (4th & 5th fingers in extension at MCP, flexion at PIP/DIP) * Commonest site of lesion = elbow (arthritis @wrist & elbow) * Froment's sign (weak adductor pollicis brevis --\> thumb flexion) = +ve if thumb arches to hold paper = _ulnar nerve palsy_ * **Ulnar paradox** - higher lesion causes lesser deformity as lower lesions spares flexor digitorum profundus (causes flexion at DIP) **Median nerve palsy** = _sign of benediction_ on asking to close hand (thumb, index finger can't close, middle finger can close partially) * Look for sensation over thenar eminence --\> if lost can't be carpal tunnel syndrome (still median nerve palsy but arises proximally to carpal tunnel) * Bilateral carpal tunnel syndrome causes: Acromegaly, Amyloid (periorbital purpura after sneezing), DM, Hypothyroid, pregnancy

Answer 134

Ix: * Bloods (metabolic, abs), CT --\> LP ± MRI spine (exclude other causes) * Nerve conduction studies Mx: ADMIT suspected cases - normally self-limiting course * MDT - psychologist, SALT (if speech muscles affected) * Plasmapheresis (plasma exchange) * High-dose IVIG * DVT prophylaxis

Answer 135

C3,4,5 keep the diaphragm alive Phrenic nerve

Answer 136

Ix: _MRI whole spine_ (often multifocal lesions) Mx: * 1st line = **surgical decompression** (if localised, fit enough) * 2nd line = radiotherapy (external beam radiotherapy)

Answer 137

Postural imbalance/swaying: * When eyes open & closed = Cerebellar ataxia * When eyes are closed = sensory ataxia (somatosensory nerve affected) * Dorsal column loss: Tabes dorsalis (syphilis), SCDC (B12), MS * Sensory peripheral neuropathy

Answer 138

Presentation * Disc herniation - acute unilateral radiculopathy (pain & numb in specific dermatome/weakness in muscle group) * Straight leg raise +ve * Worse on flexion (bending over/sitting) * Spinal stenosis - insidious neurogenic claudication (intermittent back pain worse on walking/standing) ± pain radiating down leg/leg paraesthesia * RFs: rev back injury/surgery, manual labour * Worse on extension (standing/walking) Ix: * Disc herniation - erect lumbar x-ray & MRI spine * Spinal stenosis - plane x-ray, MRI (T2-weighted) Mx: surgical decompression

Answer 139

**Cerebellar** signs _ipsilateral_ **Motor nerves** travel laterally in brainstem & cross @medulla **Dorsal columns** are _posterior_ & cross @medulla **Spinothalamic tract** is _anterior_ in spinal cord & cross in spinal cord Localisation: * **Cortical** - UMN pyramidal signs (hypertonia, hyperreflexia, babinski) * **Basal ganglia** - rigidity, tremor, bradykinesia * **Cerebellar** - DANISH * **Nerve root** (dermatome/myotome)/single nerve - LMN signs (hypotonia, hyporeflexia, fasciculations, wasting, sensory loss)

Answer 140

**_LMN_** presentation = muscle pathology * Face: * Myopathic facies (sunken cheeks, bilateral ptosis, expressionless) * Wasting of facial & muscles of mastication * Frontotemporal balding * Distal wasting, weakness w/ loss of ankle jerks * Associations: cataracts, dysphagia, cardiac (cardiomyopathy, heart block), DM, hypogonadism (gynaecomastia/testicular atrophy) * Exam - failure of immediate relaxation after voluntary contraction * _Percussion myotonia_ - tap thenar eminence and thumb contracts * Slow-releasing grip - SHAKE HANDS (or make a fist and then spread fingers quickly or squeeze eyes shut and open quickly) Ix: * Conservative: _full functional assessment_ (incl. SALT), lung function tests (NM resp insufficiency), ECG/echo (CMO/HB), slit lamp (cataracts) * Bloods - BM (DM assoc), _CK_, genetic testing * Imaging & invasive: * Electromyography (EMG) - 'dive-bomber' potentials * Muscle/nerve biopsy Mx: MDT approach * Phenytoin for myotonia, weakness has no Tx * Genetic counselling - AD w/ genetic anticipation (trinucleotide repeat - worse severity/earlier presentation with each generation) * Avoid _statins_ (can cause myopathy)

Answer 141

**Myasthenia Gravis** * Def: * Chr AI disorder of post-synaptic membrane of NMJ in skeletal muscle * _Abs to AChR_ on post-synaptic membrane * Presentation: * **_Muscle fatiguability incl dysphagia_**, rarely SoB * **Eyes** - _bilateral ptosis_ (and compensatory increased frontalis muscle activity = raised eyebrows), diplopia * Face - dysarthria (slurred speech), facial paresis * _Curtain sign_ - when raising one upper eyelid the other one drops down * Assoc: **thymomas** (in the chest) * Ix: * Abs: **AChR** (on post-synaptic membrane), MUSK abs * Serial pul funct tests (FVC & negative inspiratory force) * NOTE: do not wait for ABG findings - late in course * CT-chest (for thymoma) * Mx: * **Acetylcholinesterase inhibitors** (Pyridostigmine) + IS (azathioprine) * IVIG/Plasmapheresis * Surgery - thymectomy * **Myasthenic crisis** = acute respiratory failure - FVC \<1L, negative inspiratory force (NIF) ≤20cm H2O, need mechanical ventilatory support * Accessory muscle use indicates sign inspiratory muscle weakness * Weak cough indicates sign expiratory muscle weakness * ABG often shows hypercapnia before hypoxia * Low threshold for endotracheal intubation (rapid deterioration of bulbar & resp muscles) * Mx: _intubation + mechanical ventilation_ (& Mx above) **Lambert-Eaton Myasthenic Syndrome (LEMS)** * Def: rare AI disorder of NMJ * Pre-synaptic membrane _Ab to voltage-gated Ca-channel_ receptors * 40% occur as paraneoplastic disorder assoc w/ SCLC * Presentation: * Limb weakness - proximal legs --\> proximal arms e.g. waddling gait * **STRONGER WITH USE** (vs MG get's weaker with use) * Hyporeflexia, NO eye involvement (compared to MG) * Autonomic disturbance - **_dry mouth_** (& orthostatic hypotension, sweating, GI & urinary problems, visual blurring, sexual dysfunction) * Associated with: _small cell lung cancer (SCLC)_ * Ix: * Nerve conduction studies, EMG, serial PFTs * Ab testing (Voltage-gated Ca-channels & AChR-abs) * CT chest (SCLC) * Mx: MDT support * Tx underlying cause, Amifampridine * IVIg/plasma exchange * Supportive care

Answer 142

**RFs:** * Exposure to high-intensity global UV radiation * Treatment w/ lipid-lowering agents, D-penicillamine (Tx for RA) * HIV, prev inf/vaccine **Presentation:** * Overall: insidious/acute symmetrical muscle weakness of proximal arm & leg --\> difficulty getting out of chair/climbing stairs * **Dermatomyositis** - _acute_, proximal muscle weakness + **rash**: * _Heliotropic rash_ (purple discolouration of upper-eyelids) * _Gottron's papules_ (erythema over knuckles) * **Polymyositis** - _subacute_, proximal muscle weakness, no rash * **Inclusion body myositis (IBM)** - _slowly_, proximal & **distal** muscle weakness + muscle atrophy (_quadriceps, distal wrist & finger flexor)_ * Assoc: * **ILD** - in 10% patients with dermatomyositis/polymyositis * Malignancy (ovarian, pancreatic, NH lymphoma, lung, bladder) * AI disease **Ix:** * Bloods: CK, ANA/myositis ab panel (anti-Jo-1) * Imaging: MRI of involved muscle, electromyogram (EMG), muscle biopsy Mx: * Induction: **CS** (PO/IV) ± IVIg * Maintenance: **IS** (methotrexate/azathioprine) ± IVIg

Answer 143

**Vasculitis** - GPA, EGPA, microscopic polyangiitis, polyarteritis nodosa **Rheum** - RA, SLE, Sjogren's, Sarcoidosis

Answer 144

**MND** **B12 - SCDC** (subacute combined degeneration of the spinal cord) Friedrich's ataxia (cause of cerebellar syndrome) Syphilitic tabo-paresis

Answer 145

Bilateral: * **MG** * **Myotonic dystrophy** * Tabes dorsalis (syphilis) = Argyll-Robertson pupil Unilateral: * 3rd nerve palsy (down & out, dilated, ptosis) * Horner's syndrome (ptosis, meiosis, anhydrosis)

Answer 146

**Brain:** stroke, SOL, MS **Spinal cord**: MS, trauma, disc herniation/spinal stenosis, spinal cord infarct, syringomyelia * _MS_ - weakness & paraesthesia based on UMN demyelination, disseminated in **_time & space_** * Optic neuritis, periorbital pain, RAPD, INO (damage to medial longitudinal fasciculus) * Ataxia, vertigo, chr constipation, blaadder dysfunct * **Lhermitte's sign** - electric shock down back on neck flexion * **Unhthoff's phenomenon** - worsening of Sx with increased body temp e.g. exercise, hot shower * Ix: MRI (brain & spinal cord) + LP (oligoclonal bands), nerve conduction study (evoked potential) * Mx: methypred for flare, INF-b long-term * _Trauma_ - extremity weakness wo/ cortical signs/facial weakness e.g. hemisection of spinal cord (Brown-Sequard syndrome) - below level of lesion: * Ipsilateral hemiparesis & loss of vibration/proprioception * **Contralateral loss of pain & temperature** * At level of lesion - loss of sensation + flaccid paralysis of muscles supplied by this spinal cord segment * _Herniated disc/spinal stenosis_ - weakness at level of lesion & lower extremities + bladder/bowel dysfunction + sciatica * _Spinal cord infarct_ - occlusion of anterior spinal artery (complication of aortic surgery) * Affects anterior 2/3 spinal cord in affected segment * Sudden-onset bilateral flaccid paralysis --\> developing into spastic paralysis after several days * Loss of pain & temp * **Light-touch, vibration & proprioception-sense spared** (dorsal columns not involved) * _Syringomyelia_ - developmental disorder * Syrinx (cavity) grows from centre of spinal cord & spreads outwards * Normally affects cervical cord but can extend into brainstem * Early - bilateral loss of **pain & temp in cape-like distribution** affecting neck, shoulders, upper arms * Late - as syrinx expands anterior horn cells affected --\> bilateral flaccid paralysis **Anterior horn** (motor neurone lesions): MND, poliomyelitis * _Poliomyelitis_ - enterovirus infection attacking anterior horn cells * **1-2wks prodrome (fever, headache, N&V)** * Asymmetrical weakness + can develop years after inf (post-polio syndrome) + can take place after taking live-attenuated polio vaccine * MND * Mixed UMN/LMN presentation * Ix (exclude other causes): EMG/NCS, MRI - whole spine * Mx: no cure - MDT approach (SALT (swallowing), physio & OT) * Sx-control: * Quinine - muscle cramp * Anticholinergics e.g. hyoscine patches - drooling * Prognostic: * Riluzole - glutamate antagonist (extend life expectancy by 3-5 months) * NIV - if respiratory muscles no longer functioning **Neuropathy:** diabetic neuropathy * Polyneuropathy (multiple nerves): DANG My THeRAPIST * _**D**iabetic neuropathy_ (most common, T1/2) * Sensory - **glove & stocking** loss of sensation/paraesthesia * Motor - same distribution as above + CN palsies (3rd - pupil-sparing) * Autonomic - orthostatic hypotension, constipation, erectile dysfunction * **A**lcoholic neuropathy (2nd most common) * **N**utritional (B1/6/12 def) * _**G**BS_ (AIDP - acute inflam demyelin polyneuropathy) * AI demyelination of peripheral nerves * 2-4wks post-inf e.g. diarrhoea with C. jejuni * **Ascending weakness in distal lower extremities** over hrs/days (worst after 4wks) * Flaccid paralysis with reduced/absent deep tendon reflexes * Can involve diaphragm --\> resp failure * Bilateral facial nerve palsy * Difficulty swallowing --\> aspiration * Autonomic dysfunction - sweating, orthostatic hypotension, urinary retention * NOTE: _sensory Sx rare_ * Ix: * LP (high protein, normal WCC) * NCS & EMG (reduced conduction velocity) * Serum abs (anti-glycolipid abs) * Mx: * Monitor FVC \<1L, NIF \<20cm H2O --\> intubate + mechanical ventilation * Monitor BP --\> IV fluids for hypo, Labetalol for hyper * IVIG, plasma exchange * **M(y)**-edications (colchicine, cisplatin, isoniazid --\> niacin def) * **T**oxins (lead) * **He**reditary - _HMSN (CMT)_ * Progressive hereditary (AD) _motor & sensory_ neuropathy (HMSN) * Distal back & lower extremity weakness: * **Foot drop** (damage to common peroneal nerve) * **High-arch foot (pes cavus)** - does not flatten with weight-bearing * Scoliosis * ± pain & sensory loss (can lead to foot ulcers) * Ix: nerve conduction study + EMG, genetic testing (electrophoresis/FISH) * Mx: physio, walking aids, foot & heel-support * **R**enal failure (uraemic nephropathy) * **A**myloidosis * **P**orphyrias * **I**nf (HIV, syphilis) * **S**ystemic (hypothyroidism) * **T**umours (multiple myeloma) * Mononeuropathy (one nerve): * _Facial nerve palsy_ - not forehead-sparing, crying/sensitive to noise/abnormal taste (ant 2/3 tongue) * Idiopathic = Bell's palsy * Secondary: * Lyme disease * Ramsay-Hunt syndrome - HZV reactivation in the geniculate ganglion, causes painful eruption in auditory canal * Tumours - acoustic neuroma, parotid * Bilateral palsy - Sarcoidosis, GBS * Tx: treat cause or if Bell's palsy --\> pred within 72hrs Sx onset + eye protection * _Carpal tunnel syndrome_ - entrapment of median nerve in flexor retinaculum * Repetitive use of wrist --\> numbness & tingling in lateral 3 fingers (& 1/2 4th finger) --\> weakness of thenar muscles * Tinel's sign - tap nerve at wrist * Phalen's sign - reverse prayer sign for 60s * Ix: EMG, wrist USS, MRI wrist (imaging to detect SOL e.g. ganglion cyst) * Tx: immobiliser wrist (splint), CS injection, carpal tunnel release **Neuromuscular junction:** MG/LEMS * _Myasthenia gravis (MG)_ - AI condition where Abs attach to NMJ post-synaptic nicotinic AChR in skeletal muscle * **FATIGUABILITY** with use * Initial - oculobulbar weakness (diplopia, ptosis, dysphagia, nasal voice) * Chr: * Asymmetrical proximal limb muscle weakness * Resp muscle failure * Assoc w/ **thymic hyperplasia/thymoma** * NOTE: normal sensation, normal deep tendon & pupillary reflexes * Ix: * Serological testing: _AChR_, MUSK abs * Repetitive nerve stimulation (CMAPs decrease) * CT chest - thymoma * Monitoring with serial pul funct tests (FVC & negative inspiratory force) if suspect myasthenic crisis * Mx: * Acetylcholinesterase inhibitors (**Pyridostigmine**) + IS (azathioprine) * Surgery - thymectomy * Myasthenic crisis = acute respiratory failure - FVC \<1L, negative inspiratory force (NIF) ≤20cm H2O * Often trigger - meds/inf * Accessory muscle use/weak cough = sign. exp muscle weakness * Mx: intubation + mechanical ventilation (& Mx above) * IVIG/Plasmapheresis * Stop pyridostigmine (increases secretions --\> aspiration risk), stop trigger (meds) * Cholinergic crisis - same presentation as above (resp muscle weakness) BUT cause = excess pyridostigmine --\> overstimulation of AChR --\> eventually stop working * Pyridostigmine also binds to nicotinic receptors --\> cholinergic Sx - SLUDGE (Salivation, Lacrimation, Urination, Diarrhoea, GI cramps, Emesis) * Mx: intubation + mechanical ventilation * Atropine (anti-muscarinic) for Sx but does not address resp weakness * Reduce dose of pyridostigmine * _Lambert-Eaton myasthenic syndrome (LEMS)_ - AI condition where Abs target pre-synaptic voltage-gated Ca channels --\> reduces release of ACh from presynaptic vesicles * Proximal muscle weakness - **IMPROVES** with use * Reflexes reduced/absent, ± autonomic Sx * Assoc w/ SCLC, Hodgkin's lymphoma * Ix: * NCS, repetitive nerve stimulation (CMAPs increase) * Serological testing: **VGCC abs** * CT chest (SCLC) * Mx: Tx underlying cause, Amifampridine * IVIg/plasma exchange * Supportive care incl. intubation + mech ventilation (if resp compromise) **Myopathy:** dermatomyositis * Inflammatory: proximal muscle weakness & pain * Dermatomyositis - **skin rash (heliotropic rash & Gottron's papules)** * Polymyositis * Assoc: ILD - in 10% patients * Ix: CK, ab panel **(anti-Jo-1**, ANA) * EMG, muscle MRI + muscle biopsy * Mx: * Induction: CS (PO/IV) ± IVIg * Maintenance: IS (methotrexate/azathioprine) ± IVIg * Inherited: * X-linked - Duchenne's & Becker's muscular dystrophy * AD - Myotonic dystrophy * **Myopathic facies (facial wasting) + frontal balding** * Distal wasting & weakness + loss of ankle jerk * Assoc: cataracts, dysphagia, cardiac, DM, hypogonadism * Exam - failure of immediate relaxation after voluntary contraction * Percussion myotonia - thumb contracts tapping thenar eminence * Slow releasing grip on shaking hands * Ix: CK, genetic testing, EMG 'dive-bomber' potentials, muscle biopsy * Mx: MDT approach * Phenytoin for myotonia, weakness has no Tx * Genetic counselling - trinucleotide repeat -severity/earlier with each generation * Avoid statins (can cause myopathy) * Endocrine: * Hypothyroidism - proximal muscle weakness & pain, deep tendon reflexes decreased, myoedema (swelling on percussion) * Also possible in Addison's Cushing's, Vit D def * Meds - statins (proximal muscle weakness & pain), glucocorticoids (muscle weakness) * Ix: serum CK, TSH lvls, EMG

Answer 147

**CONGENITAL MIND** * **CONGENITAL** - mitochondrial * **M**etabolic - Cushing's, hypothyroidism * **I**nflammatory - _dermato/poly/inclusion body myositis_ * **N**euromuscular - _MG/LEMS_ * **D**ystrophy - Becker

Answer 148

Bilateral = **3Ms** * **M**S * **M**ND (normal sensation) * **M**yelopathy (sensory level) - SOL, cervical myelopathy, disc prolapse, transverse myelitis, syringomyelia Unilateral: * Intracranial - CVA, SOL, MS * Brainstem - MS * Spinal cord - trauma, SOL, haemorrhage

Answer 149

* **Def:** a sudden decrease in limb perfusion that threatens the viability of limb * AF = major RF for acute limb ischemia * **Presentation** - 6Ps: * Pale * Pulseless * Painful * Perishingly cold * NOTE: need immediate vascularisation (\<6hrs) if: * Paralysis * Paraesthesia (esp worrying) * **Ix (after initial Mx):** * Bedside: ABPI (PAD), ECG (AF) * Bloods: FBC, U&E, clotting, HbA1c, lipid profile * Imaging: duplex USS, CT/MR angiography * **Mx:** * Initial: * A-E, IV access, analgesia * **IV heparin infusion** - reduces the chance of the clot getting worse * Limb viability: * Immediate - tender muscles, loss of power, loss of sensation * Urgent - pale, pulseless, painful, cold * Irreversible - fixed, mottled skin, woody, hard muscles * Refer to vascular surgery: * Thrombotic - _local intra-arterial thrombolysis_, angioplasty, bypass * Embolic - _embolectomy_/local intra-arterial thrombolysis/bypass

Answer 150

* Both sides all reduced pulse = aorta-iliac --\> aorto-bifemoral * One side reduced pulse from the popliteal down = femoro-popliteal * One side reduced pulse distally in anterior tibial = femoro-distal * One side reduced pulse distally in posterior tibial = femoro-distal

Answer 151

Sx: * Central abdo pain * Radiates to back * Bloating * Pulsatile mass on palpation (expansile - moves to sides) * NOTE: always consider if abdo pain + RFs (male, \>65yrs, HTN, smoking etc.) Ruptured AAA Sx: * Severe pain radiating to back * Visible pulsating abdo mass * Shock (circulatory compromise) Ix: * Abdo duplex USS if part of national screening - male age 65yrs * CT angiography if stable but suspicious of rupture Mx: * **\<5.5cm** --\> Conservative: monitor w/ USS + RF modification * \<4.5cm --\> yearly USS * 4.5≤x\<5.5com --\> 3 monthly USS * Medical: optimise BP control, statin, aspirin * **Sx/\>5.5cm/expanding \>1cm/yr** --\> Surgical: endovascular (catheter into aorta to insert stent)/open repair

Answer 152

**Def:** limb ischemia (chronic) from atherosclerosis in lower limb vasculature **RFs:** male, older, smoker, HTN, DM **Spectrum:** * **Intermittent claudication** (mild) - cramping leg pain after walking (& have to stop) + _relieved by rest_ * NOTE: the equivalent of stable angina (worse on exertion) * Worse going uphill/upstairs * **Critical limb ischemia** (severe) - ulcers, gangrene, night pain & _rest pain_ * NOTE: the equivalent of unstable angina (present at rest) **Ix:** * Bedside: * Exam special test = _Buerger's angle_ - elevation pallor --\> sudden drop feet down = sunset sign * exercise-treadmill ABPI (ankle-brachial pressure index) - \<0.8 (\<0.3 = CLI) * Bloods - FBC, U&E, LFTs, CRP, clotting * Imaging: * Arterial duplex USS * CT/MR angiography **Mx:** dealt with by vascular surgeons --\> optimise meds + surgery (bypass) * Conservative: smoking cessation * Medical: ACEi, clopidogrel, statin, DM control * Surgery: angioplasty/stent/bypass graft/amputation

Answer 153

Causes: * Failures: * Liver cirrhosis due to alcoholism (failure of liver to metabolise oestrogens) * Renal failure * Neoplasm: * Bronchial carcinoma * Pituitary tumours (hyperprolactinaemia) * Testicular tumours * Hyperthyroidism, Hypogonadism * Drug-related (spironolatone) Presentation: elderly/puberty Dx: bilateral USS Mx: * Cause * Tamoxifen * Surgery * NOTE: do not stop meds just because they are causing gynecomastia

Answer 154

Def: tear in **tunica intima** (inner layer of BV) --\> blood collection between tunica intima and tunica media --\> _false lumen_ (can occlude blood flows through aorta) --\> AR, myocardial ischaemia, stroke Sx: sudden onset, central tearing chest pain --\> radiating to between shoulder blades * Hx of intermittent claudication * Haemodynamic instability (high HR, low BP) * Before left subclavian artery - left arm smaller than right arm * After left subclavian artery - lower body less developed than upper body Ix: * BP in both arms - radio-radial delay * ECG, CXR (widened mediastinum) * Gold-standard: _CT-aortogram w/ contrast_ Mx: * Stanford A (ascending aorta) - more WORRYING (compromise blood to brain, cause aortic regurg): * BP control - _B-blockers & CCB_ (aim 100-120mmHg) * **Immediate referral for vascular surgery** * Stanford B (descending aorta) * BP control - _B-blockers & CCB_ (aim 100-120mmHg) * Urgent referral to vascular surgery (repair likely if complicated)

Answer 155

Venous: * Hx: **varicose veins, previous DVT**, obesity, preg, recurrent phlebitis * Location: lower calf-medial malleolus * Characteristics: mild pain * Ulcer - **shallow/flat margins, exudate,** sloughing @base, granulation tissue * Surrounding skin - **haemosiderin staining, eczematous, oedematous**, thickening skin, (normal CRT) * Tx: **compression bandaging**, leg elevation, surgical Mx Arterial: * Hx: **HTN**, DM, smoking, prev vascular disease * Location: **pressure points**, toes/feet, lateral malleolus, tibia * Characteristics: painful * Ulcer - **punched-out/deep**, irreg shape, necrosis, no exudate (unless inf) * Surrounding skin: thin, shiny, reduced hair, **6Ps** (pallor, pain, perishingly cold, pulselessness, _paraesthesia, paralysis_) * Tx: revascularization (e.g. bypass), anti-platelet, manage RFs Neuropathic: * Hx: **DM** (peripheral neuropathy), trauma, prolonged pressure * Location: plantar foot, tip of toe, lateral-fifth metatarsal * Characteristics: no pain * Ulcer - **deep, surrounded by callus, insensate** (no feeling) * Surrounding skin - dry, cracked, callus, insensate * Tx: off-loading pressure, topical GF Pressure: * Hx: limited mobility * Location: bony prominence, heel * Characteristics: * Ulcer - deep, macerated (moist, wrinkly) * Surrounding skin - atrophic skin, lost muscle mass * Tx: off-loading pressure, reduced moisture, increased nutrition

Answer 156

Presentation: * Oedema, haemosiderin deposition, lipodermatosclerosis (inverted-champagne bottle), eczema, venous ulcers * Varicose veins - dilated tortuous, superficial veins * Pain, swelling, itching, restless legs, cramps * Feel for thrombosis (hard = thrombophlebitis) * Cough impulse at SFJ (for _Saphena Varix_ - dilation of saphenous vein @junction w/ femoral vein) * _Trendelenburg test_ * Lying flat, lift up leg & empty veins * Compression over SFJ --\> stand up (maintain pressure) - if do not fill = competent valves below SFJ * If do fill = incompetent valves below SFJ (blood flow from deep to superficial vein via perforating veins) * Repeat with pressure lower down until filling stops * Perthe's test - apply tourniquet to mid-thigh + walk for 5-mins --\> compresses superficial vein * Less distended - normal deep veins as calf compression pushes blood into deep venous system * Remain distended - impaired deep veins * Doppler US for reflux * Warfarin - previous DVT * Abdo mass with compression Ix: duplex USS (allow DVT to be ruled out) Venous insufficiency Mx: * ABPI \> 0.8 --\> Compression bandaging * Varicose veins: * Conservative - weight loss, avoid standing for prolonged periods * Minimally invasive procedures - injection sclerotherapy, endovenous radiofrequency ablation * Surgical - vein ligation Varicose Veins complications: * thrombophlebitis - Tx for superficial: NSAIDs * Eczema * Bleeding * Haemosiderin deposition * Lipodermatosclerosis (champagne bottle) * Ulceration

Answer 157

**Breast pain** * Presentation: * Benign breast pain, cyclic/non-cyclic (**fibrocystic breast)** * Other causes - inf, trauma (fat necrosis), haematoma (on anti-coag) * Dx: nothing if no masses/concerning features on exam * Mx: * Reassurance, supportive bra * Ibuprofen/voltarol gel * Evening primrose oil **Breast Cyst** * Presentation: * Sudden tender, small, smooth lump --\> disappears after a period * Multiple w/ previous similar episodes * Younger * Dx: * USS only \<35ys; USS + MMG ≥35yrs * USS - fluid-filled, well-circumscribed collection * Disappears after aspiration, biopsy if solid posterior residual lesion * Mx: USS-guided aspiration only if large + painful **Fibroadenoma** - common benign breast tumours of both glandular and stromal tissue * Presentation: * Mobile, easily palpable, can be lobulated * Young women * Dx: * Age-dependent * Biopsy \>25yrs/very large/concerns over phyllodes tumour * Re-scan small FAD again in 3-6 months to monitor for rapid enlargement * Mx: * Surgical excision - if rapid enlargement/\>4cm * Reassurance otherwise **Mammary duct ectasia** (periductal mastitis) * Presentation: * Milk ducts dilate and fill with fluid --\> breast pain + green-white nipple discharge * Assoc w/ smoking, menopause * Dx: can mimic breast cancer --\> need triple assessment * Mx: conservative ± abx ± surgery for complications **Breast abscess** * Presentation: * breast-feeding, DM, post-op, smokers * Red, hot, tender fluctuant mass, systemic (febrile, unwell) * Acute Hx * Dx: * Too painful to tolerate MMG - USS only initially * MMG on resolution if ≥35yrs * Mx: * USS-guided aspiration + Abx * Clinical review in 48hrs --\> possible repeat aspiration * Incision & drainage under GA if overlying necrotic skin

Answer 158

Causes: * Physiological (90%) * Duct ectasia - benign, normal in post-menopausal, multi-duct * Intraductal papilloma - papilloma growth in single duct * Epithelial hyperplasia * Galactorrhoea - pregnancy/prolactinoma Presentation: * Smokers - green multi-duct * Duct ectasia (dilated ducts) - yellow multi duct --\> _cheesy watery discharge_ ± bloodstained * Prolactinoma/pregnancy - b/l milky, multi duct * Underlying pathology (cancer, PCIS, papilloma) - bloody discharge from a single duct (can be watery/serous) * Epithelial hyperplasia has a similar but less severe presentation Dx: * Age-related ± MRI * USS retro-areolar w/ biopsy of visible lesions Mx: * Treat cancer incl. excision of NAC * Papilloma - single/total duct excision

Answer 159

RFs: * Increase: * FHx (breast, ovarian, colon) * Genetic mutations (BRCA1/2 - sign increase risk of breast/ovarian cancer) * Post-menopausal, ≥40yrs, early menopause/late menarche * OCP (decreases risk of endometrial/ovarian/colorectal) * Decrease: pregnancy, breastfeeding Types: * **Invasive ductal carcinoma** - 70%, firm/hard * Lobular carcinoma - 10%, bilateral in 20%, multicentric * Tubular - 10%, small stellate lesions, picked up on screening * Other: medullary (soft/fleshy, good prog), mucoid (rare, good prog), Paget's (nipple excoriation, underly intraductal tumour, poor prog) Receptor involvement: ER (oestrogen), PR (progesterone), HER2 (Herceptin) * ER/PR-receptive = good prognostic signs * HER2 = bad prognostic sign (but now Tx for it) Presentation: * Post-menopausal * Firm mass ± skin tethering/dimpling * LNs in axilla Ix: * Triple assessment: * ≥35yrs - MMG + USS + biopsy (FNA/core biopsy) * \<35yrs - _USS + biopsy_ --if proven cancer--\> MMG + MRI * Axilla - USS + biopsy if any abnormal LNs * **Staging** CT & bone scan if \>3cm/LNs involved - TNM * T1-4 (size, 4= invasive), N0/1 (no/yes), MO/1 (no/yes) * Mets - _bone_, lung, liver * **_Nottingham prognostic index_** - size & grade of tumour & LNs * MRI if lobular cancer Mx: * ALWAYS - _Surgery:_ * __Mastectomy/wide local excision - depends on tumour size vs breast size * ALWAYS - _SLNB/ALNC_ * Sentinel LN biopsy vs axillary LN clearance = remove all * Chemo - if involve **LNs**/large cancer/young patient/**HER2 +ve/Triple -ve disease** * Radio - \>4cm, LN involvement, skin/muscle involvement * Endo: ONLY if ER +ve * _Tamoxifen_ pre-menopausal * Letrozole if post-menopausal * Herceptin (Trastuzumab) for HER2+ * MDT approach (incl psychological support)

Answer 160

Ductal carcinoma in-situ * Def: * Limited to mammary ducts by basement membrane --\> can't metastasise * Can transform into invasive (ductal) malignancy * Presentation: often not palpable, picked up on screening * Mx: breast-conserving surgery - wide local excision Lobular carcinoma in-situ

Answer 161

Localise + describe lump: 3Ss, 3Cs, 3Ts * Site, Size, Shape * Consistency, Contours, Colour * Tenderness, Temperature, Tethering

Answer 162

Def: occlusion of deep vein in lower limb RFs: SICC - Surgery, Immobility, Cancer, COCP Presentation: pain, swelling (if extends proximally to iliacs --\> bilateral swelling), pitting oedema, warmth, erythema Scoring & Ix: Well's score * 0-1= D-Dimer --sign raised--\> as below * ≥2 = proximal leg vein USS + D-Dimer * Obtain baseline before starting anti-coag: FBC, U&E, LFTs, clotting screen Mx: * Ongoing anticoagulation - DOAC/Warfarin * Provoked - 3 months (SICC) * Unprovoked - \>6 months + thrombophilia testing

Answer 163

Clinical examination Breast imaging (MMG, USS) Breast biopsy

Answer 164

BP targets: * \<140/90 * \<150/95 for over 80yrs * Causes of hypertensive crisis ≥180/120: pregnancy, scleroderma, vasculitis, renovascular, endo, cocaine --\> reduce BP slowly Ix: * Bedside - ECG, urine dip * Bloods - FBC, U&E, lipids, BM, TFTs Drug treatment: * Conservative management - diet (low salt), exercise, reduce alcohol * 1. a) \<55yrs/DM --\> ACEi (ramipril)/ANG-II receptor antagonist (Losartan) * 1. b) ≥55yrs/black --\> CCB (amlodipine)/thiazide diuretic (bendroflumethiazide) * 2. _ACEi + CCB_ OR _ACEi + thiazide diuretic_ * 3. ACEi + CCB + thiazide diuretic * 4. Add: * Spironolactone (or other diuretic) * Alpha-blocker * Beta-blocker * Specialist advice

Answer 165

Screening MMG * ≥50yrs - 3yrly * \>40yrs - attending clinics USS focused: * \<40yrs USS only * ≥40yrs USS + MMG Biopsy: * all breast lumps in women \>25yrs * USS-guided

Answer 166

* BP cuff above ankle with leads upwards – find dorsalis pedis pulse with doppler * Inflate cuff until signal disappears – let down cuff until signal reappears = ankle pressure * Repeat procedure in arm using brachial artery signal to record the brachial pressure * ABPI = ankle pressure/brachial pressure Range: * 0.8-1 = normal * 0.6-0.8 = claudication (may only drop to this with exercise) * Below 0.6 = critical limb ischaemia

Answer 167

ABC-\>P * Appendix * Bleeding/bowel obstruction/BV obstruction * GI bleed * Obstruction - small/large, mechanical/non-mechanical, complete/incomplete * Ischaemia/infarct * Cholecystitis/angiitis * Pancreatitis/Perforation (upper/lower GI)

Answer 168

Def: protrusion of a viscus through its wall Types: * Incisional hernia - iatrogenic following surgery * Groin hernia - ASIS & pubic tubercle palpated: * Femoral (W\>M) - below and lateral to the pubic tubercle, requires more urgent repair than inguinal hernia - high risk of strangulation * **Inguinal** - above & medial to the pubic tubercle * Direct = weakness in posterior wall of inguinal canal, abdo contents emerge medial to deep ring and through superficial ring * Indirect (75%, most common hernias in M/W) = abdo contents passes through inguinal canal through deep ring and exits via superficial ring * Reduce hernia & compression on deep inguinal ring ask the patient to cough if it is direct it will reappear * Other groin lumps: * Lymphadenopathy - along inguinal ligament * Vascular - pulsatile varicose veins below inguinal ligament Mx: surgical (mesh) NOTE: hernias are safer the larger the defect as less likely to strangulate

Answer 169

* Midline sternotomy - AAA, laparotomy * Rooftop scar - liver transplant, Whipple's procedure, gastric surgery, oesophagectomy * Kocher – open gallbladder surgery * Nephrectomy can also be subcostal (like Kocher) or Rutherford-Morrison (hockey stick) * Lanz/McBurney’s = Appendicectomy * Pfannenstiel = C-section/prostatectomy/cystectomy

Answer 170

Presentation: * Bowel habit change * Palpable mass * IDA, PR bleed (clots, fresh) * Acute (obstruction, perforation) Ix: colonoscopy Mx: based on TNM staging post-CT * Colon cancer * T4 (local advancement) --\> neoadjuvant Tx * Otherwise --\> colonic resection --\> if T3+/nodal disease --\> adjuvant chemo * Rectal cancer * T3-4 --\> neoadjuvant Tx --\> colonic resection --\> if T3+/nodal disease --\> adjuvant chemo * T1-2NOMO --\> transanal excision Screen: 60-74yrs FIT testing (or FOB)

Answer 171

Upper: * RUQ pain: cholecystitis, ascending cholangitis, acute hepatitis * Epigastric pain: PUD, GORD, pancreatitis Middle: * Flank pain: pyelonephritis (loin to groin pain) * Umbilical pain - AAA (consider if \>65yrs, HTN) Lower: * RIF pain: appendicitis, ureteric colic, hernia, testicular torsion * Suprapubic pain: UTI * LIF pain: diverticulitis, inflammatory colitis, ischaemic colitis, ureteric colic, hernia, testicular torsion * In women - causes of lower Abdo pain: ectopic pregnancy, ovarian torsion, PID * Ask about **_P**_ain, _**P**_regnancy, _**P**_V bleeding, _**P_**V discharge NOTE: also consider psych cause of generalised abdo pain (esp in kids)

Answer 172

* **_Right and left hepatic ducts_** merge to form the common hepatic duct * **Gallbladder** - stores & concentrates bile and releases it to emulsify fats * _Cystic duct_ connects gallbladder to the biliary tree * Cystic duct and common hepatic duct come together to form the **_common bile duct_** * _Pancreatic duct_ feeds into the common bile duct - where it secretes exocrine hormones * All of the above feed through the **_Ampulla of Vater_** into the duodenum --\> allowing secretion of bile into the intestines

Answer 173

Presentation: * Acute umbilical to _RIF pain_ (McBurney's point) * Tenderness + guarding (if rigid abdo - perforated apendix) * N&V --\> anorexia (not wanting to eat anything from nausea), change in bowel habit * Rovsig's sign - pain in RIF on LIF palpation * Psoas sign & Obturator sign DDx: ectopic, ovarian torsion, IBS/D, bowel obstruction Ix: * Urinalysis, bloods - FBC, U&E, CRP * USS abdo/pelvis --\> consider contrast-enhanced CT-AP **Alvarado score** - \>4 = likely appendicitis Mx: * A-E (incl. fluids) * Sepsis bundle - abx when Dx confirmed * **Laparoscopic appendicectomy** * Conservative only if uncomplicated appendicitis

Answer 174

**Immediate Mx:** * NBM, Ryles tube (aspirate stomach contents) * IV fluids * AXR -\> CT (identify transition point of obstruction) **Small bowel obstruction:** * _Causes_: _Adhesions_ (prev surgery?), Hernia, Malignancy (incl. non-GI e.g. ovarian) * _Features_: central dilated loops of bowel, \>3cm, valvulae coniventes * _Mx_: surgery (but can be counterintuitive if surgery was cause), gastrografin (oral contrast medium, acts as an osmotic laxative) **Large bowel obstruction:** * _Causes_: tumour, volvulus * _Features_: peripheral dilated loops of bowel, \>6cm, haustra * _Mx_: surgery, flatus tube (in sigmoid volvulus) NOTE: 3/6/9 rule

Answer 175

**Right hemicolectomy** - right colon * Indication: problems affecting the right side of the colon e.g. malignancy * Process: removing from ileocaecal valve to 1/3 the way along the transverse colon * What are you left with: * Primary anastomoses (ileum attached to the remaining colon) * Sometimes left with a stoma **Left hemicolectomy** - left colon * Indication: problems affecting the descending colon e.g. tumour * Process: removing from 2/3 the way along the transverse colon to the sigmoid area * What are you left with: primary anastomoses from the transverse colon to the sigmoid colon **Panproctocolectomy** - total colon & rectum e.g. UC * Indication: a diffuse disease affecting the full colon e.g. FAP (familial adenomatous polyposis) or UC * Process: remove full colon & rectum (from ileocaecal valve to the anus) * What are you left with: **_end ileostomy_** (loose end of ileum brought to the skin) **Total colectomy vs subtotal colectomy** * Total colectomy: * Process: remove full colon but not the rectum * What are you left with: **_ileal-pouch anal anastomosis_** (loose end of ileum used to reform a rectum, don't need a stoma) * Subtotal colectomy: * Process: remove colon except for the rectum and part of the sigmoid colon * What are you left with: **_end-ileostomy & rectal/sigmoid stump_** **Hartmann procedure** - emergency sigmoid colon * Indication: emergency circumstances for diseases affecting sigmoid colon e.g. malignant obstruction, sigmoid volvulus, diverticular complication (e.g. perforation - healing suboptimal so don't want to create anastomoses as unlikely to succeed) * Process: sigmoidectomy * What are you left with: **_end-colostomy and rectal stump_** --\> at a future date can be reversed but many just stay with end-colostomy **Anterior vs AP resection** - for rectal tumours (A higher; P lower) * Anterior: * Indication: _higher_ rectal tumours * Process: removing sigmoid colon + top part of the rectum * What are you left with: end-colostomy/primary anastomoses ± **_defunctioning loop ileostomy_** * DLI - loop of ileum brought to surface, split so 2 lumens on surface --\> divert faecal stream (into stoma bag) from distal anastomosis = gives best chance of healing * NOTE: sometimes low anterior resection is performed where the distal margin of resection is brought down (very little rectum remains) * AP (abdominoperineal): * Indication: _low_-lying rectal tumours * What are you left with: end-colostomy * Process: remove everything up to the top of the sigmoid colon **Colostomy (ileal conduit)** * Indications: * Bladder cancer (had cystectomy) * Neurogenic bladder Radiation injury to the bladder * Chronic pelvic pain * Process: removing some ileum, forming pouch & bringing to surface so forms stoma - ureters are connected to this pouch

Answer 176

Colostomy - RIF, flushed, normal faecal matter Ileostomy - LIF, spouted (as contents irritant to skin), runny & green faecal matter Urostomy (via ileal conduit) - if urinary flow not possible via bladder/urethra e.g. post-cystectomy with bladder cancer * NOTE: nephrostomy is an opening created between the kidney & skin if urine flow from the kidney to the ureter is blocked e.g. in pyonephrosis (renal stones + inf) Stoma examination: * Hands around stoma and ask to cough --\> check for hernia + check for skin changes * Offer stoma rectal examination (finger into stoma)

Answer 177

Indications: * Traumatic rupture * Idiopathic thrombocytopenia * Spherocytosis Problem: increased risk from encapsulated bacteria e.g. strep pneumo Prophylaxis: * Vaccines: Pneumococcus, Meningococcus, Haemophilus Influenzae Type B * Penicillin V

Answer 178

**Def:** sudden, severe abdo pain that requires urgent medical/surgical attention **Immediate Tx & Ix:** * Immediate Tx - _NBM_, IV fluids, analgesia * Bedside - urine dip * Bloods - basics, VBG (lactate), amylase, G&S, clotting * Imaging - errect CXR, AXR (bowel obstruction): * USS/MRCP/ERCP - gallstones * CT-KUB - renal stones * CT-AP - perforation/obstruction * CT-angiogram - ischaemic/bleed/AAA

Answer 179

**Presentation:** progressive dysphagia (solids --\> then liquids) + FLAWS **Types:** * Squamous cell carcinoma (SCC) - less common in UK, **_middle oesophagus_**, RFs: alcohol, smoking * Adenocarcinoma - most common in UK, **_lower oesophagus_**, assoc w/ _GORD_ (long-term --\> metaplasia - Barrett's oesophagus --\> eventually become dysplastic/ malignant) **Mx:** SURGICAL * **Ivor Lewis oesophagectomy** - involves _midline laparotomy_ + _right thoracotomy_ (stomach is mobilised and pushed through oesophageal hiatus) * **McKeown oesophagectomy** - as above + _left neck incision_ (oesophagus can be pulled up through neck incision)

Answer 180

* Causes: alcohol, gallstones (GET SMASHED) * Duct obstruction: _gallstones (50%),_ trauma, tumours * Metabolic/toxic: _alcohol (33%),_ drugs, hypercalcaemia/hyperlipidaemia * Ischaemia: shock * Infection/inflammation: viruses (mumps), AI * Patterns of injury: * **Periductal** – cause: duct obstruction * Necrosis of acinar cells near ducts * **Perilobular** – cause: ischaemia (shock) * Necrosis @edges of lobule – blood supply comes w/ ducts = periphery most affected * **Panlobular** – develops as ½ progress * **Pathophysiology:** vicious cycle **-** activated enzymes --\> acinar necrosis --\> enzyme release * Lipase release --\> fat necrosis (Ca ions bind to free fatty acids forming soaps = yellow/white deposits) * Ix: * Bloods – FBC, U&E, LFTs, CRP, Amylase * Imaging – USS (looking for biliary problem, sentinel loop – early sign of ileus), CXR * NOTE: Epigastric pain --\> remember to do rectal exam (looking for melaena) * Mx - supportive (IV fluids + analgesia first) * Resus patient (IV fluids, analgesia, antiemetic, abx) --\> ITU if glasgow score \>3 * VTE prophylaxis * Complications: * Pancreatic pseudocyst – cystic space wo/ epithelial lining, lined with necrotic & granulation tissue --\> can be infected --\> abscess * Systemic: shock, hypoglycaemia, hypocalcaemia Severity criteria = **GLASGOW score (PANCREAS):** * **P**aO2 * **A**ge * **N**eutrophils (WBC) * **C**a * **R**enal funct (urea) * **E**nzymes (LDH) * **A**lbumin * **S**ugar (glucose)

Answer 181

**Diverticulosis:** colonic outpouching in mucosa & submucosa of colon - happen @weak points in colonic wall subject to increased pressure (common in elderly, low fibre diet) **Diverticular disease:** above + Sx **Diverticulitis:** infection & inflammation of diverticulum * **Hinchey classification** for acute diverticulitis: 1. a) Pericolic phlegmon & inflammation, no fluid collection b) pericolic abscess \<4cm 2. Pelvic/interloop abscess/abscess \>4cm 3. Purulent peritonitis 4. Faeculent peritonitis Presentation: * RFs: \>50yrs, low dietary fibre * LIF pain, raised WCC, fever, painless rectal bleed Ix: * FBC, U&E, CRP, (BC, ABG & lactate if septic) * **_Contrast CT abdo_** (if suspected acute diverticulitis) * Other imaging: * CXR (rule out pneumoperitoneum) * Colonoscopy/sigmoidoscopy (if Dx unclear, could be cancer/ischaemia) * CT angiogram (if excess bleeding) Mx: * Asymptomatic diverticulosis: * Increased fibre & fluids * Excercise, weight loss, stop smoking * Fybogel - if constipated * Symptomatic diverticular disease: * Above + paracetamol * _PO Dicycloverine_ = anti-spasmodic (for abdo cramping) * Acute diverticulitis: * Uncomplicated: * Low-residue diet + Paracetamol + PO Dicycloverine * Oral abx (amoxicillin) * Complicated: * Excess bleeding - resus + endoscopic Tx (e.g. band ligation, 2nd = surgery) * Abscess/perf/fistulae/obstruct - radiological drainage/surgery + IV abx * Reccurent = open/laparoscopic resection

Answer 182

**RFs (5Fs):** Fat, Female, Fertile, Forty, Fair **Types of gallstone:** mixed (80%), cholesterol (10%, bigger & smaller in #), pigment (10%, smaller & more numerous) **RUQ Pain Ix:** * Abdo USS * Stone in CBD (common bile duct) --\> ERCP * Deranged LFTs/dilated ducts --\> MRCP * None of above --\> cholecystectomy **Biliary colic:** * **Def:** pain due to blockage of bile flow due to a gallstone * **Presentation:** RUQ pain, worse after fatty meals (stimulates gallbladder contraction --\> bile release for fat emulsification) **Cholecystitis:** * **Def:** inflammation of the gallbladder (typically in context of gallstones) * **Presentation:** RUQ pain (+ tenderness - Murphy's sign), _FEVER_ * Murphy's only +ve if not present on the left as well * Ix: * Urine dip – infection, bHCG * Bloods – FBC, U&E, LFTs, CRP, amylase, clotting screen * Imaging – USS (want to be fasted – so gallbladder larger), erect CXR (pneumoperitoneum – perforation of duodenum) **Ascending cholangitis:** * **Def:** inf ascending the biliary tree, usually in the context of gallstone * **Presentation** (due to obstruction of Common Bile Duct - bile stagnates and becomes infected): * Charcot's triad - RUQ pain, fever, _JAUNDICE_ * Reynold's pentad (severe) - above + **shock** + **confusion** * **Surgical EMERGENCY** - Mx via _sepsis 6_ protocol (abx = Tazocin) + drain obstruction: * **Endoscopic retrograde cholangiopancreatography (ERCP)** - Dx & Tx (dye can be used to enhance the obstruction) - endoscope passed up to Ampulla of Vater with wire passed into the biliary system * Complications: **_pancreatitis_**, bleeding (from dilation of AoV), perforation * **Percutaneous transhepatic cholangiogram (PTC)** - interventional radiology - passing a wire through the liver into a hepatic duct and then into the top end of the biliary tree --\> dislodge stone/alternative route for bile to flow - leave in cholecystostomy * **Cholecystostomy** - interventional radiology - insert wire directly into the gallbladder and allow it to be drained - leave in cholecystostomy * Patients will likely require a later _cholecystectomy_ (after dealing with the acute infection)

Answer 183

Indications: * Acute liver failure - acute viral hep, paracetamol overdose * Chronic liver failure Unsuitable for liver transplant: * Sign. co-morbidity (renal/heart failure) * Excess weight loss/malnutrition * Active hep B/C (other inf), end-stage HIV * Active alcohol - 6 months abstinence needed Surgery: Rooftop/Mercedes Benz scar Post-transplant care: * IS - steroids, azathioprine, tacrolimus (careful drug monitoring) * Conservative - no alcohol/smoking, monitor for disease recurrence, cancer, transplant rejection (fatigue, fever, jaundice, abn LFTs) * Tx opportunistic inf