Pulsenotes Flashcards
1
Q
What is CPPD disease also known as?
A
Pseudogout
2
Q
Aetiology of haemochromatosis
A
Recessive inheritance
3
Q
Complications of haemochromatosis
A
Arthropathy (50% of patients). Either osteoarthritis-like, inflammatory or pseudogout
Diabetes
Hypopituitarism, hypothyroidism, hypogonadism
Cardiomyopathy
4
Q
Likely diagnosis in a previously fit and well young adult who has developed malaise and erythema multiforme
A
Mycoplasma pneumoniae
5
Q
Most common cause of community acquired pneumonia
A
Strep pneumoniae
6
Q
What patients need follow-up after pneumonia?
A
Smokers over 50 offered a CXR 6 weeks later, as there is a high incidence of lung cancer in these patients
7
Q
What is G6PD deficiency?
A
G6PD deficiency is an x-linked recessive inherited haemolytic anaemia, which can cause red cell lysis when erythrocytes are put under oxidative stress
8
Q
Risk factors for idiopathic thrombocytopenic purpura
A
Children under 10 (most common in 2-4 yrs)
Post viral infection
9
Q
Symptoms of idiopathic thrombocytopenic purpura
A
Increased risk of bleeding (petechiae, purpura, GI bleeding, menorrhagia, retinal haemorrhage, epistaxis) In children, there is usually an abrupt onset and it is self limiting compared to a gradual onset and chronicity seen in adults.
10
Q
Treatment for idiopathic thrombocytopenic purpura
A
control of any bleeding complications and corticosteroid therapy
In severe cases, immunosuppressive drugs and platelet transfusions
11
Q
Is Hodgkin lymphoma or non-Hodgkin lymphoma more common?
A
Non-Hodgkin
12
Q
What defines Hodgkin lymphoma?
A
presence of Hodgkin/Reed-Sternberg cells (HRS cells)
13
Q
Lymphoma symptoms
A
Lymphadenopathy: Typically painless, firm, enlarged lymph nodes, most commonly found in the neck.
Fever, night sweats and weight loss, fatigue, malaise
Mediastinal mass: May be incidental finding on chest imaging or present with shortness of breath, cough, pain or superior vena cava obstruction.
Pruritis
Hepatosplenomegaly
In extra-nodal disease there may be other symptoms such as CNS, skin or GI symtpoms
14
Q
Lymphoma diagnosis
A
Excisional biopsy
15
Q
Management of Hodgkin lymphoma
A
Chemo and radiotherapy
16
Q
Hodgkin lymphoma prognosis
A
Good
17
Q
HHS symptoms
A
Polydipsia and polyuria Headache Nausea and vomiting Abdo pain Cramps Late features - confusion, seizures, coma
18
Q
Mainstay of treatment in HHS
A
Fluids
Monitor glucose and electrolytes and consider insulin
19
Q
Complications of HHS
A
Thrombosis (need prophylaxis) Seizures Coma Electrolyte derangement Cerebral oedema due to fluid resuscitation
20
Q
What cancers are most at risk for tumour lysis syndrome?
A
Haematological malignancy
21
Q
What are the main molecules released in tumour lysis syndrome?
A
Phosphate, nucleic acid, calcium
22
Q
Symptoms of tumour lysis syndrome
A
Nausea and vomiting, lethargy, weakness, spasms or arrhythmias within a few days of starting chemo or radiotherapy
23
Q
Blood tests results in tumour lysis syndrome
A
Hyperphosphatemia
Hyperkalaemia
Hyperuricaemia
Hypocalcaemia
24
Q
Diagnosis of tumour lysis syndrome
A
Laboratory diagnosis (hyperphosphatemia, hyperkalaemia, hyperuricaemia, hypocalcaemia) plus clinical diagnosis (raised creatinine, arrhythmias, seizures)
25
Prevention of tumour lysis syndrome
Risk stratification and giving IV fluids (and maybe uric acid lowering agents e.g. allopurinol or raspuricase) to high risk patients
26
Management of tumour lysis syndrome
Correction of electrolytes (calcium gluconate, insulin and dextrose, phosphate binders, uric acid lowering agents e.g. allopurinol or raspuricase, IV hydration)
May need dialysis
27
Where should patients with acute liver failure be managed?
Transplant centre / ITU
28
Management of acute liver failure
Intensive monitoring and supportive management
| Liver transplant if eligible
29
When is the Rockall score used?
GI bleeding (after endoscopy to assess risk of death and re-bleeding)
30
Components of Rockall score
Age, BP & HR, Comorbidities, Diagnosis on endoscopy, Endoscopic findings
31
Management of testicular torsion
testicular exploration +/- bilateral orchidopexy +/- orchidectomy
32
Blood tests results in beta-thalassaemia
Microcytic anaemia
Iron studies normal (differentiates it from iron-deficiency anaemia)
Elevated HbA2 as it doesn't have the HbB to bind to
33
Symptoms of one allele for beta-thalassaemia
Termed beta-thalassaemia minor / trait
| Usually have mild, often asymptomatic anaemia
34
Cause of raised reticulocytes
Rapid blood loss (as body is making more)
35
Cause of lowered reticulocytes
Iron deficiency anaemia
36
Total iron binding capacity in iron deficiency anaemia
High
37
Serum ferritin in iron deficiency anaemia
Low
38
Gold standard for diagnosis of iron deficiency anaemia
Low serum ferritin
39
What type of anaemia is anaemia of chronic disease?
Normocytic (75%) or microcytic (25%)
40
Total iron binding capacity in anaemia of chronic disease
Low
41
Serum ferritin in anaemia of chronic disease
Normal / raised (as it's an acute phase reactant)
42
Symptoms of beta-thalassaemia
Hepatomegaly
Splenomegaly
Skeletal abnormalities
Symptoms of iron overload form repeated transfusions (hypogonadism, growth failure, diabetes mellitus, hypothyroidism)
43
Key diagnostic test in beta-thallasaemia
Haemoglobin electrophoresis
44
Management of beta-thallasaemia
Blood transfusions
45
Causes of neutopaenia
```
Congenital
Infection e.g. HIV / TB
Cancer
Drugs e.g. chemo / carbimazole
Autoimmune
```
46
Most common type of lung cancer
Adenocarcinoma
47
CURB-65 score
```
Confusion
Urea >7
Resp rate >30
BP <90
Age >65
```
48
What referral is necessary to consider in iron deficiency anaemia?
Upper and lower endoscopy via urgent suspected cancer pathway
Males and post-menopausal women
49
What part of the lungs is adenocarcinoma usually seen?
Peripheries
50
What part of the lungs is squamous cell lung cancer usually seen?
Centrally
51
Prognosis in small cell lung cancer
Very poor
52
What is a pancoast tumour?
Tumour of the lung apex
53
Definition of multiple endocrine neoplasia
Development of many endocrine tumours
54
Aetiology of multiple endocrine neoplasia
Autosomal dominant
55
What is multiple endocrine neoplasia type 1 (MEN1)?
Mutation of MEN1 gene causes tumours of parathyroid, pancreas and pituitary. May also be angiofibromas
56
What is an angiofibroma?
Small cutaneous tumours that are dome shaped and skin coloured
57
Symptoms of multiple endocrine neoplasia 1 (MEN1)
Pituitary tumours - headache, visual disturbance, Cushings, acromegaly, prolactinoma (low libido, galactorrhoea, menstrual irregularity)
Parathyroid hyperplasia - hypercalcaemia (bone pain, renal stones, abdo pain, polyuria, psych issues)
Pancreatic tumours - insulinoma (hypoglycaemia), gastrinoma (peptic ulcer disease)
58
What is multiple endocrine neoplasia type 2 (MEN2)?
Mutation of RET gene causes thyroid cancer and pheochromocytoma
59
Symptoms of multiple endocrine neoplasia 2 (MEN2)
Medullary thyroid cancer - thyroid often removed as prophylaxis
Parathyroid hyperplasia - hypercalcaemia (bone pain, renal stones, abdo pain, polyuria, psych issues)
Pheochromocytoma - flushing, tachycardia, palpitations
60
Diagnosis of multiple endocrine neoplasia (MEN)
Blood tests for increased levels of the hormones involved (e.g. PTH, prolactin, pancreatic polypeptide, gastrin, calcitonin, catecholamines)
Imaging for where tumour is suspected
Genetic testing
61
Screening for multiple endocrine neoplasia 1 (MEN1)
Annual health check looking for tumours in first and second degree relatives
62
Screening for multiple endocrine neoplasia 2 (MEN2)
Health check in relatives looking for tumours
63
Management of multiple endocrine neoplasia 1 (MEN1)
Parathyroid hyperplasia - surgical resection
Pituitary adenoma - surgical resection or medical management
Pancreatic tumours - more difficult to treat, either excision or medications (e.g. PPIs in gastrinoma)
64
Management of multiple endocrine neoplasia 2 (MEN2)
Parathyroid hyperplasia - surgical resection
Pheochromocytoma - adrenalectomy
Medullary thyroid cancer - prophylactic resection
65
Grading system in acute limb ischaemia
Rutherford
66
Polymyalgia rheumatica symptoms
The hallmark is symmetrical muscle aching and stiffness, worse in the morning, that affects the shoulders, hips, neck and torso
May also have systemic features e.g. low fever, fatigue, weight loss, low mood
67
Signs of polymyalgia rheumatica on examination
Reduced range of movement: shoulder, cervical spine, and hips
Synovitis and swelling
Normal power, though pain may make this difficult
68
Diagnosis of polymyalgia rheumatica
The diagnosis of PMR is based on identifying typical clinical features and assessing response to corticosteroids (rapid resolution within 1 week)
69
Treatment of polymyalgia rheumatica
Low dose steroids. Normally dose tapered off after a few weeks but in some patients it is tapered more slowly
70
Tests needed before starting amiodarone
CXR, U&Es, TFTs, LFTs
71
CLL symptoms
Painless enlarged lymph nodes
Constitutional symptoms e.g. weight loss, fever, anorexia, night sweats, lethargy
May have hepatomegaly or splenomegaly
72
Diagnostic test in CLL
Raised lymphocytes on FBC
73
What is Binet staging used for and what staging system is used?
CLL
Stage A: <3 lymphoid sites
Stage B: ≥3 lymphoid sites
Stage C: presence of anaemia and/or thrombocytopaenia
74
Management of CLL
Watch and wait with supportive care e.g. flu vaccine and treating infections
Chemotherapy (chemo, biologics, monoclonal antibodies, steroids)
Stem cell transplant
75
CLL complications
Transformation to more aggressive lymphoma or leukaemia
Infections
Autoimmune conditions
Increased risk of haematological or other cancers
76
CLL prognosis
Good
77
What is Bell's palsy?
Bell’s palsy is rapid onset (< 72 hours) unilateral facial weakness of unknown cause
78
Does Bell's palsy affect the forehead?
Yes (a way to differentiate it from stroke)
79
Bell's palsy prognosis
The majority of patients with Bell’s palsy will make a full recovery within four months.
80
Bell's palsy management
Mostly reassurance and advice on supportive care e.g. eye care
Prednisolone if presenting within 72 hours of symptom onset
81
Inheritance of Lynch Syndrome
Autosomal dominant
82
Haemorrhoids treatment
Treatment is commonly conservative. It aims to prevent or reduce constipation and symptoms. Symptomatic relief involves simple analgesics and topical anaesthetics.
Refractory disease may require treatment with rubber band ligation, sclerotherapy, diathermy and haemorrhoidectomy.
83
What is multiple myeloma?
A malignant disorder of plasma cells which will secrete monoclonal antibodies
84
Symptoms of multiple myeloma
Constitutional features e.g. weight loss, fatigue, night sweats, anorexia
Bone disease (typically lytic lesions that can lead to fractures)
Renal impairment
Anaemia
Hypercalcaemia
Recurrent infections
85
What cancer is hyperviscosity syndrome particularly associated with?
Multiple myeloma
86
Symptoms of hyperviscosity syndrome
Blurred vision, headaches, mucosal bleeding and dyspnoea
87
Treatment of hyperviscosity syndrome
Urgent plasma exchange
88
Tests to diagnose multiple myeloma
Protein electrophoresis to look for monoclonal antibodies
Immunofixation may be used to look for monoclonal antibodies
May do urine electrophoresis to look for Bence-Jones protein (free light chains in the urine)
May do bone marrow biopsy
89
Treatment principles in multiple myeloma
The four key areas of management include: induction therapy (chemotherapy and steroid), autologous stem cell transplantation (ASCT), maintenance therapy (chemotherapy) and managing relapse or refractory disease.
90
Prognosis in multiple myeloma
Variable but usually poor
Beta-2 microglobulin is often used as a prognostic tool
Most patients will have a period of remission then relapse
91
Acute pulmonary oedema management
furosemide 40mg IV
high-flow Oxygen
nitrates (Sublingual / infusion)
diamorphine IV
92
Non-massive vs sub-massive PE
Non-massive: haemodynamically stable and no evidence of right heart strain
Sub-massive: haemodynamically stable, but evidence of right heart strain on imaging (e.g. CT, ECHO) or biochemistry (e.g. elevated troponin)
93
Treatment in minimal change disease
Steroids first line
Other immunosuppressants may be used in adults with recurrent disease
ACE inhibitors / ARBs to manage HTN and diuretics to manage oedema
94
Most common cause of nephrotic syndrome in adults
Membranous glomerulonephropathy
95
First line in focal epliepsy
Carbamazepine
96
Staging sarcoidosis
Stage 0: Normal CXR
Stage I: Bilateral hilar lymphadenopathy
Stage II: Bilateral hilar lymphadenopathy and infiltrates
Stage III: Infiltrates alone
Stage IV: Pulmonary fibrosis (volume loss predominantly in the upper zones)
97
What is sarcoidosis?
Sarcoidosis is a rare multisystem granulomatous inflammatory disorder of unknown aetiology
98
Age of onset of sarcoidosis
20-40
99
Symptoms of sarcoidosis
Asymptomatic
Lungs most commonly involved: will have signs of fibrosis e.g. fine crackles, restrictive spirometry, exertional breathlessness, may have right heart strain
Eyes may be affected: uveitis
Skin may be affected: papules / erythema nodosum
Other manifestations e.g. renal disease or hypercalcaemia
100
Management of sarcoidosis
Often no management needed
If severe, may have steroids (high dose then tapered to low dose) or other immunosuppressants if steroids not tolerated
Lung transplant if very severe
101
Prognosis in sarcoidosis
Good prognosis and it often regresses spontaneously
| Pulmonary disease may increase mortality
102
CXR findings in sarcoidosis
Bilateral hilar and mediastinal lymphadenopathy
Reticulonodular / airspace opacities
Pulmonary fibrosis
Normal in 20%
103
Most common causes of hypercalcaemia
Malignancy or hyperparathyroidism
104
Pathophysiology of malignant hypercalcaemia
Parathyroid hormone related peptide (PTHrP) secretion from tumours
Osteolytic lesions (release calcium)
Secretion of activated vitamin D (rarer)
105
Medications that can be used to manage hypercalcaemia
Bisphosphonates
| Calcitonin
106
Most common organism in acute otitis media
Strep pneumoniae
107
What is eosinophilic oesophagitis?
Eosinophilic oesophagitis is a chronic immune-mediated disease, characterised by eosinophil-predominant inflammation of the oesophagus
108
Risk factors for eosinophilic oesophagitis
Male
30s-40s
Other allergic conditions such as asthma, atopic dermatitis, food or environmental allergies
109
Symptoms of eosinophilic oesophagitis
Dysphagia (often slow eating needing lots of water to help swallow food)
May have heartburn / dyspepsia / chest pain
110
Diagnosis of eosinophilic oesophagitis
Endoscopy with biopsy to show raised eosinophils
111
Management of eosinophilic oesophagitis
Conservative: diet modification
Medical: PPI, steroids (either inhaled or a slurry to make it topical)
May need endoscopic surgery e.g. to treat strictures
112
Drug to treat spasticity
Baclofen
113
Definition of MS
Multiple sclerosis (MS) is a demyelinating neuroinflammatory condition, which affects the central nervous system (CNS). Focal areas of demyelination are known as plaques
114
Risk factors for MS
Women
Onset 20-40
Genetics
Environmental e.g. EBV infection
115
Commonly sites of lesions in MS
Optic nerves
Spinal cord
Brainstem
Cerebellum
116
Most common course of MS
Relapsing-remitting (90% of MS)
117
pattern in relapsing-remitting MS
Relapses of more severe symptoms followed by periods of full or partial recovery with few symptoms
118
Pattern in primary progressive MS
Sustained progression of disease severity from onset. May also have relapses
119
Pattern in secondary progressive MS
Starts as relapsing and remitting pattern then becomes a pattern with sustained progression
120
What is clinically isolated syndrome with respect to MS?
CIS describes the first clinical episode of suspected MS.
121
Symptoms of MS
Optic nerve involvement: visual symptoms e.g. vision loss / blurring or pain
Cerebellar lesions: ataxia, gait disturbance, cerebellar signs
Brainstem lesions: cranial nerve palsies
Spinal cord lesions: movement / sensory disorders
Others: pain, sexual dysfunction, bowel / bladder dysfunction, depression
122
Diagnosis of MS
2 or more bouts
2 or more locations (seen as plaques on MRI)
If diagnosis uncertain can look for oligoclonal bands in CSF
123
Management of MS
General: help with bladder or bowel dysfunction e.g. catheters for retention / meds for incontinence / laxitives, meds / CBT for depression, walking aids, meds for neuropathic pain, physio / meds for spasticity
Treatment of relapses: Steroids
Long term treatment: Biologics may be indicated as disease modifying therapy
124
Indication for punch biopsy
Biopsy in sensitive areas e.g. face to see if it needs excision
125
Diagnostic test of choice in BCC
Excisional biopsy
126
Definition of BCC
Slow growing locally invasive malignant skin tumour with very limited metastatic potential
127
Prognosis in BCC
Good
128
What does a classic BCC look like?
Telangiectasia (small blood vessels)
Ulceration
Rolled edges
Pearly edge
129
Definition of SCC
Malignant fast growing tumour of epidermis with metastatic potential. Typically occurs in sun exposed areas
130
What does a classic SCC look like?
Indurated, nodular, keratinising or crusted tumour with or without ulceration
131
Management of skin cancer
Surgery: excisional / destructive (if biopsy not needed)
| Non-surgical: Topical immunotherapy (low risk cancer), cryotherapy (low risk cancer), radiotherapy
132
What sort of rash is typhoid associated with?
Small red dots often on chest
133
is C.diff gram positive or negative?
Positive
134
Most common pathogen in prostatitis
E. coli
135
Acute bacterial prostatitis symptoms
Pain (abdominal, rectal, pelvic or back pain)
Dysuria, urinary frequency or retention
Systemic signs of infection e.g. fever, rigors, myalgia, tachycardia
136
What cultures and screening are important in acute bacterial prostatitis?
Blood, urine and semen cultures
| STI screen
137
Imaging in acute bacterial prostatitis
MRI (look for abscesses)
138
What prophylactic medication should patients with HHS be started on and why?
Prophylactic LMWH as dehydration predisposes to thrombosis
139
Oesophagitis scoring system
Los Angeles
140
Risk factors for variocele
```
Adolescence
Malignancy (rare)
```
141
Symptoms of variocele
```
Testicular swelling (described as "bag of worms", may be better on lying down and worse with the valsalva manoeuvre)
Classically painless but some patients experience pain or discomfort
```
142
Complications of variocele
Infertility
| Testicular atrophy
143
Indications for referral in variocele
Symptomatic
Doesn't drain on lying down
Isolated on the right side
Testicular atrophy in adolescents
144
Management of variocele
Yearly observation if asymptomatic
| If symptomatic may have surgery
145
Demographic of myasthenia gravis
Younger females
| Older males
146
Myasthenia gravis is associated with pathology of which organ?
Thymus gland (thymoma, thymic hyperplasia, atrophy)
147
Result of ice pack test in myasthenia gravis
Improves with ice
148
Main antibodies in myasthenia gravis
AChR-Ab (antibodies against acetylcholine receptor)
149
Treatment for myasthenia gravis
Acetylcholine esterase inhibitors first line (e.g. pyridostigmine)
Corticosteroids second line
Immunosuppressants third line
Thymectomy can improve symptoms if there is a thymoma
150
Key monitoring in patients with myasthenic crisis
FVC
151
Treatment in myasthenic crisis
IVIG (IV immunoglobulins)
Steroids
Plasma exchange if severe
152
Most common organism in native valve endocarditis
Streptococci
153
What syndrome does anca associated vasculitis cause?
Nephritic
154
Symptoms of granulomatosis with polyangiitis
Vasculitic rash
AKI
Nasal features e.g. epistaxis
155
Autoantibody present in granulomatosis with polyangiitis
cANCA
156
Symptoms in microscopic polyangiitis
Vasculitic rash
AKI
Peripheral neuropathy
157
Autoantibody present in microscopic polyangiitis
pANCA
158
Symptoms of eosinophilic granulomatosis with polyangiitis
Adult onset asthma
| Allergic features
159
Autoantibody present in eosinophilic granulomatosis with polyangiitis
cANCA or pANCA
160
Pathophysiology of tubulointerstitial nephritis
Hypersensitivity causes inflammation of the kidney tubules. Often caused by drugs e.g. abx or diclofenac
161
Symptoms of tubulointerstitial nephritis
Fever, rash, eosinophilia, arthralgia, myalgia
162
Treatment in tubulointerstitial nephritis
Discontinue drugs that may have caused it
Dialysis if severe
May give steroids if severe
163
Renal artery stenosis symtoms
severe HTN
variable renal function
recurrent pulmonary oedema
164
Renal artery stenosis diagnosis
doppler ultrasound
| CT
165
Management of renal artery stenosis
```
HTN management (but ACE inhibitors contraindicated)
Manage comorbidities
```
166
Diagnosis of Parkinson's
Step 1: Parkinsonism (bradykinesia with either rigidity, postural instability or resting tremor)
Step 2: Considering differentials (e.g. stroke / trauma / encephalitis)
Step 3: Supportive features (progressive, unilateral onset, asymmetry, responds well to levodopa)
167
What are parkinson plus syndromes:
Other conditions that can present similarly to Parkinsons (multisystem atrophy, progressive supranuclear palsy, corticobasal degeneration, lewi body dementia)
168
What is multisystem atrophy?
A parkinson plus syndrome
MSA is an adult-onset, rapidly progressive disease that is characterised by profound autonomic dysfunction leading to severe postural hypotension, urogenital dysfunction and other features including cerebellar and corticospinal features. There is a poor response to treatment.
169
What is progressive supranuclear palsy?
A parkinson plus syndrome
PSP is a neurodegenerative disorder that typically begins at age 50-60 years and is characterised by vertical gaze dysfunction, dysarthria and cognitive decline. Tremor is rare in this condition.
170
What is corticobasal degeneration?
A parkinson plus syndrome
CBD is a neurodegenerative disorder that is characterised by a progressive dementia, parkinsonism and limb apraxia. Apraxia refers to problems with motor planning (i.e. unable to wave hello).
171
Paraneoplastic syndromes associated with squamous cell carcinoma
PTH release
| Cushings
172
Paraneoplastic syndromes associated with small cell lung cancer
SIADH
| Cushings
173
Symptoms of renal cell cancer
```
Haematuria
Flank pain
Flank mass
Constitutional symptoms e.g. fever / night sweats / malaise / weight loss
Variocele
Paraneoplastic syndromes
```
174
Imaging in renal cell cancer
CT first line
MRI if CT contraindicated
May be picked up on ultrasound
175
Management of renal cell carcinoma
Partial / total nephrectomy
| Chemotherapy in advanced disease and palliative care if necessary
176
Management of combined B12 and folate deficiency
Correct B12 first
177
Kernig's sign
Kernig's sign describes an inability to fully extend at the knee when the hip is flexed at 90º due to pain
Suggests meningism
178
Brudzinski's sign
Brudzinski's sign describes spontaneous flexion of the knees and hips on active flexion of the neck due to pain
Suggests meningism
179
Grey Turner's sign
bruising in both flanks due to retroperitoneal haemorrhage (characteristic in acute pancreatitis)
180
Battle's sign
bruising over the mastoid bone suggestive of basal skull fracture
181
Hutchinson's sign
herpetic lesion on the tip of the nose, which can be an early warning of ocular herpes zoster
182
Muller's sign
visible pulsation or bobbing of uvula seen in aortic regurgitation
183
Factors that can artificially increase PSA
Vigorous exercise in previous 48 hours
Ejaculation in previous 48 hours
Urinary / prostatic infection
Prostate biopsy
184
Management of BPH
Watchful waiting
Medical (alpha blockers e.g. Tamsulosin or 5-alpha reductase inhibitors e.g. finasteride)
Surgical resection (transurethral resection or incision or laser techniques)
185
Complications of surgical procedures for BPH
Retrograde ejaculation (up to 75% for a transurethral resection), urinary infection, need for urinary catheter are all relatively common. Occasionally clot retention, urinary incontinence, urethral stricture and erectile dysfunction may occur.
186
First line imaging in BPH
Ultrasound
187
Management of an infective exacerbation of COPD
nebulisers, steroids and antibiotics. Controlled oxygen therapy should be given to patients if required.
188
Symptoms of optic neuritis
Pain behind the eye which is worse on eye movement
Reduced visual acuity
Blurred vision
Central scotoma
May have reduced ability to see the colour red
Optic disc swelling on fundoscopy
189
Drug to treat erectile dysfunction
Sildenafil
190
Pathophysiology of primary TB
A Ghon focus develops composed of tubercle-laden macrophages
| In immunocompetent people, this usually heals by fibrosis.
191
Monitoring of lithium
Serum-lithium monitoring should be performed weekly after initiation and after each dose change until concentrations are stable, then every 3 months for the first year, and every 6 months thereafter.
192
Indication for lithium
Mood disorders (bipolar)
193
What condition are pencil cells associated with?
Iron deficiency anaemia
194
What condition are Howell-Joly bodies associated with?
Splenectomy
195
What condition are spherocytes associated with?
Hereditary shperocytosis
196
What condition are schistocytes associated with?
Metallic valve replacement or some haemolytic anaemias
197
Management of asymptomatic gallstones
Nothing
198
Fibroadenoma examination findings
smooth, hard, painless lump in the outer upper quadrant of the breast
199
Management of fibroadenoma
Referral for triple assessment to exclude breast cancer. Consider urgent suspected cancer referral if over 30 or other features of breast cancer)
Once fibroadenoma is confirmed no management is needed (but should advise to check breasts regularly)
200
Age range associated with fibroadenomas
Young women
201
Most common cause of primary aldosteronism
Bilateral idiopathic hyperplasia
202
Symptoms of primary aldosteronism
Asymptomatic
Hypertension (may present with CKD, cerebrovascular disease, heart failure or retinopathy)
Hypokalaemia (may present with muscle weakness, paraesthesia, mood disturbance and polyuria)
203
Who to test for primary hyperaldosteronism
Hypertension with hypokalaemia
Severe hypertension (systolic > 150, diastolic > 100)
Hypertension resistant to treatment
Hypertension and:
Adrenal incidentaloma
Sleep apnea
Family history of early onset hypertension
Family history of early onset CVA
Primary aldosteronism affecting all 1st degree relatives with hypertension
204
Testing for primary aldosteronism
Aldosterone: Renin ratio (will be raised)
If raised, CT adrenals
May do adrenal vein sampling prior to surgery to determine if it is bilateral or unilateral
205
Management of primary aldosteronism
Unilateral: Surgery or mineralocorticoid receptor antagonists
Bilateral: Mineralocorticoid receptor antagonists
206
Most common organism in IVDU infective endocarditis
Staph aureus
207
Most common organism in native valve infective endocarditis
Streptococcus
208
Most common organism in prosthetic valve infective endocarditis
Staphylococcus if early or streptococcus if late
209
What are Roth spots? What do they signify?
Haemorrhage on the retina due to emboli
| Associated with infective endocarditis
210
Criteria used to diagnose infective endocarditis
Duke criteria
211
What is Zollinger-Ellison syndrome?
Zollinger-Ellison syndrome is characterised by multiple peptic ulcers secondary to hypergastrinaemia in patients with a gastrinoma.
212
Formula used to calculate fluid replacement in burns
Parkland formula
213
Which patients with ADPKD get screening for berry aneurisms?
- Personal or family history of intracerebral haemorrhage
- Anticoagulation
- High-risk occupations
- Patients needing major surgery
214
Symptoms of anaphylactoid reaction
nausea, vomiting, urticarial rash, angioedema, tachycardia, and bronchospasm but shock is uncommon
215
Management of suspected DVT if doppler ultrasound not available within 4 hours
Start interim anticoagulation
216
Management of patient with suspected DVT but negative doppler ultrasound
Stop anticoagulation
D-dimer
If negative, consider alternate diagnosis
If positive, stop anticoagulation and re-ultrasound in a week
217
DVT management
DOAC first line
| LMWH if DOAC not suitable
218
Symptoms of post-thrombotic syndrome
chronic swelling, pain and skin changes within 2 years of a DVT
219
Scoring system to assess risk in confirmed PE
PESI score
220
Properties of TB pathogen
aerobic, acid-fast, slow-growing bacteria
221
Definition of primary-progressive TB
Progressive-primary TB: primary infection is not suppressed, and prolonged infection occurs.
222
What is a Gohn complex?
A small caseating lung lesion with an associated enlarged lymph node indicative of TB (primary or latent)
223
TB symptoms
weight loss, malaise, fever
Pulmonary symptoms e.g. cough, SOB, haemoptysis
Enlarged lymph nodes
Other organs may be effected with a range of other symptoms e.g. epididymo-orchitis, meningitis, back pain, lupus vulgaris, pericardial effusion, Addison's, terminal ileitis
224
Who should be screened for latent TB?
Close contacts of patients with active TB
Immunocompromised patients
Prior to starting meds that may cause reactivation (e.g. biologics)
Entry to UK from areas of high prevalence
225
Principle of Mantoux test
The Mantoux test Involves an intradermal injection of tuberculin, a purified protein derivative from M. tuberculosis. If a patient has had exposure to TB they exhibit a delayed (type IV) hypersensitivity reaction. Diagnosis is based on the degree of the local epidermal reaction.
226
Limitation of Mantoux test
BCG vaccination affects results
227
Principle of interferon gamma release assay testing for TB
These assays detect the bodies cellular immune response to TB. It tests for the T-cell interferon gamma response to M. tuberculosis antigens.
228
Tests for latent TB
Mantoux or interferon gamma release assay
229
Key investigations in active TB
CXR
3x early morning sputum for culture
Others for extra-pulmonary TB (e.g. CSF culture or other imaging)
230
Efficacy of BCG vaccine
Poor
231
Indication for treating latent TB
Under 65 without hepatic impairment and with contact with active or drug resistant TB
232
Treatment for latent TB
6 months isoniazid or 3 months isoniazid and rifampicin
233
Treatment for active TB (without CNS involvement)
isoniazid and rifampicin for 6 months
| pyrazinamide and ethambutol for 2 months
234
Treatment for active TB with CNS involvement
isoniazid and rifampicin for 12 months
pyrazinamide and ethambutol for 2 months
Steroids weaned down over 4-8 weeks
235
Testing for drug resistant TB (Who to test and how?)
Previous TB
Contact with resistant TB
Born / Lived in country with high prevalence of resistant TB
Test with nucleic acid amplification
236
Treatment for drug resistant TB
Specialist, usually a combination of at least 6 meds
237
Cholesterol emboli risk factors
Cardiac angiography or initiation of thrombolysis 1-2 weeks previously
238
Cholesterol emboli symptoms
Worsening renal function
Blue toes
Red-blue skin mottling
Necrosis if severe
239
Management of cholesterol emboli
Analgesia
Some meds but limited evidence
Amputation if severe
240
What is the name of the variant of T1DM that onsets in adulthood?
LADA (latent onset autoimmune diabetes in adults)
241
What is the name for monogenic diabetes?
MODY (maturity onset diabetes of the young)
242
Management of Budd-Chiari syndrome
recanalisation of the hepatic veins using anticoagulation, thrombolysis, stents or a transjugular intrahepatic portacaval shunt (TIPS)
Transplantation if severe
243
Symptoms of post-coital headache
Severe headache during / shortly after intercourse / orgasm. Typically occipital and lasts 1-24 hours. Important to exclude sub-arachnoid haemorrhage
244
Overview of diffuse large B cell lymphoma
Most common non-Hodgkin lymphoma
Aggressive
Usually presents as rapidly enlarging mass
245
Overview of follicular lymphoma
A type of B cell non-Hodgkin lymphoma
Second most common non-Hodgkin lymphoma
Indolent (non-aggressive)
Usually presents with gradual lymphadenopathy
246
Overview of Burkitt's lymphoma
A type of B cell non-Hodgkin lymphoma
Fairly rare but commonly affects children
Aggressive
Usually presents as rapidly enlarging tumour in the jaw with lymphadenopathy and there may be abdominal symptoms
247
Inheritance of Wilson's disease
Autosomal recessive
248
Symptoms of Wilsons disease
Kayser-Fleischer rings
Liver complications e.g. acute liver disease, chronic hepatitis or cirrhosis
Neurological complications e.g. akinesis / tremor / ataxia
Psychiatric complications e.g. behaviour changes / depression / psychosis
Anaemia
Others e.g. cataracts / renal failure / osteoarthritis / infertility
249
Definition of Wilson's disease
Genetic condition of abnormal copper deposition
250
Key tests in Wilson's disease
Serum caeruloplasmin: main carrier of copper in the blood. It tends to be decreased in patients with Wilson’s.
Serum copper: Tends to be decreased though it may be normal or elevated in acute liver failure
Serum ‘free’ copper: tends to be elevated.
24-hour urinary copper: Tends to be elevated.
251
Screening for Wilson's disease
Siblings and children
252
Management of Wilson's disease
Conservative (counselling, lifestyle advice, follow-up)
Meds (D-penicillamine first line)
Liver transplant may be indicated
253
Definition of haemochromatosis
Genetic condition of excess iron in the body with abnormal deposition
254
Inheritance of haemochromatosis
Autosomal recessive
255
Age of onset in Wilson's disease
Older children / Young adults
256
Ago of onset of haemochromatosis
Middle age - old age (typically after menopause in females)
257
Symptoms of haemochromatosis
```
Fatigue
Arthritis
Bronze pigmentation of skin
Hair loss
Erectile dysfunction / amenorrhoea
Memory problems or mood disturbance
```
258
Diagnosis of haemochromatosis
Raised serum ferritin
Raised transferrin saturation
Genetic testing
259
Serum ferritin in haemochromatosis
High
260
Transferrin saturation in haemochromatosis
High
261
Complications of haemochromatosis
T1DM
Liver damage and cirrhosis or hepatocellular carcinoma
Endocrine / sexual problems e.g. hypogonadism / hypothyroidism
Cardiomyopathy
Arthritis
262
Management of haemochromatosis
Weekly venesection to remove excess iron
263
Conservative management of epistaxis
Pinch fleshy part of nose and lean forward over sink for 20 mins
Spit out blood in the mouth
Ice packs on forehead and neck
Consider anticoagulant reversal (senior decision)
264
When to involve ENT in epistaxis
If conservative measures failed after 20 mins
265
What bloods to do in epistaxis and when
FBC, clotting screen and group and save if conservative measures failed after 20 mins
266
Management of epistaxis if conservative measures failed
Local anaesthetic
Cautery with silver nitrate
Prophylactic naseptin topical abx
267
Management of epistaxis if cautery failed
Nasal packing
268
Care of patient with nasal packing
Admit under ENT for monitoring
Analgesia
Make NBM incase surgery needed
Prophylactic abx according to local guidelines
269
Management of posterior epistaxis
Senior ENT help
| Catheterisation of posterior nasal cavity
270
Post epistaxis advice
Topical naseptin abx
| Avoid blowing / picking nose, hot drinks, heavy lifting or lying flat for 1-2 days
271
When to refer in epistaxis
```
Under 2 (epistaxis uncommon and consider NAI)
Recurrent nosebleeds and risk factors for underlying cancer / condition
```
272
Posterior stroke symptoms
Balance issues
Visual disturbance
Cranial nerve involvement
273
Symptoms of strangulated hernia
Hernia symptoms
Bowel obstruction symptoms
Severe pain
274
Imaging in hernias
Not usually necessary for diagnosis
USS may be done if there is diagnostic uncertainty
CT if there are complications e.g. strangulation
275
Indications for urgent referral in hernias
Strangulation / bowel obstruction (emergency referral)
Female
Irreducible
276
Management of asymtpomatic herniae
Watchful waiting and education on signs of strangulation
277
Management of symptomatic hernias
Surgery (open or laparoscopic)
278
Management of ADPKD
BP control with ACE inhibitors
| Renal replacement therapy (dialysis / transplant) in end-stage disease
279
Criteria to describe Barratt's oesophagus
Prague (split into two components: circumferential extent and maximal length)
280
What are Heberden's nodes?
Bony swellings on the distal interphalangeal joints
281
What are Bouchard's nodes?
Bony swellings on the proximal interphalangeal joints
282
What is Pemberton's sign?
Pemberton’s sign describes an increase in facial plethora, venous dilation and respiratory distress on raising the arms above the head for 1-2 minutes.
Suggests SVCO
283
Most common type of prostate cancer
Adenocarcinoma
284
First line imaging in prostate cancer
MRI
285
Scoring system for likelihood of prostate cancer based on MRI
Likert (out of 5)
286
Management of low risk prostate cancer
Surveillance, radiotherapy or prostatectomy
287
Management of intermediate risk prostate cancer
Radiotherapy or prostatectomy. May also have hormone therapy
288
Management of high risk prostate cancer
Radiotherapy or prostatectomy. May also have hormone or chemo therapy
289
Age of onset of Eosinophilic granulomatosis with polyangiitis
40s
290
What is Churgg-Strauss syndrome known as?
Eosinophilic granulomatosis with polyangiitis
291
What is Wegeners granulomatosis known as?
Granulomatosis with polyangiitis
292
What is pseudoxanthoma elasticum?
a rare condition characterised by progressive calcification and fragmentation of elastic fibres. It can cause gastrointestinal haemorrhage
293
What faecal test can assess pancreatic function?
Faecal elastase
294
Symptoms of sickle cell anaemia
Increased infections
Anaemia
Acute painful episodes (typical sites are back, chest, abdomen and extremities)
Acute chest syndrome (acute respiratory symptoms)
Organ damage
295
Symptoms of acute chest syndrome
```
Fever
Chest pain
Hypoxaemia
Wheezing
Cough
Respiratory distress
```
296
Conservative management in sickle cell
```
Education
Close follow-up
Folate supplements
Prophylactic abx
Immunisations
```
297
Types of transfusion in sickle cell
```
Top-up transfusions (give donor blood)
Exchange transfusions (remove some blood then give donor blood)
```
298
Medication to reduce sickling in sickle cell
Hydroxycarbamide/Hydroxyurea (various indications)
299
What can precipitate acute painful episode in sickle cell?
hypoxia, infection, dehydration, cold weather or even pregnancy
300
Management of acute painful episode in sickle cell
ABCDE and obs
Check sickle care plan (personalised care plan for patients to manage painful episodes)
Analgesia (usually morphine)
Regular observation
Managing exacerbating factors (ensure well hydrated, treat concurrent infections and provide oxygen as needed)
Haematology referral
301
Acute chest syndrome on X-ray
Pulmonary infiltrates
302
Management of acute chest syndrome
```
Abx
O2
Pain relief
IV fluids
VTE prophylaxis
May need ventilation
May need rapid transfusion
```
303
Treatment of pseudogout with 2 joints or less affected
Intraarticular steroid injection (may also add lidocaine)
304
Treatment of pseudogout with more than 2 joints affected
NSAID
Colchicine is an alternative
Steroids if severe
305
What does silver wiring on ophthalmoscopy indicate?
Vessel sclerosis
306
What is von-Hippel Lindau syndrome?
autosomal dominant syndrome associated with numerous malignancies including renal cell carcinoma
307
Colour of gram positive organisms on gram stain
violet
308
Colour of gram negative organisms on gram stain
pink
309
Classification of renal cysts
```
Bosnaik classification
(I - simple, II - minimally complex, III - intermediate, IV - malignant)
```
310
What is haptoglobin
Haptoglobin is an acute phase plasma protein, which binds to free haemoglobin within the blood.
311
What does low haptoglobin indicate?
Intravascular haemolysis (as the haptoglobin mops up the Hb)
312
Driving restrictions after a stroke
Don't drive for 1 month (longer for HGVs)
313
Frequency of endoscopic screening in Barratt's oesophagus
Dysplasia- 6 months
Long segment metaplasia - 3 years
Short segment metaplasia - 5 years
314
Most common cause of tubulointerstitial nephritis
Drugs
315
Symptoms of tubulointerstitial nephritis
```
Asymptomatic
Nausea & vomiting
Oliguria
Malaise
Arthralgia
Fever
Rash (maculopapular and typically starts on trunk)
```
316
Management of tubulointerstitial nephritis
Remove causative drug (or treat infection or systemic illness that has caused it)
Observation
Steroids if severe
Dialysis if very severe
317
What is a jerky pulse associated with?
HOCM
318
Meningitis contacts prophylaxis
A single dose of ciprofloxacin (500 mg) should be offered to patients, relatives and healthcare workers who have been in contact
319
Treatment of IgA nephropathy
ACE inhibitors / ARBs for HTN and proteinuria
| Immunosuppressants if severe and ongoing
320
Complications of epididymo-orchitis
Testicular abscess
Testicular infarction
Subfertility
321
Treatment of epididymo-orchitis
Simple analgesia
Advise on abstinence from sexual activity
Antibiotics (if STI-related, IM dose of ceftriaxone followed by course of oral doxycycline. if UTI-related, course of ofloxacin or levofloxacin)
322
Referral in epididymo-orchitis
Referral to urology for outpatient USS to exclude tumour
323
What cancers does Lynch syndrome increase risk of?
bowel, endometrial, ovarian, gastric, small bowel, urothelial, hepatobiliary and brain
324
Treatment in testicular cancer
Orchidectomy
