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1
Q

CURB 65 CRITERIA

A 
Confusion
Urea >7mM
RR >30
BP <90
>_65
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2
Q

Complications of pneumonia

A 
Lung abscess
Empyema
Sepsis
AF
Pleural effusion
Resp failure 
Hypotension
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3
Q

Empyema- presentation, ix, rx

A

Presentation - recovering from pneumonia becomes feverish again
Ix - TAP - pH <7.2, decrease glucose, high LDH
Mx - US guided chest drain + abx

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4
Q

Mx of any condition

A

A-E if acute

Look at all symptoms and see how to treat each one individually

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5
Q

SIRS Criteria

A 
at least 2 of 
Temp >38 or <36 
HR >90
RR >20
WCC > 12x10^9
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6
Q

Causes of non resolving pneumonia

A 
CHAOS
Complication 
Host
Abx
Organism
Secondary diagnosis
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7
Q

Causes of transudate effusions

A

Common

  • HF
  • hypoalbuminaemia
  • cirrhosis

Less common

  • hypothyroidism
  • PE
  • Mitral stenosis

Rare

  • SVCO
  • constrictive pericarditis
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8
Q

Causes of exudative pleural effusions

A

Common
Malignancy - particularly gynae
Infection - pneumonia, TB, legionella

Less common
Inflammation - RA, pancreatitis, dressler’s
Lymphatic drainage issues

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9
Q

Lights criteria - when to use and what is it

A

When protein in pleural aspirate is between 25 and 30

Criteria
Exudate if one or more of the following:

Pleural fluid/serum protein >0.5
Pleural fluid/serum LDH >0.6
Pleural fluid LDH > 2/3 of upper limit of normal

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10
Q

Ix to diagnose pleural effusion

A

US guided pleural aspiration

CXR

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11
Q

Pulmonary effusion CXR

A

Meniscus

Blunted costaphrenic angles

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12
Q

Tension pneumothorax mx

A

A-E
Insert large bore IV cannula into 2nd ICS MC line
Chest drain into affected side

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13
Q

Causes of pnuemothorax

A

Spontaneous
primary - without disease - young thin men, smokers
secondary - with disease eg COPD, Marfan’s, Ehlers Danlos, ppulmonary fibrosis, sarcoidosis

Traumatic

Iatrogenic

  • Central line insertion
  • positive pressure ventilation
  • pacemaker insertion
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14
Q

Pneumothorax rf

A 
Height
Male
COPD, marfans, ehlers danlos, sarcoidosis 
Procedure eg central line or pacemaker 
Smoker - particularly of cannabis 
Trauma
Diving
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15
Q

Rf of PE

A

SPASMODICAL

Sex: f
Pregnancy
Age: older
Surgery
Malignancy
Oestrogen
DVT
Immobility
Colossally obese
Antiphospholipid antibodies 
Lupus anti-coagulant
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16
Q

PE - from front door to treament

A

A-E
Wells Score to determine probability
If highly probable - CTPA
If low probability - D Dimer. If D Dimer high - CTPA. If low - exclude PE
Give interim anticoagulation - rivoroxaban or apixaban first line. If CI, give LMWH

Treatment
Pharmaco - oral anticoags eg warfarin, DOACs (in UHL), LMWH, fondaparinux
Mechanical - IVC filter
Thrombolytic - if large. Streptokinase

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17
Q

Wells Score Categories

A

Symptoms of DVT
Previous VTE
Immobilisation for 3 days or surgery in the past 4 weeks
HR >100
Cancer
Haemoptysis
An alternative diagnosis is less likely than PE

If >4points PE likely

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18
Q

PE Ix

A 
CTPA
Doppler calfs
Clotting factors
ECG
CXR
ABG
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19
Q

4 causes of ILD they want us to know about

A

Extrinsic allergic alveolitis
Usual Interstitial pneumonia (UIP)
Non specific interstitial pneumonia (NSIP)
Sarcoidosis

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20
Q

Signs of ILD

A

Fine inspiratory respiratory crackles

Clubbing

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21
Q

Symptoms of Extrinsic allergic alveolitis (acute and chronic)

A

Acute 4-8hrs after exposure

  • dyspnoea
  • dry cough
  • fever, rigors, malaise

Chronic

  • increasing dyspnoea
  • weight loss
  • T1 resp failure
  • cor pulmonale
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22
Q

Sarcoidosis definition

A

Multistystem granulomatous disease of unknown origin

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23
Q

Symptoms of sarcoidosis

A

GRANULOMA
General - fever, malaise, lymphadenopathy
Respiratory - 90% have dry cough, dyspnoea, chest pain, reduced lung function
Arthralgia
Neurological - Bells palsy, meningitis, SOL
Urinary - increased calcium - renal stones
Low hormones - pituitary - amenorrhoea
Opthalmological - uveitis, sjrogens
Myocardial - restrictive cardiomyopathy secondary to granulomas, pericardial effusion
Abdominal - splenomegaly and hepatomegaly

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24
Q

CXR finding of sarcoidosis

A

BHL

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25
Ix of sarcoidosis
``` PFTs ECHO and ECG for cardiac innvolvement CT head for neuro involvement Urinary calcium levels CXR ```
26
Treatment principles of ILD
``` A to E Remove exposure Stop smoking Treatment of infective exacerbations MDT approach Palliation Transplantation ```
27
Ddx for resp issues that is apt to think about
covid19
28
Types of Lung Cancer
Small cell | Non small cell - SCC, Adeno, Large
29
Differences in presentation between SCLC and NSCLC (SCC and adeno)
SCLC - smokers - centrally located near bronchioles - typically presents as advanced metastatic disease - associated with cushings SCC - smokers - centrally located - slow to metastasise - locally invasive - PTHrP secreting Adeno - non-smokers - peripherally located - often presents with metastases
30
Group symptoms/signs of cancers
Local/organ General Metastatic
31
How to group complications of cancers
Local Paraneoplastic Metastatic
32
Signs of lung cancer
Lungs - consolidation, collapse, pleural effusion General - cachexia, clubbing, anaemia, lymphadenopathy Metastatic - bone pain, hepatomegaly, confusion fits focal neurological signs
33
NSCLS Mx
MDT Surgical resection - lobectomy, pulmonectomy, wedge resection + adjuvant chemo Chemo Chemo + radio
34
SCLC Mx
MDT Can do radio but tend to relapse Palliation and analgesia Very poor prognosis
35
Complications of lung cancer
Local - SVCO - RLN palsy - phrenic nerve palsy - Horner’s syndrome (pancoast cancer) Paraneoplastic - hypercalcaemia - SIADH - Cushings - Acanthosis Nigricans Metastatic - pathological fractures - hepatomegaly - addisons - confusion, fits, focal neurology
36
Presentation of TB
Fever with drenching night sweats Haemoptysis Weight loss Productive cough with purulent sputum
37
TB risk factord
- TB contact - travelled to a high risk TB country or born there - immunocompromised
38
Anti - TB therapy plus side effects and initial ix
Rifampicin - hepatitis and rashes, can cause orange secretions Isoniazid - hepatitis and rashes, peripheral neuropathy Pyrazinamide - hepatitis and rashes, arthralgia Ethambutol - retrobulbar neuritis LFTs need close monitoring Visual acuity assessed before ethambutol Pyridoxine given whilst on isoniazid as prophylaxis against peripheral neuropathy RIPE for 2 months followed by RI for 4 months
39
Mx principles of TB
negative pressure side room | ziel nielsson stain of sputum
40
Causes of bronchiectasis
Post infective - whooping cough - TB Immune deficiency - hypogammaglobulinanaemia Genetic Mucocilliary Clearance issues - CF - Kartageners syndrome Secondary Immune Deficiency - RA - HIV Toxic Insult - gastric aspiration Also Allergic Bronchopulmonary Aspergillosus
41
Ix of bronchiectasis
``` Immunoglobulin levels Rheumatoid factor Cystic fibrosis gene screening Aspergillus IgE Auto antibodies ``` Definitive = High Contrast CT
42
Definition of a bronchiectasis exacerbation
A patient with bronchiectasis who presents with a deterioration of 3 or more of the following over 48hrs - cough - sputum volume and consistency - Sputum purulence - Breathlessness - fatigue - haemoptysis
43
What are pts with bronchiectasis at increased risk of
Recurrent infections
44
What conditions is ABPA associated with
asthma bronchiectasis CF
45
Ix of ABPA
Raised aspergillus IgE as well as total IgE
46
What type of pathogen is aspergillus fumigatus
Fungi
47
Mx of ABPA
Steroids
48
How is Cf diagnosed
Newborn screening Sweat chloride test CF genotyping
49
How does CF often intially present
Meconium ileus in newborns Intestinal Malabsorption Recurrent chest infections Most picked up by newborn screening
50
Common CF complications
``` Recurrent chest infections Malabsorption Distal Intestinal Obstruction Syndrome Infertility CF related diabetes ```
51
Mx of CF
``` Lifestyle factors which I know Chest physio Mucolytics Pancreatic enzyme replacement Long term antibiotics ADEK replacement and nutritional support Long term monitoring of CF diabetes ```
52
Pathophysiology of asthma
IgE release Eosinophils Inflammation Increased goblet cells so increased mucus
53
Symptoms of mild asthma
PEFR >75 | no symptoms of severe asthma
54
Symptoms of moderate asthma attack
PEFR 50-75% | No symptoms of severe asthma
55
Symtpoms of severe asthma
``` PEFR 33-50% O2 < 92% Cant complete full sentences Increased RR >25 HR >110 ```
56
Symptoms of life threatening asthma attack
PEFR <33 Normal pCO2 Cyanotic, hypotensive, confused, increased respiratory effort, near or full silent chest, exhaustion, arrythmias
57
Near fatal asthma attack
Increased pCO2
58
Mx of asthma
A-E approach Give O2 if less than 92% 5mg Neb Salbutamol 40mg oral prednisolone If severe: Neb 500 micrograms ipatropium bromide Back to back salbutamol every 15 mins If life threatening or near fatal IV aminophylline IV salbutamol Urgent ITU or anaesthetist review
59
What drugs can trigger asthma
Aspirin and betblockers
60
COPD pathophysiology
Chronic bronchitis and emphysema hyperplasia of mucous glands Loss of cilial function Chronic inflammation and fibrosis of small airways
61
Obstructive spirometry
FEV1:FVC = <0.7 | Inwards ‘L’ shape spirometry curve - cant insert pic hence this is just description
62
3 main causes of COPD
- smoking - occupational exposure/pollution - alpha 1 antitrypsin disorder
63
how to mx an acute exacerbation of COPD
- A-E - O2 levels between 88 and 92 - Nebs - salbutamol and ipatropium - Steroids - prednisolone 30mg stat and then for 7 days x - Abx if infective cause - - IV aminophylline - consider NIV if acidotic and type 2 resp failure
64
Talk about LTOT
specific criteria eg must be non smoker, O2 must be safe in house has to be used for at least 16hrs a day for survival benefit lose independence and reduced activity levels
65
aims of pulmonary rehabilitation
break the cycle of exercise and breathlessness. Avoid exercise that makes you breathless increasingly makes you more breathless
66
Causes of Type 1 resp failure (CO2 <6kPa)
V/Q mismatch - pneumothorax - early asthma - PE - PHT Diffusion failure - Fluid (pulmonary oedema, pneumonia, infarction, blood) - Fibrosis
67
Causes of Type 2 Resp Failure (paCO2>6kPa)
V/Q mistmatch Alveolar hypoventilation - Obstructive - asthma, COPD, bronchiectasis epiglottitis - Restrictive - CNS sedation, cervical cord lesion, fluid and fibrosis
68
Sx and signs of hypercapnia
- headaches - peripheral vasodilation - confusion - coma - flap - bounding pulse
69
A-a gradient and normal value
Normal = <4 Greater than 4 means something wrong with lungs PAO2 - PaO2 PAO2 = PIO2 - (PaCO2/0.8)
70
Causes of ARDS
Pulmonary - pneumonia - aspiration - inhalation injury Systemic - sepsis - pancreatitis - DIC
71
Scale used to assess sleepiness in OSA
Epworth sleepiness scale
72
Mx of OSA
Weight loss Sleep decubitus rather than supine Mandibular advancement devices CPAP - opens collapsed airways and improves V/Q mismatching Should notify DVLA Can use BiPAP if severe OSA with CO2 retention
73
Ix of Infective endocarditis
3 blood cultures at least an hr apart - gold FBC, CRP, ESR, U+E(septic emboli) Urine dip - haematuria - septic emboli ECHO ECG - long PR interval - perivalvular abcess
74
Most common IE organisms and people at risk of these
Strep viridans - Dental practice or long prosthetic Staph aureus - IVDU Staph epidermidis - short prosthetic
75
Abx for IE
Strep - benpen Staph - fluclox Pen allergic - vancomycin
76
Monitoring of IE
2 ECGs a week 1 ECHO a week 2 bloods a week 6 weeks of abx
77
Sign of fast AF
non palpable pulse bc loss of diastolic filling
78
Mx of persistent AF
Rate control 1st - beta blocker 2nd - diltiazem or verapamil
79
Mx of paroxysmal AF
Rhythm control | 1st line - amiodarone
80
Amiodarone long term ADR
- pulmonary fibrosis (BANSMe) | - hypothyroidism
81
When do you use warfarin and when use DOAC for AF? (Given the chadvasc score warrants its use)
Warfarin for valvular AF | DOAC for non-valvular
82
Mx of following situation <48hr hx of acute AF haemodynamically unstable
A-E | Emergency cardioversion - amiodarone or flecanide
83
Drugs used for different tachycardias
SVT - adenosine VT - amiodarone AF - amiodarone
84
Process of looking through ECG for tachycardias
``` Rate Rhythm Sinus or not V1 - LBBB or RBBB, VT Concordance ```
85
2 types of SVT
AVNRT | ANRT - only one we need to know is WPW. Seen by short PR and delta wave
86
Features of VT on ECG
``` Concordance Broad QRS complex AV dissociation - p waves all over the place Capture and fusion beats Regular ``` If irregular likely to be AF w/ BBB or pre excited AF
87
Causes of VT
IM QVICK ``` Iatrogenic - digoxin, anti arrhythmics Myocarditis QT increased Valvular issues Infarction Cardiomyopathy K low K ```
88
Treatment for torsades de pointes
Magnesium sulfate
89
Mobitz 1 vs Mobitz 2
1 is increasing PR interval followed by dropped QRS | 2 is same PR interval followed by dropped QRS
90
Causes of bradycardias
DIVISIONS ``` Drugs - Anti arrythmics (type 1a - amiodarone) - Beta blockers - Calcium channel blockers - Digoxin Ischaemia/inferior infarct Vagal hypertonia Infections Sick sinus Infiltration O - hypOthermia, hypOthyroidism, hypOkalaemia Neuro - increased ICP Surgery or septal defect ```
91
Hr <40 treatment
500 micrograms IV atropine
92
htn stages
1 >140/90 2 > 160/100 3 >180/110
93
HTN targets
<80 yrs <140/90 | >80yrs <150/90
94
Differential of paroxysmal hypertension associated with headaches and sweating
Phaechromocytoma
95
What is a hypertensive crisis
an increase in BP which if sustained over a few hrs will cause end organ damage (LV failure, encephalopathy, aortic dissection, renal failure, unstable angina)
96
Mx of a hypertensive crisis
A-E ``` IV: 1 sodium nitroprusside - needs arterial line BP monitoring 2 GTN 3 Labetalol 4 esmolol ```
97
Heart murmurs sounds
Aortic stenosis - luuuub dub Aortic regurge - lub tahh Mitral regurge - durrr durr Mitral stenosis - lub durr
98
Mx of oesophageal ca
Most have mets on diagnosis so majority are palliative - median survival is 4mo after dx Some can go for an ivor lewis oesophagectomy - prognosis 5% survive 5years
99
Achalasia pathophys
Degeneration of myenteric plexus reduces peristalsis LOS fails to relax
100
What di 3-5% of pts with achalasia go on to develop
Oesophageal SCC
101
Ix for achalasia and sign shown
Barium swallow - bird bea sign | OGD to exclude malignancy
102
How does the dysphagia in achalasia present
liquids then solids
103
H Pylori Triple therapy
PPI + Clarithromycin + Amoxicillin/metronidazole
104
Where are gastric and duodenal ulcers most likely found
Gastric - lesser curve if stomach antrum | Duodenal - 1st part of duodenum
105
What is the rockall score used for
Predict risk of re bleeding in upper GI bleeds
106
Symptoms and signs of gastric cancer
Sx - usually presents late - epigastric pain - fevers, w/l - dyspepsia - dysphagia Signs - epigastric mass - anaemia - virchows node - sister mary josephs node - ascitis - acanthosis nigricans
107
Mx of gastric cancer
Mostly palliative due to late presentation Medical - analgesia, PPI Surgical - pyloric stenting or bypass Curative surgical - endoscopic resection, partial or total gastrectomy
108
What is Zollinger Ellison and presentation
gastrin secreting tumour (gastrinoma) | Dyspepsia with chronic diarrhoea (bc of inactivation of pancreatic enzymes)
109
When to refer someone with GORD
``` If: >65 Failed to respond to medical treatment Haematemesis/malena Weight loss Anaemia Progressive symptoms Dysphagia ```
110
Surgery for GORD
Nissen fundoplication
111
Pathophys of Barrett’s oesophagus
Trauma to oesophagus | metaplasia -> dysplasia -> adenocarcinoma
112
Two types of hiatus hernia and which should you always treat even if asymptomatic
Rolling (15%) and sliding (80%) and mixed (5%) Rolling should always be treated as risk of strangulation
113
Difference between rolling and sliding hiatus hernias
Rolling - gastro oesophageal junction remains in abdomen and part of stomach rolls out in tk the chest Sliding - gastro oesophageal junction herniates into chest
114
Haematemesis Differential Acromym
``` VINTAGE Vascular - varices Inflammatory - PUD Neoplasia - oesophageal or gastric Trauma - Mallory Weiss, Boehaaves syndrome Angiodysplasia and HHT Generalised bleeding disorders - warfarin, thrombolytics Epistaxis ```
115
Rectal Bleeding Differentials Acronym
DRIPING Arse ``` Diverticular disease Rectal haemorrhoids Infection - shigella, E coli, campylobacter Polyps Inflammation - IBD Neoplasms Gastric upper GI bleeding Anal fissure/ Angiodysplasia + HHT+ ischaemic colitis rse ```
116
5 stages of fracture healing
Haematoma formation Inflammation Proliferation - of osteoblasts and fibroblasts Consolidation - woven bone to lamellar bone Remodelling
117
What factros can extend healing time of fractures
Adult Smoker Diaphysial Open
118
3 key principles of fracture mx
Reduce Hold Rehabilitate
119
Benefits of reduction
- Tamponade bleeding - reduce inflammation - reduced neuropraxia risk - reduced ischaemia risk
120
classification of open fractures
``` Gustillo-Anderson 1 - <1cm, clean 2 - 1-10cm clean 3A >10cm, adequate skin coverage 3B >10cm, inadequate skin coverage 3C - any open fracture with vascular injury ```
121
Mx of open fractures
``` 6A’s Analgesia Anti sepsis - copious fluid irrigation, debridement, cover with betadine soaked bandages Assess - NV status, soft tissues Anti-tetanus - give vaccine Abx - broad spec eg co amox Align - align and splint ```
122
Complications of fractures generally
Immediate - bleeding - neurovascular damage Short term - compartment syndrome - infection - fat embolism Long term - malunion - post traumatic OA - growth disturbance - complex pain syndromes
123
Seddon classification of nerve injuries
Neuropraxia - temp loss of conduction with loss of axon continuity Axonotmeses - disruption of nerve axon. Get wallerian degeneration. recovery is possible Neurotmesis - disruption of entire nerve fibre. Surgery needed, recovery not usually complete
124
What palsy can an anterior shoulder dislocation cause
axillary nerve
125
what palsy can a fracture of humeral shaft cause? deformity?
radial nerve - waiters tip
126
what palsy can an elbow dislocation cause? deformity?
Ulnar nerve - claw hand
127
what palsy can a hip dislocation cause? deformity?
sciatic nerve - foot drop
128
what palsy can a fracture of neck of fibula cause? deformity?
Fibular nerve - foot drop
129
common organisms causing septic arthritis
Neisseria gonnorhoea Staph aureus Strep pyogenes
130
ddx of septic arthritis
OA flare haemarthritis reactive arthritis lymes disease
131
Ix of septic arthritis
Synovial fluid aspirate prior to abx - look for leucocytes, gram stain, microscopy and culture 2 x blood cultures at different times Routine Bloods X ray
132
Length of abx course for septic arthritis
2 weeks of IV then 2-4 weeks of oral
133
Complications of septic arthritis
OA | Osteomyelitis
134
Mx of compartment syndrome
Fasciotomy Analgesia Remove tight bandages, splints, casts Monitor renal function for signs of rhabdo - high CK, or for reperfusion injury
135
Grade Classification used for OA
Kellgreen and Lawrence
136
What is a segond fracture? what is it pathognomonic of?
avulsion of lateral proximal tibial. ACL
137
difference in surgical methods for outer third and inner third of meniscus
outer third often sutured as good blood supply | inner third often trimmed
138
types of meniscal tears
longitudinal - bucket handle Transverse - parrot beak Degenerative Vertical
139
Complications of knee arthroscopy
``` DVT Damage to: - Saphenous vein and nerve - popliteal vessels - perineal nerve ```
140
Complications of MCL injury
Saphenous nerve damage | Joint instability
141
What is the ITB
aponeurosis of the tensor fascia lata and the gluteus maximus
142
Rf of ITB syndrome
Repetitive flexion and extension eg runners | Bowleggedness
143
Special tests for ITB syndrome
Nobles - lie supine, finger on lateral femoral epicondyle. pt extends leg, pain at 30 degrees Renne - pt stands, finger on lateral femoral epicondyle, pt squats, pain at 30 degrees as this is when ITB crosses over
144
Surgical mx for ITB syndrome
ITB release - but only if symptoms and loss of function for greater than 6 months
145
What condition to be aware of when looking at patella for a fracture
bipartite patella - failure of medial and lateral facets to fuse so held together by fibrocartilage
146
Mx of patella fracture
Conservative - ensure early extension - wear brace or cylinder cast Surgical. - ORIF with tension band wiring
147
How does ORIF with tension band wiring work for patella fractures
converts tensile force applied to patella during extension into a compression force
148
Complications of patella fractures
Reduced ROM | post traumatic OA at the patellofemoral joint
149
Which tibial plateau is injured more frequently
lateral due to varus force
150
Which nerve can be damaged in a tibial plateau fracture
common fibular nerve
151
What will you see on xray of tibial plateau fracture? what other scan is usually required?
Lipohaemarthrosis | CT
152
The presence of fat in a joint indicates what
an intraarticular fracture
153
Classification of tibial plateau fractures
Schatzker
154
Criteria to receive conservative mx for a tibial plateau fracture . What is the mx
uncomplicated - articular step <2mm - no ligament injury - no tibial subluxation Non or partial weight bearing in a high knee brace for 8-12 weeks Physio Analgesia
155
Criteria to receive surgical mx for tibial plateau fracture and what is it
Complicated fracture - articular slope >2mm - tibial subluxation - ligament injuries Compartment syndrome Open fracture ORIF - metaphyseal gap filled in with bone graft or substitutes
156
When may ORIF be unsuitable and what would you do instead
highly comminuted fractures/polytrauma significant soft tissue injury Do external fixation
157
why is risk of compartment syndrome and open fractures greater along the tibial shaft
Bc there is a lack of significant soft tissue envelope
158
Mx of tibial shaft fracture
``` Realign stat Monitor for compartment syndrome Above Knee back-slab If stable - sarmiento cast If unstable - surgery - intramedullary nailing or ORIF with locking plates Fibula fractures tend to be left alone ```
159
Causes of sensironeural hearing loss
``` acoustic neuroma labrynthitis presbyacusis noise related drug induced ```
160
conductive hearing loss causes
``` ear wax acute otitis media otitis media with effusion foreign body cholesteatoma otosclerosis ```
161
Causes of vertigo
``` BPPV Labrynthitis Menieres Vestibular neuritis benign vestibulopathy ```
162
External ear
Otitis externa | Malignant otitis externa
163
Rinnes and webers
If lateralises to the right - right conductive - left sensorineural Conductive BC>AC Sensorineural AC>BC Normal AC>BC
164
Acoustic neuroma presentation
``` Unilateral hearing loss Unilateral Tinnitus Symptoms of increased ICP Vertigo May present with facial nerve palsy ```
165
Ix of acoustic neuroma
webers and rinnes Audiograms MRI head
166
Labrynthitis presentation
Sudden onset unilateral hearing loss, tinnitus and vertigo Nystagmus, vomiting Recent hx of URTI
167
Mx of labrynthitis
vestibular suppressants eg prochlorperazine (also anti emetic)
168
BPPV presentation
Episodes of vertigo after turning head - lasts seconds | Nystagmus, nausea
169
BPPV ix and mx
Dix-Hallpike then Epley manoeuvre
170
Suggested cause of menieres
Too much endolymph
171
Presentation of menieres
Episodes of vertigo, tinnitus, hearing loss lasting mins to hrs Aural fullness, muffled sound Nustagmus, nausea
172
Mx of menieres
``` Vestibular supressant - prochlorperazine Betahistidine Low salt diet Thiazides Hearing aids Surgery ```
173
Presbyacusis presentation
bilateral hearing loss Lose high frequency first - eg female voice, might have TV really loud Old
174
Mx of presbyacusis
Social - eg flashing lights instead of doorbell, telephone amplifiers Hearing aids or cochlear implants
175
Ix for hearing loss problems
Otoscope Rinnes and Webers Audiogram MRI head
176
Pathophys of noise related hearing loss
Damage to stereocilia in the cochlear
177
Ototoxic drugs
Gentamicin | Furosemide
178
How to identify which ear on otoscopy image
Cone of light is on the same side as the ear | The malleus points away from direction of ear
179
What causes otitis media with effusion
Negative pressure in the ET tube
180
Presentation of otitis media with effusion (glue ear)
Developmental delays - speech and learning | Not very responsive to sound
181
Otoscopy of glue ear
Yellow retracted TM, air bubbles
182
Mx of glue ear
leave for 3 months as most self resolving | If >3 months - grommets
183
Acute otits media pathogens
Bacteria - moraxella, haemophillus, pneumococcus | Viral
184
Mx of acute otitis media
Most likely viral so wait at least 48hrs before giving abx Fluid, rest, analgesia Safety Net
185
Complications of acute otitis media
Mastoiditis then meningitis | Cerebral abcess
186
Cholesteatoma pathophys
trapped squamous epithelium erodes into the bones
187
Causesnof cholesteatoma
Recurrent infections paired with ET dysfunction
188
Mx of cholesteatoma
Semi urgent referral | or urgent if signs of nerve palsy
189
Presentation of cholesteatoma
Otalgia | Smelly otorrhoea
190
Rf for cholesteatoma
recurrent infections down syndrome Male low socio economic status
191
Complications of cholesteatoma
Facial nerve palsy meningitis cerebral abscess
192
What is otosclerosis
fusion of the ossicles, most commonly stapes to oval window
193
Common organism of otitis externa
pseudamonas
194
RF for otitis externa
Moist environments eg swimmers immunocompromised hearing aids
195
Presentation of otitis externa
Otalgia - tragus and in mastoid area behind ear | otorrhoea
196
complicatons of otitis externa
osteomyelitis | temporal bone destruction
197
Malignant otitis externa and who is it more common in
Otitis externa with its complications + facial nerve palsy | Common in diabetics and CF patients
198
Mx of acute sinusitis
Send to hospital if has complications Otherwise wait 10 days, self care measures If no improvement - corticosteroid nasal spray, back up abx,
199
Complications of acute sinusitis
``` Cavernous sinus thrombosis Cerebral abcesses Meningitis Periorbital cellulitis Osteomyelitis ```
200
when is sinusitis classed as chronic
>12 weeks
201
Causes of chronic sinusitis
Kartageners CF Facial deformity Septal deviation
202
Mx of chronic sinusitis
Nasal douching Corticosteroid spray Antihistamines Macrolides
203
Arteries we need to know in the nose
Sphenopalatine Posterior and anterior ethmoid Kesselbachs area and littles area
204
Causes of epistaxis
``` Trauma HTN idiopathic HHT/angiodysplasia Coagulation disorders Malignancy Unilateral polyp ```
205
Mx of epistaxis
``` A+E if bleeds for >30mins Anterior packing Silver nitrate Cautery Posterior packing Electrocautery in Surgery ```
206
Red flag nose
unilateral bleeding
207
Red flag ear
unilateral tinnitus | unilateral hearing loss
208
Mx of allergic rhinitis
antihistamines steroid nasal spray or oral pred if severe Nasal irrigation septoplasty
209
Septal haematoma mechanism
blunt force trauma blood between periosteum and perichondrium reduce blood supply to cartilage Can end up with saddle nose (or cauliflower ear if pinna haematoma)
210
Mx of septal haematoma
drain blood | tamponade
211
pathogens causing tonsillitis
Group A strep EBV Viruses eg influenza
212
Score to determine if tonsillitis caused by Group A Strep
FeverPAIN score
213
Abx for bacterial tonsilitis
phenoxymethylpenicillin
214
Epiglottits presentation
``` 4Ds Distress - respiratory Drooling Dysphasia Dysphonia ``` Soft stridor compared to croup which is harsh
215
Mx of epiglottitis
try and calm them sedation intubation ceftriaxone - as most common cause is haemophillus
216
complications of tonsillitis
peritonsillar abscess - quinsy
217
Bells Palsy mx
steroids eye drops antivirals eg acyclovir
218
Becks triad - what is it and what is it for
``` Cardiac tamponade Acutely unwell person with - raised JVP - hypotension - muffled heart sounds ```
219
What ECG anomaly can thiazide diuretics such as indapamide cause as a result of their side effect profile
flattened t waves as a result of hypokalaemia and hypocalcaemia
220
common adverse effects of thiazides
``` dehydration postural hypotension hypokalaemia, hypocalcaemia, hyponatraemia gout impaired glucose tolerance impotence ```
221
criteria for Hyperosmolar Hyperglycaemic State (HHS)
hypovolaemia hyperglycaemia >30 serum osmolarity >320
222
calculating serum osmolality
2xNa + glucose + urea
223
Causes of dactylitis
spondyloarthropathies eg psoriatic and reactive arthritis, systemic sclerosis Sickle cell disease Rare - TB, sarcoidosis, syphillis
224
how long are provoked PEs treated for
3 months
225
what is the first line abx for c diff
oral vancomycin
226
What is the main antibody test for coeliacs disease
anti-TTG
227
when do you use rhythm control as first line in AF
if reversible cause, coexistent heart failure or if first onset AF
228
What tests should adults with suspected asthma have
Both - fraction of exhaled nitric oxide (FeNO) test - spirometry with reversibility testing
229
what abx class can cause torsades de pointes
macrolides
230
sign of LVH on ecg
large R waves in V5 and V6 (left sided leads) and deep S waves in V1 and V2 (right sided leads)
231
What is a Bartons fracture
Intra articular fracture of the distal radius with associated dislocation of the radio-carpal joint
232
Presentation of scaphoid fracture
Sudden onset pain pain in anatomical snuffbox Pain on scaphoid tubercle
233
Invs of scaphoid fracture
Xray If none seen repeat at 10-14 days And then MRI if still no evidence
234
mx of undisplaced scaphoid
thumb plaster and spica splint BUT if fracture of proximal pole then surgery as high risk of avascular necrosis
235
mx of displaced scaphoid #
percutaneous variable pitch screw for compression
236
complications of scaphoid #
avn | non-union
237
Presentation of carpal tunnel
pain and parasthesia of lateral 3 and a half digits Worse at night Late stages - may get atrophy of thenar eminence
238
Where is spared in carpal tunnel and why
Palm | Palmar branch exits before enters beneath flexor retinaculum
239
Ddx of carpal tunnel syndrome
``` cervical radiculopathy (C6) pronator teres syndrome ```
240
Mx of carpal tunnel
NSAIDs Splint (at night) physio steroid injections surgical - decompression by cutting flexor retinaculum
241
what is dupuytrens
contraction of longitudinal fascia
242
RF of dupuytrens
``` Male Alcoholic liver cirrhosis T1DM Occupational exposure Age 40-60 ```
243
Pathophys of dupuytrens
fibroplastic hyperplasia and altered collagen matrix of palmar fascia
244
Typical progression of dupuytrens
- pitting and thickening - painless nodules - cord contracts - flexion deformity
245
Test for dupuytrens
Heustons test | Lie palm flat - positive if unable to
246
Mx of dupuytrens
Therapy Inject Collagenase clostridium histolyticum (NO STEROIDS) Surgery - fasciectomy
247
What is de quervajns tenosynovitis
inflammation of the tendons of the first extensor compartment of the wrist. (by the thumb)
248
Presentation of de quervains
pain at base of thumb grasping movements difficult and painful Finkelstein’s test positive
249
Mx of de quervains
splint physio Steroid injections Surgical - decompression of extensor compatment
250
What are ganglionic cysts a d where are they found
Synovial fluid filled soft tissue lumps caused by degeneration of joints or tendon sheaths Found along joints and tendons
251
Presentation of ganglionic cyst
smooth, soft, fluctuant lump along tendon or joint, transilluminates May have neuro features if compressing nerve
252
Mx of ganglionic cysts
Usually sort then selves out | If not and rom severely affected, aspirate or excise
253
what is trigger finger
finger and/or thumb lock or click when in flexion
254
pathophys of trigger finger
flexor tenosynovitis - due to repetitive movements = inf;lammation tenosynovitis at metacarpal head (superficial and deep flexor tendons) = nodal formation, distal to the pulley (A1 pulley ligament most common) moves proximal to pulley when flexed, but cant move back under it on extension = locked in flexed position
255
rf of trigger dinger
female | age DM
256
presentation of trigger finger
painful snapping/clicking on finger extension | ca be bilateral and more than one finger
257
Mx of trigger finger
splint activity modification steroid injections surgical -percutaneous trigger finger release under local
258
What abx can prolong QT interval?
Macrolides
259
What bloods need to be routinely monitored in the first 12 months of treatment with Simvastatin
LFTs
260
How long before an op should warfarin be stopped? What is it substituted with? What should INR be less than?
at least 5 days before, LMWH | INR should be less than 1.4
261
NSAIDs mechanism of action
COX inhibitors | Inhibits prostaglandin synthesis from arachidonic acid
262
Aspirin MOA
inhibits production of thromboxane A by inhibiting both COX1 and 2 Thromboxane A usually enables platelet aggregation
263
What does a transaminase (elevated ALT and AST) in the 10 000s commonly indicate
paracetamol overdose
264
Side effects of calcium channel blockers
ankle swelling headache flushing
265
moa of heparins (both LMWH and unfractionated)
Both activate antithrombin 3 LMWH - increase action of antithrombin 3 on factor Xa so greater inhibition Unfractionated - increase action o pf antithrombin 3 on factors Xa, IXa, XIa and XIIa so greater inhibition
266
When is unfractionated heparin often used
used in situations where there is high risk of bleeding as it can be terminated rapidly. Also useful in renal failure
267
What is adhesive capsulitis
glenohumeral capsule becomes contracted and adherent to the humeral head
268
Rf of adhesive capsulitis
Woman 40-60 previous contralateral adhesive capsulitis DM
269
Presentation of adhesive capsulitis
general shoulder pain that may radiate to biceps reduced ROM Stiffness Tender to touch
270
Mx of adhesive capsulitis
Medical - physio - analgesia - Corticosteroid injections Surgical - after months to years of medical mx - manoeuvre joint under GA - surgical release of capsule
271
Complications of peri operative hypothermia
Coagulation - impaired clotting Infection Reduced wound healing bc of vasoconstriction Prolonged recovery from anaesthesia
272
Components of the different fluids
Hartmanns - 131 mmol/L Na - 111 Cl - 29 HCO3 - 5 K - 2 Ca 0. 9%NaCl - 154 Na - 154 Cl Dextrose - 278 glucose
273
Tonicity and compartment movement of the fluids
Hypotonic - hartmanns and NaCl so stay extracellular in vasular and interstitial space Isotonic - dextrose
274
Colloid products
FFP Platelets Red blood cells
275
Why would you give FFP and platelets in a DIC pt
Losing them due to clotting
276
Daily requirements
1mmol/kg/day Na, Cl, K 50-100g per day glucose 25-30ml/kg/day water
277
Daily urine output
0.5ml/kg/day
278
What are the categories of a comprehensive geriatric assessment
``` Medical - problem list, nutrition, meds, co morbidities Functional - baseline Social Psychiatric Environmental ```
279
ADR of dextrose
hypokalaemia
280
in who would you consider a lower does of opioids for pain mx
renal failure as vulnerable to overdose | patients with delirium
281
Drugs to be stopped before surgery
COCP 4 weeks Warfarin 5 days Clopidogrel 7 days
282
DVT complications
``` PE Chronic venous insufficiency - lipodermatosclerosis - venous eczema - venous ulcer - hyperpigmentation ```
283
PE complications
Death Type 1 resp failure/hypoxia RHF Arrythmias
284
Steps taken to reduce the stress of an op on body
``` Oxygenate Avoid hypothermia Maintain BP Nutrition Analgesia ```
285
What are people on steroids at risk of post op
Addisonian crisis
286
Why are pts on steroids at increased risk of addisonian crisis
HPA axis supression Cant increase steroids according to demand after trauma So adrenal insufficiency
287
Symptoms and signs of addisonian crisis
``` hypotension Fatigued n+v abdo pain myalgia hyponatraemia hypoglycaemia ```
288
mx of addisonian crisis
immediate resus with IV hydrocortisone
289
Mx of diabetes perioperatively
T1DM - stop sc insulin - use variable rate - NBM - regular monitoring of BM - first on theatre list - maintenance fluid - generally 5% dextrose
290
what effect does stress have on goucose levels
hyperglycaemic
291
Components of MUST score
BMI Unintentional weight loss percentage over last 3-6months Acutely unwell and no nutritional intake for >5 days
292
What blood type is universal donor and what is universal recipient
Donor - O | Recipient - AB
293
Difference between G+S and crossmatch
G+S identifies blood group - there is no issuing of blood. | Cross match identifies if any immune reactions with matched units of blood and then issues x amount of blood bags
294
When would you halve the dose of prophylactic dalteparin
if eGFR <30
295
referral criteria for possible colorectal cancer
``` >40 with unexplained weight loss and abdo pain >50 with unexplained rectal bleeding >60 with any of - iron deficiency anaemia - changes in bowel habit <50 with rectal bleeding AND any of the following unexplained symptoms - abdo pain - change in bowel habit - weight loss - iron deficiency anaemia ```
296
Dukes classification for colorectal cancer
A limited to bowel B extending through bowel wall (beyond the muscularis) C regional lymph node involvement D distant metastases
297
Complications of stomas
Early - bowel ischaemia/necrosis - bowel retraction - parasternal abscess - poor stoma functtion - high output Late - parastomal hernia - stenosis - prolapse - adhesion leading to BO - parastomal dermatitis - bowel dysmobility - malnutrition - psychosocial complications
298
Chronic mesenteric ischaemia presentation
Older people with rf of arterial disease Diffuse colicky abdo pain worse after eating Weight loss due to pain as aboid eating May have diarrhoea and malaena or haematochezia Abdo tenderness Epigastric bruits may be present
299
Indications for liver transplant after paracetamol imduced liver failure
pH <7.3 24 hrs after ingestion prothrombin time >100s creatinine >300 grade 3 or 4 encephalopathy
300
Mx of paracetamol overdose
less than 1 hr - activated charcoal Otherwise acetylcysteine (wait 4 hrs after ingestion to get paracetamol level)
301
extra intestinal features of IBD
Dermatology - erythema nodosum, pyoderma gangrenosum Ocular - anterior uveitis, episcleritis, conjunctivitis MSK - assymetrical arthritis HPB - primary sclerosing cholangitis (more common in UC) AA amyloidosis
302
Colonoscopy and biopsy results in UC
continuous inflammation with an erythematous mucose, loss of haustra and pseudopolyps Biopsy - loss of goblet cells, crypt abscess and inflammatory cells (predominantly lymphocytes)
303
mx of acute UC
1 - IV corticosteroids 2 - Add IV cyclosporin or consider surgery 3 surgery (indications are toxic megacolon, acute fulminant UC)
304
``` 1 Ivor Lewis oesophagectomy 2 Nissen fundoplication 3 gastrectomy 4 lap chole 5 whipples pancreaticoduodenectomy 6 Hartmanns ```
``` 1- oesophageal cancer 2 - GORD/hiatus hernia 3 - gastric cancer, Zollinger ellison 4 - gall stones 5 - pancreatic cancer 6 - diverticulitis, LBO, (resection of rectosigmoid colon) ```
305
inducing remission in UC pts first line drugs
5ASA’s – sulfasalazine | 2nd line prednisolone
306
Hyperkalaemia ve early STEMI ECG changes
Both have hyperacute t waves | Hyperkalaemia would be widespread, stemi would be regional
307
Presentation of a heart attack in a female with poor diabetic control
Atypical Mild non specifc upper abdo pain Central autonomic neuropathy so may not get sweating and tachycardia
308
complications of RCA occlusion
Supplies SAN and AVN so can get bradycardia/heart block
309
Leads of the ecg and territories
Inferior - 2,3 and avF Lateral - 1,avL and V5 V6 Anterior - V1-V4 Septal - V1-V2
310
what can you hear on auscultation of heart in a stemi
4th heart sound
311
ECHO finding on STEMI
regional wall muscle abnormality - not contracting properly
312
pulmonary oedema signs on CXR
kerley b lines - horizontal lines at bases bat wing sign may have increased cardio thoracic ratio if cardiogenic in cause
313
mx of STEMI
``` ROMANCE Reassurance Oxygen Morphine and Metoclopramide Aspirin 300mg PO Nitrates - GTN Clopidogrel/prasugrel Enoxaparin or another LMWH ``` Then PCI ``` Then Meds for life Aspiring 75mg ACEi Beta blocker Clopidogrel - for first 12 months Statin ```
314
Mx of NSTEMI
315
GTN action
vasodilates (risk of hypotension) | Venodilates - reduces pre load of heart and increases blood flow to heart
316
Complications of MI
``` DREAD Death Rupture eg of papillary muscles oEdema Arrythmias Dresslers - post MI syndrome - get pericarditis about 2 weeks after MI ```
317
ECG of pericarditis
global ST elevation - saddle back | PR depression
318
Signs of cardiac tamponade
Becks triad - hypotension - Increased JVP - muffled heart sounds
319
Tx of cardiac tamponade
pericardiocentesis
320
mx of SVT
vagal manoeuvre Adenosine (up to 3 times) synchronised DC cardioversion if haemodynamically unstabel and above not worked
321
causes of VT
MI | Structural heart disease
322
cause of torsades de pointes
long QT - caused by drugs
323
digoxin toxicity ecg findings
ventricular ectopics, AF Bradycardias Reverse tick sign
324
if arrythmia cant be controlled what is the mx
ICD or pacemaker
325
mobitz type 1 vs 2
type 1 increases | type 2 stays the same - higher risk of going into heart block
326
Where best to hear murmurs
aortic stenosis - aortic area and carotids aortic regurge - er s when leaning forward and inspiring mitral regurge - axilla Mitral stenosis - apex
327
Ix of hf
ECHO ECG pro-BNP CXR
328
pink frothy sputum supign of what…
pulmonary oedema
329
normal ejection fracture
greater than 50%
330
cause of raised bnp in copd
cor pulmonale
331
Score used to classify heart failure
New York
332
mx of hf
Symptom control - loop diuretics eg furosemide - GTN Reduced mortality - beta blockers - ACEi/ARBSx
333
Which valvular problem can cause AF
Mitral stenosis
334
side effect of hartmanns solution and when not to use
hyperkalaemia and lactic acidosis | with care in sepsis mx
335
Rules of fluid resus
give 500ml bolus unless HF/very fail (250ml) or pancreatitis (1L) Not hartmanns if lactate or hyperkalaemic
336
Rules of potassium in maintenance fluids
max 40mmol per bag max 10mmol/hr of KCL max 80ml a day
337
target INR pre surgery for pt on warfarin
<1.5
338
Complications of meningits
339
Complications of meningits
``` Septic shock DIC Seizures Coma Subdural effusions Death SIADH ``` Abscess Hearing loss
340
organisms causing menitngitis
``` Neisseria meningitidis Streptococcus pneumoniae Haemophilus influenza Listeria Measles and rubella ```
341
Abx for streps
Group A, viridans - benpen | Pneumonia - amoxicllin, clarithromycin, IV cephalosporin
342
Abx for MRSA
glycopeptide such as vancomycin
343
abx for sepsis
meropenem | or as per local guidelines
344
abx for c diff
metronidazole or vancomycin
345
sepsis definition
life threatening organ dysfunction caused by dysregulated host response to infection
346
septic shock definition
a subset of sepsis with profound circulatory cellular and metabolic abnormalities associated with greater risk of mortality than sepsis alone
347
Red flags of sepsis
``` resp rate >25 HR>130 New need for greater than 40% O2 to keep sats over 91% systolic BP <90 or fall of 40 from normal No urine output for 16hrz New onset delirium Non blanching rash Neutropenia or chemo in last 6 weeks ```
348
Which malaria organism causes most severe form of malaria
o falciparum
349
presentation of malaria
abrupt onset of rigors followed by high fever, malaise, severe headache and myalgia Vague abdo pain, n+v
350
signs of malaria
jaundice | hepatosplenomegaly
351
presentation of typhoid
``` sustained fever rose spots anorexia malaise vague abdo discomfort constipation or diarrhoea dry cough ```
352
signs of typhoid
hepatosplenomegaly rose spots pulse temperature dissociation
353
definition/criteria of PUO
temp >38 degrees on multiple occasions illness >3 weeks No diagnosis despite 1 week worth of inpatiemt
354
screening for latent TB
cxr and quantiFERON (measurement of interferon gamma)
355
can quantiFERKN differentiate between active and latent TB
no
356
who is screened for TB
healthcare workers Immigrants from high prevalance countries HIV positive pts patients starting on immunosupression
357
treatment of latent TB
3 months Rifampicin and isoniazid pts aged >35 are at increased risk of hepatotoxicity so advised against treating TB in these pts unless they have other risk factors eg HIV
358
Active TB presentation
non resolving cough unexplained persistent fever Drenching night sweats weight loss
359
gold standard for TB ix
cultures of sputum
360
paradoxical reaction of TB treatment
increased inflammation as bacteria die causing symptom worsening If TB is affecting sites where swelling cant be tolerated eg meningeal/spinal/pericardial, then steroids are given at the start of treatment
361
what further ix should those with miliary tb have and why
CT/MRI head and LP to exclude CNS involvement
362
where should TB pts be managed
in negative pressure side rooms and staff should use PPE
363
Baseline ix for pts newly dx with HIV
Confirmatory HIV test CD4 count HIV viral load HIV resistance profile HLA B*5701 status Serology for syphilis, hepatitis B (sAg, cAb, sAb), hepatitis C, hepatitis A Toxoplasma IgG, measles IgG, varicella IgG, rubella IgG FBC, U&Es, LFTs, bone profile, lipid profile  Schistosoma serology (if has spent >1 month in sub-Saharan Africa)  Women should have annual cervical cytology.
364
What opportunistic infections are pts with a CD4 count <200 at risk of
PCO MAI CMV
365
what vaccinations should HIV pts recieve
Hep B and pneumococcus | Annual influenza vaccine
366
Needle stick injury guidelines
``` bleed wound wash with soap and water May also use antiseptic Contact OH or ED if out of hrs need for post exposure prophylaxis (PEP) will be assessed ```
367
broad spectrum abx
Ceftriaxone Clarithromycin meropenem Amoxicillin
368
best ix for gonorrhoea and chlamidyia
NAAT - urine nucleic acid amplification test
369
top 2 causes of hypercalacaemia
primary hyperparathyroidism eg parathyroid adenoma | cancers eg lung cancer releasing PTHrP, or bone mets,
370
causes of hypercapcaemia with a low PTH
cancers TB sarcoidosis
371
why get hypercalcaemia in CKD
renal bone disease parathyroid gland hypertrophy as a result of tertiary hyperparathyroidism (Calcium levels start low but eventually raise as PTH levels go crazy)
372
what diuretic causes raised calcium
thiazides
373
presentation of hypercalcaemia
``` stones moans bones groans dehydration, polydipsia ```
374
effect of hypecalcaemia on ecg
shortens QT so can get arrythmias
375
hypercalcaemia mx
large amounts of fluids to rehydrate | Bisphosphonates
376
which diuretics lower calcium
loop diuretics
377
ix for hypercalcaemia
calcium PTH Parathyroid ultrasound search for underlying cause - think cancer, kidneys,
378
causes of hypocalcaemia
``` autoimmune destruction of parathyroid surgery damage radiation tumour low magnesium prostate cancer (osteoblastic) ```
379
causes of low calcium and high PTH (secondary hyperparathyroidism)
poor diet malabsorption reduced vit D early ckd stages
380
presentation of hypocalcaemia
``` Parasthesia in hands and lips Chvosteks sign carpo pedal spasm tetany abdo cramping prolonged QT seizures and laryngospasm - complications to prevent Diarrhoe ```
381
mx of hypocalcaemia
IV or oral calcium depending on severity | treat caues eg give magnesium or vit d
382
causes of hyperkalaemia
renal - reduce excretion - spirinolactone - ACEi/ARBs - NSAIDs (can worsen AKI) - AKI/CKD increased intake - diet extracellular shift - hypoglycaemia - DKA - rhabdomyolysis - tumour lysis
383
cause of pseudonyperkalaemia
leaving tourniquet on too long or too tight
384
what type of arrythmia does hyperkalaemia cause
bradyarrythmias
385
what is classed as severe hyperkalaemia
>6.5 | or with any ecg changes
386
mx of hyperkalaemia
protect heart - slow 10% IV calcium gluconate 30ml Drive into cells - 10 units insulin (actrapid) in 50ml 5% dextrose in 100ml bag of saline, or 5mg Neb salbutamol Clear from gut - calcium resonium if doesnt work, ITU and haemodialysis
387
hypokalaemia causes
``` loops and thiazides vomiting and diarrhoea decreased intake intracellular shift - alkaline, insulin, salbutamol, laxatives hyperaldosteronism ```
388
gi complication of low potassium
paralytic ileus
389
what toxicity can hypokalaemia aggravate
digoxin
390
causes of hypernatraemia
hyperaldosteronism dehydration - d+v, sweating, burns conns syndrome - raised aldosterone cushings - cortisol can mimic aldosterone in high concentrations ix using serum and urine osmolality
391
mx of hypernatraemia
give fluids to dilute sodium
392
what can happen if correct hypernatraemia to quickly
cerebral oedema
393
hyponatraemia causes
``` SIADH SSRIs primary polydypsia thiazides addisons ``` fluid overload- HF, CKD, liver cirrhosis
394
epinephrine
IM 0.5mg (1in1000) every 5 mins
395
Hydrocortisone
IV 100mg
396
Chlorphenamine
IM or IV 10mg
397
Atropine
IV 500 micrograms
398
Aspirin
PO 300mg
399
clopidogrel
300mg PO prior to PCI
400
calcium gluconate
IV 30ml 10%
401
Insulin dextrose infusion
10 units of insulin in 50ml 5% dextrose in 100ml normal saline
402
diazepam
IV 10mg or PR 10mg
403
Lorazepam
IV 4 mg
404
salbutamol
Neb 5mg
405
prednisolone in asthma
PO 40mg
406
morphine
PO 10mg or IV 5mg Given with metoclopramide also 10mg M+M 10+10
407
Naloxone
IV 400 micrograms
408
describing lesion acronym
``` SCAM Site/distribution Colour/configuration Associated features Morphology (shape) ```
409
BCC presentation
shiny pearly rolled edge Talengiectasia commonly occurs in head and neck
410
rf of bcc
previous skin cancer sun exposure - sun beds or frequently burned fhx immunosuppressed
411
referall for BCC
routine referral unless near eye or 2 mm from nasolabial folds or immunosupressed then urgent 2 ww
412
skin scc presentation
``` ulcerated bleeding crusty oozing painful ```
413
ddx for melanoma
sebharroeic keratosis
414
glasgow score for melnoma
``` major change in -size -shape -colour ``` minor - diameter >7mm - oozing - change in sensation - looks inflammed
415
gp conservative mx of skin cancers
advise against sun bed use | regularly check skin
416
what is actinic keratosis? what is it a risk factor for?
Old man bald head skin lesion | can predispose to skin scc
417
cellulitis description
confluent erythematous rash
418
mx of impetigo
topical fusidic acid
419
what to say for mx
safety net
420
varicella zoster (shingles) treatment within 72hrs
``` give acyclovir, doesmt work after stay away from pregnant lady avoid people who havent had it antihistamines and calamine lotion wear mittens ```
421
fetal varicella syndrome
can cause developmental delays and deformities
422
Causes of hyperparathyroidism
Primary - solitary pituitary adenoma (80%) Secondary - chronic renal insufficiency - vit D deficiency
422
Causes of hyperparathyroidism
Primary - solitary pituitary adenoma (80%) Secondary - chronic renal insufficiency - vit D deficiency
423
Mx of hyperparathyroidism
Treat cause eg surgical excision of adenoma Vit D replacement Phosphate binders
424
Causes of hypoparathyroidism
Autoimmune Congenital - Di George, fallot Iatrogenic - surgery, radiation
425
Presentation of hypoparathyroidism
``` low calcium Spasms Tetany Carpo pedal spasm Chovsteks seizures ```
426
mx of hypoparathyroidism
ca supplements | calcitriol
426
mx of hypoparathyroidism
ca supplements | calcitriol
427
What is pseudohyperparathyroidism
PTH resistance due to mutated G protein
428
phaechromocytoma presentation
``` paroxysmal hypertension sweating palpitations pale - bc adrenaline vasoconstricts headaches ```
429
what hormones do phaechromocytoma secret
Adrenaline | Some can secrete EPO so get polycythaemia
430
blood test for phaeo
metanephrines
431
mx of phaechromocytoma
alpha blocker! Then beta blockers then adrenalectomy
432
side effect of tamsulosin in older people to be aware of
hypotension. its an alpha blocker
433
example of mineral clrticoid
aldosterone
434
what inhibits prolactin
dopamine
435
na and k in addisons
low sodium | high potassium
436
addisons ix
9am cortisol | SynACHTen - differentiates whether it is primary or secondary
437
what enzyme attacks adrenal gland in autoimmune addisons
21 hydroxylase
438
3S’s of treating addisonian crisis
Steroids - IV hydrocortisone Sugar - as hypoglycaemic Saline - hypotensive
439
what will pt need to be given for long term steroid use
steroid emergency card | medical wristband
440
Side effects of long term steroid use
``` Cataracts Ulcers Striae Hypertension, hirsutism Infection Necrosis GI upset Osteoporosis Insomnia Diabetes ```
441
Advise for long term steroid users
increase dose when ill wear steroid emergency bracelet dont stop abruptly
442
what female drugs can affect cortisol levels
any containing oestrogen. Check if they are on it if have elevated cortisol
443
What is conns
adrenal tumour secreting aldosterone
444
causes of cushings
exogenous steroid use Small cell lung cancer cushings disease - pituitary adenoma Cortisol releasing adrenal tumour
445
why can you get hyperpigmentation in cushings disease
bc releases acth which mimics ACTH
446
mx of cushings
depends on cause | mentiripone
447
Acromegaly ix and common cause
Pituitary adenoma OGTT - bc GH increases insulin resistance IGF1 MRI head
448
sx and signs of acromegaly
``` Clumsy Big feet big hands deep voice teeth gap underbite carpal tunnel at night prominent forehead ```
449
what cancer is associated with acromegaly
colorectal
450
commonest cause of goitre worldwide
iodine deficiency
451
causes of goitre with normal tfts
menarche pregnancy menopause
452
antibodies in graves
tsh stimulating ab
453
presentation of graves
``` relapsing remitting palpitations heat intolerance and weight loss agitation !anxiety exopthalmos and lid lag pretibal myxedema thyroid acropachy ```
454
what heart drug can cause hyperthyroidism
amiodarone
455
goitre and pain
thyroiditis - de quervains
456
mx of hyperthyroid
block and replace - high dose carbomazole + thyroxine
457
bad side effect if carbimazole
agranulocytosis - lowers neutrophils so increased risk of infection. may present with tonsilitis do urgent fbc
458
hashimotos ab
anti - TPO
459
shehan syndrome
pregnancy and haemorrhage
460
hypothyroidism presentation
``` eyelid swelling hoarseness bradycardia weight gain cold intolerence ```
461
svever complication of hypothyoodism
mxodema coma
462
calculating anion gap
Na - (Cl + HCO3)
463
When will you get metabolic acidosis with a normal anion gap
If there is a reduced alkali - GI losses such as vomiting - renal losses such as renal tubular acidosis, addisons - toxins
464
when will you get a metabolic acidosis with high anion gap
acidosis due to acid increase - Lactic acidosis eg exercise, sepsis - ketoacidosis - diabetes - toxins - renal failure
465
how to differentiate CKD and AKI on U+Es
Urea high in AKI, can be normal in CKD (but can get uraemia?) eGFR drops suddenly in AKI, gradual decline in CKD
466
AKI staging
Serum Creatinine. Urine output 1 - 1.5-1.9x baseline. <0.5ml/kg/hr for 6-12hrs 2 - 2 - 2.9x baseline. <0.5ml/kg/hr for 12-24hrs 3 - 3x baseline. <0.3ml/kg for >24hrs OR anuria for 12hrs
467
Rf for AKI
``` dehydration elderly hospital stay DM CKD Sepsis Nephrotoxic meds ```
468
Causes of AKI
Pre renal - hypovolaemia, renal artery stenosis, reduced CO, meds Renal - sepsis, vasculitis, acute glomerular nephritis Post renal - bladder outflow obstruction, B/L pelvicoreteral blockage
469
Indications for RRT in AKI
``` hyperkalaemia persisting after therapy metabolic acidosis persisting after therapy uraemic encephalitis uraemic pericarditis fluid overload resistant to diuretics ``` ``` AEIOU Acidosis Electrolytes Intoxicants Overload Uraemia ```
470
causes of ckd
``` hypertension dm renovascular disease chronic/recurrent pyelonephritis glomerulonephritis ```
471
complications of CKD
renal mineral bone disease Anaemia of chronic disease Hyperparathyroidism
472
Pathophys of mineral bone disease in ckd
reduced calcidiol to calcitriol (activated Vit D) as happens in kidney so less gut absorption of ca. Increased absorption from bones also get hyperparathyroidism
473
pathophys of anaemia in CKD
reduced EPO production Anaemia of chronic disease uraemia can cause bone marrow suppression functional B12 deficiency
474
classification of lateral malleolus fractures
Weber A- Below sydesmosis B- At syndesmosis C- Above syndesomosis
475
Which weber fracture is most unstable
Weber C | Proximal ankle fractures are more unstable than distal
476
Ottawa ankle rules are used when diagnostic uncertainty. They indicate when an xray must be done in the presence of what 3 features?
bone tenderness at posterir edge or tip of lateral malleolus OR bone tenderness at posterior edge or tip of the medial malleolus OR an inability to weight bear both immediately and in the emergency department for 4 steps
477
when cant ottawa ankle rules be used
intoxicated pt uncooperative pt distracting painful injuries else where diminished sensation in legs
478
what position should an ankle be xrayed in and why
dorsi flexion ( if plantar it can appear to have talar shift)
479
how is leg positioned for a mortise view1
5-20 degrees internal rotation
480
what needs to be lax for talar shift
deltoid ligament
481
Immediate Mx of ankle fracture
immediate reduction then ankle below knee back slab post reduction neurovascular exam repeat plain film radiograph
482
Conservative mx of ankle fractures and in who
non displaced medial malleolus fractures or Weber A and B. | Cast for pain relief, weight bearing, re xray 5-7 days after
483
surgical mx of xray fractures and in who
Weber C Weber B with talar shift displace bimalleolar or trimalleolar fractures open fractures ORIG
484
Complications of ankle fractures
post traumatic OA mal union infection haemorrhage blah blah blah
485
MOI of calcaneal fracture
jump from height, axial loading
486
why is there a high risk of avascular necrosis in a talar fracture
most commonly fractures through neck | has extra osseous arterial supply which is susceptible to interruption
487
ddx of ankle fractures caused by jumping from height
talar fracture calcaneal fracture tibial pilon/plafond fracture tibial plateau
488
mx options for ankle OA
analgesia activity modification limit movement in an ankle brace Surgical - realignement osteotomy, arthrodesis (but lose plantar flexion), replacement (but revision is poor)
489
low ankle sprain is injury to what ligaments
``` calcaneofibular ligament (most common) anterior talofibular ligaments ```
490
mx of halux valgus
change shoes spacer socks braces surgery - metatarsal osteotomy
491
blood supply to NOF
medial circumflex artery - lies on the intracapsular femoral neck
492
classic appearance of NOF#
shortened externally rotated
493
ddx of NOF#
pelvic (pubic ramus) fractures acetabular fracture femoral diaphysis fracture femoral head fracture
494
what imaging would you do if suspected a pathological NOF fracture
full length femoral radiographs
495
Surgical options of NOF#
Extracapsular - Dynamic Hip Screw (DHS) | Intracapsular - partial or total hip replacement based on pts age and mobility
496
Complications of NOF repair
dislocation - more in total than hemi perinprosthetic fracture infection mortality
497
RF of hip OA
``` female age obesity vit D deficiency trauma hx anatomical abnormalities high impact sort participation ```
498
gait abnormalities in hip OA
antalgic gait | End stage OA - trendelenberg gait
499
Ddx of hip OA
trochanteric bursitis sciatica femoral neck fracture gluteus medius tendonopathy
500
how long can a hip replacement last for on average
10-15 years
501
what is the normal oxygen extraction rate
250ml/min
502
what is the apnoea timeth
time it takes to consume all oxygen in lungs when apnoeic. time you have to establish oxygen supply to pt
503
Calculate apnoea time
(FRCxFraction of oxygen in alveolus) / O2 consumption O2 consumption = 250ml/min fraction of O2 in alveolus=0.14 Pts FRC varies so example 2500ml (2500x0.14)/250
504
How does pre oxygenation affect hypoxia apnoea time
Increases it by quite a few minutes | fraction of O2 in alveoli becomes 0.9
505
what position should patients be in to be intubated
sniffing position
506
why is the point of oxygen mask when pt is going under
to build up oxygen reserve in the lungs to make a longer hypoxia apnoea time
507
where does the spinal cord end
L1/2
508
what layers do you have to get through to get to the epidural space
``` skin subcutaneous fat supraspinous ligament interspinous ligament ligamentum flavum epidural space ```
509
at what level do you insert needle for spinal procedures
L4/5 (upper border of iliac crests)
510
what space does a spinal go into
Subarachnoid
511
how do you know you are in the subarachnoid space
CSF will leak out
512
how do you know you are in the epidural space
loss of resistance to saline technique
513
advantage of epidural over spinal
bc catheter is inserted it acts more long term than spinal does
514
otherdifferences between spinal and epidural
spinal - done below L2, CSF flow confirms, narrow needle, 2-4ml drug volume, rapid onset epidural - cervical to caudal, lasts for days, no CSF, wider needle, 10-20mls needed, slower onset
515
indication for using neuroaxial blocks
surgery below level of umbilicus
516
benefits of neuroaxial blocks opposed to GA
avoids complications of GA, lower risk of thrombosis, bleeding and in elderly theres a lower cognitive decline
517
contraindications of neuroaxial blocks
``` infection at site pt refusal uncorrected hypovolaemia allergies increased ICP - can cause coning ```
518
complications of neuroaxial blocks
minor - n+v, hypotension, hearing issues, shivering, itching, retention Moderate - failure, postdural puncture headache, transient nerve injury Major - infection (meningitis), cauda equina, haematoma, total spinal anaesthesia, permenant nerve injury/paralysis, cardiovascular collapse/death
519
triad of anaesthetics
analgesia. hypnosis muscle relaxation
520
4 stages of GA
Induction Maintenance Emergence Recovery
521
agents used for induction
IV propofol Thiopentone sodium Ketamine Volatile agents eg sevoflurane
522
paralytic agents used in GA
depolarising muscle relaxant - succinylcholine | Non depolarising muscle relaxant - atracurium, rocuronium
523
indications for endotracheal intubation vs supraglottal airways such as iGel
ET - emergencies, major surgery, long duration surgery, full stomach S - elective, well fasted, short duration
524
maintenance drugs
TIVA eg propofol fluid mx abx, insulin etc drugs for pain
525
Side effects of GA
``` PONV urinary retention anaphylaxis malignant hyperthermia drowsiness paralytic ileus aspiration ```
526
what is local aneasthetic often used with and when is this pairing contraindicated
adrenaline as can increase the amount of local anaesthetic that can be used. Cant use together in areas with an end arterial supply such as the digits, the oinna, penis or nose as vasoconstriction can cause gangrene
527
max dose of lidocaine, lignocaine and bupivacains
lido - max dose 4.5mg/kg, with vasoconstriction 6-7mg/kg Ligno 3mg/kg, with vasoconstriction 6mg/kg Bup - 2mg/kg, with vasoconstriction 2.5mg/kg
528
PE treatment in pregnant lady
dalteparin
529
acute v chronic. graft vs host disease,
acute happens <100 days | tends to be more specifically symptomatic
530
first line treatment of atelectasis + other mx
chest physio + oxygen, deep breathing exercises, PAIN CONTROL CPAP if very severe
531
which anaesthetic agent has anti emetic properties
propofol
532
pathophys of RA
inflammatory proliferation of synovium forming a panus. Causes a thickened synovial membrane causing underlying articular damage
533
Xray findings in RA
``` LESS Loss of joint space Erosions (periarticular) Subluxation Soft tissue swelling ```
534
antibodies in RA
Rheumatoid factor and anti CCP
535
Mx of Ra
acute - steroid injections DMARDS eg methotrexate. Can combine if not working. Or change to biologics such a s anti tnf NSAIDS
536
extra articular features of RA
CAPS 3C- carpal tunnel, cervical myelopathy 3A - normocytic anaemia of chronic disease, macrocytic anaemia bc of folate deficiency, arteritis, amyloidosis 3P - pericarditis, pleural disease, pulmonary disease 3S - sjrogens, splenomegaly (Feltys), scleritis
537
adverse effects of methotrexate
``` macrocytic anaemia nausea bone marrow suppression hair thinning hepatitis, cirrhosis, pneumonitis ```
538
bloods to monitor in methotrexate
fbc - neutropaenia, anaemia u+e’s lft’s as can cause cirrhosis folate
539
side effect of carbimazole
agranulocytosis in first couple of months. May present with sore throat symptoms
540
risk factors of GCA
``` older - 90% in over 60s HLAB27 strong association with polymyalgia rheumatica women white ```
541
signs and symptoms of GCA
``` tender and pain over temple headache vision loss - sudden curtain comes down jaw claudication fever malaise joint pain - polymyalgia rheumatica ```
542
why may biopsy not be successful in diagnosis. GCA
skip lesions
543
mx of GCA
60-100mg po prednisolone for 2 weeks if visual symptoms 1mg methylprednisolone IV for 1-3 days low dose aspirin therapy for VT prophylaxis
544
complication of GCA if not treated | permenant vision loss
545
pattern. of pain in pmr
shoulders, hips, neck
546
what condition is pmr associated with
GCA
547
when to suspect pmr
elderly pt with new sudden onset of proximal limb pain and stiffness. Difficulty rising from chair or combing hair
548
how is diagnosis of pmr madee
ESR or PV plus CRP | Temporal artery biopsy if symptoms of GCA
549
treatment of pmr
15mg of pred daily for 1-2 yrs | should see dramatic response
550
what gene are the sondhloarthropathies associated with
HLAB27
551
presentation of ankylosing spondylitis
usually in young men | bilateral buttock pain, chest wall and thoracic pain
552
examination findings in ankylosing spondylitis
loss of lumbar lordosis | Schobers test - mark skin 10cm above and 5 cm below PSIS, bend forward with straight legs, >20 cm increase is norma,
553
ix of Ankylosing spondylitis
MRI spine and sacroiliac jointx, (more sensitive than xray)
554
mx of as
NSAIDs Physio TNFinhibitors
555
arthritis pattern in psoriatic arthritis
can be symmetrical or monon
556
mx of psoriatic arthritis affecting spine
NSAIDS DMARDS TNF inhibitors
557
reactive arthritis cause
sterile synovitis developing after distant infection eg salmonella, shigella, chlamydia
558
presentation of reactive arthritis
few days - 2 weeks after infection, acute asymmetrical lower limb arthritis may also have conjunctivitis and skin issues
559
who is enteropathic arthritis common in
IBD
560
why wouldnt you give NSAIDs in enteropathic arthritis
can flare IBD
561
mx of enteropathic arthritis
DMARDS
562
extra articular manifestations of AS
``` “The A Disease” Anterior uveitis AV block Apical lung fibrosis Amyloidosis Aortic incompetence ```
563
Features of inflammatory back pain acronym
``` IPAIN insidious onset Pain at night Age <40 improvement with exercise no inmprovement with rest ```
563
Features of inflammatory back pain acronym
``` IPAIN insidious onset Pain at night Age <40 improvement with exercise no inmprovement with rest ```
564
Sumboeyes spondyloarthropathy pneumonic
``` SPINE ACHE Sausage fingers Psoriasis Iritis NSAID Response Enthesitis Arthritis Crohns HLAB27 Elevated CRP, ESR, PV ```
565
SLE Symptom Acronym
``` SOAP BRAIN Serositis - pleurisy, pericarditis Oral ulcers Arthritis Photosensitivity - malar rash Blood disorders - low WCC, lymphopenia Renal involvement - glomerulonephritis Autoantibodies (ANA positive) Immunologic tests eg low complements Neurological disorder - seizures or psychosis ```
566
Ix for SLE
``` ESR or PV anaemia or leukopenia are common ANA positive urinalysis for renal disease skin biopsy and renal biopsy can be diagnostic ```
567
treatment of SLE
sun protection healthy lifestyle advice in view of cardiovascular risk hydroxychloroquine for rash and arthralgia mycophenolate mofetil, azathioprine and rituximab short courses of pred for flares
568
complication of pernicious anaemia
gastric cancer
569
what drug can cause gynaecomastia
spiro
570
mx of BPH
Lifestyle - reduce caffeine, double voiding, bladder training Medical - Tamsulosin (alpha blocker), Finasteride (5Alpha reductease inhibitor stops T-DHT) Surgical - TURP
571
Side effect of tamsulosin
lowers BP
572
complications of TURP
retrograde ejaculation incontinence ED Haemorrhage infection
573
which parts of prostate do BPH and prostate cancer effect
BPH - transitional | Prostate - peripheral
574
Ix for prostate cancer
DRE - hard irregular multiparametric MRI Biopsy Bone scan
575
when do renal stones need urgent intervention
uncontrollable pain renal impairment infection
576
Mx of renal stones
Wait until pass - xray at 1 week to check ESWL - ultrasound shock waves PCNL - percutaneous nephrolithotomy
577
lifestyle advice to help reduce recurrence of stones
increase citrate and fluid intake | reduce animal protein, salt and sugar
578
gold standard renal stone ix
non contrast CT KUB
579
size of kidney stone that requires active removal
>10 mm
580
what type of cancer in renal cell carcinoma
adenocarcinoma
581
Triad of presentation of RCC
haematuria loin pain loin mass
582
Potential finding of RCC in males
varicocoele
583
difference in age of presentation between RCC and TCC
R - 55 | T - 50-80
584
RF of TCC
smoking | cyclophosphamide
585
presentation of TCC
painless haematuria frequency urgency obstruction
586
type of cancer in bladder cancer
transitional cell
587
presentation of bladder cancer
painless haematuria recurrent UTIs LUTS Retention
588
ix of bladder cancer
urine, cystoscopy with biopsy CT CAP to stage
589
mx of bladder cancer
``` surveillance intravesicular chemo with mitomycin C or BCG Radical cystectomy with ileal conduit Palliation Long term catheter ```
590
mx of acute urinary retention
``` analgesia catheterise abx cover tamsulosin if caused by BOH TWOC after 24-72hrs ```
591
two types of chronic urinary retention
high pressure - bladder outflow obstruction. tend to get b/l hydronephrosis and decreased renal function low pressure - no hydropnephrosis and normal renal function
592
mx of high pressure chronic retention
catheterise | consider TURP
593
low pressure urinary retention mx
avoid catheters as infection risk | Early TURP
594
CI of suprapubic catheterisation
knnown or suspected bladder carcinoma undiagnosed haematuria previous lower abdo surgery
595
complication of relieving urinary obstruction
post obstructive diuresis | need to keep hydrated to avoid fluid loss
596
grading for prostate cancer
gleason | sum of 2 worst areas. 4+3 worse than 3+4
597
exam of testicular tumour
painless lump - solid mass inseperable from testis
598
diagnostic test of testicular cancer
scrotum US
599
stress incontinence mx
pelvic floor exercises ring pessart artificial urinary sphincter
600
urge incontinence mx
bladder training, weight loss Anti AChM - tolterodine oxybutynin - can cause dry eyes and dry mouth surgical - botox (CI in myasthaenia gravis) sacral nerve stimulation (S3) Clam ileocystoplasty
601
COPD Stepwise mx nice guidelines
SABA/SAMA No asthmatic features or features suggesting steroid responsiveness - add LABA + LAMA - if taking a SAMA discontinue and switch to a SABA Asthmatic features/features suggesting steroid responsiveness - LABA + ICS if still breathless triple therapy - LABA + ICS + LAMA
602
when to give amoxicillin to an under 2 with acute otitis media
bilateral infection in children under 2, otorrhoea, perforated tympanic membrane and symptoms not improving after 3 days.
603
when to operate on AAA
if greater than 5.5cm or greater than 1cm growth in a year
604
Modified Glasgow Criteria. What does score mean
``` PaO2 <7.9 Age >55 Neutrophils >15x10^3 Calcium <2 Renal function Urea >16 Enzymes LDL >600 Albumin <32 Sugar >10 ``` Score greater than 3 indicates severe pancreatitis with high risk of progressing to SIRS. Need to be treated in HDU or ITU
604
Modified Glasgow Criteria. What does score mean
``` PaO2 <7.9 Age >55 Neutrophils >15x10^3 Calcium <2 Renal function Urea >16 Enzymes LDL >600 Albumin <32 Sugar >10 ``` Score greater than 3 indicates severe pancreatitis with high risk of progressing to SIRS. Need to be treated in HDU or ITU
605
complications of acute pancreatitis
``` sepsis ARDS SIRS chronic pancreatitis DM ```
606
sit up right milestone
6-8 months
607
stand up right holding object
9
608
pulls to stand
10 months
609
walks with assistance
12 months
610
walk unaided
15 months
611
cut off for walking - to think about developmental delay
18 months
612
run uinaided
18 months
613
what does 6 week check involve
Mum - stopped bleeding - wound sites - post partum depression Child - weigh - general assessment of what they look like - rashes birth mark - head circumference - tone, reflexes - babinski, moro’s - exam everything - organs, genitalia, hips (ddh) - barlows for ddh
614
5 childhood exanthems
``` 1st disease Measles 2nd disease Scarlet fever 3rd disease Rubella 5th disease erythema infectiosum - slap cheek 6th disease roseola infantum ```
615
presentation of measles
``` 4days of fever 3C’s - Cough, coryza, conjunctivitis Koplik spots - pathognomonic. white palatal spots rash starts behind ears confluent erythematous rash ```
616
scarlet fever presentation
``` post strep infection strawberry tongue fever, phayngeal erythema pasta lines in skin folds ‘sandpaper’ rash lymphadenopathy ```
617
ix for strep
anti streptolysin O titre
618
mx of scarlet fever
abx as strep | probs penicillin V or benpen
619
rubella presentation
swollen lump behind ear coughing, sneezing, aching, fever red spots along palet - forschemer
620
complication of rubella in pregnant lady
congenital rubella syndrome
621
fifth disease presentation
lace like and reticular on trunk and limbs, blotchy on cheeks fever, coryza, before the slapped cheek shows up Not infective when slap cheek shows Think Safeguarding!!!! non accidental injury
622
cause of slapped cheek pa
parvovirus B19
623
advice for all exanthems
stay away from preggers and immunocompromised
624
roseola infantum (3 day fever)
mostly torso | 3 days of high fever then suddenly drops to normal
625
mongolian spots
big blue spots THINK SAFEGUARDING birth marks so last a long time
626
mx of nappy rash
education for parents | E45, sudacrem
627
chicken pox rash description
itchy generalised discrete erythematous vesicular rash with blisters (varicella is vesicular)
628
bronchiolitis cause
Respiritory Syncitial virus (rsv)
629
bronchiolitis presentation
``` <2 yrs recessions - sucking in diaphragm grunting/wheezing nasal flaring blue baby dry cough doesnt want to play, not feeding ```
630
rf for bronchiolitis
premature | Chronic lung disease eg CF
631
mx of bronchiolitis
``` supportive safety net!!! reasurre paractetamol, ibuprofen admit babies that are severe ```
631
mx of bronchiolitis
``` supportive safety net!!! reasurre paractetamol, ibuprofen admit babies that are severe ```
632
type of wheeze in asthma and why
polyphonic - multiple airways
633
what could cause a monophonic wheeze
foreign body, one airway effected
634
when can asthma not be diagnosed in children
<5yrs
635
Asthma BTS guidelines
``` 1 SABA as required 2 low dose ICS 3 LABA + low dose ICS 4 increase dose of ICS or LTRA 5 refer for specialist care ```
636
colic definition
637
advice for colic for parents
638
dx to think of when child wetting bed
type 1 dm | abuse, trauma
639
what is perthes disease
avascular necrosis of femoral head in children
640
GCS categories and point
``` Eyes Motor Verbal Eyes 1 no eye opening 2 eye open to pain 3 eye open to verbal command 4 eye open spontaneously ``` ``` Motor 1 no motor response 2 extension response to pain 3 flexion response to pain 4 withdraws from pain 5 localises pain 6 obeys command ``` ``` Verbal 1 no verbal response 2 incomprehensible sounds 3 inappropriate words 4 confused 5 orientated ```
641
at what gcs do you need to consider intubation
8
642
what effect of chlorpheramine sets it apart from other anti histamines
sedative
643
how quick do you need to donall sepsis 6 interventions
within an hr
644
types of shock
``` SHOCK Sepsis/anaphlaxis Hypovolaemia Obstructive eg tamponade Cardiogenic K(cortisol) - adrenal ```
645
cause of hypocalcaemia in pancreatitis
fat necrosis of pancreas | breakdown products bind to calcium reducing levels
646
adverse signs in arrythmias
shock chest pain heart failure syncope
647
adenosine dosing for SVT
6,12,18
648
what size pneumothorax do you need to insert needles
2 cm
649
pneumothorax algorithm
650
why stop metformin in aki
bc of lactic acidosis risk
651
ddx for chronic limb ischaemia
spinal stenosis (claudication)
652
ix for chronic limb ischaemia
lipid profile ABPI blood glucose duplex ultrasound
653
benefits of exercise in claudicationc
encourages formation of collateral vessels
654
calculating ABPI
ankle systolic pressure/brachial systolic pressure
655
normal ABPI value and abnormal values
0.9-1.4 normal <0.9 peripheral artery disease >1.4 calcification of arteries
656
mx of chronic arterial insufficiency
lifestyle - weight loss, optimal diabetic control, encourage exercise pharm - clopidogrel 75mg, statin surgery - bypass or percutaneous transluminal angioplasty
657
test used for acute limb ischaemia and description
beurgers test - raise leg to 45 degrees | positive = feet become pale, not the angle. And then out foot doen below bed
658
pain pattern in acute limb ischaemia
worse at night | hang leg out of bed to relieve
659
definitive mx of acute limb ischaemia
catheter embolectomy
660
complications associated with post revascularisation
o2 radicals leading to inflammation and oedema | be aware of compartment syndrome and muscular necrosis
661
how long for complete acute limb ischaemia to cause extensive tissue necrosis
6hrs
662
important cause of varicose veins to remember and ask about
DVT
663
mx of varicose veins
reassurance compression stripping
664
complications of varicose veins
haemorrhage symptoms and signs of chronic venous insufficiency eg lipodermatosclerosis, thrombophlebitis, venous ulcers and eczema, haemosiderin staining
665
mx of chronic venous insufficiency
compression socks analgesia if ulcer then full compressive treatment
665
mx of chronic venous insufficiency
compression socks analgesia if ulcer then full compressive treatment venous stunting if very severe
666
causes of aaa
``` degenerative eg smokers connective tissue disorders eg marfans congenital familial infective dissection ```
667
numbers to know for aaa
if <5.5 surveillance - every 3 months if 4.5 to 5.5. Every year if 3-4.4cm if grows >1cm in 12 months, surgery if >5.5 surgery aneurysm = 1 and a half times normal size normal size = approx 2cm
668
surgery for aaa
endovascular stent
669
screening for aaa
men aged 65
670
ix for vascular problems
``` ABPI Duplex uss doppler lipid profiles clotting screens ```
671
arterial vs neuropathic ulcers
arterial - punched out, unhealthy wound bed, lateral malleolus, pressure points, necrotic tissue neuro - painless, plantar aspect, surrounded by callous
672
what value must ABPI be for safe compression bandaging
>0.8
673
what fractures have a high association with vascular injury
supracondylar humeral - brachial high tibial - popliteal posterior dislocation of shoulder - axillary
674
what does a biphasic sound on doppler indicate? what is normal sound?
artery stiffening | triphasic
675
most likely diagnosis of breast lump by age
young - fibroadenoma 50s - cysts old - cancer
676
gp mx of ALL breast lumps
2ww
677
duct ectasia - waht is it
dilatation of lactiferous duct
678
presentation of duct ectasia
``` mastalgia yellow discharge from nipples can feel like a lump peri menopausal nipple retraction bc of inflammation ```
679
mx of duct ectasia
analgesia and abx
680
what can present similarly to duct ectasia
peri ductal mastitis
681
presentation of breast cyst
tender smooth lump, well defined | usually multiple
682
mx of breast cyst
self resolving - analgesia | if large, aspirate and send off for cytology if blood or if lump doesn’t go away
683
what is involved in breast triple assessment
mammogram exam biopsy
684
presentation of intraductal papilloma
40-50 subaereolar region (less than 1 cm away from nipple) can mimic carcinoma on imaging so requires biopsy usually clear or bloody discharge from nipple
685
benign breast lumps
``` fibroadenoma lipoma intraductal papilloma duct ectasia breast cyst ```
686
what is cyclical mastalgia
pre menopausal women | pain and increased nodularity of breast related to hormonal changes throughout menstrual cycle
687
presentation of DCIS
cheesy discharge confined to ducts lump asymptomatic
688
mx of DCIS
wide local excision or mastectomy
689
what is pagets disease of the nipple
erythematous, ulceration itchy, flaky painful involves both areola and nipple some have underlying malignancy so need to biopsy
690
main ddx for pagets and how do you differentiate this from pagets
eczema - spares nipple
691
mx of pagets
excision of nipple and areola or mastectomy | radiotherapy if underlying malignancy
692
what is most common breast cancer
invasive ductal carcinoma
693
signs of breast cancer
nipple retraction/inversion nipple discharge - bloody hard lump in breast +/- axilla skin changes - peau de orange, pagets disease of the nipple
694
rf of breast cancer
``` fhx smoking increased age nulliparity first child when >30 early menarche and late menopause radiation exposure hx of breastfeeding ```
695
first line treatment of mastitis in breastfeeding ladies and why
continue breastfeeding or expressing milk throughout treatment can give fluclox for 10-14 days
696
complication of mastitis
breast abcess
697
ages targeted in breast screening
50-70
698
how often are women screened for breast cancer
every 3 years
698
how often are women screened for breast cancer
every 3 years
699
what to do with oral diabetic medications the day before surgery
should be taken as normal
699
what to do with oral diabetic medications the day before surgery
should be taken as normal
700
mx of ascending cholangitis
iv abx | ERCP after 24-48hrs to relieve obstruction
701
likely presentation of overactive bladder in men and mx drug
voiding and storage symptoms on background of BPH | add anti muscarinic such as tolterodine or oxybutynin
702
first line medical treatment for fissures
stool softeners topical diltiazem to relax sphincter and facilitate healing
703
main ix for a young male with acute prostatitis
sti screen
704
what type of drug is propofol
GABA receptor agonist
705
what anaesthetic agents can cause malignant hyperthermias
suxamethonium, volatile liquid anaesthetics eg sevoflurane, isoflurane
706
when is dalteparin started perioperatively
about 6hrs POST op
707
what does % mean in drugs eg 2% lidocaine
eg 2g of lidocaine in 100ml
708
timetable and 5Ws of causes of post operative fever
``` Day 1-2 Wind - pneumonia, atelectasis, PE Day 3-5 Water - UTI Day 5-7 wound - infection or abscess Day 5+ Walking - DVT or PE Anytime Wonder about drugs ```
709
before ileus becomes symtpomatic with nausea and vomiting, what can it cause
hypovolaemia, electrolyte disturbances
710
what is a potential serious cause of AF after a gastrointestinal surgery
anastomotic leak
711
what can local anaesthetic toxicity be treated with
IV 20% lipid emulsion
712
examples of quinolones
ciprofloxacin | levofloxacin
713
adverse effects of quinolones eg ciprofloxacin
lowers seizure threshold tendon damage/rupture increased QT interval
714
most common organisms causing acute cholecystitis
E coli klebsiella strep
715
what is reynolds pentad for
ascending cholangitis | Charcots + signs of shock
716
FeverPAIN
``` Fever in past 24hrs Purulent tonsils Attended within 3 days Inflammation severe No cough and coryza ```
717
syndrome caused by giving aspirin to under 16
Reye’s syndrome - cerebral oedema
718
CKD Staging
``` eGFR. ACR G1 >90. A1 <3 G2 60-89. A2 3-30 G3a 45-59. A3 >30 G3b 30-44 G4 15-29 G5 <15 ```
719
talk through peritoneal dialysis process
Dialysate fluid pumped into peritoneum and left for few hrs Dialysate has high glucose content so high osmolality. Draws water and electrolytes out into the peritoneum fluid is then drained
719
talk through peritoneal dialysis process
Dialysate fluid pumped into peritoneum and left for few hrs Dialysate has high glucose content so high osmolality. Draws water and electrolytes out into the peritoneum fluid is then drained
720
complications of peritoneal dialysis
encapsulated peritoneal sclerosis peritonitis hernias
721
haemodialysis process
fistula blood passed through dialyser. Dialyser has lots of semi permeable channels surrounding by a constant flow of dialysate (going opposite direction to blood) 3x a week for 4 hrs
722
if pt cant have fistula for haemodialysis, what can you do instead
insert a permcath
723
rank rrt in order of effectiveness
renal transplant haemodialysis peritoneal dialysis
724
complications of haemodialysis
infection/bacteraemia reactions to dialysers cramps anaemia
725
what criteria make you unsuitable for RRT (no additional survival benefit)
age >80 with WHO performance score of 3 or more
726
what can you do for pts who are unsuitable for RRT
active conservative mx - treating symptoms, palliative care
726
what can you do for pts who are unsuitable for RRT
active conservative mx - treating symptoms, palliative care
727
contraindications of renal transplant
``` cardiac failure active infection or malignancy reversible renal disease non compliance to treatment short life expectancy substance abuse ```
727
contraindications of renal transplant
``` cardiac failure active infection or malignancy reversible renal disease non compliance to treatment short life expectancy substance abuse ```
728
3 types of kidney transplant
living donor related living donor unrelated dead donor
728
3 types of kidney transplant
living donor related living donor unrelated dead donor
729
induction therapy for kidney transplant
immunosupression drugs such as methylprednisolone in combo with basiliximab
730
maintenance drugs after renal transplant
steroids calcineurin inhibitors such as tacrolimus and cyclosporin mycophenalate mofitil azathioprine
731
complications of renal transplant
rejection infection bc of immunosupression so opportunistic cancers - 3 times more likely to develop any cancer so need monitoring NODAT - new onset diabetes after transplant
732
colic definition
infant cries for more than 3 hrs a day for more than 3 days a week
733
pathophys of DKA
insulin deficiency causes decreased glucose uptake Glycogenolysis. Lipolysis and muscle breakdown for gluconeogenesis which causes hyperglycaemia with ketones as a by product Acidosis Osmotic diuresis - loss of water and electrolytes
733
pathophys of DKA
insulin deficiency causes decreased glucose uptake Glycogenolysis. Lipolysis and muscle breakdown for gluconeogenesis which causes hyperglycaemia with ketones as a by product Acidosis Osmotic diuresis - loss of water and electrolytes
734
symptoms of hypoglycaemia
``` Sweating Tremor Anxious Dizzy Drowsy Seizures Loss of consciousness blurred vision palpitations ```
735
what value is hypoglycaemic
<3.9
736
non diabetic causes of hypoglycaemia
Addisons Exogenous drugs insulinoma too mich exercise not enough food
736
non diabetic causes of hypoglycaemia
Addisons Exogenous drugs insulinoma too mich exercise not enough food
737
signs of DKA
``` Dry mucus membranes Sunken eyes Tachycardia Hypotension Ketotic breath Kussmaul resp. Altered mental state Hypothermia ```
738
Symptoms of DKA
``` Polyuria polydipsia nausea/vomiting blurred vision abdo pain - bc acidosis can cause ileus ```
739
diagnostic criteria for dka
ketonuria hyperglycaemia acidosis
740
ketone level in dka
>3
741
why do HHS not have ketonuria
bc still have some insulin sensitivity
741
why do HHS not have ketonuria
bc still have some insulin sensitivity which can shpress lipolysis enough to prevent ketone production
742
complications of HHS and prevention
DVT, stroke bc VeRy DEHYDRATED | VTE tprophylaxis
743
causes of HHS
diabetic meds non compliance infection MI bowel infarct
744
glucose level in hhs
usually >30
745
signs of hhs
signs of severe dehydration - dry mucus membranes - sunken eyes
746
osmolality in hhs
>320
747
mx of hhs
IV fluids Potassium IV insulin DVT prophlaxis - bc increased risk bc of dehydration
748
meds used in basal bolus dosing
long acting - lantus | rapid acting - novorapid
749
advise to give diabetics starting on insulin
how to monitor blood glucose injection technique - rotate sites to avoid lipohypertrophy risk of DKA and hypoglycaemia and how to recognise inform DVLA complications of poor glycaemic control
750
diagnosis of diabetes
fasting glucose >7 on 2 occasions or 1 w/ symptoms Random glucose >11.1 on 2 occassions or 1 w/ symptoms HbA1c (type 2 only) >48
751
when do you not use HbA1c
``` pregnant child type 1 renal failure HIV steroid use ```
752
Contraindications of metformin
eGFR<30 | alcohol intoxication
753
gliclazide (sulfonylurea) ADRs
weight gain | hypoglycaemia
754
glitazones ADRs
hypoglycaemia fluid retention bladder cancer risk increased fracture risk
755
CI of glitazones
heart failure
756
DPP4 (sitagliptin) CI and why
hx of pancreatitis as small risk pf pancreatitis
756
DPP4 (sitagliptin) CI and why
hx of pancreatitis as small risk pf pancreatitis
757
presentation of raynauds
young female vasospasm of digits causing colour changes in response to cold or stress stimulus white-blue-red
758
Raynauds developing over age of 30 should alert you to what diseases:
scleroderma SLE dermato and polymyositis sjogrens drug induced: beta blockers
759
mx of raynauds
keep warm avoid smoking ccb are first line eg nifedipine then phosphodiesterse 5 inhibitors
760
complications of raynauds
digital ulcers infection gangrene
761
ix for raynauds
nail fold capillaroscopy
762
Examples of small vessel vasculitis
Granulomatosis with polyangiitis (wegeners) IgA vasculitis (henoch schonlein purpura) microscopic polyangiitis
763
example of medium vessel vasculitis
kawasaki disease
764
example of large vessel vasculitis
GCA
765
causes of secondary vasculitis
infectiom drugs malignancy connective tissue disease much more common than primary vasculitis
765
causes of secondary vasculitis
infectiom drugs malignancy connective tissue disease much more common than primary vasculitis
766
symptoms of vasculitis
general - fever, loss of appetitie. weight loss, fatigue | specific - depends on vessels affected eg could get haematuria, haemoptysis, neuropathy,visual loss
767
treatment of vasculitis
1st line - corticosteroids | 2 - cytotoxic meds or biologic agents eg methotrexate, azathioprine. rituximab
768
what is dermatomyositis
inflammation of striated muscle
769
presentation of dermatomyositis
insidious onset of muscle proximal weakness, often painless May have SOB or rash Raynauds commonly associated
770
Ix in dermatomyositis
raised muscle ALT but normal liverALT ANA - positive Anti Jo 1 MRI - myositis well demonstrated
771
mx of dermatomyositis
high dose corticosteroids long term control with azathioprine Sun protection importqnat - hydroxychloroquine useful
772
why is there a risk of aspiration. pneumonia in dermatomyositis
bc oesophagus is striated muscle so swallowing may be affected
772
why is there a risk of aspiration. pneumonia in dermatomyositis
bc oesophagus is striated muscle so swallowing may be affected
773
signs of dermatomyositis
photosensitive rash - scalp face and neck Gottrons papules - linear plaques on dorsum of hand dilated nail fold capillaires and dry cracked palms periorbital oedema heliotrope rash - violet rash of eyelids
774
pathophys of systemic sclerosis
multisystem autoimmune disease increased fibroblast activity resulting in abnormal growth of connective tissue vascular damage and fibrosis
775
2 stypes of systemis sclerosis
limited and diffuse
776
symptoms and signs of limited scleroderma
``` CREST Calcinosis Raynauds E oesophageal dysmotility Sclerodactyly Telangiectasia ```
777
ix of systemic sclerosis
``` xray hands - calcinosis CXR for pulmonary disease ECG, ECHO ANA + anti centromere ab with limited scleroderma ```
778
mx of scleroderma
``` no cure ccb for raynauds methotrexate ACEi prevent HTN crisis prednisolone for flares ```
779
complication of diffuse SSc
scleroderma renal crisis causing HTN and renal failure
779
complication of diffuse SSc
scleroderma renal crisis causing HTN and renal failure
780
mnemonic for symptoms and signs of sjogrens
``` MAD FRED Myalgia Arthralgia Dry mouth Fatigue Raynauds Enlarged parotids Dry eyes ```
781
Ix for sjogrens
salivary gland biopsy Anti Ro and Anti La RF and Anti - ds DNA
782
antibodies associated with SLE
anti Ro anti La Anti dsDNA antiphospholipid ab
783
Mx of sjogrens
treat symptoms eg avoid dry atmospheres, eye drops, skin emollients, artificial saliva
784
what do you see on biobsy in sjogrens
focal lymphocytic infiltration of exocrine glands
785
symptoms and signs of hypermobility
``` pain around joints fatigue marfanoid habitus, arachnodactyly drooping eyelids, myopia hernia and prolapses ```
786
Mx of hypermobility
strengthening exercises to reduce subluxation/dislocation | paracetamol for pain
787
what score is used for hypermobility
beighton score - max score of 9. hands on floor elbow backwards, knee backwards. thumb to wrist, 90 degree pinky
788
pathophys of OA
progressive degeneration of articular cartilage accompanied by new bone formation and capsular fibrosis
789
rf of OA
obesity joint malalignement through trauma or muscle weakness female
790
mx of OA
``` physio weight loss NSAIDS intra articular steroid injections joint replacements ```
791
nodal OA sign names
bouchards and heberdens nodes
792
main 3 symptoms pf fibromyalgia
pain everywhere no energy unrefreshed sleep
792
main 3 symptoms pf fibromyalgia
pain everywhere no energy unrefreshed sleep
793
mx of fibromyalgia
dealing with depression, fatigue, sleep disturbance if drugs then low dose amitrypytline or pregabalin may be effective CBT
794
Rf of osteoporosis
``` Age, female, fhx, hx of low trauma fracture Low BMI premature menopause calcium/vit d deficiency inadequate ohysical activity smoking excessive alcohol intake steroids ```
795
diagnosis of osteoporosis
DEXA scan T score x number of SDs from mean bone density of same gender at age of peak density (25) T score - 2.5 or less = osteoporosis
796
scores in osteoporosis
T score | Z score
797
mx of osteoporosis
risk modification - weight bearing exercise, vit D3 supplements, reduce alcohol and smoking, dietary advice regarding calcium calcium and vit D supplements plus: 1st line oral bisphosphonates 2nd line denosumab
798
pathophys of gout
hyperuricaemia | deposition of monosodium urate crystals in joints and soft tissues
799
rf for gout
``` age >40 male increased purine uptake (fish) high fructose obese chf renal disease HtN smoking DM Meds eg thiazides ```
800
mx of gout
risk modification - reduce weight,diet mod, reduce alcohol NSAIDS, steroids, colchicine for flares Allopurinol for chronic. don’t stop allopurinol in acute flares if already on it but dont start if not
801
when is colchicine CI
pregnancy renal failure - eGFR <10 blood disorders
802
appearance of gout in joint aspirate
negatively birefringent needle shaped crystals
803
who is pseudogout common in
older women with OA
804
what abx can be used as prophylaxis for infective exacerbations of COPD
azithromycin
805
which CCB is most likely to precipitate pulmonary oedema in a pt with known chronic heart failure
verapamil
806
why do pts with coeliacs need a pneumococcal vaccine
bc of hyposplenism
807
what skin condition can co amox cause
erythema multiforme
808
examples of UKMEC4
``` current breast cancer migraine with aura - bc of ischaemic stroke risk BMI >40 smokers >15 a day liver tumours ```
809
CI for IUD
PID | Fibroids causing distortion of uterus
809
CI for IUD
PID | Fibroids causing distortion of uterus
810
causes of avn of femoral head
long term steroid use trauma chemo alcohol excess
810
causes of avn of femoral head
long term steroid use trauma chemo alcohol excess
811
what is an important back pain differential to consider in IVDU
psoas abscess
812
what disease is most associated with carpal tunnel
rheumatoid
813
what can ivdu with underlying infective endocarditis present with?
discitis
814
position of leg in posterior hip dislocation
shortened and internally rotated
814
position of leg in posterior hip dislocation
shortened and internally rotated
814
position of leg in posterior hip dislocation
shortened and internally rotated
815
what does pain on radial styloid of wrist indicated
de quervains tenosynovitis
815
what does pain on radial styloid of wrist indicated
de quervains tenosynovitis
816
if a diabetic is ill what advice should you give them about their insulin and why
continue to take it and frequently check blood glucose. At increased risk of DKA
816
if a diabetic is ill what advice should you give them about their insulin and why
continue to take it and frequently check blood glucose. At increased risk of DKA so stopping would be very dangerous
817
what does curb65 tell us and how does this change mx plans
risk of death | if 3/4, NICE recommend urgent admission to hospital
818
which diabetic drug is CI in HF
glitazones bc cause fluid retention
819
which HTN drug class should be avoided in preggers
ACEi
820
drugs to avoid in asthma
NSAIDS B Blockers Adenosine
821
what drugs are CI in heart failure
pioglitazone verapamil NSAIDs with caution Class 1 antiarrhythmics eg flecainide
822
which cancer does tamoxifen increase risk of
endometrial
822
which cancer does tamoxifen increase risk of
endometrial
823
what drug can precipitate digoxin toxicity
thiazides bc they can cause hypokalaemia
824
what is the most important prognostic factor in paracetamol overdose
pH
825
what anti emetics do you not give in bowel obstruction and why
pro kinetics eg metoclopramide and domperidone | Can increase risk of perforation
825
what anti emetics do you not give in bowel obstruction and why
pro kinetics eg metoclopramide and domperidone | Can increase risk of perforation
826
causes of raised ALP
Biliary obstruction eg - gall stones, hepatic tumour (SOL) | Bone eg - pagets, osteomalacia, bone mets,
827
interpreting ALT and ALP
ALT 10 fold increase with ALP less than 3 fold increase = hepatocellular injury ALP 3 fold increase with ALT less than 10 fold increase = cholestasis
828
ALT/AST ratio meanings
ALT>AST = chronic liver disease | ALT
829
what is purpose of gamma GT
determines whether rise in ALP is hepatobilliary or non hepatobilliary eg vit d deficiency, pagets, osteomalacia
830
when catheterising pt for urinary retention how can you tell whether it is acute or chronic based off the fluid output
Chronic >1.5 L and is often painless
831
histological features of crohns
granuloma formation lymphocytes infiltration transmural inflammation
832
which IBD has perianal disease and what does this mean
Crohns - perianal abcesses, fissures, fistulae
833
complications of crohns
``` perianal abscess or fistulae, perforated bowel small bowel obstruction colonic carcinoma malnutrition ```
833
complications of crohns
``` perianal abscess or fistulae, perforated bowel small bowel obstruction colonic carcinoma malnutrition ```
834
Treatment of Wilsons
penicillamine - heavy metal antagonist
835
Psoas abscess presentation
lower abdo pain, relived by hip flexion, worsens with extension and internal rotation low grade fever
835
Psoas abscess presentation
lower abdo pain, relived by hip flexion, worsens with extension and internal rotation low grade fever
836
what cancers is COCP protective against
ovarian and endometrial
837
reversal agent for dabigatran
Idarucizumab
838
reversal agent for doacs other than dabigatran
adexanate alfa
839
ullipristal acetate CI
asthma
840
why does resp rate increase in sepsis
to compensate for metabolic acidosis, blow of CO2
841
mx of mechanical back pain
``` physio rest education : manual handling technique analgesia: paracetamol+-NSAIDS+-Codeine muscle relaxant - diazepam (short term) ```
842
what is a disc prolapse pathophys
herniation of nucleus polposus through annulus fibrosus
843
what discs are most likely to prolapse and which nerves are most commonly affected
L4/L5 and L5/S1 | L5 root. S1 root
844
Presentation of an L4/5 prolapse
Compression of L5 so: Sensory loss along lateral aspect of leg and dorsum of foot Weakness or abscence of great toe extension lower back pain limited spinal flexion and extension pain on straight leg raise
845
Presentation of L5/S1 prolapse
general: back pain reduced spine flexion and extension pain on passive straight leg lift - lasegue sign specific: S1 compression Sensory loss on sole of foot Motor weakness of plantar flexion and eversion
846
big syndrome to rule out in a central herniation
cauda equina
846
big syndrome to rule out in a central herniation
cauda equina
846
big syndrome to rule out in a central herniation
cauda equina
847
imaging of spine to rule out cauda equina
MRI
848
what is spondylolisthesis
displacement of a vertebra usually anteriorly to the one below
849
what is spinal stenosis
facet joint arthritis causing narrowing of spinal canal
850
presentation of spinal stenosis
CLAUDICATION - aching or heavy buttock or lower limb pain when walking Pain relieved by flexion Pain worsened by extension
851
Mx of spinal stenosis
NSAIDS Epidural steroid injection Canal decompression surgery
852
surgery for cauda equina
decompression - laminectomy or discectomy
853
causes of cauda equina
``` disc prolapse malignancy infection haemorrhage in spinal canal spinal stenosis ```
853
causes of cauda equina
``` disc prolapse malignancy infection haemorrhage in spinal canal spinal stenosis ```
854
cauda equina red flags
``` perianal numbness fecal incontinence painless urinary retention bilateral sciatica erectile dysfunction Anal sphincter laxaty ```
855
imaging choices for achilles rupture
US or MRI | but most diagnosed on clinical examination alone
856
tumour marker in hepatocellular carcinoma
serum AFP
857
Mx of pericarditis
NSAIDS and colchicine
858
what is electrical alternans and what can cause it
pericarditis causing exudative effusion causes heart to change position every beat seen by alternating sizes of qrs complexes
859
what signs would you see with electrical alternans
Beck’s triad - basically cardiac tamponade
860
what does a posterior MI look like on ECG
st depression from leads V1-3 and tall R waves
861
why not give oxygen if >94 in MI?
Risk of reperfusion injury
862
3 common causes of ascites
cirrhosis Chronic cardiac failure cancer - mets most common
863
what ix should be performed on all pts with ascites and why
diagnostic ascitic tap (cell count and MC&S) | for spontaneous bacterial peritonitis
864
mx of ascites
spironolactone | pericentesis if tense - if pt is in a lot of discomfort and pain
865
what prophylactic treatments can reduce risk of GI bleeding from varices
propanalol (non selective beta blocker) | endoscopic band ligation
866
MSK complication of cirrhosis and how do you screen for it
osteoporosis - DEXA
867
most important predictor of bleeding in surgery
bleeding history NOT Coag screen
868
what dies joint aspirate in RA look like
yellow fluid high lymphocyte count polymorphonuclear neutrophil predominance
869
threshold for blood transfusion in normal people vs people with ACS
Hb <70g/L in normal | <80g/L in those with ACS
870
what rash is mycoplasma pneumoniae associated with
erythema multiforme - target shaped rash
871
what 4 changes happen in hypovolaemic shock
decreased CO Increased HR Reduced left ventricular filling pressures Reduced BP
872
what must pts do for 6 weeks before getting tested for coeliacs
eat gluten
872
what must pts do for 6 weeks before getting tested for coeliacs
eat gluten
872
what must pts do for 6 weeks before getting tested for coeliacs
eat gluten
873
xray findings in as
subchondral erosisons sclerosis squaring of lumbar verterbre sacroilitis
874
what drug should be discontinued 48hrs following a contrast CT
metformin bc of renal impairment risk
875
what is the medication used for hepatic encephalopathy
lactulose
875
what is the medication used for hepatic encephalopathy
lactulose
876
ADRs of beta blockers
tired, dizzy, lightheaded - sx of slow HR hypotension cold peripheries bronchospasm if have asthma
877
how is pseudogout different to gout
deposition of calcium pyrophosphate in the joints rather than monosodium urate typically affects knee first Associated with hypothyroidism, hypoparathyroid and hypomagnasaemia. positively bifringent rhomboid shaped crystals
878
indications for a permanent pacemaker
``` heart block - 2:2 and 3 symptomatic brady sick sinus heart failure drug resistant tachy ```
879
what drugs to stop in heart block
beta blockers, CCBs
880
pathophys of Dresslers
immune response to the pericardium post MI | happens few weeks after MI
881
complication of nephrotic syndrome
``` renal vein thrombosis infection hyperlipidaemia hypocalcaemia acute renal failure ```
882
differentiate hf swelling from nephrotic syndrome swelling
nephrotic you get periorbital as well as leg
883
what condition causes muddy brown casts
rhabdo causing Acute Tubular Necrosis
884
what increases risk of rhabdo when prescribed with statins
clarithromycin
885
electrolyte complications of rhabdo
metabolic acidosis hyperkalaemia hypocalcaemia
885
electrolyte complications of rhabdo
metabolic acidosis hyperkalaemia Hyperphosphataemia hypocalcaemia
886
mx of rhabdo
treat hyperkalaemia IV fluid can also give IV sodium bicarbonate or dialysis if severe renal failure
886
mx of rhabdo
treat hyperkalaemia IV fluid can also give IV sodium bicarbonate or dialysis if severe renal failure
887
what drug is used to prevent progression of renal failure in diabetic nephropathy and MOA
ACEi to treat microalbuminuria - dilates efferent arteriole which reduces glomerular capillary filtration pressure and GFR and reduces risk of glomerulosclerosis
888
what supplements can reduce absorption of levothyroxine and cause hypothyroidism relapse
iron and calcium | should be taken 4 hrs apart from levothyroxine
888
what supplements can reduce absorption of levothyroxine and cause hypothyroidism relapse
iron and calcium | should be taken 4 hrs apart from levothyroxine
888
what supplements can reduce absorption of levothyroxine and cause hypothyroidism relapse
iron and calcium | should be taken 4 hrs apart from levothyroxine
888
what supplements can reduce absorption of levothyroxine and cause hypothyroidism relapse
iron and calcium | should be taken 4 hrs apart from levothyroxine
888
what supplements can reduce absorption of levothyroxine and cause hypothyroidism relapse
iron and calcium | should be taken 4 hrs apart from levothyroxine
889
resuktnof OGTT in acromegaly
no suppression of growth hormone after oral glucose bolus
890
management for phaeochromocytoma
phenoxybenzamine (irreversible alpha blocker) otherwise risk hypertensive crisis For at least 3 weeks then surgery
890
management for phaeochromocytoma
phenoxybenzamine (irreversible alpha blocker) otherwise risk hypertensive crisis For at least 3 weeks then surgery
891
what incontinence drug should be avoided in frail older people
oxytocin as increased risk of confusion and falls
891
what incontinence drug should be avoided in frail older people
oxytocin as increased risk of confusion and falls
891
what incontinence drug should be avoided in frail older people
oxytocin as increased risk of confusion and falls
891
what incontinence drug should be avoided in frail older people
oxytocin as increased risk of confusion and falls
891
what incontinence drug should be avoided in frail older people
oxytocin as increased risk of confusion and falls
892
what incontinence drug should be avoided in frail older people
oxytocin as increased risk of confusion and falls
893
first line pharm mx of delirium
haloperidol | But if have parkinsons or lewy body then use lorazepam
894
factor differentiating delirium from dementia
ACUTE onset impairment of conscious level in dementia fluctuation of symptoms - worse at night abnormal perceptions - delusions and hallucinations agitation
895
cause of secondary polycythaemia in copd
response to chronic hypoxia
896
abx for acute IE of COPD
co amox for 5 days | or doxy if pen allergic
897
what rash is pathognomonic of coeliacs
dermatitis herpetiformis - itchy vesicular extensor rash
897
what rash is pathognomonic of coeliacs
dermatitis herpetiformis - itchy vesicular extensor rash
897
what rash is pathognomonic of coeliacs
dermatitis herpetiformis - itchy vesicular extensor rash
898
what pathogen is associated with secondary pneumonia after a preceding influenza infection
staph aureus
899
virus associated with eczema herpeticum
herpes simplex 1 and 2
900
who does a kelbsiella pneumonia mostly effect
alcoholics
900
who does a kelbsiella pneumonia mostly effect
alcoholics
901
what rash is associated with mycoplasma pneumoniae
erythema multiforme
902
lfts in biliary colic
normal
903
what blood can differentiate between upper and lower GI bleed
urea - high in upper
903
what blood can differentiate between upper and lower GI bleed
urea - high in upper
904
what surgical procedure is used for upper rectum
anterior resection
904
what surgical procedure is used for upper rectum
anterior resection
904
what surgical procedure is used for upper rectum
anterior resection
905
most common heart murmur in IVDU
tricuspid regurge
906
bisphosphonate example
allendronic acid
906
bisphosphonate example
allendronic acid
907
scoring system for RA
DAS28
908
mx of excema (different severity levels)
mild - emollients eg E45 - topical hydrocortisone 1% moderate - emollients - betnovate for 48hrs until flare controlled - topical hydrocortisone 1% for face - dry bandages - antihistamines - certirizine, loratidine Severe - emollients - betnovate or eumovate for 5 days - dry bandaging - sedative antihistamine if struggling to sleep - avoid triggers
908
mx of excema (different severity levels)
mild - emollients eg E45 - topical hydrocortisone 1% moderate - emollients - betnovate for 48hrs until flare controlled - topical hydrocortisone 1% for face - dry bandages - antihistamines - certirizine, loratidine Severe - emollients - betnovate or eumovate for 5 days - dry bandaging - sedative antihistamine if struggling to sleep - avoid triggers
908
mx of excema (different severity levels)
mild - emollients eg E45 - topical hydrocortisone 1% moderate - emollients - betnovate for 48hrs until flare controlled - topical hydrocortisone 1% for face - dry bandages - antihistamines - certirizine, loratidine Severe - emollients - betnovate or eumovate for 5 days - dry bandaging - sedative antihistamine if struggling to sleep - avoid triggers
909
advice for topical steroids
``` 1 finger tip unit downward motion in direction of heair dont rub in wash hands thotoughly afterwards wait 30 mins or more before applying emollient ```
909
advice for topical steroids
``` 1 finger tip unit downward motion in direction of heair dont rub in wash hands thotoughly afterwards wait 30 mins or more before applying emollient ```
909
advice for topical steroids
``` 1 finger tip unit downward motion in direction of heair dont rub in wash hands thotoughly afterwards wait 30 mins or more before applying emollient ```
910
side effects of topicla steroids
``` skin thinning temporary stunging/burning stretch marks acne rash mild lightening of the skin ```
911
diagnosis to consider if eczema becomes weepy, bleeding, blisters
eczema herpeticum
912
acne management
non pharm - frangrance free cleaners - reduce make up use - do not squeeze - healthy diet Mild - topical retinoids eg benzoyl peroxide, adapalene - topical abx (erythromycin) in combination with topical retinoids Moderate - oral abx (lymecycline or doxycycline) with topical retinoid Severe - roacutain
913
psoriasis mx
- avoid precipitating factors eg beta blockers - topical corticosteroids - emollients - vit D analogues - coal tar preps - calcinuerininhibitors - tacrolimus
914
dexamethasone supression
low dose - low cortisol = normal - high cortisol = cushings syndrome high dose - low cortisol = cushings disease - high cortisol, low ACTH = adrenal cushings - high cortisol, high ACTH = ectopic cushings
915
causes of secondary hyperaldosteronism
heart failure renin secreting tumour cor pulmonale cirrhosis
915
causes of secondary hyperaldosteronism
heart failure renin secreting tumour cor pulmonale cirrhosis Renalartery stenosis bc reduced perfusion
915
causes of secondary hyperaldosteronism
heart failure renin secreting tumour cor pulmonale cirrhosis Renal artery stenosis
916
renin:aldosterone
low r:low a = cushings low r:high a = primary hyperaldosteronism high r:low a = addisons high r:high a = secondary hyperaldosteronism
917
tumour markers to know CEA,AFP, Ca199, Ca125, Ca153
``` CEA - colorectal AFP - hepatocellular Ca199 pancreatic Ca125 ovarian Ca153 breast ```
918
coeliac disease histology
villous atrophy, crypt hyperplasia, lymphocyte infiltration
919
lvh causes
htn aortic stenosis hypertrophic cardiomyopathy
920
ix for htn
24hr BP USS kidney MRI renal/aorta bloods
921
complications of HTN
aortic dissection strokes renal failure
921
complications of HTN
aortic dissection strokes renal failure
922
hypertrophic cardiomyopathy - where is it thick
thickened septum
923
causes of hf
``` ischaemic heart disease valvular heart disease arryhtmias alcohol and drugs cancer drugs congenital heart disease ```
924
what med is efficaciis in controlling future symptoms of svt
flecainide
924
what med is efficaciis in controlling future symptoms of svt
flecainide
924
what med is efficaciis in controlling future symptoms of svt
flecainide
924
what med is efficaciis in controlling future symptoms of svt
flecainide
925
why leg swelling in h f
reduced RV function so reduced venous return | blood pools in veins in legs and so increased pressure forces fluid out of the vasculature
926
risk factors of rcc
``` smoking male Caucasian dialysis obesity aromatic hydrocarbons htn ```
927
?rxof a renal tumour????
partial or radical nephrectomy cryotherapy percutaneous radio frequency ablation
928
what cancer treatment does not work on renal tumours
chemo
928
what cancer treatment does not work on renal tumours
chemo
929
What is the most common type of thyroid cancer?
Papillary cancer
930
Digoxin monitoring
No routine monitoring required, unless toxicity is suspected. If toxicity suspected, measure 8-12 hours after last dose.
931
Red flags warranting further ix for ovarian cysts
Irregular solid tumour Ascites At least 4 papillary structures Irregular multilocular Very strong blood flow
932
Rx of pre menstrual syndrome
Lifestyle - smoking, alcohol COCP SSRI if severe
933
Most common thyroid cancer Prognosis Most likely complication
Papillary Good Spread to cervical lymph nodes
934
Features of digoxin toxicity
generally unwell, lethargy, nausea & vomiting, anorexia, confusion, yellow-green vision arrhythmias (e.g. AV block, bradycardia) gynaecomastia
935
Mx digoxin toxicity
Digibind correct arrhythmias monitor potassium
936
937
Presentation of myasthenia gravis crisis
Bilateral ptosis Slurred speech Respiratory failure
938
Triple therapy for H Pylori
PPI Amoxicillin/metronidazole Clarithromycin
939
What is pseudomembranous colitis What abx are associated with it Blood results (WCC)
Inflammation of the colon associated with an overgrowth of C Diff. Get abdo pain, diarrhoea and fever Leukocytosis Clindamycin Penicillins Cephalosporins
940
Drugs causing diarrhoea
Abx PPI NSAIDs Digoxin
941
What is Klinefelters syndrome? - karyotype?
47XXY Hypergonadotrophic hypogonadism - tall stature - low volume testes - sparse pubic hair - gynaecomastia High LH and FSH, low testosterone
942
What drug can be used for rapid sequence induction? - intubation
Suxamethonium
943
Clozapine has been missed for 2 doses. What are the next steps with regards to this?
If clozapine has been missed for 48 hours, should retitrate doses slowly. - after a break of 48 hours or more, side effects are worse
944
List some ototoxic medications
Aminoglycosides- gentamicin, neomycin Furosemide- esp when give by rapid IV infusion. Usually reversible Cisplatin Aspirin- can cause tinnitus
945
In what cases should you send an MSU if UTI is suspected?
-Aged over 65 -Visible or non visible haematuria -Pregnancy - Men
946
Medical management ectopic pregnancy? What is important to make the patient aware of? (think future)
IM methotrexate The methotrexate will be teratogenic for 3 months- ensure adequate contraception
947
A patient has an ectopic source of ACTH. What will a high dose dexamethasone suppression test show?
Cortisol not suppressed ACTH not suppressed
948
What drug should be considered in patients with T1DM with BMI over 25?
Metformin
949
What screening test would you use for diabetic neuropathy of feet?
10 g monofilament
950
Causes of pseudo-Cushings?
Alcohol excess Severe depression
951
First line ix for acromegaly?
Serum IGF-1 Then OGTT
952
1st line treatments for diabetic neuropathy?
Pregabalin Gabapentin Duloxetine Amitriptyline Any of the above
953
Drug causes of gynaecomastia?
-spironolactone (most common drug cause) -cimetidine -digoxin -cannabis -finasteride -GnRH agonists e.g. goserelin, buserelin -oestrogens, anabolic steroids
954
What result would you expect to see on FBC following 3 weeks of high dose steroids?
Neutrophilia- although steroids are immunosuppressive, steroids have contradictory effect on neutrophils

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