Wednesday [26/4/23] Flashcards

Question

what should be given pregnancy? [1]

Answer 1

Which one of the following interventions should be offered to reduce the risk of developing pre-eclampsia again?

Answer 2

Painful third nerve palsy = posterior communicating artery aneurysm

Answer 3

eye is deviated 'down and out' ptosis pupil may be dilated (sometimes called a 'surgical' third nerve palsy)

Answer 4

endoscopic retrograde cholangiopancreatography (ERCP) or magnetic resonance cholangiopancreatography (MRCP) are the standard diagnostic investigations, showing multiple biliary strictures giving a 'beaded' appearance p-ANCA may be positive there is a limited role for liver biopsy, which may show fibrous, obliterative cholangitis often described as 'onion skin'

Answer 5

Primary sclerosing cholangitis is a biliary disease of unknown aetiology characterised by inflammation and fibrosis of intra and extra-hepatic bile ducts. Associations ulcerative colitis: 4% of patients with UC have PSC, 80% of patients with PSC have UC Crohn's (much less common association than UC) HIV Features cholestasis jaundice, pruritus raised bilirubin + ALP right upper quadrant pain fatigue

Answer 6

Ankylosing spondylitis - x-ray findings: subchondral erosions, sclerosis and squaring of lumbar vertebrae

Answer 7

Rifampicin mechanism of action: inhibits bacterial DNA dependent RNA polymerase preventing transcription of DNA into mRNA potent liver enzyme inducer hepatitis, orange secretions flu-like symptoms Isoniazid mechanism of action: inhibits mycolic acid synthesis peripheral neuropathy: prevent with pyridoxine (Vitamin B6) hepatitis, agranulocytosis liver enzyme inhibitor Pyrazinamide mechanism of action: converted by pyrazinamidase into pyrazinoic acid which in turn inhibits fatty acid synthase (FAS) I hyperuricaemia causing gout arthralgia, myalgia hepatitis Ethambutol mechanism of action: inhibits the enzyme arabinosyl transferase which polymerizes arabinose into arabinan optic neuritis: check visual acuity before and during treatment dose needs adjusting in patients with renal impairment

Answer 8

Congenital Drugs* Other Jervell-Lange-Nielsen syndrome (includes deafness and is due to an abnormal potassium channel) Romano-Ward syndrome (no deafness) amiodarone, sotalol, class 1a antiarrhythmic drugs tricyclic antidepressants, selective serotonin reuptake inhibitors (especially citalopram) methadone chloroquine terfenadine** erythromycin haloperidol ondanestron electrolyte: hypocalcaemia, hypokalaemia, hypomagnesaemia acute myocardial infarction myocarditis hypothermia subarachnoid haemorrhage

Answer 9

Inflammatory arthritis involving DIP swelling and dactylitis points to a diagnosis of psoriatic arthritis

Answer 10

Serositis: pleurisy or pericarditis Oral ulcers Arthritis Photosensitivity Blood: anaemia, leukopenia, lymphopenia and thrombocytopenia Renal disorder: lupus nephritis - minimal mesangial, mesangial proliferative, focal, diffuse, membranous and advanced sclerosis Antinuclear antibody Immunology: anti-Smith, anti-ds DNA and antiphospholipid antibody Neurologic disorder: seizures or psychosis Malar rash Discoid rash

Answer 11

Type Frequency Shape Notes IgG 75% Monomer * Enhance phagocytosis of bacteria and viruses * Fixes complement and passes to the fetal circulation * Most abundant isotype in blood serum IgA 15% Monomer/ dimer * IgA is the predominant immunoglobulin found in breast milk. It is also found in the secretions of digestive, respiratory and urogenital tracts and systems * Provides localized protection on mucous membranes * Most commonly produced immunoglobulin in the body (but blood serum concentrations lower than IgG .) * Transported across the interior of the cell via transcytosis IgM 10% Pentamer * First immunoglobulins to be secreted in response to an infection * Fixes complement but does not pass to the fetal circulation * Anti-A, B blood antibodies (note how they cannot pass to the fetal circulation, which could of course result in haemolysis) Pentamer when secreted IgD 1% Monomer * Role in immune system largely unknown * Involved in activation of B cells IgE 0.1% Monomer * Mediates type 1 hypersensitivity reactions * Synthesised by plasma cells * Binds to Fc receptors found on the surface of mast cells and basophils * Provides immunity to parasites such as helminths * Least abundant isotype in blood serum

Answer 12

A minority of people above 4,000m go onto develop high altitude pulmonary oedema (HAPE) or high altitude cerebral oedema (HACE), potentially fatal conditions HAPE presents with classical pulmonary oedema features HACE presents with headache, ataxia, papilloedema

Answer 13

Prevention and treatment of AMS the risk of AMS may actually be positively correlated to physical fitness gain altitude at no more than 500 m per day acetazolamide (a carbonic anhydrase inhibitor) is widely used to prevent AMS and has a supporting evidence base it causes a primary metabolic acidosis and compensatory respiratory alkalosis which increases respiratory rate and improves oxygenation treatment: descent

Answer 14

descent, dexamethasone

Answer 15

ciprofloxacin, levofloxacin

Answer 16

lower seizure threshold in patients with epilepsy tendon damage (including rupture) - the risk is increased in patients also taking steroids cartilage damage has been demonstrated in animal models and for this reason quinolones are generally avoided (but not necessarily contraindicated) in children lengthens QT interval

Answer 17

women pregnant or breastfeeding

Answer 18

Therefore, only a small list of Gram-positive rods (bacilli) need to be memorised to categorise all bacteria - mnemonic = ABCD L Actinomyces Bacillus anthracis (anthrax) Clostridium Diphtheria: Corynebacterium diphtheriae Listeria monocytogenes Remaining organisms are Gram-negative rods, e.g.: Escherichia coli Haemophilus influenzae Pseudomonas aeruginosa Salmonella sp. Shigella sp. Campylobacter jejuni

Answer 19

Therefore, only a small list of Gram-positive rods (bacilli) need to be memorised to categorise all bacteria - mnemonic = ABCD L Actinomyces Bacillus anthracis (anthrax) Clostridium Diphtheria: Corynebacterium diphtheriae Listeria monocytogenes Remaining organisms are Gram-negative rods, e.g.: Escherichia coli Haemophilus influenzae Pseudomonas aeruginosa Salmonella sp. Shigella sp. Campylobacter jejuni

Answer 20

A patient with persistent AF is one who experiences AF at all times This is defined by the AHA/ACC/HRS guidelines (2014) as ‘continuous AF that is sustained for more than 7 days’ These guidelines also note that some patients in this group can be described as having permanent AF, where a return to sinus rhythm is no longer part of their treatment plan A patient with paroxysmal AF only experiences AF at certain times. At all other times their heart contracts in sinus rhythm This is defined by the AHA/ACC/HRS guidelines (2014) as ‘AF that terminates spontaneously within 7 days of onset’ Most patients in this group have multiple short episodes of AF which may or may not have an obvious trigger Paroxysmal AF can progress to persistent AF over the course of many years. The AHA/ACC/HRS guidelines (2014) note that episodes of paroxysmal AF occur more often and for a longer duration as the condition progresses

Answer 21

Heart Rate >150 bpm Blood Pressure <90 mmHg Syncope or severe dizziness Shortness of breath Chest Pain

Answer 22

Indication: 2014 NICE guidelines recommend that echocardiograms should be used in patients where the investigation may aid in acute or long term management or in whom an underlying cardiac risk factor is suspected. In contrast the 2014 AHA/ACC/HRS guidelines recommend echocardiograms are used in all patients with a diagnosis of AF, but this may not be feasible in many clinical contexts

Answer 23

beta-blockers Non-Dihydropyridine Calcium Channel Blockers such as verapamil and diltiazem NICE (2014) recommend that physicians should decide between these two drugs based on patient factors, such as co-morbidities Digoxin can be used, but NICE (2014) do not recommended its use outside of sedentary patients with non-paroxysmal AF It is important to note that, as mentioned in the AHA/ACC/HRS guidelines (2014) and by Burns (2019), the above drugs as well as amiodarone (which is used for rhythm control) are potentially harmful in those with Wolf-Parkinson-White syndrome and other pre-excitation syndromes in association with AF. As mentioned by Burns (2019), DC cardioversion is generally preferred in these patients in the acute setting, and accessory pathway ablation is recommended by the AHA/ACC/HRS guidelines (2014) as a management option in certain patients NICE CKS (2020) suggest that clinicians aim for a resting heart rate of 60 to 80 in patients taking rate control, going up to 90-115 bpm during exertion If required, NICE BNF (n.d.) advise that rate control can be intensified by using the above drugs in combination but if this is not effective then specialist management under cardiology is warranted In terms of the application of rate control in practice, Gutierrez and Blanchard (2016) note in American Family Physician that rate control is generally used more often than rhythm control, as the constituent drugs have better side effect profiles and there is no need to worry about patients coming out of sinus rhythm, as one would for rhythm control patients

Answer 24

DC Cardioversion, which is the use of electrical stimulation to restore sinus rhythm. NICE BNF (n.d.) note that anti-arrhythmic medication or beta-blocker therapy can subsequently be used to maintain sinus rhythm Amiodarone, which is an antiarrhythmic drug which can restore sinus rhythm on its own. It is suitable in most patients Flecainide, which is an antiarrhythmic drug that can be used in some patients to restore sinus rhythm, but is contraindicated in those with possible structural or ischaemic heart disease NICE BNF (n.d.) notes that all of the above methods must be initiated in secondary care. NICE guidelines (2014) also state that the use of cardioversion is an indication for echocardiogram Patients who are successfully cardioverted are no longer symptomatic but may have a risk of coming out of sinus rhythm and returning to AF. Gutierrez and Blanchard (2016) note that this is can be of concern as maintaining sinus rhythm in certain patients, particularly those over 65, can be a struggle and the medication above can be toxic

Answer 25

Heparin and Low Molecular Weight Heparin (LMWH) are non-oral anticoagulants that are most commonly used in the acute setting over a short length of time or while oral therapy is initiated. Heparin and LMWH are easily cleared by the body, so their anticoagulant effect is lost soon after treatment is stopped Warfarin is an oral anticoagulant used in certain patients. It requires regular INR monitoring because of its various drug and food interactions, which can mean its anticoagulant effect can be unreliable unless monitored closely. AHA/ACC/HRS guidelines (2014) recommend that doses of warfarin are changed based on these results to achieve an INR of 2-3 for most patients without valve disease, although exact targets may vary based on co-morbidities. Warfarin also needs to be prescribed with LMWH until its anticoagulant effect is established, as it is initially prothrombotic Direct Oral Anticoagulants (DOACs) are a group of oral anticoagulants including Rivaroxaban, Apixaban and Dabigatran. They are now some of the most commonly used medications in this group. They have a highly predictable and reliable anti-coagulant effect and therefore require reduced blood monitoring compared to warfarin. They do no need to be prescribed with LMWH, but their action is more difficult to reverse

Answer 26

brain tumours 9.5 idiopathic intranial HTN 1 SAH 4.0

Answer 27

female, obesity, pregnanct

Answer 28

Common symptoms: Headache - 90% The features of headaches in IIH patients are variable and are not specific to IIH. They may be intermittent or persistent, occur daily or less frequently. Nausea and vomiting may occur in association with the headache. Transient visual obscurations - 70% These last seconds at a time and can be bilateral or unilateral. The frequency is variable, ranging from rare or isolated episodes to those occurring several times a day. The visual obscurations may be associated with changes in position (usually standing) or Valsalva May be due to transient optic nerve ischaemia Pulsatile tinnitus - 55% This symptom in association with a headache is very suggestive of IIH. Photopsia - 50% Bright flashes of light that may occur following changes in position, Valsalva, bright light or eye movement. Back pain - 50% Retrobulbar pain - 45%

Answer 29

Papilloedema - 95% Typically bilateral and symmetric, but may also be asymmetric/unilateral. Visual field loss - 95% Typically peripheral , but central visual field can be involved late in the course of disease or earlier if there is concurrent macular disease. 6th nerve palsy Relative afferent pupillary defect

Answer 30

n the assessment of an individual with symptoms and signs of increased intracranial pressure, secondary causes of intracranial hypertension must be considered. All of the following can cause symptoms similar to that of IIH: Intracranial mass lesions (tumor, abscess) Differences Tend to affect children and older adults May cause further focal neurological deficits such as limb weakness/paraesthesia May cause seizures, fluctuating level of consciousness Subarachnoid haemorrhage Differences Usually sudden onset (thunderclap headache) May cause further focal neurological deficits such as limb weakness/paraesthesia May cause seizures, fluctuating level of consciousness Obstruction of venous outflow, eg, venous sinus thrombosis, jugular vein compression, neck surgery Differences Often develops suddenly (thunderclap headache) May cause further focal neurological deficits such as limb weakness/paraesthesia May cause seizures, fluctuating level of consciousness Decreased CSF absorption, eg, arachnoid granulation adhesions after bacterial or other infectious meningitis, subarachnoid hemorrhage Differences Past medical history of infectious meningitis/SAH Malignant systemic hypertension Differences Systemic blood pressure >180/120

Answer 31

Conservative Weight loss: all overweight patients should be prescribed a low sodium weight reduction programme (IIH Treatment Trial). BMJ Best Practice guidelines suggest that overweight patients should aim to lose 5-10% of total body weight. Where possible, potentially causative medications such as tetracyclines, retinoids and thyroid replacement therapies, should be stopped. Regular ophthalmic follow-up with visual field testing is required to assess response to treatment and disease course. Medical Acetazolamide is first-line for all patients with visual loss on presentation Topiramate may be used as an alternative and has the added benefit of causing weight loss in most patients Refractory cases loop diuretics may be used repeated lumbar punctures may be used as a 'holding' measure in refractory cases but are not used longer-term Analgesia: Paracetamol/NSAIDs are recommended first-line for head or back pain. Surgical If patients lose vision in spite of maximal medical therapy, surgical treatment by optic nerve sheath fenestration or CSF shunting can be done. With treatment, there is usually gradual improvement and/or stabilisation, but not necessarily recovery; many patients have persistent papilloedema, elevated intracranial pressure (ICP) and persistent visual field deficits.

Answer 32

The visual field loss is due to post-papilloedema optic atrophy. The peripheries of vision are typically affected first with predominantly nerve fibre bundle type defects. Symptomatic patients with extensive field loss and severe papilloedema should be considered for a surgical procedure emergently. Community and clinic-based studies suggest that permanent severe visual loss occurs in about 10% of patients.

Answer 33

(REH-troh-PAYR-ih-toh-NEE-ul) Having to do with the area outside or behind the peritoneum (the tissue that lines the abdominal wall and covers most of the organs in the abdomen).

Answer 34

such as rifaximin

Answer 35

More than 40% of people with cirrhosis develop hepatic encephalopathy.[7] More than half of those with cirrhosis and significant HE live less than a year.[1] In those who are able to get a liver transplant, the risk of death is less than 30% over the subsequent five years.[1] The condition has been described since at least 1860

Answer 36

Fetor hepaticus or foetor hepaticus (Latin, "fetid liver") (see spelling differences), also known as breath of the dead or hepatic foetor, is a condition seen in portal hypertension where portosystemic shunting allows thiols to pass directly into the lungs. It is a late sign in liver failure and is one of the clinical features of hepatic encephalopathy. Other possible causes are the presence of ammonia and ketones in the breath. The breath has a sweet, fecal smell to it and also described as having the odour of freshly mown ha

Answer 37

The mildest form of hepatic encephalopathy is difficult to detect clinically, but may be demonstrated on neuropsychological testing. It is experienced as forgetfulness, mild confusion, and irritability. The first stage of hepatic encephalopathy is characterised by an inverted sleep-wake pattern (sleeping by day, being awake at night). The second stage is marked by lethargy and personality changes. The third stage is marked by worsened confusion. The fourth stage is marked by a progression to coma

Answer 38

Excessive nitrogen load Consumption of large amounts of protein, gastrointestinal bleeding e.g. from esophageal varices (blood is high in protein, which is reabsorbed from the bowel), kidney failure (inability to excrete nitrogen-containing waste products such as urea), constipation Electrolyte or metabolic disturbance Hyponatraemia (low sodium level in the blood) and hypokalaemia (low potassium levels)—these are both common in those taking diuretics, often used for the treatment of ascites; furthermore alkalosis (decreased acid level), hypoxia (insufficient oxygen levels), dehydration Drugs and medications Sedatives such as benzodiazepines (often used to suppress alcohol withdrawal or anxiety disorder), narcotics (used as painkillers or drugs of abuse), antipsychotics, alcohol intoxication Infection Pneumonia, urinary tract infection, spontaneous bacterial peritonitis, other infections Others Surgery, progression of the liver disease, additional cause for liver damage (e.g. alcoholic hepatitis, hepatitis A) Unknown In 20–30% of cases, no clear cause for an attack can be found

Answer 39

Hepatic encephalopathy may also occur after the creation of a transjugular intrahepatic portosystemic shunt (TIPS)

Answer 40

In the past, it was thought that consumption of protein even at normal levels increased the risk of hepatic encephalopathy. This has been shown to be incorrect. Furthermore, many people with chronic liver disease are malnourished and require adequate protein to maintain a stable body weight. A diet with adequate protein and energy is therefore recommended.[4][9] Dietary supplementation with branched-chain amino acids has shown improvement of encephalopathy and other complications of cirrhosis.[4][9] Some studies have shown benefit of administration of probiotics ("healthy bacteria")

Answer 41

Lactulose and lactitol are disaccharides that are not absorbed from the digestive tract. They are thought to decrease the generation of ammonia by bacteria, render the ammonia inabsorbable by converting it to ammonium (NH4+) ions, and increase transit of bowel content through the gut. Doses of 15-30 mL are typically administered three times a day; the result is aimed to be 3–5 soft stools a day, or (in some settings) a stool pH of <6.0.[4][8][9][17] Lactulose may also be given by enema, especially if encephalopathy is severe.[17] More commonly, phosphate enemas are used. This may relieve constipation, one of the causes of encephalopathy, and increase bowel transit.[4] Lactulose and lactitol are beneficial for treating hepatic encephalopathy, and are the recommended first-line treatment.[4][21] Lactulose does not appear to be more effective than lactitol for treating people with hepatic encephalopathy.[21] Side effects of lactulose and lactitol include the possibility of diarrhea, abdominal bloating, gassiness, and nausea.[21] In acute liver failure, it is unclear whether lactulose is beneficial. The possible side effect of bloating may interfere with a liver transplant procedure if required

Answer 42

The medication midodrine can benefit people with orthostatic hypotension,[30][32] The main side effect is piloerection ("goose bumps").[32] Fludrocortisone is also used, although based on more limited evidence

Answer 43

Headache Tinnitus Changes in vision

Answer 44

is used to assess the prognosis of chronic liver disease, mainly cirrhosis

Answer 45

UDCA has been used as medical therapy in gallstone disease (cholelithiasis) and for biliary sludge.[8][9] UDCA helps reduce the cholesterol saturation of bile and leads to gradual dissolution of cholesterol-rich gallstones

Answer 46

Fragility fracture is a type of pathologic fracture that occurs as a result of an injury that would be insufficient to cause fracture in a normal bone.[2] There are three fracture sites said to be typical of fragility fractures: vertebral fractures, fractures of the neck of the femur, and Colles fracture of the wrist. This definition arises because a normal human being ought to be able to fall from standing height without breaking any bones, and a fracture, therefore, suggests weakness of the skeleton.

Answer 47

Pathological fractures present as a chalkstick fracture in long bones, and appear as a transverse fractures nearly 90 degrees to the long axis of the bone. In a pathological compression fracture of a spinal vertebra fractures will commonly appear to collapse the entire body of vertebra.

Answer 48

Small bowel obstructions are most often due to adhesions and hernias

Answer 49

while large bowel obstructions are most often due to tumors and volvulus

Answer 50

In small bowel obstruction, the pain tends to be colicky (cramping and intermittent) in nature, with spasms lasting a few minutes. The pain tends to be central and mid-abdominal. Vomiting may occur before constipation.[9] In large bowel obstruction, the pain is felt lower in the abdomen and the spasms last longer. Constipation occurs earlier and vomiting may be less prominent. Proximal obstruction of the large bowel may present as small bowel obstructio

Answer 51

Nephrotic syndrome is characterized by large amounts of proteinuria (>3.5 g per 1.73 m2 body surface area per day,[6] or > 40 mg per square meter body surface area per hour in children), hypoalbuminemia (< 3.5 g/dl), hyperlipidaemia, and edema that begins in the face

Answer 52

1. Proteinuria (> 3g/24hr) causing 2. Hypoalbuminaemia (< 30g/L) and 3. Oedema

Answer 53

Primary glomerulonephritis accounts for around 80% of cases Minimal change glomerulonephritis (causes 80% in children, 30% in adults) Membranous glomerulonephritis Focal segmental glomerulosclerosis Membranoproliferative glomerulonephritis Systemic disease (about 20%) Diabetes mellitus Systemic lupus erythematosus Amyloidosis Drugs Gold (sodium aurothiomalate), penicillamine Others Congenital Neoplasia: carcinoma, lymphoma, leukaemia, myeloma Infection: bacterial endocarditis, hepatitis B, malaria

Answer 54

very highh elvels of protein in the urine [proteinuria], low levels protein in the blood, swelling especially around the eyes/feet/hands

Answer 55

A pathologic fracture is a bone fracture caused by weakness of the bone structure that leads to decrease mechanical resistance to normal mechanical loads.[1] This process is most commonly due to osteoporosis, but may also be due to other pathologies such as cancer, infection (such as osteomyelitis), inherited bone disorders, or a bone cyst. Only a small number of conditions are commonly responsible for pathological fractures, including osteoporosis, osteomalacia, Paget's disease, Osteitis, osteogenesis imperfecta, benign bone tumours and cysts, secondary malignant bone tumours and primary malignant bone tumours.

Answer 56

an oral triptan and an NSAID, or an oral triptan and paracetamol

Answer 57

propranolol topiramate: should be avoided in women of childbearing age as it may be teratogenic and it can reduce the effectiveness of hormonal contraceptives amitriptyline

Answer 58

Gender Men are more likely to develop gout. A woman's risk of gout increases following the menopause. Age Most commonly, the first attack of gout occurs between the ages of 30 and 50. Risk increases with age. Diet A diet high in purines includes foods such as meat, seafood and fructose-containing foods. These purines are metabolised to uric acid in the body and so increased consumption of such foods increases the risk of gout. Alcohol - much like diet, the role of alcohol in gout is linked to purine metabolism. Metabolic syndrome Medications associated with increased risk of gout: Loop and thiazide diuretics Low dose aspirin Levodopa Chronic kidney disease Physiologically, the kidneys flush out uric acid. If kidneys are impaired, uric acid will build up in the body. The reverse also happens that persistently high serum uric acid damage the kidneys.

Answer 59

Purines are obtained from the diet. This is why diet plays a large role in management - reduced purines = reduced serum uric acid = reduced risk for gout. Dietary items high in purines include: Alcohol Red meat Organ meat e.g. liver/kidney. Sweetened beverages due to their fructose content (a precursor for purines).

Answer 60

Purines play an important role in serum uric acid balance. They are metabolised into uric acid via a multi-step pathway involving the enzyme xanthine oxidase hence the efficacy of the use of allopurinol (a xanthine oxidase inhibitor) as prophylactic treatment for gout.

Answer 61

In contrast to many forms of arthritis, gout develops rapidly reaching maximal severity within 24 hours, and resolves within 5-15 days. Rarely, gout symptoms may appear gradually. 70% of first presentations involve the first MTP however gout may affect other peripheral joints including: Other joints of the feet, ankle and knee Joints of the hand, wrist and elbow. It rarely affects more central joints such as hip and spine.

Answer 62

Crystals Gout Pseudogout Birefringence Negatively birefringent Positively birefringent Shape Needle shaped Rhomboidal Crystal type Monosodium urate Calcium pyrophosphate

Answer 63

Pseudogout Pseudogout presents very similarly to gout but few clinical features differentiate the two: Pseudogout is more likely to affect larger joints such as the knee . Pseudogout is more likely in the elderly. It typically presents with a less intense pain. Chondrocalcinosis may be identified on x-ray. It is definitively distinguished by rhomboid shaped positively birefringent calcium pyrophosphate crystals in the synovial fluid but often this is not a feasible test.

Answer 64

Chronic gout may be confused with RA despite mono-articular RA being rare. Distinguishing features include: The onset of pain in RA is usually more gradual than gout. Rheumatoid nodules may be present however are easily confused with tophi. If patient experiences recurrent flares, this is more suggestive of gout. Rheumatoid factor may be present in both RA and gout so is not useful to distinguish the two. Anti-CCP is much more specific for RA but has relatively low sensitivity. Synovial fluid analysis would show inflammation in RA but no MSU crystals which would be present in gout.

Answer 65

Management includes: Self-care - patient should be advised to keep joint elevated to reduce inflammation, limit any trauma to joint and keep it cool (consider using an ice-pack) Prescription of either of the first line treatments recommended by NICE: colchicine or NSAIDs such as indomethacin. Choice is based on patient preference, renal function and any co-morbidities. Aspirin is not indicated as it may increase uric acid levels. This is because it prevents excretion of uric acid from the kidneys. Aspirin may be prescribed in cases of cardiovascular disease and stroke as the benefits outweigh the risk of potentially inducing a gout flare. Corticosteroids: A short course of oral corticosteroids such as prednisolone may be used if a patient cannot tolerate NSAIDs. Intra-articular corticosteroids can also be used.

Answer 66

EULAR recommends allopurinol as the first-line urate lowering therapy with target uric acid levels of 360µmol/L or less. It is a xanthine oxidase inhibitor metabolising xanthine to uric acid. This results in reduced deposition of MSU crystals in joints hence the application for gout. It is generally well tolerated but side effects may include: Common side-effects - skin rash (may indicate Stevens-Johnson Syndrome) and joint paint/swelling Rare side effects - drug hypersensitivity syndrome (signs include eosinophilia, lymphadenopathy, fever and multi-organ involvement) *NOTE* Allopurinol should not be commenced during an acute attack as it may worsen it and so should be started 1-2 weeks after an acute attack. As it may also precipitate another acute attack, the British Society for Rheumatology recommends prophylactic colchicine (or NSAID if colchicine not tolerated) should be prescribed alongside for up to six months to avoid this.

Answer 67

Second-line therapy is febuxostat and is used for those who do not tolerate allopurinol. It is a non-purine xanthine oxidase inhibitor. Check liver function prior to commencing treatment.

Answer 68

As mentioned previously, tophi form when MSU crystals deposit to form hard lumps. They can form in tissues, bone and cartilage and if large and painful may impact a patients ability to perform daily tasks. Tophi are usually a sign of chronic gout, their presence indicates that there are likely to be MSU crystal deposits elsewhere in the body. Bone complications Repeated attacks of gout and the presence of tophi all contribute to bone erosion and weakening of joints resulting in degenerative arthritis. In the most serious of cases, surgery will be required to rectify this damage. A 2018 population-based study found that gout conferred a 20% increased risk of osteoporosis. Renal complications Kidney stones may occur due to deposits of MSU crystals in the urinary tract as a result of hyperuricaemia. They can disrupt the flow of urine, cause pain and make the patient more susceptible to an infection of the urinary tract or kidney. Although kidney disease is a risk factor for gout, gout can also cause kidney disease. Although not fully understood, it is believed kidney disease may result due to the passage of MSU crystals through kidneys causing scarring. This scarring then reduces functionality of the kidneys.

Answer 69

IM ceftriaxone 1g

Answer 70

Tumour lysis syndrome (TLS) is a potentially deadly condition related to the treatment of high-grade lymphomas and leukaemias. It can occur in the absence of chemotherapy but is usually triggered by the introduction of combination chemotherapy.

Answer 71

Symptoms Feeling of apprehension or 'something wrong'. Flushing. Chills. Pain at the venepuncture site. Myalgia. Nausea. Pain in the abdomen, flank or chest. Shortness of breath. Signs Fever (rise of 1.5°C or more) and rigors. Hypotension or hypertension. Tachycardia. Respiratory distress. Oozing from wounds or puncture sites. Haemoglobinaemia. Haemoglobinuria.

Answer 72

ncompatible transfused red cells react with the patient's own anti-A or anti-B antibodies or other alloantibodies (eg, anti-rhesus (Rh) D, RhE, Rhc and Kell) to red cell antigens. Complement can be activated and may lead to disseminated intravascular coagulation (DIC). Infusion of ABO incompatible blood almost always arises from errors in labelling sample tubes/request forms or from inadequate checks at the time of transfusion. Where red cells are mistakenly administered, there is about a 1 in 3 risk of ABO incompatibility and 10% mortality with the severest reaction seen in a group O individual receiving group A red cells. Non-ABO red cell antibody haemolytic reactions tend to be less severe but the Kidd and Duffy antigens also activate complement and can cause severe intravascular haemolysis.

Answer 73

Bacterial contamination of a blood component is a rare but severe and sometimes fatal cause of transfusion reactions. Acute onset of hypertension or hypotension, rigors and collapse rapidly follows the transfusion. No UK cases of bacterial contamination of blood products were confirmed by SHOT in 2020[2]. Platelets are more likely to be associated with bacterial contamination than red cells, as they are stored at a higher temperature.

Answer 74

TRALI is a form of acute respiratory distress due to donor plasma containing antibodies against the patient's leukocytes. Transfusion is followed within six hours of transfusion by the development of prominent nonproductive cough, breathlessness, hypoxia and frothy sputum[6]. Fever and rigors may be present. CXR shows multiple perihilar nodules with infiltration of the lower lung fields. Implicated donors are usually multiparous women (who are more likely to have become alloimmunised) and should be removed from the blood panel where possible. Gas exchange was significantly worse after transfusion of female but not male donor blood products in one study of high plasma volume transfusions in the critically ill

Answer 75

Pain in the morning Systemic features Raised inflammatory markers

Answer 76

Due to repeated movement of the fibroelastic iliotibial band Pain and tenderness over the lateral side of thigh Most common in women aged 50-70 years

Answer 77

Caused by compression of lateral cutaneous nerve of thigh Typically burning sensation over antero-lateral aspect of thigh

Answer 78

Diabetes insipidus (DI) is a condition characterised by either a decreased secretion of antidiuretic hormone (ADH) from the pituitary (cranial DI) or an insensitivity to antidiuretic hormone (nephrogenic DI).

Answer 79

high plasma osmolality, low urine osmolality a urine osmolality of >700 mOsm/kg excludes diabetes insipidus water deprivation test

Answer 80

Causes of cranial DI idiopathic post head injury pituitary surgery craniopharyngiomas infiltrative histiocytosis X sarcoidosis DIDMOAD is the association of cranial Diabetes Insipidus, Diabetes Mellitus, Optic Atrophy and Deafness (also known as Wolfram's syndrome) haemochromatosis Causes of nephrogenic DI genetic: more common form affects the vasopression (ADH) receptor less common form results from a mutation in the gene that encodes the aquaporin 2 channel electrolytes hypercalcaemia hypokalaemia lithium lithium desensitizes the kidney's ability to respond to ADH in the collecting ducts demeclocycline tubulo-interstitial disease: obstruction, sickle-cell, pyelonephritis

Wednesday [26/4/23] Flashcards

(104 cards)