1
Q
Acute DKA management
A
A-E, senior, admit
- Fluids resuscitation (0.9% saline)
- Insulin (0.1 unit/kg/hour)
- Potassium and glucose replacement
Monitor - VBG (pH and electrolytes), capillary glucose, capillary ketones
2
Q
DKA diagnostic criteria
A
PH < 7.3
Glucose > 11
Ketones > 3 serum, ++ urine
3
Q
Acute stroke (ischaemic)
A
- A-E, alert stroke team (stroke call)
- CT Head, BP, ECG, bloods (esp. clotting)
- Aspirin 300mg
- Thrombolysis if within 4.5 hours +/- thrombectomy
If > 4.5 hours supportive treatment on specialist stroke ward
4
Q
Acute stroke (haemorrhagic)
A
- A-E, stroke call/senior
- CT head, ECG, BP, bloods (esp. clotting)
- BP control if HTN, aim 130-140
- Reverse coagulation if patient on
- Surgical decompression if severe, else supportive care
5
Q
Acute ACS management - STEMI
A
- A-E, cardio bleep
- ECG, trop, BP, bloods incl. VBG, CXR
- MONA - morphine + anti-emeric , oxygen, nitrate, aspirin 300mg
- Ticareglol 180mg
- PCI or thrombolysis (alteplase, if no PCI)
6
Q
Acute ACS management - NSTEMI
A
- A-E, cardio bleep
- ECG, trop, BP, bloods incl. VBG, CXR
- MONA - morphine + anti-emeric , oxygen, nitrate, aspirin 300mg
- Fondaparinux (LMWH)
- Calculate GRACE score (6 month mortality)
7
Q
How does GRACE score change treatment of NSTEMI patients?
A
GRACE - 6 month mortality score, considered high if > 3%
HIGH - second anti-platelet (ticagrelol), PCI within 72 hours
LOW - can be d/c once stable, likely elective OP PCI
8
Q
Long term post MI management
A
Conservative
- Lifestyle - smoking, diet, activity
- Cardiac rehabilitation programme
Medicine - BADS
Beta blocker
ACEi
Dual antiplatelet - aspirin 75mg (lifelong) + ticagrelol 90mg (1 year)
Statin - high dose
9
Q
Complications of MI
A
DARTH VADAR
Death
Arrythmia
Rupture - V wall, papillary muscle (MR)
Tamponade
Heart failure
Valve disease
Aneurysm of ventricle
Dressler’s syndrome (pericarditis)
thromboEmbolism
Recurrence
10
Q
Acute management of heart failure
A
POD MAN
Position - sit up
Oxygen
Diuretics - furosemide 50mg IV
Morphine
Anti-emetic
Nitrates
11
Q
Long term management of heart failure
A
CONSERVATIVE
- Cardiology MDT
- Lifestyle - smoking, execise
MEDICAL
Treat the underlying cause if possible
- ACEi + beta blocker + loop diuretic if oedema
- Add spironolactone
- Specialist Tx such as ibravadine, sacubitral-valsartan
SURGICAL
- Cardiac resynchronisation
- ICD
12
Q
Interpreting NT pro BNP
A
> 2000 ng/L - 2 week referral to cardio
400-2000 - 6 week referral to cardio
< 400 - unlikely heart failure
13
Q
Acute management of PE
A
A-E assessment, breif history for RF, alert seniors
Calculate wells score
- low - D.Dimer
- high - CTPA
CXR, ECG, BP, bloods incl. clotting
Unstable - thrombolysis with alteplase
Stable - anti-coagulation with apixaban
14
Q
Acute management of asthma
A
A-E
O SHIT ME
Oxygen
Salbutamol nebs
Hydrocortisone
Ipratropium nebs
Theophylline IV
Magnesium sulphate IV
Escalation - intubation and ventilation
15
Q
Acute management of COPD
A
O SHIT
Oxygen - titrate with venturi
Salbutamol nebs
Hydrocortison
Ipratropium nebs
Theophylline
If infection + antibiotics e.g. doxy
If not responding - NIV (BiPaP)
16
Q
When do you use BiPap vs CPAP?
A
Type 1 RF - 1 thing wrong (hypoxic) - CPAP
Type 2 RF - 2 things wrong (hypoxic, hypercapnic) - BiPaP
17
Q
Acute management of pneumothorax
A
A-E assessment
CXR, sats, RR, tracheal deviation, BP
Stop NIV if running and high suspicion of pneumo
Tension - needle decompression 2nd ICS MCL then chest drain
Non tension - assess size of rim of air on CXR, if patient is symptomatic and if primary/secondary
18
Q
Management of a non tension pneumothorax (after A-E)
A
Primary
- < 2cm and no SOB - d/c, repeat CXR in 2-3 weeks
- > 2cm or Sx - needle aspirate
- failure of aspiration - chest drain
Secondary - always admit
- <1cm + no SOB - 24 hours oxygeb
- 1-2cm + no SOB - needle aspiration
- > 2cm, SOB or failed aspiration - chest drain
19
Q
Management of sepsis
A
A-E, senior input
Sepsis 6
Urine output, IV fluids
Blood cultures, IV antibiotics
Lactate (Blood gas), Oxygen
Assess for source - CXR, urine dip, cultures, assess neuro/CNS
20
Q
Management of meningitis and/encephalitis
A
- A-E approach, senior input
- CT head, lumbar puncture
- IV antibiotics (ceftriaxone +/- amoxicillin)
- Anti-viral if ?encephalitis/viral → IV aciclovir
- Sepsis 6 if unstable/septic
21
Q
Long term stroke management (ischaemic specific?
A
Reducing recurrence risk
- CVD RF modification
- look for emboli - ECG and ECHO
- look for carotid stenosis (doppler)
Conservative
- SALT, OT/PT
- lifestyle - smoking, alcohol, etc
Medical
- aspirin 300mg for 2 weeks then life long clopidogrel
- BP control
- high dose statin
- glycaemic control if DM
22
Q
Acute management of upper GI bleed
A
- A-E, if shocked major haemorrhage call
- Fluid resusciation +/- blood
- Fastbleep gastro for endoscopy consideration
- NBM
- IV Abx
- Analgesia + anti-emetic
- Terlipressin if likely/known varicela bleed
- Stengstaken-blakemore if life-threatening
23
Q
Acute management of anaphylaxis
A
- A-E, if stridor - anaesthetics, stop ?offending drugs, IV access
- IM Adrenaline 0.5ml 1 in 1000 (500mcg)
- IV fluids - manage hypotension
- Repeat IM adrenaline if 5 minutes if no change
After 2 doses = refractory - set up IV infusion adrenaline via central line, goes to ITU
24
Q
Acute management of status epilepticus
A
- A-E, start timing, follow status protocol, alert seniors
- Reversible causes - VBG, glucose, blood panel
- 5 minutes - IV lorazepam or buccal midazolam
- After 10 minutes - repeat benzo, ensure ITU/anaesthetics attending
- After another 10 minutes - IV phenytoin + cardiac monitoring
- After another 10 minutes - RSI with propofol, ITU + EEG
25
components of A in A-E
## Footnote
**airway**
* assessment
* talking = patent
* stridor
* sounds of upper airway obstruction
* interventions
* head tilt + chin lift
* jaw thrust
* oro/nasopharyngeal airway
* LMA
* ET/tracheostomy
26
components of B in A-E
## Footnote
**breathing**
* assessment
* RR + sats
* Auscultate, percuss, expansion, trachea
* CXR
* ABG
* interventions
* 15L non-rebreathe mask
* ventilation in severe
27
components of C in A-E
## Footnote
**circulation**
* assessment
* BP, HR
* heart sounds
* fluid status - JVP, mucus membranes, CRT, UO
* ECG
* bloods - VBG + specific for scenario
* interventions
* 2 x large bore IV cannula
* fluid challenge if hypotensive
* blood transfusion if major bleed
28
components of D in A-E
## Footnote
**disability**
* assessment
* capillary blood glucose
* GCS calculation
* Pupils - equal/reactive to light
* CT head if reduced GCS
* intervention
* glucose replacement
* head up, neuro _+_ mannitol for raised ICP
29
components of E in A-E
## Footnote
**exposure/everything else**
* assessment
* limbs - neurovascular status
* skin - rash
* abdo - SNT?
* orifices for other sites of bleeding
30
Acute management of hypoglycaemia
* conscious + moderate - glucogel
* unconscious/severe + IV access - 75ml 10% glucose
* unconscious, no access - IM glucagon
31
acute management of bradycardia with life-threatening signs
1. A-E with IV access, seniors
2. monitor BP, sats + cardiac monitoring, ECG
3. Atropine 500mcg IV - repeat up to 6 doses
4. Transcutaneous pacing or IV adrenaline or IV isoprenaline
5. Transvenous pacing
32
what are the life-threatening signs in arrhythmias?
HISS
* heart failure
* ischaemia (MI)
* shock
* syncope
33
acute management of bradycardia without life-threatening signs
1. A-E approach
2. monitor BP, ECG, sats, cardiac monitoring
3. observe and urgent cardio review
34
what are the shockable rhythms of arrest?
ventricular fibrillation
pulseless ventricular tachycardia
35
what are the non-shockable rhythms of arrest?
PEA
asystole
36
management of **regular narrow complex tachycardia**
no life-threatening features
1. A-E, cardiac monitoring, sats, BP
2. Vagal manoeuvres
3. IV adenosine - up to 3 doses
1. verapamil if asthmatic
4. beta-blocker or verapamil
5. synchronised DC cardioversion
37
management of **regular narrow complex tachycardia**
_with_ life-threatening features
1. A-E, senior support
2. synchronised DC cardioversion
38
management of **narrow complex, irregular tachycardia**
no life-threatening features
1. A-E, senior input, likely AF
2. beta-blocker
1. if evidence of HF - digoxin or amiodarone
3. anticoagulation if \> 48 hours, consider DC if \< 48 for rhythm control
39
management of **polymorphic broad complex tachycardia**
no life-threatening features
1. A-E, senior
2. IV magnesium sulphate
3. assess for reversible causes - drug review, electrolytes
40
management of **broad complex tachycardia**
_with_ life threatening features
* synchronised DC cardioversion
41
management of **regular broad complex tachycardia**
no life-threatening signs
1. A-E, senior input, monitoring
2. 300mg IV amiodarone over 10-20 minutes, then 900mg over 24 hours
3. consider DC cardioversion if no response
via central line
42
ALS algorithm for shockable rhythms
1. Defibrillation shock
2. CPR - 30:2
3. Reassess rhythm
4. Repeat steps 1-3 provided rhythm remains shockable
_Drugs_
* after 3rd shock
* 1mg adrenaline IV/IM
* 300mg IV amiodarone bolus
* after
* continue adrenaline every 3-5 mins
* another 150mg amiodarone after 5th shock
43
ALS algorithm for non-shockable rhythms
1. Start CPR - 30:2
2. Adrenaline 1mg IM - give every other cycle of CPR
3. Atropine 3mg IV if rate \< 60bpm
44
what type of hypersensitivity reaction is asthma?
type 1
45
Ix for diagnosing asthma
* bedside
* Peak flow diary
* sats + RR + resp examination
* bloods - FBC, IgE
* imaging - CXR
* special
* spirometry + bronchodilator - improvement of FEV1 \> 12% or volume \> 200
* FeNO \> 40 parts per billion
46
aims of asthma treatment?
* no daytime symptoms
* no night time waking due to symptoms
* no need for rescue medications
* no attacks
* no limitations on daily activities
* normal lung function
47
CXR features of bronchiectasis
* tram lines
* ring shadows
48
describe the CURB-65 score
* confusion (AMTS \< 8)
* urea ( \> 7)
* respiratory rate (\>30)
* blood pressure (low, SBP \< 90 or DBP \< 60)
* age ( \>65)
49
what are the drugs used to treat TB?
RIPE
rifampicin, isoniazid, pyrazinamide, ethambutol
50
SE of rifampicin
orange secretions e.g. urine
hepatitis
induces liver enzymes
51
SE of isoniazid?
hepatitis
peripheral neuropathy
52
SE of pyrazinamide
hepatitis
photo sensitivity
gout
53
SE of ethambutol
optic neuritis
54
causes of upper lobe fibrosis?
A TEA SHOP
* A - allergic bronchopulmonary aspergillosis
* T - TB
* E - extrinsic allergic alveolitis
* A - ankylosing spondylitis
* S - sarcoidosis
* H - histiocytes
* O - occupation (silicosis, berylliosis)
* P - pneumoconiosis (coal worker's)
55
causes of lower lobe fibrosis
IPAS - BM
* IP - infection, interstitial pneumonia
* A - alpha-1 anti-trypsin deficiency, asbestosis
* S - systemic sclerosis, CTD e.g. RA
* B - bronchiectasis
* M - medications
56
causes of exudative pleural effusion
* Infection
* Malignancy
* Inflammation e.g. RA, SLE, acute pancreatitis
* Pulmonary infarct e.g. secondary to PE
57
causes of transudative pleural effusion
* ↑ capillary hydrostatic pressure
* Heart failure
* ↓ capillary oncotic pressure
* Cirrhosis
* Nephrotic syndrome
* CKD
* GI malabsorption or malnutrition e.g. Crohn's
58
medications that cause fibrosis
BANS ME
* Bleomycin
* Amiodarone
* Nitrofurantoin
* Sulfasalazine
* MEthotrexate
59
PEF criteria for grading asthma attack
* 50-70 = moderate
* 33-49 - severe
* \< 33 - life-threatening
60
who does ABPA tend to effect? what does it lead to?
asthmatics
poor control
61
Allergic bronchopulmonary aspergillosis management
1. oral glucocorticoids
2. itraconazole
62
NICE treatment ladder for asthma (long-term)
1. **SABA**, salbutamol
2. **SABA +** ***_ICS_*** e.g. budesonide
3. **SABA + ICS +** ***_LTRA_*** e.g. Montelukast, PO
4. **SABA + ICS +** ***_LABA_*** (salmeterol) **_+_ LTRA**
* Continue LTRA if responsive
5. Switch LABA/ICS → **maintenance and reliever** **herapy** with low-dose ICS
* **SABA + MART _+_ LRTA**
6. Increase ICS to medium dose - **SABA + MART with medium dose ICS _+_ LRTA**
7. Referral to specialist - biologic, high dose ICS
63
drugs contraindicated in asthma
beta-blockers
NSAIDs
ACEi
adenosine
64
conservative management of COPD
* smoking cessation
* flu + pneumococcal vaccines
* pulmonary rehabilitation/chest physio
65
long term medical management of COPD
* **1st - SABA or SAMA**
* **2nd - _Asthmatic features_ → add** **LABA + ICS**
* **2nd - _No asthmatic features_ → add** **LABA and LAMA**
* if on SAMA → SABA
* **3rd line -** **LAMA + LABA + ICS**
66
what are the asthmatic features of COPD?
PEDS
* PMHx atopy/asthma
* Eosinophils high
* Diurnal variation PEFR
* Steroid responsive before
67
what are the specialist medical interventions for COPD?
* prophylactic antibiotics (azithromycin) - multiple exacerbations/year
* LTOT
68
what is the criteria for LTOT in all resp conditions (COPD, fibrosis)
* non smoker
* PaO2 \< 7.3 kPa on 2 ABG 3 weeks apart
* PaO2 7.3 - 8 kPa with 1 of:
* polycythaemia
* peripheral oedema
* pulmonary HTN
69
what are the surgical options for COPD?
bullectomy
lung volume reduction surgery
70
diagnostic test for pulmonary fibrosis?
high resolution CT
honeycombing
71
management of idiopathic pulmonary fibrosis
**best supportive care pathway,** **respiratory MDT**.
* **Conservative**
* Chest physiotherapy
* Pulmonary rehabilitation
* Smoking cessation
* **Medical**
* Anti-fibrotic - Pirfenidone,
* LTOT
* **Surgical**
* Transplant
72
features of small cell lung cancer
* central
* associated with smoking
* paraneoplastic syndromes - ACTH, lambert-eaton
73
features of squamous cell lung cancer
* associated with smoking
* central tumours
* cavitating lesions
* paraneoplastic - high calcium, PTHrP secreting
74
features of adenocarcinoma of the lung
* non-smokers
* peripherally located
75
investigations for suspected lung cancer
CXR
CT chest
then if confirmed- imaging to stage
76
common pneumonia CAP organisms
* **Streptococcus pneumoniae** (70% of CAP)
* Haemophilus influenzae (2nd most common)
* Morexalla catarrhalis
* Group A streptococci
* Klebsiella pneumoniae
* Staphylococcus Aureus
77
what are the common atypical pathogens of CAP?
* Chlamydia pneumonia
* Mycoplasma pneumoniae
* Legionella
* Chlamydia psittaci
78
what pathogen of pneumonia:
* rusty coloured sputum
* lobar on CXR
* +ve diplococci
s. pneumoniae
79
what pathogen of pneumonia:
* smoking + COPD
* gram -ve cocco-baccili
haemophilus influenzae
80
what pathogen of pneumonia
* following recent viral infection/flu
* cavitation on CXR
* +ve cocci
s. aureus
81
who gets klebsiella pneumonia?
alcoholics and elderly
82
treatment of pneumonia
admit if high CURB
* **medical treatment**
* **Typical CAP**
* Mild → (**_amoxicillin_**_)_
* Moderate-severe → penicillin + macrolide
* **Atypical CAPs**
* generally = clarithromycin or doxycycline
* **supportive treatment**
* Oxygen, IV fluids, Analgesics
* NIV/ventilation
* Drainage of abscess or empyema
83
acute abdomen core principles
NBM
IV fluids
analgesia
antiemetic
Abx (cef + met)
84
investigations for the surgeon
* CT abdo
* FBC + CRP
* U&E, LFTs
* clotting + G&S
* amylase
* calcium
85
definition of AAA?
Abdominal aorta develops a permanent localised dilation of \> 50% of expected artery diameter (\>3cm)
86
cardiovascular RF
* HTN
* Hyperlipidaemia
* Smoking
* Previous CVD disease
* DM
* Male
* Older
87
what conditions in which to screen/consider for CVD RF?
* stroke
* ACS
* AAA/aneurysms
* peripheral vascular disease
* CKD
* DM
88
describe screening for AAA
* **men one off USS at 65**
* women at high risk USS at 70
* (RF - vascular disease, FHx AAA, high risk of CVD)
89
describe the monitoring of AAA
* 3-4.4cm - yearly USS
* 4.4 - 5.4cm - USS every 3 months
90
indications for elective repair of AAA
* symptomatic
* asymptomatic + _\>_ 5.5 cm
* asymptomatic + growing \> 1cm/year
91
acute management of ruptured AAA
1. A-E assessment, major haemorrhage call, vascular
2. CT with contrast, G&S + X-match, IV access + resuscitate
3. permissive hypotension (\< 100mmHg)
4. surgery - open repair usually
92
management of unruptured AAA
* active monitoring
* conservative - stop smoking
* medical - HTN Tx, statin, aspirin
* surgery - EVAR or open procedure
* EVAR for older/frail
* open for younger
93
6 P's of acute limb ischaemia
* Pain - constant, persistent
* Pulseless - ankle pulses absent
* Pallor (or cyanosis or mottling)
* Perishingly cold
* *Paraesthesia* or ↓ sensation or numbness
* *Paralysis* or power loss
94
key vascular investigations
* **bedside**
* vascular examination
* BP, HR
* ECG
* ABPI
* handheld doppler USS
* **bloods**
* FBC, lipids, HbA1c
* clotting
* **imaging**
* doppler USS
* CT angiogram
* digital subtraction angiography
* **special**
* carotid dopplers
95
acute management of acute limb ischaemia
1. A-E, vascular review urgent
2. Limb down (promote blood flow)
3. Heparin IV
4. Assess if salvageable → if yes revascularisation (embolectomy, thrombolysis or bypass)
96
what are the revascularisation options for acute limb ischaemia?
* emboli
* embolectomy (balloon, Fogarty catheter)
* thrombus
* bypass grafting (usually if incomplete occlusion)
* thrombolysis _+_ stent
97
how to assess limb viability in acute ischaemia?
* neurosensory deficit → time critical, late stage ischamia
* paraesthesia + paralysis
* skin appearance
* mottling → suggests non-salvageable
98
options for non-salvageable limbs
* amputation
* palliation - supportive measures until auto-amputation
99
what are the risks of revascularisation?
* reperfusion injury → hyperkalaemia, acidosis, rhabdomyolysis, acute renal failure, sepsis
* compartment syndrome
100
describe IV maintenance fluid guidance
* daily requirements
* water - 30ml/kg/day if fit; 25ml/kg/day if old, kidney or heart failure
* 1 mmol/kg per day of K+, Na+, Cl-
* 50g-100g of glucose each day
101
how you could estimate surface area of burns?
rule of 9s
102
acute management of burns (A-E)
* severe → Burns centre
* **A** - assess for inhalation injury, consider pre-emptive intubation if high risk
* **B** - 100% O2, ABG, check carboxyhaemoglobin levels
* **C -** 2 large bore IV
* routine bloods, G&S, clotting, CK
* aggressive fluid therapy - Parkland's formula, 0.9% NaCl warmed
* IV analgesia (morphine)
* **D** - GCS, temperature (risk of hypothermia), PEARL
* **E** - estimate % burns + wound care
103
describe Parkland's formula for burns fluid resuscitation in adults
* Parklands = fluid volume for 1st 24 hrs after major burns
* Adults - **4mL (Hartmann's) x weight (kg) x % TBSA burned**
* Give 50% calculated in 8 hours post burn and 50% in remaining 16 hours
104
differentials for life-threatening chest injuries
ATOMIC
* airway obstruction
* tension pneumothorax
* open pneumothorax (sucking)
* massive haemothorax
* intercostal disruption + pulmonary contusion
* cardiac tamponade
105
what is the management of variceal bleeding?
* acute upper GI management
* acute specific
* Terlipressin + IV Abx pre-op
* endoscopy - variceal banding, endoscopy ligation, endoscopic injection
* long term
* beta-blocker (propanolol)
* TIPSS procedure
* address chronic liver disease
106
causes of cauda equina syndrome
* disc prolapse (most common, L4/5, L5/S1)
* trauma - #
* malignancy
* infection - discitis, Pott's
* iatrogenic - haematoma after spinal anaesthetic
107
red flags for cauda equina syndrome?
* Bilateral sciatica
* Progressive evolving neurology, rapid
* Saddle anaesthesia
* Urinary symptoms - incontinence, loss of urge or retention
* Bowel symptoms - unable to open bowels, incontinence
108
acute management of spinal compression/CES
1. Urgent **MRI** and urgent referral to **neurosurgery**
2. Pre-op measures → Analgesia + NBM + G&S
3. Catheterisation - prevent post-renal AKI
4. *Metastatic spinal cord compression*
* Dexamethasone 16mg in divided doses PO (high dose corticosteroids) + PPI
109
definitive management of spinal compression/cauda equina syndrome
* **surgical**
* *Surgical decompression* - within 48 hours, laminectomy, posterior decompression
* Radiotherapy _+_ chemotherapy if cancer
* Steroids - if cancer, some inflammation e.g. AS
* **post-operative**
* PT/OT
* treat any underlying/contributive cause
110
causes of encephalitis?
* **infection**
* **viruses** → **herpes simplex virus 1** (most common)
* bacteria - N. meningitides
* fungal
* autoimmune encephalitis
111
cord compression vs cauda equina
differentiating by: tone, power, reflex, clonus, plantars, bowel, bladder and sensation
112
what are the CSF findings in **bacterial** infection?
_variables_: appearance; WCC, protein, glucose
113
what are the CSF findings in **virus** infection?
_variables_: appearance; WCC, protein, glucose
114
what are the CSF findings in **GBS** infection?
_variables_: appearance; WCC, protein, glucose
115
what are the CSF findings in **SAH** infection?
_variables_: appearance; WCC, protein, glucose
116
what are the CSF findings in **TB** infection?
_variables_: appearance; WCC, protein, glucose
117
describe the components of GCS (broad categories + total score) ?
eye - 4
verbal - 5
motor - 6
118
detailed GCS score
119
what are the signs of basal skull #?
* haemotympanum
* "panda" eyes
* CSF leak from ear or nose
* Battle's sign
120
what are the indications for **CT head within _1 hour_ ADULT?**
* consciousness related
* Initial A&E GCS \< 13
* GCS \< 15 at 2 hours after the injury
* injury related
* Suspected open or depressed skull fracture
* Any sign of basal skull #
* concerning neurology
* Focal neurological deficit
* Post-traumatic seizure
* _\>_ 1 episode of vomiting
121
what are the indications for **CT head within _8_ hours in ADULTS?**
* over 65 years
* Hx of bleeding or clotting disorder
* On anti-coagulants
* Dangerous mechanism of injury
* \> 30 minutes retrograde amnesia of events immediately prior to head injury
122
acute management of raised ICP
1. A-E
2. Urgent neurosurgical referral
3. Head up 40 degrees
4. If intubated → hyperventilate (↓ PaCO2 → cerebral vasoconstriction → ↓ ICP)
5. Osmotic agents e.g. mannitol
6. Steroids - if ↑ ICP due to malignancy
123
what are the common organisms of meningitis in **neonates?**
* group B streptococci
* *listeria monocytogenes*
* *Escherichia coli*
124
what are the common organisms of meningitis **overall?**
NHS
* *N. meningitides*
* *H. influenza B*
* *S. pneumoniae,*
125
what are encapsulated bacteria that are clinically important after splenectomy?
NHS
* *N. meningitides*
* *H. influenza B*
* *S. pneumoniae*
126
what are the common organisms of meningitis **older and immunocompromised?**
* *s. pneumoniae*
* *L. monocytogenes*
* *TB*
* gram negative organisms
127
what is the prophylaxis for meningococcal meningitis?
ciprofloxacin to close household contacts
128
what are the causes of spinal cord compression?
* metastatic cord compression (most common)
* lung, breast, prostate
* traumatic
* infective - abscess, TB, discitis
* disc prolapse (rare in upper spine)
129
what # are most commonly associated with compartment syndrome?
supracondylar
tibial
130
key features of compartment syndrome
* pain out of proportion to injury
* sensation of pressure
* paraesthesia
* paralysis of muscle group
131
management of compartment syndrome
1. **Dressing release**
2. Analgesia + urgent T&O/surgery review
3. **Fasciotomy**
4. Monitor for rhabdomyolysis and renal impairment
5. **Surgical intervention** - if frankly necrotic muscle is seen on fasciotomy → debridement _+_ amputation
132
what is the diagnostic criteria of creatine kinase?
5 x the upper limit of normal
133
what are some causes of rhabdomyolysis?
* _Trauma_
* _long lie_ - elderly after falls
* _Ischaemia_ - compartment syndrome, reperfusion
* _Medical causes_ - seizure, infections, metabolic abnormalities
* _Drug induced_ - cocaine, diuretics (severe K+ depletion), statin, anti-psychotics, DDP-4 inhibitors (e.g. sitagliptin)
* _Toxins_ - cyanide, copper, CO
134
management of rhabdomyolysis
1. **IV fluids** + correct electrolyte abnormalities
2. **Urine alkalinisation -** IV sodium bicarbonate
3. **Haemodialysis** - refractory raised K+ or acidosis
* **Helps with ↑ K+ and acidosis**
* **Indicated if anuric with severe acidosis and hyperkalaemia**
135
management of acute alcohol withdrawal?
1. seizure prevention - reducing dose of chlordiazepoxide
2. Wernicke-Korsakoff prevention - IV thiamine
3. screen for liver disease
4. involve alcohol services
136
features of salicyclate/aspirin OD?
* flushed
* fever
* hyperventilation
* _tinnitus_, dizziness
* Respiratory alkalosis → lactic acidosis (mixed pH disturbance)
137
management of salicyclate OD?
* IV sodium bicarbonate
* emergency haemodialysis if life-threatening OD or coma due to OD
138
treatment of opiate OD?
naloxone 400mcg IM/IV
can repeat if unresponsive
139
risks of hepatotoxicity after paracetamol OD?
* enzyme inducing medication (PC BRASS)
* malnourish - anorexia, chronic ETOH
* staggered OD
* delayed presentation
140
what is the management of paracetamol OD?
* N-acetylcysteine
* anti-emetic + fluids, monitor electrolytes + LFTS
* liver transplant - acute liver failure
141
who should get an immediate NAC infusion? what is usually done?
* single OD → bloods at 4 hours, nomogram to see if needs NAC
* immediate NAC at presentation if:
* staggered, unsure of time of ingestion
* high risk of toxicity e.g. alcoholic
142
benzodiazepine antidote
flumazenil
143
management of beta blocker OD
* atropine for bradycardia
* anti-dote = glucagon
144
antidote to digoxin
digifab
145
antidote for ethylene glycol poisoning
fomepizole
146
antidote for local anaesthetic overdose
intralipid
147
management of TCA overdose
* cardiac monitoring - risk of QTc prolongation and ventricular arrhythmias
* sodium bicarbonate
*
148
features + treatment of duct ectasia
* older woman
* characterised by dilation of ducts
* nipple discharge - green/brown
* management
* conservative - reassurance
* surgical - if persistent Sx - duct excision
149
most common type of breast cancer
ductal carcinoma (either in situ or invasive)
150
RF for breast cancer
* genetic - BRCA 1 or 2
* high oestrogen exposure
* nulliparity
* early menarche, late menopause
* COCP/HRT
* PMHx breast, ovarian, endometrial, colorectal cancer
* obesity
151
what is the triple assessment for breast cancer?
1. clinical examination
2. imaging - USS \< 35; mammogram if \> 35
3. histology - FNA or core biopsy
152
what is the screening program for breast cancer?
mammogram every 3 years (2 views) from 50-70
153
general description of cancer treatment
* MDT
* treatment combination based on patient factors, tumour staging and patient wishes
* curative or palliative intent
* conservative - psychological support
* medical - chemotherapy, radiotherapy, immunotherapy
* surgical - resection
154
management of breast cancer
* **general**
* MDT
* **surgical resection**
* wide local excision - if small, localised
* mastectomy
* _+_ axillary LN clearance
* **adjunct treatment**
* radiotherapy
* chemotherapy
* hormonal treatment
* tamoxifen (SERM) if pre-menopausal
* anastrozole (aromatase inhibitor) if post-menopausal
* **reconstruction** - prosthetic or flap
155
complications of mastectomy
* Pain
* Infection
* Bleeding
* Lymphoedema of the arm if axillary clearance conducted
* Phantom breast pain
* Seroma
156
common cause of mastitis/breast abscess?
flucloxacillin
157
management of mastitis
1. anti-pyretic
2. antibiotics - flucloxacillin PO, if severe IV Abx
158
management of breast abscess
1. anti-pyretic
2. antibiotics - flucloxacillin PO, if severe IV Abx
3. needle aspiration - LA, USS, send for MC&S
4. Incision and drainage - if failed multiple aspiration, very large or multi-loculated
159
classification of aortic dissection (stanford)
* **Type A** - dissection of the ascending aorta or arch of the aorta
* Most common
* **Type B** - dissection of aorta distal to the left subclavian aorta (descending)
160
diagnostic test for aortic dissection
CT angiogram
161
acute management of aortic dissection
* A-E assessment, major haemorrhage protocol, vascular referral
* haemodynamically unstable
* theatre - graft or repair
* haemodynamically stable
* type A - surgery, graft repair
* type B - strict BP control (IV labetalol), bed rest, EVAR/open if develop end organ damage
162
RF for aortic dissection
* _HTN_
* _CTD_ (EDS, SLE, Marfan's)
* aortitis
* trauma/iatrogenic
* _cocaine/amphetamines_
* _valvular heart disease_
163
common secondary causes of AF
* ischaemic heart disease
* rheumatic heart disease
* thyrotoxicosis
* pneumonia
* PE
* sepsis
* alcohol
* mitral valve disease
164
investigations for AF
* **Bedside**
* **ECG** - _diagnostic_. Irregularly irregular rhythm, No P waves
* **Bloods**
* Exclude contributing cause - FBC + CRP, TFTs, U&Es
* **Imaging**
* Echocardiogram - structure heart disease
* **Specialist or scoring**
* CHA2DS2-VASc stroke risk score
* ORBIT bleeding risk score
165
what is the CHADsVASc and how to interpret?
* \> 2 F - should be anticoagulated
* \> 1 M - should be
* C - congestive cardiac failure (1)
* H - HTN (1)
* A2 - \> 75 (2)
* D - DM (1)
* S2 - Stroke/TIA (2)
* V- Vascular disease (1)
* A - 65-74 (1)
* Sc - female (1)
166
new-onset AF - guidance for DC cardioversion?
\< 48 hours - can cardiovert
48+ hours - TOE to exclude thrombus + DC _or_ anti-coagulate for 3/52 then elective cardiovert
167
management of AF
* **conservative**
* cardiovascular RF modification
* education about AF + stroke signs
* **medical**
* rate control
* rhythm control
* stroke prevention
* **surgical**
* atrial ablation - refractory, identifiable originating loci
168
detailed medical management of AF?
* **rate control**
* beta-blocker (bisoprolol)
* rate-limiting CCB (verapamil)
* digoxin - if hypotension, heart failure
* **rhythm control**
* elective electrical cardioversion
* pharmacological - flecainide (pill in pocket), amiodarone
* **stroke prevention** - DOAC (apixiban), warfarin + LMWH bridging (always if valvular AF)
169
what is atrial flutter?
* re-entrant atrial tachycardia
* atrial rate 250-320 bpm
* fixed or variable AV condition, narrow QRS
* saw-tooth pattern on ECG
170
management of atrial flutter
* haemodynamically unstable → DC cardioversion
* stable
* rate control - beta-blocker, CCB
* rhythm control - elective cardioversion
* VTE prophylaxis e.g. apixiban
* catheter radiofrequency ablation - 1st line if normal/mild enlarged LA
* pacemaker (atrial if refractory to Tx)
171
causes of high output failure?
anaemia
sepsis
pregnancy
Paget's
hyperthyroidism
172
what is a reduced EF?
\< 45%
173
features of LV heart failure
* pulmonary congestion - SOB, PND, orthopnoea
* hypotension/syncope - low CO
* S3 gallop
* functional MR
174
CXR features of heart failure
* A - alveolar oedema ("batwing" perihilar shadowing)
* B - Kerley B lines, interstitial oedema
* C - Cardiomegaly (\> 0.5)
* D - upper lobe blood diversion
* E - pleural effusions (usually bilateral, transudates)
* F - fluid in the horizontal fissure
175
types of cardiomyopathy
* dilated
* hypertrophic
* restrictive
176
Dilated cardiomyopathy summary
* **description**
* **causes**
* **management**
Dilated cardiomyopathy summary
* **description**- systolic dysfunction, dilation of heart
* **causes** - idiopathy (majority), post-viral, alcoholism, post-partum
* **management**
* symptomatic support + HF management
* ICD if arrhythmias
* heart transplant
177
Ix for cardiomyopathy
* **bedside** - ECG
* **bloods** - NT pro-BNP, lipids, HBA1c, U&Es, FBC
* **imaging** - CXR, echo
* **specialist**
* endomyocardial biopsy
* genetic analysis
* cardiac catheterisation
178
Hypertrophic cardiomyopathy summary
* **description**
* **causes**
* **management**
Hypertrophic cardiomyopathy summary
* **description** - thickened heart tissue, diastolic dysfunction, preserved EF till end
* **causes** - genetic, AD
* **management**
* ICD - high risk of sudden cardiac death
* exercise restriction
* reducing outflow obstruction
* beta-blocker, verapamil
* surgical myomectomy
* alcohol septal ablation
* screening of relatives
179
Restrictive cardiomyopathy summary
* **description**
* **causes**
* **management**
Restrictive cardiomyopathy summary
* **description** - diastolic dysfunction, reduced compliance of heart tissue, RARE
* **causes** - familial, infiltrative (sarcoid, amyloid), storage (haemochromatosis), radiation induced fibrosis
* **management**
* symptomatic + HF
* ICD if arrhythmia
* heart transplant
180
DVT well's score
* 2+ - likely, 1 or less - unlikely.
* Criteria are:
* Active cancer 1
* Paralysis, paresis or recent plaster immobilisation of lower extremities 1
* Recently bedridden for _\>_ 3 days, or major surgery within 3/12 = 1
* Tenderness along deep vein system = 1
* Entire leg swollen = 1
* Calf swelling at least 3 cm = 1
* Pitting oedema = 1
* Collateral superficial veins (non-varicose) = 1
* Previously documented DVT = 1
* An alternative diagnosis is at least as likely as DVT = -2
181
management if high DVT Well's score (\> 2)
* USS to confirm diagnosis within 4 hours
* anticoagulation if +ve USS → DOAC (apixiban), LMWH
* mechanical intervention - thrombectomy _+_ IVC filter only if can't anticoagulate
182
how long to anti-coagulate for in VTE?
3 months if provoked
6 months if unprovoked
183
management if low DVT Well's score
D-dimer test within 4 hours
* If cannot get result within 4 hr → offer interim anticoagulation
* If negative - consider alternative diagnosis
* If positive - offer USS (if within 4 hours) + interim anticoagulation
184
what to do if D-dimer +ve and USS negative in DVT?
stop anti-coagulation
repeat USS in 1 week
185
what is the primary prevention statin choice?
20mg atorvastatin
186
what is the secondary prevention statin of choice?
80mg of atorvastatin
187
indications for amputation
* Death → tissue death most commonly due PAD
* Dangerous → infected or malignancy in limb
* Damage → trauma, burns, frostbite
* Damn annoying → pain, etc, refractory to other treatment
188
what are the types of heart block?
* **first degree** - consistent PR prolongation, no loss of QRS
* **Second degree** - prolonged PR with loss of QRS complexes in a predictable manner
* **Mobitz type 1 -** progressive lengthening of the PR interval until P wave with failed conduction of QRS
* **Mobitz type 2** - intermittent non-conduction of P to QRS with a fixed constant PR interval
* **Third degree** - *complete heart block*, atrial impulses fail to be conducted to ventricles
189
causes of 1st degree heart block?
* athletes - high vagal tone (not pathological)
* acute inferior MI
* electrolyte abnormalities
* meds
190
what medications can cause heart block?
* beta-blockers
* CCB
* digoxin
* amiodarone
191
what is a major cause of second and third degree heart block?
myocardial infarction
192
management of 1st degree heart block?
benign, doesn't require treatment
screen for any underlying cause, if found treat
193
management of second degree heart block
* **Mobitz type 1**
* asymptomatic - no Tx
* symptomatic - most no Tx, ECG monitoring, review medication, consider pacemaker
* **Mobitz type 2**
* pace maker as high risk of complete high block
194
management of third degree heart block
permanent pacemaker
195
what is malignant HTN
> *over 180/120*
196
secondary causes of HTN
* *Renal:* renal artery stenosis, PCKD, CKD
* *Endocrine:* hyperthyroidism, Cushing’s, Conn’s syndrome, pheochromocytoma, acromegaly
* *Cardiovascular:* coarctation of aorta
* *Drugs:* sympathomimetics, corticosteroids, COCP
197
investigations of HTN
* diagnosis
* clinic + confirmed with ambulatory (1st line) or home BP readings
* assess for complications
* urine dipstick - protein
* ECG
* bloods - U&E (renal function), HbA1c (CVD risk), lipids (CVD risk)
* fundoscopy
198
medical management of HTN
199
management of severe HTN (\> 180/120)
* asymptomatic
* urgent assessment for end organ damage - headache, eyes, renal, heart
* initiate oral HTN treatment
* symptomatic
* hospital assessment + admission
* IV labetalol
200
what are the HTN retinopathy stages
1. Silver wiring
2. Silver wiring + **arteriovenous nipping**
3. Silver wiring, arteriovenous nipping, **flame haemorrhages and cotton wool exudates**
4. Silver wiring, arteriovenous nipping, flame haemorrhages, cotton wool exudates + **papilloedema**
201
complications of HTN
* cardiac - HF, coronary artery disease, PVD
* neuro - CVA, HTN encephalopathy
* renal - HTN nephropathy, CKD
* eyes - hypertensive retinopathy
202
Duke's criteria for infective endocarditis
* **major**
* +ve blood cultures (2 +ve, 12 hours apart, different site)
* echocardiogram findings - vegetations
* **minor**
* RF e.g. IVDU
* fever \> 38
* immune complex - haematuria/glomerulonephritis, osler's, roth spots
* embolic phenomena - stroke/PE, splinter, janeway
* +ve echo not meeting criteria
203
pathogens seen in IE
* subacute - Strep. viridans
* acute - S. Aureus, S. epidermis
204
what valves are most common affected in IE?
mitral and aortic, unless IVDU then RH valves
205
management of infective endocarditis
1. **Admit**
2. **A-E**
3. **IV antibiotics -** 4-6 week course, should respond within 48 hours of initiation treatment
4. **Surgical intervention** - severe cases, uncontrolled infection
206
management of stable angina
* **conservative**
* education
* lifestyle and RF modification
* **medical**
* short term nitrate PRN
* anti-anginal medication
* 1st - beta blocker or CCB
* 2nd - ivabradine
* secondary prevention - 75mg aspirin, 80mg statin, HTN management
* **surgical**
* CT angiography 1st line to assess suitability for surgery
* PCI _+_ stenting
* CABG
207
management of intermittent claudication
* **conservative**
* RF - smoking, lifestyle
* **supervised exercise program**
* **medical**
* secondary prevention - 75mg clopidogrel
* vasodilator
* **surgical**
* revascularisation - angioplasty + stenting; bypass
208
what does ABPI tell you?
* high - calcification, seen in DM
* \< 0.9 = PAD
* 0.9-0.8 - mild; 0.8-0.5 - moderate; \< 0.5 - severe/critical
209
what is the management of critical limb ischaemia?
* **urgent referral vascular**
* **medical**
* analgesia
* secondary prevention - clopidogrel
* **surgical**
* revascularisation - bypass
* amputation if gangrene
210
what is rheumatic fever?
Rheumatic fever is a systemic inflammatory condition following group A beta-haemolytic streptococcal infection
211
what is the Jones criteria
Infection + 2 major _or_ 1 major + 2 minor
* Evidence of recent streptococcal infection
* Major criteria
* Arthritis
* Pancarditis
* Sydenham's chorea
* Erythema marginatum
* Subcutaneous nodules
* Minor criteria
* Fever
* Arthralgia - unless arthritis met as major
* ↑ acute phase proteins (ESR, CRP)
* Prolonged PR interval on ECG
212
which valves are most commonly affected in rheumatic fever?
most common = mitral
2nd most common = aortic
213
treatment of rheumatic fever
* eradicate group A beta-haemolytic strep - IV benzypenicillin
* bed rest
* analgesia
* cardiac assessment - may require valve replacement
214
general ulcer management
* treat any underlying contributing cause
* wound care
* treat any complicating infection
* severe wounds - assessment by plastics for ?debridement _+_ grafting
215
features of arterial ulcers
* lower legs, areas of trauma or pressure
* small, deep lesions
* painful
* clear edges
* features of peripheral arterial disease - cold peripheries, thick nails, hair loss, long CRT
216
features of venous ulcers
* gaiter region
* large and shallow
* sloped edges
* sloughing ulcer
* painful
* features of venous insufficiency e.g. varicose veins
217
4 main types of ulcers
* arterial
* venous
* neuropathic
* pressure
218
features of neuropathic ulcers
* bony areas e.g. heel, plantar aspect
* deep, clear edges
* painless
* surrounding features - dry, cracked, insensate, calluses, charcot joint
* associated with peripheral neuropathies (DM, B12)
219
treatment of arterial ulcers
* general ulcer principles
* refer to vascular as sign of critical limb ischaemia
* CVD risk factor modification
* surgery - revascularisation (stenting or bypass)
220
treatment of venous ulcers
* **conservative**
* leg elevation, increased exercise, weight reduction
* **medical**
* general ulcer principles
* compression bandaging - check ABPI first
* **surgical**
* treat concurrent venous insufficiency
221
management of neuropathic ulcers
* wound care
* optimise factors affecting peripheral neuropathy - e.g. glycaemic control in DM
222
causes of aortic regurgitation
* acute
* IE
* aortic dissection
* trauma
* chronic
* rheumatic heart disease
* bicuspid valve
* IE
* CTD
223
key clinical features of AR
* early diastolic murmur, LLSE, expiration
* wide pulse pressure
* collapsing pulse
* LH failure - SOB
224
eponymous signs of aortic regurgitation
* Corrigans - exaggerated carotid
* Quinke's - nailbed pulsation
* De Musset's - head nodding
* Traube's sign - “pistol shot” at femoral
225
investigating valve disease
* **bedside**
* cardio examination, ECG
* **bloods** - FBC, U&E, lipids, glucose
* **imaging** - echo, CXR
* **special** - angiogram if for open repair
226
management of aortic regurgitation
* **conservative**
* RF modification
* regular review by cardio
* **medical**
* reducing afterload → beta-blocker, ACEi, diuretics
* treat underlying cause
* **surgical**
* open aortic valve replacement _+_ aortic root graft
227
general indications for valve replacement (R heart)
* symptomatic
* features of heart failure
* severe valve disease on echo
228
causes of aortic stenosis
* bicuspid valve
* senile calcification
* rheumatic heart disease
229
clinical features of aortic stenosis
* ejection systolic murmur, aortic region, 2nd ICS
* S4
* heaving, non-displaced apex beat
* slow rising pulse, narrow pulse pressure
* quiet S2 (severe)
230
what are the key symptoms of aortic stenosis?
syncope
angina
dyspnoea
231
management of aortic stenosis
* **conservative**
* monitoring, severe 6-12 monthly
* RF modification
* **medical**
* symptomatic treatment if features of HF
* **surgical**
* open aortic valve repair
* TAVI (preferred in older/frail)
232
causes of mitral regurgitation
* acute
* ischaemic - papillary muscle rupture
* IE
* rheumatic heart disease
* chronic
* degeneration of valve (age)
* CTD
* dilated cardiomyopathy
233
clinical features of mitral regurgitation
* pansystolic murmur at the apex, radiate to axilla, expiration
* quiet/soft S1
* parasternal heave
* irregularly irregular pulse
* prolapse - mid-systolic click
234
management of mitral regurgitation
* **conservative**- monitoring and RF
* **medical**
* AF management
* HF management if present
* **surgery**
* valve repair (1st)
* valve repalcement (2nd)
235
causes of mitral stenosis
* rheumatic heart disease (most common)
* mitral calcification
* carcinoid syndrome
236
clinical features of mitral stenosis
* rumbling mid-diastolic murmur over apex, bell, expiration, left lateral
* tapping + non-displaced apex
* parasternal heave
* loud S1
* malar flush
* AF
237
management of mitral stenosis
* **conservative** - monitoring and RF
* **medical**
* manage AF
* consider diuretics (reduce pre-load)
* **surgical**
* transcatheter valvotomy (rheumatic MS)
* mitral valve replacement
238
complications of varicose veins
* bleeding
* superficial vein thrombosis
* skin ulceration
* depression
* reduced QOL
239
RF for varicose veins
* older age
* FHx
* female
* pregnancy
* obesity
* prolonged sitting/standing
* Hx of DVT
240
management of varicose veins
* **conservative**
* reduce standing, elevate stocking, weight loss
* **medical**
* compression stocking
* **interventional**
* radiofrequency ablation
* injection sclerotherapy
* **surgery**
* ligation
* stripping
241
what are the indications for interventional or surgical treatment of varicose veins?
bleeding, symptomatic, venous insufficiency chronic changes, venous ulcers
242
pathology of vasovagal syncope
* neural mediated reflex syncope
* **excessive vagal discharge** causing **reflex bradycardia _+_ peripheral vasodilation**.
243
management of vagal attack
* education about triggers
* if impending syncope → lie down, legs up, volume expansion (more fluids, salt)
* severe/unpredictable → tilt training, isometric counterpressure manoeuvres
244
what is wolff-Parkinson white?
WPW is a syndrome characterised by a congenital abnormality which predisposes to _supraventricular tachycardia_ secondary to an accessory pathway
245
clinical features of WPW
* bundle of kent (congenital)
* syncope, palpitation, dizzy
* short PR
* delta wave on ECG
246
management of WPW
* **acute**
* unstable - cardiovert
* stable - IV adenosine, if feature of flutter amiodarone
* **chronic**
* medication review
* ablation of accessory pathway - radiofrequency or surgical
247
indications for carotid endarterectomy
* Carotid artery disease - in prevention of ischaemia stroke
* Symptomatic carotid stenosis of 50-99%
* \> 50% stenosis and \> 1 TIA in last six months provided stenosis on side accounting for TIA
248
clinical features of cluster headache
* _trigger_ - ETOH, smoking, exercise
* severe, unilateral headache, rapid, clustered, night
* _associated_ - red, teary eye, rhinorrhoea, lacrimation, facial vasodilation
249
management of cluster headache
* **conservative**
* avoid trigger, good sleep hygiene
* **acute**
* high flow O2
* sumatriptan SC
* **long term**
* verapamil
250
what are the types of seizure?
* focal
* simple
* complex - impaired consciousness
* generalised
* absence
* tonic
* myoclonic
* tonic-clonic
* atonic
251
features of temporal lobe seizure
* automatism e.g. lip smacking
* deja vu
* emotional disturbance
* hallucination (sensory e.g. olfactory)
252
features of frontal lobe seizure
motor
jacksonian march, Todd's paresis
253
features of parietal lobe seizures
sensory - tingling, numbness
can develop into motor as electrical activity spreads into frontal lobe
254
management of alzheimer's dementia
* bio
* acetylcholinesterase inhibitor (donepezil)
* NMDA antagonist (memantine)
* psycho
* managing psychological symptoms e.g. mood disturbance
* social
* support at home + carers
* home safety
255
features of Miller Fisher syndrome
ataxia + opthalmoplegia + areflexia
subtype of GBS
256
key features of Guillain-Barre syndrome
* ascending symmetrical paralysis (LMN)
* risk of T2RF
* anti-ganglioside antibodies
* LP - raised protein, normal cell count + glucose
* reduced nerve conduction studies
257
what are the main triggers for GBS?
respiratory or GI infection (Campylobacter, mycoplasma, EBV)
258
management of GBS?
* serial ABG + spirometry for resp. function
* IVIG + plasmapheresis
* ventilation of required
259
causes of horner's syndrome
* central
* stroke, MS, tumour
* pre-ganglionic
* Pancoast, trauma, cervical rib
* post-ganglionic
* carotid dissection, endartectomy, cavernous sinus thrombosis
260
triad of Horner's
* ptosis
* miosis
* anhidrosis
261
what is the genetics of Huntingtons?
trinucleotid repeat (CAG, Chr 4, huntingtin protein)
AD condition
262
what are the clinical features of Huntington?
* choreoathetosis (chorea)
* dementia
* familial condition
263
what are the types of hydrocephalus?
1. **Non-communicating/obstructive** where the flow of CSF is blocked
2. **Communicating** - is an issue with reduced absorption or blockage of the venous drainage system
264
causes of obstructive hydrocephalus
* obstructing tumour or cyst
* congenital
265
causes of communicating hydrocephalus
* infective meningitis
* SAH
* normal pressure hydrocephalus
266
management of hydrocephalus
* medical - acetazolamide (limited use)
* surgical - ventriculo-peritoneal shunt
267
What bleeds in an extradural?
Middle meningeal artery (most common)
268
Key features of extradural
- blood collects between bone and dura - lucid period then reduced GCS - features of raised ICP
269
What is the appearance of an extradural on CT?
Hyperdense biconvex/lentiform haematoma
270
Management of extradural
General principles - A-E - neurosurgery - raised ICP management Definitive - surgery (burr holes, craniotomy) if GCS \< 8, large, midline shift, focal neuro deficits - conservative - everyone else - neurorehab
271
What bleeds in a subarachnoid haemorrhage?
Aneurysm - e.g Berry AV malformations
272
Key features of SAH
- blood accumulating in subarachnoid space - sudden onset thunderclap headache - associated with PCKD
273
Diagnosing SAH
- CT head - blood in SA space often around circle Willis - CT angiogram/DSA - LP 12 hours after Sx onset - xanthochromia
274
Management of SAH
1. A-E, neurosurgical review 2. Nimodipine 4hrl to prevent vasospasm 3. BP control \< 180 systolic 4. Surgical - coiling or clipping of aneurysm 5. Neuro-obs + rehab
275
What is bleeding in a subdural?
Briding veins between cortex and venous sinuses
276
Types of subdural haemorrhage
Acute - \<72hrs, associated with trauma Subacute - 3-20 days Chronic - \> 3 weeks
277
Key features of subdural
* bleeding between dura mater and brain surface
* fluctuating consciousness
* may have long hx
* gait deterioration
* psych symptoms / CI
278
appearance of a subdural haemorrhage on CT?
* crescent shaped
* acute - homogenous hyperdensity
* subacute/chronic - varying density
279
management of subdural haemorrhage
* A-E, neurosurgical review
* anti-convulsant for 1 week (seizure prophylaxis)
* surgical intervention - large, midline shift, neurological deficit
* trauma craniotomy
* burr hole _+_ drain
* conservative otherwise
280
classical migraine features
* unilateral throbbing headache, hours
* aura
* N&V
* photophobia
* phonophobia
* still/reduction in function
281
acute management of migraine
* oral triptan e.g. sumitriptan
* analgesia - OTC
* anti-emetic e.g. metoclopramide
282
long term management of migraine
* **conservative**
* trigger avoidance
* OCP CI (meds r/v)
* **medical**
* indicated - multiple episodes in month
* 1st line - propranolol (F), topiramate
* 2nd - amitriptyline
283
what is motor neurone disease
Motor neurone disease refers to a spectrum of heredodegenerative disease of the peripheral and central motor neurones
has UMN and LMN features
284
what are the 4 types of MND?
* amyotrophic lateral sclerosis
* bulbar amyotrophic lateral sclerosis
* progressive muscular atrophy
* progressive lateral sclerosis
285
what is the most common form of MND?
amyotrophic lateral sclerosis
286
key features of bulbar amyotrophic lateral sclerosis
* early bulbar involvement
* dysarthria, dysphagia, wasted fasciculation tongue
* poor prognosis
287
investigations for MND
* **bedside** - neuro examination
* **bloods** - CK, ESR, anti-ganglioside AB (Exclude GBS)
* **imaging** - MRI head and spine
* **special**
* nerve conduction studies
* spirometry
288
management of MND
* neurology MDT
* **conservative**
* PT/OT
* education
* psych
* **medical**
* _riluzole_
* respiratory support e.g. NIV
* symptom management
* cramps → quinine
* spasticity → baclofen
* pain Tx
289
what is the medication used to treat/prolong life in MND?
riluzole
290
what is MS?
MS is an autoimmune condition whereby T cell mediated immune response leads to discrete areas of demyelination within the CNS.
291
what are the types of MS?
* Relapsing-remitting - 80% at PC
* Primary progressive
* Progressive-relapsing disease
* Secondary progressive
292
what criteria is used to diagnose MS?
McDonald
293
what investigations for MS?
* **bedside** - neuro + eye exam
* **blood** - exclude other causes
* **imaging**
* MRI brain + spine with contrast (plaques of demyelination)
* **special**
* LP - IgG oligoclonal bands, electrophoresis
294
management of acute MS relapse?
1. high dose glucocorticoids
2. plasma exchange if no response to steroids
295
long term management of MS
* MDT neuro
* **conservative**
* PT/OT, psych, education
* **medical - disease modifying**
* beta-interferon (glatiramir) - 1st line
* biologic - natalizumab
* **medical - symptoms**
* spasticity - baclofen
* clonazepam - tremor
* anti-cholinergic/catheter = bladder dysfunction
296
what is the 1st line disease modifying drug for MS?
beta-interferon (glatiramir)
297
what is a biologic used in MS?
natalizumab
prevents migration of leucocytes over BBB by blocking receptor
298
what are the key Ab in myasthenia gravis?
anti-acetylcholine receptor Ab
299
what is myasthenia gravis associated with? how to assess?
thymoma
CT chest
300
what are complications of myasthenia gravis?
* myasthenic crisis (respiratory failure)
* reduced QOL
301
how to differentiate myasthenia gravis from lambert eaton?
MG - worse with repetition
LE - better with repetition
302
management of acute myasthenia gravis crisis
1. A-E
2. serial FVC monitoring _+_ ventilatory support
3. steroids
4. IVIG or plasmapheresis if severe/steroid unresponsive
303
long term management of myasthenia gravis
* thymectomy if thymoma +
* anti-cholinesterase inhibitor - **pyridostigmine**
304
core features of parkinson's
rest tremor
rigidity
bradykinesia
postural instability
305
what are the parkinson plus syndromes?
* progressive supranuclear palsy - impaired downgaze
* multiple system atrophy - autonomic + cerebellar signs
* corticobasal degeneratoin
* lewy-body - fluctuating consciousness, hallucination
306
what is the underlying issue in parkinsons (pathology)
loss of DA neurons in substantia nigra
307
medical management of parkinson's disease
* Levodopa + COMT inhibitor
* inhibitor - prevent peripheral metabolism
* Levodopa - boost DA levels
308
key features of tension headache
* mild
* bilateral, non pulsatile headache
* tight band
* often end of day/associated with stress
309
management of tension headache
* OTC pain relief - advice r.e. overuse
* stress management
* reassure benign condition
310
TIA vs stroke?
TIA refers to focal neurology which resolves with no evidence of infarct on scans (MRI)
311
what are the Ix for TIA
* **bedside**
* neuro exam + cardio
* BP
* ECG
* **bloods**
* FBC, U&E, LFTs, lipids, glucose
* **imaging**
* CT head (acute, current neurology)
* diffusion weight MRI - assess for ischemia
* carotid USS
312
what is the initial management of TIA?
* 300mg aspirin
* referral
* ongoing neuro Sx → A&E
* TIA in last 7 days → TIA clinic within 24 hours
* TIA \> 7 days → TIA clinic within a week
313
long term management of TIA
* CVD risk reduction
* anti-platelet - clopidogrel
* treat AF if present
* consider carotid endarterectomy
314
key features of trigeminal neuralgia
* severe sharp pain in trigeminal distribution
* unilateral
* triggers - light touch, wind, shaving
315
what is the treatment for trigeminal neuralgia?
* **medical**
* 1st line - carbamazepine
* **surgical**
* microvascular decompression
316
what is Wernicke's encephalopathy?
triad of: mental status change + ophthalmoplegia + gait dysfunction
317
what causes Wernicke's encephalopathy?
B12 deficiency
318
what is the management of Wernicke's encephalopathy
* acute
* IV pabrinex (thiamine)
* long term
* reduce drinking if alcoholic
* manage liver disease if present
319
definition of achalasia
oesophageal motility disorder of impaired muscle activity leading to failure/incomplete relaxation of the lower oesophageal sphincter
320
gold standard test for achalasia
oesophageal manometry
* shows:
* Absence of oesophageal peristalsis
* Failure of relaxation of lower oesophageal sphincter
* High resting lower oesophageal sphincter tone
321
management of achalasia
* **conservative**
* reflux management strategies
* nutritional support if required
* **medical**
* botulinum toxin injection
* CCB/nitrates - short lasting effect
* **surgical**
* oesophageal endoscopic balloon dilatation
* Heller's myotomy - division of lower oesophageal sphincter
322
stages of alcoholic liver disease
fatty liver → alcoholic hepatitis → alcoholic cirrhosis
323
what LFT would suggest alcoholic liver disease?
* **LFTs** - ↑ AST + ALT, **_AST:ALT \> 2_** → indicative of alcoholic liver disease; ↓ albumin
* **GGT** - ↑↑
324
what is seen on biopsy of alcoholic liver disease?
* centrilobar hepatocyte balooning
* Mallory-Denk bodies (mallory-hyaline inclusion)
* evidence of inflammation and fibrosis
325
management of alcoholic liver disease
* **acute**
* acute withdrawal - chlordiazepoxide + pabrinex
* manage liver decompensation as appropriate
* **conservative**
* reduce ETOH
* **medical**
* *prednisolone*
* **surgical**
* liver transplant - abstinent for 3/12
326
causes of anal fissure
* primary
* secondary
* constipation
* IBD
* STI
* rectal malignancy
* birth
327
management of anal fissure
* **conservative**
* high fibre diet + good hydration
* **medical**
* laxatives - bulk forming (ispaghula husk)
* local anaesthetic ointment
* GTN ointment if \> 1 week + no improvement
* Topical 2% diltiazem, specialist guidance
* **surgical**
* lateral sphincterotomy - unresponsive to medical Tx
328
management of anal fissure
* **conservative**
* high fibre diet + good hydration
* **medical**
* laxatives - bulk forming (ispaghula husk)
* local anaesthetic ointment
* GTN ointment if \> 1 week + no improvement
* Topical 2% diltiazem, specialist guidance
* **surgical**
* lateral sphincterotomy - unresponsive to medical Tx
329
what are the signs associated with appendicitis?
* periumbilical pain → RIF
* **Rovsing's sign** - palpation of LIF produces pain in RIF
* **Psoas sign** - RIF pain with extension of right hip
* **Cope sign** - pain on flexion + internal rotation of hip (occurs if appendix near obturator internus)
330
differentials for appendicitis?
* Gynae - ovarian cyst accident, ectopic, PID
* Renal - ureteric stone, UTI
* GI - obstruction, strangulated hernia, IBD
* Urological - testicular torsion, epididymo-orchitis
* Other - DKA, pneumonia, porphyria
331
what score is used for appedicitis?
Alvarado
332
what is the management of appendicitis?
* **Medical**
* Septic 6 - if required
* IV antibiotics - cefuroxime, metronidazole
* NBM + IVF + analgesia + anti-emetic
* **Surgery**
* Laparoscopic appendicectomy (1st line)
333
antibodies associated with autoimmune hepatitis
* type 1 - anti-smooth muscle Ab, ANA
* type 2 - anti liver/kidney microsomal Ab type 1
334
what are the nerves for the ankle reflex?
**S1**/S2
335
nerves for patella reflex?
L3/L4
336
nerve for triceps reflex?
**C7**-C8
337
nerve for biceps reflex?
C5/**C6**
338
supinator reflex (brachioradialis) nerve root
C5/**C6**
339
management of autoimmune hepatitis
* **Medical**
* Induction → _steroids_
* Maintenance therapy → _azathioprine_
* _Vaccinate_ against hepatitis A and B, test prior to vaccination
* surveillance for HCC → USS + serum AFP
* **Surgical**
* _Liver transplant_ - terminal stages, recurrence after transplant occurs in some
340
what is Barret's oesophagus?
Barrett's oesophagus refers metaplasia of squamous epithelium to columnar epithelium following chronic acid exposure
341
Ix for Barret's
* Gi examination
* H. pylori testing
* endoscopy + biopsy - _histological diagnosis_
342
complications of Barret's oesophagus
Oesophageal adenocarcinoma, oesophageal stricture
343
management of Barret's oesophagus
* **Conservative -** all
* ↓ ETOH intake, normal weight
* meds r/v - ↓ gastric protection or affecting oesophageal motility
* Reflux prevention
* **No dysplasia**
* Endoscopy every 2-5 years
* **Low grade dysplasia**
* High dose PPI (BD)
* Endoscopic surveillance every 6/12, quandrantic biopsies every 1cm
* **High grade dysplasia**
* Endoscopy every 3/12
* Treat any visible lesions → resection (photodynamic, radiofrequency or laser)
344
what is cholangiocarcinoma?
* cancer of biliary tree - usually extrahepatic
* most common at bifurcation of hepatic duct
* 95% adenocarcinoma
345
what is the tumour marker for cholangiocarinoma?
CA19-9
346
management of cholangiocarcinoma
* **Management under MDT**
* **_Curative treatment_**
* **Surgical**
* **Complete surgical resection** - gives definitive treatment
* Intrahepatic and tumours at hepatic bifurcation → *partial hepatectomy and reconstruction of biliary tree*
* Distal common duct tumours - *pancreaticoduodenectomy* (Whipple's procedure)
* **Radiotherapy**
* **_Palliative treatment_**
* ERCP stenting - dilate bile duct to relieve obstruction
* Surgical bypass procedures
* Chemotherapy
347
what is cirrhosis?
Cirrhosis refers to the diffuse fibrosis and structural abnormality of liver characteristic of chronic liver disease
* impairment of Liver function
348
major causes of cirrhosis
Alcoholic liver disease
* Non-alcoholic fatty liver disease
* Chronic viral hepatitis
* Autoimmune hepatitis
* Biliary causes - PBC, PSC
* Genetic causes - haemochromatosis, Wilson's disease, alpha-1 antitrypsin deficiency,
* Medications
* Budd-Chiari syndrome
349
liver panel bloods
* LFTs
* bone profile + albumin
* FBC + clotting
* U&E - hepatorenal
* cause:
* viral hepatitis serology
* iron studies
* auto-antibodies - smooth muscle, anti-mitochondrial, etc
* aceruloplasmin
* alpha-1 anti-trypsin
350
what are the components of the Child Pugh score?
* Albumin
* Bilirubin
* Clotting - PT/INR
* Distended abdomen - Ascites
* Encephalopathy
graded A-C with C most severe, high risk for variceal bleed if B/C
351
what is coeliac disease?
T cell mediated inflammation AI disease due to sensitivity to gluten components (prolamin) resulting in villous atrophy + malabsorption
352
investigations for coeliac disease
* **bedside**
* stool MC&S - exclude infection
* **bloods**
* total IgA
* IgA anti-TTG, and IgA anti-endomysial
* FBC, U&E/bone profile, LFT, iron, B12, folate
* **imaging**
* **specialist**
* jejunal/duodenal biopsy - villous atrophy, crypt:villous ratio \< 2:1
353
what are the biopsy features of coeliac?
* villous atrophy, ↑ intraepithelial lymphocytes, crypt hyperplasia
* ↓ crypt: villous ratio ( \< 2:1)
354
what do patients going for endoscopy for coeliacs need to do?
eat gluten for 6 weeks
355
management of coeliac
* **conservative**
* **gluten exclusion**
* **medical**
* screening for other AI disease
* management malnutrition complications e.g. Fe2+ supplements
356
what cancer is coeliac a RF for?
T cell lymphoma (enteropathy associated T cell lymphoma)
357
what are the familial syndrome associated with colorectal cancer?
* familial adenomatosis polyposis - APC gene
* Gardner's
* Peutz-Jegher's
* hereditary non-polyposis colorectal cancer (NPCC/Lynch syndrome)
358
what runs through the cavernous sinus?
* Abducens nerve (CN VI)
* Carotid plexus (post-ganglionic sympathetic nerve fibres)
* Internal carotid artery (cavernous portion)
359
what runs lateral to the cavernous sinus?
* Oculomotor nerve (CN III)
* Trochlear nerve (CN IV)
* Ophthalmic (V1) and maxillary (V2) branches of the trigeminal nerve
360
investigations for colon cancer?
* **bedside**
* GI examination + DRE
* faecal immunohistochemistry test
* **bloods**
* CEA - tumour marker
* routine
* **imaging**
* barium enema - apple core stricture
* CT colonoscopy - if unable to do actual
* Staging CT (CAP)
* **specialist**
* colonoscopy + biopsy = gold standard for diagnosis
361
what is the tumour marker for colon cancer?
carcinoembryonic antigen (CEA)
362
describe the 2WW for colorectal cancer
* _\>_ 40 + unexplained weight loss + abdominal pain
* _\>_ 50 + unexplained PR bleeding
* _\>_ 60 with IDA or changes in bowel habit
* +ve occult blood in faeces
363
describe the screening for colorectal cancer
* Kit sent at: 56 years, then every 2 years from 60-74
* Colonoscopy if +ve
* ↓ risk of dying from bowel cancer by 16%
* Offer another FIT to those with PR bleeding, IDA, CIBH who don't meet 2WW
364
describe the Duke's criteria for colorectal cancer
365
what is the management of colorectal cancer?
* **Management under MDT**
* **curative**
* **surgery → Resection**
* Type of surgery is depending on region affected by malignancy
* **_+_ chemotherapy** (before or after depends on staging)
* **_+_ neoadjuvant radiotherapy** - _rectal_ cancers
* **Non-surgical treatments**
* FOLFOX or FOLRIR chemotherapy regime - unsuitable for surgery
* Stenting - palliative procedure for symptomatic relief
366
what are the surgeries for colorectal cancer?
* _No rectal-disease_
* Right hemicolectomy - caecum + ascending colon
* Left hemicolectomy - distal transverse colon descending colon
* Sigmoid colectomy - sigmoid colon
* _Rectal disease_
* Anterior resection - tumour \> 8cm from anal canal or involving proximal 2/3 of rectum
* Abdomino-perineal resection - tumour \< 8cm from anal canal or involves distal 1/3 of rectum
367
key histological features of Crohn's
* transmural inflammation
* goblet cells
* non-caseating granulomas
368
features of crohn's
* mouth → anus
* skip lesions
* bowel obstruction
* fistula
* usually non bloody diarrhoea
* arthritis
* erythema nodosum
* pyoderma gangrenosum
369
features of UC
* continuous disease
* no inflammation beyond submucosa
* crypt abscess
* bloody diarrhoea
* PSC
* uveitis
* colorectal cancer
* erythema nodosum
* pyoderma gangrenosum
370
what is the genetic link with crohn'?
CARD15
371
Ix for Crohn's
* **bedside**
* GI examination + PR
* faecal calprotectin
* **bloods**
* FBC, CRP, ER, LFT, bone, TPMT
* **imaging**
* CT abdomen
* **specialist**
* ileocolonoscopy + biopsy - gold standard Dx
372
management of Crohn's
* **conservative**
* smoking cessation
* education + IBD nurse, nutrition
* **medical**
* remission - corticosteroids
* maintenance (\>2/yr) - azathioprine, methotrexate
* biologic - TNF-alpa (infliximab)
* symptomatic Mx
* **surgical**
* resection _+_ stoma as required
373
treatment of pyoderma gangrenosum?
topical or systemic steroids
ciclosporin if resistant
374
types of diverticular disease
* diverticula - outpouching of gut wall
* diverticulosis - asymptomatic
* diverticular disease - symptomatic
* diverticulitis - inflammation _+_ bleeding
375
RF for diverticulitis
older age, low dietary fibre, obesity
376
complications of diverticulitis
* recurrence
* perforation
* haemorrhage
* abscess
* stricture/obstruction
* fistula
377
management of diverticulosis?
high fibre diet + fluid intake
laxatives if ongoing constipation
378
management of diverticular disease
* high fibre diet
* bulk forming laxatives
* analgesia
* anti-spasmodic - relief cramping if required
379
management of diverticulitis
* admission if severe
* antibiotics
* co-amoxiclav (IV or PO)
* cef + met IV (2nd)
* transfusion if required
* angiography + embolectomy for haemorrhage if distal branch
* surgical
* Hartmann's - emergency
* resection _+_ stoma elective
380
what are the types of gallstone?
* **cholesterol** (90%)
* **pigment** - associated with haemolysis
* **mixed stones**
381
RF for gallstone disease
fat, fair (Caucasian), fertile, forties, female, FHx
382
management of biliary colic
1. Analgesia
2. Lifestyle advice - Low fat diet, maintain normal weight, ↑ exercise
3. Elective laparoscopic cholecystectomy - within 6 weeks of 1st PC
383
acute cholecystitis vs ascending cholangitis
* acute cholecystitis - no jaundice
* ascending cholangitis - jaundice, transaminases deranged, CBD obstruction
384
what is mirizzi syndrome?
stone in Hartmann's pouch of gallbladder or in cystic duct → can compressed adjacent common hepatic duct causing an obstructive jaundice despite no stone in the CBD
385
what is gallstone ileus?
after formation of a cholecystoduodenal fistula → gallstone passes into bowel and impacts terminal ileum → small bowel obstruciton
386
what are features of mild vs moderate vs severe cholecystitis
* **mild** - stable, short Hx
* **moderate** - majority, raised WCC, palpable mass in RUQ, \> 72hrs, localised inflammation
* **severe** - resistant hypotension, lowered GCS, oliguria, hepatic dysfunction, hypoxia
387
management of mild cholecystitis
* oral antibiotics
* analgesia (OTC)
* early laparoscopic cholecystectomy - 1 week within 1st PC
388
management of moderate cholecystitis
* A-E + admit + general surg. pt Tx
* IV antibiotics
* laparoscopic cholecystectomy - within 1 week (NICE)
* percutaneous cholecystostomy - IR, unfit for surgery + not responding to Abx, drain insertion + delayed cholecystectomy (6 weeks)
389
management of severe cholecystitis
* as moderate _+_ ICU
* more likely for drain + delayed cholecystectomy
* open cholecystectomy if: mass, sig. inflammation or bleeding, pregnant
390
major organisms of ascending cholangitis?
E. coli, klebsiella, enterococcus
391
what is Charcot's triad? what for?
RUQ pain + fever + jaundice
ascending cholangitis
392
management of ascending cholangitis
* A-E, resuscitation
* IV antibiotics
* ERCP (1st line)
* percutaneous transhepatic cholangiography - T-tube for drainage (2nd)
* cholecystectomy - definitive
393
indications for ERCP
* Choledocholithiasis
* Acute pancreatitis
* Chronic pancreatitis (dilatation or stent placement)
* Lesion within biliary system that requires biopsy
* Dilatation of benign stricture
* Manometry reading for sphincter of Oddi dysfunction
394
types of gastric cancer
* adenocarcinoma (95%)
* intestinal type - smoking, chronic gastritis, lesser curve
* diffuse type - signet cell CA, leather bottle stomach
* SCC
* lymphoma/MALT - H.pylori
395
what are some associated conditions with gastric cancer
* GI - pernicious anaemia, H. pylori, atrophic gastritis, adenomatous polyps
* blood group A
* smoking
* diet - high nitrates, high salt, low Vit C
* nitrosamine exposure
396
where does gastric cancer usually affect?
antrum
397
investigations for gastric cancer
* **bedside**
* GI examination
* **bloods**
* FBC, LFTs
* **imaging**
* endoscopic USS - assess depth
* CT CAP
* **specialist**
* gastroscopy + biopsy
398
2WW for gastric cancer
2WW appointment:
* Upper abdominal mass
Urgent upper GI endoscopy with 2/52 if:
* Dysphagia
* _\>_ 55 + weight loss + one of: upper abdominal pain, reflux, dyspepsia
399
management of gastric cancer
* MDT
* surgical
* early T1a - endoscopic mucosal resection
* locally invasive - partial/total gastrectomy + reconstruction _+_ neoadjuvant chemo
* medical - nutritional
* palliative - majority by time diagnosed
400
causes of GORD
* Lower oesophageal sphincter incompetence
* Hiatus hernia
* Loss of oesophageal peristaltic function
* obesity
* _Gastric factors_ - gastric acid hypersecretion, slow gastric emptying
* _Patient factors_ - smoking, alcohol, pregnancy
* medications (TCA, anti-cholinergic, nitrates)
* _Associated conditions_ - systemic sclerosis, H. pylori infection
401
Ix for GORD
* **bedside**- GI exam
* **bloods** - FBC
* **imaging**
* **specialist**
* endoscopy (OGD) + biopsy
* H. pylori (urea breath, stool antigen)
* barium swallow - if ? hernia
* 24 hour pH monitoring - gold standard, uncommon
402
management of GORD
* **conservative**
* medication r/v
* raise bed
* smoking cessation, low fat, smaller meals
* avoid triggers
* **medical**
* acute - anti-acid, alginate
* PPI
403
management of dyspepsi
* dyspepsia = reflux, no OGD, clinically diagnosed
* review meds
* trial full dose PPI 4 weeks or “test and treat” H. pylori
* treatment resistant → non urgent OGD
404
what should be done after H. pylori eradication treatment in ulcer patients?
test of cure 6-8 weeks after treatment
405
what is the treatment of H. pylori
* PPI + amoxicillin + clarithromycin/metronidazole BD 7 days
* pen allergic = PPI + clarithromycin + metronidazole BD 7 days
406
management of GORD
* reflux + histological Dx after OGD
* full dose PPI 4-8 weeks
* recurrent → high dose PPI
* refractory + sever → Nissen fundoplication
407
treatment of C. Diff
* 1st line - oral vancomycin 10/7 or oral fidaxomicin
* 2nd line - oral vancomycin _+_ IV metronidazole (1st if severe, life-threatening)
408
key facts of haemochromatosis including issue
* hereditary, AR
* increased intestinal iron absorption → iron overload
* HFE C282Y Chr 6
409
key Ix for haemochromatosis
* FBC
* iron studies - raised ferritin, transferrin saturation, low transferrin, low TIBC
* LFTs - deranged
* CRP - exclude acute ferritin
* HbA1c, hormone levels
410
complications of haemachromatosis
* Liver fibrosis, cirrhosis, hepatocellular carcinoma
* Severe myocardial siderosis, cardiac dysfunction
* DM
* Skin hyperpigmentation
* Arthropathy
411
management of haemochromatosis
* venesection - 500mg (450mg iron) 1-2 x week; aim ferritin \< 50 ug/L
* desferrioxamine
* liver transplant
* screening for HCC, monitor ferritin levels
412
what are the types of haemorrhoid?
internal - above dentate
external - below dentate line
413
what are the grades of haemorrhoids?
1. Project into lumen of canal but don't prolapse
2. Prolapse on straining but spontaneously reduce
3. Prolapse on straining, require manual reduction
4. Prolapsed and incarcerated, cannot be reduced
414
what is the management of haemorrhoids?
* **conservative** - minimise straining, fibre + fluid
* **medical**
* laxative
* analgesia - LA + steroid
* **minor procedure**
* rubber band ligation
* injection sclerotherapy
* photocoagulation
* **surgical**
* haemorrhoidectomy
415
RF for hepatocellular carcinoma
* hep B and hep C - chronic
* alcoholism
* haemochromatosis
* PBC
* aflatoxins
* cirrhosis
416
Ix for hepatocellular carcinoma
* LFT
* clotting
* liver screen
* AFP
* abdominal USS + biopsy
417
tumour marker for hepatocellular carcinoma
alfa-fetoprotein
418
how to differentiate groin hernia using pubic tubercle?
superior + medial → inguinal
inferior and lateral → femoral
419
hernia superior + medial to pubic tubercle
inguinal
420
hernia inferior and lateral to pubic tubercle
femoral hernia
421
differentiating inguinal hernias related to inferior epigastric vessels
direct = medial
indirect = lateral
422
differentiating indirect vs direct clinically
pressure on deep inguinal ring and assess cough impulse
* direct = protrudes
* indirect - no protrusion
423
descriptions of hernia
* **Reducible hernia -** uncomplicated
* **Irreducible or incarcerated** - contents of hernia cannot be returned to their original cavity
* **Obstruction** - bowel lumen becomes obstructed
* **Strangulated** - compression of hernia which cannot be reduced leads to blood supply compromise, leading to the bowel becoming ischaemia
424
RF for femoral hernia
female, pregnancy, raised intra-abdominal pressure, older age
425
RF for inguinal hernia
male, increasing age, raised intra-abdominal pressure, obesity
426
management of inguinal hernia
* **non-surgical/conservative**
* small + no sx → watchful wait
* RF modification
* **surgical**
* open mesh repair - primary unilateral
* laparoscopic repair - bilateral, recurrent, primary unilateral, female
427
management of femoral hernia
* **surgical** - urgent, within 2 weeks
* low or high approach repair relative to inguinal ligament
* repair defect with suture or mesh
* high approach preferred for emergencies
428
types of hiatus hernia
* **sliding**
* 80%, gastro-oesophageal junction moves up into chest
* **rolling**
* 20%, stomach herniates into chest (upward movement of fundus)
429
management of hiatus hernia
* **conservative**
* elevate head at night, small meals, avoid alcohol, smoking cessation
* **medical**
* PPI
* **surgical**
* Nissen fundoplication
430
what is acute mesenteric ischaemia?
* acute compromise to blood flow, usually emboli in arteries, usually small bowel
* Life-threatening, surgical emergency
* Sudden onset intestinal hypoperfusion
* Most common site → superior mesenteric artery
431
what is chronic mesenteric ischaemia
* "intestinal angina", ↓ blood supply which gradually deteriorates over time, usually due to atherosclerosis
* Common sites - coeliac trunk, SMA, IMA
432
what is ischaemic colitis?
acute but transient compromise in blood flow to _large bowel_. Can result in _inflammation_, ulceration and haemorrhage
433
causes of acute mesenteric ischaemia
* thrombus due to atherosclerotic plaque
* emboli - AF, aneurysm
* non-occlusive e.g. cardiogenic shock
* venous occlusion + congestion
434
definitive diagnostic test for acute mesenteric ischaemia\>
**CT abdomen with IV contrast (CT angiogram)** - triple phase scan with thin slices in arterial phase → definitive diagnosis of acute mesenteric
435
management of acute mesenteric ischaemia
* A-E, admit, surgical Tx + referral
* surgical
* necrotic bowel resection
* re-vascularisation - IR + angioplasty 1st line
436
management of chronic mesenteric ischaemia
* **conservative** - cardio RF modification
* **medical**
* anti-platelet + statin
* nutritional optimisation
* **surgical**
* EVAR - angioplasty and stenting of mesenteric vessels
* open re-vascularisation (endartectomy or bypass)
437
management of ischaemic colitis
* supportive care incl. transfusion
* broad spec IV Abx
* surgery - if generalised peritonitis, perforation, ongoing bleeding, failed conservative Tx
438
causes of small bowel obstruction?
**HAT**
Hernia
Adhesions
Tumour
439
causes of large bowel obstruction?
**CVS**
cancer
volvulus
strictures (diverticular \> IBD)
440
pathophysiology in SBO
The blockage → proximal dilation → perforation. In acute cases hyperperistalsis distal to obstruction occurs leading to diarrhoea.
441
pathophysiology of LBO
Colon proximal to obstruction dilates → increased colonic pressure → mesenteric blood flow reduced → mucosal oedema. If arterial supply is compromised → ulceration and necrosis. Perforation eventually occurs
442
management of sigmoid volvulus
* decompression with flexible sigmoidoscope
* open/laparoscopic repair if fails
443
management of SBO
* conservative
* dip + suck
* water soluble contrast study - if no contrast in colon after 6 hrs → surgery
* surgery
* adhesionlysis, resection, hernia repair
444
what are the functional bowel obstructions?
paralytic ileus
pseudo-obstruction (large bowel)
445
what is the criteria for IBS?
**Manning criteria for IBS - NICE recommended**
* At least 6/12
* Abdominal discomfort of pain relieved by defecation or associated with altered bowel habit or stool form
* At least 2 of:
* Altered stool passage e.g. straining or urgency
* Abdominal bloating
* Symptoms made worse by eating
* Passage of mucus
446
how to diagnose IBS?
* diagnosis of exclusion
* conservative
* diet, review fibre, low FODMAP
* medical - symptomatic
* anti-spasmodic - buscopan
* prokinetic (metoclopramide)
* anti-diarrhoea - loperamide
* laxative
* psych - CBT, relaxation
447
what is the most common cause of amoebic liver abscess? + treatment
Entamoeba histolytica
metronidazole _+_ drainage/resection
448
what scores are used to assess for liver transplant?
MELD score - chronic liver disease
King's college hospital criteria - acute liver failure
449
factors in Child Pugh score
Albumin
Bilirubin
Clotting (INR)
Distended abdomen (ascites)
Encephalopathy (present, grade)
A-C, associated with life expectancy
450
complications of liver failure
* infection - usually bacterial
* cerebral oedema + high ICP
* bleeding
* hypoglycaemia
* SBP
* portal HTN
* variceal bleeding
* hepatorenal syndrome
451
management of ascites?
* dietary salt + fluid restrict
* spironolactone _+_ furosemide
* therapeutic paracentesis
* IV albumin
* \< 15 g/L prophylactic Abx (ciprofloxacin)
* TIPSS procedure
452
when to give ABx in ascites? and which?
\< 15 g/L protein in ascitic fluid or previous SBP
ciprofloxacin
453
management of SBP
broad spectrum IV Abx
454
describe serum-ascites albumin gradient
> over 11g/L = transudate
\< 11 g/L = exudate
455
causes of ascitic transudate
* \> 11g/L SAAG
* portal HTN
* cirrhosis, acute liver failure, liver met/cancer
* RH failure
* constrictive pericarditis
* budd-chiari
* portal vein thrombosis
456
causes of ascitic exudate
* SAAG \< 11g/L
* low albumin - nephrotic, malnutrition
* peritoneal cancers
* TB peritonitis
* pancreatitis
* biliary ascites
* post-op lymphatic leak
457
management of hepatic encephalopathy
* conservative
* avoid sedatives
* 30 degree head tilt
* medical
* lactulose
* rifaximin (secondary prophylaxis)
* IV mannitol
458
management of variceal bleeding
* A-E resuscitation
* Blood transfusion
* Vitamin K, FFP and platelet transfusions as required
* **Terlipressin** - splanchnic vasoconstriction, ↓ portal pressure and bleeding
* **Broad spectrum Abx**
* **Sengstaken-Blakemore tube** -
* **Urgent OGD** ideally within 24 hrs (band, sclerotheraoy)
459
long term prophylaxis of variceal bleeding
propranolol (beta blocker)
460
stages of non-alcoholic liver disease
steatosis → steatohepatitis (NASH) → liver fibrosis → cirrhosis
461
what test is used to assess for liver fibrosis?
enhanced liver fibrosis blood test
hyaluronic acid + procollagen III + tissue inhibitor of metalloproteinase 1
462
gold standard for diagnosis of NASH
USS guided liver biopsy (histological diagnosis)
463
management of NASH
* refer to HBP team if fibrosis/end stage liver disease
* healthy weight (weight loss)
* healthy diet
* avoid ETOH and hepatotoxic drugs
* CVD risk factor modification
464
types of oesophageal cancer?
* **squamous cell** - upper oesophagus, aggressive
* **adenocarcinoma** - most common UK, lower ⅓, reflux
465
1st line for focal seizures
carbamazepine or lamotrigine
466
1st line for absence seizure
sodium valproate or ethiosuximide
467
1st line for tonic clonic seizures
sodium valproate or lamotrigine
468
1st line for myoclonic seizures
sodium valproate
469
1st line for atonic seizures
sodium valproate or lamotrigine
470
what is oesophageal adenocarcinoma associated with?
barrett's oesophagus, GORD, smoking, high fat intake
471
Ix for oesphageal cancer
* **bedside**
* **blood** - baseline bloods
* **imaging**
* endoscopic USS - assess depth of invasion
* staging CT CAP + neck
* **specialist**
* OGD + biopsy - gold standard, diagnostic
* staging laparoscopy - junctional tumor for intra-peritoneal metastases
472
2WW rules for urgent OGD for oesophageal cancer
* Dysphagia
* _\>_ 55 years + weight loss + 1 of: abdominal pain, reflux, dyspepsia
473
management of oesophageal cancer
* MDT
* **curative**
* adenocarcinoma - surgery _+_ chemo/radiotherapy
* oesophagectomy with reconstruction
* SCC - chemoradiotherapy
* intense nutritional support - jejunostomy
* **palliative** - majority
* stent
* chemo/radiotherapy
* nutritional support including RIG
474
types of pancreatic cancer
* ductal adenocarcinoma = 90%, from exocrine region
* exocrine tumours
* endocrine tumours - derived from islet cell, better prognosis
475
where is the most common site for pancreatic cancer?
head
476
Rf for pancreatic cancer
* smoking
* chronic pancreatitis
* diet - high red meat
* FHx - MEN, HNPCC, FAP, VHL
* late onset DM
477
Ix for pancreatic cancer
* **bedside**
* **bloods** - baseline
* CA19-9 (tumour marker), clotting
* **imaging**
* abdominal USS
* CT imaging with panreatic protocol (HR) - _gold standard for prelim diagnosis_
* endoscopic USS _+_ biopsy
478
2WW for pancreatic cancer
_\>_ 40 + jaundice
479
management of pancreatic cancer
* MDT
* **curative**
* radial resection
* adjuvant chemotherapy
* **palliative** - majority
* chemotherapy
* symptom control - biliary stenting, Creon, pain management (coeliac plexus block)
480
what are the radical resections for pancreatic cancer?
* **Pancreaticoduodenectomy (Whipple's)** + **regional lymphadenectomy** → if _head_ of pancreas cancer
* Remove head of pancreas, antrum of stomach, 1st + 2nd part of duodenum, CBD, gallbladder
* **Distal pancreatectomy _+_ splenectomy + regional lymphadenectomy** → if _body/tail_ of pancreas cancer
* High morbidity associated
481
causes of acute pancreatitis
**GET SMASHED** (mnemonic)
* ***Gallstones***
* ***Ethanol***
* Trauma
* Steroids
* Mumps
* Autoimmune (PAN, SLE)
* Scorpion bite
* Hyperlipidaemia, hypothermia, **hypercalcaemia**
* **ERCP** and emboli
* Drugs - azathioprine, NSAIDs, diuretics
482
ix for pancreatitis (acute)
* **bedside** - exam
* **blood**
* VBG
* bone profile - Calcium
* LFT + albumin
* clotting
* serum amylase/lipase
* lipase - more sensitive
* **imaging**
* abdominal USS - ?gallstones
* **specialist**
* calculate glasgow score
483
when should a contrast enhanced CT be done in pancreatitis and why?
6-10 days after PC
assess for severity - indicated if persistent inflammatory response or organ failure
e.g. detect pseudocyst
484
describe the glasgow criteria for pancreatitis
* **P**aO2 \< 8kPa on ABG
* **A**ge _\>_ 55 years
* **N**eutrophilia – WBC \> 15x 109/L
* **C**alcium \<2mmol/L
* **R**enal function – urea \>16mmol/L
* **E**nzymes – LDH \>600iu/L or AST \> 200 iu/L
* **A**lbumin \< 32 g/L (serum)
* **S**ugar – blood glucose \> 10mmol/L
485
complications of acute pancreatitis
* Chronic pancreatitis
* DIC, ARDs, hypocalcaemia, hyperglycaemia
* Pancreatic necrosis, pancreatic pseudocyst, pancreatic abscess, haemorrhage
486
management of acute pancreatitis
* A-E, admit, glasgow \> 3 ITU
* conservative
* UO
* medical
* treat underlying e.g. ERCP
* aggressive IV fluid resuscitation
* NG if sig. vomit else oral intake as tolerated
* opioid analgesia
* broad spec Abx if confirmed necrosis
* surgical
* pancreatic debridement
487
management of pancreatic pseudocyst
* 50% spontaneously resolve, give up to 12 weeks to resolve
* If there after 6/52 unlikely to resolve → surgical debridement or endoscopic drainage often into stomach
488
causes of chronic pancreatitis
* Chronic alcohol excess (80%)
* Idiopathic (15-20%)
* Cystic fibrosis
* Obstruction - pancreatic cancer
* Recurrent acute pancreatitis
* Metabolic - ↑ triglycerides, hypercalcaemia
* Autoimmune - autoimmune pancreatitis, SLE
489
what is chronic pancreatitis?
caused by chronic inflammation and fibrosis of both the exocrine and endocrine components of the pancreas
490
Ix for chronic pancreatitis
* baseline bloods
* glucose/HbA1c
* faecal elastase
* AXR/CT - pancreatic calcification
* secretin stimulation test - only if dx uncertain
491
management of chronic pancreatitis
* **conservative**
* reduce alcohol
* **medical**
* analgesia _+_ coeliac plexus block
* insulin
* Creon - exocrine enzyme replacement
* A, D, E, K vitamin supplement
* **surgical**
* pancreatectomy
492
duodenal vs gastric ulcer
* duodenal more common 4:1
* worse after eating - gastric
* better with food, worse with fast/night → duodenal
493
tests for peptic ulcer disease
* **bedside**
* H. pylori carbon 13 urea breath test
* H. pylori stool antigen
* **blood** - FBC, CRP
* **imaging**
* erect CXR in acute
* **specialist**
* upper GI endoscopy
494
prep urea breath test for h. pylori what can't patients do?
No Abx or bismuth products for 4 weeks and no PPI for 2 weeks before H. Pylori diagnosis
495
complications of peptic ulcer disease
gastric outlet obstruction, upper GI bleed, perforation
496
acute management of peptic ulcer disease
* A-E approach
* Urgent endoscopy
* PPI after endoscopy
* Urgent intervention angiography with trans-arterial embolization or surgery
* If endoscopic procedures fail or too unstable for endoscopy
497
management of peptic ulcer disease
* **conservative**
* stop smoking, less ETOH
* diet - avoid trigger, healthy, weight loss
* medication r/v
* stress management
* **medical**
* 4-8 weeks full dose PPI
* H. pylori eradication if +ve
* **surgical**
* partial gastrectomy in severe/emergencies
498
what drugs are associated with peptic ulcer disease
NSAIDS, steroids, bisphosphonates, potassium supplements, SSRIs, cocaine
499
management of peri-anal fistula
* asymptomatic - watch and wait
* surgical
* drainage seton (1st line if trans-sphinteric)
* fistulotomy (1st line if low, submucosal fistula)
500
definition of portal hypertension
portal HTN is abnormally high pressure in hepatic portal vein \> 10 mmHg
501
causes of portal HTN
* **pre-hepatic**
* thrombosis (splenic vein)
* extrinsic compression
* **intra-hepatic**
* cirrhosis
* idiopathic portal HTN
* **post-hepatic**
* Budd-chiari
* right heart failure
* constrictive pericarditis
502
management of portal HTN
* **conservative**
* salt restriction _ fluid
* **medical**
* spiro _+_ furo
* non-selective beta blocker - propranolol
* terlipressin - acute
* **surgical**
* transjugular intrahepatic portosystemic shunt (TIPSS)
* liver transplant
503
definition of primary biliary cirrhosis
Autoimmune inflammatory destruction of the **intrahepatic bile ducts** which results in cholestasis and progressive development of cirrhosis over many years.
504
antibody for primary biliary cirrhosis
anti-mitochondrial
505
treatment of PBC
* conservative
* avoid systemic oestrogen
* medical
* **ursodeoxycholic acid** - can induce remission
* cholestyramine - itch tx
* surgical - transplant (liver)
506
what is primary sclerosing cholangitis?
chronic cholestatic disorder characterised by inflammation and fibrosis of _intrahepatic and extrahepatic_ bile ducts, resulting in multifocal biliary strictures
507
what is PSC associated with?
IBD esp. UC
508
antibodies associated with PSC
pANCA
anti-smooth muscle
509
Ix for PSC
* LFT
* anti-smooth muscle, pANCA
* biliary tree USS - duct dilation
* ERCP/MRCP - beading of bile ducts
* biopsy - onion skinning fibrosis
510
management of PSC
* yearly screening for malignancy
* cholestyramine - manage pruritus
* stricture dilation via ERCP
* liver transplant
511
what is ulcerative colitis?
Ulcerative colitis is the most common form of inflammatory granulomatous bowel disease
* Characterised by diffuse continual mucosal inflammation of the large bowel, beginning in rectum and spreading proximally
512
investigations of UC
* **bedside -** faecal calprotectin
* **bloods** - FBC, CRP, U&Es, LFTs, clotting
* **imaging**
* AXR - lead pipe colon, thumbprinting, toxic megacolon
* barium - lead-pipe
* **specialist**
* colonoscopy + biopsy = diagnostic
513
how is UC severity graded in acute?
truelove and witt score
514
management of UC
* **Medical**
* ***Inducing remission - severe disease***
* IV fluid resuscitation
* Nutritional support
* Prophylactic heparin - VTE prevention
* *IV corticosteroids + immunosuppression (ciclosporin or 5-ASA suppositories)*
* ***Inducing remission - mild-moderate***
* topical/oral 5-ASA (aminosalicylates)
* _+_ oral prednisolone
* Oral tacrolimus
* ***Maintaining remission***
* 1st line - 5-ASA's e.g. mesalazine or sulfasalazine
* 2nd line - azathioprine
* ***Colonoscopic surveillance*** - if \> 10 yrs with \> 1 segment of bowel affected
* **Surgical**
* Segmental bowel resection _+_ stome
* *_Total proctocolectomy_* - curative, forms end-ileostomy
515
what is the most common renal stone?
calcium oxalate
516
what stone is associated with haemolysis?
uric acid
renal stone
517
what bacteria is associated with staghorn calculus
proteus
made of struvite
IK6 - Exams
flashcards
Decks in class (24)
# Cards
-
Acute care40
-
Breast and vascular27
-
Cardiovascular152
-
Dermatology82
-
ENT + Ophthalmology49
-
Gastrointestinal111
-
Endocrinology188
-
Haematology61
-
Infection and Immunology43
-
Neurology147
-
Renal and urology70
-
Respiratory156
-
Rheumatology and musculoskeletal86
-
Miscellaneous84
-
PACES - Images20
-
PACES - Instruments96
-
DPD107
-
Scoring Systems21
-
Murmurs24
-
signs22
-
Research methods9
-
Core Content517
-
PPQ7
-
Viva20
