Renal tubular acidosis
due to pathology in the tubules where H+ and HCO3- are balanced.
causes hyperchloraemic metabolic acidosis (normal anion gap)
type 4 most common - low/ impaired aldosterone -> reduced ammonium excretion in tubules -> hyperkalaemia, low urine pH. causes: hypoaldosteronism, diabetes, ACE/ spiro/ eplerenone
type 1 - distal tubule cannot excrete H+, high urine pH (>6) and hypokalaemia. causes nephrocalcinosis and renal stones. causes: SLE, RA, Sjogrens
type 2 - proximal tubule cannot reabsorb bicarbonate, high urine pH and hypokalaemia. causes osteomalacia. causes: wilson’s disease, acetazolamide, topiramate, multiple myeloma, fanconi’s syndrome
Manage T1/2 with oral bicarb. T4: fludrocortisone, oral bicarb, hyperkalaemia treatement
capillary haemangiomas/ strawberry naevi - RF, complications, features, management
not present at birth but develop rapidly in the first month of life before self-resolving
no treatment is needed and there is no sinister cause
RF: white, female, premature, CVS babies
complications: can obstruct visual fields or airways, bleeds, ulcers, thrombocytopenia
management: can use propanolol and topical timolol
osteomalacia/ rickets
low vitamin D causes decreased bone mineral content, causes soft bones
causes: vit D deficiency, CKD, liver disease like cirrhosis, coeliac, anti-convulsants
Presents: bone pain, muscle tenderness, fractures (NOF), proximal myopathy (waddling gait)
ix: low vitain D, low calcium, low phosphate, raised ALP. XR would show translcuent bands called Looser’s zones, pseudofractures
Mx: vitamin D + loading dose, can supplement calcium
SAH
most common cause is head injury. Otherwise saccular ‘berry; aneurysms (HTN, PCKD, EDS, coarctation of aorta), AV malformation, pituitary apoplexy
presents: thunderclap headache, N and V, meningism, coma, seizures, can see ST elevation on ECG
Ix: CT head. LP should be done 12 hours after LP to see xanthochromia (RBC breakdown, as opposed to just traumatic LP tap), normal/ raised opening pressure
If SAH confirmed: CT intranial angiogram/ catheter angiogram to see if any aneurysm or AVM
Mx: bed rest, analgesia, VTE px, nimodipine to prevent vasospasm. Most intracranial aneurysm treated with coil in 24 hours as risk of rebleeding. craniotomy and clipping done for a minority.
Complications: rebleeding, hydrocephalus, vasospasm, hyponatraemia secondary to SIADH, seizures
predictive factors: conscious? age? how much blood visible on CT?
Disseminated intravascular coagulation
thrombin turns fibrinogen into fibrin (clot). plasmin breaks down fibrin. In DIC, tissue factor (normally hidden membrane protein), binds to factor VII to start extrinsic pathway which amplifies intrinsic pathway, causes uncontrolled coagulation. TF found in placenta, lung and brain -> making trauma and obstetric cases high risk. TF appears after vascular injury, cytokines, endotoxin, sepsis.
causes of DIC: sepsis, trauma, obstetrics like HELPP, malignancy
bloods: low plts, low fibrinogen, raised PT, APTT and fibrinogen degradation products, schistocytes due to microangiopathic haemolytic anaemia.
Hip fracture
The blood supply to the femoral head runs up the neck and thus avascular necrosis is a risk in displaced fractures, mainly garden 3 and 4.
intracapsular or extracapsular (trochanteric, subtrochanteric)
Garden system:
Type I: Stable fracture with impaction in valgus
Type II: Complete fracture but undisplaced
Type III: Displaced fracture, usually rotated and angulated, but still has boney contact
Type IV: Complete boney disruption
undisplaced intracapsular: internal fixation, hemi if unfit
displaced intracapsular: total or hemi. total preferred in independent walkers, cognition good, fit enough for anaesthesia
extracapsular: dynamic hip screw.
use intermedullary device if reverse oblique/ transverse/ subtrochanteric
laryngomalacia
most common cause of stridor in infants. presents at 4 weeks.
congenital, due to a floppy epiglottis which folds into the airway on inspiration
normally a self-limiting condition, but if the stridor becomes severe with signs of respiratory distress, or if there is failure to thrive (due to poor feeding), then surgery is recommended to improve the airway
pneumothorax
conservative management if minimally symptomatic
if symptomatic, is it high risk? eg haemodynamic compromise, hypoxia, bilateral, other lung disease, older than 50 and lung disease, haemothorax
if high risk and at least 2cm big/ seen on CT -> chest drain
conservative: monitoring only
ambulatory device with one way valve. needle aspiration.
mx not working/ persistent/ recurrent: video-assisted thoracoscopic surgery (VATS) should be considered to allow for mechanical/chemical pleurodesis +/- bullectomy
discharge advice: stop smoking, can’t fly until 1 week of good CXR, avoid diving forever
diabetic neuropathy
sensory loss in glove and stocking distribution, can be painful. manage with amitriptyline/ duloxetine/ gabapentin/ pregabalin with tramadol used as rescue therapy.
GI autonomic neuropathy
gastroparesis: erratic blood glucose control, bloating and vomiting.management options include metoclopramide, domperidone or erythromycin (prokinetic agents). You can get GORD and chronic diarrhoea.
Benzodiazepines
increases chloride channels to enhance the effect of inhibitory GABA.
sedation
hypnotic
anticonvulsant
muscle relaxant
The dose should be withdrawn in steps of about 1/8 (range 1/10 to 1/4) of the daily dose every fortnight. A suggested protocol for patients experiencing difficulty is given:
switch patients to the equivalent dose of diazepam
reduce dose of diazepam every 2-3 weeks in steps of 2 or 2.5 mg
time needed for withdrawal can vary from 4 weeks to a year or more
Benzo withdrawal:
insomnia
irritability
anxiety
tremor
loss of appetite
tinnitus
perspiration
perceptual disturbances
seizures
barbiturates also act on GABA but they increase the duration of chloride channel opening
breast cancer management
practically everyone is offered surgery. if no palpable lymph nodes, do axillary US and sentinel nodal burden. if palpable lymph nodes do axillary lymph node clearance (can cause lymphedema and arm impairment)
WLE done in 2/3’s, mastectomy done if multifocal, central tumour, big lesion in small breast, DCIS > 4cm. followed by breast reconstruction.
Radiotherapy done after WLE to reduce recurrence risk by 2/3s. done after mastectomy if t3/t4 tumours or 4+ positive axillary lymph nodes.
hormonal therapy: tamoxifen in pre and perimenopause. anastrozole (aromatase inhibitors) in post-menopausal. Tamoxifen SE: endometrial cancer, VTE, menopausal symptoms
biologic therapy like trastuzumab (herceptin)useful in HER2+ve. Can’t be used if heart problems.
chemotherapy can be used neoadjuvant or after surgery. axillary node disease FEC-D is used
cervical cancer screening
tested for high risk HPV (16,18)
-ve: normal recall unless test of cure (6 months)/ untreated CIN1
+ve: cytology. if cytology abnormal then colposcopy. if cytology normal then repeat at 12 months. can repeat twice then colposcopy if it remains positive.
if inadequate sample, repeat at 3 months.
CIN is treated with LLETZ. alternative is cryotherapy.
DVT and PE in pregnancy
hypercoagulable state, mainly happens in last trimester.
more VII, VIII, 10 and fibrinogen, decrease in protein S, uterus presses on IVC causing venous stasis in legs
management: SC LMWH
HIV and pregnancy
reduce vertical transmission with maternal ARVT, c-section, neonatal ARVT and bottle feeding
can have vaginal delivery if viral load < 50 at 36 weeks
zidovudine infusion started 4 hours before beginning of c-section. continue zidovudine orally for 6 weeks if mum < 50 copies. if more, then baby needs triple therapy.
No breast feeding!
PDE-5 inhibitors
used for erectile dysfunction and pulmonary hypertension. increases cGMP which relaxes blood vessels and causes vasodilation.
sildenafil - an hour before sex
tadalafil - longer acting
CI - nitrate drugs, hypotension, stroke/ MI in previous 6 months
side effects: blue vision, congestion, priapism, flushing, headache, anterior ischaemic neuropathy
which medications worsen heart failure?
pioglitazone (fluid retention), verapamil (-ve inotropic) , NSAIDS (FR), glucocorticoids, flecanaide (-ve)
T2DM
hba1c targets are 48 if lifestyle/ metformin. 53 if anything else.
add a second drug if 58
metformin or with SGLT2i once established if high risk CVD, established CVD or heart failure.
then add DPP4, pioglitazone, sulfonylurea, SGLT2i. up to triple therapy.
If triple therapy not working, switch one to GLP1 mimetic. only continue if hba1c drops by 11/ 3% body weight drop in 6 months
then metformin + insulin
ACE/ ARB preferred if also diabetic. ARB preferred if black. Give statin if qrisk.
obesity in children
mainly lifestyle.
can be growth hormone deficiency, hypothyroidism, down’s, cushing’s, prader willi.
consequences: SUFE, psychological, sleep apnoea, HTN/ IHD/ T2DM
rabies
viral disease that causes acute encephalitis, transmitted through salivary glands.
prodrome: headache, fever, agitation. hydrophobia. hypersalivation. negri bodies.
no risk in UK. if bitten: wash wound, 2 further doses of vaccine as booster. if not vaccinated human rabies immunoglobulin administered around wound.
If untreated, nearly always fatal.
