1
Q
Beck’s Triad
Found in Cardiac Tamponade
A
Fall in BP
Rise in JVP
Muffled heart sounds
2
Q
Eating Disorders
- Atypical (most common)
- Binge Eating
- Bulimia
- Anorexia (least common; 10% mortality; 20% suicide risk)
Diagnosis:person’s history, suggestive clinical features, and supported, where possible, by corroboration from a relative or friend
Management:
- clear agreement between primary and secondary care about responsibility for monitoring
- Monitoring ongoing level of risk to the person’s mental and physical health and managing complications —
- Placing an alert in the person’s prescribing record
- ECG monitoring to people with an eating disorder who are taking medication that can compromise cardiac functioning for example drugs that may cause electrolyte imbalance, bradycardia, hypokalaemia, or a prolonged QT interval.
- Adults - 1st line CBT-ED, Maudsley Anorexia Nervosa Treatment (MANTRA); Children - 1st line Familt therapy, 2nd line CBT
- Giving advice on contraceptive use and pregnancy to women (LARC - implants and IUS recommended - not Depot) Ensuring the person and their family/carers have access to information and support.
A
Referral criteria for Anorexia: -
- BMI <13
- CVS instability,
- hypothermia
- metabolic and electrolyte imbalance
- oncurrent infection, overall ill health or abnormal blood tests.
- reduced muscle power
- risk of refeeding syndrome.
- lack of support at home.
- acute mental health risk — risk of suicide attempt/ DSH
3
Q
Pemberton Sign
Signs of Superior Vena Cava Obstruction e.g in lung cancer, thyroid goitre
A
Neck + facial erythema and oedema
More pronounced on elevation of the arms over the head
4
Q
Erythema Nodosum
Auto-immune T III reaction
A
Behcet,
Sarcoid,
IBD,
Streptococcal infect,
TB,
OCP,
Other drugs
5
Q
Quadrantanopia
Lesion is on the opposite Parietal or Temporal site
A
PITS
Parietal - Inferior
Temporal - Superior
Visual field om opposite side is affected
6
Q
Polymyalgia Rheumatica (PMR)
A
- > 50 years-old
- at least 2 weeks of bilateral shoulder and/or pelvic girdle pain
and
- stiffness lasting for at least 45 minutes after waking or periods of rest
7
Q
Fibromyalgia
A
11 tender points in the body - 9/11 points should be positive
8
Q
Ischemic stroke
A
- Aspirin 300 mg daily for 2 weeks
then,
- clopidogrel 75 mg daily long-term (life-long if Stroke with AF - give Warfarin)
9
Q
Neuropathic Pain Mx
A
Amitriptyline, Duloxetine, Gabapentin or Pregabalin
Switch drugs - don’t add
Tramadol - rescue therapy for exacerbations
Topical Capsaicin- FRUIT Extract for localised neuropathic pain
10
Q
Ovarian mass/ lump
Most common
Benign - Follicular cyst
Malignant - Serous Adenocarcinoma
A
Types:
Germ cell tumours
- Yolk Sac tumours (endodermal sinus tumour)- S_A_C Schiller Duval bodies, raised AFP, children
- Dysgerminomas: DysGERMANoma - German flag (Raised LDH and HCG)
- Teratoma - TERROR toma - monster - all kinds of tissues
Sex cord stromal tumour
- Fibroma (Meig’s Syn)
- Sertoli Leydig tumour: Virilisation due yo raised Androgens, Reinke Crystals (LeDIG for Crystals!)
- Granulosa Theca Call Tumour = Raised Estrogen, Call-Exner bodies (Gran Exner)
Others
- Brenner tumour (Bladder like)
- Krukenberg: metastasises from gut to ovary
11
Q
Vomiting in neonate
A
Duodenal atresia - within few hours of birth (double bubble sign)
Meconium ileus - 24 - 48 hrs after birth
Necrotising enterocolitis - after 2 weeks, premature
12
Q
Screening programmes in NHS -1
- Antenatal - diabetes (preconception, 28 weeks, anaemia at 16 weeks incl Hbinopathy, infection (HIV, Hep B and syphilis), FASP (10 -20 weeks; scan +/- blood tests), diabetic eye screen of T1DM and T2DM
- Neonatal: NIPE (72 hrs; eye, heart, hips, testes); heel prick/ blood spot (5 - 8 days; 9 disease - SCD, CF, CHT, PKU, MCAACD, MSUD, IVA1, GA1, HCU); Hearing (6-8 weeks; OAER/ AABR)
- Chlamydia - opportunistic; men and women <25 years, urine or swabs for females
- Cervical - cervical smear, 25-49 yrs women 3 yearly then 50-64 yrs 5 yearly
A
Screening programmes in NHS -2
- Breast - Mammogram; 47-73 yrs women (50 - 70 yrs); 3 yearly
- Bowel - FOB, 2 yrly; men and women 60 - 74 yrs
- Aortic Aneurysm - Ultrasound for men at 65 years
- Diabetes Eye screening - annual all T1 and T2 DM
- No screening for Prostate/ Ovarian Ca
13
Q
Respiratory infections and common pathogens
A
Common cold - rhinovirus
Flu - influenza virus
Epiglottis - Haemophilus influenza B (HiB)
Bronchiolitis - Respiratory syncytial virus
Croup - parainfluenza virus
Bonchiectasis exarcebations - Hib
Pneumonia
- post flu: staphylococcus aureus
- community-acquired pneumonia: mycoplasma
- atypical pneumonia - Mycoplasma (flu-like, precedes dry cough & complications - haemolytic anaemia erythema multiforme); Legionella (A/C spread, lymphopaenia, hyponatraemia, and deranged LFT); Pneumocystis jiroveci in HIV+ (few chest signs - hilar interstitial infiltration and exertional dyspnoea). Mycobaterium TB - Cough, night sweats and weight loss, Klebsiella - apical and cavitating, associated with Alcohol misuse
14
Q
Antipsychotic Drugs - Typical (old)
- Haloperidol
- Chlorpromazine
Side Effects:
Extra- Pyramidal e.g. Parkinsonisim, Tardive dyskinesia
Acute dystonia e.g. oculogyric crisis
Thromboembolism
Hyperprolactinaemia
A
Antipsychotic - Atypical (New drugs)
Quetiapine, Risperidone, Olanzapine, Clozapine
Side Effects: • Weight gain • Agranulocytosis • Hyperprolactinaemia • Stroke & thrombolembolism in elderly, amisulpride, aripiprazole
Clozapine causes:
agranulocytosis (1%), neutropaenia (3%), reduced seizure threshold - can induce seizures in up to 3% of patients, constipation, myocarditis: a baseline ECG should be taken before starting treatment, hypersalivation
15
Q
School exclusions
A
- Measles: 4 days
- Mumps & Rubella: 5 days
- Chicken Pox: Till all the lesions have crusted
- Scarlet fever: 24 hrs after abx
- Whooping cough: 48 hrs after abx
- Impetigo: 48 hrs after starting abx or after crusting
- Diarrhoea: 48 hrs after recovery
- Hand foot and mouth, head lice: No exclusion
16
Q
Ecstasy poisoning
Ecstasy aka MDMA, aka 3,4-Methylenedioxymethamphetamine
c/f: • Hyperthermia • Agitation, anxiety, confusion, ataxia • tachycardia, hypertension • hyponatremia • rhabdomyolysis
A
Supportive
Dantrolene for hyperthermia
17
Q
Key features of atypical pneumonia
Mycoplasma A - dry cough, flu, auto-haemolytic anaemia, erythema multiforme
Klebsiella - Alcoholism, red-currant jelly sputum, cavitating in upper lobe
Legionella - AC, travel hx, lymphopenia, low sodium, abnormal LFT
Pneumocystis jiroveci - HIV +
Chlamydia psittaci - Birds, parrots
Tuberculosis (TB) - weight loss, fever, night sweat, cough with sputum
A
Treatment of atypical pneumonia
Mycoplasma - erythromycin
Klebsiella - erythromycin
Legionella - erythromycin
Pneumocystis jiroveci - co-tromoxazole
Chlamydia psittaci - erythromycin
TB - RIPE for 4/12, then RI for 2/12
18
Q
Angina
breathlessness on exertion
Causes: Ishaemia, valvular ds (AS), HTN, HOCM
Types: Stable or Unstable
Referral to Specialist: if no relief on BB + CCB, worsening symps, unstable angina
A
Mx:
- Quit smoking,
- Cardioprotective diet,
- physical activity within limitation
- healthy weight
- alcohol use within limits
- Anti-anginal medication: sublingual GTN for rapid relief or before activity that triggers, beta blocker or calcium channel blocker - singly first, them switch to other, then combine, long acting nitrates - isosorbide, nicorandil, ivabradine, ranolazine - third drug while awaiting specialist review and cardiac revascularisation
- secondary protection = aspirin 75 mg, ACE inhibitor, statin, control of HTN +/- DM
19
Q
Contraindications to COC use
4 point scale
UKMEC 1: no restriction
UKMEC 2: benefits outweigh the risks
UKMEC 3: risks outweigh benefits
UKMEC 4: unacceptable health risk
A
Relative contraindications to COC (UKMEC3)
> 35 years and smoking <15 cigarettes/day
BMI > 35 kg/m^2*
family hx of VTE disease in first degree relatives < 45 years
controlled hypertension
immobility e.g. wheel chair use
carrier of known gene mutations of breast cancer (e.g. BRCA1/BRCA2)
current gallbladder disease
Absolute contraindications to COC use (UKMEC4)
> 35 years and smoking <>5 cigarettes/day
Liver ds - cirrhosis, malignancy
migraine with aura
history of thromboembolic disease or thrombogenic mutation
history of stroke or ischaemic heart disease
breast feeding < 6 weeks post-partum
uncontrolled hypertension
current breast cancer
major surgery with prolonged immobilisation
20
Q
Aspirin use in pregnancy
A
- Mother age above 40 years & first pregnancy
- FHx of eclampsia
- BMI above 35
- 10 yrs age between pregnancies
21
Q
Types of Hypersensitivity reactions
A
A - Allergen, Atopy, Asthma, Allergic rhinitis, Anaphylaxis - IgE, basophils & mast cells - Rapid (<30’) - TYPE I
C - Cytotoxic - Complement mediated (csmooth deposition) activated by IgG/ IgM - GoodPasture’s, Myasthenia, AHA, Graves’, Intravascular reaction, Blood transfusion reaction - TYPE 2
I - Immunecomplex mediated, Ag and IgG & IgM form complexes (lumpi + bumpi) deposits, Tissue Damage RA, Erythema nodosum - Post streptococcal GN, SLE - TYPE 3
D - Delayed Cytotoxic - cell mediated, CD8 + killer cells - Lymphocyte, T-cells; 48-72 hrs later - Diabetes, dermatitis, Tuberculin test (Mantoux’s), contact dermatitis, graft - TYPE 4
22
Q
Medical conditions notifiable to DVLA
Group 1 - car and motorcycles
Group 2 - lorries, heavy vehicles, buses
- diabetes taking insulin
- syncope (fainting) and sudden dizziness, Meniere’s disease - till symptoms in control
- heart conditions (including AF and pacemakers eg implanted defibrillator
- sleep apnoea
- epilepsy
- strokes & TIA
- glaucoma
A
hypertension: drive unless treatment causes unacceptable side effects, no need to notify DVLA - if Group 2 driver disqualified from driving if resting SBP consistently >180 mmHg or DBP > 100 mm Hg
angioplasty (elective) - 1 week off driving
CABG - 4 weeks off driving
acute coronary syndrome- 4 weeks off driving - 1 week if successfully treated by angioplasty
angina - driving must cease if symptoms occur at rest/at the wheel
pacemaker insertion - 1 week off driving
implantable cardioverter-defibrillator (ICD) - if implanted for sustained ventricular arrhythmia - stop driving for 6 months; if implanted prophylactically then cease driving for 1 month. Having an ICD results in a permanent bar for Group 2 drivers
successful catheter ablation for an arrhythmia - 2 days off driving
aortic aneurysm of 6cm or more - notify DVLA. Licensing will be permitted subject to annual review; an aortic diameter of 6.5 cm or more disqualifies patients from driving
heart transplant: do not drive for 6 weeks, no need to notify DVLA
1st seizure: 6 mth no driving, with established epilepsy till fit free for 12 months
Multiple TIA’s - 3 mth no driving
Stroke: 1/12 no driving
Craniotomy: 1 yaer of driving
Pituitary tumour - 6 mth off driving
Narcolepsy/ cataplexy: stop driivng on diagnosis
23
Q
Drug Causes of Pernicious Anaemia
Auto-immune
Severe Vit B12 deficiency
A
PPI
H2 receptor antagonist
Metformin
Colchicine
Nitrous Oxide
24
Q
Immunisation for those born before 2020
2 mth: 6 in 1, rotavirus, PCV, Men B
3 mth: 6 in 1, rotavirus
4 mth: 6 in 1, PCV, Men B
12 - 15 mth: MMR, Hib/MenC, Men B, PCV
3 - 4 yrs: pre-school 4 in 1 (DTP, polio), MMR
2 - 11 yrs: annual flu (LAIV - fluenz tetra; live)
12 - 13 yrs: HPV x 2 dose 6-24 mth apart
14 yrs: pre-university (DT, polio), Men ACWY
Pertussis: Pregnancy 28 - 32 weeks
A
Immunisation for those born after 2020
2 mth: 6 in 1, rotavirus, Men B
3 mth: 6 in 1, rotavirus, PCV
4 mth: 6 in 1, PCV, Men B
12 - 15 mth: MMR, Hib/MenC, Men B, PCV
3 - 4 yrs: pre-school 4 in 1 (DTP, polio), MMR
2 - 11 yrs: annual flu (LAIV - fluenz tetra; live)
12 - 13 yrs: HPV x 2 dose 6-24 mth apart
14 yrs: pre-university (DT, polio), Men ACWY
Pertussis: Pregnancy 28 - 32 weeks
25
Benzylpenicillin Dose in suspected Meningitis
\< 1 year - 300 mg im/iv
1 - 10 years - 600 mg im/iv
\>10 years - 1200 mg im/iv
26
**Febrile convulsions in Children**
## Footnote
Lasts 3 - 6 mins; tonic-clonic
May be simple (recovers in 10', no recurrence in 24 hrs) or complex (lasts \> 15', recurs in \<24 hrs, focal s/s)
d/d: epilepsy, hypoglycaemia, brain injury, apnoea, rigors, syncope, meningitis, encephalitis
referral criteria: \< 18 mths old; first seizure, diagnostic uncertainty, complex seizures, parental anxiety, recently taken abx
Febrile convulsions
## Footnote
Treatment
- Midazolam buccal/ rectal diazepam
27
Diagnosing Diabetes
* Fasting glucose \>7.0 mmol/ l
* Random or After oral 75 gm glucose \> 11.1 mmol/ l
* done once in symptomatic patient and x 2 in asymptomatic
* HbA1C \> 48 mmol/l
Impaired Fasting Glucose: FBS 6.1 - 7 mmol/ l
Impaired Glucose Tolerance: FBS \< 7.0 mmol/l and OGTT 2-hour \> 7.8 and above
Pre-diabetes: HbA1 C 42 - 47 mmol/ l
Diabetes: 48 mmol/ l
**Blood Sugar Control targets**
On metformin alone 48 mmol/ l
On insulin or combined drug producung hypoglycaemia 53 mmol/l
28
**2 WW - Referral Criteria**
**https://www.nice.org.uk/guidance/ng12/resources/suspected-cancer-recognition-and-referral-pdf-1837268071621**
- Suspected Oral Ca: Unexplained oral ulceration \>3weeks; Lump on lip or in mouth, ?erythroplakia (red or red+white patch), Erythroleukoplakia; Persistent unexplained neck lump
- Suspected Laryngeal Ca: \>=45 years PLUS Persistent unexplained hoarseness/ Unexplained neck lump
- Suspected ENT Ca: unilateral symptoms or unilatetal nasal polyp
- Suspected Lung Ca: chest X-ray findings that suggest lung cancer OR =\>40years AND unexplained haemoptysis
URGENT CXR criteria (=\>40 yrs over AND =\>2 or more of unexplained symptoms, or if they have ever smoked and have 1 or more of the unexplained symptoms: cough, fatigue, SOB, chest pain, weight loss, appetite loss, finger clubbing
- Suspected Breast Ca: Aged =\>30 years AND Unexplained breast/ axillary lump +/- pain; Aged =\>50 years AND Unilateral discharge, retraction, other concerning changes like skin changes
- Suspected Oesophageal Ca: Dysphagia in \>= 55 yrs PLUS weight loss AND upper abdominal mass, pain +/- reflux
- Suspected Stomach Ca: Dysphagia AND Aged \>=55 with weight loss and upper abdo pain, reflux, dyspepsia
- Suspected Pancreatic Ca: Aged \>=40 + jaundice OR Aged \>=60 with weight loss and diarrhoea, back pain, abdo pain, nausea, vomiting, constipation, new diabetes
**2 WW - Referral Criteria**
- Suspected Colorectal Ca: Aged \>=40 PLUS Unexplained weight loss + abdo pain; Aged \<50 AND Rectal bleeding, abdo pain, change in bowel habit, weight loss, IDA; Aged \>=50 PLUS Unexplained rectal bleeding; Aged \>=60 PLUS Iron deficiency anaemia/ Changed in bowel habit, Any age AND FOBT +ve or Rectal/abdominal mass
- Suspected Anal Ca: Unexplained anal mass or Unexplained anal ulceration
Suspected Ovarian Ca: Ascites, Pelvic or abdo mass, USS suggestive ovarian cancer and raised Ca 125
Suspected Endometrial Ca: Aged \>=55 with PMB or increased ET
Suspected Cervical Ca: On examination, appearance of cervix consistent with cervical cancer
Suspected Vulval Ca: Unexplained vulval lump, ulceration or bleeding
Suspected Vaginal Ca: Unexplained palpable mass in entrance to vagina
Suspected Prostate Ca: Feels malignant on DRE; PSA over age-specific range
Suspected Bladder Ca: \>=45 AND Unexplained visible haematuria without UTI or after successful treatment of UTI or \>=60 AND Unexplained non-visible haematuria AND dysuria with raised serum WCC
Suspected Renal Ca: Aged \>=45 + unexplained visible haematuria without UTI or after successful treatment of UTI
Suspected Testicular Ca: Non-painful enlargement/change in shape or texture of testis
Suspected Penile Ca: Penile mass/ulcer with STI excluded or STI treated
Suspected Melanoma: Major features scoring 2 points each with change in size, irregular shape, irregular colour. Minor features of the lesions (scoring 1 point each): largest diameter 7 mm or more, inflammation, oozing, change in sensation.
29
Tests in Upper Limb
## Footnote
Hoffman's sign - sign of UMN dysfunction due to degenratice cervical myopathy.
(Hoffman)-Tinel's sign (wrist): paraesthesia on tapping at wrist in medial nerve distribution in carpal tunnel syndrome:
Phalen's sign: Forced dorsiflexion of wrists in carpal tunnel syndrome
Finkelstein's test: De Quervain's tenosynovitis (gamer's wrist or berry thumb) - pulls the thumb of the patient in ulnar deviation and longitudinal traction - pain over lateral styloid process.
Mill's test: Lateral epicondilytis (tennis elbow)
Forced extension of the wrist with a supinated and extended forearm: Medial epicondilytis (Golfer's elbow)
## Footnote
Tinel test (ankle) tapping in front and behind medial malleolus to check for compression/ damagetp ant tibial and post tibial nerve respectively.
30
Mental Health Act (supercedes Mental Health Capacity Act)
## Footnote
Sectioning to admit/ treat \> 16 yrs old not agreed voluntarily and at risk to self and others (under influence of alcohol/ drugs excluded)
**Section 2**
admit for assessment for up to 28 days, *not renewable*; applied to by AMHP or NR on the recommendation of 2 doctors, one 'approved' under Section 12(2) of the Mental Health Act (usually a consultant psychiatrist); treatment can be given against a patient's wishes
**Section 3**
admit for treatment for up to 6 months, can be renewed, AMHP along with 2 doctors, both have seen the patient \<24 hours; treatment can be given against a patient's wishes
**Section 4**
72 hour assessment order in emergency, when delays with section 2; a GP and an AMHP or NR; changed to a section 2 upon arrival at hospital
**Section 5(2)**
voluntary patient in hospital - legally detained by a doctor, for 72 hours
**Section 5(4)**
allows a nurse to detain a patient who is voluntarily in hospital, for 6 hours
**Section 17a**
Supervised Community Treatment Order (CTO); used to recall a patient to hospital for treatment if they do not comply with conditions of the order in the community.
**Section 135**
a court order to allow police to break into property to remove a person to Safety
**Section 136**
someone found in a public place who appears to have a mental disorder can be taken by the police to a Place of Safety; can only be used for up to 24 hours, whilst a Mental Health Act assessment is arranged
31
Functional Somatic Disorders
## Footnote
**Somatisation disorder**
multiple physical SYMPTOMS since 2 years, patient refuses to accept reassurance or negative test results
**Hypochondriasis**
persistent belief in the presence of an underlying serious DISEASE, e.g. cancer; patient refuses to accept reassurance or negative test results
**Conversion disorder**
involves loss of motor/ sensory function, the patient doesn't consciously feign/ seek material gain
**Dissociative disorder**
'separating off' memories from normal consciousness, dissociative identity disorder (DID) is the new term for multiple personality disorder; intentional production of physical or psychological symptom. Has psychiatric symptoms of amnesia, fugue, stupor
**Factitious disorder** - patient feigns illness, Munchausen's syndrome - describes the intentional production of symptoms, for example self poisoning
**Malingering** patient seek material gain by pretending to be ill
32
Drugs that can cause agranulocytosis
Antipsychotics (predominantly Clozapine)
Antiepileptics
Antithyroid Drugs (Carbimazole)
Antibiotics (Penicillin, Chloramphenicol and Co-Trimoxazole)
Cytotoxic Drugs
Gold
NSAIDs (Naproxen, Indomethacin)
Allopurinol
Mirtazapine
33
Delusions
* *Othello syndrome** - belief that partner is committing infidelity despite no evidence.
* *De Clerambault syndrome (erotomania)**, - believes that a person of a higher social/ professional standing is in love with them.
* *Ekbom syndrome** is also known as delusional parasitosis and is the belief that they are infected with parasites or have 'bugs' under their skin.
* *Capgras delusion** - belief that friends/ family members have been replaced by an identical looking imposter.
34
Drugs causing hyponatraemia
Diuretics (especially thiazides),
SSRIs
Antipsychotics - haloperidol
NSAID
Carbamazepine.
35
Autosomal Dominant Conditions -1
## Footnote
achondroplasia
acute intermittent porphyria
adult polycystic kidney disease
antithrombin III deficiency
benign congenital hypotonia
Charcot-Marie-Tooth disease
cleft hand
cleidocranial dysostosis
diaphyseal aclasis
dysplastic naevi syndrome
Ehlers-Danlos syndrome (EDS)
fascioscapulohumeral muscular dystrophy
familial hypocalciuric hypercalcaemia
familial medullary thyroid carcinoma
familial triglyceridaemia
Gilbert's disease
Hayley-Hayley disease
hereditary pancreatitis
hereditary haemorrhagic telangiectasia
Holt-Oram syndrome
hereditary elliptocytosis
hypertrophic cardiomyopathy
hereditary spherocytosis
Huntington's disease
idiopathic hypoparathyroidism
medullary adenocarcinoma of the thyroid
mucosal neuroma
Machado-Joseph disease
oculopharyngeal muscular dystrophy
intestinal polyposis
Autosomal Dominant Conditions - 2
## Footnote
Marfan's syndrome
myotonia congenita
multiple epiphyseal dysplasia
marble bone disease
neurofibromatosis
osteogenesis imperfecta type I - mild disease
osteogenesis imperfecta type IV - moderately severe disease
Noonan's syndrome
osteogenesis imperfecta
retinoblastoma
Peutz-Jegher's syndrome
protein C deficiency
Sipple's syndrome
Sturge-Weber syndrome
tuberous sclerosis
Treacher-Collins syndrome
variegate porphyria
von Hippel-Lindau syndrome
von Willebrand's disease (congenital deficiency of von Willebrand's factor )
Wermer's syndrome
Marfan's syndrome
myotonia congenita
multiple epiphyseal dysplasia
marble bone disease
neurofibromatosis
osteogenesis imperfecta type I - mild disease
osteogenesis imperfecta type IV - moderately severe disease
Noonan's syndrome
osteogenesis imperfecta
retinoblastoma
Peutz-Jegher's syndrome
protein C deficiency
Sipple's syndrome
Sturge-Weber syndrome
tuberous sclerosis
Treacher-Collins syndrome
variegate porphyria
von Hippel-Lindau syndrome
von Willebrand's disease (congenital deficiency of von Willebrand's factor )
Wermer's syndrome
36
Autosomal Recessive - 1
## Footnote
oculocutaneous albinism
5 alpha reductase deficiency
abetalipoproteinaemia
alkaptonuria
alpha -1 - antitrypsin deficiency
apo C-II deficiency
Bartter's syndrome
cystinosis
cystinuria
Bloom's syndrome
Crigler-Najjar syndrome
congenital adrenal hyperplasia
factor XI deficiency
familial amaurotic idiocy
cystic fibrosis
Dubin-Johnson syndrome
galactosaemia
Gaucher's disease (GD)
hereditary haemochromatosis (HH)
homocystinuria
infantile polycystic kidney disease
Laron type dwarfism
Autosomal Recessive - 2
## Footnote
microcephaly (autosomal recessive)
ochronosis
osteogenesis imperfecta type II - perinatal lethal
Kugelberg-Welander disease
Hurler syndrome
polyglandular autoimmune syndrome I
limb girdle dystrophy
methaemoglobinaemia
Pendred's syndrome
Laurence-Moon-Biedl syndrome
marble bone disease
pseudoxanthoma elasticum
Prader-Willi syndrome
phenylketonuria
Refsum's disease
Smith-Lemli-Opitz syndrome
spinal muscular atrophy
Rotor's syndrome
severe combined immunodeficiency disease
sickle cell anaemia
Tay-Sachs disease
thalassaemia
vitamin D dependent rickets type I
Werdnig-Hoffman disease
Wilson's disease
xeroderma pigmentosum
Zellweger syndrome
37
X linked Recessive
## Footnote
adrenoleukodystrophy
Alport's syndrome
Becker muscular dystrophy
colour blindness
Duchenne muscular dystrophy
glucose-6-phosphate dehydrogenase deficiency
haemophilia
idiopathic hypoparathyroidism
Lesch-Nyhan syndrome
severe combined immunodeficiency disease
X-linked ichthyosis
X-linked agammaglobulinaemia of Bruton
38
Causes of Neonatal Jaundice
## Footnote
First 24 hrs:
Causes of jaundice in the first 24 hrs
rhesus haemolytic disease
ABO haemolytic disease
hereditary spherocytosis
glucose-6-phosphodehydrogenase deficiency
Day 2 - 14
Physiological jaundice
Causes of Neonatal Jaundice
**Prolonged jaundice**
* biliary atresia
* hypothyroidism
* galactosaemia
* urinary tract infection
* breast milk jaundice
* congenital infections e.g. CMV, toxoplasmosis
39
Gross Development Milestones
* 3 mths: Little/ no head lag on being pulled to sit, lying on abdomen with good head control, Held sitting, lumbar curve
* 6 mths: Lying on abdomen, arms extended, lying on back, lifts and grasps feet, pulls self to sitting, held sitting, back straight, rolls front to back
* 7-8 mths: Sits without support (Refer at 12 months)
* 9 mths: Pulls to standing, crawls
* 12 mths: Cruises, walks with one hand held
* 13-15 mths: Walks unsupported (refer at 18 months)
* 18 mths: Squats to pick up a toy
* 2 yrs: Runs, walks upstairs and downstairs holding on to rail
* 3 yrs: Rides a tricycle using pedals, walks up stairs without holding on to rail
* 4 yrs: Hops on one leg
40
Speech Milestones
* 3 mths: Quietens to parents voice, turns towards sound, squeals
* 6 mths: Double syllables 'adah', 'erleh'
* 9 mths: 'mama' and 'dada', nderstands 'no'
* 12 mths: Knows and responds to own name
* 12-15 mths: Knows about 2-6 words (Refer at 18 months), understands simple commands - 'give it to mummy'
* 2 yrs: Combine two words, points to parts of the body
* 2½ yrs: Vocabulary of 200 words
* 3 yrs: Talks in short sentences (e.g. 3-5 words), asks 'what' and 'who' questions, identifies colours, counts to 10 (little appreciation of numbers though)
* 4 yrs: Asks 'why', 'when' and 'how' questions
41
Strokes
* Anterior cerebral artery: Opposite side hemiparesis, sensory loss, LL \> UL
* Middle cerebral artery: Opposite side hemiparesis, sensory loss, UL \> LL, Opposite side homonymous hemianopia, Aphasia
* Posterior cerebral artery: Opposite side homonymous hemianopia with macular sparing, visual agnosia
* Weber's syndrome (branches of the posterior cerebral artery that supply the midbrain): Same side CN III palsy, weakness of upper and lower extremity
* Posterior inferior cerebellar artery (lateral medullary syndrome, Wallenberg syndrome): Ipsilateral facial pain and temperature loss, Contralateral: limb/torso pain and temperature loss, Ataxia, nystagmus
* Anterior inferior cerebellar artery (lateral pontine syndrome): Symptoms are similar to Wallenberg's (see above), but: Ipsilateral: facial paralysis and deafness
* Retinal/ophthalmic artery: Amaurosis fugax
* Basilar artery: 'Locked-in' syndrome
42
**Poisoning Management**
## Footnote
Paracetamol: Activated charcoal if \< 1 hour ago, N-acetylcysteine (NAC), liver transplantation
Salicylate: urinary alkalinization with IV bicarbonate, haemodialysis
Opioid/opiates: Naloxone
Benzodiazepines: Mainly supportive only, Flumazenil - risk of seizures only used with severe/ iatrogenic overdoses.
Tricyclic antidepressants: IV bicarbonate - reduces risk of seizures and arrhythmias in severe toxicity; for arrhythmias - class 1a (e.g. Quinidine) and class Ic antiarrhythmics (e.g. Flecainide) are contraindicated as they prolong depolarisation; Class III drugs such as amiodarone should be avoided as they prolong the QT interval. Response to lignocaine is variable and it should be emphasized that correction of acidosis is the first line in management of tricyclic induced arrhythmias; dialysis is ineffective in removing tricyclics
Lithium: for mild-moderate toxicity volume resuscitation with normal saline, haemodialysis needed when severe, sodium bicarbonate is sometimes used - increasing the alkalinity of urine, promotes lithium excretion
Warfarin: Vitamin K, prothrombin complex
Heparin: Protamine sulphate
Beta-blockers: If bradycardic then atropine, in resistant cases glucagon may be used
**Poisoning Management**
## Footnote
Ethylene glycol: ethanol -used for many years, works by competing with ethylene glycol for the enzyme alcohol dehydrogenase - this limits the formation of toxic metabolites (e.g. Glycoaldehyde and glycolic acid) which are responsible for the haemodynamic/metabolic features of poisoning, **fomepizole, an inhibitor of alcohol dehydrogenase, is now used first-line in preference to ethanol**, haemodialysis also has a role in refractory cases
Methanol poisoning: Fomepizole or ethanol, haemodialysis
Organophosphate insecticides: atropine the role of pralidoxime is still unclear - meta-analyses to date have failed to show any clear benefit
Digoxin: Digoxin-specific antibody fragments
IronDesferrioxamine, a chelating agent
Lead: Dimercaprol, calcium edetate
Carbon monoxide: 100% oxygen, hyperbaric oxygen
Cyanide: Hydroxocobalamin; also combination of amyl nitrite, sodium nitrite, and sodium thiosulfate
43
Causes of Dysphagia
**Extrinsic**
* Mediastinal masses
* Cervical spondylosis
**Oesophageal wall**
* Achalasia
* Diffuse oesophageal spasm
* Hypertensive lower oesophageal sphincter
**Intrinsic**
* Tumours
* Strictures
* Oesophageal web
* Schatzki rings
**Neurological**
* CVA
* Parkinson's disease
* Multiple Sclerosis
* Brainstem pathology
* Myasthenia Gravis
44
Contraindication to thrombolysis after MI
Thrombolysis done with streptokinase
* Any bleeding/ trauma/ operation/ dental extraction
* Coma
* Pericarditidis
* Pulmonary cavitation
* Pancreatitis
* Peptic Ulcer
* Oesophageal varices
* Endocarditis
* Severe HTN
* Aortic aneurysm/ Aortic dissection
* Coagulation defect
* Bacterial endocarditis
* Bleeding disorders
45
Learning Difficulty Classification
Based on IQ
* Mild IQ 50-69
* Moderate IQ 35 - 49
* Severe IQ 20 - 34
* Profound. IQ \<20
46
Classification of Obesity
Based on BMI
* Normal BMI 18.5 - 24.9
* Overweight BMI 25 - 29.9
* Obesity Grade 1 BMI 30 - 34.9
* Obesity Grade 2 BMI 35 - 39.9
* Obesity Grade 3. BMI \> 40
47
Causes of Hyperprolactinaemia
* Physiological - pregnancy, puerperium, excessive exercise
* Endocrine - Hypothyroidism, Cushing's syndrome
* Metabolic - Chronic Renal Failure
* Tumours - Pituitary adenomas
* Traumatic - Head Injury, brain surgery
* Drugs - Risperidone, Metoclopromide, Domperidone, Tricyclic Antidepressant
48
**Autoimmune Disease Association with MHC Antigens**
## Footnote
https://www.immunopaedia.org.za/immunology/advanced/10-antibody-mediated-autoimmune-diseases/
Addison's disease DR3 RR 6
Ankylosing spondylitis B27 RR 70 - 100
Behcet's syndrome B51 RR 3–6
Celiac disease. DR3, DQA1\*0501, DQβ1\*0201 RR \> 200
Congenital adrenal hyperplasia. B47 RR 15
Dermatitis herpetiformis. DR3 RR 15–18
Goodpasture syndrome DR2 RR 16–20
Graves' disease DR3 RR 4
**Autoimmune Disease Association with MHC Antigens**
## Footnote
Hashimoto's disease. DR11 RR 3
Hereditary hemochromatosis A3/B14 RR 90
Insulin-dependent diabetes mellitus B35, Cw04 RR 1–3
Idiopathic membranous glomerulonephritis DR3 RR 12
Multiple sclerosis. DR2, DQ6 RR 5–12
Myasthenia gravis DR3 RR 10
Narcolepsy DR2, DQβ1\*0602. RR 130
Psoriasis vulgaris. Cw613
Pemphigus vulgaris. DRβ1\*0402-DQβ1\*0302 RR 14–21
DRβ1\*1401-DQβ1\*0503
Rheumatoid arthritis. DR4 RR 4–10
Systemic lupus erythematosus DR3 RR 3–6
Sarcoidosis DRβ1\*1101 RR 1.5–3.6
49
**Autoimmune Disease and AutoAntibody**
**https://youtu.be/bXecMhv-ZzE**
**Systemic Antibodies:**
Antinuclear Antibodies (ANA) - SLE
Antineutrophil Cytoplasmic Antibodies (ANCA) - Vasculitis affecting lungs and kidneys (Wegener's, polyangitis, polyarteritis)
Anti-Double Stranded DNA (anti-dsDNA): SLE
Anticentromere Antibodies (ACA): Limited scleroderma (CREST syndrome)
Antihistone Antibodies: Drug induced SLE
Cyclic Citrullinated Peptide Antibodies (CCP) - Rheumatoid Arthritis
Extractable Nuclear Antigen Antibodies e.g., anti-SS-A (Ro) and anti-SS-B (La) - in Sjogren's syndrome, anti-RNP (ribonucleic proteins) like anti-Jo-1 (anti-tRNA synthetase in polymyositis/ dermatomyositis), anti-Sm, anti -Scl-70 (also called anti-DNA Topoisomerase 1 - found in diffuse scleroderma), Anti PM1 in polymyositis, Anti C-anca in Wegener's ds, Anti U1RNP in Mixed connective tissue ds
Rheumatoid Factor (RF) also called Anti IgG - in Rheumatoid Arthritis.
**Organ-specific autoantibodies**
*Clotting (coagulation) system*
* Cardiolipin Antibodies
* Beta-2 Glycoprotein 1 Antibodies - Antiphospholipid Syndrome
* Glycoprotein IIb/IIIa: Immune thrombocytopenic purpura
* Antiphospholipid Antibodies (APA)
* Lupus anticoagulants (LA)
*Endocrine/metabolic system*
* Islet Autoantibodies in Diabetes
* Anti-glutamate debarboxylase - T1DM
*Gastrointestinal tract*
* Anti-Tissue Transglutaminase (anti-tTG), Anti-Gliadin Antibodies (AGA) & Anti-endomysial - Coeliac disease (there is deficiency og IgA in 3% of patients)
* Intrinsic Factor Antibodies
* Parietal Cell Antibodies
*Thyroid*
* Anti-Thyroid Peroxidase, TSH receptor antibodies - Graves Disease
* Anti-microsomal & Anti-thyroglobulin - Hashimoto's disease
*Liver*
* Smooth Muscle Antibodies (SMA) and F-actin Antibody - Autoimmune Hepatitis
* Antimitochondrial Antibodies (AMA) and AMA M2 - Primary Biliary Cirrhosis
* Liver Kidney Microsome Type 1 Antibodies (anti-LKM-1)
* Kidney*
* Anti-Glomerular Basement Membrane (GBM) - Goodpasture's Syndrome
* Muscles*
* Acetylcholine Receptor (AChR) Antibodies - Myasthenia gravis
* Skin*
* Anti-Desmoglein - Pemphigus Vulgaris
50
Drugs affecting coagulation
Anti-platelet
Anti coagulants
Thrombolytics
**Anti-platelets**
* Aspirin - inhibits COX1 and so inhibit thromboxane release
* Clopidogrel, ticagrelor, prasugrel, ticlopidine - Inhibit P2Y12 receptors for ADP binding
* Abciximab, eptifibatide, tirofimab -GPIIb/IIIa inhibitors (prevent fibrinogen cross-linking - can be given iv
* Dipyridamole, cilostazole -Phosphodiesterase inhibitors - raise cAMP and promote vasodilation
**Anti-coagulants**
* Heparin - inactivates both Xa and thrombin formation by binding to antithrombin IIIa
* Enoxaparin, dalteparin (LMWH) - accelerate inactivation of Xa by binding to antithrombin III a
* Fondaparinux - directly accelerates inactivation of Xa
* Apixaban, rivaroxaban - bind to active site of Xa and prevent conversion of prothrombin to thrombin- oral
* Argatroban, dapigatran - univalent binding (Xa receptor), direct thrombin inhibitor
* Bivalirudin, desirudin - bivalent binding (Xa and prothrombin exosite receptor), direct thrombin inhibitor
* Warfarin - reduces activation of II, VII, IX & X through inhibition of Vit K epoxide reductase, INR, narrow therapeutic index, antidote vit K
**Thrombolytics**
Alteplase, Reteplase, Tenecteplase
Urokinase, Streptokinase
Antidotes: Protamine sulphate, Vit K, aminocaproic acid, tranexamic acid
51
**Side/ Adverse effects of Drugs**
## Footnote
**Antibiotics**:
Amoxicillin: diarrohoea, nausea, non allergic rash
Azithromycin - hearing loss and tinnitus
Doxicycline - photosensitivity, skin rash - DRESS, Stevens Johnson Syndrome
Gentamicin: nephrotoxicity (acute tubular necrosis), ototoxicity (irreversible auditory or vestibular nerve damage)
Macrolides like clarithromycin, erythromycin: prolongation of the QT interval, GI side-effects, Nausea is less common with clarithromycin than erythromycin, cholestatic jaundice: risk may be reduced if erythromycin stearate is used, P450 inhibitor (see below)
Metronidazole: metallic taste, nausea, disulfiram like reaction
Mefloquine: Neuropsychiatric
Proguanil:
Quninine:
Chloroquin:
Isoniazid: Peripheral neuropathy, headache
Rifampicin: orange urine, p450 inducer
Ethambutol: Optic neuritis
Pyrizinamide:
**CVS**:
Amiodarone: corneal deposits, photosensitivity (grey slate), hypo - and hyperthyroidism, pulmonary fibrosis, deranged LFT, peripheral nephropathy, low K (pre rx tests - CX`R, LFT, U &E, TFT; after 6/12 TFT & LFT)
Verapamil: Ca Channel Blocker (CCB) - Heart failure, constipation, hypotension, bradycardia, flushing, heart block if when given with Beta blocker (BB)
Diltiazem: Ca Channel Blocker (CCB - Hypotension, bradycardia, heart failure, ankle swelling, Caution with heart failure or BB
Amlodipine, Nifidepine, Felodipine (CCB) - Flushing, headache, ankle swelling, gingival hyperplasia, diarrhoea
Beta blockers - bisoprolol: peripheral coldness due to vasoconstriction, hypotension and bronchospasm, erectile dysfunction
Digoxin: Yellow/ Orange vision
Bendroflumethiazide:
Beta blockers - bisoprolol: peripheral coldness due to vasoconstriction, hypotension and bronchospasm
**CNS**
Lithium: increased thirst, polyuria, metallic taste, fine tremor, weight gain
Mirtazapine - shows noradrenergic and serotonergic activity -drowsiness, increased appetite, dry mouth, or constipation, agitation, aggression and forgetfulness - not to use mirtazapine with buspirone, fentanyl lithium tryptophan, St. John's wort, or migraine/pain medicines (triptans, tramadol), best to stop drinking alcohol
Sodium Valproate: hair loss, nausea, diarrhoea, weight gain, drowsiness, suicidal thoughts, inhibits P450
Phenytoin - Gingival hyperplasia
Phenobarbital
Sodium Valproate
Carbamazepine
Ethosuximide
**Hormonal**
Tamoxifen: Hot flushes, Amenorrhoea, PV bleeding, Endometrial Ca, Alopecia, cataracts, VTE (Raloxifene - less endometrial Ca)
Goserelin: hot flashes (flushing), dizziness, headache, increased sweating, increased or decreased sexual interest, impotence, fewer erections than usual, trouble sleeping, nausea, breast swelling or tenderness, vaginal dryness/itching/discharge, hair loss, mental/mood changes (such as depression, mood swings, hallucinations)
injection site reactions (pain, bruising, bleeding, redness, or swelling), bone pain, diarrhea, constipation, sleep problems (insomnia), acne, or skin rash or itching
Sildenafil (Viagra): Blue vision, nasal congestion, flushing, GI side - Other drugs - tadalfil, vardenafil
(contd)
## Footnote
ACE inhibitors: hypotension, renal dysfunction, dry cough
Angiotensin II Receptor Blockers
Clopidogrel: GI symptoms, bleeding
Sulfasalazine (DMARD) - oligospermia, Stevens-Johnson syndrome, pneumonitis / lung fibrosis, myelosuppression, Heinz body anaemia, megaloblastic anaemia, may colour tears → stained contact lense
Methotrexate: Myelosuppression, Liver cirrhosis, Pneumonitis
Leflunomide: Liver impairment, Interstitial lung disease, Hypertension
Hydroxychloroquine: Retinopathy, Corneal deposits
Prednisolone: Cushingoid features, Osteoporosis, Impaired glucose tolerance, Hypertension, Cataracts
Cyclosporin: gingival hyperplasia
Azathioprine - bone marrow depression, nausea/vomiting, pancreatitis, increased risk of non-melanoma skin cancer
Gold: Proteinuria
Penicillamine: Proteinuria, Exacerbation of myasthenia gravis
Etanercept: Demyelination, Reactivation of tuberculosis
Infliximab: Reactivation of tuberculosis
Adalimumab: Reactivation of tuberculosis
Rituximab: Infusion reactions are common
NSAIDs (e.g. naproxen, ibuprofen): Bronchospasm in asthmatics, Dyspepsia/peptic ulceration
Cimedidine
Ranitidine
Ondansteron
**Alpha-1 antagonists e.g. tamsulosin, alfuzosin** - dizziness, postural hypotension, dry mouth, depression
**5- alpha reductase inhibitor - Finasteride:** erectile dysfunction, reduced libido, ejaculation problems, gynaecomastia
Isoretinoin: dry skin, hair loss, hyperlipidaemia,
52
Causes of Clubbling
Respiratory - Lung cancer, abscess, bronchiectasis, empyema, Interstitial lung disease,fibrosing alveolitis, cystic fibrosis
Cardiac - atrial myxoma, congenital heart disease, infective endocarditis
GI - Inflammatory bowel disease, Coeliac disease, Primary Biliary Cirrhosis, GI myxoma
Miscellaneous - pregnancy, familial, thyroid acropachy, congenital
53
**NYHA Classification of Heart failure**
Class 1 - No limitation of physical activity, comfortable with physical activity
Class 2 - Slight limitation of physical activity, comfortable at rest, symptom with ordinary activity
Class 3 - Marked limitation of physical activity, comfortable at rest, symptom with less than ordinary activity
Class 4 - Inability to do any physical activity without symptoms
54
**P450 System of Drug Metabolism**
Inducers: enhance metabolism and clearance, reduce effectiveness
Inhibitors: Delay metabolism, increase therapeutic conc, increase side/ adverse effects
CYP 1A2 - AcetAminophen
CYP 2E1 - Alcohol
CYP 2C9 - Warfarin
CYP 2D6 - CVS drugs
CYP 3A4 - most common
**P450 Inducers: P450 Inhibitors**
## Footnote
Carbamazepine Valproate
Rifampicin Ketoconazole
Alcohol Isoniazid
Phenytoin Sulphonamide
Griseofulvin Chloramphenicol
Phenobarbital Amiodarone
Sulphonylureas Erythromycin
Quinidine
Grapefruit Juice
CRAP GPS induces rage
VK IS CA EQG
55
**Clinical Tests for MSK conditions**
## Footnote
Lachman - Anterior Cruciate Liament Injury
Finkelstein
Trendelenburg
McMurray
Babinsky
Faber
Thomson's - achilles tendon rupture
Barlow
Ortolani
Tinel
56
**Clinical Scores**
## Footnote
APGAR: assesses health of newborn at birth - (Appearance, Pulse, Grimace, Activity, Respiration)
CHA2DS2-VaSC: risk of stroke in AF patients. CHF, HTN, Age (65-74 & \>75), Diabetes, Stroke/TIA, Vascular ds, sex
HAS BLED: risk of bleeding in patients of AF on anticoagulant. HTN, abnormal LFT/ RFT, Stroke, bleeding, labile INR, elderly, drugs (NSAID, aspirin, clopidogrel) or alcohol use \> 8 units/ week
NYHA: Severity of heart failure (1 - 4 increasing severity)
CURB 65: Risk scoring for pneumonia severity for inpatient/ outpatient Rx, Confusion, urea \> 19mg/dl (7 mmol/l), RR \>30, BP \<90/60 for site of care, severity of pneumonia & choice of abx
Glasgow Coma Scale:
Wells Score for DVT
Wells Score for PE
Child Pugh Score: Assesses severity of liver cirrhosis
DAS 28: Disease Activity Score in RA
Ranson Criteria: For Acute Pancreatitis (G-A-L-L/ E-T-O-H - Glucose, Age \> 55, Leucocytes, LFT; Electrolytes - low Ca, Third spacing - raised urea, hypovolemia, Oxygen low, Haematocrit
IPSS: Intenational Protate Symptom Score
Gleason Score - Prognosis in Prostate Ca
Waterlow Score: Risk of developing pressure sore
FRAX: estimation of 10 year of developinh osteoporosis related fracture
Epworth: Assess obstructive sleep apnoea
MMSE (Mini mental state examination), assess cognitive impairment
AMTS: Abbreviated Mental Test Score to rapidly assess elderly patients for the possibility of dementia.
HAD: Hospital anxiety & Depression scale, assess severity of anxiety depressionPatient Health Questionnaire, assess severity of depression
GAD - 7: Screening generalised anxiety disorder
PHQ-9: Patient Health Questionnaire to assess severity of depression
Edinburgh Postnatal Depression Scale: Screen for PND
SCOFF: To detect Eating disorder and aid treatment
AUDIT: Alcohol misuse screening
CAGE: Alcohol misuse screening
FAST: Alcohol misuse screening
57
**Conversion of Opiate Dose**
Oral morphine to Subcutaneous morphine - Divide by 2
Oral morphine to Subcutaneous diamorphine - Divide by 3
Oral oxycodone to Subcutaneous diamorphine - Divide by 1.5
Oral codeine to Oral morphine - Divide dose by by 10
Oral tramadol to Oral morphine - Divide by 10
Oral morphine to Oral oxycodone - Divide by 1.5-2
Transdermal fentanyl 12 mcg patch = 30 mg oral morphine/ d
Transdermal buprenorphine 10 mag patch = 24 mg oral morphine/d
58
**Paraneoplastic syndromes**
## Footnote
Paraneoplastic syndromes - group of rare disorders triggered by abnormal immune system response to neoplasm.
Happens when cancer-fighting antibodies or white blood cells (known as T cells) mistakenly attack normal cells in the nervous system
Progressive neurological damage.
No cures
Stage of cancer at diagnosis determines outcome.
Gastric Ca - Acanthosis Nigricans
Lung Ca
Small Cell - Hyponatraemia(SIADH); SVC syndrome, Eaton Lambert Syn, Cushing syn (inc ACTH), carcinoid (flushing&diarrhoea)
Squamous cell - Hypercalcaemia (PTH rp), Horner's syn (ptosis, miosis & anhydrosis), Pancoast's tumour - T1&2 nerve, shoulder pain & ulnar nv pain)
Large Cell - SVC syn, gynaecomastia
Adenoca - Pulmonary osteoarthropathy,
Breast Ca -
Ovarian Ca -
Lympatic system Ca - Hodgkin’s disease (PCD)
Testicular cancer (brainstem and limbic encephalitis),
Neuroblastoma (opsoclonus–myoclonus).
59
Strokes
80% ischaemic
20% haemorrhagic
Anterior cerebral artery: Contralateral hemiparesis and sensory loss, lower extremity \> upper
Middle cerebral artery: Contralateral hemiparesis and sensory loss, upper extremity \> lower
Contralateral homonymous hemianopia, Aphasia
Posterior cerebral artery: Contralateral homonymous hemianopia with macular sparing,Visual agnosia
Weber's syndrome (branches of the posterior cerebral artery that supply the midbrain): Ipsilateral CN III palsy
Contralateral weakness of upper and lower extremity
Posterior inferior cerebellar artery (lateral medullary syndrome, Wallenberg syndrome): Ipsilateral: facial pain and temperature loss, Contralateral: limb/torso pain and temperature loss, Ataxia, nystagmus
Anterior inferior cerebellar artery (lateral pontine syndrome): Symptoms are similar to Wallenberg's (see above), but:
Ipsilateral: facial paralysis and deafness
Retinal/ophthalmic artery: Amaurosis fugax
Basilar artery: 'Locked-in' syndrome
60
**Delusions**
Capgras - belief that friends/ family members have been replaced by an identical looking imposter
Othello - belief that partner is committing infidelity
Cotard - belief that insides are rotting as one is deceased
De Clerambault (erotomania), belief that a person of a higher social/ professional standing is in love with them
Ekbom - belief that they are infected with parasites or have 'bugs' under their skin - delusional parasitosis
61
NICE Traffic light system for disease in children
1. Colour
2. Activity
3. Respiration
4. Hydration & Circulation
5. Others
Green – low risk
Amber – intermediate risk
Red – high risk
Colour
(of skin, lips or tongue)
• Normal colour
Activity
• Responds
normally to
social cues
Content/smiles
Stays awake
or awakens
quickly
Strong normal
cry/not crying
• Pallor reported by parent/carer
social cues
No smile
Wakes only with prolonged
stimulation
Decreased activity
* Pale/mottled/ashen/ blue
* Not responding normally to
* No response to
social cues
Appears ill to a
healthcare
professional
Does not wake or if
roused does not
stay awake
Weak, high-pitched
or continuous cry
Respiratory
• Nasal flaring • Tachypnoea:
- RR \>50 breaths/
minute, age 6–12 months
- RR \>40 breaths/ minute, age \>12 months
Oxygen saturation ≤95% in air
Crackles in the chest
Grunting
Tachypnoea:
RR \>60
breaths/minute
Moderate or severe
chest indrawing
Circulation and hydration
Normal skin and eyes
Moist mucous membranes
Tachycardia:
- \>160beats/minute,
age \<12 months
- \>150beats/minute, age 12–24 months - \>140beats/minute,
age 2–5 years
CRT ≥3 seconds
Dry mucous membranes
Poor feeding in infants
Reduced urine output
• Reduced skin turgor
Other
• None of the amber or red symptoms or signs
Age 3–6 months, temperature ≥39°C
Fever for ≥5 days
Rigors
Swelling of a limb or joint
Non-weight bearing limb/not
using an extremity
Age \<3 months, temperature
≥38°C\*
Non-blanching rash
Bulging fontanelle
Neck stiffness
Status epilepticus
Focal neurological
signs
Focal seizures
CRT, capillary refill time; RR, respiratory rate
\* Some vaccinations have been found to induce fever in children aged under 3 months This traffic light table should be used in conjunction with the recommendations in the NICE guideline on fever in under 5s.
62
**Causes of Mydriasis**
_Large pupil_
* 3rd nerve palsy
* Holmes-Adie pupil
* Traumatic iridoplegia
* Phaeochromocytoma
* Congenital
* Drugs: topical - tropicamide, atropine; sympathomimetic drugs: amphetamines, cocaine, anticholinergic drugs: tricyclic antidepressants
Anisocoria - unequal pupils, sympathetic palsy - cortical, pre- and post ganglionic
Small pupil: Horner's syndrome, Argyll Robertson,
**Pupillary conditions**
## Footnote
Marcus Gunn - both pupils dilate to swinging light
Argyll Robertson
Holmes Adie
Horner's
Acute angle closure glaucoma Primary open angle glaucoma
63
**Heart Failure**
## Footnote
ability of the heart to maintain the circulation of blood is impaired as a result of a structural or functional impairment
symptoms - SOB, fluid retention, and fatigue
signs: SOB, basal crepitations, and peripheral oedema, reduced/ preserved ejection fraction.
New York Heart Association (NYHA) functional classification.
most common underlying cause is coronary artery disease.
Complications - arrhythmias, depression, cachexia, CKD, sexual dysfunction, and sudden cardiac death.
Prognosis: 50% of people with heart failure die within 5 years of diagnosis, and about 40% of people admitted to hospital with heart failure die or are readmitted within 1 year. High levels of NT‑proBNP carry a poor prognosis
Ix:
NT‑proBNP level above 2,000 ng/litre (236 pmol/litre) - specialist assessment and transthoracic echocardiography \< \< 2 weeks.
NT‑proBNP level between 400 and 2,000 ng/litre (47 to 236 pmol/litre) - specialist referral and transthoracic echocardiography \< 6 weeks.
Arrange 12-lead ECG for all
**Management**
## Footnote
A loop diuretic may - for symptom relief while awaiting specialist assessment.
To relieve symptoms of fluid overload, a diuretic should be prescribed.
To reduce morbidity and mortality - angiotensin-converting enzyme (ACE) inhibitor and a beta-blocker should be prescribed. One drug should be introduced at a time, adding the second drug once the person is stable on the first drug.
If symptomatic despite optimal treatment with an ACE-inhibitor and beta-blocker - arrange specialist referral
heart failure with preserved ejection fraction - a low to medium dose diuretic should be prescribed and specialist referral
antiplatelet drug and statin should be considered.
Comorbidities and precipitating factors should be managed.
Screening for depression or anxiety should be undertaken.
Supervised exercise-based rehabilitation programme should be offered.
Appropriate vaccinations .
Self-care advice
Nutritional status - assess.
Follow-up and advanced care planning should be offered, if appropriate.
Women of child-bearing age should be given advice about contraception and pregnancy.
64
**Antidepressants**
Act by improving the levels of Serotonin, Dopamine, & Norepinephrine at synaptic junctions
**Categories of Antidepressants**
* SSRI (Selective Serotononin Reuptake Inhibitors) - fluoxetine (1st choice - in young \<30, Citalopram in elderly), Sertraline (in presence of Heart Conditions, in post natal depression)
* SNRI (Serotonin and Norepinephrine Uptake) Inhibitors: Duloxetine, Venlafaxine
* TCI (Tricyclic Inhibitor Antidepressants): Amitrptiline, Desipramine, imipramine
* MAOI (Monoamine Oxidase Inhibitor): Selegeline, phenelzine, Isocarboxazid
* NDRI (Norepinephrine and Dopamine Reupdake Inhibitors): Bupropion
* Tetracyclics - Mirtazapine; stops neurotransmitters from binding to receptors
* (SARI) Serotonin Antagonist and reuptake inhibitors; Nefaxodone, trazodone
65
**Acute Coronary syndrome**
**Non STEMI**
**STEMI**
**https://youtu.be/TBG9Jw3yd9I**
NSTEMI - Subendocardial infarct - ST depression
STEMI - Transmural infarct - ST elevation
Anteroseptal - Left anterior descending - V1-V4
Inferior - Right coronary - II, II, aVF
Anterolateral - Left ant descending/ left circumflex - V4-V6, I, aVL
Lateral - Left Circumflex - 1, aVL, +/- V5-6
Posterior - left circumflex, right coronary - Tall R waves in V1-2
T/t - initial M-O-N-A: Morphine, Oxygen if sats \< 94%, Nitrates, Aspirin
then, PCI within 90%, if not possible then Thrombolysis (TPA, streptokinase, tenecteplase, ateleptase)
Long term: A-B-A-S (ACE inhibitor, Beta blocker, Aspirin+Clopidogrel, Statin)
No driving for 4 weeks after MI, No driving for 1 week after successful PCI
66
**Diet**
* Cardiovascular diseases
* Coronary artery disease,
* Hypertension
* Heart attacks
* Stroke.
* Diabetics
* GI diseases - Crohn's disease, ulcerative colitis and celiac disease
Cardioprotective diet:
Anti-Diabetic diet: high fibre, high glycaemic index
Crohn's ds: Gluten and diary free diet
IBS: low sugar, low fibre (only soluble sugar), low fat, FODMAP (fermentable oligo, di-, mono-
67
**Drug Side effects**
## Footnote
Causing **impaired glucose tolerance:** thiazide diuretics typical antipsychotics, goserelin
Causing **hypoglycaemia:** Beta blockers, disopramide, pentamidine, quinine, sulphonylurea, sulphonamide, salicylates
Drugs causing hyperlipaemia: **hyperlipidaemia**: thiazide diuretics, beta adrenergic blockers, anabolic steroids, prednisolone, estrogens, androgens, immunosuppressive, antineoplastic, atypical antipsychotics, HIV protease inhibitors, amiodarone, cyclosporin, olanzapine
Drugs causing **hyponatraemia**: ACEI, Heparin, Diuretics, Antidepressants, antipsychotics, carbamazepine
Causing **hyperprolactinaemia**: haloperidol and chlorpromazine, atypical antipsychotics
Causing **gynaecomastia**: **D-I-S-C-O-S** Digoxin, Isoniazid, Spironolactone, Cimetidine, Oestrogen, Stilboesterol Finasteride, antipsychotics, alcohol, keoconazole, methadone
Causing **erectile dysfunction: S-T-O-P** SSRI, Thioridazine, Methyldopa, Propanolol
Causing o**steoporosis:** steroids, alcohol, antiepileptic, lithium, cytotoxic drugs, cyclosporin
Drugs causing **psychosis**: steroids,
Causing **long QT**: Citalopram, low K, haloperidol and chlorpromazine
Drugs causing **bradycardia:** beta blockers, clonidine, lithium, opiates, phenytoin, neostigminr, TCA, phenylpropanolamine, lidocaine, mexiletene, beta blockers, amiodarone, sotalol, ticagrelor
Drugs causing **bronchospasm**: NSAID, aspirin
Drugs causing **erythema nodosum**: streptococcal infections, sarcoidosis, inflammatory bowel disease and drugs (penicillins, sulphonamides, oral contraceptive pill)
Worsening **Psoriasis**: Alcohol, lithium, beta blockers, NSAIDs, antimalarials (chloroquine and hydroxychloroquine), ACE inhibitors, infliximab, withdrawal of systemic steroid
Causing **hair loss:** Isoretinoin**,** ACEI**,** lithium, heparin, allopurinol, antidepressants, chemotherapy drugs
Causing **SLE**: Hydralazine, Minocycline, Methadone, Procainamide, Chlorpromazine, Quinidine
Causing **gout:** diuretics: thiazides, furosemide, ciclosporin, alcohol, cytotoxic agents, pyrazinamide, aspirin
Causing Interstitial pulmonatry fibrosis: methotrexate, sulfasalzine
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**Myocardical Infarction**
https://youtu.be/TBG9Jw3yd9I
* Anteroseptal - V1-V4: Left anterior descending
* Inferior - II, III, aVF: Right coronary
* Anterolateral - V4-6, I, aVL: Left anterior descending or left circumflex
* Lateral - I, aVL +/- V5-6: Left circumflex
* Posterior - Tall R waves V1-2: Usually left circumflex, also right coronary
* Septal = V1-2
* Anterior = V2-5
* Extensive anterior / anterolateral = V1-6, I + aVL
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**Heart Block**
https://youtu.be/d8b3VeT77IE
70
COC preparations
Ethinylestradiol 20 microgramsDesogestrel 150 microgramsGedarel® 20/150
Ethinylestradiol 20 microgramsDesogestrel 150 microgramsMercilon®
Ethinylestradiol 20 microgramsGestodene 75 microgramsFemodette®
Ethinylestradiol 20 microgramsGestodene 75 microgramsMillinette® 20/75
Ethinylestradiol 20 microgramsGestodene 75 microgramsSunya® 20/75
Ethinylestradiol 20 microgramsNorethisterone acetate 1 mgLoestrin® 20
Ethinylestradiol 30 microgramsDesogestrel 150 microgramsGedarel® 30/150
Ethinylestradiol 30 microgramsDesogestrel 150 microgramsMarvelon®
Ethinylestradiol 30 microgramsDrospirenone 3 mgYasmin®
Ethinylestradiol 30 microgramsGestodene 75 microgramsFemodene®
Ethinylestradiol 30 microgramsGestodene 75 microgramsKatya® 30/75
Ethinylestradiol 30 microgramsGestodene 75 microgramsMillinette® 30/75
Ethinylestradiol 30 microgramsLevonorgestrel 150 microgramsLevest®
Ethinylestradiol 30 microgramsLevonorgestrel 150 microgramsMicrogynon® 30
Ethinylestradiol 30 microgramsLevonorgestrel 150 microgramsOvranette®
Ethinylestradiol 30 microgramsLevonorgestrel 150 microgramsRigevidon®
Ethinylestradiol 30 microgramsNorethisterone acetate 1.5 mgLoestrin® 30
Ethinylestradiol 35 microgramsNorgestimate 250 microgramsCilest®
Ethinylestradiol 35 microgramsNorethisterone 500 microgramsBrevinor®
Ethinylestradiol 35 microgramsNorethisterone 1 mgNorimin®
Mestranol 50 microgramsNorethisterone 1 mgNorinyl-1®
Ethinylestradiol 30 microgramsGestodene 75 microgramsFemodene® ED
Ethinylestradiol 30 microgramsLevonorgestrel 150 microgramsMicrogynon® 30 ED
Estradiol (as hemihydrate) 1.5 mgNomegestrol acetate 2.5 mgZoely®
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PE and ECG
* Sinus tachycardia (44%) – the most common abnormality
* Complete or incomplete RBBB (18%) – associated with increased mortality
* Right ventricular strain pattern (34%)– T wave inversions in the right precordial leads (V1-4) ± the inferior leads (II, III, aVF).
* Right axis deviation – seen in 16% of patients. Extreme right axis deviation may occur, with axis between zero and -90 degrees, giving the appearance of left axis deviation **(“pseudo left axis”**).
* Dominant R wave in V1 – a manifestation of acute right ventricular dilatation.
* Right atrial enlargement (P pulmonale) 9% – peaked P wave in lead II \> 2.5 mm in height.
* SI QIII TIII pattern (20%) – deep S wave in lead I, Q wave in III, inverted T wave in III. This “classic” finding is neither sensitive nor specific for pulmonary embolism
* Clockwise rotation – shift of the R/S transition point towards V6 with a persistent S wave in V6 (“pulmonary disease pattern”), implying rotation of the heart due to right ventricular dilatation.
* Atrial tachyarrhythmias (8%) – AF, flutter, atrial tachycardia.
* Non-specific ST segment and T wave changes, including ST elevation and depression (50%)
* Simultaneous **T wave inversions in the inferior (II, III, aVF)** and right precordial leads (V1-4) is the **most specific** finding in favour of PE
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**Rashes**
## Footnote
**Childhood**
chicken pox (VZ virus)- macular, papular vesicular and scabbing - head to trunk
Measles (Measles virus): **koplik's - grains of salt**, blotchy maculopapular rash
mumps (mumps virus): parotid swelling and earache
rubella (rubella virus): pink maculopapular suboccipital and postauricular
Erythema infectiosum (parvo virus): '**Slapped-cheek**' rash, proximal arms - extensor
Scarlet fever (Grp A Strep): **'Strawberry' tongue**, Rash - fine punctate erythema sparing mouth - **perioral pallor**
Hand, foot and mouth disease - sore throat, feverVesicles in the mouth and on the palms and soles of the feet
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Leukaemias
ALL: children ~ 10, myeloperoxidase neg, LN enlargement, fatigue and flu like,, immature lymphocytes, cytarabine for t/t
CML: Middle age ~40, myeloid chain ,defect mature neutrophils, philadelphia chromosome, Imatinib for t/t
AML: Middle age ~50, pancytopaenia, immature neutrophils, myeloperoxidase +, Auer bodies, ATRA and Vit A
CLL: Elderly ~80, mature lymphocytosis, LNs enlarged, weight loss, night sweats No Rx
MSRA Revision
flashcards
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