0015 key points 2015
TRANSCRIPT
8/18/2019 0015 Key Points 2015
http://slidepdf.com/reader/full/0015-key-points-2015 1/29
Cardiology
Streptococcus bovis endocarditis is associated with colorectal cancer
Aortic dissection
• type A - ascending aorta - control BP(IV labetalol) + surgery
• type B - descending aorta - control BP(IV labetalol)
Aortic stenosis - S4 is a marker of severity
Aortic stenosis - most common cause:
• younger patients < 65 years: bicuspid aortic valve
• older patients > 65 years: calcification
Aortic stenosis management: AVR if symptomatic, otherwise cut-off is gradient of 50 mmHg
Atrial fibrillation - cardioversion: amiodarone + flecainide
Atrial fibrillation: rate control - beta blockers preferable to digoxin
Bosentan - endothelin-1 receptor antagonist
Calcium channel blockers are now preferred to thiazides in the treatment of hypertension
Complete heart block following a MI? - right coronary artery lesion
Complete heart block following an inferior MI is NOT an indication for pacing, unlike with an
anterior MI
Congenital heart disease
• cyanotic: TGA most common at birth, Fallot's most common overall
• acyanotic: VSD most common cause
DVLA advice following angioplasty - cannot drive for 1 week
DVLA advice post MI - cannot drive for 4 weeks
Flash pulmonary oedema, U&Es worse on ACE inhibitor, asymmetrical kidneys → renal
artery stenosis - do MR angiography
HOCM is the most common cause of sudden cardiac death in the young
Hypertension - NICE now recommend ambulatory blood pressure monitoring to aid
1
8/18/2019 0015 Key Points 2015
http://slidepdf.com/reader/full/0015-key-points-2015 2/29
diagnosis
Hypertension - step 4
• K+ < 4.5 then spironolactone
• K+ > 4.5 then higher-dose thiazide-like diuretic
Inferior MI - right coronary artery lesion
JVP:C wave -closure of the tricuspid valve
Labetalol is first-line for pregnancy-induced hypertension
Methadone is a common cause of QT prolongation
Most common cause of endocarditis:
• Streptococcus viridans
• Staphylococcus epidermidis if < 2 months post valve surgery
Myoglobin rises first following a myocardial infarction
Patent ductus arteriosus - collapsing pulse
Patients with established CVD should take atorvastatin 80mg on
Prosthetic heart valves - mechanical valves last longer and tend to be given to younger
patients
Second heart sound (S2)
• loud: hypertension
• soft: AS
• fixed split: ASD
• reversed split: LBBB
Sudden death, unusual collapse in young person - ? HOCM
Tachycardia with a rate of 150/min ?atrial flutter
Turner's syndrome - most common cardiac defect is bicuspid aortic valve
Ventricular tachycardia - verapamil is contraindicated
Young man with AF, no TIA or risk factors, no treatment is now preferred to aspirin
2
8/18/2019 0015 Key Points 2015
http://slidepdf.com/reader/full/0015-key-points-2015 3/29
Cardiac action potential: phases
Phase 3 - efflux of potassium
Congenital heart disease
Pulmonary valve stenosis is cyanotic Notes0 / 1
Drug adverse efects
Amiodarone may cause hyperthyroidism Notes0 / 1
Amiodarone may cause photosensitivity Notes0 / 1
Amlodipine may cause flushing Notes1 / 2
Amiodarone may cause thrombophlebitis Notes0 / 1
Amiodarone may cause slate-grey appearance Notes0 / 1
pironolactone may cause precipitation of digoxin toxicity Notes0 / 1
Drug indications
!holestyramine " uses include# treatment resistant diarrhoea in !rohn$s
disease Notes0 / 1
Drug mechanism o action
Amiodarone - bloc%s potassium channels Notes0 / 1
&icagrelor - antagonist of the P2'12 adenosine diphosphate (A)P*
receptor Notes1 / 2
ECG: coronary territories
+schaemic changes in leads ++" +++" a, - right coronary Notes0 / 1
&all . aves ,1-2 - usually left circumflex" also right coronary Notes1 / 2
ECG: pathological changes
P. depression pericarditis Notes1 / 2
.ight axis deviation - olff-Par%inson-hite syndrome (left-sided
accessory pathay* Notes0 / 1
Features (cardiovascular disorders)
Patent ductus arteriosus - collapsing pulse Notes1 / 2
eart sounds.eversed split 2 Notes0 / 1
ourth heart sound - aortic stenosis Notes0 / 1
oft 2 - aortic stenosis Notes0 / 1
ixed split 2 - atrial septal defect Notes0 / 3
oud 2 - atrial septal defect Notes1 / 2
oud 1 - mitral stenosis Notes0 / 1
&hird heart sound - constrictive pericarditis Notes0 / 1
.eversed split 2 - P type Notes0 / 1
!
8/18/2019 0015 Key Points 2015
http://slidepdf.com/reader/full/0015-key-points-2015 4/29
.eversed split 2 - aortic stenosis Notes0 / 1
oud 1 - left-to-right shunts Notes0 / 1
oud 2 - hyperdynamic states Notes0 / 1
ourth heart sound 45!6 Notes0 / 1
ypertension levels
lood pressure target (7 80 years" clinic reading* - 190/:0 mm4g Notes1 / 2
lood pressure target (; 80 years" clinic reading* - 1<0/:0 mm4g Notes0 / 1
)efinition of stage 2 hypertension (!linic reading* - 1=0/100 mm4g Notes0 / 1
!riteria for considering immediate treatment - 180/110 mm4g Notes0 / 1
)efinition of stage 2 hypertension (AP6/4P6* - 1<0/:< mm4g Notes0 / 1
ypertension: ne"t stepPoorly controlled hypertension" already ta%ing an A!> inhibitor"
calcium channel bloc%er and a thia?ide diuretic@ B ; 9@<mmol/l -
increase dose of thia?ide diuretic
Notes0 / 1
#nective endocarditis
!olorectal cancer - Streptococcus bovis Notes2 / 3
Patients ith no past medical history - Streptococcus viridans Notes1 / 2
Prosthetic valves after to months - Streptococcus viridans Notes0 / 1
$%&
An absent ' descent in the C,P may be caused by cardiac tamponade Notes0 / 1
A paradoxical rise in the C,P during inspiration may be caused by
constrictive pericarditis Notes1 / 2
'urmurs
Atrial septal defect - eDection systolic murmur Notes0 / 1
Eraham-teel murmur (pulmonary regurgitation* - early diastolic
murmur" high-pitched and $bloing$ in character Notes0 / 2
,entricular septal defect - holosystolic murmur" $harsh$ in character Notes0 / 1
6itral regurgitation - holosystolic murmur" high-pitched and $bloing$ in
character Notes0 / 1
&ulses
Pulsus parodoxus - severe asthma Notes1 / 2
Pulsus parodoxus - cardiac tamponade Notes1 / 2
lo-rising/plateau pulse - aortic stenosis Notes1 / 2
!ollapsing pulse - patent ductus arteriosus Notes0 / 2
isferiens pulse - mixed aortic valve disease Notes0 / 1
8/18/2019 0015 Key Points 2015
http://slidepdf.com/reader/full/0015-key-points-2015 5/29
!ollapsing pulse - hyper%inetic states Notes0 / 1
tereotypical histories (cardiovascular disorders)
A 30-year-old man presents ith recurrent palpitations and syncope@ A
resting >!E shos & ave inversion in ,1-3 and epsilon aves@ 4e has
a family history of sudden death - arrhythmogenic right ventricular
cardiomyopathy
Notes1 / 2
A patient develops acute heart failure < days after a myocardial
infarction@ A ne pan-systolic murmur is noted on examination -
ventricular septal defect
Notes1 / 2
Back to top
*
8/18/2019 0015 Key Points 2015
http://slidepdf.com/reader/full/0015-key-points-2015 6/29
Clinical ematology and +ncology
Activated protein C resistance (Factor V Leiden) is the most common inherited thrombophilia
Acute myeloid leukaemia - good prognosis: t(15;17)
Acute myeloid leukaemia - poor prognosis: deletion of chromosome 5 or 7
Acute promyelocytic leukaemia - t(15;17)
Anaplastic thyroid cancer - aggressive, difficult to treat and often causes pressure symptoms
Antiphospholipid syndrome in pregnancy: aspirin + LMWH
Antiphospholipid syndrome: (paradoxically) prolonged APTT + low platelets
Burkitt's lymphoma - c-myc gene translocation
Burkitt's lymphoma is a common cause of tumour lysis syndrome
CLL - immunophenotyping is investigation of choice
CLL - treatment: Fludarabine, Cyclophosphamide and Rituximab (FCR)
CML - Philadelphia chromosome - t(9:22)
Cancer patients with VTE - 6 months of LMWH
Cetuximab - monoclonal antibody against the epidermal growth factor receptor
Chronic myeloid leukaemia - imatinib = tyrosine kinase inhibitor
Cisplatin is associated with hypomagnesaemia
Colorectal cancer screening - PPV of FOB = 5 - 15%
Cyclophosphamide - haemorrhagic cystitis - prevent with mesna
Desmopressiin - induces release of von Willebrand's factor from endothelial cells
Disproportionate microcytic anaemia - think beta-thalassaemia trait
,
8/18/2019 0015 Key Points 2015
http://slidepdf.com/reader/full/0015-key-points-2015 7/29
EBV: associated malignancies:
• Burkitt's lymphoma
• Hodgkin's lymphoma
• nasopharyngeal carcinoma
Factor V Leiden mutation results in activated protein C resistance
Gastric adenocarcinoma - signet ring cells
Gingival hyperplasia: phenytoin, ciclosporin, calcium channel blockers and AML
HRT: adding a progestogen increases the risk of breast cancer
Hereditary haemorrhagic telangiectasia - autosomal dominant
Hodgkin's lymphoma - best prognosis = lymphocyte predominant
Hodgkin's lymphoma - most common type = nodular sclerosing
ITP - give oral prednisolone
IgM paraproteinaemia - ?Waldenstrom's macroglobulinaemia
Metastatic bone pain may respond to NSAIDs, bisphosphonates or radiotherapy
Myelofibrosis - most common presenting symptom - lethargy
Oesophageal adenocarcinoma is associated with GORD or Barrett's
Paraneoplastic features of lung cancer
• squamous cell: PTHrp, clubbing, HPOA
• small cell: ADH, ACTH, Lambert-Eaton syndrome
Patients with Sjogren's syndrome have an increased risk of lymphoid malignancies
Philadelphia translocation, t(9;22) - good prognosis in CML, poor prognosis in AML + ALL
Polycythaemia rubra vera - JAK2 mutation
Polycythaemia rubra vera - around 5-15% progress to myelofibrosis or AML
Polycythaemia rubra vera is associated with a low ESR
Rasburicase - a recombinant version of urate oxidase, an enzyme that metabolizes uric acid
-
8/18/2019 0015 Key Points 2015
http://slidepdf.com/reader/full/0015-key-points-2015 8/29
to allantoin
Screening for haemochromatosis
• general population: transferrin saturation > ferritin
• family members: HFE genetic testing
TTP - plasma exchange is first-line
Taxanes (e.g. Docetaxel) prevent microtubule disassembly
Tear-drop poikilocytes = myelofibrosis
Trastuzumab (Herceptin) - cardiac toxicity is common
Trimethoprim may cause pantcytopaenia
Venous thromoboembolism - length of warfarin treatment
• provoked (e.g. recent surgery): 3 months
• unprovoked: 6 months
Vincristine - peripheral neuropathy
.lood /lm a0normalities
&ear-drop poi%ilocytes - myelofibrosis Notes0 / 1
Drug adverse efects
PrimaFuine may cause haemolysis in patients ith E=P) deficiency Notes0 / 2
Drug mechanism o action
+matinib - inhibitor of the tyrosine %inase associated ith the !.-A
defect Notes0 / 1
aemolytic anaemia
>xtravascular haemolysis - arm autoimmune haemolytic anaemia Notes0 / 1
Back to top
8/18/2019 0015 Key Points 2015
http://slidepdf.com/reader/full/0015-key-points-2015 9/29
Clinical &harmacologyDrug adverse efects
Amiodarone may cause hyperthyroidism Notes0 / 1
Amiodarone may cause photosensitivity Notes0 / 1
Amlodipine may cause flushing Notes1 / 2
Amiodarone may cause thrombophlebitis Notes0 / 1
Amiodarone may cause slate-grey appearance Notes0 / 1
pironolactone may cause precipitation of digoxin toxicity Notes0 / 1Drug indications
!holestyramine " uses include# treatment resistant diarrhoea in !rohn$s
disease Notes0 / 1
Drug mechanism o action
Amiodarone - bloc%s potassium channels Notes0 / 1
5ndansetron - <-4&3 antagonist Notes1 / 2
&icagrelor - antagonist of the P2'12 adenosine diphosphate (A)P*
receptor Notes1 / 2
Back to top
8/18/2019 0015 Key Points 2015
http://slidepdf.com/reader/full/0015-key-points-2015 10/29
Clinical science
AIP - porphobilinogen deAminase; PCT - uroporphyrinogen deCarboxylase
Absolute risk reduction = (Control event rate) - (Experimental event rate)
Adrenal cortex mnemonic: GFR - ACD
Anaphylaxis = type I hypersensitivity reaction
Anticipation in trinucleotide repeat disorders =earlier onset in successive generations
Antidiuretic hormone (ADH) - site of action = collecting ducts
Autosomal recessive conditions are 'metabolic' - exceptions: inherited ataxias
Autosomal dominant conditions are 'structural' - exceptions: hyperlipidaemia type II,
hypokalaemic periodic paralysis
BNP - actions:
• vasodilator
• diuretic and natriuretic
• suppresses both sympathetic tone and the renin-angiotensin-aldosterone system
Cohort studies - relative risk
Combined B- and T-cell disorders: SCID WAS ataxic (SCID, Wiskott-Aldrich syndrome,
ataxic telangiectasia)
Correlation
13
8/18/2019 0015 Key Points 2015
http://slidepdf.com/reader/full/0015-key-points-2015 11/29
• parametric (normally distributed): Pearson's coefficient
• non-parametric: Spearman's coefficient
DiGeorge syndrome - a T-cell disorder
Epidermis - 5 layers - bottom layer = stratum germinativum which gives rise to keratinocytes
and contains melanocytes
Funnel plots - show publication bias in meta-analyses
Hereditary angioedema - C1-INH deficiency
Hereditary angioedema - C4 is the best screening test inbetween attacks
Human genome - 25,000 protein-coding genes
Hypokalaemia - U waves on ECG
Klinefelter's? - do a karyotype
Methaemoglobinaemia = oxidation of Fe2+ in haemoglobin to Fe3+
Mitochondrial diseases follow a maternal inheritance pattern
Molecular biology techniques
• SNOW (South -NOrth -West)
• DROP (DNA -RNA -Protein)
NNT = 1 / Absolute Risk Reduction
Nitric oxide - vasodilation + inhibits platelet aggregation
Obesity hormones
• LeptinLowers appetite
• GhrelinGains appetite
Odds - remember a ratio of the number of people who incur a particular outcome to the
number of people who do not incur the outcome
NOT a ratio of the number of people who incur a particular outcome to the total number of
people
Osteomalacia
11
8/18/2019 0015 Key Points 2015
http://slidepdf.com/reader/full/0015-key-points-2015 12/29
• low: calcium, phosphate
• raised: alkaline phosphatase
Oxygen dissociation curve
• shiftsLeft -Lower oxygen delivery -Lower acidity, temp, 2-3 DPG - also HbF,
carboxy/methaemoglobin• shiftsRight -Raised oxygen delivery -Raised acidity, temp, 2-3 DPG
Power = 1 - the probability of a type II error
Prolactin - under continuous inhibition
Pulmonary surfactant - main constituent isdipalmitoyl phosphatidylcholine (DPPC)
Refeeding syndrome causes hypophosphataemia
Relative risk = EER / CER
Renal tubular acidosis causes a normal anion gap
Rheumatoid arthritis - HLA DR4
Rheumatoid factor is an IgM antibody against IgG
Rituximab - monoclonal antibody against CD20
SIADH - drug causes: carbamazepine, sulfonylureas, SSRIs, tricyclics
Skewed distributions
• alphabetical order: mean - median - mode
• '>' for positive, '<' for negative
Standard error of the mean = standard deviation / square root (number of patients)
The PTH level in primary hyperparathyroidism may be normal
Transfer factor
• raised: asthma, haemorrhage, left-to-right shunts, polycythaemia
• low: everything else
Vitamin B12 is actively absorbed in the terminal ileum
Warfarin - clotting factors affected mnemonic - 1972 (10,9,7,2)
Wiskott-Aldrich syndrome
12
8/18/2019 0015 Key Points 2015
http://slidepdf.com/reader/full/0015-key-points-2015 13/29
• recurrent bacterial infections (e.g. Chest)
• eczema
• thrombocytopaenia
X-linked conditions: Duchenne/Becker, haemophilia, G6PD
X-linked recessive conditions - there is no male-to-male transmission. Affected males can
only have unaffected sons and carrier daughters.
4nti0odies
!hurg-trauss syndrome - p-AN!A Notes0 / 1
54 associations
.heumatoid arthritis - 4A-).9 Notes0 / 1
ormone6 en7yme and protein actionsecretin - increased pancreatic bicarbonate secretion Notes0 / 1
#nective endocarditis
!olorectal cancer - Streptococcus bovis Notes2 / 3
Patients ith no past medical history - Streptococcus viridans Notes1 / 2
Prosthetic valves after to months - Streptococcus viridans Notes0 / 1
igni/cance tests
!hi-sFuared test - non-parametric test used to compare proportions or
percentages Notes0 / 1
tudent$s t-test - parametric test of paired or unpaired data Notes0 / 1
tatistical de/nitions
pecificity - proportion of patients ithout the condition ho have a
negative test result Notes1 / 2
Back to top
Dermatology
Acne rosacea treatment#• mild/moderate# topical metronida?ole
• severe/resistant# oral tetracycline
listers/bullae
• no mucosal involvement (in exams at leastG*# bullous pemphigoid
• mucosal involvement# pemphigus vulgaris
listers/bullae
• no mucosal involvement# bullous pemphigoid
• mucosal involvement# pemphigus vulgaris
1!
8/18/2019 0015 Key Points 2015
http://slidepdf.com/reader/full/0015-key-points-2015 14/29
)ermatitis herpetiformis - caused by +gA deposition in the dermis
)ermatophyte nail infections - use oral terbinafine
)iscoid lupus erythematous - topical steroids H oral hydroxychloroFuine
)ry s%in is the most common side-effect of isotretinoin
lexural psoriasis - topical steroid
+mpetigo - topical fusidic acid H oral flucloxacillin / topical retapamulin
eloid scars - more common in young" blac%" male adults
eloid scars are most common on the sternum
ichen
• planus# purple" pruritic" papular" polygonal rash on flexor surfaces@ ic%ham$s striae over
surface@ 5ral involvement common
• sclerosus# itchy hite spots typically seen on the vulva of elderly omen
6anagement of venous ulceration - compression bandaging
6elanoma# the invasion depth of the tumour is the single most important prognostic factor
Polymorphic eruption of pregnancy is not associated ith blistering
Porphyria cutanea tarda
• blistering photosensitive rash
• hypertrichosis
• hyperpigmentation
Psoriasis# common triggers are beta-bloc%ers and lithium
cabies - permethrin treatment# all s%in including scalp B leave for 12 hours B retreat in I days
eborrhoeic dermatitis - first-line treatment is topical %etocona?ole
&opical steroids• moderate# !lobetasone butyrate 0@0<J
• potent# etamethasone valerate 0@1J
• very potent# !lobetasol propionate 0@0<J
Krinary histamine is used to diagnose systemic mastocytosis
aterlo score - used to identify patients at ris% of pressure sores
ac% to top
tereotypical histories (dermatology)
1
8/18/2019 0015 Key Points 2015
http://slidepdf.com/reader/full/0015-key-points-2015 15/29
An elderly omen develops itchy" tense blisters around the flexures@
&here is no mucosal involvement - bullous pemphigoid Notes0 / 1
An elderly Ceish oman develops painful" flaccid" easily ruptured
vesicles and bullae on the s%in@ &hey are not itchy and ere preceded by
mouth lesions - pemphigus vulgaris
Notes0 / 1
Back to top
EndocrinologyPHaeochromocytoma - give PHenoxyben?amine before beta-bloc%ers
Acromegaly# increased seating is caused by seat gland hypertrophy
Addison$s disease is associated ith a metabolic acidosis
artter$s syndrome is associated ith normotension
ilateral idiopathic adrenal hyperplasia is the most common cause of primary hyperaldosteronism
!ushing$s syndrome - hypo%alaemic metabolic al%alosis
)iabetes diagnosis# fasting ; I@0" random ; 11@1 - if asymptomatic need to readings
1*
8/18/2019 0015 Key Points 2015
http://slidepdf.com/reader/full/0015-key-points-2015 16/29
)iabetes mellitus - 4bA1c of =@<J or greater is no diagnostic (45 2011*
)uring .amadan" one-third of the normal metformin dose should be ta%en before sunrise and to-
thirds should be ta%en after sunset
>xenatide causes vomiting
lushing" diarrhoea" bronchospasm" tricuspid stenosis" pellagra H carcinoid ith liver mets -diagnosis# urinary <-4+AA
Eitelman$s syndrome# normotension ith hypo%alaemia
Elita?ones are agonists of PPA.-gamma receptors" reducing peripheral insulin resistance
Eraves$ disease is the most common cause of thyrotoxicosis
4aemochromatosis is autosomal recessive
4ashimoto$s thyroiditis L hypothyroidism B goitre B anti-&P5
4ashimoto$s thyroiditis is associated ith thyroid lymphoma
4bA1! - rechec% after 2-3 months
4ypercholesterolaemia rather than hypertriglyceridaemia# nephrotic syndrome" cholestasis"
hypothyroidism
+n the primary prevention of !,) using statins aim for a reduction in non-4) cholesterol of ; 90J
+nfertility in P!5 - clomifene is superior to metformin
+nsulinoma is diagnosed ith supervised prolonged fasting
iddle$s syndrome# hypo%alaemia B hypertension
6eglitinides - stimulate insulin release - good for erratic lifestyle
6etformin should be titrated sloly" leave at least 1 ee% before increasing dose
5besity - N+!> bariatric referral cut-offs
• ith ris% factors (&2)6" P etc*# ; 3< %g/mM2
• no ris% factors# ; 90 %g/mM2
Patients on insulin may no hold a 4E, licence if they meet strict ),A criteria
Patients on long-term steroids should have their doses doubled during intercurrent illness
Phaeochromocytoma# do 29 hr urinary metanephrines" not catecholamines
Polycystic ovarian syndrome - ovarian cysts are the most consistent feature
mall cell lung cancer accounts <0-I<J of case of ectopic A!&4
1,
8/18/2019 0015 Key Points 2015
http://slidepdf.com/reader/full/0015-key-points-2015 17/29
&he diagnostic test for acromegaly is an oral glucose tolerance ith groth hormone measurements
&he overnight dexamethasone suppression test is the best test to diagnosis !ushing$s syndrome
&he short synacthen test is the best test to diagnose Addison$s disease
&hia?ides cause hypercalcaemia
&hyrotoxicosis ith tender goitre L subacute ()e uervain$s* thyroiditis
ac% to top
All contents of this site
Gastroenterology
ilson$s disease - serum caeruloplasmin is decreased
29hr oesophageal p4 monitoring is gold standard investigation in E5.)
E. coli is the most common cause of travellers$ diarrhoea
H. pylori eradication#
• PP+ B amoxicillin B clarithromycin" or
• PP+ B metronida?ole B clarithromycin
!auses of villous atrophy (other than coeliacs*# tropical sprue" hipple$s" lymphoma"
hypogammaglobulinaemia
!oeliac disease - tissue transglutaminase antibodies first-line test
)eterioration in patient ith hepatitis - O hepatocellular carcinoma
1-
8/18/2019 0015 Key Points 2015
http://slidepdf.com/reader/full/0015-key-points-2015 18/29
)ysphagia affecting both solids and liFuids from the start - thin% achalasia
lucloxacillin B co-amoxiclav are ell recognised causes of cholestasis
Eastric 6A& lymphoma - eradicate H. pylori
Eive <0J of normal energy inta%e in starved patients (; < days* to avoid refeeding syndrome
4epatocellular carcinoma
• hepatitis most common cause orldide
• hepatitis ! most common cause in >urope
5bese &2)6 ith abnormal &s - O non-alcoholic fatty liver disease
Paracetamol overdose - high ris% if chronic alcohol" 4+," anorexia or P9<0 inducers
Peut?-Ceghers syndrome - autosomal dominant
Primary biliary cirrhosis - the M rule
• +gM
• anti-Mitochondrial antibodies" M2 subtype
• Middle aged females
creening for haemochromatosis
• general population# transferrin saturation ; ferritin
• family members# 4> genetic testing
&he gold standard test for achalasia is oesophageal manometry
Klcerative colitis - the rectum is the most common site affected
Krea breath test - no antibiotics in past 9 ee%s" no antisecretory drugs (e@g@ PP+* in past 2 ee%s
hipple$s disease# DeDunal biopsy shos deposition of macrophages containing Periodic acid-chiff
(PA* granules
ollinger->llison syndrome# epigastric pain and diarrhoea
Back to top
Drug mechanism o action
5ndansetron - <-4&3 antagonist Notes1 / 2
#n8ammatory 0o9el disease: ey diferences
Klcerative colitis - primary sclerosing cholangitis Notes0 / 1
!rohn$s disease granulomas Notes0 / 1
tereotypical histories (gastroenterology)
A 9<-year-old man is being investigated for diarrhoea" eight loss andarthralgia@ CeDunal biopsy shos deposition of macrophages containing
PA-positive granules - hipple$s disease
Notes1 / 2
1
8/18/2019 0015 Key Points 2015
http://slidepdf.com/reader/full/0015-key-points-2015 19/29
A 30-year-old oman presents ith foul smelling oily diarrhoea"
abdominal bloating" fatigue and eight loss@ 5n examination she has
papulovesicular lesions on the extensor aspects of her arms - coeliac
disease
Notes0 / 1
tereotypical histories (hepato0iliary disorders)
A =<-year-old man ith a history of chronic hepatitis b infection
presents ith symptoms and signs of liver cirrhosis@ Alpha-fetoprotein is
elevated@ - hepatocellular carcinoma
Notes0 / 1
tereotypical histories (upper gastrointestinal disorders)
A patient ith a history of heartburn presents ith odynophagia@ &here
no eight loss" vomiting or anorexia - oesophagitis Notes0 / 1
Back to top
#nectious Diseases
Legionella pneumophilia is best diagnosed by theurinary antigen test
Chlamydia - treat with azithromycin or doxycycline
Chickenpox exposure in pregnancy - first step is to check antibodies
Genital ulcers
• painful: herpes much more common than chancroid
• painless: syphilis more common than lymphogranuloma venereum + granuloma
inguinale
Live attenuated vaccines• BCG
1
8/18/2019 0015 Key Points 2015
http://slidepdf.com/reader/full/0015-key-points-2015 20/29
• MMR
• oral polio
• yellow fever
• oral typhoid
Schistosomahaematobium causeshaematuria
Supportive therapy is the mainstay of treatment in Cryptosporidium diarrhoea
URTI symptoms + amoxicillin → rash ?glandular fever
4nti0iotic guidelines
Animal or human bite - co-amoxiclav Notes0 / 3
.acteria: classi/cation
Neisseria meningitidis - Eram-negative cocci Notes1 / 2
Back to top
;ephrology
Goodpasture's syndrome
• IgG deposits on renal biopsy
• anti-GBM antibodies
;eurology
$asciculations$ - thin% motor neuron disease
23
8/18/2019 0015 Key Points 2015
http://slidepdf.com/reader/full/0015-key-points-2015 21/29
Chorea is caused by damage to the basal ganglia" in particular the Caudate nucleus
Dystrophia myotonica - D61
• distal ea%ness initially
• autosomal dominant
• diabetes
• dysarthria
Absence sei?ures - good prognosis# :0-:<J become sei?ure free in adolescence
Antiplatelets
• &+A# clopidogrel
• ischaemic stro%e# clopidogrel
Asymmetrical symptoms suggests idiopathic Par%inson$s
itemporal hemianopia• lesion of optic chiasm
• upper Fuadrant defect ; loer Fuadrant defect L inferior chiasmal compression" commonly a
pituitary tumour
• loer Fuadrant defect ; upper Fuadrant defect L superior chiasmal compression" commonly a
craniopharyngioma
urning thigh pain - O meralgia paraesthetica - lateral cutaneous nerve of thigh compression
!& head shoing temporal lobe changes - thin% herpes simplex encephalitis
!luster headache - acute treatment# subcutaneous sumatriptan B 100J 52
),A advice post !,A# cannot drive for 1 month
),A advice post multipler &+As# cannot drive for 3 months
>clampsia - give magnesium sulphate first-line
>pidural haematoma - lucid interval
>pilepsy B pregnancy L <mg folic acid
>pilepsy medication# first-line
• generalised sei?ure# sodium valproate
• partial sei?ure# carbama?epine
>pisodic eye pain" lacrimation" nasal stuffiness occurring daily - cluster headache
>ssential tremor is an A) condition that is made orse hen arms are outstretched" made better by
alcohol and propranolol
,! is used to monitor respiratory function in Euillain-arre syndrome
21
8/18/2019 0015 Key Points 2015
http://slidepdf.com/reader/full/0015-key-points-2015 22/29
luctuating confusion/consciousnessO - subdural haematoma
luctuating consciousness L subdural haemorrhage
4emiballism is caused by damage to the subthalamic nucleus
4orner$s syndrome - anhydrosis determines site of lesion#
• head" arm" trun% L central lesion# stro%e" syringomyelia
• Dust face L pre-ganglionic lesion# Pancoast$s" cervical rib
• absent L post-ganglionic lesion# carotid artery
4ypertension should not be treated in the initial period folloing a stro%e
earns-ayre syndrome
• mitochondrial inheritance
• onset 7 20-years-old
• external ophthalmoplegia• retinitis pigmentosa
ateral medullary syndrome - P+!A lesion - cerebellar signs" contralateral sensory loss Q ipsilateral
4orner$s
oss of corneal reflex - thin% acoustic neuroma
6edication overuse headache
• simple analgesia B triptans# stop abruptly
• opioid analgesia# ithdra gradually
6igraine
• acute# triptan B NA+) or triptan B paracetamol
• prophylaxis# topiramate or propranolol
6iller isher syndrome - areflexia" ataxia" ophthalmoplegia
6otor neuron disease - rilu?ole
6otor neuron disease - treatment# N+, is better than rilu?ole
Neuroimaging is reFuired to diagnose dementia
Nitrofurantoin may cause peripheral neuropathy
5bese" young female ith headaches / blurred vision thin% idiopathic intracranial hypertension
Painful third nerve palsy L posterior communicating artery aneurysm
Patients cannot drive for = months folloing a sei?ure
Progressive supranuclear palsy# par%insonism" impairment of vertical ga?e
22
8/18/2019 0015 Key Points 2015
http://slidepdf.com/reader/full/0015-key-points-2015 23/29
Prolactinoma management - medical therapy is almost alays first-line
Ptosis B dilated pupil L third nerve palsyR ptosis B constricted pupil L 4orner$s
.estless leg syndrome - management includes dopamine agonists such as ropinirole
.opinirole - dopamine receptor agonist
tro%e thrombolysis - only consider if less than 9@< hours and haemorrhage excluded
yringomyelia - spinothalamic sensory loss (pain and temperature*
&rigeminal neuralgia - carbama?epine is first-line
Krinary incontinence B gait abnormality B dementia L normal pressure hydrocephalus
, for ,igabatrin - , for ,isual field defects
,isual field defects#• left homonymous hemianopia means visual field defect to the left" i@e@ lesion of right optic
tract
• homonymous Fuadrantanopias# P+& (Parietal-+nferior" &emporal-uperior*
• incongruous defects L optic tract lesionR congruous defectsL optic radiation lesion or occipital
cortex
ilson$s disease - autosomal recessive
Back to top
.rain anatomy
rontal lobe lesions may cause perseveration Notes1 / 3
tereotypical histories (neurological disorders)
A <<-year-old presents ith fever" headache" confusion and aphasia@ A
!& shos petechial haemorrhages in the temporal lobe - herpes simplex
encephalitis
Notes2 / 9
Back to top
+phthalmology
Drusen L Dry macular degeneration
Acute angle closure glaucoma is associated ith hypermetropia" here as primary open-angle
glaucoma is associated ith myopia
!entral retinal vein occlusion - sudden painless loss of vision" severe retinal haemorrhages on
fundoscopy
lashes and floaters - vitreous/retinal detachment
2!
8/18/2019 0015 Key Points 2015
http://slidepdf.com/reader/full/0015-key-points-2015 24/29
4olmes A)+e L )+lated pupil" females" absent leg reflexes
4orner$s syndrome - anhydrosis determines site of lesion#
• head" arm" trun% L central lesion# stro%e" syringomyelia
• Dust face L pre-ganglionic lesion# Pancoast$s" cervical rib
• absent L post-ganglionic lesion# carotid artery
6acular degeneration - smo%ing is ris% factor
.ed eye - glaucoma or uveitisO
• glaucoma# severe pain" haloes" $semi-dilated$ pupil
• uveitis# small" fixed oval pupil" ciliary flush
.etinitis pigmentosa - night blindness B funnel vision
cleritis is painful" episcleritis is not painful
&reatment of acute glaucoma - aceta?olamide B pilocarpine
Back to top
&sychiatry
Alcohol ithdraal
• symptoms# =-12 hours
• sei?ures# 3= hours
• delirium tremens# I2 hours
Anorexia features• most things lo
• G$s and C$s raised# groth hormone" glucose"
2
8/18/2019 0015 Key Points 2015
http://slidepdf.com/reader/full/0015-key-points-2015 25/29
salivary glands" cortisol"cholesterol" carotinaemia
Antipsychotics in the elderly - increased ris% of stro%e and ,&>
Atypical antipsychotics commonly cause eight gain
!lo?apine is no longer used first-line due to the ris% of agranulocytosis
)osulepin - avoid as dangerous in overdose
ofepramine - the safest &!A in overdosage
Par%inson$s disease - most common psychiatric problem is depression
Paroxetine - higher incidence of discontinuation symptoms
Post-natal depression is seen in around 10J of omen
.+ B NA+) L E+ bleeding ris% - give a PP+
Knexplained symptoms
• Somatisation L Symptoms
• hypoChondria L Cancer
Back to top
<espiratory 'edicine
Streptococcus pneumoniae is associated ith cold sores
Saccharopolyspora rectivirgula causes farmer$s lung" a type of >AA
Alpha-1 antitrypsin deficiency - autosomal recessive / co-dominant
Aspergillus clavatus causes malt or%ers$ lung" a type of >AA
Asthma - intermediate probability - do spirometry first-line
2*
8/18/2019 0015 Key Points 2015
http://slidepdf.com/reader/full/0015-key-points-2015 26/29
Asthma diagnosis - if high probability of asthma - start treatment
ronchiectasis# most common organism L Haemophilus influenzae
!5P) - &5& if 2 measurements of p52 7 I@3 %Pa
!5P) - reason for using inhaled corticosteroids - reduced exacerbations
!5P) - still breathless despite using inhalers as reFuiredO
• >,1 ; <0J# AA or A6A
• >,1 7 <0J# AA B +! or A6A
!&PA is the first line investigation for P> according to current & guidelines
!ontraindications to lung cancer surgery include ,! obstruction" >, 7 1@<" 6A+ENAN& pleural
effusion" and vocal cord paralysis
>rythema nodosum is associated ith a good prognosis in sarcoidosis
lo volume loop is the investigation of choice for upper airay compression
+socyanates are the most common cause of occupational asthma
ung adenocarcinoma
• most common type in non-smo%ers
• peripheral lesion
6assive P> B hypotension thrombolyse
6ycoplasma pneumonia if allergic/intolerant to macrolides - doxycycline
6ycoplasmaO - serology is diagnostic
Paraneoplastic features of lung cancer
• sFuamous cell# P&4rp" clubbing" 4P5A
• small cell# A)4" A!&4" ambert->aton syndrome
Pneumocystis Diroveci pneumonia - pneumothorax is a common complication
Pneumonia in an alcoholic lebsiella
Preceding influen?a predisposes to Staphylococcus aureus pneumonia
Pulmonary embolism - !&PA is first-line investigation
Pulmonary embolism - normal !S.
arcoidosis !S.
•
1 L 4• 2 L 4 B infiltrates
• 3 L infiltrates
2,
8/18/2019 0015 Key Points 2015
http://slidepdf.com/reader/full/0015-key-points-2015 27/29
• 9 L fibrosis
erial pea% flo measurements at or% and at home are used to detect occupational asthma
leep apnoea causes include obesity and macroglossia
ymptom control in non-! bronchiectasis - inspiratory muscle training B postural drainage
&he maDority of patients ith sarcoidosis get better ithout treatment
&ransfer factor
• raised# asthma" haemorrhage" left-to-right shunts" polycythaemia
• lo# everything else
Back to top
<heumatology
An%ylosing spondylitis - x-ray findings# subchondral erosions" sclerosis
and sFuaring of lumbar vertebrae
An%ylosing spondylitis features - the $A$s
• Apical fibrosis
•
Anterior uveitis• Aortic regurgitation
• Achilles tendonitis
2-
8/18/2019 0015 Key Points 2015
http://slidepdf.com/reader/full/0015-key-points-2015 28/29
• A, node bloc%
• Amyloidosis
Anti-Co-1 antibodies are more common in polymyositis than dermatomyositis
Anti-cyclic citrullinated peptide antibodies are associated ith rheumatoid arthritis
Anti-ribonuclear protein (anti-.NP* L mixed connective tissue disease
Antiphospholipid syndrome# arterial/venous thrombosis" miscarriage" livedo reticularis
A?athioprine - chec% thiopurine methyltransferase deficiency (&P6&* before treatment
)ermatomyositis antibodies# ANA most common" anti-6i-2 most specific
Eout# start allopurinol if ;L 2 attac%s in 12 month period
ateral epicondylitis# orse on resisted rist extension/suppination hilst elbo extended
imited (central* systemic sclerosis L anti-centromere antibodies
N+!> recommend co-prescribing a PP+ ith NA+)s in all patients ith osteoarthritis
5ral ulcers B genital ulcers B anterior uveitis L ehcet$s
5steoarthritis - paracetamol B topical NA+)s (if %nee/hand* first-line
5steoporosis in a man - chec% testosterone
Paget$s disease - old man" bone pain" raised AP
Pseudogout - positively birefringent rhomboid shaped crystals
.aynaud$s disease (i@e@ primary* presents in young omen ith bilateral symptoms
.heumatoid arthritis - &N is %ey in pathophysiology
.heumatoid arthritis# patients have an increased ris% of +4)
> - antibodies associated ith congenital heart bloc% L anti-.o
># ANA is ::J sensitive - anti-m Q anti-ds)NA are ::J specific
># !3 Q !9 lo
cleritis is painful" episcleritis is not painful
eptic arthritis - most common organism# Staphylococcus aureus
&he vast maDority of gout is due to decreased renal excretion of uric acid
Krethritis B arthritis B conDunctivitis L reactive arthritis
cAN!A L egener$sR pAN!A L !hurg-trauss B others
2
8/18/2019 0015 Key Points 2015
http://slidepdf.com/reader/full/0015-key-points-2015 29/29
Back to top