Key points and some collections 2015

Cardiology Streptococcus bovis endocarditis is associated with colorectal cancer Aortic dissection  type A - ascending aorta - control BPIV labetalol + surgery  type B - descending

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 aldosterone system

renin-angiotensin-Cohort studies - relative risk

Combined B- and T-cell disorders: SCID WAS ataxic (SCID, Wiskott-Aldrich syndrome, ataxic telangiectasia)

Correlation

 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

 Leptin Lowers appetite

 Ghrelin Gains 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

 low: calcium, phosphate

 raised: alkaline phosphatase

Oxygen dissociation curve

 shifts Left - Lower oxygen delivery - Lower acidity, temp, 2-3 DPG

- also HbF, carboxy/methaemoglobin

 shifts Right - 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 is dipalmitoyl 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

 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

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 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

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

Cardiac action potential: phases

Phase 3 - efflux of potassium

Congenital heart disease

Pulmonary valve stenosis is cyanotic

Drug adverse effects

Amiodarone may cause hyperthyroidism

Amiodarone may cause photosensitivity

Amlodipine may cause flushing

Amiodarone may cause thrombophlebitis

Amiodarone may cause slate-grey appearance

Spironolactone may cause precipitation of digoxin toxicity

Drug indications

Cholestyramine , uses include: treatment resistant diarrhoea

in Crohn's disease

Drug mechanism of action

Amiodarone - blocks potassium channels

Ticagrelor - antagonist of the P2Y 12 adenosine diphosphate (ADP) receptor

ECG: coronary territories

Ischaemic changes in leads II, III, aVF - right coronary

Tall R waves V1-2 - usually left circumflex, also right coronary

ECG: pathological changes

Heart sounds

Reversed split S2 – LBBB

Fourth heart sound - aortic stenosis

Soft S2 - aortic stenosis

Fixed split S2 - atrial septal defect

Loud S2 - atrial septal defect

Loud S1 - mitral stenosis

Third heart sound - constrictive pericarditis

Reversed split S2 - WPW type B

Reversed split S2 - aortic stenosis

Loud S1 - left-to-right shunts

Loud S2 - hyperdynamic states

Fourth heart sound – HOCM

Hypertension levels

Blood pressure target (< 80 years, clinic reading) - 140/90 mmHg

Blood pressure target (> 80 years, clinic reading) - 150/90 mmHg

Definition of stage 2 hypertension (Clinic reading) - 160/100 mmHg

Criteria for considering immediate treatment - 180/110 mmHg

Definition of stage 2 hypertension (ABPM/HBPM) - 150/95 mmHg

Hypertension: next step

Poorly controlled hypertension, already taking an ACE inhibitor, calcium channel blocker and a thiazide diuretic K+ > 4.5mmol/l - increase dose of thiazide diuretic Infective endocarditis

Colorectal cancer - Streptococcus bovis

Patients with no past medical history - Streptococcus viridians

Prosthetic valves after two months - Streptococcus viridians

JVP

An absent Y descent in the JVP may be caused by cardiac tamponade

A paradoxical rise in the JVP during inspiration may be caused by constrictive

pericarditis

Murmurs

Atrial septal defect - ejection systolic murmur

Graham-Steel murmur (pulmonary regurgitation) - early diastolic murmur, pitched and 'blowing' in character

high-Ventricular septal defect - holosystolic murmur, 'harsh' in character

Mitral regurgitation - holosystolic murmur, high-pitched and 'blowing' in character

Pulses

Pulsus parodoxus - severe asthma

Pulsus parodoxus - cardiac tamponade

Slow-rising/plateau pulse - aortic stenosis

Collapsing pulse - patent ductus arteriosus

Bisferiens pulse - mixed aortic valve disease

Collapsing pulse - hyperkinetic states

Stereotypical histories (cardiovascular disorders)

A 30-year-old man presents with recurrent palpitations and syncope A resting ECG shows T wave inversion in V1-3 and epsilon waves He has a family history of sudden death - arrhythmogenic right ventricular cardiomyopathy

A patient develops acute heart failure 5 days after a myocardial infarction A new systolic murmur is noted on examination - ventricular septal defect

pan-Clinical Hematology and Oncology 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

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 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

Blood film abnormalities

Tear-drop poikilocytes – myelofibrosis

Drug adverse effects

Primaquine may cause haemolysis in patients with G6PD deficiency

Drug mechanism of action

Imatinib - inhibitor of the tyrosine kinase associated with the BCR-ABL defect Haemolytic anaemia

Extravascular haemolysis - warm autoimmune haemolytic anaemia

Clinical Pharmacology Amiodarone may cause hyperthyroidism

Amiodarone may cause photosensitivity

Amlodipine may cause flushing

Amiodarone may cause thrombophlebitis

Amiodarone may cause slate-grey appearance

Spironolactone may cause precipitation of digoxin toxicity

Drug indications

Cholestyramine , uses include: treatment resistant diarrhoea in Crohn's disease

Drug mechanism of action

Amiodarone - blocks potassium channels

Ondansetron - 5-HT3 antagonist

Ticagrelor - antagonist of the P2Y 12 adenosine diphosphate (ADP) receptor

Churg-Strauss syndrome - p-ANCA

Rheumatoid arthritis - HLA-DR4

Secretin - increased pancreatic bicarbonate secretion

Infective endocarditis

Colorectal cancer - Streptococcus bovis

Patients with no past medical history – Streptococcus viridians

Prosthetic valves after two months - Streptococcus viridians

Chi-squared test - non-parametric test used to compare proportions or percentages Student's t-test - parametric test of paired or unpaired data

Specificity - proportion of patients without the condition who have a negative test result

Dermatology Acne rosacea treatment:

 mild/moderate: topical metronidazole

 severe/resistant: oral tetracycline

Blisters/bullae

 no mucosal involvement (in exams at least*): bullous pemphigoid

 mucosal involvement: pemphigus vulgaris

Blisters/bullae

 no mucosal involvement: bullous pemphigoid

 mucosal involvement: pemphigus vulgaris

Dermatitis herpetiformis - caused by IgA deposition in the dermis

Dermatophyte nail infections - use oral terbinafine

Discoid lupus erythematous - topical steroids → oral hydroxychloroquine

Dry skin is the most common side-effect of isotretinoin

Flexural psoriasis - topical steroid

Impetigo - topical fusidic acid → oral flucloxacillin / topical retapamulin

Keloid scars - more common in young, black, male adults

Keloid scars are most common on the sternum

Porphyria cutanea tarda

 blistering photosensitive rash

 hypertrichosis

 hyperpigmentation

Psoriasis: common triggers are beta-blockers and lithium

Scabies - permethrin treatment: all skin including scalp + leave for 12 hours + retreat

in 7 days

Seborrhoeic dermatitis - first-line treatment is topical ketoconazole

Topical steroids

 moderate: Clobetasone butyrate 0.05%

 potent: Betamethasone valerate 0.1%

 very potent: Clobetasol propionate 0.05%

Urinary histamine is used to diagnose systemic mastocytosis

Waterlow score - used to identify patients at risk of pressure sores

Stereotypical histories (dermatology)

An elderly women develops itchy, tense blisters around the flexures There is no mucosal involvement - bullous pemphigoid

An elderly Jewish woman develops painful, flaccid, easily ruptured vesicles and bullae

on the skin They are not itchy and were preceded by mouth lesions - pemphigus

vulgaris

Endocrinology PHaeochromocytoma - give PHenoxybenzamine before beta-blockers

Acromegaly: increased sweating is caused by sweat gland hypertrophy

Addison's disease is associated with a metabolic acidosis

Bartter's syndrome is associated with normotension

Bilateral idiopathic adrenal hyperplasia is the most common cause of primary

hyperaldosteronism

Cushing's syndrome - hypokalaemic metabolic alkalosis

Diabetes diagnosis: fasting > 7.0, random > 11.1 - if asymptomatic need two readings Diabetes mellitus - HbA1c of 6.5% or greater is now diagnostic (WHO 2011)

During Ramadan, one-third of the normal metformin dose should be taken before sunrise and two-thirds should be taken after sunset

Exenatide causes vomiting

Flushing, diarrhoea, bronchospasm, tricuspid stenosis, pellagra → carcinoid with liver mets - diagnosis: urinary 5-HIAA

Gitelman's syndrome: normotension with hypokalaemia

Glitazones are agonists of PPAR-gamma receptors, reducing peripheral insulin resistance

Graves' disease is the most common cause of thyrotoxicosis

Haemochromatosis is autosomal recessive

Hashimoto's thyroiditis = hypothyroidism + goitre + anti-TPO

Hashimoto's thyroiditis is associated with thyroid lymphoma

HbA1C - recheck after 2-3 months

Hypercholesterolaemia rather than hypertriglyceridaemia: nephrotic syndrome, cholestasis, hypothyroidism

In the primary prevention of CVD using statins aim for a reduction in non-HDL cholesterol of > 40%

Infertility in PCOS - clomifene is superior to metformin

Insulinoma is diagnosed with supervised prolonged fasting

Liddle's syndrome: hypokalaemia + hypertension

Meglitinides - stimulate insulin release - good for erratic lifestyle

Metformin should be titrated slowly, leave at least 1 week before increasing dose Obesity - NICE bariatric referral cut-offs

 with risk factors (T2DM, BP etc): > 35 kg/m^2

 no risk factors: > 40 kg/m^2

Patients on insulin may now hold a HGV licence if they meet strict DVLA criteria Patients on long-term steroids should have their doses doubled during intercurrent illness

Phaeochromocytoma: do 24 hr urinary metanephrines, not catecholamines

Polycystic ovarian syndrome - ovarian cysts are the most consistent feature

Small cell lung cancer accounts 50-75% of case of ectopic ACTH

The diagnostic test for acromegaly is an oral glucose tolerance with growth hormone measurements

The overnight dexamethasone suppression test is the best test to diagnosis Cushing's syndrome

The short synacthen test is the best test to diagnose Addison's disease

Thiazides cause hypercalcaemia

Thyrotoxicosis with tender goitre = subacute (De Quervain's) thyroiditis

Gastroenterology Wilson's disease - serum caeruloplasmin is decreased

24hr oesophageal pH monitoring is gold standard investigation in GORD

E coli is the most common cause of travellers' diarrhea

H pylori eradication:

 PPI + amoxicillin + clarithromycin, or

 PPI + metronidazole + clarithromycin

Causes of villous atrophy (other than coeliacs): tropical sprue, Whipple's, lymphoma, hypogammaglobulinaemia

Coeliac disease - tissue transglutaminase antibodies first-line test

Deterioration in patient with hepatitis B - ? hepatocellular carcinoma

Dysphagia affecting both solids and liquids from the start - think achalasia

Flucloxacillin + co-amoxiclav are well recognised causes of cholestasis

Gastric MALT lymphoma - eradicate H pylori

Give 50% of normal energy intake in starved patients (> 5 days) to avoid refeeding syndrome

Hepatocellular carcinoma

 hepatitis B most common cause worldwide

 hepatitis C most common cause in Europe

Obese T2DM with abnormal LFTs - ? non-alcoholic fatty liver disease

Paracetamol overdose - high risk if chronic alcohol, HIV, anorexia or P450 inducers Peutz-Jeghers syndrome - autosomal dominant

Primary biliary cirrhosis - the M rule

 IgM

 anti-Mitochondrial antibodies, M2 subtype

 Middle aged females

Screening for haemochromatosis

 general population: transferrin saturation > ferritin

 family members: HFE genetic testing

The gold standard test for achalasia is oesophageal manometry

Ulcerative colitis - the rectum is the most common site affected

Urea breath test - no antibiotics in past 4 weeks, no antisecretory drugs (e.g PPI) in

past 2 weeks

Whipple's disease: jejunal biopsy shows deposition of macrophages containing

Periodic acid-Schiff (PAS) granules

Zollinger-Ellison syndrome: epigastric pain and diarrhoea

Drug mechanism of action

Ondansetron - 5-HT3 antagonist

Inflammatory bowel disease: key differences

Ulcerative colitis - primary sclerosing cholangitis

Crohn's disease – granulomas

Stereotypical histories (gastroenterology)

A 45-year-old man is being investigated for diarrhoea, weight loss and arthralgia Jejunal biopsy shows deposition of macrophages containing PAS-positive granules - Whipple's disease

A 30-year-old woman presents with foul smelling oily diarrhoea, abdominal bloating,

fatigue and weight loss On examination she has papulovesicular lesions on the extensor aspects of her arms - coeliac disease

Stereotypical histories (hepatobiliary disorders)

A 65-year-old man with a history of chronic hepatitis b infection presents with

symptoms and signs of liver cirrhosis Alpha-fetoprotein is elevated - hepatocellular

carcinoma

Stereotypical histories (upper gastrointestinal disorders)

A patient with a history of heartburn presents with odynophagia There no weight loss, vomiting or anorexia – oesophagitis

Infectious Diseases Legionella pneumophilia is best diagnosed by the urinary 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

Schistosoma haematobium causes haematuria

Supportive therapy is the mainstay of treatment in Cryptosporidium diarrhoea

URTI symptoms + amoxicillin → rash ?glandular fever

Nephrology Goodpasture's syndrome

 IgG deposits on renal biopsy

 anti-GBM antibodies

Neurology 'Fasciculations' - think motor neuron disease

Chorea is caused by damage to the basal ganglia, in particular the Caudate nucleus Dystrophia myotonica - DM1

 distal weakness initially

 ischaemic stroke: clopidogrel

Asymmetrical symptoms suggests idiopathic Parkinson's

Bitemporal hemianopia

 lesion of optic chiasm

 upper quadrant defect > lower quadrant defect = inferior chiasmal compression, commonly a pituitary tumour

 lower quadrant defect > upper quadrant defect = superior chiasmal compression, commonly a craniopharyngioma

Burning thigh pain - ? meralgia paraesthetica - lateral cutaneous nerve of thigh compression

CT head showing temporal lobe changes - think herpes simplex encephalitis

Cluster headache - acute treatment: subcutaneous sumatriptan + 100% O2

DVLA advice post CVA: cannot drive for 1 month

DVLA advice post multipler TIAs: cannot drive for 3 months

Eclampsia - give magnesium sulphate first-line

Epidural haematoma - lucid interval

Epilepsy + pregnancy = 5mg folic acid

Epilepsy medication: first-line

 generalised seizure: sodium valproate

 partial seizure: carbamazepine

Episodic eye pain, lacrimation, nasal stuffiness occurring daily - cluster headache Essential tremor is an AD condition that is made worse when arms are outstretched, made better by alcohol and propranolol

FVC is used to monitor respiratory function in Guillain-Barre syndrome

Fluctuating confusion/consciousness? - subdural haematoma

Fluctuating consciousness = subdural haemorrhage

Hemiballism is caused by damage to the subthalamic nucleus

Horner's syndrome - anhydrosis determines site of lesion:

 head, arm, trunk = central lesion: stroke, syringomyelia

 just face = pre-ganglionic lesion: Pancoast's, cervical rib

 absent = post-ganglionic lesion: carotid artery

Hypertension should not be treated in the initial period following a stroke

Medication overuse headache

 simple analgesia + triptans: stop abruptly

 opioid analgesia: withdraw gradually

Migraine

 acute: triptan + NSAID or triptan + paracetamol

 prophylaxis: topiramate or propranolol

Miller Fisher syndrome - areflexia, ataxia, ophthalmoplegia

Motor neuron disease – riluzole

Motor neuron disease - treatment: NIV is better than riluzole

Neuroimaging is required to diagnose dementia

Nitrofurantoin may cause peripheral neuropathy

Obese, young female with headaches / blurred vision think idiopathic intracranial hypertension

Painful third nerve palsy = posterior communicating artery aneurysm

Patients cannot drive for 6 months following a seizure

Progressive supranuclear palsy: parkinsonism, impairment of vertical gaze

Prolactinoma management - medical therapy is almost always first-line

Ptosis + dilated pupil = third nerve palsy; ptosis + constricted pupil = Horner's

Restless leg syndrome - management includes dopamine agonists such as ropinirole Ropinirole - dopamine receptor agonist

Stroke thrombolysis - only consider if less than 4.5 hours and haemorrhage excluded Syringomyelia - spinothalamic sensory loss (pain and temperature)

Trigeminal neuralgia - carbamazepine is first-line

Urinary incontinence + gait abnormality + dementia = normal pressure

hydrocephalus

V for Vigabatrin - V for Visual field defects

Visual field defects:

 left homonymous hemianopia means visual field defect to the left, i.e lesion of right optic tract

 homonymous quadrantanopias: PITS (Parietal-Inferior, Superior)

Temporal- incongruous defects = optic tract lesion; congruous defects= optic radiation lesion or occipital cortex

Wilson's disease - autosomal recessive

Brain anatomy

Frontal lobe lesions may cause perseveration

Stereotypical histories (neurological disorders)

A 55-year-old presents with fever, headache, confusion and aphasia A CT shows petechial haemorrhages in the temporal lobe - herpes simplex encephalitis

Ophthalmology Drusen = Dry macular degeneration

Acute angle closure glaucoma is associated with hypermetropia, where as primary open-angle glaucoma is associated with myopia

Central retinal vein occlusion - sudden painless loss of vision, severe retinal

haemorrhages on fundoscopy

Flashes and floaters - vitreous/retinal detachment

Holmes ADIe = DIlated pupil, females, absent leg reflexes

Horner's syndrome - anhydrosis determines site of lesion:

 head, arm, trunk = central lesion: stroke, syringomyelia

 just face = pre-ganglionic lesion: Pancoast's, cervical rib

 absent = post-ganglionic lesion: carotid artery

Macular degeneration - smoking is risk factor

Red eye - glaucoma or uveitis?

 glaucoma: severe pain, haloes, 'semi-dilated' pupil

 uveitis: small, fixed oval pupil, ciliary flush

Retinitis pigmentosa - night blindness + funnel vision

Scleritis is painful, episcleritis is not painful

Treatment of acute glaucoma - acetazolamide + pilocarpine

Psychiatry Alcohol withdrawal

 symptoms: 6-12 hours

 seizures: 36 hours

 delirium tremens: 72 hours

Anorexia features

 most things low

 G's and C's raised: growth hormone, glucose,

salivary glands, cortisol,cholesterol, carotinaemia Antipsychotics in the elderly - increased risk of stroke and VTE

Atypical antipsychotics commonly cause weight gain

Clozapine is no longer used first-line due to the risk of agranulocytosis Dosulepin - avoid as dangerous in overdose

Lofepramine - the safest TCA in overdosage

Parkinson's disease - most common psychiatric problem is depression Paroxetine - higher incidence of discontinuation symptoms

Post-natal depression is seen in around 10% of women

SSRI + NSAID = GI bleeding risk - give a PPI

Unexplained symptoms

 Somatisation = Symptoms

 hypoChondria = Cancer

Respiratory Medicine

Streptococcus pneumoniae is associated with cold sores

Saccharopolyspora rectivirgula causes farmer's lung, a type of EAA

Alpha-1 antitrypsin deficiency - autosomal recessive / co-dominant

Aspergillus clavatus causes malt workers' lung, a type of EAA

Asthma - intermediate probability - do spirometry first-line

Asthma diagnosis - if high probability of asthma - start treatment

Bronchiectasis: most common organism = Haemophilus influenza

COPD - LTOT if 2 measurements of pO2 < 7.3 kPa

COPD - reason for using inhaled corticosteroids - reduced exacerbations

COPD - still breathless despite using inhalers as required?

 FEV1 > 50%: LABA or LAMA

 FEV1 < 50%: LABA + ICS or LAMA

CTPA is the first line investigation for PE according to current BTS guidelines Contraindications to lung cancer surgery include SVC obstruction, FEV < 1.5, MALIGNANT pleural effusion, and vocal cord paralysis

Erythema nodosum is associated with a good prognosis in sarcoidosis

Flow volume loop is the investigation of choice for upper airway compression Isocyanates are the most common cause of occupational asthma

Lung adenocarcinoma

 most common type in non-smokers

 peripheral lesion

Massive PE + hypotension – thrombolyse

Mycoplasma pneumonia if allergic/intolerant to macrolides – doxycycline Mycoplasma? - serology is diagnostic

Paraneoplastic features of lung cancer

 squamous cell: PTHrp, clubbing, HPOA

 small cell: ADH, ACTH, Lambert-Eaton syndrome

Pneumocystis jiroveci pneumonia - pneumothorax is a common complication

Pneumonia in an alcoholic – Klebsiella

Preceding influenza predisposes to Staphylococcus aureus pneumonia

Pulmonary embolism - CTPA is first-line investigation

Pulmonary embolism - normal CXR

Sleep apnoea causes include obesity and macroglossia

Symptom control in non-CF bronchiectasis - inspiratory muscle training + postural drainage

The majority of patients with sarcoidosis get better without treatment

Transfer factor

 raised: asthma, haemorrhage, left-to-right shunts, polycythaemia

 low: everything else

Rheumatology Ankylosing spondylitis - x-ray findings: subchondral erosions, sclerosis

and squaring of lumbar vertebrae

Ankylosing spondylitis features - the 'A's

Anti-Jo-1 antibodies are more common in polymyositis than dermatomyositis

Anti-cyclic citrullinated peptide antibodies are associated with rheumatoid arthritis Anti-ribonuclear protein (anti-RNP) = mixed connective tissue disease

Antiphospholipid syndrome: arterial/venous thrombosis, miscarriage, livedo

reticularis

Azathioprine - check thiopurine methyltransferase deficiency (TPMT) before

treatment

Dermatomyositis antibodies: ANA most common, anti-Mi-2 most specific

Gout: start allopurinol if >= 2 attacks in 12 month period

Lateral epicondylitis: worse on resisted wrist extension/suppination whilst elbow

extended

Limited (central) systemic sclerosis = anti-centromere antibodies

NICE recommend co-prescribing a PPI with NSAIDs in all patients with osteoarthritis Oral ulcers + genital ulcers + anterior uveitis = Behcet's

Osteoarthritis - paracetamol + topical NSAIDs (if knee/hand) first-line

Osteoporosis in a man - check testosterone

Paget's disease - old man, bone pain, raised ALP

Pseudogout - positively birefringent rhomboid shaped crystals

Raynaud's disease (i.e primary) presents in young women with bilateral symptoms Rheumatoid arthritis - TNF is key in pathophysiology

Rheumatoid arthritis: patients have an increased risk of IHD

SLE - antibodies associated with congenital heart block = anti-Ro

SLE: ANA is 99% sensitive - anti-Sm & anti-dsDNA are 99% specific

SLE: C3 & C4 low

Scleritis is painful, episcleritis is not painful

Septic arthritis - most common organism: Staphylococcus aureus

The vast majority of gout is due to decreased renal excretion of uric acid

Urethritis + arthritis + conjunctivitis = reactive arthritis

cANCA = Wegener's; pANCA = Churg-Strauss + others

On examination learning points

Endocrinology

 Hyponatreamia with urine sodium <30, raised BUN and hypotension is likely

multifactorial and should be treated with Normal Saline

 Hyponatraemia should be corrected slowly except where seizures or significant

neurological dysfunction occurs

 Hypoadrenalism is associated with hyponatreamia, hyperkalaemia, elevated TSH and mild hypercalcaemia

 Inability to concentrate urine during the water deprivation test, which improves with DDAVP is central DI

 Cheiroarthropathy causes skin tightening in the hands resulting in contracture of the fingers

 Urinary free cortisol or 1 mg overnight dexamethasone suppression test has 95%

sensitivity and specificity for diagnosing Cushing's syndrome

 Failure to suppress cortisol below 50 nmol/L on a ODST test is highly suggestive of

Cushing's disease

 Hypokalaemic metabolic alkalosis is seen in Cushing's syndrome

 Petrosal sinus sampling helps to differentiate pituitary from ectopic ACTH-dependent Cushing's syndrome

 40% of microadenomas will not be seen on imaging, therefore petrosal sinus sampling is necessary to confirm pituitary source of cortisol (ACTH) excess

 Short synacthen test confirms diagnosis of Addison's disease

 Hypogonadotrophic hypogonadism in the presence of raised prolactin is likely secondary

to microprolactinoma

 Hypogonadotrophic hypogonadism (low testosterone with inappropriately low or

normal LH & FSH) requires pituitary investigation primarily

 Abnormal GTT with GH measurement is diagnostic of acromegaly

 A raised 17-OHP concentration is diagnostic for CAH (congenital adrenal hyperplasia)

 The synacthen stimulation test can evaluate adrenal gland function, and when 17-OHP levels are measured concurrently, can help to distinguish between PCOS and non-classical CAH.

 Congenital GnRH deficiency (hypogonadotrophic hypogonadism) due to Kallmann's syndrome is associated with anosmia, deafness, colour blindness and midline deformity

 In women with oopthrectomy unopposed oestrogen HRT is appropriate

 Oestrogen therapy causes raised thyroxie binding globulin, effecting total thyroid

hormone levels

 AntiTPO antibodies are present in 10% females without thyroid pathology

 Grave's disease is associated with vitiligo (7%)

 Propylthiouracil is best used in breast feeding mothers

 Grave's disease may be some times associated with papillary carcinoma

 Follicular thyroid cancer is treated surgically

 Non-suppressed TSH with elevated alpha subunit is in keeping with TSH secreting

adenoma

 Radioiodine uptake scan will show reduced uptake in De Quervain's thyroiditis

 Inappropriately normal PTH in the face of hypercalcaemia is diagnostic of primary

hyperparathyroidism

 Psuedohypoparathyroidism is associated with slipped epiphyseal plate in childhood

 Amitryptilline can also cause glaucoma

 Klinefelters does not have a genetic pattern of inheritance

 Serum ferritin is a useful screenig test for haemochromatosis

 70-90% of people with T1 diabetes will have anti-GAD antibodies

 Xendos study concludes orlistat and diet control reduces risk of diabetes in obese patients by 38%

 Testosterone replacement may improve bone mineral density

Respiratory Medicine

 Hyponatreamia with urine sodium <30, raised BUN and hypotension is likely

multifactorial and should be treated with Normal Saline

 A high-PEEP (open-lung) ventilator strategy will reduce atelectotrauma

 The first line test for correct placement of a nasogastric tube is a pH check of gastric aspirate using pH indicator paper There is no place for the 'whoosh' test

 Symptomatic spontaneous pneumothoraces of more than 2 cm size should not be

 illicit drug use can cause pulmonary hypertension

 Oxygen titration in COPD based on arterial blood gas interpretation

 This man has a severe pneumonia with a history highly suggestive of underlying

immunosuppression from HIV As a result he is at risk from atypical and opportunistic organisms especially Pneumocystis pneumonia

 The Wells score is the most commonly used method to predict probability of pulmonary embolism

Gastroenterology

 Manifestations and management of hereditary haemorrhagic telangectasia

 Carcinoid heart disease has a poor prognosis

 Liver biopsy is diagnostic of haemochromatosis and is the gold standard for diagnosis In patients homozygous for the HFE gene, a liver biopsy is indicated where there is

abnormal liver biochemistry or ferritin > 1000 microg/l All liver biopsies should be

stained for iron (Perls' stain)

 Patients with gastric ulceration tend to suffer from anorexia and weight loss while those with a duodenal ulcer maintain or gain weight

 The treatment of choice for large, symptomatic ascites is large volume therapeutic

paracentesis

 Anti-intrinsic factor antibodies are diagnostic of pernicious anaemia though may be absent in up to 50% of patients with the condition