0015 Key Points 2015

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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

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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

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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

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.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

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!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

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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

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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

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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


+matinib - inhibitor of the tyrosine %inase associated ith the !.-A

defect Notes0 / 1

aemolytic anaemia

>xtravascular haemolysis - arm autoimmune haemolytic anaemia Notes0 / 1

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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


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

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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

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• 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

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• 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

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• 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

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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

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)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

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tereotypical histories (dermatology)

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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

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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

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)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

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&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

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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

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)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

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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

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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

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#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

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• 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

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;ephrology

Goodpasture's syndrome

• IgG deposits on renal biopsy

• anti-GBM antibodies

;eurology

$asciculations$ - thin% motor neuron disease

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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

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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

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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

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.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

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+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

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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

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&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"

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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

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<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

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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

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• 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

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<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

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• 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

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0015 Key Points 2015